Much ado about malaria mortality

progress-impact-8-sm.pngAttention has recently focused on the news that malaria deaths are reducing and therefore, we may actually experience no malaria deaths by 2015 in line with the Millennium Development Goals. The excitement has been generated by a new report in the Progress and Impact series that documents great increases in malaria funding. Optimism helps spur action, but occasionally caution is needed so that slight disappointments do not grind action to a halt.

Two recent publications should encourage a little caution without dampening enthusiasm.

A headline in Ghana Business News states that, “Ghana risks missing some MDGs by 2015.”  The article explains that “… a study jointly conducted by the Ministry of Health and Ghana Health Service (GHS) has revealed … certain bottlenecks and organisational weaknesses …”  These weaknesses include –

  • absence of integration of programmes
  • general health service financial resources at national levels
  • weak community participation in health planning and management
  • increasing sense of frustration and neglect on the side of community volunteers

These are health systems and management issues – the very framework on which good malaria interventions are built.  Even the MDG website itself encourages us that “efforts must be sustained to win the battle.”

The Demographic and Health Survey (DHS) has published the preliminary results of the Nigeria 2010 Malaria Indicator Survey (MIS). Because of its large population Nigeria is the bellwether for controlling malaria on the continent with the overall highest number of malaria cases. Compared to the 2008 DHS, the 2010 MIS shows an increase from 17% to 44% of households that own any kind of bednet.  Gains are greatest in states supported by special programs such as the World Bank Booster, but are smaller than needed for achieving the 2010 Roll Back Malaria targets.

Speaking of targets, the proportion of young children sleeping under any kind of bednet in 2008 was 12% and rose to only 30% in 2010.  The figures are lower for insecticide treated bednets. Even in households with a net, only 59% of children slept under them.

Once can argue that Nigeria did not complete its net distribution for universal coverage in 2010 as hoped, but this gets back to the health systems bottlenecks mentioned in Ghana. Further caution is needed when one realizes that these millions of nets distributed up through 2010 will likely need replacement before 2015.

At present 51.5% of the children under five years of age tested with Rapid Diagnostic Tests in the 2010 Nigeria MIS tested positive for malaria.  We can certainly reduce mortality even if bednets are not used, but only 6% of this age group who had fever in the two weeks preceding the MIS had received the recommended artemisinin-based combination therapy.

Funding increases for malaria commodities alone will not achieve the desired reductions in malaria mortality, not will funding alone be able to tackle the health systems bottlenecks identified in many high prevalence countries.  A change in attitude is needed from top level political will to front line health worker perceptions.  If primary health care generally is not working, not reaching the people, malaria will still kill.

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