Malaria elimination efforts move along a pathway outlined by the Roll Back Malaria Partnership that begins with limited control, moves on to scaling up and then aims as sustaining the scaled up interventions so that incidence drops and we can enter the pre-elimination phase.Â The scale up efforts that have been most intense in the past three-year effort to reach universal coverage (UC) have been known by the acronyn SUFI – scale up for intervention.
SUFI and UC are also viewed against the backdrop of RBM targets set in 2000 to achieve 60% coverage by 2005 and 80% by 2010.Â The implication is that we may claim success with 20% of the population still not reached, which appears to counter the aims of UC.Â Therefore a bigger question is whether we are simultaneously achieving SUFE – scale up for equity.
From the standpoint of malaria control equity should focus on whether those people who are most vulnerable to infection have access to interventions.Â Vulnerability or risk has been viewed from two perspectives: 1) people who are more likely to experience infection because of their immune status such as children below 5 years of age and pregnant women and 2) people living in poverty whose financial and housing situation expose them more to infection and whose incomes are more at risk when they suffer from malaria.
Presented here are snapshots from health surveys in Nigeria, Liberia and Senegal that compare household net ownership with wealth quintile (Demographic and Health Survey, Malaria Indicator Survey). These countries have achieved differing levels of coverage and access to low income groups that help us question how equity relates to malaria control.
Nigeria is characterized by low overall coverage. During recent discussions at a retreate among maternal and child health professionals, colleagues raised the question of whether we can consider equity when coverage is very low. Nigeria prior to the mass net distribution efforts of 2009-11 provides some interesting information for the discussion. AlthoughÂ households in the lower wealth quintiles are slightly more likely to have any kind of bednet, the ownership of an insecticide treated net (ITN) is much greater in the wealthier homes. This may not be unrelated to the fact that ITNs in the early phases of control were often sold or subsidized, limiting their access to people with better income.
Liberia and Senegal with moderate and higher levels of coverage display the same overall trend as Nigeria with poorer household more likely to have some kind of bednet, but when it comes to ITNs, the poorer ones also have some advantage.Â At the time of their surveys, both Senegal and Liberia had been doing some mass net distributions, and the benefit to the lower income people in their countries seems apparent.Â It should be noted that higher income people may not need nets as a main protecteive measure if they live in better constructed homes that usually have window and door screening, an expensive intervention on its own.
One might conclude that Universal Coverage does have a strong equity or SUFE component.Â We also need to investigate whether other interventions like prompt case management and intermittent preventive treatment are also reaching the people in most need.