Introduction

Purpose and Scope of Study

The purpose of this fifteen-month study, and its report, is to provide recommendations for the prevention and control of malaria in sub-Saharan Africa. These recommendations should assist the setting of policies and of priorities for investments in malaria control in the region by the US Agency for International Development (USAID) and other international development agencies, as well as ministries and scientific institutions in Africa, and others concerned with African development.

In requesting this study, USAID urged AAAS to take a broad, multidisciplinary approach in order to devise innovative policy strategies, and provided the following guidance:

• Examine the contributions made to the spread of malaria in Africa by sectoral development programs, particularly in agriculture and water resource management, and by social and behavioral factors, such as migration and other changes in human habitat -- and devise recommendations accordingly for malaria control programs.
• Propose creative, novel methods that will strengthen current malaria prevention and control activities.
• Consider ways to raise awareness regarding the toll of malaria in Africa. Decisionmakers and individuals responsible for supporting development activities may not be fully cognizant of the potentially adverse impact of these operations on malaria, or of practicable ways to avoid these negative consequences.
• Develop an approach that will channel all available resources into a concerted attack against malaria in Africa. According to USAID, the resources allocated to most development sectors far exceed those designated for the health sector.

AAAS Method for Developing Recommendations

In response to the above guidelines proposed by USAID, AAAS established as its principal objective the development of recommendations that address the environmental, social, and behavioral aspects of malaria control in sub-Saharan Africa, emphasizing the potential impact of malaria of socioeconomic development.

A multidisciplinary team of specialists, with a broad range of scientific expertise and African experience, was identified, and then brought together to devise recommendations. Several criteria were used in selecting experts to participate in this study effort. First, the team would include specialists from the key sectors identified as falling within the purview of this study, particularly agriculture and water management, and other development areas where the impact on malaria was significant. Individuals who could address the social, cultural, and behavioral components of malaria control were also included. Second, as noted in the Foreword, experience administering programs or conducting research in Africa was also deemed essential. Third, the composition of the expert group should cover different country and regional experiences within Africa. Finally, specialists were included who have been active participants themselves in cross-sectoral initiatives. A list of participants is included in the Appendix.

This group of 27 included experts from 15 different countries in Africa (20 specialists), Europe (2 specialists), and the US (5 specialists). Professional specialties represented were: agriculture, anthropology, biology, botany, community development, demography, ecology, economics, environment, epidemiology, health education, immunology, medical entomology, microbiology, parasitology, urban planning, and water and sanitation.

AAAS relied primarily upon African experts, for the following reasons:

• to tap Africans' own experience regarding program needs, constraints, and likely successes; and
• to build the capacity of African experts and their institutions.

Initially, a small Steering Committee was formed, and convened twice, in order to discern the most important strategies and design considerations for malaria control for further deliberation later by the full group.

Listed below, without any order of priority, are the principal points of agreement reached by the Steering Committee:

• Design considerations necessary to apply when developing malaria control approaches for Africa:
  • Diverse environmental and ecological systems, where patterns of malaria transmission may differ even between neighboring villages.
  • Local variations in human behavior, social organization, and culture reflected in varying definitions of priority problems and different understandings about disease transmission.
  • Lack of epidemiological and entomological data on actual patterns of malaria and habits of the mosquito vector, critical to determining means to control malaria.
• Potential approaches identified for further deliberation by full team of experts:
  • Cross-sectoral planning and organization: cooperation among different specialties within the health sector, e.g., clinicians, epidemiologists, health educators, as well as between representatives of health and development sectors such as agriculture, water and sanitation, and economics.
  • Community participation: determination by communities of their own priorities, as well as of design and implementation of activities required to attain their own objectives.
  • Capacity building: incorporation of training and support measures aimed at strengthening African institutions and individuals, thereby ensuring local sustainability.
  • Health impact assessment: measurement of the potential adverse impact of development activities on health, specifically malaria, and recommendations to alleviate those effects.
  • High-risk groups: studying the particular needs of individuals and communities at greatest risk of morbidity and mortality related to malaria, and designing control and prevention programs accordingly.
  • Appropriate roles for institutions at subnational, national, regional, and international levels: specification of how various individuals and organizations, including international development agencies, can most effectively contribute to malaria control.

On the basis of the procedures and directives established by the Steering Committee, and summarized above, AAAS convened a workshop in Mombasa, Kenya, that brought together the full team of experts needed to specify a cross-sectoral approach to malaria in Africa. Particular attention was given to examining ways to ensure sectoral cooperation for the control of malaria associated with development efforts, with an emphasis on agriculture and water resource management. Priority was also given to human habitats, migration, settlement, and land use, and their relationships to malaria prevention and control in Africa.

Participants prepared background papers providing, in most instances, case examples of actual experience in or design considerations for developing and implementing effective malaria control programs. These papers are included in the Appendix [note: background papers are not currently available online]. These papers were the focus of "brainstorming" at the Mombasa workshop, and were discussed and evaluated by all participants on the basis of sustainability, suitability for replication or adaptation in other settings, economic viability, and other criteria.

The report that follows is the result of the efforts described here. The recommendations are based on those derived in the course of our expert meetings. Examples have been added from participant papers to amplify and substantiate recommendations made during those several working sessions.