Recommendation VI: Encourage Innovative Approaches to Malaria Prevention and Control

Because of the unique nature of the malaria situation, and the virulence of mosquitoes nad parasites in Africa, innovative approaches to the problem are necessary. Donors, governments, and NGOs should initiate new solutions appropriate for individual situations. No single approach to malaria control will be successful across the continent; therefore multiple strategies, appropriate to culturally and ecologically unique settings, must be implemented.

Focus on Priority Populations in Addition to Pregnant Women and Children under Five Years of Age

It is widely recognized that pregnant women and children under the age of five are at particularly high risk of malaria morbidity and mortality. Program interventions and research are required for other vulnerable groups as well.

Certain groups, for example, forced to migrate for political, economic, or cultural reasons, may become exposed to a higher risk of malaria morbidity and mortality. Carriers of malaria parasites who move into non-endemic areas serve as reservoirs for transmission of the disease among non-immune populations. Furthermore, non-immune populations may choose or be forced to move into endemic regions. These movements may occur as water becomes scarce during droughs, when populations often move closer to water sources and breeding areas, thereby increasing the risk of malaria morbidity and mortality. All these at-risk groups are ideal targets for health education and control programs tailored to their social, cultural, and geographical settings and needs.

1. Urban and peri-urban populations require special interventions.

In planned urban areas, and other arranged settlements, planners must allow for an integrated approach to community design that considers features such as settlement site selection, minimum housing standards, chemoprophylaxis, environmental modification, larviciding, and residual spraying. After the community is established, malaria control should be under local purview: diagnosis, treatment, intervention, water management, housing, etc. Industrial development sites should be dispersed to avoid over-concentrations of population. Planners at any level must consult the populations for which the settlement is being developed. Health education, geared toward prevention in the new setting, should be implemented in the very early stages of the relocation of populations, in cooperation with leaders of these communities. They should be encouraged to maintain, with the assistance of NGOs, their own systems for diagnosis, treatment, and intervention, as part of a community-level integrated approach.

Case studies: lessons learned

Pawie Settlement, Ethiopia: In a planned settlement scheme in Pawie, Ethiopia, the Ethiopian government anticipated malaria problems when a largely non-immune population entered a malaria-endemic area. Prevention and control measures were instituted including: weekly chemoprophylaxis; diagnostic and treatment centers; training of community health workers; organization of health committees with representation from agriculture, construction, health, education, as well as from community leadership; source reduction and environmental control activities; spraying, etc. In spite of these efforts, the Pawie settlement experienced a drastic increase in malaria prevalence from 1985 to 1988.

Although attempts were made to control the problem, certain critical features were neglected. The increase in prevalence was attributable to ineffectiveness of spraying because tukul (home) walls were not plastered; also tukuls were frequently within 100 meters of breeding sites; human-vector contact was high because of outdoor sleeping patterns; and chloroquine resistance emerged. Steps taken since 1988 include: plastering of walls, surveillance of chloroquine-resistant P. falciparum, and drainage of major breeding sites.

Arba Minch, Ethiopia: In a planned urban area, Arba Minch, where malaria had been endemic but controlled, the introduction of development projects, and subsequent influx of non-immune populations, resulted in a resurgence of malaria between 1985 and 1989. Training institutes, a textile factory, and cotton plantations were opened during the time period, all bringing in laborers, many from non-malaria endemic regions. However, measures to mitigate these effects were not taken, and malaria prevalence and incidence rates consequently nearly doubled between 1986 and 1988.

In unplanned urban areas (i.e., urban fringes densely populated mostly inhabitated by individuals who seek economic opportunities, but who remain on the city outskirts, usually in unsafe, unsanitary surroundings), no single plan is appropriate because of the heterogeneity of these peri-urban areas. Attempts to organize the disparate community members may be hindered by the transient nature of such a community. Efforts should be made to extend services available within the cities to the peri-urban fringe:

• The primary focus should be on general sanitation, e.g, safe water supply, latrines, drainage, waste disposal, etc. Control programs could be built into general sanitation as the latter develops and becomes sustainable.
• NGO activity should be encouraged in these unplanned areas because frequently there are few supporting, traditional infrastructures on which to base control programs. NGOs could play a critical part in developing and implementing malaria control programs, including a role in identifying "natural" community leaders (religious, social, and educational) and developing local health committees.

2. Migratory populations, comprising a significant high-risk population in Africa, may enter areas where malaria is more prevalent or where there are parasites to which they have developed no immunity.

Nomadic populations: Social and anthropological research is still required to determine how best to address malaria in this kind of population. Moreoever, there exists very little epidemiological data on the patterns of prevalence of malaria among nomadic populations. However, we do know that some migratory patterns (in Somalia, for example) bring non-immune populations into endemic areas, often when a population has moved in search of water, more fertile land, pastures for cattle, sheep, etc. Such movements may have been shown to raise the incidence of malaria to epidemic proportions and, in the case of Somalia (among others), to increase chloroquine resistance.

Seasonal laborers: The problems of groups of seasonal laborers who migrate once, twice, or several times annually also need to be explored. The unique problems that they face, leaving and or entering malaria-endemic areas, losing any natural immunity that they may have had, need to be assessed. Moreover, in cases where workers who previously inhabited endemic areas arrive in non-endemic areas, frequently as labor for development projects, these carriers serve as a parasite reservoir, permitting malaria transmission among the native, non-immune populations.

Currently there are few data and little experience upon which to base an effective approach to malaria among these inherently transient groups. More research is required on structures available that could support malaria control efforts. Strategies must be developed that are suitable for a population that moves frequently, and may sleep outside, often near water. Emphasis needs to be placed on protecting non-immune populations from exposure to parasites brought in by the migrant-labor carriers. Successful health education programs must be tailored to this way of life. Social, political, and cultural leaders must be identified and their leadership solicited for health education efforts.

Traditional rural communities: Community health workers, like district-level specialists, require continuing education and training. The village health worker, in addition to providing simple treatments, should mobilize the community through other existing diverse groups and their leaders, e.g., women's groups, schools, agricultural workers. In many cases community members do practice their own control measures, and village health workers should coordinate and promote members' efforts.

Again, because of geographical, ecological, and cultural diversity, these communities' practices, priorities, and existing control programs need to be evaluated, before strategies and health education efforts can be implemented, e.g., if a community has a long history of sleeping outdoors, neither bed nets nor window screening would seem to be appropriate measures.

Take Advantage of the Recent Movement toward Decentralization of Governments

The current trend toward decentralization of government planning and management in Africa (Ghana and Kenya, for example), providing increased responsibility to the district or equivalent level, offers a unique opportunity for malaria control

• In general, there is probably a greater chance for success in establishing cross-sectoral cooperation at the district level where typically there is less conflict between the sectors than at ministry levels.
• For developing malaria control plans specifically suited to the local environment, the increasing responsibility of district level officers provides an ideal setting for implementing control programs uniquely tailored to individual districts. This decentralization enables further specialization of control policies, allowing for ecological and cultural diversity. The district level also provides a more manageable area for monitoring and surveillance programs, and for carrying out pilot projects.

In Ghana, for example: By Local Government Law, 1988...a District Assembly exercises political and administrative authority in the district...This includes, among other things, preparing and submitting to the government the development plan and budget for the district, ensuring effective use of the resources of the district, social development, development of basic infrastructure (which should include water and health amenities), and management of human settlements and the environment. The role the district assembly plays in the area of mitigation of adverse impacts of water resource development is thus clear. The Planning Committee is to guide and coordinate local communities and all other agencies (Section 15, Development, Planning and Budgeting Unit of Assembly). The assembly is empowered to seek technical advice from professionals in the district. With the necessary collaboration of all concerned, then, the Planning Committee should be able to incorporate adequate public health and other preventive measures in developmental projects and in other activities of the community. (Laing)

In Kenya, the District Development Committees (DDCs) are responsible for intersectoral environmental planning and implementation of district-level water projects. In addition, they have supervisory roles in the development of national-level projects, within the involved districts. The DDCs, through their recently established District Water Boards, also supervise and advise the community-level projects. NGOs are now required to submit proposals for water resource management in communities to DDCs for approval in order to avoid conflict and duplication of effort (Thitai).

Establish Pilot Initiatives to Serve as Models for an Integrated, Cross-Sectoral Approach to Malaria Control

Complete pilot projects should be designed for and implemented in small sections of a problem area, e.g., in one community in a peri-urban area, to be replicated elsewhere if successful. This approach may be preferable to testing only parts of an integrated approach in different communities, which would result in never seeing the viability of a complete, integrated program. The potential for replicability will depend on geographical, ecological, cultural, social, political, and economic factors.

NGOs are typically better suited than bilateral or multilateral donors (e.g., USAID, World Bank, WHO) to support pilot projects that might be high risk. Moreover, NGOs may be least rigid and sector-bound, therefore best suited to effect cross-sectoral programs.

Establish Incentives and Penalties for Individual Behaviors and Commercial Practices That Affect Malaria Transmission

Governments and donors can develop and enforce incentives and/or penalties to encourage implementation of malaria control projects as part of development activities, in order to ensure that these activities engender no adverse impacts:

• Subsidizing expensive forms of vector control or drug treatment; or materials needed for source-reduction activities, "positive externalities." (Barlow)
• Fining individuals for engaging in practices detrimental to malaria control, practices that generate negative externalities. (Barlow)
• Encouraging local development and production of control materials, e.g, bed nets, screens, insecticides, etc.

Promote Strategies to Prevent Human-Vector Contact

As part of a multifaceted environmental, social, and behavioral approach to malaria control, and given the particular virulence of the mosquito and parasite in Africa, recommendations also underscored the importance of reducing human-vector contact in order to reduce transmission of malaria:

• Facilitate the widespread use by the population of impregnated bed nets, as part of an integrated approach. Especially important are government actions to bring down the cost of bed netting such as cost subsidization, elimination of customs duties on bed net importation, and promotion of competition in the manufacturing and importation of bed netting. It is understood that efficacy of bed nets is currently undergoing testing, and that this intervention is suitable primarily for individuals resting indoors during periods when malaria-carrying mosquitoes feed. It is also understood that this process must include education; if bed nets are found to be effective, efforts must go into education on how to use them correctly.
• Disseminate extensive health education messages targeted to populations at risk, i.e., young children and pregnant women. The messages should stress the importance of sleeping inside under bed nets, of draining/removing standing water accumulations near the home, and of taking prompt action to stop any leaks in water supply systems.
• Undertake efforts to increase the use of window screening in the home where appropriate and affordable. Emphasis should be placed on education and developing innovative methods for coupling screening into the design/redesign of housing and for increasing competition among potential suppliers of materials and manufacturing facilities used in the construction of screening.
• Support increased research on improved mosquito repellents (including those derived from natural products), and on the proper use of household insecticides. Consideration should be given to a possible international agreement restricting the use of chemicals known to be effective household insecticides for public health purposes only.
• Ensure that projects, such as water resource projects built in semi-arid and arid regions of low endemicity, are designed to minimize contact between the mosquito vector and the human population, and to prevent these regions from becoming highly endemic. Such projects will inevitably attract human resettlement into the newly developed area, and should therefore make use, to the extent appropriate and feasible, of such measures as low elevation reservoirs, efficient drainage systems, and well-maintained canals.

In sum: "Success of malaria control programs depends on the extent to which both the design and the implementation of malaria control programs are informed by interactions between economic development and malaria." (Mwabu)