The Fallacy of Policy: Rolling Back Malaria in East Africa

1. The Fallacy of Policy: Rolling Back Malaria in East Africa 2nd AIACC Regional Workshop for Africa and Indian Ocean Islands 24-27th March 2004 Dakar, Senegal Maggie Opondo AF 91 University of Nairobi Department of Geography

3. Introduction • Health policy increasingly gravitating towards espousing the public-private partnership model in both the provision of health infrastructure and delivery of services in East Africa. • Policy approach reinforced by the Global Malaria Control strategy that is increasingly becoming the vehicle for combating malaria in East Africa.

4. Introduction contd. . . • A survey conducted the Lake Victoria Basin reveals that the interplay of poverty and other variables usually intensifies the vulnerability of a population to the impact of disease. • This is because of lack of economic resources to invest in health coping mechanisms that can offset the costs of adaptation.

5. Introduction contd. . . • Analyses of certain socio-economic variables characteristic of communities affected by highland malaria epidemics indicates the gap between policies and their effectiveness in rolling back malaria. • Data set = Semi-structured interviews, focus-group discussions and stakeholder meetings conducted in Muleba (Tanzania), Kabaale (Uganda) and Kericho (Kenya).

6. Malaria Policies • Malaria programmes and strategies in East Africa are guided by the overall health policy whose goal is to provide universal primary healthcare. • Such strategies seek to reduce malaria through the promotion of primary health care, increasing access to health care services and encouraging the private sector to play a greater role in the delivery and financing of health care services.

7. Malaria Policies contd. . . • Co-existing with national health policies are international ones such as the Global Malaria Control Strategy that advocates four technical measures: • Sustainable preventive measures such as the use of ITNs; • Early diagnosis and treatment; • Early detection and prevention of epidemics; and • Strengthening local research capacities.

8. Malaria Policies contd. . . • Population Services International (PSI), a social marketing NGO (with assistance from USAID and DfID) intends to increase the use of ITNs in Kenya. • It seeks to increase household ownership of nets and avail the ITNs within 15 minutes’ walk in the malaria endemic areas.

9. Malaria Policies contd. . . • The efficacy of these programmes can be measured against the objective of effectively combating malaria, which has not been met since malaria epidemics continue to take a toll on the affected communities. • Moreover, these programmes make certain assumptions about the socio-economic status of the affected communities and related health infrastructure.

10. Malaria Policies contd. . . • But the socio-economic reality of the affected communities gives a very different picture. • This is because certain socio-economic characteristics (such as incomes, household size, and state of health infrastructure) ultimately determine the effectiveness of these programmes.

11. Use of Insecticide Treated Mosquito Nets (ITNs) • The survey reveals that use of insecticide treated mosquito nets (ITNs) are not very widespread. • A major determining factor encouraging the use of ITNs is affordability since most of these communities are poor, relying predominantly on either farm incomes or self-employment. • That the households in these communities are predominantly poor is well illustrated by the data.

12. Sources of Income - Kericho

13. Sources of Income - Kabaale

14. Sources of Income - Muleba

16. Household Size • The size of the household and the number of mosquito nets available may affect the effectiveness of ITNs in rolling back malaria.

17. Household Size and Use of Bednets

18. Treatment of Bednets • Those using bed nets tend not to treat the nets with insecticides (75.0%) and if it happens there is treatment, it is likely to be once or twice a year (25.0%). • Treatment of nets with insecticides is clearly not a common practice.

19. Coping Mechanisms • This is reinforced by the coping mechanisms utilised by the respondents in the face of malaria epidemics to cover the cost of treatment, the majority (75.5% in Kericho and 76.4 in Muleba) of whom sell their food crops. • Other ways of respondents coping with increased malaria cases are borrowing, or remittances from relatives.

20. Coping Mechanisms contd. . . • The coping mechanisms tend to make use of respondents’ resources and can lead to increased debts and poverty. • Not surprising then, that nearly half of the respondents indicated that they find the cost of treating malaria to be high. • About 72.7%, 72.4%, and 54.5% of the respondents in Kericho, Kabaale and Muleba respectively stated that the costs are prohibitive.

22. Early Diagnosis and Treatment • Early diagnosis and effective treatment of malaria presupposes the availability and accessibility of properly equipped health facilities. • Most respondents tend to visit the local dispensary and rarely do they visit the provincial hospitals that are better equipped and have in-patient facilities. • Often results in misdiagnosis or self-medication by the respondents.

23. Type of Health Facility Visited

24. Early Diagnosis and Treatmentcontd. . . • Such health facilities are not accessible and respondents either walk or rely on bicycles to reach them. • Bicycles are not only the cheaper, but also often the only available mode of transportation. • The frequency of visits to the health facilities confirms this.

25. Early Diagnosis and Treatmentcontd. . . • In Muleba, households are located at distances ranging from 0.5 km to 40 km with the majority of households within the 1-6 km. • In Kericho, health facilities are located at distances ranging from 0.2 km to 20 km but most households are within 1 – 2 km range.

26. Mode of Transport to Health Facilities

27. Visits to hospitals in the last three months by hsehold members

29. Knowledge of Disease • For early dectection and prevention of malaria epidemics requires proper knowledge. • Knowledge among both the communities and local health officials is couched in myths. • Public Health Act advocates the clearing of bushes so as to reduce malaria habitats. • Stakeholders’ meeting in Kericho – the health expert in AF91 shattered this myth

30. Knowledge of Disease • 2002 – a malaria epidemic year. • 2003 – was not because the Temperatures reduced by 2 degrees. • But the Medical Director of Litein Hospital attributed the lack of epidemic to the effectiveness of the ITNs campaign.

31. Community Myths ”ukikula mafuta ya chipsy inaamusha malaria mara moja” (If one eats food cooked with chipsy then the malaria parasite is reactivated). • The local community in Kericho believe that one of the causes of malaria is ”CHIPSY” – edible oil introduced in the early 90s coincided with the onset of malaria epidemics. • They also believe that drinking water from a different stream also leads to malaria

32. Efforts towards Early Warning Systems • Met. Dept. increasingly making weather information more public and linking it with possible impacts (e.g. health). • But not taken seriously by the Min. of Health. • Due to lack of collaboration, protection of territory and mistrust. • Met. Dept. Also sensistizing journalists on the importance of weather information

33. Conclusion • Given the low socio-economic status of most of the communities affected by climate-induced malaria epidemics, it is necessary to integrate strategies for rolling back malaria into the overall development and poverty reduction strategies. • Such strategies need to be informed by the impacts of climate change on health. • This calls for closer collaboration between policy makers and climate change researchers. • There is also a need for greater engagement of the primary stakeholders in designing policies that are intended to help them in combating malaria epidemics.

34. etcend of talking capacity! Thank You!