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.