Focus on continuing struggle against malaria

"The biggest threat to the fight against malaria today is HIV-AIDS," says Dr Alex Mwita, Programme Manager of Tanzania’s National Malaria Control Programme (NMCP). "This is not to say that the focus should not be on HIV-AIDS, but that the attention has shifted completely off malaria," he added. This view is supported by recent estimates of funding made available for health projects in Tanzania. There will be an estimated US $54 million available for HIV-related projects in Tanzania in 2002/03, according to the joint UN programme on HIV/AIDS, known as UNAIDS; the NMCP figures suggest that, at the moment, there is just $731,000 available for combating malaria during the same period. Given that malaria kills more people in Tanzania than does AIDS, and the socioeconomic impact malaria has on a country that is keenly trying to tackle poverty, this is a worrying trend to many humanitarian workers. Figures published this month show that 93.7 percent of the people of Tanzania run the risk of catching malaria, resulting in over 18 million cases of the disease and 100,000 deaths every year. This makes malaria the major cause of morbidity, mortality and socioeconomic problems in Tanzania at the moment - notwithstanding the serious, and growing, problem of HIV/AIDS. While those most at risk from malaria are children under five and pregnant mothers, the recently announced National Malaria Medium Term Strategic Plan cites the disease as "a major cause of decreased learning capacity in children, students and trainees in age groups 5 to 25 years". The consequences of all this are enormously damaging at a national level. "Health economists have estimated that the economic impact of the disease through loss in production and time at work results in the equivalent loss of 3.4 percent of GDP [Gross Domestic Product, or the value of goods and services produced within a country in a given period]," Mwita told IRIN. However, recent developments in malaria prevention techniques, which encourage private-sector involvement and changes in drug policy, mean that now there seems to be a real move to establish a coordinated approach to fighting the disease. A change in drug policy has greatly improved the treatment of malaria throughout Tanzania, according to health workers. After studies in 1998 and 1999 revealed extremely high levels of parasite resistance - averaging around 78 percent - to Chloroquine, the traditional antimalarial drug, the Tanzanian government changed to the more effective Sulphadoxine Pyrimethamine (SP) as the first-line drug. However, the change has not been entirely smooth. There are still significant stocks of Chloroquine that retailers are trying to sell and, recently, there has been an influx of ineffective SP into the country. Concern has also emerged in the press over the potential side effects of the drug (which may, in certain circumstances, include rashes and respiratory problems), though these are considered minimal - especially considering the dangers of malaria. Though regarded by some as a more costly treatment, the SP combination is almost the same price as Chloroquine in Tanzania. According to Medical Stores Department, the government’s drug procurement agency, a single dose of Chloroquine costs the patient 50 shillings (about 5 US cents) while treatment with SP will cost 54 shillings (less than 6 US cents). There are, though, already problems with the new drug. When it was introduced, there was an 8 percent resistance to SP. Research in neighbouring Burundi has shown resistance to SP as high as 50 percent in some areas, and the combination is seen by Tanzania’s NMCP as very much a temporary option. "We know it’s not the best solution and it can’t serve us for a long time, so we are already looking at alternatives," Mwita told IRIN. A more long-term alternative may have been found in artemisia, a plant that has been made into a tea and used by Chinese traditional healers to get rid of fevers for almost 2,000 years. Its ultimate efficacy has yet to be established, and research is being carried out on combinations of the drug, but there are signs that artemisia might form the basis of the next generation of antimalarial drugs. The best way to avert malaria, though, is to avoid getting stung by the mosquito in the first place - though that is easier said than done in a malaria-endemic country, with over nine-tenths of the population at risk. Environmental management is increasingly difficult, so the use of Insecticide Treated Nets (ITNs) is being seen as a practical solution. Studies across Africa have revealed that malarial cases amongst children that sleep under nets are reduced by 50 percent. The nets have also been shown to reduce all-cause mortality by up to 20 percent. While the price of nets has tumbled to about $2.80 each, as opposed to $6 three years ago, cost is still a major factor in encouraging people to use ITNs. For that very reason, the World Health Organisation (WHO) has emphasised that initiatives aimed at curbing malaria - such as the distribution of ITNs - must consider subsidised or free distribution to some of the poorest segments of the population, while at the same time educating them on the importance of using such preventive methods. "When we talk of health for all, it usually has to do with financing," Dominic Mutie, WHO Disease Control Officer for Kenya, told IRIN on Thursday. "As we start, we should identify those who may not afford the nets. We should subsidise the cost or distribute to them free, depending on how poor people are." In an effort to counter this problem, Tanzania has recently applied for a slice of the Global Health Fund money that has been allocated to fight AIDS, tuberculosis and malaria. Its application, for $19.8 million over three years, includes a proposal to set up a voucher scheme for targeted subsidy of ITNs for infants and pregnant women. The concept is a voucher scheme that enables women attending antenatal clinics to receive a voucher worth two-thirds of the price of an ITN. They can also pick up a voucher that helps pay for a malaria treatment kit. "This is a high-risk strategy that has never been attempted before," said Alastair Unwin of the NMCP. "Not only are we encouraging net use but also attendance at antenatal clinics, so there is a synergy between the new ideas and the existing, more established systems." Handing out mosquito nets is not sustainable long-term, however, so there has also been a move by health organisations such as Population Services International (PSI) to introduce social marketing – a concept that uses commercial techniques to promote affordable and high-quality health products. Tanzania is now by far the largest producer of ITNs in Africa and, according to PSI, this is because of local manufacturers. Through social marketing, investors like A-Z Textile Mills in Arusha, northern Tanzania, were provided with a guaranteed market for a certain number of nets and, as a consequence, the private sector has been stimulated. A-Z Textile Mills is one of these companies cashing in on the expanding market in mosquito nets. Making some 4.8 million nets annually, the company is the country’s leading manufacturer. "Our reasoning in getting involved was two-fold," said Binesh Haria, one of the company’s directors. "In humanitarian terms, we realised that a large number of people could be protected from malaria by using ITNs and, in pure economic terms, there was a demand for them." "It is a growing market, but one facing great challenges in pricing versus the cost of raw materials," Haria added. It is not only a question of vulnerable people having a net: these ITNs need to be kept treated over time. "We are initially advocating treatment twice a year, but in fact every 12 months maintains adequate protection," said Paul Smithson, Health and Population Adviser with the British government's Department for International Development. "However, if you are not treating your net, not only are you doubling the risk of your catching malaria but you are also increasing the risk for others. The mosquito is not killed and, subsequently, can pass on the disease," he explained. The process of treating nets has been greatly simplified in recent years. It now only involves buying a tablet that contains the insecticide, dissolving it in water and washing the net in the mixture. In Tanzania, the Ngao brand of insecticide, widely promoted, can be bought in shops for 400 shillings (about 43 US cents). However, figures from community surveys show that only 9 percent of mosquito nets have been treated at least once. The next stage of health awareness around malaria is, therefore, to concentrate on promoting the treatment of nets, according to Dr Jane Miller, PSI’s senior ITN adviser. "We have already sold over one million treatment kits, but we need to battle to get the price down," she told IRIN. PSI is encouraging competition among manufacturers and a cut in the price of products across the board, because it believes that the insecticides can be sold cheaper - and be made more accessible - while still allowing manufacturers to make money. In the long-term, the aim is to try and move towards long-life impregnated nets that do not need re-treatment and are, therefore, more effective. While this is still some while off, activists are confident that Tanzania may be on its way towards meeting the target of 60 percent of pregnant women and under-5-year-olds sleeping under bed nets by 2006.