Rethinking human resources and capacity building needs for malaria control and elimination in Africa.

Despite considerable success in controlling malaria worldwide, progress toward achieving malaria elimination has largely stalled. In particular, strategies to overcome roadblocks in malaria control and elimination in Africa are critical to achieving worldwide malaria elimination goals-this continent carries 94% of the global malaria case burden. To identify key areas for targeted efforts, we combined a comprehensive review of current literature with direct feedback gathered from frontline malaria workers, leaders, and scholars from Africa. Our analysis identified deficiencies in human resources, training, and capacity building at all levels, from research and development to community involvement. Addressing these needs will require active and coordinated engagement of stakeholders as well as implementation of effective strategies, with malaria-endemic countries owning the relevant processes. This paper reports those valuable identified needs and their concomitant opportunities to accelerate progress toward the goals of the World Health Organization's Global Technical Strategy for Malaria 2016-2030. Ultimately, we underscore the critical need to re-think current approaches and expand concerted efforts toward increasing relevant human resources for health and capacity building at all levels if we are to develop the relevant competencies necessary to maintain current gains while accelerating momentum toward malaria control and elimination.

Immediate assessment of performance of medical laboratory scientists following a 10-day malaria microscopy training programme in Nigeria.

BACKGROUND: Rapid and precise diagnosis of malaria is an essential element in effective case management and control of malaria. Malaria microscopy is used as the gold standard for malaria diagnosis, however results remain poor as positivity rate in Nigeria is consistently over 90%. The United States President's Malaria Initiative (PMI) through the Malaria Action Program for States (MAPS) supported selected states in Nigeria to build capacity for malaria microscopy. This study demonstrates the effectiveness of in-service training on malaria microscopy amongst medical laboratory scientists. METHOD: The training was based on the World Health Organization (WHO) basic microscopy training manual. The 10-day training utilized a series of didactic lectures and examination of teaching slides using a CX 21 Olympus binocular microscope. All 108 medical laboratory scientists trained from 2012 to 2015 across five states in Nigeria supported by PMI were included in the study. Evaluation of the training using a pre-and post-test method was based on written test questions; reading photographic slide images of malaria parasites; and prepared slides. RESULT: There was a significant improvement in the mean written pre-and post-tests scores from 37.9% (95% CI 36.2-39.6%) to 70.7% (95% CI 68.4-73.1%) (p < 0.001). The mean counting post-test score improved significantly from 4.2% (95% CI 2.6-5.7%) to 27.9% (95% CI 25.3-30.5%) (p < 0.001). Mean post-test score for computer-based picture speciation test (63.0%) and picture detection test (89.2%) were significantly higher than the mean post-test score for slide reading speciation test (38.3%) and slide reading detection test (70.7%), p < 0.001 in both cases. CONCLUSION: Parasite detection and speciation using enhanced visual imaging was significantly improved compared with using direct microscopy. Regular in-service training and provision of functional and high resolution microscopes are needed to ensure quality routine malaria microscopy.

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).

Social science research in malaria prevention, management and control in the last two decades: an overview.

In the recent past, considerable progress has been made in understanding how human behavior and social organization, macro- and micro-level economic processes, and health and political systems affect responses to malaria at global, national, community, household, and individual levels. Advances in malaria-related social, behavioral, economic, evaluation, health systems, and policy (social science) research have resulted in improvements in the design and implementation of malaria prevention, management and control (PMC) strategies. Indeed, the past two decades chronicle dramatic advances in the implementation of evidence-based interventions, drawn not only from biomedical but also from social science research. Malaria awareness-raising, advocacy, case management, and prevention efforts have reaped the benefits of social science research and as a result, many programs are implemented and evaluated in a more effective manner than in the past. However, the pace at which findings from social science research are integrated into program and policy implementation is unsatisfactory. Additionally, examples remain of programs that fail to utilize findings from social science research and as a result, achieve minimal results. Furthermore, there is a sizeable body of knowledge that is underutilized and which, if assimilated into programs and policies, could accelerate progress in malaria PMC. Examples include information on meaningful community participation, gender, socio-economic status, and health systems. Regrettably, although social science input is necessary for almost all interventions for malaria management and control, the numbers of scientists working in this area are dismal in most of the key disciplines-medical anthropology; demography; geography and sociology; health economics and health policy; social psychology; social epidemiology; and behavior-change communication. Further, skills of program workers charged with implementation of interventions and strategies at country level are most often inadequate. The Special Program for Research and training in tropical diseases (TDR) and the multi-lateral initiative on malaria (MIM) have remained in the forefront of capacity building for this area of research, but additional efforts are needed to bring more applied social scientists into the fold. Their skills are necessary to ensure that social science findings get to program planners and implementers in a useful form that allows for more rapid and appropriate integration of the results into malaria PMC programs and policies. A re-thinking of the current focus within capacity building efforts is proposed.

Community reactions to the introduction of permethrin-treated bed nets for malaria control during a randomized controlled trial in western Kenya.

Prior to implementation of a randomized controlled trial of insecticide (permethrin)-treated bed nets (ITNs) in western Kenya, ethnographic studies were conducted to understand local perceptions of disease, sleeping patterns, and other factors that might affect use of ITNs. Educational activities took place prior to distribution, but immediately after distribution in Asembo only approximately half of the ITNs were in use. A qualitative study was then conducted to identify the community's perceptions about ITNs and the ITN project. While participants ranked malaria as important and recognized that malaria prevention could be beneficial, they believed ITNs would be only partly effective due to the perception that malaria has multiple causes. Concerns expressed included fear of the insecticide, thought by some to be a toxic family planning aid, the taking of blood during clinical studies, and the mixing up of family ITNs during net re-treatment, which would violate cultural taboos. Attempts were made to allay fears by improved communication on these subjects and modification of the study design.

Perceptions of bed nets and malaria prevention before and after a randomized controlled trial of permethrin-treated bed nets in western Kenya.

A study of mothers' perceptions regarding bed nets and malaria was conducted before and after a randomized controlled trial of insecticide (permethrin)-treated bed nets (ITNs) in western Kenya. Awareness about the trial and the rationale for bed net use increased by the end of the trial. Knowledge that mosquitoes caused malaria also increased; however, a higher proportion of mothers from control, rather than intervention villages, cited this (44.4% versus 27.9%; P < 0.001). Mothers from intervention villages were more knowledgeable about the use and maintenance of bed nets and re-treatment with insecticide. Both groups specified advantages of ITNs. Mothers from intervention villages noted practical advantages such as protection against bedbugs and falling roof debris. Few (< 1%) mothers indicated that ITNs protected children against malaria. Intervention homes used significantly fewer mosquito coils, insect spray, medicines, and burned cow dung less often compared with those in control villages. Mothers were willing to pay approximately 4.5 U.S. dollars for a regular bed net, but only 10.5 U.S. cents (intervention) and 0.036 (control) for re-treating a bed net. This study suggests that, despite two years of experience of use, bed nets and insecticides would not be purchased as a household priority in this impoverished rural community.

The role of drug delivery systems in health care: the case of self- medication.

Up to 80 % of illness episodes are first defined, diagnosed and treated at the household-level. In the developing world especially, approximately half the population has no access to public health services. It is obvious then that other sources of care will be used. We examined the availability of proprietary drugs in communities, and the extent and reasons for their use in the treatment of childhood malaria on the Kenyan Coast. Retail outlets are extensively used as the first tier of health care for illnesses considered to be mild or mundane. However, the wide range, types and formulations of over-the- counter (OTC) drugs including antimalarials available in these retail outlets constitute a major health hazard. Yet, both users and proprietors of retail outlets know little or nothing about the drugs and thus use or sell them inappropriately. Even, children are treated promptly by purchase of OTC drugs. The policy implications of these findings are discussed.