Scaling up malaria intervention "packages" in Senegal: using cost effectiveness data for improving allocative efficiency and programmatic decision-making.

BACKGROUND: Senegal's National Malaria Control Programme (NMCP) implements control interventions in the form of targeted packages: (1) scale-up for impact (SUFI), which includes bed nets, intermittent preventive treatment in pregnancy, rapid diagnostic tests, and artemisinin combination therapy; (2) SUFI + reactive case investigation (focal test and treat); (3) SUFI + indoor residual spraying (IRS); (4) SUFI + seasonal malaria chemoprophylaxis (SMC); and, (5) SUFI + SMC + IRS. This study estimates the cost effectiveness of each of these packages to provide the NMCP with data for improving allocative efficiency and programmatic decision-making. METHODS: This study is a retrospective analysis for the period 2013-2014 covering all 76 Senegal districts. The yearly implementation cost for each intervention was estimated and the information was aggregated into a package cost for all covered districts. The change in the burden of malaria associated with each package was estimated using the number of disability adjusted life-years (DALYs) averted. The cost effectiveness (cost per DALY averted) was then calculated for each package. RESULTS: The cost per DALY averted ranged from $76 to $1591 across packages. Using World Health Organization standards, 4 of the 5 packages were "very cost effective" (less than Senegal's GDP per capita). Relative to the 2 other packages implemented in malaria control districts, the SUFI + SMC package was the most cost-effective package at $76 per DALY averted. SMC seems to make IRS more cost effective: $582 per DALY averted for SUFI + IRS compared with $272 for the SUFI + IRS + SMC package. The SUFI + focal test and treat, implemented in malaria elimination districts, had a cost per DALY averted of $1591 and was only "cost-effective" (less than three times Senegal's per capita GDP). CONCLUSION: Senegal's choice of deploying malaria interventions by packages seems to be effectively targeting high burden areas with a wide range of interventions. However, not all districts showed the same level of performance, indicating that efficiency gains are still possible.

Exploring the use of routinely-available, retrospective data to study the association between malaria control scale-up and micro-economic outcomes in Zambia.

BACKGROUND: Country-level evidence on the impact of malaria control on micro-economic outcomes is vital for mobilizing domestic and donor resources for malaria control. Using routinely available survey data could facilitate this investigation in a cost-efficient way. METHODS: The authors used Malaria Indicator Surveys (MIS) and Living Conditions Monitoring Survey (LCMS) data from 2006 to 2010 for all 72 districts in Zambia to relate malaria control scale-up with household food spending (proxy for household well-being), educational attainment and agricultural production. The authors used two quasi-experimental designs: (1) a generalized propensity score for a continuous treatment variable (defined as coverage from owning insecticide-treated bed nets and/or receipt of indoor residual spraying); and, (2) a district fixed effects model to assess changes in the outcome relative to changes in treatment pre-post scale-up. The unit of analysis was at district level. The authors also conducted simulations post-analysis to assess statistical power. RESULTS: Micro-economic outcomes increased (33% increase in food spending) concurrently with malaria control coverage (62% increase) from 2006 to 2010. Despite using data from all 72 districts, both analytic methods yielded wide confidence intervals that do not conclusively link outcomes and malaria control coverage increases. The authors cannot rule out positive, null or negative effects. The upper bound estimates of the results show that if malaria control coverage increases from 60 to 70%, food spending could increase up to 14%, maize production could increase up to 57%, and years of schooling could increase up to 0.5 years. Simulations indicated that the generalized propensity score model did not have good statistical power. CONCLUSION: While it is technically possible to use routinely available survey data to relate malaria control scale-up and micro-economic outcomes, it is not clear from this analysis that meaningful results can be obtained when survey data are highly aggregated. Researchers in similar settings should assess the feasibility of disaggregating existing survey data. Additionally, large surveys, such as LCMS and MIS, could incorporate data on both malaria coverage and household expenditures, respectively.

The effectiveness of non-pyrethroid insecticide-treated durable wall lining to control malaria in rural Tanzania: study protocol for a two-armed cluster randomized trial.

BACKGROUND: Despite considerable reductions in malaria achieved by scaling-up long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS), maintaining sustained community protection remains operationally challenging. Increasing insecticide resistance also threatens to jeopardize the future of both strategies. Non-pyrethroid insecticide-treated wall lining (ITWL) may represent an alternate or complementary control method and a potential tool to manage insecticide resistance. To date no study has demonstrated whether ITWL can reduce malaria transmission nor provide additional protection beyond the current best practice of universal coverage (UC) of LLINs and prompt case management. METHODS/DESIGN: A two-arm cluster randomized controlled trial will be conducted in rural Tanzania to assess whether non-pyrethroid ITWL and UC of LLINs provide added protection against malaria infection in children, compared to UC of LLINs alone. Stratified randomization based on malaria prevalence will be used to select 22 village clusters per arm. All 44 clusters will receive LLINs and half will also have ITWL installed on interior house walls. Study children, aged 6 months to 11 years old, will be enrolled from each cluster and followed monthly to estimate cumulative incidence of malaria parasitaemia (primary endpoint), time to first malaria episode and prevalence of anaemia before and after intervention. Entomological inoculation rate will be estimated using indoor CDC light traps and outdoor tent traps followed by detection of Anopheles gambiae species, sporozoite infection, insecticide resistance and blood meal source. ITWL bioefficacy and durability will be monitored using WHO cone bioassays and household surveys, respectively. Social and cultural factors influencing community and household ITWL acceptability will be explored through focus-group discussions and in-depth interviews. Cost-effectiveness, compared between study arms, will be estimated per malaria case averted. DISCUSSION: This protocol describes the large-scale evaluation of a novel vector control product, designed to overcome some of the known limitations of existing methods. If ITWL is proven to be effective and durable under field conditions, it may warrant consideration for programmatic implementation, particularly in areas with long transmission seasons and where pyrethroid-resistant vectors predominate. Trial findings will provide crucial information for policy makers in Tanzania and other malaria-endemic countries to guide resource allocations for future control efforts. TRIAL REGISTRATION: NCT02533336 registered on 13 July 2014.

Strategic roles for behaviour change communication in a changing malaria landscape.

Strong evidence suggests that quality strategic behaviour change communication (BCC) can improve malaria prevention and treatment behaviours. As progress is made towards malaria elimination, BCC becomes an even more important tool. BCC can be used 1) to reach populations who remain at risk as transmission dynamics change (e.g. mobile populations), 2) to facilitate identification of people with asymptomatic infections and their compliance with treatment, 3) to inform communities of the optimal timing of malaria control interventions, and 4) to explain changing diagnostic concerns (e.g. increasing false negatives as parasite density and multiplicity of infections fall) and treatment guidelines. The purpose of this commentary is to highlight the benefits and value for money that BCC brings to all aspects of malaria control, and to discuss areas of operations research needed as transmission dynamics change.

The role of health systems and policy in producing behavior and social change to enhance child survival and development in low- and middle-income countries: an examination of the evidence.

Evidence-based behavior change interventions addressing health systems must be identified and disseminated to improve child health outcomes. Studies of the efficacy of such interventions were identified from systematic searches of the published literature. Two hundred twenty-nine of the initially identified references were judged to be relevant and were further reviewed for the quality and strength of the evidence. Studies were eligible if an intervention addressed policy or health systems interventions, measured relevant behavioral or health outcomes (e.g., nutrition, childhood immunization, malaria prevention and treatment), used at least a moderate quality research design, and were implemented in low- or middle-income countries. Policy or systems interventions able to produce behavior change reviewed included media (e.g., mass media, social media), community mobilization, educational programs (for caregivers, communities, or providers), social marketing, opinion leadership, economic incentives (for both caregiver and provider), health systems strengthening/policy/legislation, and others. Recommendations for policy, practice, and research are given based on fairly strong data across the areas of health service delivery, health workforce, health financing, governance and leadership, and research.

Broken promise? Taxes and tariffs on insecticide treated mosquito nets.

Seven years ago, the removal of taxes and tariffs on insecticide treated nets (ITNs) was considered one of the easiest resolutions for most countries to implement among the targets agreed upon at the African Summit on Roll Back Malaria in Abuja, Nigeria, on April 25, 2000. However, seven years later, 24 of the 39 Abuja signatories continue to impose taxes and tariffs on this life-saving tool. Taxes and tariffs significantly increase the price of an insecticide treated net, reduce affordability, and discourage the commercial sector from importing insecticide treated net products. Consequently, Roll Back Malaria partners are engaged in advocacy efforts to remove taxes and tariffs on insecticide treated nets in malaria-endemic countries of Africa. This viewpoint summarizes key obstacles to the removal of taxes and tariffs that have been identified through a review of country situations. To achieve the goal of producing and supplying more than 160 million insecticide treated nets needed to reach the revised Roll Back Malaria Partnership targets by 2010, tax and tariff reforms are urgently needed. Such reforms must be accompanied by country-specific systems to protect the poor (e.g., through voucher systems for vulnerable groups and other forms of targeted subsidies).

Conquering the intolerable burden of malaria: what's new, what's needed: a summary.

Each year, up to three million deaths due to malaria and close to five billion episodes of clinical illness possibly meriting antimalarial therapy occur throughout the world, with Africa having more than 90% of this burden. Almost 3% of disability adjusted life years are due to malaria mortality globally, 10% in Africa. New information is presented in this supplement on malaria-related perinatal mortality, occurrence of human immunodeficiency virus in pregnancy, undernutrition, and neurologic, cognitive, and developmental sequelae. The entomologic determinants of transmission and uses of modeling for program planning and disease prediction and prevention are discussed. New data are presented from the Democratic Republic of the Congo, Tanzania, Ethiopia, and Zimbabwe on the increasing urban malaria problem and on epidemic malaria. Between 6% and 28% of the malaria burden may occur in cities, which comprise less than 2% of the African surface. Macroeconomic projections show that the costs are far greater than the costs of individual cases, with a substantial deleterious impact of malaria on schooling of patients, external investments into endemic countries, and tourism. Poor populations are at greatest risk; 58% of the cases occur in the poorest 20% of the world's population and these patients receive the worst care and have catastrophic economic consequences from their illness. This social vulnerability requires better understanding for improving deployment, access, quality, and use of effective interventions. Studies from Ghana and elsewhere indicate that for every patient with febrile illness assumed to be malaria seen in health facilities, 4-5 episodes occur in the community. Effective actions for malaria control mandate rational public policies; market forces, which often drive sales and use of drugs and other interventions, are unlikely to guarantee their use. Artemisinin-based combination therapy (ACT) for malaria is rapidly gaining acceptance as an effective approach for countering the spread and intensity of Plasmodium falciparum resistance to chloroquine, sulfadoxine/pyrimethamine, and other antimalarial drugs. Although costly, ACT ($1.20-2.50 per adult treatment) becomes more cost-effective as resistance to alternative drugs increases; early use of ACT may delay development of resistance to these drugs and prevent the medical toll associated with use of ineffective drugs. The burden of malaria in one district in Tanzania has not decreased since the primary health care approach replaced the vertical malaria control efforts of the 1960s. Despite decentralization, this situation resulted, in part, from weak district management capacity, poor coordination, inadequate monitoring, and lack of training of key staff. Experience in the Solomon Islands showed that spraying with DDT, use of insecticide-treated bed nets (ITNs), and health education were all associated with disease reduction. The use of nets permitted a reduction in DDT spraying, but could not replace it without an increased malaria incidence. Baseline data and reliable monitoring of key outcome indicators are needed to measure whether the ambitious goals for the control of malaria and other diseases has occurred. Such systems are being used for evidence-based decision making in Tanzania and several other countries. Baseline cluster sampling surveys in several countries across Africa indicate that only 53% of the children with febrile illness in malarious areas are being treated; chloroquine (CQ) is used 84% of the time, even where the drug may be ineffective. Insecticide-treated bed nets were used only 2% of the time by children less than five years of age. Progress in malaria vaccine research has been substantial over the past five years; 35 candidate malaria vaccines are in development, many of which are in clinical trials. Development of new vaccines and drugs has been the result of increased investments and formation of public-private partnerships. Before malaria vaccine becomes deployed, consideration must be given to disease burden, cost-effectiveness, financing, delivery systems, and approval by regulatory agencies. Key to evaluation of vaccine effectiveness will be collection and prompt analysis of epidemiologic information. Training of persons in every aspect of malaria research and control is essential for programs to succeed. The Multilateral Initiative on Malaria (MIM) is actively promoting research capacity strengthening and has established networks of institutions and scientists throughout the African continent, most of whom are now linked by modern information-sharing networks. Evidence over the past century is that successful control malaria programs have been linked to strong research activities. To ensure effective coordination and cooperation between the growing number of research and control coalitions forming in support of malaria activities, an umbrella group is needed. With continued support for scientists and control workers globally, particularly in low-income malarious countries, the long-deferred dream of malaria elimination can become a reality.

Tying up lions: multilateral initiative on malaria communications: the first chapter of a malaria research network in Africa.

"When spider webs unite, they can tie up a lion" (Ethiopian folk adage). The Multilateral Initiative on Malaria Communications Network (MIMCom) facilitates a new way of doing research in Africa and African scientists' participation in the international scientific community. The MIMCom supports full access to the Internet and the resources of the WorldWide Web at 19 research sites in 11 African countries. Furthermore, the MIMCom project comprises two websites: one includes links to resources, databases, and publications as well as a document delivery service for full text journal articles, and the other is a research agenda specific website with a server for a research network desiring to share raw data. Other important components of MIMCom are training and evaluation components. The MIMCom was conceived in 1997 by African researchers and has been designed, implemented, and overseen by the U.S. National Library of Medicine in collaboration with partners in Africa, the United States, and the United Kingdom. This project demonstrates clearly that it can make a positive difference in the functioning of remote research sites in Africa, in terms of site growth and productivity and in the professional lives of individual researchers. This report reviews the project's background, methods of operation with an emphasis on local needs and priorities, cost effectiveness, and local responsibility; results focusing on a technical network; documentation of the system and two-way exchange of information; the MIMCom website; a network approach to research; and financial sustainability. The report concludes with summaries of evaluations by an independent panel, the Multilateral Initiative on Malaria Secretariat, and the U.S. National Library of Medicine.

Are multilateral malaria research and control programs the most successful? Lessons from the past 100 years in Africa.

Multilateral malaria research and control programs in Africa have regained prominence recently as bilateral assistance has diminished. The transnational nature of the threat and the need for inspired leadership, good coordination, and new discoveries to decrease the impact of the disease has led to the founding of the Multilateral Initiative on Malaria, the Roll Back Malaria Project, Global Fund for HIV, Tuberculosis and Malaria (Global Fund), the Medicines for Malaria Venture, and the Malaria Vaccine Initiative, among other groups. Historically, the most striking feature of malaria control and elimination activities was the connectedness and balance between malaria research and control especially, from 1892 to 1949. A combination of scientific originality, perseverance in research, integrated approaches, and social concern were the keys for success. The elimination of Anopheles gambiae from Upper Egypt in 1942 using integrated vector control methods is a prime example of malaria control during the first half of the 20th century where those factors were brought together. After 1949, there were three decades of great optimism. Four notable landmarks characterized this period: the Kampala Conference in 1950; the Global Malaria Eradication Program beginning in 1955; the primary health care strategies adopted by most African States after attaining their political independence in the 1960s, and accelerating in the 1980s; and creation of the Special Program in Training and Research in Tropical Diseases at the World Health Organization in 1975. The initial highly encouraging operational results, largely obtained in temperate or subtropical areas where transmission was unstable, engendered undue expectations for the success of identical antimalarial measures elsewhere. Many were convinced that the eradication was in sight, such that support for malaria research virtually ceased. Young, bright scientists were discouraged from seeking a career in a discipline that appeared to soon become superfluous. It took more than three decades to modify antimalarial strategies and to rehabilitate long-term control as an intermediate objective. In Africa, although multilateral malaria programs have grown over the past half century and proved the most successful, fragmentation of co-ordination remains and is a major challenge. The proliferation of malaria programs in the late 1990s has brought substantial additional funds and expertise. However, excessive funding competition and failure of different programs to collaborate has resulted in poor communication and duplication of activities. The capacities of the African nations to conduct high-quality research and to coordinate control efforts are in great jeopardy. There is an urgent need for a non-partisan umbrella organ to coordinate and facilitate the network of alliances and programs in malaria research and control in Africa.

Malaria control at the district level in Africa: the case of the muheza district in northeastern Tanzania.

An assessment was done in Tanzania to determine the extent to which the primary health care services have contributed to reducing the burden of malaria since the system was initiated in the 1980s. Seven descriptive processes and outcome indicators of effectiveness were used: changes of malaria transmission and incidence over time; use of facility-based care services for malaria; patients' access to professional advice; the trend of treatment failure over time of sulfadoxine-pyrimethamine and chloroquine; survival rates of severe cases at the district hospital; a district malaria control strategy; number of malaria specific training for care providers; and the number of activities carried out on mosquito control measures. The data were collected from 1996 to 2003 in the Muheza district northeastern Tanzania. It covered household interviews with a stratified sample of 1,250 respondents, and in-depth interviews with all 175 health care providers in the 35 health facilities within the district. All six members of the district health management team were also interviewed. Additional data came from dispensary and hospital records, and published literature. The results show an unchanged malaria disease burden. The average number of clinical malaria episodes per child less than five years of age remained between 3 and 3.5 episodes per year in the district since the 1960s. The comparison of cases expected in the population less than five years old with those seen in the district health facilities shows a coverage rate of 33%. Furthermore, between 1990 and 2003, little training on malaria was provided to health staff. The findings imply a limited effectiveness of district health services on malaria control, suggesting a weak process of translating national malaria goals to activities at the district level.

Crossing the digital divide: the contribution of information technology to the professional performance of malaria researchers in Africa.

BACKGROUND: The US National Library of Medicine supports the Multilateral Initiative on Malaria (MIM) through the design, implementation, and operation of the Multilateral Initiative on Malaria Communications Network (MIMCom.) MIMCom makes possible enhanced access to the Internet and to medical literature. OBJECTIVES: The main objectives of the present study were to examine the use of MIMCom supported information technology (IT) by scientists, students, and administrative personnel to facilitate communication, retrieve information, obtain documents, write proposals, and prepare papers for publication; and to determine the contribution of this intervention to their professional performance. METHODS: The authors analyzed the contribution of enhanced Internet connectivity and access to electronic information resources to the performance of malaria research staff and their institutes through a cross-sectional questionnaire survey of 181 respondents at 14 health research centers in Africa. Separate reviews of bandwidth usage, requests for document delivery, and publications in peer reviewed journals support the data of the survey. RESULTS: The MIMCom network makes a positive contribution to the performance of malaria researchers and support staff at the sites reviewed by improving e-mail exchange, access to published literature, and research proposal development and submission. Implications of these findings are discussed. CONCLUSION: By providing full access to the Internet and the resources of the WorldWide Web, MIMCom has been shown to be invaluable to malaria researchers and their institutes in Africa. This access has increased visibility of scientists in their respective institutions and provided opportunities for stronger engagement with the international scientific community.