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Home » Malaria Matters » Malaria Matters: Issue 9, February 2001

Malaria Matters: Issue 9, February 2001

This issue of Malaria Matters - Featuring Netting News was funded by Syngenta. They can be reached at:

1004.7.18, Schwarzwaldallee 215, CH-4058 Basel, Switzerland

Phone: +41 61 323 5490 Fax: +41 61 323 5608

john.koenig@syngenta.com

www.syngenta.com

Malaria and ITN Programmes in Malawi

By Dr. Mark Young

Malaria is the most frequent cause of morbidity and mortality in children under 5 years of age in Malawi, and over 40% of deaths in children under 2 years of age are caused by Malaria. Malawi has the 8th highest childhood mortality rate (223/1000) in the world, and many of these deaths are malaria related. It has been estimated from previous studies that children under 5 suffer on average 9.7 malaria episodes/year, with the average for adults being 6.1episodes/yr. There are a number of studies that have looked at prevalence rates of parasitemia among pregnant women and children in Malawi, and all reveal quite significant levels in the 30%-70% range, depending on season. The highest rates are generally found along the lakeshore area and towards to the end of the rainy season in Malawi (December to April), with the peak usually seen in March and April. The lowest prevalence is generally found at the height of the dry season, from August to October.

In addition to the costs of treatment, hospitalisation and travel, the economic costs of malaria include low productivity and potential loss of income through days of work lost. It has been estimated that the total annual cost of malaria to the average Malawian household is US$35, this amounts to 7.2% of average household income. For very low income households (more than 50% of households earn <$167 per year) the annual cost of malaria is $22 which is equivalent to a staggering 32% of annual household income. Malaria control in Malawi has concentrated on the early recognition and treatment of the disease and is coordinated by the National Malaria Control Programme (NMCP) based in Lilongwe. Malawi was the first country in Sub-Saharan Africa, to switch from Chloroquine (CQ) to Sulfadoxine-Pyrimethamine (SP) as "first-line" treatment in 1993, and there are sentinel surveillance sites for continued periodic measurement of drug resistance. There is a National Policy in place to provide intermittent, presumptive treatment (prophylaxis) with SP to all pregnant women on two occasions during pregnancy (1st visit and beginning of 3rd trimester), although coverage at this time is not necessarily adequate.

In recent years, ITNs have been promoted by the NMCP as a major malaria prevention strategy through government health channels, mission hospitals, NGOs and the private sector (see other articles in this issue). With UNICEF and JICA assistance, a number of District Government Hospitals have developed ITN programmes and there are also a number of mission hospitals and NGOs with community programmes. A large "social marketing" ITN initiative was started in 1998 by Population Services International (PSI); this is at present the largest ITN programme in the country. Malawi held its first "National ITN Conference" in 1998, followed earlier this year (May, 2000) with the "2nd National ITN Conference". These conferences are seen as an important way to bring the key players from all sectors in Malawi involved in ITN projects together to review, discuss and plan. The conferences have been well received and have allowed for the building of networks and "public-private partnerships", which are so important for an effective ITN response to malaria control. Plans and priorities were developed which the NMCP is now in the process of integrating into a National Roll Back Malaria initiative for Malawi, in which ITNs will play a prominent role.

The Church of Central Africa, Presbyterian (CCAP), Synod of Livingstonia, Malawi

By Dr. Mark Young

A) HEALTH UNITS

The Church of Central Africa, Presbyterian (CCAP) Synod of Livingstonia provides health care to a large proportion of the population of northern Malawi through three large Hospitals (Ekwendeni, Embangweni and David Gordon Memorial) and a number of smaller health clinics. Each of the Synod hospitals has a well-developed ITN programme that reaches out into the community through the primary health care delivery system.

Ekwendeni CCAP Hospital statistics reveal that malaria has been the most common cause of admission to children's ward and to female ward for the past four years and is the most common problem encountered among all age groups in the outpatient department. Many more children die as a result of malaria infection at the community level without ever coming to the attention of the health system. A community survey revealed parasitemia rates (the presence of malaria parasites in the blood) of almost 50% in children under the age of five. Malaria also makes a significant contribution to the high rate of mortality among pregnant women and to the high levels of anaemia among both women and children. Community members identified malaria as the major health problem affecting children in their communities on a health needs assessment survey in 1996 and expressed interest in using ITNs as a preventative measure.

The ITN component of the Ekwendeni Malaria Control Programme was begun in early 1997 with the main target groups being children under the age of five years and pregnant women. An intensive IEC (information, education and communication) campaign was started first among the hospital and primary health care staff. Health workers and staff members were offered ITNs at a subsidized rate by the hospital administration, as this was felt to be both an advocacy tool for promoting community education and a strategy for reducing time lost from work due to illness. At the same time, ITNs were placed on the children's ward at the hospital. In this way, community members who are staying with children on the hospital ward (usually the child's mother), can become familiar with the use of ITNs and the hospital staff can use the opportunity for further teaching about the use and care of ITNs.

This initial stage was followed by intensive community-based IEC through the mobile Maternal-Child Health Clinics held on a monthly basis by the Primary Health Care (PHC) team. Communities within the hospital catchment area (approximately 50,000 people living in 10,000 households within 110 villages) were asked to nominate male and female volunteers to receive training on malaria control and ITNs. Often those selected were already working as health volunteers in their area. These volunteers (1 or 2 from each village, depending on the size of the village) received 2 days of training on malaria control and ITNs by the Project Coordinator and other members of the PHC team, and were provided with an ITN as an incentive for their participation. They then educated their respective communities on the issue and signed up households for purchasing ITNs. During the initial baseline survey before project implementation as well as in focus group discussions, the issue of cost was discussed and a price was agreed upon which was felt to reflect a good balance between cost-recovery and affordability. In initial stages, this meant a subsidy of about 20% on the cost of the ITNs, however it was felt that as demand increased and procurement practices were improved, the wholesale cost of the ITNs would be reduced and the current selling price would result in complete cost recovery. A campaign was also held to promote the sale of more than one ITN per household, as it was recognized that if only one net was available, the male head of household would probably use it rather than children. Community education on this issue is continuing, but in the meantime households were given the option of receiving a second ITN for half price.

Two years after programme implementation, more than 6,000 ITNs have been purchased by community members. An evaluation survey in late 1999 revealed that 50% of households in the catchment area were using ITNs and that there had been a significant improvement in knowledge about ITNs (see Table 1). One concern, which is also shared with other ITN programmes, is the relatively low rate of "retreatment" of ITNs. The Ekwendeni programme uses "mass community dipping campaigns" to promote ITN retreatment. This has resulted in 40-50% of ITNs being retreated, however the programme staff would like this to be higher and therefore more intensive IEC is being implemented on the important role of the insecticide.

Table 1. Summary of Attitudes & Practices related to ITNs at baseline and 2 years post intervention


1997

1999

Knowledge of Nets

70%

93%

Proportions of Households using nets

8%

50%

Proportion of children under 5 yr. using nets

3%

46%

Proportion of under 5's using a 'treated' net (ITN)

0%

26%

Another problem which has been identified, and which the Ekwendeni programme has in common with others, is the affordability of ITNs for poor, rural households, those most in need. People in the area rely on subsistence maize farming for their livelihood. Many do not have the cash available for necessary items such as ITNs, and would rather use a "barter system", trading maize for ITNs. This is most useful during the post-harvest months of June-August in Malawi. An innovative programme that has assisted with this process and allowed the easy trading of maize for ITNs is the "Ekwendeni Community Grain Bank Programme", started as part of the overall Primary Health Care Programme at Ekwendeni in 1991, with initial funding from the USAID SHARED Project. A community structure for the storage of maize was constructed in 11 sites spread throughout the area. These cement block and tin roof structures are large enough to hold about 20 tons of maize packed in 90-kg sacks. A committee made up of 8 women and 2 men from the community is chosen to operate each of the grain banks and they are responsible for the buying and selling of the maize. Buying normally occurs during the months of June to August and selling usually from December or January until the next harvest period or until the maize stocks are depleted. The standard buying and selling price is set each year by the community during a meeting at the beginning of the year. Households then have the option of selling an amount of maize equivalent to the price of an ITN to their local community grain bank, in exchange for an ITN. The grain bank committee then passes on the appropriate amount of cash to the malaria control committee account for the ITN revolving fund. This has resulted in a higher volume of sales among the Ekwendeni community and higher sales among rural, subsistence farmers who might not otherwise have the opportunity to purchase an ITN.

For more information contact:

Ms. Grace Chavula - Malaria Control Programme Coordinator

Ekwendeni CCAP Hospital

Ekwendeni, Malawi

E-mail: c/o ekwehealth@sdnp.org.mw

B) CHURCH-BASED WOMEN'S GROUPS

Many community health projects have been undertaken in different countries using insecticide treated nets, with varying degrees of success. Involvement of a locally defined group in the community in the implementation of health projects usually improves the local incentive of the community to sustain the beneficial health practices once a project has "phased out". Since women in Africa are the primary health care-givers in their families, they play an important role in determining the health status of the entire family. Thus, they are a natural group to involve in community health activities and often are trained as village health workers (VHWs) or traditional birth attendants (TBAs). Church-based women's organizations can be a particularly effective tool in the organization of health projects in their community. Furthermore, their involvement helps to re-emphasize or underline the concept of health as being a "holistic" state, which includes physical, mental, social and spiritual wellbeing, all of which are very much inter-related.

A project such as this, utilizing the "Umanyano" women's groups of the CCAP Livingstonia Synod in northern Malawi, was begun during 1999. This followed on the ITN health projects started within the Synod Hospitals in 1996/7, with the major aim to empower local church women to develop a health ministry and economically empower the local community through development of a local enterprise (sale and/or production of bednets). The objectives are to increase the community's awareness of malaria prevention, increase ITN use among vulnerable groups, assist local church women to develop the capacity for conducting health projects, and to develop income generation in the community through the local production and sale of ITNs.

A team of women from within the "Umanyano" is identified at each church site and trained in the provision of basic malaria prevention, recognition and treatment messages. These messages are passed on to their respective communities through normal daily activities and as well through community and church meetings. In this area of Malawi, the majority of families attend a church meeting on Sunday, and this provides another opportunity for the provision of basic health education messages. These women are provided with ITNs and insecticide, which they sell to families in their community. The initial supply of ITNs and insecticide was provided by one of the church partners based in the USA (Presbyterian Church, USA) and this allowed a community fund to be established from the sale of the nets in the community. The fund is managed by the local church women on the project team.

Although this project is still in its infancy, there is much interest on the part of the church women and the wider church community itself. Health education on malaria, and ITN sales are available to all who live in the vicinity. There are plans in the coming year for the small-scale local production of nets through sewing projects among the Synod women's groups.

For more information contact:

Mr. Richard Kerr - Health Coordinator

CCAP Synod of Livingstonia

P. O. Box 1000, Mzuzu

Malawi

E-mail: ccaphealth@malawi.net

Blantyre Insecticide Treated Net (BITNET) Project: Population Services International (PSI) Malawi

By Dr. Mark Young & Dr. Desmond Chavasse

BITNET is a social marketing initiative which aims to reduce malaria disease and death in the densely populated Blantyre District of southern Malawi by maximising ownership and appropriate use of ITNs through creating demand and improving access to affordable products. BITNET supplies two types of mosquito net packed with an insecticide treatment kit and branded "Chitetezo Net" (protector net). One is a blue conical net which is most appropriate for urban people sleeping on beds and small mats (as it needs to be tucked in) and is sold to consumers for Mk 295 ($US6.8). The other type is a green rectangular net which is most appropriate for rural people sleeping on large mats (as the net holds its shape without tucking) and is sold to consumers for Mk 195 ($US4.5). The procurement cost of the nets is the same, but by introducing a price differential so that the most desired net type (blue conical) is more expensive, it is possible to maximise cost recovery from richer urban people whilst subsidising the net most appropriate for poorer rural people (green rectangular).

Each net is packaged with a treatment kit which contains a 20ml bottle of 5% cyfluthrin EW, a pair of disposable plastic gloves, a water measuring sachet and a set of pictorial instructions. The treatment kit, branded "M'bwezera Chitetezo" (restore protection), is also sold separately for retreating any type of mosquito net every six months. Chitetezo Net and M'bwezera Chitetezo are sold through supermarkets, grocery shops, companies (employee schemes) and through rural public clinics. Generic (unbranded) nets and insecticide is also sold to NGOs outside Blantyre District.

Advertising and promotion of Chitetezo Net and M'bwezera Chitetezo relies heavily on national and local radio for airing short spots and jingles for brand awareness and key messages. Longer radio dramas and radio phone-in shows are also used to convey more complicated IEC messages. Other communications media include drama shows at rural markets, outdoor mobile video shows and press articles. Branded advertising media include billboards, painted walls, stickers in public transport and painted PSI delivery vans. Branded T-shirts and wall clocks are also used as promotional items.

Chitetezo Net was launched on 31st October 1998. After 2 years, 120,000 mosquito nets with insecticide treatment had been sold in Blantyre District. The 3 year sales target was 100,000 nets. BITNET has sold a further 11,081 nets to NGOs outside Blantyre District. The retreatment kit, M'bwezera Chitetezo, was launched on the 20th February 1999; by September 2000 30,000 units had been sold.

An evaluation was undertaken to assess progress one year after implementation. A summary of the results is included here:

NET SALES AND RETREATMENT

Blue net sales accounted for 70% of the total sales. 18% of sales took place in rural areas where 20% of Blantyre district´s population live. Urban net sales were highest during the rainy season (Oct- Mar) when mosquito nuisance is worst. Rural sales were highest during the harvest season (Apr-Jun) when cash is more available. During the harvest season BITNET organised a rural promotion on green nets only (selling three for the price of two) via rural public health clinics in order to increase penetration of rural areas with nets. Overall net sales were lowest during the cold dry months of July to September. A large proportion of M'bwezera Chitetezo sales took place in the last quarter of 1999 in response to an intensive retreatment promotional campaign during the peak mosquito/malaria season.

COST RECOVERY

BITNET achieves efficient public health impact by balancing cost recovery with equity. Cost recovery is maximised by negotiating cheaper procurement prices and through market segmentation. The unit wholesale cost of a mosquito net has been reduced by 38% since the first order of nets. The blue conical net is sold at a price above cost through all types of outlets. The green rectangular net is sold at a price below cost through rural outlets and township groceries only, and a further price reduction is made during the harvest season promotion. The effect of this strategy is to achieve 100 per cent cost recovery on direct product costs (all products) whilst achieving equivalent per capita sales in rural and urban areas. Using research findings to guide retreatment marketing strategy:

POSITIVE FINDINGS

CONSTRAINTS TO RETREATMENT

NEW MARKETING STRATEGIES AND TACTICS

FOCUS ON RETREATMENT PRODUCT

INCREASE ACCESS

INCREASE VISIBILITY

BEHAVIOUR CHANGE COMMUNICATIONS (7-MINUTE RADIO DRAMAS TO ADDRESS KEY CONSTRAINTS)

For more information contact:

Dr. Desmond Chavasse - BITNET Director, PSI/Malawi

16 Leslie Road

Box 529, Blantyre

Malawi

Tel: (265) 677 295 Fax: (265) 674 138 E-mail: chavasse@malawi.net

Our Readers Write...

The April 2000 issue of Malaria Matters, inquiring about the washing frequency of nets, prompted a number of projects to conduct surveys in their areas.

"We are happy to receive Malaria Matters featuring Netting News. [The] April issue of 2000 prompted us to elicit information on washing frequency of mosquito nets in our experimental areas. Accordingly, a questionnaire was developed for public response among malaria endemic villages of Kamrup district of Assam State (India). It was observed that 52% of the respondents (total respondents 236) washed their net at quarterly intervals, 43% at monthly intervals, and only 5% did wash half yearly. State of Assam (North-East Region of India) is a malaria endemic state, and P. falciparum is the predominant parasite species. ITNs have been field evaluated successfully and are considered as the main intervention strategy for malaria control. Based on our field studies it was observed that synthetic pyrethroid (deltamethrin 2.5% flow) was effective for over six months (if not washed) over nylon/polyester Fibre at dosage of 25 mg/sq. meter, much less over cotton Fibre. Over 90% of the respondents preferred synthetic Fibre net over cotton nets.

"I hope this information will help program future strategies to combat malaria."

Sincerely,

Dr. Vas Dev, Officer-in-Charge

Malaria Research Centre

Sonapur, Kamrup, Assam-782402 (India)

"With regard to malaria in Niger, I am responding to the question in Malaria Matters, Issue No. 7. The frequency of washing of ITNs is estimated to be a maximum of three times per year. The use of dark coloured nets and screens for privacy explains this frequency. The effectiveness of EC25% insecticide that we use in Niger is known to the population. We will shortly introduce Deltamethrin in the form of KO-Tabs for autonomous impregnation at the household level."

Sincerely,

Bernard Huon-Dumentat Niger

Suggested Reading

ECONOMIC ANALYSIS OF MALARIA CONTROL IN SUB-SAHARAN AFRICA

Goodman C, Coleman P, Mills A. Global Forum for Health Research, May 2000

The aim of this report is to support the RBM initiative through an analysis of the cost-effectiveness and economic benefits of malaria control in Sub-Saharan Africa (SSA). Chapter 1 describes the burden of disease due to malaria and reviews existing literature, identifying many gaps and inadequacies in the present studies and economic evaluations. More studies are obviously needed, which assess cost-effectiveness in operational settings for a variety of interventions, however policy decisions on the allocation of resources to malaria control cannot be delayed. For the purposes of this report therefore, a modeling approach was used to provide a range of comparable estimates for the cost-effectiveness of the main prevention and treatment interventions, drawing on all available cost and effectiveness data. The effectiveness of each of the major malaria control interventions was modeled using a hypothetical population based on a model life table, and was calculated in terms of disability adjusted life years (DALs) averted. Estimates of DALYs averted were then combined with information on costs to both governments and households to produce a likely range for the "cost per DALY averted" of each intervention. Results for SSA are stratified by broad epidemiological zone where feasible, and by three economic zones stratified on the basis of per capita GNP: very low income (under $315); middle income ($315-$1,000); and higher income (above $1,000). The resultant cost-effectiveness ratios (CERs) are expressed in terms of likely "ranges" rather than point estimates.

For the prevention of malaria in children, the following strategies were evaluated: Insecticide Treated Nets (ITNs), residual spraying of houses, and chemoprophylaxis of children.

Insecticide Treated Nets: The analysis of ITNs is based on the delivery mechanism used in the WHO/TDR trials, where net treatment was done on a communal basis. Two possible scenarios are considered: first, where nets are distributed to households as part of the programme, and secondly where there is already a high degree of net ownership, and treatment is arranged for the existing nets. Estimates of the effectiveness of ITNs are drawn from the Cochrane meta-analysis of WHO/TDR trials conducted in SSA, adjusted using estimates of net retreatment rates in operational settings. The results show that if net coverage is low and nets must be distributed as well as treated, the cost per DALY averted in a very low income country fell within the range of $19-$85 and therefore would be considered "attractive", as it would be also for middle income countries. If net coverage was already high and only treatment of nets was required, costs were significantly reduced to the range of $4-10 for very low income countries and would be considered "highly attractive".

Residual Spraying: With one round of spraying per year, the CER in very low income countries was $16-29. If two rounds of spraying per year were required, the costs almost double, although it would still be considered "attractive" in low and middle income countries.

Chemoprophylaxis for Children: This is based on a system of distribution of the antimalarial Maloprim® by village health workers (VHWs). If a network of VHWs already exists, the CER in very low income countries fell between $3 & $12 and would be considered "highly attractive". Even if it was necessary to set up a VHW prorgamme, the intervention would still be considered "attractive" with a CER of $8-41.

It must be kept in mind that the cost-effectiveness of any of these interventions could be adversely affected by the development of either insecticide or drug resistance. In summary, all the interventions analysed that prevent childhood malaria are potentially attractive uses of resources. There is considerable overlap in the ranges of cost-effectiveness, so no one intervention can be identified as the most cost-effective in all situations. Although the interventions are cost-effective, the financial costs of wide coverage are high and affordability is likely to be a major barrier to widespread implementation. Unless nets are already in use, or a strong network of VHWs is in place, achieving national coverage of the target group with any of the interventions is likely to increase the existing health sector budget by over 20%.

The report goes on to estimate CERs for the prevention of malaria in pregnancy ($4-$26 for use of 2-dose SP in very low income countries - "highly attractive"); improving compliance to treatment (CER < $25 in very low income countries); improving availability of 2nd and 3rd line drugs (highly attractive at any level of Chloroquine resistance in high transmission areas); changing 1st line drug treatment (highly cost-effective, although growth of drug resistance must be considered); use of combination therapy (attractive if the growth rate of SP resistance was reduced by at least 47%); and, diagnostic tests (use of additional diagnostic technology unlikely to be a cost-saving in SSA because the current range of 1st line treatment is relatively inexpensive).

Finally, information on the total and per capita costs of "packages" of malaria control measures are summarized, ranging from a low of $0.03 (antenatal intermittent treatment for primips, improving compliance and improving accessibility of 2nd and 3rd line drugs) to a high of $2.06 (2 rounds of residual spraying, antenatal intermittent treatment for all pregnant women, improving compliance, improving accessibility to 2nd and 3rd line drugs and confirming diagnosis for every suspected case). Malaria Control "Packages" which included net treatment, or net distribution as well as treatment, were estimated to cost $0.14 and $0.81 respectively.

Copies of the report can be obtained for free from:

Global Forum for Health Research

c/o World Health Organization

20 Avenue Appia, 1211 Geneva 27, Switzerland

info@globalforumhealth.org

www.globalforumhealth.org