Tropical Health Matters

The New Vision reports that, “ALL Ugandans will be given free insecticide-treated mosquito nets, the health ministry has said, adding that their distribution will start in September,” according to government officials. The is is keeping with the United Nations drive to achieve universal net coverage by 2010.  Could this approach have any downsides?

Karen Grepin has observed that after free net distribution in Ethiopia, “the private distribution channels that existed before this distribution programs suffered major set backs. No one needed to buy a net anymore, so no one did. Importers stopped importing nets, distributors stopped distributing nets, and retailers stopped selling nets. Selling bed nets was no longer good business.”

Karen is not suggesting that nets should not be provided free, she does feel that, “donor funds (could have) been used to purchase some of the nets from local distributors, using local channels, than the networks might have been saved – even rewarded for their efforts.”  Without these local sources, Karen asks how people will buy additional and replacement nets.

This problem gets at the heart of the challenge of undertaking both catch-up and keep-up net distribution strategies.  Without alternative sources of net supplies, we may not be able to keep up with need in case donor program money does not flow continuously.

Up until recently net delivery strategies in Africa are categorised as public, private or mixed. Voucher schemes that include a public sector subsidy and private sector distribution are a good example of the mixed.  Voucher schemes have never been touted as a solution to universal coverage, but now they are being made redundant by mass or universal distribution.

Campaigns are needed, especially if they can guarantee that people actually use the insecticide-treated nets they receive, but if they kill local business as well as mosquitoes, we have cause to worry.  Malaria itself created economic burdens, and we don’t want malaria control to add to the burden.  Local net production can benefit from campaigns if governments buy and distribute these local ITNs.  Keeping local net production and sales alive can benefit the keep-up strategies, especially in these days of unxcertain economic and donor vitality.

Nigeria’ drive to achieve universal net coverage campaign – two per household – just wrapped up its first effort with over 2 million LLINs for 21 of the 44 local government areas (LGAs) in Kano State. Distribution in the remaining LGAs will occur later. All the partners were on board, and many lessons were learned – some quite unexpected.  This is the first step in distributing 22 million nets in 12 states before the end of 2009 and 60 million in all states by the end of 2010.

The scheme started at the household level with the provision of two net vouchers. People were told to present these at one of the 2-4 distribution points in their ward over the upcoming two weeks.  UNICEF introduced a unique SMS tracking system to monitor the net distribution that provided clues where there more or less vouchers than expected and where efforts to increase or shift commodities were needed.  This system apparently worked well in the rural areas, but complications arose in the urban communities.

There was a rush for nets at some distribution points with people fearing that supplies of something free would not be adequate, so the sooner one claimed his/her nets the better.  In addition some people, variously termed traders and hooligans thought that this would be an ideal way to make a profit and raided distribution points, stealing the nets they could carry away.  Some obverses termed what happened as a ‘riot’ or a ‘stampede’, while others spoke of teargas. Unconfirmed injuries were also rumored. Security was not adequate for this unexpected ‘net-frenzy.’

At a point the exercise was suspended for a couple days. Additional police were provided, and eventually those with vouchers were served.  The LLINs were packaged kust like those already on sale in some shops, and so a suggestion for future distributions that would reduce the enticement of theft would be branding of those nets provided free by the malaria partners.  Another suggestion is to use the community directed approach to distribute the nets by local volunteers right to the households.  If vouchers can be distributed to the household, so can LLINs, and that way distributors would see the actual house and its inhabitants and could engage immediately in education on proper net use.

Net use is the big remaining question. People certainly rushed to get the nets, whether for legitimate needs or not. The question is whether a few months for now one will see these nets hanging on beds in the various households and see vulnerable groups – small children and pregnant women, actually sleeping under them.

Anambra State is gearing up to distribute nearly 1.8 million nets in June. Hopefully Anambra will have adequate community involvement, good distributor training, detailed supervision, strong security and culturally relevant health education to prevent ‘stampedes’ and ensure real universal coverage.

Malaria-related headlines have focused on Rwanda, Ethiopia and Zanzibar where it has been possible to work in a relatively focused area to bring about large malaria program impacts.  Efforts in Mali have slipped under the radar according to Claudia Vondrasek, The VOICES field operations coordinator based in Bamako.  Claudia shares results from a Mali national survey conducted by HealthBridge Canada in Aug 2008 that have now become available.  Net progress is substantial.

• 81.1% of households with at least 1 ITN
• 78.5%  children under 5 years of age slept under a net the night before
• 96.3% of children under 6 years of age slept under a net in households with at least 1 ITN
• 73.9% of pregnant women slept under a net the night before

Two important trends to mention – Not only are we closing the gap in Mali to achieve 2010 LLIN targets (80% use nationally) in Mali, it looks like many countries are making great strides on their way to reaching those targets in recent years. This is mainly due to a sustained commitment by the international partnership to support National Malaria Control Programs to achieve 2010 RBM targets of 80% coverage of key interventions.

The other less heartening trend is the lag time being recorded between grant approval, signature and Phase 1 disbursement.  Many suspect this is a function of evaporating resources available for GF grants.

Progress in Mali has been building for the past two years.  The US President’s Malaria Initiative has played a key role in “a unique public-private partnership with the American Red Cross, the International Federation of Red Cross and Red Crescent Societies, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and others, the President’s Malaria Initiative (PMI), through USAID, provided $1 million for the purchase of 169,800 long-lasting insecticide-treated mosquito nets (LLINs) as part of a national child survival campaign in Mali conducted in December 2007.”

There is even more to this partnership. Other key members “include ExxonMobil, the Measles Initiative (The United Nations Foundation, WHO, UNICEF, the U.S. Centers for Disease Control and Prevention, … the Canadian Red Cross/Red Crescent Societies, Malaria No More, Nothing But Nets, Major League Soccer (MLS), the Women’s National Basketball Association (WNBA), Malian government agencies, numerous local nongovernmental and faith-based organizations, … Assistance Technique Nationale Santé/USAID, the Mali Red Cross, … Helen Keller International, the Ministry of Social Development, Solidarity and the Elderly, the National Federation of Community Health Associations, Population Services International, the Network of Traditional Communicators, and journalists from local media.”

It is important to note that partner efforts went beyond the campaign in 2007, and continued to encourage people to USE the nets that they had received.  Partners must continue their efforts toward the universal coverage targets and the reduction of malaria morbidity and mortality envisioned in the Millennium Development Goals for 2015.

The Malaria Atlas Project (MAP) has been working hard over the past several years to assemble what is known – published and unpublished – about the distribution of malaria around the world.  A press release notes that now, “The most detailed map ever created of malaria risk worldwide is published today by an international team of researchers funded by the Wellcome Trust. The Malaria Atlas Project (MAP) will be a powerful tool for helping target malaria control programmes and suggests that elimination of malaria in three-quarters of the world’s at-risk areas might be less difficult than previously thought.”

The Executive Director of the Global Fund has stressed the importance of MAP in helping donors like GFATM measure and count progress of their investments: “We need to increase the information available to us and to our donors to demonstrate that investing in malaria control does indeed reduce the numbers of people at risk worldwide. With this kind of information, we can reassure donors by graphically showing progress and highlight where further investments are most needed.”

While the publication of the 2007 MAP in this month’s PLoS Medicine marks a culmination in efforts to locate Plasmodium falciparum in the world, it is also a baseline for future updating.  The team now wants to map vivax malaria, too. In addition, the team has been publishing findings in over 30 scientific articles since 2004.

A particularly instructive publication concerned comparison of ITN coverage compared with levels of malaria endemicity and poverty. They documented that areas with some of the highest levels of malaria as well as largest burden of disease have some of the lowest levels of net coverage.  Nigeria was a case in point where its large population accounts for 25% of the children at risk in stable transmission areas of Africa and yet its net coverage was projected at 4% for 2007.

Another important finding from the net study was the clear indication that net distribution mechanism affected coverage.  The best coverage was achieved where nets were free, followed by areas with subsidies. The lowest coverage figures were found in areas where nets were made available through the commercial sector.  Such information about distribution strategies and coverage can help national program planners.

The continued success of MAP depends on researchers and program managers in endemic countries.  Data need to be shared on a regular basis so that the malaria maps can be updated and national and international partners can better target their interventions.  Researchers and program managers with up-to-date malaria information are encouraged to share their results with the MAP team at map@zoo.ox.ac.uk.

Review of surveys from 15 countries shows that, “Within ITN-owning households, many children and pregnant women are still not using them. Between-country analysis with linear regression showed child ITN use increases as intra-household access to ITNs increases,” according to Eisele and colleagues. They note further that –

Results from within-country logistic regression analyses were consistent with between-country analysis showing intra-household access to ITNs is the strongest and most consistent determinant of use among children. The gaps in ITN use and possession will likely persist in the absence of achieving a ratio of no more than two people per ITN.

The Roll Back Malaria Partnership asserts that, “To achieve universal coverage, countries must go beyond the procurement and financing of interventions to ensure that the products can reach every person at risk.” Calls for universal coverage have been simplified to two nets per household.

Many households in Africa contain between 5-6 people. Are two nets enough to ensure vulnerable groups are covered? If one generously estimates the population of pregnant women and children under fiver years of age to be 25%, then yes, two nets may suffice. But what really happens in terms of intrahousehold allocation of valuable resources?

Again Eisele et al. suggest that, “Countries should aim to achieve greater than one ITN per household to ensure adequate intra-household access for children and pregnant women.” They realized that having a net does not guarantee its use, but the more nets there are in a household, the greater likelihood that vulnerable groups have a chance at being protected. Specifically they recommend that –

Once intra-household access to ITNs is attained, the remaining gap between ITN use among children and pregnant women within households possessing them may be minimized further with behavior change communication campaigns.

BCC alone will not solve the problem – communities must be actively involved in their own net distribution and use promotion programs.

The buzz about the 2008 World Malaria Report (WMR) has been largely centered around the recalculation and subsequent reduction of annual morbidity estimates. Some good news identified 10 countries including some in the Mediterranean and Middle Eastern area that are close to elimination.

At the same time concerns about coverage have surfaced. Leadership News of Abuja explained that, “The report, however, noted that much more work remained to be done. ‘In Africa , only 125 million people were protected by bed nets in 2007, while 650 million are at risk.'”  One of the challenges with the figures is that the 2008 WMR draws primarily on 2006 data.

That being the case, it is only fair to judge progress toward the Abuja goals and indicators in the WMR based on the 2005 target of 60% coverage.  MICS or DHS data from 2006 were available in the WMR Annex concerning whether children under five years of age slept under an insecticide treated net for 17 African countries.

The attached chart gives a sobering perspective on the Abuja targets.  In 2006 reports none of the 17 countries had achieved the desired 60% of these children having slept under an ITN the night before the survey.  The figures ranged from a low of 6% in Cote d’Ivoire to 49% in the Gambia.  Half of these countries achieved 20% or less.

Great strides continue to be made in distribution and use of ITNs and other malaria interventions, but clearly the Abuja targets served more as an inspiration than a realistic goal.  The Global Fund in June of this year reported a doubling in the numbers of ITNs distributed. The United Nations has called for universal coverage.  The pressure mounts.  Will donors and endemic-country governments be up to the task of reaching 80% coverage by 2010 – which is a quadrupling of the 2006 figures in Africa?

People are creative. People designed and produced a bednet that was impregnated with insecticides in order to prevent malaria. Other people look at these nets and think of their own ‘creative’ ways to deploy them.

A case in point was just published in Malaria Journal. Minikawa and colleagues visited the shorelines of Lake Victoria in Kenya and found that LLINs and non-treated nets were being used to catch and dry fish.  They provided pictorial evidence as seen at the right. Specifically at seven villages 283 nets were being used to dry fish and 72 were used for fishing.  Most of these nets (84.5%) had been obtained free or at subsidized rates from health centers and NGOs, while the remainder were bought in the market. These nets accounted for 44.4% of the area of drying sheets spread in these villages. Fishing nets and papyrus mats made up the rest of the drying surfaces.

The three most popular reasons for using bednets to dry fish were: fish dry faster on these nets, they don’t stick and not surprisingly, these nets are cheaper.

A total of 220 nets, both LLIN and not, were found in the 111 houses of these seven villages. In contrast to the bednets used for fishing/drying, most (60%) of these had been purchased in the market. The total bednets found in homes were almost enough to meet coverage targets of two per household, and the 145 LLINs were definitely enough for use by the 70 children under five and estimated 20 pregnant women in these villages. But this still does not resolve the ethical issue of providing free or low cost nets to communities only to find them diverted.

Net stories include use for fishing in Zambia, as bridal veils in Zambia and other countries and trapping edible ants in Uganda. These problems arise when LLIN distribution programs focus on the wrong numbers. It is not enough to say how many hundreds of nets have been distributed in a community. The real concern is whether they are used correctly and for the intended purpose.  Maybe in the Kenyan case there were too many LLINs given without attention to actual population.

More than likely the bednets for villages along Lake Victoria were distributed without community involvement and follow-up.  Local leaders and volunteers should take part in the process so they can remind people about appropriate use, help people install the bednets correctly in their homes and monitor actual bednet use.

Tanzania has three main ITN distribution mechanisms, the commercial market, a voucher system for subsidized net purchases and free nets distributed during campaigns. Khatib and colleagues found that, “All three delivery strategies enabled a poor rural community to achieve net coverage high enough to yield both personal and community level protection for the entire population. Each of them reached their relevant target group and free nets only temporarily suppressed the net market, illustrating that in this setting that these are complementary rather than mutually exclusive approaches.”

Different distribution strategies reached different groups: vouchers and free nets were more likely to be obtained for young children, while nets purchased at market price were more likely to be obtained for adults. In the study district, “Net use was 62.7% overall, 87.2% amongst infants (0 to1 year), 81.8% amongst young children (>1 to 5 years).” This process appears to have enabled achievement of RBM 2010 targets as early as 2006. Technically since LLINs were not introduced until after the study and some of the ITNs had not been treated in more than six months, the coverage results are not a perfect match for the RBM target, but they do indicate that products can actually be put in place for a large portion of the population.

Another important aspect of the complementarity of the strategies was, “Provision of nets at no cost through the public sector did not compromise the viability of either the voucher scheme or the commercial market.”

While the authors explain that a number of strategies are available to the National Malaria Control Program, it does not appear that the NMCP actually sat down with partners to plan how to achieve coverage using a multi-strategy approach. The results in a way appear to be that of a ‘natural experiment,’ i.e. that it just so happens that three different approaches were in place at the same time in the same district.

We discussed the involvement of the private sector yesterday, and this Tanzanian example reinforces the points made. The challenge is getting partners to sit down together and ensure that coordination happens – that one district does not get only free net distribution while another depends solely on vouchers. Planning is needed to ensure that each strategy reaches its appropriate audience depending in part on service utilization patterns and ability to pay.

The US President’s Malaria Initiative has certainly been able to work with partners, such as national malaria control agencies with GFATM grants, to boost coverage with major malaria interventions. A success story from Mali was posted on the PMI website for World Malaria Day as an example. The story reports –

According to survey results announced by the Malian Ministry of Health, 88 percent of households in Mali and 80 percent of children received an LLIN during the campaign. Usage of LLINs by vulnerable groups is also high. Some 63 percent of households surveyed declared using LLINs the previous night. Some 51 percent of all under fives included in the survey were reported to have slept under an LLIN the previous night. This is a significant increase from 27 percent of children under five reported to have slept under a treated net from the 2006 DHS survey in Mali.

This is certainly a major logistical effort and bodes well for promises by the UN to achieve 100% coverage by 2010, but we are still concerned that owning a net does not always mean using it. Stories abound about ‘alternative’ net uses ranging from fishing to wedding gowns to keeping in a trunk as dowry. None of these protect people who need to be free of malaria.

As we have advocated, there needs to be a strong health education component using local/community people who speak in a language people understand and can be on the spot to encourage net use. Mass media may reinforce use, but the personal touch is needed to ensure use.

World Malaria Day is time for hope, and the United Nations Secretary-General, Ban Ki-moon, is not disappointing. The BBC reports that, “In a video message for a UN World Malaria Day event, the Secretary-General announces an initiative offering household sprays and bed nets treated with insecticide “to all people at risk, especially women and children in Africa” by the end of 2010.”

This is an almost unbelievable though desirable goal, much over the 80% RBM targets for 2010. The Secretary-General prefers to call this goal “bold, but achievable.” Even with help from GFATM, PMI, the World Bank Booster program, UNITAID and others, many countries are struggling to meet the 2005 target of 60% coverage of vulnerable populations with ITNs and medicines. The new UN malaria envoy, Ray Chambers has done the math –

• 500 million additional people
• 250 million additional ITNs/LLINs
• less than 1,000 days to achieve this
• “That’s four-to-five times what we’ve done in the past”

While this effort will push us toward eradication, Chambers is realistic in stating that the goal of complete elimination of the disease will depend on vaccine development, which is still some years away.

Reuters News also adds a note of realism by quoting a statement from the U.S. National Institutes of Health which said that malaria has proven to be “remarkably resilient, resurging because of the emergence of drug-resistant parasites and insecticide-resistant mosquitoes.” Reuters also mentions the unknowns created by global warming for consideration. These concerns add a sense of urgency that simple mentioning of 2010 may not confer.

Ironically, targeting these new malaria intervention and coverage goals comes on the heels of concern that African countries, where malaria is endemic, are unlikely to meet the Millennium Development Goals, which include malaria reduction. Clearly there are serious challenges in terms of finance and health systems issues to achieving universal overage in under 1,000 days – we hope all partners will heed this challenge on World Malaria Day and work together to meet it.