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Tehip case 5_eC a s e s t u d y
New Weapons in the War on Malaria
Halting the disease is crucial to improving overall health in Tanzania
Evidence showing the large impact of malaria on Tanzanians’ health has provided the impetus for significant policy changes on how to treat and prevent the disease across the country. The fight against malaria is now proceeding on many fronts, from preventative measures such as the promotion of insecticide-treated bednets to the introduction of more effective treatments, such as new drug A plastic bag hangs from the ceiling of a village clinic inMorogoro, Tanzania, where mothers and babies wait patientlyfor treatment. Inside the bag is a large colourful net. The pictureon the bag shows an enormous mosquito held at bay by thesymmetrical grid of a mosquito net. A few feet away, tacked upon a wooden door, a bright yellow poster depicts a warrior —shield and spear extended — ready to repel malaria-carryingmosquitoes. Still another poster shows a smiling mother andbaby resting securely against the warrior’s shield. The unmistak-able message of all these images? That insecticide-treated nets(ITNs) provide vital protection against the mosquitoes that carrymalaria. That message is being heard throughout Tanzania. Asthe message spreads, treated bednets are becoming increasinglycommon. More than an illustration of the rising acceptance of ITNs, those c.ca/tehip
posters are proof of the new prominence antimalaria effortshave acquired as health officials struggle to reduce Tanzania’shigh levels of mortality. The fight against malaria is proceeding on many fronts, from preventative measures such as the promo-tion of ITNs, to the introduction of more effective treatments,such as new drug therapies.
Insecticide-treated nets provide vital protection
against the mosquitoes that carry malaria.
Combating a major killer
A need for effective treatment
This multipronged effort comes in response to the realiza- “We reported to the Ministry that IMCI would not work if tion of the high toll malaria takes on the health and well- we continued working with the wrong drug, chloroquine, being of Tanzanians. Statistics compiled by the Tanzania because the research showed that resistance ranges from Essential Health Interventions Project (TEHIP) show that 50% to 70%,” says Dr Kasale. “If you look at data from the malaria accounts for roughly 30% of the country’s burden surveillance, it showed that children suffering from malaria of disease (BOD). In some districts, such as Morogoro, it is did attend the clinic, but they still died. That’s because they the largest single contributor to loss of life. Even those were getting the wrong medicine. The Ministry did allow who survive can pay a heavy price, with recurrent bouts of the districts to change to new drugs, and that meant that IMCI became a viable intervention using viable drugs —using credible, effective drugs.” This, in turn, has a large economic impact in countrieswhere malaria is endemic. A recent study by the Centre for At first it was decided to replace choroquine with alterna- International Development at Harvard University and the tive drugs that would comprise three new tiers of treat- London School of Hygiene and Tropical Medicine suggests ment. The first-line drug for treating malaria would be that malaria-prone countries pay an economic “growth sulfadoxine-pyrimethamine (SP), with amodiaquine (AQ) as penalty” as high as 1.3 percentage points per year, with the second line, and quinine as the third line (although the cumulative effect that — when the loss is compounded quinine would be the first-line drug in severe cases). The over 15 years — the gross national product of those coun- problem that remained, however, was that resistance was already being observed with these new drugs: SP’s treat-ment failure was calculated at 9.5%, and AQ’s treatment TEHIP — a joint project of the Tanzanian Ministry of Health and Canada’s International Development Research Centre(IDRC) — contributed to this new focus on malaria. By It was therefore suggested to get ready to move to “com- developing a series of computer-based planning tools, bination therapy” (CT) in which malaria patients would be TEHIP made it possible for District Health Management prescribed a course of pills containing more than one anti- Teams (DHMTs) in two highly populated Tanzanian districts malaria medicine. The advantage of CT to the patient is to weigh their budget commitments and priorities against that if one drug fails, the other one takes over. More the local BOD. The research showed that malaria generally, it is believed that CT can slow the progression accounted for 30% of the years of life lost to death and of drug resistance in malaria parasites. This resistance disease in the two regions. Yet, in 1996, only 5% of health generally develops when a malaria parasite that is partially budgets went toward malaria treatment and prevention.
resistant to a drug survives long enough to reproduce.
Today this has changed: spending on malaria has increased With combination therapy, however, the second drug kills the malaria parasite before it has an opportunity to passon its genetic material, thus interrupting the process of In the test districts of Rufiji and Morogoro, DHMTs redi- rected funding priorities toward two large but previouslyunder-supported problems: malaria and a cluster of child-hood ailments that could be addressed collectively by a A powerful demonstration effect
system of treatment known as the Integrated Managementof Childhood Illness (IMCI). At the national level, the pres- According to Dr Kasale, introducing more effective entation of data showing the large impact of malaria on approaches for managing malaria has bolstered the Tanzanians’ health provided the impetus for significant public’s confidence that the health system can deal with policy changes on how to treat and prevent the disease the disease. For instance, many mothers whose children suffered from late stage malaria with convulsions werereluctant to have those children treated in a health facility.
The two test districts’ new focus on malaria and IMCI were Although malaria with convulsions is very dangerous — mutually reinforcing. TEHIP Project Coordinator Dr Harun likely to lead to death — the condition, known in Tanzania Kasale recalls that it was the districts’ inability to effec- as ndegedege, is often not associated with malaria, but to tively implement IMCI without changes to the standard the presence of spirits or changes in the weather. These procedure for treating malaria that led TEHIP to lobby the parents were more likely to consult traditional healers. This Ministry for a new antimalaria drug policy. Malaria, he was reinforced by the fact that health practitioners con- recounts, was one of that interlocking group of childhood ventionally gave the child an injection to treat the convul- illnesses that IMCI was designed to address. Yet since sions. “The parents also believed that if that child got an chloroquine, the standard drug for treating malaria, had injection [to treat convulsions], that was a ticket for that lost much of its effectiveness as the malaria parasite has grown increasingly resistant to the drug, IMCI could notsignificantly improve children’s health until a better To assuage parents’ fears, practitioners in community health facilities opted for a new form of treatment to stop the convulsions: they mixed valium with water and admin-istered the solution rectally. “Within a minute the child isbetter,” says Dr Kasale, adding that the child who is nolonger convulsing can then be treated with oral anti-malarial drugs and transferred to a larger health centre for treatment. This nearly instant recovery from convulsions had a miracu-lous impact on the public perception of the health system.
“The health worker gave the child this treatment in frontof the rest of the mothers,” continues Dr Kasale. “Afterseeing the child recover without an injection, they wereamazed. So the word went around, and mothers startedbringing these children to the health facilities.” Dr Kasalebelieves that this demonstration effect — patients seeingthe beneficial results and then telling others aboutthem — is one reason that attendance at clinics in Rufjiand Morogoro has risen dramatically. Making inroads against this devastating disease
requires an effective prevention program. The main
The efficacy of treated nets
tool: insecticide-treated bednets.
Better treatment, however, is only half of the struggleagainst malaria. Policymakers and practitioners know thatmaking inroads against this devastating disease alsorequires an effective prevention program. The main tool: treated nets in a community will afford some protection to all people in the area, even those who do not own a bed-net themselves.
According to Dr Kasale, communities have long understoodthat there are advantages to being shielded from mosquito Not surprisingly, promoting the use of ITNs has become a bites. In Rufiji, for instance, many households used tradi- key weapon in health officials’ battle against malaria.
tional woven grass sleeping bags to protect against Because the high cost of the early treated nets — about mosquito bites. But while untreated nets and traditional US $10 for a family-sized net — discouraged many people barriers can reduce the nuisance factor associated with from purchasing them, the nets were promoted through a mosquitoes, they have their limitations. Mosquitoes can social marketing campaign in Tanzania, led by Population enter the net if it is torn or hung badly, and can bite any Services International, a nongovernmental organization, part of the body in contact with the net. with support from the UK Department for InternationalDevelopment. These efforts proved effective at enhancing By contrast, nets treated with pyrethroid insecticides (ITNs) awareness of the benefits of ITNs, dramatically decreasing provide much more than a physical barrier; they actually the cost of nets and increasing their use.
kill or deter mosquitoes from feeding and drive them fromtheir hiding places. Even a treated net with large holes in Today, the nets are widely available. As their popularity it provides as much protection as an intact one, reducing spread, the cost declined to about US $4 and public health mosquito bites by up to 95%. Mosquitoes are killed by the officials have turned their attention to those at highest risk insecticide before they can find a place to bite through the from malaria — pregnant women and young children.
net or push through a hole. The Ifakara Health Research The goal: to see 60% of children and pregnant women and Development Centre has determined that ITNs could protected by a net by 2005. In the next phase of the avert 30 000 deaths and more than 5 million clinical national ITN strategy, every pregnant woman who visits a episodes of malaria annually in Tanzania.
health centre will receive a voucher for a bednet. She canredeem the voucher for an ITN by visiting a private vendor.
Research results summarized in Net Gain: A New Method In turn, the vendor will be reimbursed after bringing the for Preventing Malaria Deaths1, a copublication of IDRC voucher to an authorized government agent.
and the World Health Organization, indicate that ITNscould reduce child mortality by at least 17%. The benefitsof using treated nets also accrue to the entire community.
Delivering multiple benefits
Recent evidence shows that a high-concentration of The voucher system is expected to bring multiple benefits.
First, it transfers responsibility for procuring and distribut- 1 Net Gain: A New Method for Preventing Malaria Deaths, ing the nets away from overburdened community health edited by Christian Lengeler, Jacqueline Cattani, and Don deSavigny. IDRC 1996, ISBN 0-88936-792-2; 260 pp.
workers to private manufacturers, wholesalers, retailers, http://web.idrc.ca/en/ev-9338-201-1-DO_TOPIC.html and distributors. Second, it focuses on a particularly vulnerablegroup: pregnant women and young children. Research has shownthat women infected with malaria during pregnancy are highlylikely to deliver low birth weight babies. As well, infants quicklylose the immunity they may have acquired passively from theirmothers. This makes them highly susceptible to malaria and arange of secondary conditions (anemia, malnutrition, febrileseizures, sudden cardiac arrest, and a general failure to thrive,among others) that are a direct result of malaria.
The voucher system also entices women who may not otherwisereceive care to establish a relationship with a health facility.
Offering a pregnant woman a voucher for an ITN — an item ofsignificant value — is a powerful incentive for her to visit a clinicwhere she can receive antenatal care. The baby can also be immu-nized and mother and child can receive follow-up health care. This is just one of the many ways in which more effective andintegrated initiatives against malaria have become a cornerstone of broader efforts to revitalize Tanzania’s health system. Public health officials have turned their attention to
those at highest risk from malaria — pregnant
This case study was written by Stephen Dale on behalf of IDRC’s women and young children.
For more information:
Dr Hassan MshindaIfakara Health Research Development Centre Governance, Equity, and Health
PO Box 8500, Ottawa, ON
Canada K1G 3H9
Fixing Health Systems
Tel.: +1 (613) 236-6163Fax: +1 (613) 567-7748 More information on the capacity building of District Health Management teams in Morogoro and Rufiji can be found in Fixing Health Systems, by Don de Savigny, Harun Kasale, Conrad Mbuya, and Graham Reid. The book describes theTanzania Essential Health Interventions Project – its origins, impact, important The International Development Research Centre lessons, observations, and recommendations for decision-makers and policy ana- (IDRC) is a public corporation created by the lysts. The full text of the book is available on a thematic Web dossier, which leads Parliament of Canada in 1970 to help researchers the reader into a virtual web of resources that explores the TEHIP story: and communities in the developing world find www.idrc.ca/tehip.
More information on malaria control can be found at: environmental problems. Support is directed http://www.rbm.who.int/
toward developing an indigenous researchcapacity to sustain policies and technologiesdeveloping countries need to build healthier,more equitable, and more prosperous societies. Published in collaboration with the Ministry of Health, Tanzania.
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