policy brief on scaling up malaria control ......pr rose leke, phd, immunologist, director...
TRANSCRIPT
CCAM IN PARTNERSHIP WITH CDBPH
POLICY BRIEF ON SCALING
UP MALARIA CONTROL
INTERVENTIONS IN
CAMEROON
ii
INITIATIVE OF CAMEROON COALITION AGAINST MALARIA (CCAM) AND
CENTRE FOR DEVELOPMENT AND BEST PRACTICES in HEALTH (CDBPH)
CORDINATED AND WRITTEN BY
Dr. John NGUM Wonghi, MD, MPH, Public Health Adviser within the Technical Secretariat of the
Steering and Follow-up Committee of the Health Sector Strategy;
Dr. Pierre Ongolo-Zogo, MD, MSc, Head of the Centre for Development of Best Practices in
Health – Yaoundé Central Hospital, Faculty of Medicine and Biomedical Sciences University of
Yaoundé 1
Dr Esther Tallah, MD Pediatrician, Manager of Cameroon Coalition Against Malaria, Board
Member UNITAID Executive Board, Alternate Board Member RBM Partnership, Communities
Delegation GFATM
Pr Rose LEKE, PhD, Immunologist, Director Biotechnology Centre – University Yaoundé 1 and
Executive Director of Cameroon Coalition Against Malaria,
Pr Wilfred MBACHAM, Microbiologist, Public Health, Biotechnology Centre – University Yaoundé
1 and Executive Secretary of Cameroon Coalition Against Malaria
The following participated at the deliberative forum during which this paper was finalised and validated.
iii
Preface
The concept of Evidence Informed Policy Making is new and has come into focus in recent years, as a
result of the observation that in the past, many a policy has been based on impression or how the boss
sees it or what we think should be, to the extent that some policies are based on fallacy and ideology
which when tested prove to be contrary to the reality.
It is therefore of utmost importance that policy-makers should use as basis proven facts in order to make
policies. The example of the belief that Sudden Infant Death Syndrome (SIDS) was thought to be due to
the situation whereby a baby is made to lie on their back which therefore made paediatricians to advise
caretakers that babies should be laid instead on their bellies, which later on, following scientific studies, it
was demonstrated that there is a predisposition at the brain of such babies who do not survive low
oxygen level in their brains, and most of them die when lying on their bellies because breathing is
compromised to some extent and therefore oxygen level in the body/brain, and that fewer deaths
occurred when such children lie on their backs, completely reversed the attitude that was advised by
paediatricians to the caretakers of young babies. This is just one among several examples and just to
emphasis the importance of evidence to inform policy.
It is in this perspective that CCAM and partner CDBPH embarked on this project funded by WHO to
research and write a policy brief on Scaling Up malaria Control interventions in Cameroon, which is
aimed at providing evidence in line with the problem of these interventions not effectively reaching the
people, such that these facts shall be taken into consideration when Cameroon engages in the universal
coverage with malaria control interventions.
This comes at a time when the world has engaged to support all malaria endemic countries to achieve
universal coverage, sustain it and move towards malaria elimination with the magic target of achieving
universal coverage in all countries by December 2010.
Cameroon is ready to join the other endemic countries in achieving this target thanks to double funding
from the Global Fund to Fight HIV, TB and Malaria in the 6th round in 2004 and the 9th round in 2009.
iv
This policy brief is therefore timely and it is our hope that it will contribute in helping the policy-makers in
Cameroon ensure that all malaria control interventions are reaching the people in an equitable manner
and with their active participation to ensure sustainability, while addressing all the bottlenecks that may
refrain this from being achieved.
v
Table of contents
Preface……………………………………………………………………………………………………iii
Key messages ............................................................................................................................................ vi
Executive summary ................................................................................................................................ viii
Acronyms ................................................................................................................................................ xiv
1 The problem ................................................................................................................................... 1
Background ................................................................................................................................. 1 1.1.1 Epidemiological profile of Malaria in Cameroon ........................................................................... 1
1.1.2 Parasite and vector Resistance profile ........................................................................................... 6
1.1.2.1 Parasite Resistance Profile.............................................................................................................. 6
1.1.2.2 Vector resistance profile ................................................................................................................. 8
1.1.3 Poverty profile ................................................................................................................................. 8
1.1.4 Historical Facts and Perspectives of the Malaria Control Interventions in Cameroon ............ 11
1.1.4.1 Historical Facts: The past and the Present .................................................................................. 11
1.1.4.2 Perspectives ................................................................................................................................... 13
1.2 Size of the problem ....................................................................................................... 13
1.3 Causes of the problem .................................................................................................. 16 1.3.2 Insufficient access of the population to MCI: ............................................................................... 16
1.3.3 Low utilisation of available services ............................................................................................ 17
1.4 Framing of the problem ............................................................................................... 17
2 Policy options of Evidenced-based Strategies for Scaling Up Malaria Control Interventions in Cameroon ............................................................................................................................................. 19
3 Implementation considerations ................................................................................................. 24
3.1 Global Considerations related to Malaria control Interventions: ............................ 24 3.1.2 Malaria Prevention Interventions ................................................................................................ 24
3.1.3 Malaria Case Management ............................................................................................................ 25
3.2 Strategy-specific Considerations: ............................................................................... 27
4 References .................................................................................................................................... 29
4.1 The epidemiological profiles ....................................................................................... 29
4.2 The poverty profile....................................................................................................... 29
4.3 The malaria services coverage .................................................................................... 29
4.4 Effective interventions ................................................................................................. 30
4.5 Implementation considerations .................................................................................. 31
vi
Key messages
Cameroon, Africa in miniature, presents diversified epidemiological strata of malaria transmission
along with the corresponding parasites and vectors. Malaria continues to be endemic and the first
major cause of morbidity and mortality among the most vulnerable groups - children under 5 years
pregnant women People Living With HIV/Aids (PLWHA) and the poor accounting respectively for 18,
5, 5.5, and 40 percent of the total population estimated at 19 million.
In spite of the efforts deployed by the National Malaria Control Program and its partners, the actual
coverage and use of malaria services and commodities are dramatically below the national targets
set in line with the Global Malaria Action Plan. Households with children aged below 5 years and
pregnant women have benefited from free Insecticide treated Nets (ITNs) and the entire population
from highly subsidized Artemisinin-based Combination Therapy (ACTs). However, the subsidized ACTs
and SP for IPTp are unevenly available due to inadequate prescription by providers, multiplicity of
licensed anti malarial drugs (over 90 in circulation) and frequent stock-outs. LLINs are not available
for purchase for the non targeted groups. Recently proven effective control interventions are not
available. Control strategies are not customised to epidemiological profiles of malaria and are
mostly health facility based.
Financial barriers, low utilisation rate of available interventions and low utilisation rate of health
facilities stand as immediate causes to the low coverage of Malaria Control interventions (MCI).
This evidence-based policy brief proposes remedial strategies to increase the coverage and
utilization rates of the effective malaria control interventions targeting the whole population at risk as
appropriate. These strategies include:
o Governance arrangements: (i) Clearing the drug market of all antimalarials that are not in
the national policy (Artesunate-Amodiaquin and Artemether-Lumefantrin for uncomplicated
malaria and Quinine for complicated, Sulfadoxine Pyrimethamine for IPTp), (ii) Enforcing
regulation through reinforced inspection and supervision activities, (iii) Shifting from the current
unified approach to specific strategies according to epidemiological profiles and the
emerging trends such as co-morbidity with HIV/Aids and, (iv) Transferring greater
vii
responsibilities to and empowering municipalities-communities for comprehensive and
integrated malaria control interventions
o Delivery arrangements: (i) Shifting from the current unified approach to specific strategies
according to epidemiological profiles and the emerging trends in the epidemiology of
diseases for example: Introduce the Intermittent Preventive Treatment for infants and
preschool children living in high and moderate transmission zones and for PLWHA, (ii)
Distribution of LLINs, IPTp, IPTi, IPTc by the communities supported by NGOs, CSOs,
Community Health Workers (CHW) and Community Based Associations (CBAs) as it is the case
with CDTI and , (iii) Fostering public private partnerships through Service Level Agreements
(SLA) or Performance Based Contracting (PBF) as appropriate e.g. pharmacists selling only
commodities and drugs recommended by the national policies, Effective private marketing
approaches for LLINs distribution.
o Financial arrangements: (i) Secure and sustain subsidies for IPT, LLINs and ACTs and, (ii)
Financial incentives for pharmacists and prescribers who comply with regulations.
o Implementation considerations: (i) Barriers such as resistance to change, low budget
allocation to health, failure of the procurement chain, and inadequate knowledge among the
stakeholders both on malaria and its effective control strategies, insufficient capacities of
community stakeholders to take ownership; and (ii) Effective Strategies such as communication,
education, advocacy building on the “malaria competence approach”.
viii
Executive summary
In Cameroon, malaria continues to be endemic and the first major cause of morbidity and mortality
among the most vulnerable groups - children under 5 years pregnant women People Living With
HIV/Aids (PLWHA) and the poor accounting respectively for 18, 5, 5.5, and 40 percent of the total
population estimated at 19 million. This means that 2/3 of the population is vulnerable to malaria
In spite of the efforts deployed by the NMCP and partners, the burden of malaria has remained the
same over the past decade and the actual coverage and use of malaria services and commodities are
still significantly behind the targets set in line with the Abuja commitments and the Global Malaria Action
Plan goals on universal coverage for 2010.
According to Demographic Health Surveys 2004, MICS 2006, NMCP 2008 annual report, malaria
accounts for 35 to 43% of all deaths in health units, 50 to 56% of morbidity among children under the
age of 5, 40 to 45% of medical consultations and 30% to 47% of hospitalizations. It is also the cause of
26% of absences in the workplace and 40% of the health expenditure of households. Malaria is
responsible for 49 % consultations and 59% of hospitalisations during pregnancy leading to abortions
and premature labour and deliveries as well as low birth weight all exposing the babies to early deaths
and mothers to death during delivery.
Data on coverage on malaria control interventions show that only 13.1 % of children aged under five
years sleep under insecticide-treated mosquito nets, 37% of pregnant women received the second dose
of Sulfadoxine Pyrimethamine and only 58% of complicated cases of malaria are promptly and
properly managed. In a recent study in Obala Health District, the coverage was as follows: 15.1% for
ACTs, 41% for LLINs, 67% for IPT2.
The burden of malaria stems from the epidemiological and poverty profiles that are inappropriately
addressed in the formulation of the national strategies. The latter are not customised to local needs and
are mostly health facilities based, consequently not reaching those most in need. In addition, some
recently proven effective control interventions are not included within these strategies.
ix
Based on the transmission pattern, the epidemiologic profile of malaria can be further categorised into 3
types: (i) Endemic and perennial zones of continuous transmission (7 to 12 months) covering the South
Cameroonian Equatorial forest, the High western plateaux altitude and the Coastal region where about
a hundred infective bites per man per month can be registered, (ii) Endemic and seasonal zones of long
seasonal transmission (4-6 months) covering High inland plateaux (Adamawa) and the Savannah-forest
transition regions where about twenty infective bites per man per month can be registered and, (iii)
Epidemic or strongly seasonal zones of short seasonal transmission (1-3 months) covering the Sudano-
sahelian region where about ten infective bites per man per month can be registered.
According to the last House Hold Survey (INS, 2007), 40% of the population are living under the poverty
line with 55% in rural as against 12.2% in urban. The low purchasing power of this poor section of the
population contributes to reduce their access to malaria control services.
From the results of Systemic Quality Improvement assessment of the performance of Health districts and
regional health facilities carried out in 2007/08, service organisation and delivery is generally not
satisfactory. Further more, LLINs are not available for purchase for the non targeted groups and also
absence of an in-built mechanism within the health system to stimulate demand.
The subsidized ACTs and SP for IPTp are unevenly available due to inadequate prescription by providers
coupled with the frequent stock-outs related to some failures in the Procurement and Supply Management
Chain.
There is low acceptability of proposed interventions by the targeted populations leading to a low
utilisation of the available services. The use of ITNs is not commensurate with their possession due to
insufficient knowledge on recommended malaria treatment and preventive interventions. As a
consequence patients indulge in inappropriate health seeking behaviours including auto medication with
wrong drugs.
With regards to governance, the malaria control drugs and commodities have been liberalised favouring
therefore their high commercialisation in a poorly regulated set up. The consequence is a multiplicity of
licensed anti malarial drugs (over 90 in circulation) and insufficient popularisation and enforcement of
regulatory texts exonerating drugs and medical commodities from taxation. The multiplicity of licensed
x
drugs besides favouring the circulation of sub standard drugs, act as a catalyser to inappropriate
prescription, self medication and poor compliance which all expose to the emergence of drug resistance.
The community organisations and municipalities are not adequately equipped (not empowered) to take
the lead in the design, the implementation and the evaluation of malaria control measures relevant to
their communities. The lack of specific strategies to empower communities has lead to and made them
passive recipients of services.
In summary, the malaria control interventions are not reaching those most in need. Insufficiently
decentralised programme with poor sense of ownership at the implementation level both by service
providers and users are the main causes. This policy brief has been prepared to inform policy and
decision makers, health workers and community to face this challenge by implementing effective malaria
control interventions targeting the whole population at risk as appropriate. These strategies include:
Governance arrangements: (i) Clearing the drug market of all antimalarials that are not in the
national policy (Artesunate-Amodiaquin and Artemether-Lumefantrin for uncomplicated malaria
and Quinine for complicated, Sulfadoxine Pyrimethamine for IPTp), (ii) Enforcing regulation
through reinforced inspection and supervision activities, (iii) Shifting from the current unified
approach to specific strategies according to epidemiological profiles and the emerging trends
such as co-morbidity with HIV/Aids and, (iv) Transferring greater responsibilities to municipalities-
communities for comprehensive and integrated malaria control interventions
Delivery arrangements: (i) Shifting from the current unified approach to specific strategies
according to epidemiological profiles and the emerging trends in the epidemiology of diseases
for example: Introduce the Intermittent Preventive Treatment for infants and preschool children
living in high and moderate transmission zones and for PLWHA, (ii) Distribution of LLINs, IPTp, IPTi,
IPTc by the communities supported by NGOs, CSOs, Community Health Workers (CHW) and
Community Based Associations (CBAs) as it is the case with CDTI and , (iii) Fostering public private
partnerships through Service Level Agreements (SLA) or Performance Based Contracting (PBF) as
appropriate e.g. pharmacists selling only commodities and drugs within the national policies,
Effective private marketing approaches for LLINs distribution.
Financial arrangements: (i) Secure and sustain subsidies for IPT, LLINs and ACTs and, (ii) Financial
incentives for pharmacists and prescribers who comply to regulations.
xi
Implementation considerations: (i) Barriers such as resistance to change, low budget allocation
to health, failure of the procurement chain, and inadequate knowledge among the stakeholders
on malaria and effective intervention strategies, insufficient capacities of community stakeholders
to take ownership; and (ii) Effective Strategies such as communication, education, advocacy
building on the “malaria competence approach”. The table below presents a summary of these
policy options and their respective implementation considerations .
Summary of policy options and their implementation considerations towards scaling up malaria
control interventions in Cameroon
Policy Option Governance arrangements Delivery arrangements Financial
arrangements
Description
Title and Activities
in the strategic
options
(i) Clear the drug market of antimalarials that
are not in the national policy (Artesunate-
Amodiaquin and Artemether-Lumefantrin for
uncomplicated malaria and Quinine for
complicated, Sulfadoxine Pyrimethamine for
IPTp), (ii) Enforce regulation through
reinforced inspection and supervision
activities, (iii) Shift from the current unified
approach to specific strategies according to
epidemiological profiles and the emerging
trends such as co-morbidity with HIV/Aids
and, (iv) Transfer greater responsibilities to
and empower municipalities-communities for
comprehensive and integrated malaria
control interventions
(i) Shift from the current unified approach to specific strategies
according to epidemiological profiles and the emerging trends
in the epidemiology of diseases for example: Introduce the
Intermittent Preventive Treatment for infants and preschool
children living in high and moderate transmission zones and for
PLWHA, (ii) Distribute LLINs, IPTp, IPTi, IPTc by the
communities supported by NGOs, CSOs, Community Health
Workers (CHW) and Community Based Associations (CBAs) as it
is the case with CDTI and , (iii) Foster public private
partnerships through Service Level Agreements (SLA) or
Performance Based Contracting (PBF) as appropriate e.g.
pharmacists selling only commodities and drugs recommended
by the national policies, Effective private marketing approaches
for LLINs distribution.
(i) Secure and sustain
subsidies for IPT, LLINs and
ACTs and, (ii) Financial
incentives for pharmacists
and prescribers who comply
with regulations.
Barriers to
implementation
Resistance to change, inadequate knowledge
among the stakeholders on both malaria and
its effective control strategies, insufficient
capacities of community stakeholders to take
ownership.
The State supply chain fails to deal with private pharmacies and
sales of other licensed antimalarials are often more profitable.
IPTi is not part of the national policy because of the fear that
S/P will lead to resistance as is the case in other countries e.g.
Tanzania
Low budget allocation to
health, Poverty, insufficient
regulation leading to high
commercialization of malaria
control
Challenges for
adaptability
Presence of strong leadership and previous
community empowerment strategies
Developing partnerships between communities, policy makers and experts. Developing local
organisational capacity and financial empowerment
Implementation
strategies
Information, education and communication, ”
malaria competence approach”, Promotional
campaigns1, Use existing social structures
and community groups
Communication, education, promotional campaigns,
management and leadership training and careful selection to
ensure only ACTs on MOH policy circulate in the market and
are used, empowerment of parents, resources mobilisation
communication,
decentralisation and
Promotional campaigns,
management and leadership
training
1 Advocacy targeting private and public, political and scientific spheres as well as the general population who should be encouraged to become partners and even
actors of vector and malaria control at their household level.
xiv
Acronyms
ACT Artemisinin Combination Therapies
AL Artemisinin + lumefantrine
AM-LM Artemether-Lumefantrine
AS+AQ Artemisinin + Amodiaquine
CBA Community Based Association
CDTI Community Directed Treatment with Ivermectine
CHW Community Health Worker
CSO Civil Society Organisation
DDT Dichlorodiphenyltrichloroethane
DH-PP Dihydroartemisinin-Peoeraquine
DHS Demographic and Health Survey
IPT2 Intermetent Preventive Treatment
IPTi Intermetent Preventive Treatment for Infants
IPTp Intermetent Preventive Treatment for Pregnant women
IRS Indoor Residual Spray
ITMN Insecticide Treated Mosquito Nets
ITN Insecticide Treated Nets
LLIN Long Lasting Insecticide Treatment Nets
MCI Malaria Control Interventions
MDG Mellinium development Goals
MICS Multi Indicator Cluster Survey
MoH Ministry of Health
NGO Non Governmental Organisation
NMCP National Malaria Control Programme
PBF Performance Based Financing
PLWHA People Living with HIV/ Aids
SLA Service Level Agreements
SP Sulfadoxine-Pyrimethamine
SQI Systemic Quality Improvement
xv
SWAp Sector Wide Approach
UNICEF United Nations of International Children's Emergency Fund
WHO World Health Organisation
“...In comparison to the current funding trajectory rapid scale up could
safe two and half million additional lives, prevent more than 430 million
additional malaria cases and help generate $ 50 billion more in economic
output over five years. What’s more, it will safe twice as many lives for
each dollar spent...” (34)
Malaria No More and McKinsey & Company on behalf of
the Roll Back malaria Partnership, January 2008
1
1 The problem
Background
1.1.1 Epidemiological profile of Malaria in Cameroon
Figure 1: Mapping of the Epidemiological strata of Malaria in Cameroon
It is commonly held that Cameroon is Africa in miniature. This is certainly true with regards to the
epidemiological strata almost all of which are represented. Seven epidemiological strata have
been identified in Cameroon (1) as illustrated in figure 1 above and details of which, including the
description of corresponding parasitological and vector profiles for each strata, are presented in
table 1 below
The mapping of the vector profile is further illustrated in fig 2.
Table 1: Synthesis of the malaria geographical strata, transmission patterns and parasitology and main vectors in
Cameroon
Geographic Characteristics defining
ecological zones
Transmission pattern and parasitology Main vectors
I-Sudano-sahelian strata. dry Savannah zones and
the steppes to the north of the country, between
latitudes 13°N and 8°N. From west to east
Malaria here is unstable with a risk of epidemic and
severe clinical forms at all ages. Here, malaria is
caused by Pl. Falciparum (93.6-98.7%) , Pl. Malariae
(0-6.4%) and Pl. Ovale (0-1.3%)
In addition to Anopheles gambiae a major
malaria vector, Anopheles arabiensis along with
Anopheles funestus have been identified here.
The first two are both resistant to DDT and
pyrethrinoides
II-High inland plateaux strata (Adamaoua). Situated
in the very heart of Cameroon between latitudes
8°N and 6°N, the Sudani-Guinean tropical climate is
tempered by the altitude (1,100 m on average).
Malaria is tropical and stable with seasonal
outbreaks, caused by Plasmodium falciparum
uniquely
Relative immunity starts appearing as of the age
of 10. Anopheles gambiae gambiaeis a major
malaria vector
III-Savannah-forest transition strata. the transition
zone that separates the forest Savannah from the
forested plateaux to the south. Located between
latitudes 6°N and 4°N, with the exception of the
mountain regions to the west
The malaria here is equatorial and stable with
seasonal outbreaks, caused by Pl. Falciparum (89.8-
100%) , Pl. Malariae (4.3-8.4%) and Pl. Ovale (0-1.8%)
Relative immunity is achieved by the age of 5.
Anopheles gambiae gambiaeis a major malaria
vector
IV-South Cameroonian Equatorial forest strata.
Situated between latitudes 5°N and 2°N, and at an
altitude of 600 m to 900 m the region is watered by
the Sanaga, Nyong, Ntem and Sangha rivers. The
forest is dense, heterogeneous.
Malaria is equatorial holo-endemic, caused by Pl.
Falciparum (62.0-96.3%), Pl. Malariae (0.6-3.0%) and
Pl. Ovale (1.1-35.0%)
Relative immunity is achieved early in life,
before the age of 5. Anopheles gambiae
gambiaeis a major malaria vector but also
Anopheles moucheti that comes in contact with
humans at sun set. Anopheles moucheti is found
here too along the sananga
Geographic Characteristics defining
ecological zones
Transmission pattern and parasitology Main vectors
V-High western plateaux altitude strata. This
polygon shaped region stretching 300km by 200km
is composed of the Bamoun and Bamiléké plateaux,
the Mbos plain, the Manengouba, Bamboutos and
Oku mountains, volcanic plateaux of Bamenda and
grassfields
The transmission of malaria is permanent, occurring
all year long, sometimes lessened by altitude though
never totally absent. Here malaria is caused by Pl.
Falciparum (95.5-96.0%), Pl. Malariae (1.7-7.0%) and
Pl. Ovale (0.1-6.8%)
This area is one of the most densely populated
regions of Cameroon Anopheles gambiae
gambiaeis a major malaria vector.
An. gambiae is more resistant to DDT than is An.
arabiensis in the tropical zone
VI-Coastal strata. This corresponds to Cameroon’s
only coastal region, from Campo to Mamfé. The
altitude is inferior to 300 m and it is a veritable cul-
de-sac often swallowed up by the monsoon
In this zone of dense hygrophile forest (Biafrican
forest) and mangrove swamp the transmission of
malaria is the highest for all the country, caused by
Pl. Falciparum (97.7-100%), Pl. Malariae (0-0.7%) and
Pl. Ovale (0-2.3%)
Anopheles gambiae gambiaeis a major malaria
vector
4
Based on the transmission pattern, the epidemiologic profile of malaria can be further categorised
into 3 types:
1. Endemic and perennial: Zone of continuous transmission (7 to 12 months) covering the
South Cameroonian Equatorial forest strata, the High western plateaux altitude strata and
the Coastal strata where about a hundred infective bites per man per month can be
registered
2. Endemic and seasonal: Zone of long seasonal transmission (4-6 months) covering High
inland plateaux strata (Adamawa) and the Savannah-forest transition strata where about
twenty infective bites per man per month can be registered
3. Epidemic or strongly seasonal: Zone of short seasonal transmission (1-3 months) covering
the Sudano-sahelian strata where about ten infective bites per man per month can be
register
The results Presentation in table 1 and figure two reveal that the intensity of malaria transmission
reduces as one moves inland suggesting a potential risk of malaria epidemic in highlands and thus
the need for a continuous epidemiological surveillance (33) in zones of seasonal transmission.
5
Figure 2: Mapping of transmission pattern
6
Figure 3: Mapping of vector species
1.1.2 Parasite and vector Resistance profile
1.1.2.1 Parasite Resistance Profile
Resistance to antimalarial drugs is proving to be a challenging problem in malaria control in most
parts of the world (2). Since early 60s the sensitivity of the parasites to chloroquine, the best and
most widely used drug for treating malaria, has been on the decline. Newer antimalarials were
discovered in an effort to tackle this problem, but all these drugs are either expensive or have
undesirable side effects. Moreover after a variable length of time, the parasites, especially the
falciparum species, have started showing resistance to these drugs also.
7
Accoording to John Ehrenberg (2), WHO regional adviser on malaria and other vector borne and
parasitic diseases, the Asia Pacific region has traditionally been the focus of resistance to
antimalarial drugs and now we have artemisinin resistance primarily on the Thai-Cambodian
border. If it is not contained, it can have global implications and the most serious one would be in
Africa which has a high disease burden and the highest mortality rates. The best way to prolong
the use of the drug would be to use it in combination with other anti malarial drugs (23).
In Cameroon, resistance to anti malarial drugs has been reported (19). Chloroquine which was
most accessible and used as the first line treatment for uncomplicated malaria, developed
resistance which was depicted for the first time in 1985 in the Limbe Township and later in other
localities in the country with high rates of therapeutic failures observed.
Confronted with this situation, other molecules (Amodiaquine, Sulfadoxine -pyrimethamine as well
as more recent artemisinine associated therapies) were proposed for use in chloroquine resistant
areas (23). However, therapeutic failures to Artemisinine Combination Therapies (ACT) are now
being registered in some towns in Cameroon as presented in Table 2 below:
Table 2: Rate of therapeutic failure related to combination of Atesunuate and
amodiaquine + sulfadoxine-pyrimethamine in Cameroon (2004-2006)
Site Year Age group Total
number
treated
No of cases of
treatment
failure
reported
Failure rate
Akom II 2002 0-5 years 59 0 0
Limbe 2004 0-5 years 250 35 14
Yaoundé 2004 0-5 years 250 50 20
Garoua 2004 0-5 years 250 42 17
Yaoundé 2006 6months-5
years
62 7 11.3
Source: NMCP Strategic Plan
8
Resistance develops most rapidly when a population of parasite encounters sub-therapeutic
concentration of antimalarial drugs (2). The following points will be helpful in reducing the
emergence of resistance:
1. Selection of drugs - Use conventional drugs first in uncomplicated cases. Greater the exposure,
higher will be the emergence of resistance.
2. Avoid drugs with longer half-life if possible.
3. Avoid basic antimalarials for non-malarial indications (e.g. Chloroquine for rheumatoid arthritis
in a malarial endemic area).
4. Ensure compliance.
5. Monitoring for resistance and early treatment of these cases to prevent their spread.
6. Clear policy of using newer antimalarials.
7. Use of combinations to inhibit emergence of resistance.
1.1.2.2 Vector resistance profile
The prevention of malaria in Cameroon is based essentially on vector control through use of
Insecticide Treated Mosquito Nets (ITN) and Indoor Residual Spray (IRS) (19). A number of
insecticide sensitivity studies have been carried out by the NMCP as well by other research
institutions in different parts of the country. The results derived through these studies show that
there is optimum sensitivity of An. Gambiae s. I. to cabamites and organophosphorates. However,
An. gambiae is more resistant to DDT than is An. arabiensis in the tropical zone. No vector
resistance, what so ever, has been noticed in Maga and Tiko for all insecticides tested.
Resistance to DDT and to pyrethrinoides has been observed both in An. Gambiae (s.s. M&S forms)
and in An. arabiensis.
1.1.3 Poverty profile
With the average monetary threshold of 269.443 francs FCFA per adult equivalent and per year
in 2007, the incidence of poverty has not changed significantly between 1996 and 2007, national
average has dropped from 53.3% to 39.9%; the objective haven been set at 25% by 2015. The
disparities between urban and rural settlements are aggravating. Between 2001 and 2007: the
incidence of poverty dropped in the urban area from 17.9% to 12.2% while increasing in the
9
rural areas from 52.1% to 55% (3, 5, 15). The cities of Douala and Yaoundé where the poverty
incidence in 2007 stood at 6% is draining the rural population that are seeking greener pasture.
The socio economic status, level of education and the size of the family tend to influence the
poverty levels within the Cameroonian society (5). The poverty profile by region is presented in
table 3 below.
Table 3: Evolution of the incidence of poverty between 1996 and 2007, and distribution
of the poor population 2001 by milieu of residence
Milieu of
Residence
Incidence
in 1996
Incidence
in 2001
Incidence
in 2007
Difference Poor population in
2001
Number %
Douala 37.3 10.9 5.5 -5.4 163 437 2.6
Yaoundé 49 13.3 5.9 -7.4 179 974 2.9
Total Douala Yaoundé 343 411 5.5
Adamawa 48.4 52.9 4.5 334 696 5.4
Centre (Outside Yaoundé) 48.2 41.2 -7 584 963 9.4
East 44 50.4 6.4. 327 642 5.3
Far North 56.3 65.9 9.6 1 545 349 24.9
Littoral (outside Douala) 35.5 30.8 4.7 267 671 4.3
North 50.1 63.7 13.6 562 503 9
North West 52.5 51 -1.5 935 409 15
West 40.3 28.9 -11.4 752 781 12.1
South 31.5 29.3 -2.2 168 602 2.7
South West 33.8 27.5 -6.3 394 032 6.3
Total regions 5 873 647 94.5
Urban 41.4 17.9 12.2 -5.7 962 415 15.5
Rural 59.6 52.1 55 2.9 5 254 643 84.5
Country level 53.3 40.2 39.9 -0.3 6 217 058 100
Source : Rapport National sur le Développement Humain 2008/2009
Substantial in-kind welfare transfer payments allocated to households by government (3) have
resulted in an improvement in the access to health and education services for the poor and also the
vulnerable groups. In the domain of the health sector, for instance, these transfers have been
10
carried out via programmes such as initiatives launched to combat HIV/aids, the extended
programme of immunization and the fight against malaria programme.
Through the fight against malaria programme, the population, particularly pregnant women and
households with children aged under-5, have benefited from free ITNs. Further more, because of
the high poverty rate (40 percent of all Cameroonians and 55 percent in rural communities) (20),
the Government, with the support of the Global Fund to fight Aids, Tuberculosis and Malaria
decided beginning in January 2007 to partially subsidize ACT for malaria treatment in public and
not-for-profit health facilities and in private pharmacies.
In spite of this partial subsidy, the cost of treatment of uncomplicated malaria with ACTs is still
above the purchasing power of most of the population. To make it worse, these ACTs are
regularly out of stock and the agreement signed by the Minister of Health and private
pharmacists’ representatives to allow them to sell subsidized, ACTs is also not adequately
implemented for several reasons, including (20):
a) AS+AQ and AL are among approximately 100 licensed anti-malarials in Cameroon,
including monotherapies.
b) Many of those are actively marketed by the pharmaceutical industry.
c) The State supply chain fails to deal with private pharmacies.
d) Sales of other licensed antimalarials are often more profitable.
In conclusion, poverty has contributed to inaccessibility of malaria control
interventions for the majority of the population thus fostering the persistence of
malaria which further aggravates poverty. To be successful, programmes oriented
toward providing minimal access by poor households to better health, nutrition, and
educational opportunities require that target groups be well identified (4).
Understanding the likely effects of policy interventions on different groups in society
allows for the possibility of fine tuning or developing mitigative actions.
11
1.1.4 Historical Facts and Perspectives of the Malaria Control
Interventions in Cameroon
1.1.4.1 Historical Facts: The past and the Present
During the fifties (9), large scale malaria vector control projects based upon house spraying were
implemented in Southern and Northern parts of Cameroon in line with malaria eradication
concept. In the South, the pilot zone of Yaoundé gathered about 150,000 inhabitants, in the forest
area. First operations started in 1953 but the programme became actually operational in 1956.
The South was divided in two parts: the western part was treated with DDT, while the eastern one
was treated with dieldrin. At the same time, the whole forested area was also treated with
dieldrin until 1960. Yaoundé itself was not treated because it was free of anopheles and malaria.
House spraying in the pilot area of Yaoundé was a complete success and plasmodic index
dropped below 1%. The same success was observed in most of the southern treated areas.
Unfortunately dieldrin resistance of An. gambiae hampered this programme which stopped in
1960. The northem pilot project dealt with some 250,000 inhabitants around Maroua, in a
savanna area. To avoid dieldrin resistance observed in 1956, DDT was selected and house
spraying started in 1959. From a strictly operational point of view, the campaign was considered
as a success. But after two years, it was noticed that plasmodic index remained still around the
same value of 35% and the programme stopped. It was thus stated that according to available
techniques it was not possible to reach the ultimate goal of eradication even when
chemoprophylaxis (chloroquin + pyrimethamin) was added. Vector control was then stopped for
a while.
The comparison between South (= success) and North (= failure) was very interesting
as it underlined the big differences between epidemiological strata, an unaccepted
concept at that time. Now ecological and epidemiological diversity is well
acknowledged. It also underlined the need of diversity of strategies according to the
epidemiology of the disease and the ecology of its vector.
In the eighties, Primary Health Care was promoted and malaria control shifted from vector to
parasite control, vector control remaining as a prevention method. But chemo-resistance of
Plasmodium falciparum appeared and quickly spread, at different levels, across the country. A
12
new emphasis was therefore given to vector control thanks to the newly developed technique of
insecticide impregnated mosquito nets. Two kinds of studies were undertaken: - what people were
actually doing in terms of mosquito control at family level, the main reason and the costs as well as
current use of mosquito nets - the efficacy of pyrethroid treated mosquito nets (ITMN) in different
areas of southern forested area against different malaria vectors: An. gambiae, An. nili, An.
moucheti.
It thus clearly appeared that ITMN were very successful in sharply reducing malaria
transmission and morbidity. But its promotion is limited by the current poor use of
mosquito nets.
1995 was a turning point in the history of malaria control marked by the drafting of the first
Malaria Control Programme (MCP) document in line with the 1992 Ministerial conference that held
in Amsterdam. This was followed in 1997 by the declaration of the national policy for the control
of malaria as approved by Government. In December 1998, the Central Technical Group for the
Malaria Control was created. The President of the Republic was personally committed to this new
drive towards malaria control activities through the letter he sent to the WHO Director General on
the 28th April 1999. Following the signing of the Abuja Declaration on the 24th of April 2000 by
the African Heads of States, this initiative was launched in Cameroon on the 25th July 2000 by the
Minister of Public Health. These initiatives were concretised in 2002 with a National Malaria
Control Strategy Plan which has given rise to what prevails today. According to this plan,
Artemisinin Combination Therapy (ACT) is the treatment of choice for uncomplicated malaria (8,
15, and 20). The implementation of this plan is financed by multiple sources: state, Global Fund to
fight HIV/Aids, Tuberculosis and Malaria (GFATM), WHO, UNICEF and Bill and Melinda Gates
Foundation. Households contribute the largest share of financing through malaria prevention and
home based care.
The NMCP has been restructured to make it more operational. In that light, the 2007-2010
strategy plan aims at contributing towards the achievement of MDG 6 through prevention,
improving case management, behaviour change communication in favour of malaria, training and
operational research, capacity building and partnership development.
13
1.1.4.2 Perspectives
The Government's objective over the next decade, with regard to malaria control, is
to significantly reduce the prevalence rate of this disease which, with a rate of 40 per
cent, is the leading cause of morbidity and consequently mortality in Cameroon (6,
7). A more coordinated approach of malaria control will be systematically sought and
established at all levels in order to make the initiatives of stakeholders involved in
this fight more complementary and better harmonized, especially health services,
hygiene and sanitation services, the education system and information and
communication services. Decentralized local authorities (councils notably) will
increasingly be entrusted with the responsibility of managing integrated malaria
control at the local level. In the medium term, (by 2015), the following goals will be
pursued by the Government: (i) 80 per cent of children under 5 will sleep in long
lasting insecticide treated mosquito nets; (ii) 80 per cent of community relays will
apply the malaria community management package in at least 4/5 health areas of
each district and (iii) 60 per cent of health units will apply the malaria management
norms and standards in at least 4/5 health districts in each region.
1.2 Size of the problem
Cameroon, Africa in miniature, presents diversified epidemiological strata of malaria transmission
along with the corresponding parasites and vectors. Malaria continues to be endemic and the first
major cause of morbidity and mortality among the most vulnerable groups - children under 5
years pregnant women People Living With HIV/Aids (PLWHA) and the poor accounting
respectively for 18, 5, 5.5, and 40 percent of the total population estimated at 19 million.
Although malaria is preventable and treatable, there were still between 189 million to 327 million
cases in 2006, resulting in between 610,000 to 1.2 million deaths. Half the world's population is
at risk, particularly the poor and those living in remote areas with limited healthcare access. A
child dies from malaria every 30 seconds.
In Cameroon, more than 930 000 cases were reported in 2005. According to the NMCP 2008
annual report (10), more than 1 650 749 cases were reported and this is most predominant
14
amongst pregnant women and children below 5 years. The clinical morbidity rate estimated at
41%, the mortality rate at 2.2%
According to Demographic Health Surveys 2004, MICS 2006, NMCP 2008 annual report, malaria
accounts for 35 to 43% of all deaths in health units, 50 to 56% of morbidity among children
under the age of 5, 40 to 45% of medical consultations and 30% to 47% of hospitalizations. It is
also the cause of 26% of absences in the workplace and 40% of the health expenditure of
households. Malaria is responsible for 49 % consultations and 59% of hospitalisations during
pregnancy leading to abortions and premature labour and deliveries as well as low birth weight
all exposing the babies to early deaths and mothers to death during delivery.
Data on coverage on malaria control interventions show that only 13.1 % of children aged under
five years sleep under insecticide-treated mosquito nets, 37% of pregnant women received the
second dose of Sulfadoxine Pyrimethamine and only 58% of complicated cases of malaria are
promptly and properly managed. In a recent study in Obala Health District (17), the coverage
was as follows: 15.1% for ACTs, 41% for LLINs, 67% for IPT2.
Based on the Systemic Quality Improvement (SQI) 2007/2008 data base (12) the number of
cases of malaria registered in the regional and operational levels of the national health system
alone is even higher (2 055 543 compared to the 1 650 749 cases reported through the NMCP),
and varies from one region to another as presented in table 4 below (in decreasing order of the
total population column).
Table 4: Burden of malaria in the operational and regional levels of the national health
system
Region Children under 5 Pregnant women Total population
Number % Number % Number %
NORD 180 457 44% 27 011 7% 409 346 20%
NORD OUEST 97 033 33% 8 785 3% 291 552 14%
EXTREME - NORD 116 732 43% 11 897 4% 268 638 13%
OUEST 98 048 38% 12 177 5% 259 582 13%
CENTRE 77 347 34% 18 551 8% 227 008 11%
SUD OUEST 99 687 65% 5 191 3% 154 535 8%
15
LITTORAL 52 492 34% 21 159 14% 152 433 7%
ADAMAOUA 52 972 37% 9 927 7% 145 009 7%
EST 45 585 40% 7 405 6% 114 007 6%
SUD 12 713 38% 2 030 6% 33 433 2%
Total for Operational and
Regional levels
833 066 41% 124 133 6% 2 055 543
100%
Source: ST/CP-SSS: Situation analysis associated to Systemic Quality Improvement (SQI) 2008
When the same data is analysed in function of the level of care (first line, 1st level of referral, and
2nd level of referral) the trend of the burden of malaria disease is presented in figure 2 below.
Source: ST/CP-SSS: Situation analysis associated to Systemic Quality Improvement (SQI) 2008.
As presented in figure 2:
1. Malaria affects mostly women and children < 5 years old,
2. Malaria is the main cause for consultation at the operational level (integrated Health Centres
as well as in District Hospitals) than it is at the regional level,
3. Malaria is the main cause of hospitalisation in the regional Hospitals than it is in the district
hospitals,
4. Malaria as a main cause of mortality at all the levels analysed. It however, kills more at the
operational level,
16
5. Though pregnant women no longer die from malaria at Regional Hospitals children < 5
continue to die from Malaria even at this level of care.
1.3 Causes of the problem
Upon critical analysis, the causes why malaria control interventions are not reaching the
population are numerous and diversified. The said causes can accordingly be categorised
under accessibility related on the one hand and to utilisation related on the other hand.
1.3.2 Insufficient access of the population to MCI:
The causes of inaccessibility are largely related to governance, organisation and delivery of
services, financing and regulation of the health system.
Poor governance within the system: This is manifested by inadequate management of
stock of drugs and commodities with resulting stockouts of ACT and LLINs in the authorised
distribution points. It is not uncommon to find the same ACTs and LLINs being sold in the
black market.
Unsatisfactory organisation and delivery of services: 50% population in Cameroon lives
more than 5km from health facility thus limiting accessibility to facility based MCI. This is
further made worse by the limited functionality of home management approach. At health
facility level, there arise problems of the quality of service delivery as the majority of
health staff tend not to prescribe ACT for simple malaria and delay in referring
complicated cases to ensure continuity of care (fig. 1 shows high proportions of mortality
from malaria in Health Centres). Just as well, they do not systematically seize the
opportunity of Antenatal Consultations (80%, DHS III) to integrate malaria control
interventions for pregnant women such as IPTp (47%, DHS III).
Low purchasing power: As mentioned earlier, close to 40% of the population lives below
the poverty line (cf. poverty profile). Even though drugs and commodities have been
subsidised to improve access to the most vulnerable and the poor, a good portion of the
population cannot still afford the cost for the treatment of uncomplicated malaria with ACT
(16), not to mention affording the cost (social and economic) of footing bills of treatment of
complicated malaria Furthermore, there are no effective social protection measures that
17
can ensure equitable access to quality health services for the section of the population with
a low purchasing power (6, 23).
Insufficient popularisation of regulatory texts: In spite of the law exonerating medical
commodities from taxes, malaria control commodities are being taxed thereby leading to
LLINs being expensive and rare. The corollary is uncontrolled proliferation of non-
recommended medical commodities
1.3.3 Low utilisation of available services
The available services are under utilised. This may be explained by
Low acceptability of proposed interventions due to lack of ACT and LLIN culture among
population as only 11.5% of children <5 years and pregnant women sleep under a mosquito
net (11). Acceptability of commodities is influenced by the milieu of residence, by the level of
education as well as income levels: 8% use mosquito nets in rural areas compared to 15% in
urban. Use of mosquito nets is more common amongst educated women and amongst women in
well to do families.
Inappropriate health seeking behaviours with over dependence on traditional healers for
wrong indications resulting in unnecessary delays to getting quality health care, and as a
bitter consequence, preventable deaths arise. In addition, there is frequent auto medication
with inappropriate drugs or without respect of the dosage if the drug where appropriate. This
obviously leads to development of resistance to recommended anti malarial medicines (2).
Lack of empowerment of the population resulting in the later remaining a passive recipient of
services.
No in-built mechanism within the health system to stimulate demand
1.4 Framing of the problem
With regards to the implementation of malaria control policy, there is still a significant disparity
between the interventions hitherto carried out and the Global Malaria Action Plan goals set for
2015. Only 13% of children below the age of five sleep under insecticide-treated mosquito nets,
37% of pregnant women are on IPT2 and 58% of complicated cases of malaria are promptly
and properly managed (6, 7, 13).
In a recent study in Obala Health District, the coverage was as follows: 15.1% for ACTs, 41% for
LLINs, 67% for IPT2.
18
IPTi has not been included in national malaria control policy though there is substantial evidence
(22) that it can reduce about 20- 30% the incidence of clinical malaria in infants living in areas of
high and moderate intensity of transmission, comparable to results obtainable from mass use of
insecticide treated nets.
In spite of the diversity in the epidemiologic profile, this malaria control policy that entails
prevention interventions (LLIN, IPTp, IRS) and curative regimens (ACT for uncomplicated malaria,
Quinine for severe malaria) is unique for the whole country and its implementation fails to respond
to contextual needs (2). Further more, in practice, a multitude of anti malarial drugs are
commercialised and even so, some as monotherapies (20) thereby increasing the risk to parasite
resistance on one hand and rendering difficult the regulation, supervision and control of the PSM
chain of all the drugs and commodities homologated on the other hand.
This coverage in MCI is clearly not promising if the goal of reaching the malaria prevalence rate
of 3 per cent by 2015 is maintained. The consequence of this low coverage of malaria control
interventions (commodities and medicines) is that malaria still persists as a major public health
problem, resulting in high malaria related morbidity and mortality affecting women and children.
There is enough evidence to inform policy and decision makers, health workers and community to
face this challenge through remedial strategies in the march towards malaria elimination in
Cameroon. This policy brief proposes contextual solutions towards scaling up malaria control
interventions in Cameroon.
19
2 Policy options of Evidenced-based Strategies
for Scaling Up Malaria Control Interventions in
Cameroon
The philosophy of evidence based policy brief is to propose sound options where there are
problems and for which, sufficient relevant evidence is available. The options hereby proposed
put through the message that to scale up malaria control interventions, prevention strategies need
to be adapted to the main epidemiological strata in function of the transmission pattern. The
options proposed in table 3 below are not mutually exclusive. As a matter of fact they are
complementary and are tailored to context.
20
Table 5: Summary table of policy options
Policy
Option
Governance arrangements Delivery arrangements Financial arrangements
Description
Title and
Activities in the
strategic
options
(i) Clear the drug market of antimalarials that
are not in the national policy (Artesunate-
Amodiaquin and Artemether-Lumefantrin for
uncomplicated malaria and Quinine for
complicated, Sulfadoxine Pyrimethamine for
IPTp), (ii) Enforce regulation through
reinforced inspection and supervision
activities (31), (iii) Shift from the current
unified approach to specific strategies
according to epidemiological profiles and the
emerging trends such as co-morbidity with
HIV/Aids and, (iv) Transfer greater
responsibilities to and empower
municipalities-communities for
comprehensive and integrated malaria
control interventions (28, 29)
(i) Shift from the current unified approach to specific
strategies according to epidemiological profiles and
the emerging trends in the epidemiology of diseases
for example: Introduce the Intermittent Preventive
Treatment (22, 26), for infants and preschool children
living in high and moderate transmission zones and for
PLWHA, (ii) Distribute LLINs, IPTp, IPTi, IPTc by the
communities supported by NGOs, CSOs (30),
Community Health Workers (CHW) and Community
Based Associations (CBAs) as it is the case with CDTI
and , (iii) Foster public private partnerships through
Incentives/budget support (32), for example Service
Level Agreements (SLA) or Performance Based
Contracting (PBF) as appropriate with pharmacists to
sell only commodities and drugs recommended by the
national policies, with business people for effective
private marketing approaches for LLINs distribution.
(i) Secure and sustain subsidies for
IPT, LLINs and ACTs and, (ii) Financial
incentives for pharmacists and
prescribers who comply with
regulations.
Barriers to
implementation
Resistance to change, inadequate knowledge
among the stakeholders on both malaria and
its effective control strategies, insufficient
capacities of community stakeholders to take
ownership.
The State supply chain fails to deal with private
pharmacies and sales of other licensed antimalarials
are often more profitable. IPTi is not part of the
national policy because of the fear that S/P will lead to
resistance as is the case in other countries e.g.
Low budget allocation to health,
Poverty, insufficient regulation
leading to high commercialization of
malaria control
21
Policy
Option
Governance arrangements Delivery arrangements Financial arrangements
Tanzania
Challenges for
adaptability
Presence of strong leadership and previous
community empowerment strategies
Developing partnerships between communities, policy makers and experts. Developing local
organisational capacity and financial empowerment
Implementatio
n strategies
Information, education and communication, ”
malaria competence approach”, Promotional
campaigns2, Use existing social structures and
community groups
Communication, education, promotional campaigns,
management and leadership training and careful
selection to ensure only ACTs on MOH policy circulate
in the market and are used, empowerment of parents,
resources mobilisation
communication, decentralisation and
Promotional campaigns,
management and leadership training
Advantages
introduction of incentive schemes is already
part of the Health Policy (7) and performance
based contracting is ongoing at pilot scale in
some health districts within the context of
SWAp
Cost-effective interventions are available (24) and all
the interventions to be scaled up have proven high
impact on MDG 4 and 5 (6, 7, 21). A 20-30 percent
reduction in incidence of clinical malaria in high and
moderate transmission epidemiologic settings using
IPTi is comparable to the levels of efficacy observed
for the massive use of impregnated mosquito nets
(22).
introduction of incentive schemes is
already part of the Health Policy (7)
and performance based contracting
is ongoing at pilot scale in some
health districts within the context of
SW
Disadvantages In spite of the relative advantage3 that Artemether-
lumefantrine [AM-LM] has over the other ACTs, it
A package of interventions to
decrease the bulk of the malaria
2 Advocacy targeting private and public, political and scientific spheres as well as the general population who should be encouraged to become partners and even
actors of vector and malaria control at their household level
3 AM-LM has potential advantage over other forms of Act as it has registered no treatment failure due to recrudescence, closely followed by dihydoartemisinin-
piperaquine (DH-PP)
22
Policy
Option
Governance arrangements Delivery arrangements Financial arrangements
requires six doses, rather than three doses for other
artemisinin-based combinations (23).
In northern Tanzania, as in many other parts of Africa
where the drug has been used extensively, resistance
to S/P is frequent4, and is expected to increase after
S/P has become first line treatment (25).
burden is not, however, affordable in
very-low income countries. Coverage
of the most vulnerable groups in
Africa will require substantial
assistance from external d o n o r s
(24)
Costs
(unit cost)
According to a systematic review conducted by Goodman CA, Coleman PG, Mills AJ on the Cost-effectiveness of malaria control in sub-Saharan
Africa (24), the cost-effectiveness range of insecticide-treated nets was US$19-85. If only insecticide treatment was required, the range would
be decreased to US$4-10 per DALY averted. Cost effectiveness was $32-58 for residual spraying (two rounds per year), $3-12 for children's
chemoprophylaxis, $4-29 for intermittent treatment of pregnant women, and $1-8 for improvement in case management. The global costs
linked to the deployment of each strategy, based on the Cameroonian context, still need to be analysed to enable stakeholders ascertain
feasibility
Additional
considerations :
Equity, gender
approach,
Human rights
approach
Monitoring and
evaluation,
PSM
The monitoring and evaluation of the impact
of the governance arrangements to
strengthen the process of extending MCI with
the community at the fore front is
fundamental in the justification of the choices
made in this policy brief. This requires the
development of specific governance
indicators to tract the effectiveness and the
efficiency of each strategy taken in context as
In view of the limited resources, universal access
could target pregnant women, Children < 5 and
PLWHA as priority groups. Routine Data on coverage
should be disaggregated to identify all aspects of
discrimination: sex, milieu of residence, education,
income levels where possible. In the approach to
empowering communities, the participation of
women and especially women groups should be
encouraged as they are the first concerned for the
Malaria prevention and treatment
should continue to benefit from
government subsidies and partner
funding.
Demand side schemes should cover
the cost of treating malaria for the
target group identified: pregnant
4In Cameroon, IPTi with Sulfadoxine Pyrimethamine (S/P) is preferable to IPTi with amodiaquine because the later is already in use for IPTp (3).
23
Policy
Option
Governance arrangements Delivery arrangements Financial arrangements
evidence points to the need to adapt any
strategy to the local context. As a matter of
fact, reviews found a weak evidence base for
claiming success of any particular health
services strengthening strategy in one LMIC
(34). There is even less evidence to expect the
same results in another country.
continuum of mother and child health.
Where and when the above is achieved, coverage
should systematically be extended to the whole
population at risk.
The CDTI experience should serve as entry point
towards the integration of public health Delivery at
the level of the community
women, children < 5 years and PLWHA
The at risk population other than the
identified priority groups should have
access (availability, affordability) to
malaria prevention products such as
LLINs through social marketing
channels
24
3 Implementation considerations
According to the systematic reviews edited by David H. Peters et al (34), strategies relying on
government oversight, strengthening human resources, strengthening management systems, public
sector reorganization, community empowerment, and financing systems have all been shown to
work. The same editors state that there is moderate evidence that most interventions require local
adaptation. Leaders will need detailed advice/consultations from local experts to formulate the
implementation process.
The strategic options considered in this policy brief rely on government oversight, strengthening
management financing systems and should therefore work. Regarding Governance arrangements
government oversight shall enhance leadership, stewardship and regulation while at the same time
ensuring community empowerment through training and participation. Similarly regarding Delivery
and financial arrangements, the strengthening of their management systems should entail
adaptation to the local context. For example, the epidemiological profile of malaria in Cameroon
reveals that the intensity of malaria transmission reduces as one moves inland and as such, there is
need to adapt policy implementation to the epidemiologic profile (table 4). Other situations to
take into consideration include the poverty profile and the HIV-malaria co-mobidity.
This chapter summarises the implementation considerations into two categories: Global and
Strategy specific.
3.1 Global Considerations related to Malaria control Interventions:
3.1.2 Malaria Prevention Interventions
According to WHO (36) neither LLINs nor indoor residual spraying (IRS) may be sufficiently
effective alone to achieve and maintain interruption of transmission in holo-endemic areas of
Africa. Operational research is needed to determine the extent to which combining the two
interventions would maximize the public health impact of malaria vector control and offer
opportunities for management of insecticide resistance.
The way in which full coverage should be achieved may vary with particular epidemiological and
operational situations. Where young children and pregnant women are the most vulnerable
25
groups, their protection is the immediate priority while progress is made towards achieving full
coverage. Apart from the use of LLINs, cchemoprophylaxis or IPT reduces antenatal parasite
prevalence and placental malaria when given to women in all parity groups. They also have
positive effects on birth weight and possibly on perinatal death in low-parity women (27). IPT also
reduces clinical malaria and severe anaemia in preschool children (22, 26). In Cameroon, due to
co-morbidity of HIV-malaria, PLWHA should automatically be the third priority group. In areas of
low transmission, where all age-groups are vulnerable, national programmes should establish
priorities on the basis of the geographical distribution of the malaria burden (cf. epidemiological
sub facies, table 1)
3.1.3 Malaria Case Management
According to a study conducted by Wilfred F Mbacham (38) the prevalence of molecular markers
for quinoline and anti-folate resistances showed high levels and differed between the south and
north of Cameroon. AQ, SP and AQ+SP treatments were well tolerated but with low levels of
efficacy that suggested alternative treatments were needed in Cameroon since 2005. According
to Whegang et al (39), further studies are needed to evaluate the clinical efficacy and tolerance
of ACT in different epidemiological contexts; artemether-lumefantrine [AM-LM], AM-LM appears
to be the most effective with no treatment failure due to recrudescence, closely followed by
dihydroartemisinin-piperaquine [DH-PP]. In Cameroon more than one ACT is being used (20)
without that this is based on proven efficacy for each given epidemiological Strata. Acces to
subsidised ACT is not equitable (16).
Table 4 summarises the malaria control interventions that may apply with respect to given
epidemiological profile.
26
Table 6: Implementation considerations based on the main epidemiological strata
Major epidemiological profile Malaria Control Intervention
Endemic and perennial: Zone of continous
transmission covering the South Cameroonian
Equatorial forest strata, the High western
plateaux altitude strata and the Coastal strata
where about a hundred infective bites per man
per month can be registered. Most of the
malaria burden occurs in children under the age
of 5 years and pregnant women
1. Universal coverage with LLINs5
2. IPTp and IPTi (35) are useful to combine
(29) with LLIN use given that the coverage
in Cameroon is still very low for both
target groups
3. Malaria case management for the general
population (37), which shall be covered
with LLIN and IRS progressively.
Endemic and seasonal: Zone of long seasonal
transmission (6-9 months) covering High inland
plateaux strata (Adamaoua) and the Savannah-
forest transition strata where about twenty
infective bites per man per month can be
registered
1. Systematic case management6
2. Operational research (36):
IRS coupled with LLIN to the general
population
impact of systematic treatment of non
clinical forms of malaria presenting with
positive smear with ACT
Epidemic or strongly seasonal: Zone of short
seasonal transmission (3-4 months) covering the
Sudano-sahelian strata where about ten
infective bites per man per month can be
registered. High risk of epidemics
1. continuous epidemiological surveillance
(33)
2. effective case management (home as well
as clinic based) (37)
5 4–5 times cheaper than IRS which, cannot be targeted to children only.
6 Establish priorities based on the geographical distribution of the malaria burden (28)
27
3.2 Strategy-specific Considerations:
Table 5 below summarises, for each strategic option (cf. table 3), the expected barriers to implementation, challenges for adaptability
and Implementation strategies in the context of Cameroon.
Table 7: Summary of implementation consideration for each strategic option
Policy
Option
Governance arrangements Delivery arrangements Financial
arrangements
Description: (i) Clear the drug market of antimalarials that are
not in the national policy (ii) Enforce regulation
through reinforced inspection and supervision
activities, (iii) Shift from the current unified
approach to specific strategies (iv) Transfer greater
responsibilities to and empower municipalities-
communities
(i) Shift from the current unified approach to specific
strategies, (ii) Distribute LLINs, IPTp, IPTi, IPTc by the
communities supported by NGOs, CSOs, CHW CBAs and
Community Based Associations, (iii) Foster public private
partnerships through Service Level Agreements (SLA) or
Performance Based Contracting (PBF) as appropriate
(i) Secure and sustain
subsidies for IPT, LLINs and
ACTs and, (ii) Financial
incentives for pharmacists
and prescribers who comply
with regulations.
Barriers to
implementation
Resistance to change, inadequate knowledge
among the stakeholders on both malaria and its
effective control strategies, insufficient capacities
of community stakeholders to take ownership.
The State supply chain fails to deal with private
pharmacies and sales of other licensed antimalarials are
often more profitable. IPTi is not part of the national
policy because of the fear that S/P will lead to resistance
as is the case in other countries e.g. Tanzania
Low budget allocation to
health, Poverty, insufficient
regulation leading to high
commercialization of malaria
control
Challenges for
adaptability
Presence of strong leadership and previous
community empowerment strategies
Developing partnerships between communities, policy makers and experts. Developing
local organisational capacity and financial empowerment
Implementation
strategies
Information, education and communication, ”
malaria competence approach”, Promotional
Communication, education, promotional campaigns,
management and leadership training and careful
communication,
decentralisation and
28
campaigns7, Use existing social structures and
community groups
selection to ensure only ACTs on MOH policy circulate in
the market and are used, empowerment of parents,
resources mobilisation
Promotional campaigns,
management and leadership
training
7 Advocacy targeting private and public, political and scientific spheres as well as the general population who should be encouraged to become partners and even
actors of vector and malaria control at their household level.
29
4 References
4.1 The epidemiological profiles
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Cameroon : http:/www.impact-malaria.com
2. WHO :Drug Resistance.http://www.who.int/tdr/research/progress9900/methods/malaria-resistance.htm
4.2 The poverty profile
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1991
5. INS : Résultats préliminaires de l’ECAM3 en 2007
4.3 The malaria services coverage
6. Government of Cameroon: Growth and Employment Strategy Paper 2010-2020,
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8. National Malaria Control Programme: Plan Stratégique National de Lutte contre le
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4.4 Effective interventions
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4.5 Implementation considerations
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