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Promotion of malaria home-based treatment in Africa: the dangers of creating a second health system
International Health 3 (2011) 219–220
Contents lists available at ScienceDirect
International Health journal homepage: http://www.elsevier.com/locate/inhe
Commentary
Promotion of malaria home-based treatment in Africa: the dangers of creating a second health system
a r t i c l e
i n f o
Keywords: Malaria Home treatment Combination therapy ACT Sub-Saharan Africa
a b s t r a c t Many African countries have begun to scale-up home-based management of malaria (HMM) with artemisinin-based combination therapy. Evidence shows that this strategy gives efficient results in reducing the malaria burden. This initiative should be promoted to reduce malaria-related mortality and morbidity. HMM could, however, lead to critical public health problems, including the misdiagnosis of serious infections distinct from malaria as well as desertion of the public health system. I wish to emphasise the importance of improving the existing health system in African malaria-endemic areas for long-term improvement of population health in this context of HMM implementation. © 2011 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved.
Deployment of artemisinin-based combination therapies (ACT) in malaria-endemic areas constitutes real progress in the fight against malaria. Artemisinin derivatives used in combination with another drug, as recommended by the WHO to slow the development of parasite resistance, have proven their efficiency in the treatment of uncomplicated malaria in endemic areas where the current antimalarial drugs have become ineffective.1 However, malaria morbidity and mortality remain high, which is mainly due to delays in treatment. Populations affected by malaria morbidity and mortality are mostly deprived with poor literacy. Relatively poor knowledge about malaria and other diseases, in addition to insufficient funds to attend a health centre, results in high mortality in children. Malaria is the third most deadly disease among the youngest African children after diarrhoea and pneumonia.2 One way proposed to reduce the malaria burden consists of distributing drugs directly in villages to give better access to treatments to the entire population. Since 2004, the WHO recommends the scaling-up of home-based management of malaria (HMM) in all malaria-endemic areas.3 Many African countries have begun to scale-up HMM with an ACT in order to honour the Abuja commitment that ≥60% of those suffering from malaria have prompt access to affordable and appropriate treatment within 24 h of the onset of symptoms. To be correctly implemented,4 the strategy relies mostly on three factors; training community members as community health
workers (CHW) to correctly diagnose malaria and to dispense antimalarial treatments; informing mothers, or more broadly caregivers, on the disease and its treatment through education campaigns before implementation; and making drugs available in villages, close to home. Reports argue that people do not attend medical facilities when they think they have malaria because they are poorly received. The main reasons that were evoked concern the time taken to be treated, the unfriendly attitude of health workers and the high cost.5–7 In addition, it appears that health workers do not give useful information to caregivers on prevention, diagnosis and treatment of malaria.8,9 HMM is, therefore, widely preferred by caregivers who favour the dispensary for serious illnesses only.7 Evidence shows, however, that HMM gives efficient results in reducing malaria burden when it is correctly implemented. This is particularly true when HMM is combined with several community-directed interventions (CDI), such as intermittent preventive treatment in children (IPTc), use of long-term insecticide-treated nets, or directly-observed treatment for tuberculosis (TB) patients.10–12 Provided that international organisations can afford the appropriate implementation of HMM, we should promote this initiative to reduce malaria-related mortality and morbidity. However, HMM also raises a number of potential problems. HMM relies mostly on presumptive treatment of fevers with an antimalarial drug, favouring malaria as the clinical diagnosis and reducing the possible role of
1876-3413/$ – see front matter © 2011 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.inhe.2011.06.004
220
Commentary / International Health 3 (2011) 219–220
other infectious diseases that may be the cause. Despite increasing efforts to introduce rapid diagnostic tests (RDT) in peripheral health centres and at the community level, the literature reports that the malaria burden is overestimated in several African countries.13 It is well known that fever in African children is widely attributed by family members and medical practitioners to malaria. This misdiagnosis is partly due to the uncertainty of clinical diagnosis and partly to the fact that malaria symptoms are often indistinct from the symptoms of other febrile diseases. In addition, CHWs are trained for the CDIs implemented in their community, and have a reduced medical knowledge. Consequently, malaria is frequently overdiagnosed, which leads to a natural overuse of antimalarial treatments. This also constitutes a financial problem that can affect the longevity of such programmes. Therefore, health-deciders should be careful that measures to roll back malaria do not hamper the management of other serious diseases such as bacterial infections.14 HMM may reduce the role of peripheral health facilities, particularly in rural areas. Some initiatives combine CDIs, adding to malaria treatment diagnosis with RDTs, prevention with bed nets and the use of IPTc, treatment of TB, supplementation of vitamin A, and the prevention of onchocerciasis.12,15 Combining initiatives is double-edged. It was shown to improve caregivers’ home management of common childhood illnesses.15 However, it widens the role of CHWs and delays caregivers attendance at health facilities. There is a clear link between public health facilities and CHWs, as health workers are involved in training and monitoring of CHWs, and public health facilities provide communities with drugs, diagnostic tests and bed nets.16 Conversely, implementing HMM and other CDIs will probably create a second health system, incapable of managing severe cases, but nevertheless requiring large funds for its operation. So, what? We need to work to decrease malaria mortality, that is a certainty. HMM is a means to achieve this. However, we should support programmes and policies targeted at healthcare providers with the aim of improving the known weak points of the existing public health system, as suggested in the Nairobi Call to Action.17 Particularly, the relationship between health staff and patients should be strengthened to improve dissemination of information, reception and management of patients and guardians, and to reduce costs. In conclusion, I wish to emphasise the importance of improving the existing health system in African malariaendemic areas for long-term improvement of population health in this context of HMM implementation. Author’s contribution: AA has undertaken all the duties of authorship and is guarantor of the paper. Acknowledgement: The author thanks to Jan Sudor for rereading of the manuscript. Funding: None. Conflicts of interest: None declared. Ethical approval: Not required.
References 1. Sinclair D, Zani B, Donegan S, Olliaro P, Garner P. Artemisinin-based combination therapy for treating uncomplicated malaria. Cochrane Database Syst Rev 2009;3:CD007483. 2. Black RE, Cousens S, Johnson HL, Lawn JE, Rudan I, Bassani DG, et al. Global, regional, and national causes of child mortality in 2008: a systematic analysis. Lancet 2010;375:1969–87. 3. WHO. Scaling up home-based management of malaria. From research to implementation. Geneva: World Health Organization; 2004. WHO/HTM/MAL/2004.1096. 4. Pagnoni F. Malaria treatment: no place like home. Trends Parasitol 20;25:115-9. 5. Arulogun OS, Gregory AU. Management practices of childhood malaria among caregivers in Ojo Military Cantonment, Lagos, Nigeria: implication for child survival. Afr J Med Med Sci 2009;38:45–54. 6. Kpanake L, Dassa KS, Mullet E. Why most Togolese people do not seek care for malaria in health care facilities: a theory-driven inventory of reasons. Psychol Health Med 2009;14:502–10. 7. Rutebemberwa E, Nsabagasani X, Pariyo G, Tomson G, Peterson S, Kallander K. Use of drugs, perceived drug efficacy and preferred providers for febrile children: implications for home management of fever. Malar J 2009;8:131. 8. Dugas M, Dubé E, Kouyaté B, Bibeau G. Evaluation of transfer of knowledge about malaria by health professionals to patients’ mothers in Nouna, Burkina Faso [in French]. Sante 2008;18:149–54. 9. Yamamoto SS, Souares A, Sié A, Sauerborn R. Does recent contact with a health care provider make a difference in malaria knowledge? J Trop Pediatr 2010;56:414–20. 10. Ngasala BE, Malmberg M, Carlsson AM, Ferreira PE, Petzold MG, Blessborn D, et al. Effectiveness of artemether–lumefantrine provided by community health workers in under-five children with uncomplicated malaria in rural Tanzania: an open label prospective study. Malar J 2011;10:64. 11. Tagbor H, Cairns M, Nakwa E, Browne E, Sarkodie B, Counihan H, et al. The clinical impact of combining intermittent preventive treatment with home management of malaria in children aged below 5 years: cluster randomised trial. Trop Med Int Health 2011;16:280–9. 12. CDI Study Group. Community-directed interventions for priority health problems in Africa: results of a multicountry study. Bull World Health Organ 2010;88:509-18. 13. A-Elgayoum SM, El-Feki Ael-K, Mahgoub BA, El-Rayah el-A, Giha HA. Malaria overdiagnosis and burden of malaria misdiagnosis in the suburbs of central Sudan: special emphasis on artemisinin-based combination therapy era. Diagn Microbiol Infect Dis 2009;64:20–6. 14. Brent AJ, Ahmed I, Ndiritu M, Lewa P, Ngetsa C, Lowe B, et al. Incidence of clinically significant bacteraemia in children who present to hospital in Kenya: community-based observational study. Lancet 2006;367:482–8. 15. Ebuehi OM, Adebajo S. Improving caregivers’ home management of common childhood illnesses through community level interventions. J Child Health Care 2010;14:225–38. 16. UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases. Community-directed interventions for major health problems in Africa: a multi-country study: final report. Geneva: TDR; 2008. 17. Catford J. Implementing the Nairobi Call to Action: Africa’s opportunity to light the way. Health Promot Int 2010;25:1–4.
Agnès Aubouy a,b,∗ Institut de Recherche pour le Développement (IRD) UMR 152, Pharmacochimie et Pharmacologie pour le développement, Toulouse, France b Université Paul Sabatier, Faculté de Pharmacie, Toulouse, France a
∗ Present
address: UMR 152 IRD/Université, Hôpital de Rangueil, Bât. L1 - 3ème étage, 1 avenue Jean Poulhès, 31400 Toulouse, France. E-mail address: [email protected]
Contents lists available at ScienceDirect
International Health journal homepage: http://www.elsevier.com/locate/inhe
Commentary
Promotion of malaria home-based treatment in Africa: the dangers of creating a second health system
a r t i c l e
i n f o
Keywords: Malaria Home treatment Combination therapy ACT Sub-Saharan Africa
a b s t r a c t Many African countries have begun to scale-up home-based management of malaria (HMM) with artemisinin-based combination therapy. Evidence shows that this strategy gives efficient results in reducing the malaria burden. This initiative should be promoted to reduce malaria-related mortality and morbidity. HMM could, however, lead to critical public health problems, including the misdiagnosis of serious infections distinct from malaria as well as desertion of the public health system. I wish to emphasise the importance of improving the existing health system in African malaria-endemic areas for long-term improvement of population health in this context of HMM implementation. © 2011 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved.
Deployment of artemisinin-based combination therapies (ACT) in malaria-endemic areas constitutes real progress in the fight against malaria. Artemisinin derivatives used in combination with another drug, as recommended by the WHO to slow the development of parasite resistance, have proven their efficiency in the treatment of uncomplicated malaria in endemic areas where the current antimalarial drugs have become ineffective.1 However, malaria morbidity and mortality remain high, which is mainly due to delays in treatment. Populations affected by malaria morbidity and mortality are mostly deprived with poor literacy. Relatively poor knowledge about malaria and other diseases, in addition to insufficient funds to attend a health centre, results in high mortality in children. Malaria is the third most deadly disease among the youngest African children after diarrhoea and pneumonia.2 One way proposed to reduce the malaria burden consists of distributing drugs directly in villages to give better access to treatments to the entire population. Since 2004, the WHO recommends the scaling-up of home-based management of malaria (HMM) in all malaria-endemic areas.3 Many African countries have begun to scale-up HMM with an ACT in order to honour the Abuja commitment that ≥60% of those suffering from malaria have prompt access to affordable and appropriate treatment within 24 h of the onset of symptoms. To be correctly implemented,4 the strategy relies mostly on three factors; training community members as community health
workers (CHW) to correctly diagnose malaria and to dispense antimalarial treatments; informing mothers, or more broadly caregivers, on the disease and its treatment through education campaigns before implementation; and making drugs available in villages, close to home. Reports argue that people do not attend medical facilities when they think they have malaria because they are poorly received. The main reasons that were evoked concern the time taken to be treated, the unfriendly attitude of health workers and the high cost.5–7 In addition, it appears that health workers do not give useful information to caregivers on prevention, diagnosis and treatment of malaria.8,9 HMM is, therefore, widely preferred by caregivers who favour the dispensary for serious illnesses only.7 Evidence shows, however, that HMM gives efficient results in reducing malaria burden when it is correctly implemented. This is particularly true when HMM is combined with several community-directed interventions (CDI), such as intermittent preventive treatment in children (IPTc), use of long-term insecticide-treated nets, or directly-observed treatment for tuberculosis (TB) patients.10–12 Provided that international organisations can afford the appropriate implementation of HMM, we should promote this initiative to reduce malaria-related mortality and morbidity. However, HMM also raises a number of potential problems. HMM relies mostly on presumptive treatment of fevers with an antimalarial drug, favouring malaria as the clinical diagnosis and reducing the possible role of
1876-3413/$ – see front matter © 2011 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.inhe.2011.06.004
220
Commentary / International Health 3 (2011) 219–220
other infectious diseases that may be the cause. Despite increasing efforts to introduce rapid diagnostic tests (RDT) in peripheral health centres and at the community level, the literature reports that the malaria burden is overestimated in several African countries.13 It is well known that fever in African children is widely attributed by family members and medical practitioners to malaria. This misdiagnosis is partly due to the uncertainty of clinical diagnosis and partly to the fact that malaria symptoms are often indistinct from the symptoms of other febrile diseases. In addition, CHWs are trained for the CDIs implemented in their community, and have a reduced medical knowledge. Consequently, malaria is frequently overdiagnosed, which leads to a natural overuse of antimalarial treatments. This also constitutes a financial problem that can affect the longevity of such programmes. Therefore, health-deciders should be careful that measures to roll back malaria do not hamper the management of other serious diseases such as bacterial infections.14 HMM may reduce the role of peripheral health facilities, particularly in rural areas. Some initiatives combine CDIs, adding to malaria treatment diagnosis with RDTs, prevention with bed nets and the use of IPTc, treatment of TB, supplementation of vitamin A, and the prevention of onchocerciasis.12,15 Combining initiatives is double-edged. It was shown to improve caregivers’ home management of common childhood illnesses.15 However, it widens the role of CHWs and delays caregivers attendance at health facilities. There is a clear link between public health facilities and CHWs, as health workers are involved in training and monitoring of CHWs, and public health facilities provide communities with drugs, diagnostic tests and bed nets.16 Conversely, implementing HMM and other CDIs will probably create a second health system, incapable of managing severe cases, but nevertheless requiring large funds for its operation. So, what? We need to work to decrease malaria mortality, that is a certainty. HMM is a means to achieve this. However, we should support programmes and policies targeted at healthcare providers with the aim of improving the known weak points of the existing public health system, as suggested in the Nairobi Call to Action.17 Particularly, the relationship between health staff and patients should be strengthened to improve dissemination of information, reception and management of patients and guardians, and to reduce costs. In conclusion, I wish to emphasise the importance of improving the existing health system in African malariaendemic areas for long-term improvement of population health in this context of HMM implementation. Author’s contribution: AA has undertaken all the duties of authorship and is guarantor of the paper. Acknowledgement: The author thanks to Jan Sudor for rereading of the manuscript. Funding: None. Conflicts of interest: None declared. Ethical approval: Not required.
References 1. Sinclair D, Zani B, Donegan S, Olliaro P, Garner P. Artemisinin-based combination therapy for treating uncomplicated malaria. Cochrane Database Syst Rev 2009;3:CD007483. 2. Black RE, Cousens S, Johnson HL, Lawn JE, Rudan I, Bassani DG, et al. Global, regional, and national causes of child mortality in 2008: a systematic analysis. Lancet 2010;375:1969–87. 3. WHO. Scaling up home-based management of malaria. From research to implementation. Geneva: World Health Organization; 2004. WHO/HTM/MAL/2004.1096. 4. Pagnoni F. Malaria treatment: no place like home. Trends Parasitol 20;25:115-9. 5. Arulogun OS, Gregory AU. Management practices of childhood malaria among caregivers in Ojo Military Cantonment, Lagos, Nigeria: implication for child survival. Afr J Med Med Sci 2009;38:45–54. 6. Kpanake L, Dassa KS, Mullet E. Why most Togolese people do not seek care for malaria in health care facilities: a theory-driven inventory of reasons. Psychol Health Med 2009;14:502–10. 7. Rutebemberwa E, Nsabagasani X, Pariyo G, Tomson G, Peterson S, Kallander K. Use of drugs, perceived drug efficacy and preferred providers for febrile children: implications for home management of fever. Malar J 2009;8:131. 8. Dugas M, Dubé E, Kouyaté B, Bibeau G. Evaluation of transfer of knowledge about malaria by health professionals to patients’ mothers in Nouna, Burkina Faso [in French]. Sante 2008;18:149–54. 9. Yamamoto SS, Souares A, Sié A, Sauerborn R. Does recent contact with a health care provider make a difference in malaria knowledge? J Trop Pediatr 2010;56:414–20. 10. Ngasala BE, Malmberg M, Carlsson AM, Ferreira PE, Petzold MG, Blessborn D, et al. Effectiveness of artemether–lumefantrine provided by community health workers in under-five children with uncomplicated malaria in rural Tanzania: an open label prospective study. Malar J 2011;10:64. 11. Tagbor H, Cairns M, Nakwa E, Browne E, Sarkodie B, Counihan H, et al. The clinical impact of combining intermittent preventive treatment with home management of malaria in children aged below 5 years: cluster randomised trial. Trop Med Int Health 2011;16:280–9. 12. CDI Study Group. Community-directed interventions for priority health problems in Africa: results of a multicountry study. Bull World Health Organ 2010;88:509-18. 13. A-Elgayoum SM, El-Feki Ael-K, Mahgoub BA, El-Rayah el-A, Giha HA. Malaria overdiagnosis and burden of malaria misdiagnosis in the suburbs of central Sudan: special emphasis on artemisinin-based combination therapy era. Diagn Microbiol Infect Dis 2009;64:20–6. 14. Brent AJ, Ahmed I, Ndiritu M, Lewa P, Ngetsa C, Lowe B, et al. Incidence of clinically significant bacteraemia in children who present to hospital in Kenya: community-based observational study. Lancet 2006;367:482–8. 15. Ebuehi OM, Adebajo S. Improving caregivers’ home management of common childhood illnesses through community level interventions. J Child Health Care 2010;14:225–38. 16. UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases. Community-directed interventions for major health problems in Africa: a multi-country study: final report. Geneva: TDR; 2008. 17. Catford J. Implementing the Nairobi Call to Action: Africa’s opportunity to light the way. Health Promot Int 2010;25:1–4.
Agnès Aubouy a,b,∗ Institut de Recherche pour le Développement (IRD) UMR 152, Pharmacochimie et Pharmacologie pour le développement, Toulouse, France b Université Paul Sabatier, Faculté de Pharmacie, Toulouse, France a
∗ Present
address: UMR 152 IRD/Université, Hôpital de Rangueil, Bât. L1 - 3ème étage, 1 avenue Jean Poulhès, 31400 Toulouse, France. E-mail address: [email protected]