id21 Special Features:

Rolling back reality: making malaria control accessible to all

Helen Guyatt of the Kenya Medical Research Institute and University of Oxford writes in a specially commissioned article for Africa Malaria Day 2003

Effective tools to control malaria are available now but are not being accessed by the populations in need. The prime example is insecticide-treated bednets (ITNs). Most malaria-carrying mosquitoes bite at night. Thus ITNs have been proven to reduce malaria infection and death rates by forming both a physical barrier against mosquitoes and, in the words of the World Health Organisation (WHO) 'generating a chemical halo' around the bed, repelling and killing mosquitoes.

However, for people in rural Africa, bednets are hard to get hold of. In these areas, access is often restricted to those with money to buy them from urban centres, or to those taking part in isolated research projects and localised bednet programmes. The WHO's estimation is that in malaria prone areas less than 10 per cent of children under five years old were sleeping under an ITN at the end of 2001. In order to reach the WHO-led 'Roll Back Malaria' target of 60 per cent by 2005 then, a massive increase in access to ITNs is required.

Recent initiatives such as social marketing aim to improve access by providing nets at subsidised prices. However, it may actually be cheaper and more effective to provide bed nets for free through existing infrastructures, such as antenatal clinics. Doing so could cost less than US$ 4 per treated bednet (Guyatt). Even so, governments in malaria endemic countries cannot afford to cover these costs, so it is up to the international community to support these efforts (Guyatt & Maxwell, forthcoming).

A similar situation exists with artemisin-based combination treatment (ACT). Resistance to antimalarial drugs is an increasing problem throughout Africa. However, when artemisin - a fast acting and highly potent antimalarial - is used in combination with one other antimalarial it appears to slow the development of resistance to the second drug.

Last year the WHO recommended that countries adopt ACT therapy as soon as levels of resistance to existing antimalarials exceed 15 per cent. Initiatives such as the East African Network for Monitoring Antimalarial Treatment (EANMAT) can provide governments with the data they need on local drug resistance (Mutabingwa and Watkins, 2002). As ACT can cost up to twenty times more than existing antimalarials, acting on this data and implementing the WHO's recommendation will require additional funding from outside malaria-struck African countries.

The Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM) was established in at the end of 2001, to channel global resources into individual country programmes. Yet only US$ 22.7 million (6 per cent) of the total US$ 378 million awarded was allocated for Malaria in Africa (Teklehaimanot & Snow). Given that at least US$ 1.3 billion is needed each year for just a minimum package of essential supplies for controlling and treating malaria in vulnerable groups, it is likely that the burden of malaria will continue to increase unless more funds are forthcoming.

Despite the increased profile of malaria as a major health threat in Africa, most control efforts continue to exclude those most in need. Wealthier households are more likely to have bednets than poorer households (Hanson & Jones), whilst the latter lack access to many healthcare services (Schellenberg). The tools are available to control malaria now. What is needed is a commitment from the international community for sufficient funds to deliver these to everyone at risk, not just to those that can afford to pay for them. (HG/id21, April 2003, 560 words)

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• Listen to and view the Voice of America's coverage of this story (click)

View the rest of id21's Africa Malaria Day coverage at http://www.id21.org/health from April 24th

Sources:

Guyatt, Ochola & Snow (2003) 'Net cost - affording bednets in rural highland Kenya', id21: http://www.id21.org/health/h4hg1g3.html

Hanson &Jones (2002) 'Widening the net: do subsidised mosquito nets cover vulnerable groups?', id21: http://www.id21.org/health/h4cj1g3.html

Maxwell & Guyatt (2003) 'The effect of community-wide use of
insecticide-treated nets for 3-4 years on malarial morbidity in Tanzania', forthcoming on id21health: http://www.id21.org/health

Mutabingwa & Watkins (2002) 'A winning alliance: researchers and policy-makers tackle malaria drug resistance' id21: http://www.id21.org/health/h4bw2g1.html

Schellenberg et al, (2003) 'Inequities among the very poor: health care for children in rural southern Tanzania', The Lancet 361: 561-567: http://www.thelancet.com/

Teklehaimanot & Snow (2002) 'Will the Global Fund help roll back malaria in Africa?', The Lancet 360: 888-889
http://www.thelancet.com/