Tropical Health Matters

The 2024 World Malaria Day Theme of “Gender, Health Equity, and Human Rights” cannot be divorced from the inequities of climate change wherein the countries that contribute the least to the problem suffer the most, including the deleterious effects of changing malaria geographics. The current severe drought in Zambia, Zimbabwe, and Malawi is a case in point.

As a recent headline in VOA news states, “UN officials in Zambia to assess worst drought in 20 years.” The government has declared a drought officially where it “has affected a total of 8 provinces across the country with highest impacts in Southern, Central, Eastern, North-western, Western, and Lusaka Provinces.”

Drought should not be confused with a “normal” dry season. What we are seeing in Southern Africa now is an extended dry period in what should have been the rainy season. A study in Mali suggests that adult malaria-carrying mosquitoes “have endured the dry season by aestivating—the hot-weather equivalent of hibernating.” Unfortunately, an extended dry period of a drought may be more difficult to endure for the adults, but possibly the eggs are more resistant. Additional studies paint a more complicated picture.

Weather cycles intensify with climate change. El Niño, which can lead to droughts also produces warming in higher elevations so there tends to be an increase in malaria transmission in areas in the highlands.

Research in Zambia published just two years ago reported increasing trends of malaria in areas covering over 47% of all health facilities, while a declining trend was seen in areas covering 27% of health facilities. The decreasing trend was noticeable in the south, where malaria risk is lowest, and current drought conditions higher. The authors stress the need for continued geographic surveillance and implementation of control strategies geared to the conditions in each area.

A systematic review of the effects of climate change identified “vector borne disease (including malaria, dengue and West Nile Virus)” as a major concern as well as “nutrition-related effects (including general malnutrition and mortality, micronutrient malnutrition, and anti-nutrient consumption),” which compromises the ability of children to fight disease. The review found different impacts of drought ranging from increase mortality a year after a drought, to the disappearance of some vector species. The lesson is that each country needs to monitor their situation carefully. For Zambia, UNICEF reports that, “significant number are children, at risk of food insecurity, acute malnutrition, and disease.”

Research on drought effects on malaria arose from a study that examined the effects of drought on malaria infection (genetic) complexity and transmission in lizards (Plasmodium mexicanum and Sceloporus occidentalis). The authors noted that, “relationship between rainfall and parasite prevalence is somewhat more ambiguous.” Thus, the authors recommended that more information is needed about human malaria parasites and drought since “drought may cause shifts in human disease outcomes independent of any changes to prevalence.”

The United Nations challenges us by observing that, “Due to the complex relationship between malaria and climate change, gaps in knowledge still exist in the mechanisms of the linkage.” Changes in temperature, rainfall, and humidity need to be monitored for effects on vectors, parasites, and human movement. The current situation requires a more nuanced and complex approach to interventions if malaria elimination can be achieved while also preventing gender discrimination, promoting health equity and preserving human rights.

We are sharing the abstract of a just published article by Moussa Sangare and colleagues entitled, “Factors hindering health care delivery in nomadic communities: a cross-sectional study in Timbuktu, Mali,” that appears in BMC Public Health. As COVID-19 has been disrupting health services generally, we need greater awareness of the serious barriers faced by more vulnerable populations even in better times.

Background: In Mali, nomadic populations are spread over one third of the territory. Their lifestyle, characterized by constant mobility, excludes them from, or at best places them at the edge of, health delivery services. This study aimed to describe nomadic populations’ characteristics, determine their perception on the current health services, and identify issues associated with community-based health interventions.

Methods: To develop a better health policy and strategic approaches adapted to nomadic populations, we conducted a cross-sectional study in the region of Timbuktu to describe the difficulties in accessing health services. The study consisted in administering questionnaires to community members in the communes of Ber and Gossi, in the Timbuktu region, to understand their perceptions of health services delivery in their settings.

Results: We interviewed 520 individuals, all members of the nomadic communities of the two study communes. Their median age was 38?years old with extremes ranging from 18 to 86?years old. Their main activities were livestock breeding (27%), housekeeping (26.4%), local trading (11%), farming (6%) and artisans (5.5%). The average distance to the local health center was 40.94?km and 23.19?km respectively in Gossi and Ber. In terms of barriers to access to health care, participants complained mainly about the transportation options (79.4%), the quality of provided services (39.2%) and the high cost of available health services (35.7%). Additionally, more than a quarter of our participants stated that they would not allow themselves to be examined by a health care worker of the opposite gender.

Conclusion: This study shows that nomadic populations do not have access to community-based health interventions. A number of factors were revealed to be important barriers per these communities’ perception including the quality of services, poverty, lifestyle, gender and current health policy strategies in the region. To be successful, future interventions should take these factors into account by adapting policies and methods.

The Demographic and Health Survey for 2018 in Nigeria has released preliminary findings. These cover insecticide Treated Nets (ITNs), Intermittent Preventive Treatment of malaria in pregnancy (IPTp), and treatment of children with Artemisinin-Based Combination Therapy (ACT).

The key findings have been converted into graphs.  We can see that ITN ownership by a household (HH) is greater in rural areas, but overall reaches only a national average of 60% of households having at least one net. People may recall that the 2010 target by the Roll Back malaria Partnership was 80% for all key indicators with the hope that by attaining and then maintaining 80% coverage or more, malaria incidence would drop and elimination would be on the horizon.

Nigeria is not among WHO’s Elimination by 2020 (E2020) countries, and it is not clear when transmission will move in that direction when key interventions are still not reaching targets. This is due also to the fact that 60% of households covered does not mean that residents are protected. In fact only 30% meet the goal of universal net coverage with at least one net for every two household members.

On the positive side, comparison of household net ownership and wealth status appears to favor the poorer households. 72% of the poorest households have at least one net compared to 48% of the highest income quintile.  Unfortunately the gap between rich and poor narrows when it comes to the target of 1 net for 2 people.

Although these days we stress universal coverage of all household members, DHS still collects data on what are often termed ‘vulnerable’ groups, children below the age of 5 years and pregnant women.  Just over half of each group slept under an ITN the night before the survey. It is obvious that access plays a role, so in those households that actually own at least one net 74% of children and 82% of pregnant women slept under an ITN. These figures might even be higher if the target of 1 net per two people were met.

Nigeria is a huge and diverse country in terms of geography, epidemiology and ethncity. The country has 6 regions that are used for planning and analysis purposes. The map attached shows that there are major regional variations in households owning at least one net and households having at least one net for every 2 people residing there.

There is better coverage of at least one net per household in the northern zones than the southern, with the Northwest achieving 86% and then 42% for covering two people with one net.  When it comes to that latter measure, the remaining 5 regions are all in the 20% level, meaning that for most of the country, there is a long way to go to achieve universal net coverage.

Intermittent preventive treatment of pregnant women  with sulphadoxine-pyrimethamine (SP) has been a long standing intervention to protect women and their unborn children from the devastating effects of malaria. For at least six years now, WHO has recommended that pregnant women take three or more monthly doses of IPTp from the 13th week of pregnancy, onward.

A challenge to getting IPTp is contact with antenatal care services, and only 67% of women who delivered a child in the 5 year preceding the survey attended ANC even once.  Not surprisingly, only 40% of those pregnant women received two doses of IPTp and only 17% got three doses.

Finally, only 28% of children with fever in the two weeks prior to the survey took ACT, although we are not certain about the proportion who had been tested. It is difficult to interpret this finding since we do not know what proportion of those with fever might have been tested and found to harbor malaria parasites. ACTs should only be given to those with positive parasitological tests.

DHS and its sister survey, the Malaria Indicator Survey are performed at approximately three-year intervals. These data sources are valuable for evaluating past interventions and planning new. Clearly some serious planning is needed to address the shortfalls in malaria intervention coverage and save more lives.

The WHO defines Equity as “the absence of avoidable, unfair, or remediable differences among groups of people, whether those groups are defined socially, economically, demographically or geographically or by other means of stratification. ‘Health equity’ or ‘equity in health’ implies that ideally everyone should have a fair opportunity to attain their full health potential and that no one should be disadvantaged from achieving this potential.”

WHO goes on to say that, “Countries and programs need to disaggregate selected health indicators by key stratifiers including demographic characteristics (gender, age), place of residence (urban/rural, subnational), socioeconomic status (wealth, education), as well as other characteristics (migrant/minority status etc.).”

Writing for the Tropical Disease Research Program, H. Kristian Heggenhougen, Veronica Hackethal, and Pramila Vivek in the publication, The behavioural and social aspects of malaria and its control, say that …

“What must now be clear is our conviction that any review of factors for world-wide malaria control must give specific attention to issues of socio-economic inequity and disease epidemiology.” Malaria is not an equal opportunity killer, but disproportionately affects certain segments of the population. Heggenhougen et al. continue that, “while we argue for a focused attack on malaria, we cannot avoid noting that without attention to these larger matters – inequity and marginalization – any improvement in health, including malaria, may be short-lived.”

The Demographic and Health Survey (DHS) and its Malaria Indicator Survey (MIS) provide an important snapshot on equity issues in the rollout and coverage of major malaria.   In particular, we look at the issue of long lasting insecticide-treated nets in two countries, Ghana (2016 MIS) and Liberia (2016 MIS), to demonstrate how equity issues can be seen. Two three measures are considered, wealth quintile, location (urban/rural) and gender/sex.

In Ghana we see that having at least one net for the household is more common in lower income groups. These groups are more vulnerable. Although not specifically shown in the MIS, one might assume that people in the higher income groups have better quality housing that provides less opportunity for mosquito entry. Likewise households in rural areas, where anopheles are more likely to breed, have a higher proportion of nets. So while nets are not ‘equally distributed by these characteristics, they are more favorably available in those households that may be more vulnerable to malaria.

When we look at the indicator of universal coverage where it is expected that there should be one net for every two household members, the proportion meeting that goal is much lower than simply having a net in the household for all groups.  That said the pattern of higher proportions among rural and lower income groups remains. Within households, the Ghana MIS a nearly equal proportion of female (43%) and male (41%) had slept under a net the night prior to the survey.

Overall, Liberia has much lower LLIN coverage than Ghana. The pattern for location is similar to that of Ghana, but for wealth, the poorest group (Q1) have lower coverage that wealth quintile groups 2-4. Also as in Ghana the Female (40%) and male (38%) are very similar.

We encourage readers to review the recent MIS and/or DHS reports from the countries where they work and look for differences in net availability as well as uptake of other malaria control interventions to determine the level of equity in intervention access and use, but also as one sees in Liberia, take action to ensure that strategies are in place to reach the poorest and most vulnerable segment of society.

The full 2017 Malaria Indicator Survey (MIS) results have been published for Tanzania providing an opportunity to look at the findings in more detail. Several important factors need highlighting since Tanzania is part of a regional block where some countries are activly considering malaria elimination – the E8 countries of the Southern Africa Development Community.

So far Tanzania has come close to achieving a target of 80% of households owning insecticide treated nets (ITNs) with 78% on the mainland and 79% in Zanzibar. A closer look shows that there is still a ways to go to get to universal coverage or at least one net for every two persons in the household. With this indicator 45% of mainland and 42% of Zanzibar households have met the target, meaning that there are unprotected people in a majority of households across the country. This indicator experienced a drop from a 2011 “high” of 56%, a drop to 39% in 2015 and a slight recovery to 45% in 2017.

Even the universal coverage target requires that people actually sleep under the nets. What the MIS report shows is that although 63% of people had access to an ITN, only 52% reported sleeping under one the night before the survey.

Equity remains an issue with 69% of households in the lowest wealth quintile owning at least one net compared to 81% and 83% in the middle and fourth quintiles. Although households in the highest quintile had 78% ownership, this group is more likely to live in better quality housing that prevents the ingress of most mosquitoes. Also residents in urban areas have an edge over rural counterparts in terms of net access.

The report show that 55% of children under 5 years of age and 51% of pregnant women slept under an ITN. This is down from 72% and 75% respectively in 2011.

We learn that 90% of existing nets were obtained through some form of public sector campaign including mass distribution (62%), village coupons redeemable at health centers (15%), and school campaigns (4%). Only 5% were obtained through routine services (ANC, child immunization) indicating that efforts to ‘keep up’ after mass campaigns need to be strengthened. The 10% of nets, whether treated or not, that were obtained in shops and markets cost the owner in the neighborhood of US$5.00.

Uptake of doses of intermittent preventive treatment for malaria in pregnancy has slowly but steadily increased over the past 15 years and stood at 83% for one dose, 56% for two doses and 26% for three in this most recent MIS. With the current target being three or more doses needed for optimal protection, Tanzania still has a far long way to go, especially considering that accessing ITNs through ANC services is also low..

Malawi has conducted four Malaria Indicator Surveys (MIS), with the most recent being in 2017. Such surveys are crucial tools for [planning and evaluating efforts by national control programs and their partners. Dr. Dan Namarika, Secretary for Health, Ministry of Health in the preface to the 2017 Report sums up the context and progress best, and so first, we have reproduced his narrative below.

Then we look at the example of the insecticide treated net (ITN) data as a way to guide future planning. The MIS format itself has seen improvements with much better color graphics in addition to the traditional tables. Some of these are also shared herein.

According to Dr Namarika, “Malaria is a major public health problem in Malawi where an estimated 4 million cases occur each year. Children under age 5 and pregnant women are most likely to have severe illness. The Ministry of Health, in collaboration with partners, has developed the Malawi Health Sector Strategic Plan 2017-2022, which articulates the priorities for health sector development in the next 6 years and prioritizes malaria. In line with that emphasis, the National Malaria Control Program has just finished the development of the National Malaria Strategic Plan 2017–2022 with the goal of scaling up malaria interventions to reduce morbidity and mortality by 50% in 2022.

“We strive for progress in achieving prompt, effective malaria treatment. We hope to improve access to early intervention and treatment by expanding village clinic services, using insecticide-treated nets, spraying inside residences, managing the environment, encouraging changes in social behaviour and communication, and preventing malaria in pregnancy. We have set for ourselves high targets for these interventions, and we are confident that we will achieve our strategic goals of halving the incidence of malaria and deaths, as well as reducing the prevalence of malaria and malaria-related anaemia.

“Surveys such as the current Malaria Indicator Survey (MIS) are essential measures of progress towards these goals. Without measurement, we can only guess about progress. The 2017 Malawi Malaria Indicator Survey (MMIS) is the country’s fourth nationally representative assessment of the coverage attained by key malaria interventions. Interventions are reported in combination with measures of malaria-related burden and anaemia prevalence testing among children under age 5.

“Overall, there has been considerable progress in scaling up interventions and controlling malaria. We noted a decline in malaria prevalence from 33% in 2014 to 24% in 2017. Insecticide-treated net (ITN) ownership has increased from 70% in 2014 to 82% in 2017.

“Results of the 2017 MIS also show improvement on use of intermittent preventive treatment during pregnancy (IPTp) by pregnant women age 15-49. Coverage has increased from 64% for two or more doses in 2014 to 77% in 2017. The percentage of women who took three or more doses of SP/Fansidar for prevention of malaria in pregnancy increased from 13% in 2014 to 43% in 2017.

“In addition, numbers of children receiving a parasitological test and artemisinin-based combination therapy continue to increase.

“These results represent the combined work of numerous partners contributing to the overall scale-up of malaria interventions. I would like to request that all partners make use of the information presented in this report as they implement projects to surmount the challenges depicted here.”

According to PMI, “The 2017-2022 National Malaria Strategic Plan (MSP) builds on the successes achieved and lessons learned during implementation of previous strategic plans.” The example of ITN targets is illustrative and is included in the target, “At least 90% pf the population use one or more malaria preventative interventions.”

So in addition to showing progress with ITNs, the MIS 2017 report also points to gaps that require strengthened intervention. While there has been an increase of household net ownership we can see in the graph that the target for universal coverage of 1 net for 2 people still needs work. We can also see in the graphs that equity remains a challenge with a lower proportion of poorer households owning a net. In addition net ownership is lower in the Central Region of the Country.

We learn from the graphs that having access to a net in the household does not guarantee that people will actually use or sleep under them. The tables show us that the traditionally defined ‘vulnerable groups’ like pregnant women (62.5%) and children below the age of 5 years (67.5%) were more likely to sleep under nets than household members in general (55.4%). The push towards universal coverage stresses that all household members contribute to the health, welfare and wealth of the family and should be protected from malaria.

Now we should Return the comments by Dr Namarika on the value of having MIS data. All endemic countries need to ensure their malaria data are up-to-date to ensure they use this information to keep their strategic plans on track to defeat malaria.

George Mwinnyaa grew up in a small village in Ghana, West Africa. “I witnessed the death of several people including my siblings and my father. I became a health volunteer and later a community health worker.” George presented at the Johns Hopkins University TEDx event on 10 March 2018. Below are excerpts from that talk focused on his experiences in malaria interventions in Ghana and reflects on numbers found in public health interventions and questions what these numbers really mean to community members on the ground. George is currently an MHS student studying infectious disease epidemiology at the JHU Bloomberg School of Public Health.

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I have always been very skeptical with numbers, particularly numbers that indicate program accomplishments from the developing world. Whenever I see numbers reporting a problem such as the mortality relating to malaria, Pneumonia, or diarrheal diseases- it puzzles me because these are all diseases that have received great attention, and there have been many interventions implemented. Yet these problems still exist, and the question is why?

Today malaria is still among the top causes of infant mortality in many African countries, including Ghana, yet we have mosquito nets, coils, sprays, long sleeved shirts that have been circulating in the country for years……and sometimes I wonder: why?

Total funding for malaria prevention and control was 2.7 billion dollars in 2016. Between 2014-2016, 582 million nets were distributed, of which 505 million were distributed in Africa, yet the number of malaria cases increased from 211 million in 2015 to 216 million in 2016 (WHO-malaria fact sheet, 2017).

I was once a supervisor for the distribution of long-lasting insecticide treated nets in rural communities. The numbers driven world saw big numbers that showed that many pregnant women were not sleeping under mosquito nets and so the solution to solve the malaria problem was to give them mosquito nets.

First, they started out by selling the nets and people would not buy them, then they offered them free to pregnant women and that did not change anything, next they distributed to families in a household and that did not change anything, and finally they implemented what is known as the hanging of long lasting insecticide treated bed nets.

This time we went into a house with a hammer, nails and ropes, and families showed us their bedroom and we hung the net for them. And yet malaria still rules. What happened with the free bed nets is now widely reported across different countries in Africa.
What do the numbers we measure mean to the people they represent?

As an example, there was a man in a small fishing village with seven children. His biggest worry was how to get food for his family. So the world of numbers develops numbers-based interventions, numbers-driven solutions. Reporters found months after the family received the mosquito nets that no one in the family slept under the mosquito nets; instead the man had sown the nets together and used them for fishing to feed his family.

Frustrations abound on both ends of the system, for public health agents and community members. Numbers act as the barrier between the two ends of the “system”, and our goal must be to break the barrier. The numbers that drive interventions can be meaningless to the community people they represent unless we engage the community and learn how our interventions can really help them.

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).

The 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 demonstrates 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.

For 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 indicators, 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.

Many 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.

In 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.

While 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.

Frequent 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.

Equity 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.

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).

Seven 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.