If 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.Â 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 Hâ€™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.Â 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.
Wen Kilama of the African Malaria Network Trust brought a challenging idea to the malaria researchers gathered at MIMâ€™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.
His 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.Â 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.Â 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.Â 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.Â 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.Â 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.
In villages of southeastern Nigeria, Uguru and colleagues found that mosquitoes do not discriminate by socio-economic status (SES), but SES does influence where people go for treatment once those bites result in malaria. “In one of the villages the most poor, very poor and poor significantly used the services of patent medicine vendors and the least poor visited hospitals.”
Expenditure to treat malaria did not vary by SES group and ranged between US$ 1 – 3, with transport costs being less than a dollar.Â The difference therefore, was that the poor paid proportionately more for their treatment than co-villagers who were least poor.Â Treatment options sought by each group also introduced possible differences in quality of care, too.
As the World Malaria Report of 2005 observed, “Patterns of malaria transmission and disease vary markedly between regions and even within individual countries. This diversity results from variations (in) … conditions that affect malaria transmission and socioeconomic factors, such as poverty and access to effective health care and prevention services.” Because of this, “Malaria control is increasingly recognized as playing a key role in poverty reduction in high burden countries.”
Clearly, people in the villages studied do not have access to cheap or free appropriate malaria medicines, although Enugu State, where the study occurred, has been included in the Global Fund Round 4 Malaria grant in Nigeria. Initially GFATM malaria medicines covered only children less than five years of age who attended government health facilities.
Nigeria has recognized the weakness of a strictly public sector approach and is now making malaria medicines available through both public and private sector sources, particularly the medicine shops frequented by the poor as described in Uguru’s study.
The Society for Family Health (SFH) in Nigeria, with USAID support, has spearheaded an effort to make quality prepackaged antimalarial drugs available cheaply through private sources, such as medicine shops.Â Now that SFH is involved with the Global Fund grant in Nigeria, there is hope that this distribution network can be strengthened to reach more people – especially the poor who find it difficult to access formal health services in either the government or the private sector.
There is still a long way to go to achieve universal treatment coverage among the 140 million plus people in Nigeria, but a mixed sector strategy seems to be a good way to start.