The 2011 Multiple Indicator Cluster Survey (MICS) from Ghana demonstrates the challenges we have in moving along the pathway toward malaria elimination. People will recall that the Roll Back Malaria indicators were for endemic countries achieve 80% coverage on basic malaria interventions by 2010 and sustain these to achieve Millennium Development goals by 2015 and then move on to pre-elimination of the disease where less than 1/1000 people at risk in a country actually experienced malaria. Now of course, everyone is talking about universal coverage of basic services, not just 80%.
The 2011 Ghana MICS reports on the standard RBM indicator of two doses of intermittent preventive treatment (IPTp) with sulphadoxine-pyrimethamine (SP) during antenatal care (ANC), although Ghana has for some time aimed at three doses. Also current WHO guidance for IPTp recommends IPTp in stable endemic countries at one dose for every antenatal care visit after quickening, which could mean three or four times. So the 2011 MICS shows 83% of recently pregnant women surveyed got one dose of IPTp during ANC while only 65% received two.
The chart to the right does show progress in IPTp coverage between the 2008 Demographic and Health Survey and the 2011 MICS. a jump from 44% to 65% for the two doses, and progress should be acknowledged, but as pointed out at the recent Pan Africa Malaria Conference in Durban, we must not work around the edges to eliminate malaria, but tackle the higher prevalence countries and areas directly and ensure that malaria is truly eliminated.
Why are coverage figures low – and this is not just a problem in Ghana? At least 96% of pregnant women in Ghana attend ANC with a skilled provider: 95% make two ANC visits, 89% make three and 86% are reported to make four. What we may be seeing are missed opportunities.
Are gaps due to health worker errors, SP stock-outs or client refusals? This needs to be investigated and rectified.
Ideally pregnant women should also get an insecticide treated net on their first ANC visit regardless of distribution through mass campaigns. Unfortunately the MICS 2011 shows that only 32% of pregnant women overall had slept under a treated net the previous night, and even in households with nets, only 58% had slept under them. Clearly malaria in pregnancy control and scale-up needs higher priority in Ghana as well as the rest of Africa.