Tropical Health Matters

The Malaria Communities Program (MCP) of the US President’s Malaria Initiative gives non-governmental organizations a chance to make an impact at the local level in 15 endemic countries. Ronald Apunyo of Medical Teams International provides us an update on MCP activities in Uganda.

The Malaria Communities Project in Uganda is currently being implemented (With funding from USAID) in Lira, Otuke, Alebtong and Dokolo Districts, part of the Lango sub-region of northern Uganda, with a population of approximately 765,458 and 166,190 households. Primary beneficiaries include 159,895 children under five years of age and 39,578 pregnant women.

According to a recent report from the World Health Organization, Uganda has the world’s highest malaria incidence, with a rate of 478 cases per 1000 population per year. Malaria is the leading cause of morbidity and mortality in Uganda and is responsible for up to 40% of all outpatient visits. Malaria is the leading cause of morbidity and mortality nation-wide, and is particularly high in the northern region, where Dokolo and Lira Districts account for 54% of the sub region’s malaria cases and only 46% of the population.

Northern Uganda is a transitional environment, and communities are in the process of resettling in their ancestral lands after 20 years of insecurity and internal displacement due to attacks from the “Lord’s Resistance Army.” The project has endevoured to fill gaps identified in Uganda Malaria Control Strategic Plan by meeting training, support and supervision needs for VHTs who have been trained by MOH and by strengthening community-level behavior change and health promotion efforts to complement PMI and National Malaria Control Program (NMCP) broader malaria prevention interventions.

The project has had two years of uninterrupted implementation in all the Sub-counties of Dokolo district, in the past two years (Since 2009/10). The project focuses on reducing malaria-related morbidity and mortality among pregnant women and children under 5 years of age in the project areas by

1. Increasing the percentage of pregnant women and children under 5 years of age sleeping under an LLIN each night.
2. Increasing the percentage of pregnant women who receive 2 or more doses of IPTp during their pregnancy
3. Increasing the percentage of children under 5 years of age with suspected malaria who receive treatment with ACT within 24 hours of onset of symptoms

A review of Dokolo district Health Management Information System between 2006/7 and 2010/11 indicates an improvement in some of the key projects target indicators pertaining to ANC attendance by pregnant women, new malaria cases in OPD IPTp uptake and stockouts of key medicines.

SUCCESSES

• There is a steady increase in ANC fourth visit in Dokolo district since project start in 2009/2010.
• Proportion of Pregnant women receiving IPTp2 increased from 60% to 69% between 2009/10 and 2010/11

LESSONS LEARNED

The successful use of Social and behaviour Change communications interventions in malaria control should be coupled with reliable supply of malaria commodities at the health facilities inorder to attain satisfactory results.

Use of community volunteers like female VHTs at the ANC to mobilize and conduct less technical work like providing clean water to pregnant women,observing Directly observed treatment (DOT), carrying out health education sessions and providing other support to pregnant mothers at the health units greatly reduces workload of health workers as well as waiting time of pregnant
women during ANC (a key reason why pregnant mothers do not attend ANC).

The role of community structures like the village health teams (VHTs) has made significantly positive contributions towards the fight against malaria within the communities.

Today I shared a link to a new publication on the Tropical Disease Research (TDR) website entitled, “Community case management of malaria in urban settings,” to members of our Malaria Update Listserve (see link at right).  A major conclusion from the multi-country study in Burkina Faso, Ethiopia, Ghana and Malawi was …

The use of the ACT (Artemisinin-based Combination Therapy) unit dose pre-pack is feasible and acceptable. When CMDs (Community Medicine Distributors) are properly trained, the community is properly sensitised and pre-packed drugs are provided either free or sold at an affordable cost, the quality of services delivered by CMDs and adherence by caregivers are similar to those seen in rural CCMm settings. The proportion of cases seen by CMDs, however, tended to be lower than was generally seen in rural CCMm. Urban CCMm is feasible, but it struggles against other sources of established healthcare providers.

One member of the listserve responded by raising a question about access and quality to malaria treatment services in urban settings. Jim Ricca from Jhpiego’s office in Maputo made the point that …

I’m interested to know why CCM was done in an urban setting where geographic access should not be a problem. If other access issues were a problem for people using facility-based services (e.g., cost, cultural/linguistic barriers), then I wonder why these barriers to use of facility based services were not addressed instead of moving to community-based services.

In places I’ve seen CCM implemented, the planners took great pains to do a situation analysis beforehand to see where there were geographic access problems for use of facility-based services and it was there that the CCM services were implemented. As much of an advocate as I am of community-based services, if CB services are the answer for ALL the shortcomings of the current health system, is there any sense having facility-based services at all?

TDR has led the way in operational research over the years and has been trying out community engagement strategies or community directed interventions (CDI) in a variety of settings – rural, urban, nomadic, migratory, etc. The question about the value of CDI when one could hopefully improve the quality of existing health services is certainly valid. But a basic question has been whether the willingness of rural community members to volunteer will work in urban areas where ‘community’ is much more diffuse. Even if the CDI approach does not translate culturally into diverse, anomic urban settings, access to care in urban areas, there are other challenges such as the plethora of provider types.

Jim is right that there have been studies about urban access that show geography is not the main issue – there may be social and financial barriers as well as perceptions of quality barriers.  To complicate the picture these issues must be addressed not only in the public sector but with private clinics and patent medicine shops.These private formal and informal sources usually provide desirable options like convenient hours, convenient locations and the ability to purchase on credit that the public sector does not.

While these private provider must be considered in any effort to improve the quality of health care in urban areas, they are also elusive. From experience in Nigerian cities, I can vouch that registries of private clinics and medicine shops are out of date and incomplete.  These entities may fail to register in the first place, move location or go out of business, and noe one seems to be responsible for updating the list.  In Kaduna, for example, an effort to study medicine shops started with a state ministry registry of 200 shops for the whole state and found by going street by street over 500 shops in one half of Kaduna alone. These providers too need to be considered as part of the total picture, and quality assurance mechanisms must be extended to them -if only we can find them.

So the answer to the basic question – is community volunteerism in the delivery of health services really necessary in urban area? – does depend not only on whether the volunteer spirit works in an urban setting, but whether quality services are already or potentially accessible thus, negating the need for community members delivering services.

A different model may be appropriate – that is the Community Navigator. Such a volunteer would help community members find the right care and get there. The Navigator could also serve as a patient advocate once she or he arrives at the point of service with their neighbors in tow.

Urban and rural settings differ dramatically in terms of culture, economy and social structure – we need to find the right community engagement model for each.

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The Cambodia Demographic and Health Survey 2010 report is now available for download.

Surprisingly little information is available about malaria.  The following narrative on ‘fever’ was provided:

“Less than 1 percent of children with fever received antimalarial drugs, whereas 44 percent received antibiotic drugs. Use of antibiotic drugs was more common in urban areas (52 percent) than in rural areas (43 percent) and more common among mothers with at least a secondary education (54 percent) than among mothers with no schooling (39 percent). Mothers in Prey Veng (85 percent) and those in Kampong Chhnang and Kampong Speu (79 percent in both) were most likely to use antibiotic drugs to treat fever.”

We note that Cambodia is a place where artimisinin resistance has been suspected and yet these DHS results do not diagnose malaria with RDTs as is done in other DHS and MIS surveys. Therefore, appropriate treatment cannot be ascertained from the results. This is made more complicated by the following list of appropriate and inappropriate medicines in the survey instrument that were lumped together under the title “antimalarials”: SP/FANSIDAR, CHLOROQUINE, QUININE, MALARINE, A+M, MEFLOQUINE, ARTEMISININ, ARTESUNATE TABLET, ARTESUNATE SUPPOSITORY, ARTEKINE, COTEXIN.

While the report mentions…

“Iron and folic acid supplementation and antimalarial prophylaxis for pregnant women, promotion of the use of insecticide-treated bednets by pregnant women and children under 5, and six-month deworming for children are some important measures used to reduce anemia revalence among vulnerable groups…”

… it does not report on bednet use.

RBM partners are trying to take the problem of malaria in Asia seriously. They would be assisted by better data on the malaria situation in countries like Cambodia.

At present artemisinin-based combination therapy medicines for malaria are our best hope for treating malaria and have the added benefit of reducing parasite transmission.  If these drugs lose their power, we are in trouble; hence there is need for continued testing to ensure that drug efficacy remains high.

The Nigeria National Malaria Control Program has just circulated its latest malaria drug testing results. All endemic countries should see this as a model for their own continued monitoring of malaria drugs.

A total of 747 children were enrolled in the two treatment arms – artemether-lumefantrine and artesunate-amodiaquine. The sample was drawn from investigations at seven sites in different geographical settings.  Below we find the main points as summarized in the Executive Summary.

1. The Therapeutic Efficacies of two Artemisinin-based Combination Therapies (ACTs) – Artesunate-Amodiaquine (AA) and Artemether-Lumefantrine (AL) were evaluated in 724 children <5 year-old drawn from 7 sentinel sites; Lagos, South-west, South-east, South-south, North-central, North-west and North-east located in 6 geographical zones of Nigeria.

2. All children recovered clinically from their illness. Fever clearance was significantly faster in children treated with AA than in those treated with AL (1.19 ± 0.49 versus 1.33 ± 0.7 d, P= 0.006).

3. Compared with AL, AA significantly reduced the proportion of children with parasitaemia 1 day after treatment began (P=0.016), but parasite clearance times were similar in AA- and AL- treated children (1.13 ± 0.4 versus 1.11 ± 0.34 d, P= 0.47).

4. Overall, adequate clinical and parasitological response (ACPR) on day 28 was 97.4%, and was similar for both AA (95.1%) and AL (96.3) P=0.108). Early treatment failure occurred in one child treated with AA.

5. Overall, PCR-corrected parasitological cure rate on day 28 was 98% and was significantly higher in AA- than in AL- treated children 99.1% (343/346) versus 96.9% (311/321), P=0.048. The cumulative probability of a reappearance of asexual parasitaemia after treatment with AA or AL were similar (Log-rank statistic = 0.027, P=0.869)

6. Recurrent infections were not age or drug dependent. Overall, recrudescence occurred in 5.3% of the children (38 of 711), and was unrelated to age or drug treatment. Recrudescent infections were significantly more common in the eastern flank (North eastern, North central, South eastern than the western flank (North-western, South-western and Lagos) of the sentinel sites [32 of 311 children (10.3%) versus 6 of 319 children (1.9%), P<0.00001].

7. Overall, gametocyte carriage after treatment with both drugs was significantly lower compared with pre-treatment [16 of 491 children (3.3%) versus 46 of 620 children (7.4%), P=0.005].

8. Anaemia, defined as haematocrit <30%, was present in 294 of 672 children (43.8%) and was significantly more common in the eastern than in the western flank of the sentinel sites. Anaemia resolved completely in all anaemic children within 14 days in 93% of the chilldren.

9. In anaemic children, anaemia resolution time was approximately 10 days for both drugs.

10. In the few sentinel sites where adverse drug reactions were monitored, both drugs were tolerated; the reported adverse drug reactions were indistinguishable from the symptoms of malaria.

11. AA and AL are safe and efficacious treatment of uncomplicated P. falciparum malaria in <5 year old Nigerian children.

The full study will be made available at the NMCP’s website.

The two-year trial balloon of the Affordable Medicines Facility, malaria (AMFm) is well underway in its eight pilot countries trying to make quality ACTs available cheaply, but it seems some people are trying to let the air out of the balloon.  In particular, one suspects that aspects of the way AMFm might be managed in some settings goes against the business-minded nature of private sector proprietors of malaria drugs.

Ghana was one of the first to get started. Ghana’s news source, Joy Online, led on this topic with a finding that, “A survey conducted by the Pharmacy Council from March to May this year, has revealed that some private pharmacy shops in five regions have been selling anti-malarial drugs for more than 200 per cent of the approved price.”

Early indications in December 2010 were that shops were keeping to the recommended price of 1-2 Cedis (0.60-1.20 USD) for adult doses.  The recent survey found prices as high as 4-5 Cedis.

The goal of the low prices was to ‘crowd out’ unapproved or non-recommended ACTs and other malaria medicines by offering WHO prequalified ACTs at subsidized prices similar to those of chloroquine or sulphadoxine-pyrimethamine, the former first line medicines. This would have had the added benefit of encouraging people to buy ACTs instead of the old medicines for which parasite resistance has developed. Ghana Business News explained that, “Despite the availability of the Artemisinin-based combination therapies (ACTs) in the country chloroquine continues to be the second most used medicine in the treatment of malaria.”

Obviously in Ghana, other forces are at work. For example Joy Online reported …

• some shop keepers were buying through unauthorized sources that added extra cost the procurement process
• many shops were still selling unapproved medicines such as chloroquine and artesunate monotherapies that were as cheap to the customer as the AMFm ACTs, but which gave the seller a larger profit
• there is no legally binding way to ensure shop keepers adhere to the recommended price

Maybe the market is to large and diverse for price controls on one product to work, especially voluntary ones.

On the other hand, the ‘high end’ prices found in the survey are still lower that the pre-AMFm market prices of up to 9 USD in Ghana. The experiment continues and given the large role that private informal providers play in reaching global and national malaria treatment targets, we will all be watching the results closely.

Ideally these days in Nigeria one should be able to get supplies of the recommended artemisinin-based combination therapy (ACT) drugs in public outlets throughout the country. Major malaria partners/donors in Nigeria include the Global Fund to fight  AIDs, TB and Malaria (GFATM), the US President’s Malaria Initiative (PMI), the SuNMaP project of the UK’s Department for International Develoment (DfID) and the World Bank’s Malaria Booster Program.

In reality one finds shortages of medicines that drive consumers and patients to medicine shops in search of whatever is available, and importantly, affordable.  The pictures herein detail what we bought in two patent medicine shops, one urban and one rural, in Sokoto State.

First, even though testing of chloroquine (CQ) for the past 10 years has shown it lacks efficacy, and in fact only ACTs are recommended first-line treatment, we found CQ in both tablet form as well as syrup for children.  Of equal concern is the sale of syrups, which in and of themselves are unstable in the environment.

That said, each of the CQ medicines was duly registered by the National Agency for Food and Drug Administration and Control (NAFDAC). This demonstrates a lack of communication between NAFDAC, one arm of the Federal Ministry of Health, and the National Malaria Control Program, another arm of the same ministry.

The ‘questionable’ products also include Artesunate, a monotherapy drug. It has only artesunate, not a combination, a situation deplored by the World Health Organizations, who explains that use of monotherapy leads down the road to resistance, and we have little in the pipeline to replace the artemisinin derivatives.  This product is registered by NAFDAC, who had promised to not renew licenses for such drugs, and in addition this packet is set to expire in a few months.
We found numerous brands of sulfadoxine-pyrimethamine (SP).  According to national malaria drug and treatment policies, SP should also not be used for first-line treatment due to increasing parasite resistance. SP should therefore be reserved only for use as Intermittent Preventive Treatment in pregnant women (IPTp).  This use is clearly stated on the Melofan packet, though we are not sure that the NMCP has given permission for such labeling. The key reason for this is that SP for IPTp should not be taken as self-treatment, but integrated into a comprehensive antenatal care program.

Finally we did find ACTs.  The card showing Coartem (artemether-lumefantrine – AL) was the only one of the four different age-specific Coartem packagings seen in the shops.  Supposedly this Coartem was being made available in shops at subsidized rates through the Affordable Medicines Facility malaria (AMFm) administered through GFATM.  Normally drugs for this program have different packaging than seen here, which is the normal format for medicines supplied for the public sector from donor programs.

We bought this Coartem pack for $1.33, which was more than the going price for AMFm drugs. The shopkeeper said she also previously had some artesunate-amodiaquine (AA), another ACT in stock, but this had sold out.
Also seen in the ACT picture is an empty carton of AL provided through private wholesalers as part of the AMFm program as evidenced by the small green leaf logo.  The medicine seller with this empty box informed us that he bought many of these cartons and shared with fellow medicine dealers. Unfortunately they did not pay him back and he has been unable to order more. He was excited that these were purchased from the wholesaler for only 50 Naira (about 33 US Cents) compared to proces of several dollars under normal commercial arrangements. Not shown was a bottle of AL suspension that could be reconstituted with water for child use.

We have been rolling back malaria since at least 1998. Nigeria changed its malaria drug policy to ACTs in 2005. Based on the Abuja Declaration of 2000, we should be seeing near universal coverage of malaria illness episodes with ACT drugs by now. There are not gaps in the system – there are wide crevasses.

Nigeria adopted artemisinin-based combination therapy as its first line of malaria treatment in 2005. While it did not ban chloroquine, it has actively discouraged its use since efficacy studies across the country showed high levels of parasite resistance. Likewise Nigeria has tried to confine sulphadoxine-pyrimethamine (SP) for use at intermittent preventive treatment during pregnancy (IPTp), and discourage its use for case management.

Specifically the National Malaria Control Program (NMCP) recommends artemether-lumefantrine and artesunate-amodiaquine, for which there are only few WHO ‘prequalified’ producers, for first line treatment of uncomplicated malaria. Based on WHO recommendations the NMCP also recommends against artesunate monotherapies (i.e. medicines not containing a combination of drugs).
One is not surprised to find inappropriate malaria drugs in patent medicine shops around the country (see picture). Unfortunately the National Agency for Food and Drug Administration and Control approves drugs based more on safety than on appropriateness to control efforts.  Thus, the chloroquine found in shops will not kill you, but it will not cure your malaria either.

With this in mind it came as a shock to see local government clinics stocking chloroquine and artesunate monotherapies, among others.  These were in clinics that were being supplied by the National Health Insurance Scheme using Millennium Development Goals special funds to provide free treatment for pregnant women and children less than five years of age. This laudable goal of reaching the poor can be undermined when drugs with questionable therapeutic value are provided.

The NHIS drug list for malaria includes the following in various forms (tablets, syrups, suspensions, injections):

• Artesunate
• Chloroquine
• SP+Meflaquine
• Dyhydroartemisinin
• Proguanil+Pyrimethamine
• Quinine
• SP
• Mefloquine
• Artemeter

While the SP in the list should ideally be used for antenatal clinic services, one is not sure this happens since several of the clinics visited had no stock of SP, but plenty of chloroquine syrup bottles – a formulation that is not very stable in these climates.

We encourage the NMCP to take stock of malaria drug stocks – basically, there are many national and international agencies supplying malaria medicines at national, state and local government level.  They should be brought together so that one coordinated national malaria drug policy is enacted. Only then will the public receive effective malaria treatment.

Results from a recently published study on “Reduction of anti-malarial consumption after rapid diagnostic tests implementation in Dar es Salaam” are being reinterpreted.

The study found that after the introduction of malaria rapid diagnostic tests in urban Tanzania the prescription of artemisinin-based combination therapy (ACT) drugs decreased and was significantly lower in intervention health facilities than the controls, which continued existing clinical diagnostic practices. Of importance, “Adherence to test result was excellent since only 7% of negative patients received an anti-malarial.”

What has given rise to concern, is that when ACT use decreased, there was an increased use of antibiotics used to treat febrile illnesses.  By following up on the story, SciDev.net gathered a more detailed understanding of the implications of the finding that, “antibiotic prescription increased from 49% before to 72% after intervention.”

Valerie D’Acremont, lead author and a senior scientist at the Swiss Tropical and Public Health Institute, Switzerland, explained to SciDev.net that, “Clinicians were handing out antibiotics, instead of anti-malarial drugs, to all patients with fever who tested negative for malaria. ‘They do that to avoid putting patients at risk,’ she told SciDev.Net, ‘especially as there are no diagnostic tools for other diseases such as typhoid or pneumonia.'”

These concerns run counter to the enthusiasm with which RDTs have been greeted by researchers.  For example, Uzochukwu and colleagues found that RDTs are more cost effective in terms of saving lives that clinical diagnosis. Overall costs associated with RDT use was significantly lower than both clinical diagnosis and traditional microscopy.

A study in Burkina Faso showed how real life problems can interfere with research objectives when they tried to compare treatment outcomes between RDT usa and clinical diagnosis. Compliance by prescribers after getting negative RDT results was too low (i.e. they gave malaria treatment even for negative tests) to compare. Health worker acceptance of RDTs is a problem in many countries, but obviously not in the Tanzania study.

The Tanzania experience led SciDev.net to interview Action on Antibiotic Resistance (ReAct) that pointed out the lack of easy to use tests for other febrile conditions (pneumonia, typhoid, viral fevers) in primary care settings as a problem.  Part of the problem is lack of rigorous adherence to clinical algorithms and guidance, and possibly a desire to give anything just to make the patient happy.

Again, the lead author of the Tanzania study was quoted by SciDev.net as saying that, “Ideally, with training and the implementation of clinical guidelines, it’s possible to reduce antibiotic use from 80 per cent to 25 per cent of patients.” Simply put, health care providers can change their behavior.  This need for training and supervision increases as we expand treatment for febrile and other illnesses into the community.  According to MCHIP (USAID) …

Experts agree that 60% of the 9.7 million children who die annually could be spared if we just delivered the life-saving interventions that we already have to families that need them most. These interventions include: antibiotics for pneumonia, dysentery and newborn sepsis; antimalarials; and oral rehydration packets and zinc supplements for diarrhea. Unfortunately the use of these interventions is low in most developing countries because services that deliver them are not accessible, not available, not of good quality, and/or not demanded.

The call therefore is for integrated case management at all level using all the tools currently available. We certainly do not want children to survive because of better malaria case management, while at the same time spurring antibiotic resistance that will threaten those same lives.

——–

One final note – the Tanzania study was based in an urban setting. Urban areas are generally less hospitable to malaria-carrying anopheles mosquitoes. One therefore wonders if the apparent large increase in antibiotic use was a result of fewer expected actual malaria cases in a city? Do we need different guidelines and training to orient health workers to the different ecological settings where malaria is endemic?

Reporting from Nairobi, Inter Press Service (IPS) documents the experience of James Odhiambo who “goes from one pharmacy to the next in search of anti-malarial drugs marked with the Global Fund’s logo of a green leaf. He is looking for this specific brand because he understands that it is more than ten times cheaper than the same drug produced by different manufacturers.” James finds what he needs at the sixth shop.

Without subsidy from the Affordable Medicines Facility malaria (AMFm), these drugs would cost about $5 or two days salary. See the much sought after medicine packet in a photo on the right by Isaiah Esipisu of IPS.

IPS, on further investigation, attributed the scarcity of the subsidized malaria medicines to the low profit margin that pharmacies who agree to sell the medicines are officially allowed. While the actual price of the AMFm drugs should be $0.50 for adult and $0.12 for child doses, IPS learned form a science reporter of the Nation Media Group that, “Two months ago, we requested our reporters from different parts of the country, including rural areas, to check on retailing prices of the subsidised anti-malarial drugs. As a result, we discovered that pharmacists sold them at varying prices ranging from 80 KES (one dollar), to 240 KES (three dollars).”

IPS learned from a private pharmacist that if she sold the commercial variety of Coartem (the approved artemether-lumefantrine combination drug) she could make $2 profit. The AMFm drugs were permitted only about $0.15 profit. For this pharmacist, ” it would not make any economic … considering her costs of transporting it from the distributors, and other inputs.”

Apparently the Ministry of Health believes the problem can be solved through an “awareness campaign (that) will help consumers make an informed choice and enable them to seek outlets that sell the drugs at the right price.” The cost of transport around town seeking the correctly priced drugs may wind up to be more that the price of the drugs themselves.

AMFm is still a new program. The Global Fund explains that, “Following the Global Fund Board’s decisions on successful applications to Phase 1 in November 2009, grant amendments or new grant agreements have been signed with most AMFm Phase 1 countries and implementation has started in several countries. The first co-paid ACTs were delivered to Ghana and Kenya in August 2010.” Seven other pilot projects are in varying stages of implementation.

Nigeria started implementation of AMFm in March 2011. The Director of the National Malaria Control Program in Abuja hoped that the AMFm subsidies would help crowd out fake and substandard malaria drugs from the market by offering medicines at around $0.50 instead of the $6-8 prices per packet in shops.  Ironically conversations with people responsible for a pre-pilot of sorts carried out under a previous GFATM grant in Nigeria identified similar attitudes about profitability by medicine shop keepers. Might Nigeria be heading down the same road as Kenya?

Word is still out on AFFm implementation in Ghana. So far the Ghana Health Service is touting the benefits of AMFm – the low costs, the savings to the national insurance scheme and the edging out of poor quality drugs from the market. Interestingly, none of the news emanating from implementing countries appear to address the need for proper diagnostics to reduce inappropriate use of the malaria medicines.

Fortunately the Global Fund is planning an evaluation of the AMFm experience. This will address availability, affordability, use and market share.  AMFm is a grand experiment. We hope it is well enough designed from the start to test real life forces in the private sector. Arbitrarily suggesting profit margin is not the way to go, but in the end shop keepers and pharmacists will hold the day through their choice to participate and the prices they set.  Whether these decisions will improve coverage with appropriate malaria medicines will eventually be known when this two-year pilot finishes. In the meantime it appears that some important operational lessons can and should be learned and applied NOW.

PS – see article on low malaria transmission risk in Nairobi in Malaria Journal.

World Malaria Day 2011 celebrates “Achieving Progress and Impact.” Major increases in intervention coverage and reductions in morbidity and mortality have been documented. Yet we are still a long way to go in achieving targets, especially for protecting pregnant women and treating vulnerable children.

In 2011 key interventions like prompt and appropriate diagnosis and treatment still do not reach all endemic communities. In several countries the health services still do not trust community members, and this is impeding progress, let alone impact.

A common belief among health workers in some countries, from upper level Ministry officials to front line primary care staff, is that the community cannot be expected to handle malaria diagnosis with RDTs and treatment with ACTs. In these locations Roll Back Malaria has yet to roll back the medical model of malaria elimination and trust the affected populations to play a major role in providing their own care.

Years of experience with onchocerciasis control tells a story of initial skepticism that communities could handle ivermectin, and yet 16 years after the African Program for Onchocerciasis Control was launched, over 100,000 communities regularly control and direct their own ivermectin distribution.

Studies by the Tropical Disease Research Program of UNCP/World Bank/UNICEF/WHO have shown that these same communities can effectively develiver malaria control services (ITNs and ACTs) along with their ivermectin duties. 

In Rwanda village health workers are the major providers of malaria diagnosis and treatment using RDTs and ACTs.  It can be done if there is willingness to form working partnerships with communities.

The problem goes beyond malaria case management.  Recently the Global Fund pointed out to a grant recipient that coverage targets could not be met without an active role of communities in malaria case management. Communities needed to do more than provide behavior change communication telling residents to trek dozens of kilometers to the nearest health facility for care. 

In fact the Global Fund learned that this country had no policy for community case management of any illness. The nature of such medicalized and inaccessible health care is to condemn thousands of malaria sufferers to death.

Community members can make a difference, as Jhpiego has found in Akwa Ibom State, Nigeria.  Through training and supervision, communities can effectively take charge of meeting their health needs.

Progress will come only when health officials recognize that they cannot achieve impact alone. They must actively involve communities in decision making, planning, service delivery and evaluation of malaria is ever to be eliminated.