Category Archives: Equity

Equity, Inequities and Malaria

The World Health Organization has just released a new report entitled, State of inequality: Reproductive, maternal, newborn and child health. Because of its effort to look across the board at low and middle income countries generally, it does not include more region specific indicators like malaria services. This led us to look at a few recent DHS/MIS  (Demographic & Health and Malaria Indicator Surveys) to see what we can learn about equity or its opposite for malaria.

For RNMCH malaria indicators and equity we can examine coverage of long lasting insecticide-treated nets for both pregnant women (abbreviated as “preg < LLIN” in the attached charts) and children below five years of age (child < LLIN), taking of at least two doses of intermittent preventive treatment by recently pregnant women (IPTp2), and finally receipt of artemisinin-based combination therapy for febrile children below five years of age (ACT child, or where ACT not specified AMD child for antimalarial drug).

Slide4The equity variables presented in these surveys include residence in a rural or urban area, education of the woman, and wealth quintile. Recent reports from Nigeria (DHS 2013), Malawi (MIS 2014), and Angola (MIS 2011) were examined.

The first issue one notices is that these countries have not achieved the Roll Back Malaria coverage target of 80% that was set for 2010, let along sustained it. One could argue that it is not important to talk about equity until a country Slide10demonstrates the health systems capacity to seriously scale up these interventions. On the other hand one could also argue that efforts toward achieving equity at any stage of a program are important as these point to future sustainability and achievement.

The three countries in question each present a very different picture when it comes to equity. Starting with women’s education it is important to note that in two of the countries the proportion women with  post secondary is too negligible to analyze separately. The underlying last of access to post-secondary education is an important equity issue in itself.

Slide7For Nigeria access to both IPTp and ACTs for children is skewed toward those with higher levels of education. Angola’s coverage is also better for more highly educated women. Malawian women with lower education have better IPTp2 coverage, but the other indicators are mixed.

Rural disparity compared to better urban access to malaria commodities is evident in Angola and Nigeria for all Slide2indicators, while Malawi is again mixed. Interestingly in Malawi children in rural areas (41%) show better use of ACTs than those in urban settings (23%).

Angola exhibits the starkest contrast among wealth quintiles with all indicators showing increased coverage as wealth increases. In Nigeria this is true for IPTp and ACTs, but for LLINs, there is a peak in the middle quintile. It is often said in Nigeria that wealthier people prefer screening their homes than sleeping under nets.

Slide9Many factors enter into the picture. Malawi which is poorer in terms of GDP that oil-rich Angola and Nigeria has achieved better overall coverage with less pronounced disparities. One should also consider the differences in physical size with implications for program logistics among the countries.

In its own report, WHO says, “Health inequality monitoring is an essential step towards achieving health equity. It has broad applications and can be conducted across diverse health topics. Applying the best practices in health inequality monitoring presents an opportunity to share the state of inequality with stakeholders, indicate areas in need of improvement and track progress over time.” With tools like DHS, MIS and even national health information systems, endemic countries should also monitor their malaria intervention coverage and bring stakeholders together to address equity gaps.

Malaria Care: Can We Achieve Universal Coverage?

uhc-day-badgeIn New York on 12 December 2014, a new global coalition of more than 500 leading health and development organizations worldwide was launched to advocate for universal coverage (UC) and urged “governments to accelerate reforms that ensure everyone, everywhere, can access quality health services without being forced into poverty.” This marked Universal Health Coverage Day which fell on the “two-year anniversary of a United Nations resolution … which endorsed universal health coverage as a pillar of sustainable development and global security.”

According to WHO delivery of UC involves four components:

  1. A strong, efficient, well-run health system
  2. Affordable care
  3. Accessible care
  4. A health workforce with sufficient capacity to meet patient needs

To this list we might add a functioning and timely procurement and supply management system, and not trust people to read between the lines on component #1 to consider this need.

DSCN2885aWhile much attention in malaria control is appropriately on prevention through various vector control measures, we cannot forget the importance of prompt and appropriate case management, especially as cases decline (according to the new 2014 World Malaria Report) and case detection assumes greater importance.

In 2000 Roll Back Malaria sponsored the Abuja Summit where targets were set for malaria intervention coverage. The goals were established at 80% for insecticide-treated nets (ITNs), intermittent preventive treatment and prompt and appropriate malaria treatment. In 2009, the United Nations declared a goal of universal coverage for ITNs. The potential for UC in malaria case management remained vague, but the new international push for US can certainly include malaria. It would not be coming too late because as we can see from the chart, many endemic countries are far from adequate malaria treatment coverage, let alone UC.

Slide1Frequent surveys help us track progress toward RBM goals and UC – Demographic and Health Survey, Malaria Information Survey, Multi Indicator Cluster Survey. Their helpfulness depends on the questions asked. The 2013 MIS from Rwanda gets closest to finding out what is really happening (Chart 2). We might infer a sequence of events that while not everyone seeks care for their febrile child, those who do are screened by the health worker (including volunteer community health workers); those suspected of malaria are tested (microscopy in clinics, RDTs in communities); and only those found positive are given ACTs.

Slide2Equity is a major concern for advocates of UC. Health insurance is one method to address this. In Ghana around 60% of people have taken part in the National Health Insurance Scheme, but only around 5% in Nigeria where 60% of health expenditure comes from out-of-pocket purchases. Rwanda has a system of mutuelles – community insurance schemes. Insurance does not meet the full need for malaria case management, and thus efforts to expand outlets for affordable quality malaria medicines through the Affordable Medicines Facility malaria (AMFm) was piloted in several countries.

A combination of approaches is needed to achieve UC in malaria case management. Public and private sources are requires. Low cost, subsidized and free care must to be part of the mix. Over half a million people, mostly children, are still dying from malaria annually. Solving the UC challenge for malaria is crucial.

Rural Health and Malaria, a South Africa Example

South Africa’s Rural Health Advocacy Project (RHAP) has released a report or fact sheet on rural health in South African provinces. Of interest is the overlap of rural problems and malaria endemicity.  Three Provinces that border Mozambique are also endemic for malaria – from north to south: Limpopo, Mpumalanga and Kwa Zulu Natal (KZN).

South Africa Provinces and MalariaSeven of the 10 poorest districts in the country fall in two of these endemic provinces, Limpopo and KZN. The two districts with the highest HIV prevalence are in Mpumalanga and KZN, and those two provinces themselves have the highest HIV prevalence among all the provinces.

The fact sheet also reports that, “Poor rural households in a Limpopo District spend up to 80% of monthly income on health expenditure, travel costs being a significant contributor.”

Limpopo and Mpumalanga are among the four provinces with the lowest distribution (or highest shortages) of human resources for health. Concerning maternal mortality, the fact sheet notes that, “Each year an estimated 4300 mothers die. KZN most affected.”

While one cannot say the exact role malaria plays in rural poverty and rural health disparities, it is important to note that interventions to control and eliminate the disease must have a strong rural focus. Hopefully there will be economic benefits to such interventions.

Five Models of Equitable Access to MCH Services

Five models of equitable access to maternal and child health (MCH) services are the focus on a new article by Talukder and Rob.  We wonder what lessons these models hold for improving access to malaria treatment and preventive services, which should be integrated into MCH.

The five model programs from Asia and Africa listed below do cover malaria-endemic communities –

  • Community Health Volunteers Program in Bangladesh (BRAC)
  • Lady Health Workers Program in Pakistan (LHW)
  • Reproductive and Child Health Alliance Program in Cambodia (RACHA)
  • Community-based Health Planning and Services in Ghana (CHPS)
  • Tanzania Essential Health Interventions Project (TEHIP)

Each model addresses innovative ways of strengthening and managing health systems so that communities are reached and linked with the wider health system. At least four of the models involve community health workers who may be volunteers or receive a stipend.

BRAC is well known for involving community members in health provision and links their sustainability to microfinance opportunities and sales of basic health commodities.  This model has been used in malaria endemic areas of Bangladesh, the Chittagong Hill Tract. An evaluation of the effort reported that …

BRAC and the Ministry of Health implemented the national malaria control programme under GFATM and BRAC would be responsible for supplying LLIN to 80% household, as well as deploying health workers in every union to provide RDT (rapid diagnostic tests) and AL (artemether-lumefantrine) at the grass root level.

Community volunteers were effective in ensuring that the target goal for the supply of LLIN and retreatment of ITN were surpassed, but there was still competition with drug vendors in the provision of malaria treatment.

BRAC is now implementing its model with community health promoters supported by microfinance to implement malaria control as part of its overall health interventions in Liberia.

RACHA takes a different approach to promoting equity, especially gender equity in health service access. “RACHA works almost exclusively in support of the Ministry of Health’s priorities and programs. It does not provide health services or operate health facilities but works through the MOH service network and its community links to translate MOH technical policy and program priorities into quality effective intervention programs in the field.”

RACHA enhances health worker skills, guarantee quality assurance, improve supply mechanisms and create demand in the community.  RACHA also provides midwife training and delivery kits and microfinance to support the midwives. Although malaria is not specifically mentioned, quality assurance is certainly essential to addressing the problem of artemisinin resistance in the region.

Lady Health Workers are an core component of Pakistan’s primary health care efforts. According to WHO LHWs …

…act as a liaison between the formal health system and the community and disseminate health education messages on hygiene and sanitation. The programme is strongly rooted in the primary health care concept and it aims to achieve universal health coverage. Each Lady Health Worker serves around 1000 individuals.

LHWS receive a small salary of about US$ 343 per year. “Lady Health Workers provide essential drugs for treatment of minor ailments such as diarrhoea, malaria, acute respiratory tract infection, intestinal worms, etc., as well as contraceptive materials to eligible couples.”

dscn0272-chps-in-a-market-stma-district-2.jpgGhana’s CHPS program ensures that communities and specially trained community nurses work together to provide primary health care to under-served rural areas, including of course, malaria treatment.  While community volunteers are part of the effort, the overall community takes responsibility for providing a simple structure for a clinic and nurse housing.

Talukder and Rob note that the CHPS effort has resulted in decreased child mortality and and fertility rates in communities with what are known as the CHPS compounds. Up-to date information on the number of CHPS compounds is not available at the Ghana Health Service website, but estimates from 2008 are that “National coverage is now approximately 9% percent of the population.”

Finally, the TEHIP focuses of strengthening planning and management capacity of district health services.  According to ODI, the two pilot districts showed that …

TEHIP has brought about a change in the way that local health policy and practice is planned and resources are allocated across geographical and technical areas. At the district level health care workers and managers are more in control of resources and processes. This has also contributed towards a more robust decentralisation of the health care provision.

Because of TEHIP, “Child mortality in the two districts fell by over 40% in the 5 years following the introduction of evidence-based planning; and death rates for men and women between 15 and 60 years old declined by 18%.”

These results were achieved because the evidence-based planning model yielded an increase in average clinic visits per child from 2.8 to 5.8 a year. “More children were treated for malaria, more early cases of worms were spotted, more eye infections were caught, more AIDS messages were shared, and more mothers had exposure to family planning information.”
While these equity-fostering interventions have resulted in improvements in malaria indicators as well as broader child and maternal health statistics, they appear to have varying levels of scale-up and sustainability.  They all demonstrate the need for new ways of planning and managing district health services, and in at least three cases show the importance of community involvement.  A couple demonstrate innovative ways of using microfinance to sustain community health worker commitment.

Overall the lesson is one that has been voiced since the dawn of the Roll Back Malaria Partnership – we cannot roll back malaria without health system reform.

Net Equity – SUFI or SUFE?

nigeria2.jpgMalaria elimination efforts move along a pathway outlined by the Roll Back Malaria Partnership that begins with limited control, moves on to scaling up and then aims as sustaining the scaled up interventions so that incidence drops and we can enter the pre-elimination phase.  The scale up efforts that have been most intense in the past three-year effort to reach universal coverage (UC) have been known by the acronyn SUFI – scale up for intervention.

SUFI and UC are also viewed against the backdrop of RBM targets set in 2000 to achieve 60% coverage by 2005 and 80% by 2010.  The implication is that we may claim success with 20% of the population still not reached, which appears to counter the aims of UC.  Therefore a bigger question is whether we are simultaneously achieving SUFE – scale up for equity.

liberia2.jpgFrom the standpoint of malaria control equity should focus on whether those people who are most vulnerable to infection have access to interventions.  Vulnerability or risk has been viewed from two perspectives: 1) people who are more likely to experience infection because of their immune status such as children below 5 years of age and pregnant women and 2) people living in poverty whose financial and housing situation expose them more to infection and whose incomes are more at risk when they suffer from malaria.

Presented here are snapshots from health surveys in Nigeria, Liberia and Senegal that compare household net ownership with wealth quintile (Demographic and Health Survey, Malaria Indicator Survey). These countries have achieved differing levels of coverage and access to low income groups that help us question how equity relates to malaria control.

Nigeria is characterized by low overall coverage. During recent discussions at a retreate among maternal and child health professionals, colleagues raised the question of whether we can consider equity when coverage is very low. Nigeria prior to the mass net distribution efforts of 2009-11 provides some interesting information for the discussion. Although households in the lower wealth quintiles are slightly more likely to have any kind of bednet, the ownership of an insecticide treated net (ITN) is much greater in the wealthier homes. This may not be unrelated to the fact that ITNs in the early phases of control were often sold or subsidized, limiting their access to people with better income.

senegal2.jpgLiberia and Senegal with moderate and higher levels of coverage display the same overall trend as Nigeria with poorer household more likely to have some kind of bednet, but when it comes to ITNs, the poorer ones also have some advantage.  At the time of their surveys, both Senegal and Liberia had been doing some mass net distributions, and the benefit to the lower income people in their countries seems apparent.  It should be noted that higher income people may not need nets as a main protecteive measure if they live in better constructed homes that usually have window and door screening, an expensive intervention on its own.

One might conclude that Universal Coverage does have a strong equity or SUFE component.  We also need to investigate whether other interventions like prompt case management and intermittent preventive treatment are also reaching the people in most need.

Health Posts – meeting rural needs

People living in rugged rural terrain often go without formal health services. The population may be remote and even migratory, as some herd cattle.

dscn0659a.JPGAngola is working to ensure that at minimum there are Health Posts staffed by trained nurses to provide services beyond the municipal/district headquarters. And since onchocerciasis is common in many of such areas, we are also talking about providing integrated disease control and health care ‘beyond the end of the road,’ as advocated by the African Program for Onchocerciasis Control.

Life for these nurses is not easy as there is usually just one staff member to run the post. Also this situation means that male nurses predominate – one reason why it is presumed that antenatal care may not be easy to provide.

dscn0699-sm.JPGA visit to such a health post recently showed that not only was the nurse enthusiastic, but that he could provide some of the basic components of antenatal care in all but name.

The post had a good supply of sulphadoxine-pyramethamine that is required for intermittent preventive treatment of malaria in pregnant women. There were other medicines and supplements routinely given pregnant women such as ferrous sulfate and de-worming drugs.  The nurse even had a fetal stethoscope.

Strengthening these rural outposts is a priority for malaria control and health equity. These rural populations do not even have access to medicine shops as found in some areas.

Regular supplies of nets, RDTs, ACTs and SP will guarantee that all parts of Africa can work toward reducing malaria deaths by 2015.

International Women’s Day … and malaria

For 99 years International Women’s Day (8 March) has been “a global day celebrating the economic, political and social achievements of women past, present and future.” According to the UN Special Envoy for Malaria, Ray Chambers

The disease strikes infants, children under five and pregnant women in astonishing disproportion, as these segments of the population account for 90 percent of malaria deaths. Given the dual role of women as both victim and primary protector of victims, malaria clearly belongs under the umbrella of traditional women’s health issues.

dscn7760sm.JPGThe protective role of women in the fight against malaria extends beyond the household. In endemic most countries the majority of front line health workers who treat malaria patients and give out bednets are women.  Women also play a major community role when they volunteer as village health workers and bring malaria treatment and prevention to the grassroots as seen in Ethiopia‘s “scheme to train thousands of young women in malaria fighting tactics.”

Although women may not have equal numbers of positions compared to men when it comes to malaria policy making and program management, it was impressive at the November meeting of the RBM Harmonization Working Group to be addressed by the women who were directors of the national malaria control programs of Kenya, Nigeria and Ghana.

The World Gender Gap Report (2008) considers economic opportunity and participation, educational attainment, political empowerment, and health and survival of women in each country.  130 countries were scored, and at ten of the lower 30 on the list are endemic for malaria compared to only 3 in the top 30. This does not mean that malaria per se creates inequality, but may have a harder time accessing malaria prevention and treatment where gender equality is highest.

Provision of Intermittent Preventive Treatment for pregnant women (IPTp) during antenatal care is an example of neglected services for women. The World Malaria Report roughly estimates that no around 20% of pregnant women in areas of stable malaria transmission in Africa received the minimum two doses of IPTp even though the target for 2005 was 60%.  The RBM website’s country facts show that coverage with two doses can be as low as 3% in Angola and 5% in the Democratic Republic of the Congo. Only one country appears to have broken the 60% ceiling, Zambia.

Countries need to step up and close the gender gap in malaria services. Resources are available from Jhpiego to help countries assess their current malaria in pregnancy program implementation status, update their malaria policies to reflect the needs of women and train health workers to deliver better malaria services to women.

User Fees – a potential threat to malaria elimination?

A nutrition clinic during 2009 in Côte d’Ivoire saw only 33% of the number of clients it helped in 2007.  IRIN reports that staff believe this was not due to decreases in malnutrition, but to the introduction of user fees.Under the hospital’s cost-recovery scheme, each family must pay 5,000 CFA francs (US$10.80) per child requiring intensive therapeutic feeding.”

Médecins Sans Frontières used to run the nutrition clinic, but fees were needed to run the service after the NGO left in 2008. “Many women who come in cannot afford to pay, Konan (who runs the clinic) said. ‘Two out of six new cases we have now could not pay… Sustaining these activities is hard … MSF wanted us to make the treatment free but we need more money to do so.'”

Cost recovery schemes have been touted, at least since the 1987 Bamako Initiative, as a way to guarantee that primary care services are sustainable. Mali, where the Bamako Initiative was penned, has been running a cost recovery system for many years that involves the community in decisions about the costs of medicines in the community health center, but ethical issues continually arise when malaria medicines are supposedly free through money from sources like the Global Fund.

A study in Burkina Faso on fees in a Bamako Initiative style program found that, “The introduction of fees-for-services had an adverse effect on service utilization. The study district is in a position to bear the financial cost of taking care of the poor and the  community is able to identify such people. Incentivesmust be introduced by the state and be swiftly applied so that the communities agree to a more equitable system and thereby allow access to care for those excluded from services because they are unable to pay.”

Our experience in Akwa Ibom State, Nigeria, attest to the negative impact of fees. Each local government decides on its own scale of registration fees for antenatal care.  While ANC registration in southern Nigeria is generally high, we found that only about 20% of pregnant women were coming to government run ANC clinics in Akwa Ibom.

After introducing a program to enhance malaria in pregnancy control services in selected local governments, we found that attendance still remained low.  The community distributors we had trained were expected to refer pregnant women to ANC, but the process was thwarted when the women were asked to pay between 200-300 Naira (upwards to US $2) to register.

Fortunately the women were able to receive their Intermittent Preventive Treatment (IPT), health education and some bednets through the trained community distributors, but the goal of linking them to improved quality comprehensive ANC services could not easily be met.

bill-on-free-medical-services-for-pregnant-women2.jpgAdvocacy efforts continue with each of the local government chairpersons and councils in the project area, but they are reluctant to relinquish these small fees. The state health services, such as secondary level district hospitals, offer free ANC, but this bypasses the primary care system. At any rate there are not enough state hospitals to make up for the need.
The State Legislature continues to debate whether to make health care for women and children free throughout all local governments. In the meantime, women in the state are effectively denied the means to protect themselves and their unborn children from the risks of malaria.

Much work is still needed to overcome the barriers to universal coverage of malaria interventions. The goals of sustaining a health system and eliminating malaria appear at odds at times, but delivery of malaria services depends on a strong primary health care system.  There are certainly better sources of revenue for health services than charging fees to poor pregnant women in communities where people earn less than a dollar a day.

Ethnic Minorities and Universal Coverage

dscn6801-sm.JPGIf we are to achieve universal coverage – a crucial step along the pathway to malaria elimination – we must be sure that all at risk populations are reached.

IRIN news gives us reasons to pause.  Reporting on Vietnam, IRIN found that, “Maternal mortality rates vary widely across the country. In Cao Bang province, with a 98 percent ethnic minority population, there are 411 maternal deaths for every 100,000 live births, according to UNICEF. In Binh Duong province, near Ho Chi Minh City, the rate is less than one-tenth of that.”

In remote mountainous areas IRIN notes that, “Minorities such as the H’Mong mostly still give birth at home, and are far less likely to access healthcare, especially antenatal care, health specialists say.” An important part of antenatal care is prevention and treatment of malaria.  Besides geographical access, minorities also have financial access problems since they are often poorer than the general population.

Minority access affects many countries and health problems. We found that in southwestern Nigeria, migrant Fulani populations were less likely to get childhood immunizations than their sedentary counterparts. The Fulani there depend more on private health providers to avoid perceived discrimination at local government health services. The settlements of these cattle herding peoples were often overlooked during guinea worm surveillance activities.

Specific to malaria, Dysoley and colleagues found that ethnic minorities working in the forests of Cambodia, while more susceptible to malaria, have been neglected in the past. Ahmed found in Balgladesh differential health and health-seeking behaviors among ethnic groups for illnesses including malaria where Bangalis were more likely to seek qualified allopaths as providers than did ethnic minorities.

Timely and equitable access to effective malaria interventions for all peoples in endemic areas is the only way that malaria can be eliminated.

Public Health Ethics and Malaria Research

Wen Kilama of the African Malaria Network Trust brought a challenging idea to the malaria researchers gathered at MIM’s 5th Pan-African Malaria Conference on Tuesday. He explained that while we have a strong tradition of biomedical ethics that protect the individual from harm in research trials, we do not have a clear code of ethical processes, not the mechanism to oversee and regulate these for public or population health research.

atiamkpat-community-1-nets-sm.jpgHis thoughts are also expounded in a current article in a supplement to Acta Tropica and ask us to consider difficult questions such as weighing individual protection and public benefit of an intervention beijng tested.  Examples of these have included immunization regimens, water fluoridation and iodization of salt. In malaria research we also must consider individual freedoms and choices balanced against the community protective effects of indoor residual spraying or wide coverage long lasting insecticide treated net (LLIN) campaigns.

Dr Kilama raised an interesting ethics about the distribution of two different types of LLINs.  One is a polyester multifiber net with insecticide coated yarn has received only Phase 2 approval from WHOPES, which approves insecticides for human safety. The other is a polyethylene monofilament net with insecticide incorporated into the yard. This has received Phase 3 WHOPES approval.  Ironically three times as many of the former were made available to the public than the later in recent years. Is this ethical?

Dr Kilama also raised an equity issue – how can we justify testing health interventions like LLINs on rural poor people who bear the greatest malaria burden when at the start of most programs, it is better off urban people who can afford the nets?

Corporate social responsibility also plays a role after research and testing for regulatory approval have been done. The manufacturers of the monofilament polyethylene nets have made provision for royalty free transfer and have already set up operations in one African country and are ready to move into others.  Their first African factory employs 6,000 people locally and has a positive economic impact on at least 30,000 in the community.

Ethical considerations in a population/public based research like vector control is complex. Community awareness and consent processes come at the start, but then effort must be made to enlist the informed participation of households and individuals.  Ghana’s Navrongo community research facility was mentioned as an example of an institution that has a codified community ethics process.

Dr Kilama called on the public health research community, and especially community malaria researchers, to develop consensus ethical procedures for community studies.