The findings and recommendations contained in this report reflect the
deliberations of our panel of experts. These conclusions are further illuminated
and substantiated by examples from case studies prepared by these specialists
and found in the Appendix [note: case studies not currently available
In presenting recommendations, we have specified contributions best made
by African governments, donors, and NGOs. A prescription is given for
the health sector to take the lead wthin each of these groups and in their
joint efforts. The role of community participation in control strategies
is also discussed.
Problem Statement 1
Malaria is a complex problem for which there is no "magic bullet," no
quick or easy solution, particularly in Africa, where approximately 80
to 85 percent of cases and 90 percent of deaths in the world due to malaria
occur. Patterns of transmission and environmental and cultural factors
all vary so greatly throughout the continent that differences in prevalence
and incidence occur even between neighboring villages. The virulence of
both parasite and vector has thwarted control efforts, and emerging "multi-drug
resistant" parasite strains appear to be inducing an increasing
human toll, with a resulting impact on already overburdened health services,
and on productivity.
In response, the development of locally sustainable approaches
is critical. these approaches must be tailored as specifically as possible
to the myriad physical and social environments across the continent. To
achieve this goal, the following strategies are recommended:
- Perhaps the most important investment to be made for malaria control
is in human capital: to build local capacity in Africa to develop solutions
specific to the affected local environment and population. Several options
are proposed for developing the expertise in Africa to enable
the design of strategies appropriate to identified ecological and human
environments: research, reference, and training centers; as well as
networks of African scientists and their institutions; and, finally,
enhanced and innovative training and exchanges, including mentorships
and short courses offered by scientific societies.
- Participation by communities throughout the project cycle is critical
to program success and sustainability. It is important to recognize
that "communities are already actively undertaking malaria control strategies
of their own," (Mwabu) with members actively seeking treatment from
health providers and carrying out preventive measures, such as clearing
homesteads of mosquito breeding sites, or purchasing drugs, nets, and
sprays. Malaria programs must be designed to be culturally sensitive:
Program objectives must conform with the beneficiaries' needs and preferences
in order to achieve success (Etkin).
- Urban and peri-urban populations, as well as groups with high mobility
(seasonal laborers, nomads), require special attention as do the traditionally
recognized high-risk groups, pregnant women and children under age
- The inhabitants of urban and peri-urban areas are often more accessible
than dispersed rural dwellers. However, urban populations are growing
rapidly, and are presently facing some of the most acute environmental
problems. Many of these city dwellers are migrants and, as such,
may lack immunity to the local parasites.
- Furthermore, the deterioration of the urban environment is enhancing
the proliferation of vectors in urban areas (Thitai).
- Population changes related to employment, resettlement, and other
events can significantly affect malaria transmission (Etkin). Migratory
groups represent a large proportion of Africa's population, and
require special strategies because their frequent movement exposes
them to high risk of morbidity and mortality from malaria (Warsame).
- Opportunities should be seized for initiating innovative approaches.
For example, the increasing decentralization fo governmental decisionmaking
in Africa offers a unique opportunity fo restablishing effective cross-sectoral
initiatives and launching pilot projects for integrated approaches to
- In Kenya, for example, the District Development Committee "is
the obvious meeting point of the representatives of all the relevant
sectors to ensure environmentally sound planning and implementation
of water [and other development] projects" (Thitai)
- With African governments increasingly looking to cost recovery
methods for health services, government incentives and penalties
for practices that influence transmission of malaria should be established.
"In practice, the pattern of financial incentives and disincentives
in the area of health behavior is sometimes the exact opposite of
what it should be. Products with positive externalities in fact
are taxed, and products with negative externalities are subsidized.
In these circumstances, useful anti-malaria work might be done by
removing the distortion." (Barlow)
Problem Statement 2
Overall development can have an impact on transmission of malaria.
Agricultural development, water resource management, industrial and infrastructural
project sites, and household and community environments can create habitats
favorable for mosquito breeding. (Gwadz) The potentially adverse impact
of overall development on malaria can be reduced by:
- Strengthening "cross-sectoral" approaches for planning and implementing
development initiatives. Furthermore, this study reveals that cross-sectoral
approaches do already exist in Africa. Support should be provided
for: (1) strengthening these efforts based on an inventory of their
needs and priorities; and (2) researching how and where best to replicate
and improve upon these models.
- Strengthening the health components of Environmental Impact Statements
and/or establishing "Malaria Impact Statements." Currently, Environmental
Impact Statements, where implemented, do not have the authority necessary
to monitor and take corrective measures to prevent or reduce the impact
on malaria of a development initiative.
To strengthen the implementation of these recommendations -- and of ongoing
malaria control efforts -- the priority of malaria control must be raised
(for governments, donors, NGOs, and affected communities), together with
the recognition that malaria is not an intractable problem across the
continent. The current increased interest in malaria must be taken advantage
of, and national as well as global commitments strengthened. The Report
to the President (March 1991), prepared by Dr. Louis Sullivan, US Secretary
for Health and Human Services, and Dr. Ronald Roskens, Director, US Agency
for International Development, placed highest priority on investing in
malaria control The October 1991 WHO meeting on malaria control in Africa
also signals increased attention toward malaria in general, and in Africa
specifically. The present opportunity must not be lost: This is a pivotal
moment for asserting as an urgent priority the long-term sustainable malaria
control strategy embodied by adopting a cross-sectoral approach and by
building the capacity of Africans themselves.