Nigeria Health Watch raises a point that could apply equally to malaria in children and pregnant women: “Maybe because they do not die in aircraft crashes, in gruesome fires following oil spills or in similar tragic circumstances no voice is raised in anguish about the Nigerian children that die from vaccine preventable diseases everyday.” They note that money is not the issue, because in the case of immunization, as funding increased in the 1990s the coverage rates decreased.
Nigeria Health Watch links us to the NIGERIA PARTNERSHIP FOR HEALTH 2008 November Conference in London to learn about why the health system has not stopped the deaths from preventable childhood diseases. Prof. Adetokunbo Lucas traced the history of the Nigerian Health Services and explained how it was initially established to protect colonial personnel, and one the side some locals might have been helped. Does that mentality persist – do only the elite get proper care? Prof. Lucas suggests several things that went wrong with the health system post-independence –
- PHC concept misunderstood: Primary care alone, Cheap, poor services
- Ignoring role of communities
- Federal, State Local government roles poorly defined
- Cost-effective interventions overlooked
- Failure of implementation
Another presentation by Fola Laoye of Hygeia (a community health insurance project) observed that malaria is the most common clinical diagnosis in Nigerian clinics. Hygeia believes that it is Necessary to seek alternative sources of financing and access to health care, shifting to demand-based and output driven schemes.” Such alternative health system models are important, but can they be taken to scale?
Finally Dr Abdulsalami Nasidi showed that malaria accounts for 24% of under-five child mortality in Nigeria. Unfortunately he did not think that the Nigerian health system had made appreciable progress since the return to democracy ten years ago and casts doubt on achieving the Millenium Development Goals. Dr Nasidi concludes as follows: “Nigeria continues to face several challenges in the efforts to deliver primary health care and child survival programmes includng routine immunization and polio eradication.” His reasons for this include –
- InadequateÂ levelÂ ofÂ financing
- WeakÂ managementÂ andÂ institutionalÂ structure
- LackÂ ofÂ integrationÂ ofÂ variousÂ componentsÂ ofÂ healthÂ wellÂ being
- PoorÂ coordinationÂ ofÂ variousÂ Stakeholders
- LowÂ levelÂ accessÂ andÂ utilizationÂ ofÂ healthÂ facilities
- PoorÂ resourceÂ allocationÂ andÂ management
- LowÂ levelÂ ofÂ communityÂ efforts
- InadequateÂ monitoringÂ andÂ evaluation
From the foregoing we have the diagnosis and some prescriptions for Nigeria’s health system. What we need is the political will to make the health system work to deliver malaria and other life saving and health promoting interventions.
For years the standard figure of malaria morbidity has been half a billion cases a year. Now, “The World Health Organization halved its estimate of the number of people who get malaria each year, saying Thursday that better measurement techniques had cut the number from 500 million people to 247 million.”
Previous figures apparently were based on estimates that mapped where people were likely to be exposed to malaria, but data collection is deemed to be more accurate in 2006, the most recent information as presented in the new World Malaria Report 2008.Â Even with reduced morbidity, “WHO left unchanged the figure of malaria deaths. An estimated 881,000 people were killed by malaria in 2006 â€” most of them were children under 5.” But even with better data, “Less than one-third of the agency’s 192 member countries have acceptable registration of malaria cases and deaths.”
Science Magazine cautioned that, “the report’s authors say that the drop isn’t a sign we’re winning the battle, just that the methodology of gathering data is better.” Health statistics are challenging. Science also noted that, “Determining the burden of malaria is notoriously hard because many patients don’t seek or receive medical attention, and even if they do their case may not be lab-confirmed or entered into government statistics. One result is that WHO’s numbers have huge error bars: For instance, the estimate for Kenya ranges from 5 million to 19 million cases.”
Robert Snow of the University of Oxford, U.K. and the Kenya Medical Research Institute in Nairobi was quoted by Science as sayingthat “WHO still relies too heavily on weak government data, resulting in too rosy a picture.” Fortunately donors are recognizing more and more the importance of strengthening malaria data and monitoring and evaluation (M&E) capacity in endemic countries.
The Global Fund offers M&E guidance and encourages countries to write into their proposals means for strengthening their health information systems. Countries do not always take full advantage of these health system strengthening components. Partners should therefore, continue to provide guidance and encouragement to countries to improve their M&S and health statistics so that the next World Malaria Report will truly reflect both reality and hopefully progress.
UNICEF reports that, “Fewer children under the age of five are dying today than in past years, according to the latest data from UNICEF. Globally, the number of young children who died in 2007 dropped to 9.2 million, compared to 12.7 million deaths in 1990.”
UNICEF explained that, â€œAs we are more successful in some ways, the task is a little harder. As coverage of basic services gets higher, the most underserved populations are sometimes the most difficult to access. To ensure further declines in child mortality in the future, UNICEF is calling for a greater focus on newborn and maternal health, as well as strengthening basic health systems in areas where young children are at risk.”
Reduced malaria deaths are part of the scenario. “Malaria in these parts (high burden) of Africa could however be substantially reduced using currently available tools. Examples of successful control are occurring in Africa where areas previously known for their high endemicity have become areas of relatively low transmission over about 10 years, including The Gambia, Zanzibar and some parts of Kenya. This reduction in malaria is often unrecognized by public health services or clinicians yet is a practical reality.”
Likewise Chambers et al. noted in April 2008 that, “Last month, WHO reported that cases of malaria in Rwanda decreased by 64% and deaths by 66% between 2005 and 2007 among children aged less than 5 years.2 Ethiopia, meanwhile, saw reductions of 51% in deaths and 60% in cases in the same age group. These remarkable outcomes were achieved through expanded access to malaria control, primarily long-lasting insecticide-treated bednets and artemisinin-based combination therapies.” The head of WHO’s Global Malaria Program was quoted as saying, “This is the first time we have seen these results with the new tools.”
Questions arise – how will the health system respond if large scale donor interventions in high burden areas continue to make improvements as seen in Rwanda, Ethiopia, Kenya, the Gambia and Zanzibar? Below are some possibilities. What do you think will happen?
- Replacement mortality will claim children if health systems do not address malnutrition and unsafe water supplies
- More surviving children may influence fertility decisions assuming the health system makes family planning commodities more readily available
- The health system will become complacent and relax malaria control efforts before achieving elimination, leading to rebound malaria mortality
Our recent discussions about health systems issues require that health system strengthening must be taken seriously if gains against malaria are to be sustained.
Today Memorial Day is being observed in the USA where the services of troops past and present are being remembered. Being in war exposes troops to more dangers than bullets and bombs. In fact war can increase malaria, among both troops and civilians through three main processes.
- movement of people – troops and displaced persons – into malaria endemic areas
- changes in local ecology that facilitate mosquito breeding and make malaria more prevalent
- disruptions of health infrastructure that limits or stops malaria control services
The effect of malaria on US troops exemplifies the problem. Records were available for Union troops during the US Civil War and documented 1.3 million cases and 10,000 deaths. Malariasite.com presents war related malaria deaths dating back to Alexander the Great, but more recently notes that “60,000 U.S. troops died in Africa and the South Pacific from malaria. U.S. Forces could succeed only after organising a successful attack on malaria.” During the Korean War “U.S. military hospitals were inundated with cases of malaria, with as many as 629 cases per week,” and in Vietnam “over 40,000 cases of Malaria were reported in US Army troops alone between 1965 and 1970 with 78 deaths.”
The Stars and Stripes news service reports the continuing threat of malaria to troops. Troops are still in South Korea, and South Korea’s own Center for Disease Control issued a malaria alert for northern Gyeonggi province where they are based. Several malaria cases have been documented according to a 15th September 2007 story, which also explained that, “None were provided with repellent-treated uniforms or mosquito nets, nor had he seen anyone issued military-grade skin lotion to protect themselves in an area known for malaria-carrying mosquitoes.” Another article titled “Afghan hazards include malaria as well as bombs,” shows the global reach of malaria when troops are spread across the world.
It is not surprising that the US Military has one of the most prominent malaria research centers in the Walter Reed Army Institute of Research. WRAIR is not modest in saying, “No organization in the world has WRAIR’s experience in the complete spectrum of malaria research. The rapidity with which malaria becomes resistant to new drugs drives researchers’ efforts to develop candidate drugs and vaccines. WRAIR has been extremely successful in developing and field testing antimalarial drugs, such as mefloquine, halofantrine, and tafenoquine, which provide treatment alternatives for drug-resistant strains. Scientists at one of the Institute’s overseas research facilities demonstrated the efficacy of doxycycline in the prevention of malaria.”
The fact that army research into malaria has civilian benefits does not justify war since war itself is a major perpetrator of the disease. To quote Randall Packard, “Developing nations also need to take a more active role in both preventing and limiting armed conflicts that disrupt economies, destroy health services, and contribute to the loss and displacement of millions of lives. The human tragedies of civil wars in Darfur, Rwanda, Cambodia, Tajikistan, and Colombia – to name a few – have all been made worse by the unleashing of malaria epidemics.”
The Washington Post reports today that “More than 100 million people are being driven deeper into poverty by a “silent tsunami” of sharply rising food prices, which have sparked riots around the world and threaten UN-backed feeding programs for 20 million children,” according to the director of the World Food Program (WFP). The article reports that the WFP is running out of funds and may cut back on school feeding programs.
The WFP Director explained that because of rapidly rising food prices, “Those living on less than $1 a day were giving up meat and vegetables, and those living on less than 50 cents were facing increasingly desperate hunger.” WFP food rations are depicted in the WFP ‘red cup’ photo seen below.
What are the implications for malaria?
In Mozambique, Bassat et al. (2008) found that. “For children aged eight months to four years, the risk factors [for dying from with malaria] were malnutrition, hypoglycaemia, chest indrawing, inability to sit and a history of vomiting.” In Tanzania Sunguya et al. (Tanzania Health Research Bulletin, 2006) found that, “coinfections [such as malaria] complicate the management of severe malnutrition and are associated with higher death rate.”
A review by Schaible and Kaufmann (2007) linked malnutrition with impaired immunity. They state that, “Malnourished children suffer in greater proportion from respiratory infections, infectious diarrhea, measles, and malaria, characterized by a protracted course and exacerbated disease. These malnourished children present with diminished functional T cell counts, increased undifferentiated lymphocyte numbers, and depressed serum complement activity.”
Whether the current food crises results from the international economic meltdown, global warming or diversion of food crops to make biofuels, the potential impact on mortality from malaria is serious. There has never been a greater need to link nutrition, agriculture policy and food aid with malaria programming. Vertical funding will not solve the problem.
The new series in The Lancet, “Who Counts?”, has serious implications for malaria programming and funding. Without being able to count the expected decreases in morbidity and mortality, program managers will lack the credibility to ask for continuing support. Ngozi Okonjo-Iweala and Philip Osafo-Kwaako explain that, “First, without adequate capacity for obtaining statistics, assessment of the magnitude of the development problems to be faced is often impossible. Second, if we get the numbers wrong, tackling development problems effectively is difficult.” They conclude that, “Governments and donors must view reliable data as an important tool in the development process, and must invest both financial and human resources in strengthening their statistical systems.”
Philip Setel and colleagues in the first of the “Who Counts?” series raise the question, “How much longer support for efforts to expand immunisation, and confront AIDS, tuberculosis, and malaria will last is questionable if counting the lives saved, and providing direct evidence of reduction of deaths due to these causesâ€”particularly in the poorest of the poorâ€”remains undone?” They worry that few countries in Africa have the capacity to measure the indicators for achieving the Millennium Development Goals, including those related to malaria and its effects on maternal and child health.
AbouZahr et al., in the fourth article in the series note that with new funding sources like GAVI and GFATM “pay particular attention to the importance of monitoring and evaluation, and could represent new opportunities to strengthen country capacities in vital statistics.” To this end the Global Fund provides a Monitoring and Evaluation Toolkit to grantees and their partners. This supports GFATM’s emphasis on performance based funding.
In the area of childhood immunizations GAVI is also “results oriented” and helps strengthen health systems to collect accurate country data. GAVI also has a Monitoring and Evaluation Technical Advisory Group. More Specific malaria monitoring and evaluation resources can be obtained from the Roll Back Malaria Monitoring and Evaluation Reference Group.
Two big challenges exist in order to make viable malaria M&E possible. First there is need to ensure that the existing health information system data collection processes – the forms, the registers, the summary sheets, the surveys – adequately and appropriately address key malaria indicators. Secondly, like in the HIV/AIDS ‘three ones’, there needs to be a unified malaria M&E system from community to national level that is used by all programs and partners – public, private and NGO.
UNICEF has just announced the results of surveys that show a major reduction in child mortality between 1990 and 2006. While it appears that immunization programs have contributed the most to this progress, the role of increased malaria intervention is important. According to UNICEF malaria currently accounts for 8% of child deaths worldwide, and to date insecticide treated nets have made the main contribution to mortality reduction. For example at present over 50% of households own at least one ITN in Malawi.Treatment is also becoming an important component, and since the start of the Global Fund to Fight AIDS, TB and Malaria and other partnership efforts is recognized. For example, to date the GFATM has helped to…
- finance 109 million bed nets to protect families from transmission of malaria, thus becoming the largest financier of insecticide-treated bed nets in the world
- deliver 264 million artemisinin-based combination drug treatments for resistant malaria
Dr. Robert Black of the Johns Hopkins Bloomberg School of Public Health stressed the importance of recognizing regional differences in tackling the challenge of reducing child mortality in the Washington Post. For example pneumonia remains a major force in South Asia, while Malaria is more of a threat to children in sub-Saharan Africa.
As seen in the attached chart from UNICEF at BBC News, child morbidity rates worldwide dropped from 55/1000 live births to 27 between 1990 ans 2006. It is in sub-Saharan Africa where the challenge of child mortality is the highest and where over half of child deaths occur. Malawi, for example, saw a fall in under-five mortality of 29 per cent between 2000 and 2004, and there were reductions of more than 20 per cent in Ethiopia, Mozambique, Namibia, Niger, Rwanda and Tanzania. So, while there were reductions in countries surveyed sub-Saharan Africa the problem remains unacceptably high.
We have addressed the issues of financing, partnership and political commitment before, but these are what it takes to solve the malaria problem. These somewhat hopeful results from UNICEF provide a further opportunity to encourage all partners take all actions needed to remove malaria from the list of major child killers in Africa.
Last week WHOâ€™s Global Malaria Program (GMP) launched its new guidance for Insecticide Treated Nets. Two key features of the guidance is the stress on providing free nets and the need to achieve total population coverage in endemic areas. The position paper begins by stating that the three primary interventions to be scaled up for effective malaria control include:
- diagnosis of malaria cases and treatment with effective medicines;
- distribution of insecticide-treated nets (ITNs), more specifically long-lasting insecticidal nets (LLINs), to achieve full coverage of populations at risk of malaria; and
- indoor residual spraying (IRS) to reduce and eliminate malaria transmission.
Nowhere in the document, let alone in this highly visible opening paragraph, is there mention of Intermittent Preventive Treatment/Therapy for pregnant women (IPTp). Thus, once again the GMP misses an important opportunity to stress a crucial and well proven intervention to protect the lives of pregnant women, their unborn babies and newborn infants from morbidity and mortality from the most dangerous form of malaria, P. falciparum.
A recent review by ter Kuile et al., has shown once again, that even in areas where there is up to 50% resistance to sulfadoxine-pyrimethamine (SP) in small children, IPTp with SP is still efficacious in controlling maternal malaria and reducing both maternal anemia and low birthweight in newborns.
We are not sure why the GMP itself has high levels of resistance to acknowledging the lifesaving effects of IPTp, and regret the poor example being set by a leader in world health. Fortunately other major development partners who actually have money to spend are still willing to help countries that suffer from malaria by supporting IPTp.
Recently we commented on an article in the Bulletin of WHO concerning fertility and equity.Â Now a manuscript by Conley, McCord and Sachs look specifically at the relationship between malaria and excess fertility (see attached map on total fertility rates in 2003 from WHO).Â They note that, â€œMuch of Africa has not yet gone through a â€˜demographic transitionâ€™ to reduced mortality and fertility rates.â€ They found that, â€œchild mortality (proxied by infant mortality) is by far the most important factor among those explaining aggregate total fertility rates, followed by farm productivity. Female literacy (or schooling) and aggregate income do not seem to matter as much, comparatively.â€
Maternal malaria is also implicated when they note that, â€œThere is some evidence that malaria may reduce lactation period, which might increase fertility through decreased child spacing. Likewise, malaria in pregnancy is also associated with low birthweight and increased neonatal and infant mortalityâ€”which is in line with our models.â€
They conclude that, â€œThis is where the theory of the demographic transition started: save the children and families will choose to have fewer children.â€Â They do explain that the transition time between reduced infant and child mortality and reduced fertility may take a generation or two.Â The lesson here is that increased fertility may in fact be an inequity caused by child deaths, especially from malaria, and that family planning alone will not address this imbalance.
Malaria is holding back the demographic transition and economic development in Africa.Â An investment in treating and preventing malaria in women and children will have long term benefits.Â International donor programs like GFATM, World Bank Booster and PMI can help start the process of reducing mother and child mortality, but the effect on fertility and economic development will require a long term commitment by governments in endemic countries. There is no room for complaints about the cost of ACTs and LLINs!
Advocacy for strengthening malaria in pregnancy control programs is founded on the assumption that malaria is an important cause of both maternal morbidity and mortality as well as child/birth outcomes. UNICEF has recently undertaken work in India to pinpoint more accurately the various causes of maternal deaths. According to The Hindu Newspaper, “The Maternal and Perinatal Death Inquiry (MAPEDI) or the social audit â€” also known as verbal autopsy.” The survey in West Bengal found that, “Of the 106 maternal mortalities reported … Fifty one per cent deaths were due to direct obstetric causes like bleeding, infection, eclampsia, and obstructed labour, 27 per cent due to indirect causes like anaemia, malaria, hepatitis, tuberculosis and cardiac, while 22 per cent died due to other causes.”
Measurement of exact cause of death in rural and poor communities can be difficult. Sometimes the association between maternal mortality and malaria is circumstantial. Romagosa et al. found in Mozambique that maternal mortality followed the same seasonal pattern as malaria illness. They reported that malaria accounted for 23% of maternal deaths.
A new study published by Fortrell et al., has shown the challenges of obtaining reliable and valid data on maternal deaths that might be malaria. These challenges included among others 1) a general underestimation of malaria in pregnancy, 2) difficulty in distinguishing clinically among febrile illnesses, and 3) HIV and malaria co-infection. Different models and approaches, including verbal autopsy, to analyzing death data in Burkina Faso yielded widely varying estimates of the cause specific mortality fraction for malaria from 10% to nearly 25%.
These efforts show that malaria is certainly a factor in maternal mortality. Continued research support is needed, as explained in the UNICEF study for, ” providing an understanding of the contributing factors that can be used by decision-makers and stakeholders to address obstacles to quality obstetric care and to identify ways to prevent avoidable deaths.”