Recommendation II: Utilize Cross-Sectoral Approach and Resources to Combat Malaria Associated with Development Efforts

Potential Impact of Resource Development Projects on Malaria

Development projects have the capacity to influence the transmission of malaria. It can be expected that if not anticipated and corrected for in the initial plan, most development projects will result in an increase in malaria transmission because of one or more of the following factors:

• irrigation
• water provision
• building sites
• road construction
• deforestation
• population shifts (resulting from economic, seasonal, or permanent migration, refugee situations)

For example, water resource development projects such as multi-purpose reservoirs, irrigation canal systems, and urban drainage projects have been shown in many cases to increase the incidence of vector-borne disease in Africa, especially malaria. These macro-scale projects are generally characterized by the following: their location in semi-arid lands (where irrigation projects are directed), the diversion and manipulation of large quantities of surface water, their requirement for significant donor funding, and a total implementation period that normally spans 10-15 years.

Furthermore, many water resource projects for irrigated semi-arid lands are implemented without any significant assessment of potential health impact. The fact that most semi-arid regions of Africa are presently low endemic areas for malaria means the potential is great to create high endemic and epidemic conditions in close proximity to the project.

Example: Irrigation Development and Malaria Incidence in Zanzibar

Irrigation development in Zanzibar was initiated with the objective of increasing rice production in the isles and consequently reducing the import bill for rice. Initially, no consideration was given to the potential for irrigation schemes to increase transmission of malaria and other vector-borne diseases. It was only later in the project phase when the Malaria Control Project of Zanzibar cautioned the project planners on the excessive use of insecticides, which were also suitable for mosquito control, that a concern for malaria was reported.

A fact-finding mission was subsequently organized to collect more information on the presence of vector mosquito larvae and snail intermediate hosts in the paddy fields. The preliminary survey indicated that the presence and, to some extent, the density of mosquito larvae of the genus Anopheles were directly related to the irrigation regime:

It was very unfortunate that during the planning phase for such endemic areas of malaria no attention was drawn to the need and the possibilities for systematic action and to indicate where research, collaboration and assistance could be most effective. (Khatibu)

In addition, the resources of development sectors other than health, frequently often the private authority responsible for the development project, must be tapped and coordinated to bring to bear the broadest approach and resource base for tackling malaria control.

Opportunities for Control of Malaria Associated with Development Efforts

Planning for and monitoring of malaria control associated with development efforts

It is recommended that all development projects take into account the potential for an adverse impact on malaria. Project plans must thus include provisions for reducing the potential for transmission. Development of such plans and mechanisms for monitoring impact can best be achieved by cross-sectoral teams.

Standard pre-project planning requires input from such teams with representation from various sectors. Controlling malaria associated with these development efforts would be strengthened by changing the requirements for project planning and implementation to mandate that these experts should operate as a team throughout the project life to monitor project impact, recommend revisions to the project as required, and evaluate actual compliance with and effectiveness of revised malaria control efforts.

Prevention of malaria associated with development can best be established at the pre-planning stage. Early prevention of malaria is generally simpler and cheaper than instituting corrective measures later.

Specified recommended components, to be carried out by the team members, must be included in the planning and implementation phases, respectively, to prevent an adverse impact on malaria. It is critical that the implementation phase must continue and reinforce the interventions initiated in the planning phase. These efforts should include:

In the planning phase:

• Epidemiologic assessment for malaria. Projects must include a baseline epidemiologic characterization of the region selected for development. This characterization will include the current malaria situation, the biology of the malaria parasite and its various vector control strategies, and the roles of the health system, the community, and the other sectors in any existing malaria program.
• A commitment to and plan for community involvement, to be developed in conjunction with the affected community. The input, consultation, and education of the affected human population, the community, are imperative.
• Design and establishment of safeguards. Preventive and corrective policies and practices must be instituted to control malaria associated with development efforts.
• Opportunity for later modifications to the development plan. The planning phase must also include a consideration of changes that the development projects may generate and, most importantly, allow for modifications to the plan to reduce the transmission of malaria in the future.

In the implementation phase:

• regular and ongoing monitoring (at least yearly) of malaria epidemiology;
• continual involvement of the community in program implementation; and
• monitoring and enforcement of safeguards.

Establish a requirement for a strengthened Environmental Impact Assessment

Current environmental impact requirements are neither strong nor specific enough to prevent or reduce malaria associated with planned development efforts. For example, A.M.A. Imevbore points out that although "the National Health Policy established since 1986 explicitly requires intersectoral collaboration among ministries of health planning, agriculture and finance, several irrigation projects have nevertheless been built without implementing this policy for intersectoral collaboration at the planning stage" (paper by Imevbore, in Appendix of print version of this report). Also, in the USAID checklist for environmental impact, public health and disease vector questions receive less attention than do endangered species, pest plants and animals, or tourism and recreation. Given the importance of malaria as a public health problem, and the potential that development schemes have to influence the intensity of malaria transmission, a requirement for malaria-specific impact statements should be justifiable in Africa. The emphasis should be placed on reviewing current requirements for Environmental Impact Assessment in USAID-funded development projects, and incorporating safeguards for malaria control throughout a project cycle.

Therefore, it is also recommended that:

• A full disclosure, cross-sectoral Environmental Impact Assessment (EIA), with a strengthened, integrated health impact component, must be prepared for all development efforts that may have a negative impact on malaria, for example: water resources, industrial development, urban development, integrated agriculture, hydro-electricity, flood control, resettlement, drainage, and wastewater treatment.
• In addition, a Malaria Impact Statement, as part of the EIA process, should be a prerequisite for all development projects. This Malaria Impact Statement may be prepared either completely by or with the assistance of a regional malaria research and training center, network, or institute.
• The Health or Malaria Impact Assessment component should be fully integrated into the EIA process with the health impact considered the most significant feature of the EIA. The health impacts should be summarized to show the net health changes due to the project's construction and implementation. The Health Impact Assessment component should consider in its analysis both on-site and off-site project impacts that are commonly associated with development projects. Such an assessment should include the following questions:
  Does the project change
  • the ability of groups of individuals to fight disease?
  • the exposure of individuals to disease and injury?
  • the virulence of disease-causing pathogens?
  • the accessibility of health care services?
  • the ability to pay for health care services?
  • the local ability to provide (manufacture) health promotion and disease-treating products?
• This EIA process should be prepared early enough in the planning process to ensure that pre-implementation baseline health data can be collected and that beneficial design changes can be incorporated into the final design. The process for both scoping and preparing the EIA should include representatives from all the involved ministries and a team of environmental/health assessors.
• Those ministy representatives will also specify the informational requirements and review the specific conclusions of the EIA.
• It is recommended that post-project monitoring for health impacts be implemented in a cross-sectoral manner by all concerned ministries.
• Critical research topics in the areas of vector biology, epidemiology, mitigation effectiveness, monitoring techniques, and design factors can and should be identified through this Health Impact Assessment process.

Establish a requirement for cross-sectoral assessment of selection, design, and construction of development sites

In addition to the recommendations provided above for general development efforts, special opportunities exist for targeting malaria control interventions to urban, industrial, and infrastructural development.

• Encourage dispersed geographic distribution of industrial development to avoid over-concentration and over-population of urban areas, factors that frequently lead to increased disease transmission.
• Development sites and construction methods should be reviewed by a cross-sectoral body concerned with malaria (including entomologists and sanitation engineers, community development specialists, and community representatives) to avoid situating the accompanying human populations near existing mosquito-breeding sites and to prevent proliferation of new mosquito breeding sites.