1.0 Introduction
Malaria has been one of the most devastating diseases in the last several decades with far reaching health and socioeconomic consequences . According to the Centre for Disease Control (CDC) (2010) report on mortality due to infectious diseases malaria ranks 5th as the cause of global mortality, while it is the 2nd cause of death from infectious disease in Africa after HIV/AIDS. The disease affects up to 10% of the world’s population. . An estimated 40- 50% of the world’s population lives in malaria endemic regions and a child dies every second due to the disease . 90% of the global reported cases of malaria are found in Africa alone (World Health Science, 2010). Economically, the direct cost of malaria is estimated at US $ 12 billion annually (CDC, 2010).
Malaria is a major public health challenge in Benin and is the principal cause of mortality and morbidity among children under five. It causes about a thousand in Benin every year. In addition, malaria has significant impact on the economy of Benin because most of the households spend up to 25% of their income on prevention and treatment of the disease. The frequency of the disease occurrence places a heavy toll on the personal lives of people living in Benin, with an individual contracting the disease an average of 3-6 times every year.. Furthermore, malaria is endemic in Benin due to the constant floods and the many rice paddies that are irrigated throughout the year hence good breeding grounds for mosquitoes. As such, almost the entire population in Benin is at risk of contracting the disease.
1.1 Questionable historical decisions that have impacted the malaria burden
The most controversial decision made in the antimalaria war was the withdrawal of DDT as a residual insecticide to control mosquitoes due to environmental concerns in late 1960s. DDT was the primary public health antimalaria tool and was successful in eradicating malaria in Europe and North America after the World War II. The main reason for the withdrawal of DDT was the effect on the environment, when used in unregulated spraying of farms, and speculation on causing of human harm. However, there is no scientific evidence (empirical data) that DDT can cause human harm and thus it is highly unlikely that low-dose indoor residual spraying with DDT can cause harm to the environment or the humans being protected against malaria. The rich nations which often fight the antimalaria campaign in the third world imposed the decision to restrict the use of DDT on the poor countries leading to a heavy malaria burden on the latter countries. While the rich nations can afford expensive alternative insect control methods the poor countries suffer the brunt of the controversial decision.
2.0 The epidemiological background of Malaria in Benin
As earlier stated Malaria is a serious public health concern in Benin and is considered endemic in Benin. The entire population is at risk of contracting the disease, with an individual contracting the disease an average of 3-6 times every year.. Never the less, malaria is considered as a disease of the poor and thus with 39% of the country’s population living below the poverty line, the disease has a greater impact among the poor. The disease is responsible for 34-44% outpatient consultation and 20-40% hospital admissions in Benin.
Malaria affects pregnant women and children under five more than any other segment of the population. In 2006, approximately 19.8% of all maternal deaths were attributed to malaria and the disease accounted for about 39% of hospital visit by children. In 2010, five hundred thousand out of the six hundred reported case of malaria were children. Infant mortality resulting from malaria continues to be unacceptably high in Benin. In 2000, malaria caused the death of 10,000 children between the age of 1 and 59 months and ten years down the line the infant mortality has not reduced significantly with 9,000 children in the same age bracket died of the disease. In addition, the morbidity associated with malaria-related anaemia continues to be significantly high. In 2006, the prevalence of anaemia (mostly caused by malaria) among children between 6 and 59 months old was 78%. However, with regard to malaria-related anaemia prevalence in the above mentioned group has reduced to 58%. In addition, some studies have shown geographical disparity in malaria prevalence with lower transmission in communities near the beach, near saline lagoons and in urban centres. As such, it is clear that the poor and particularly children under five and pregnant women in Benin remain vulnerable to malaria, begging the question what inequalities have led to the disparity?
2.1 Inequalities and factors leading to the disparity in malaria prevalence in Benin
As earlier stated malaria is more prevalent among the poor and thus considered one of the of diseases of poverty. The correlation between malaria prevalence, particularly the impact of the disease, and socioeconomic status is linked to inequalities in access to preventive and treatment medicine. Albeit malaria being highly preventable by regular use of insecticide treated bednets, due to low access to healthcare services and information among the poor, there is very low use of nets (especially the long-lasting insecticidal nets (LLIN). It was reported that before 2007 only 35.5% of mothers and 34% of children under five slept under LLIN. Since the LLIN are distributed through health facilities a majority of the poor are unable to access the facilities due to the distance they have to travel to the facilities consequently they are unable to get the nets.
Low access to health facilities is also attributed to the cost of preventive and treatment medicine and thus the poor are left vulnerable and denied a chance to get early and accurate diagnosis and treatment. As a result, the poor either wait until the disease has reached the complicated stage before they can visit a healthcare facility or seek home based treatment. Early diagnosis and appropriate treatment of malaria is highly effective while severe malaria can be difficult to treat and is partly to blame for the high morbidity and mortality associated to malaria. On the other hand, while home-based treatment can be effective in most cases it is ineffective due to the fact that in most cases the providers of such services are not adequately trained. It has been reported that about 86.7% of mothers only sought help from health facilities after home-based treatment failed. Due to the high cost of treating malaria there are also those who choose to self medicate rather than go for professional diagnosis and treatment. This trend can be blamed for the high mortality and morbidity associated with malaria among the poor. In Benin, antimalaria drugs are openly sold in the markets without requiring a doctor’s prescription from the buyer.
In 2011, the government of Benin instituted a free malaria treatment program targeting pregnant mothers and children under the age of five. However, since the program is only available in government hospitals that are far from the majority poor, they are able to access the services and end up depending on home-based care or buying drugs in the markets. In addition, the poor are not able to get the free insecticide treated bed nets provided to pregnant women in government facilities. As such, the distance to health facilities and the cost of treatment remain as major barriers to access of healthcare by the poor. In addition, it has been established that there is a difference in the type of drugs available to the poor and the rich as well as the healthcare facilities accessed by the two groups. The rich are said to have the ability to buy and use newer drugs to which the malaria parasite has not developed resistance while the poor use older and cheaper drugs, such as chloroquine, to which the parasites have developed resistance. In addition to the old drugs, the poor are more likely to use counterfeit drugs peddled in the markets and hence experience higher morbidity and mortality. There are also cases of the poor using un-validated traditional medicine. With regard to the type of health facilities, the rich access modern facilities with high-tech equipments and thus higher chances of accurate diagnosis and effective treatment of malaria.
Other malaria prevalence demographic disparities are linked to environmental factors. As earlier, started there is a lower prevalence of the disease among the people living near saline lagoons and the sea. This is mainly because saline water does not provide good breeding sites for mosquitoes. The lower prevalence of malaria among people living in urban areas has been linked to socioeconomic factors and the associated access to modern health facilities. The people living in urban areas are often economically empowered and are informed (educated) on the danger signs of the disease and the protective measures they should take. Conversely, there is lower level of awareness. In addition, the most modern health facilities are in the urban centres and the urban dwellers have a higher chance of getting accurate and timely diagnosis and treatment.
2.2 Recommendations to remediate the inequalities and disparities
While it is worth appreciating the fact that there has been some improvement in the inequalities leading to the malaria prevalence disparities, a lot can be to reduce the burden associated with the disease. First and foremost there is need to establish more health facilities to reduce the distance travelled to get to a health facility. The government ought to seek more funding to build modern health facilities in the rural areas and use innovative means to reach out to the poor. On innovative method is to provide the existing health facilities with mobile unit that can be visiting the rural areas around the health facilities to provide free diagnosis, treatment and LLINs. The same units could be used to create awareness on the danger signs of malaria and the need to sleep under insecticide treated bed nets.
Another innovative means to reach the rural poor is to empower the home-based health providers. The government and other stockholders (NGO’s, research and education institutions, healthcare providers) should come up with a simplified programs to train the home-based care givers and traditional healers. The program should also include the registration of such providers with the government to help in the monitoring of their work and continuous training. The home-based health providers should also be trained in report keeping and their records submitted to the visiting mobile healthcare units. This would help the government in terms of surveillance and monitoring the trends and occurrences of malaria. An important component of the program should be the provision of materials for prevention, diagnosis and treatment of malaria. The government can give the home-based health providers malaria rapid diagnosis kits (RDT), after training them on how to use the kits. Unlike the gold standard malaria test (microscopy), non-technical people with minimum training can use RDTs. The government can also use the home-based providers to provide free treatment and LLNs. Suffice to say that the collaboration between the government (and other conversional stakeholders) and home-based health providers ought to be well structured to avoid resale of the free drugs, LLNs and diagnosis services. The government could for instance, give the home-based health providers financial incentives to participate in the programme.
Another innovative channel to increase access to malaria preventive and treatment is to use existing non-hospital government facilities. The government has administrative offices in virtually every rural area that are accessible as compared to fewer health facilities. These facilities could be particularly useful in the provision of free LLNs to households in their vicinity. Again, such a program requires an elaborate record keeping and integrity by the offices in charge to avoid misappropriation.
With regard to treatment, the government needs to put more effort in getting rid of trade in counterfeit drugs. Recently, the police raided stalls and pill traders in Cotonou markets. These activity needs to spread to the rural areas where the unsuspecting poor are more susceptible to the unscrupulous peddlers of antimalaria drugs. In addition, the government fight against counterfeit and substandard drugs should not be a one off event but continuous and regular to rid the markets of such traders. The government should also introduce stiff penalties for those found trading in substandard and counterfeit antimalaria drugs to discourage the trade as well as introduce awareness campaigns to educate the masses on the dangers of self-medication, counterfeit and substandard drugs. The expansion of the free malaria treatment could also help reduce the illegal trade.
The governments and other stakeholders should also increase the prevention initiatives. Of particular importance is the indoor residual spraying (IRS) campaign. The is a great potential of eradicating malaria by use of indoor spraying with DDT despite the environmental controversy surrounding DDT. This method was successful in eradicating malaria in Europe and North America after the World War II. The main reason for the withdrawal of DDT was the effect on the environment, when used in unregulated spraying of farms, and speculation on causing of human harm. However, there is no scientific evidence (empirical data) that DDT can cause human harm and thus it is highly unlikely that low-dose indoor residual spraying with DDT can cause harm to the environment or the humans being protected against malaria. This method could be particularly useful in areas with constant floods and poor irrigation systems.
3.0 Current legislation and regulation on Malaria and recommendations
Currently there is no specific legislation to deal with malaria but the government has, through the National malaria control programs (NMCP), come up with different policies and programs to aid in the antimalaria campaign. One such policies and program is the provision of free antimalaria drugs to pregnant women and children under the age of five in government hospitals. The NMCP is also working with donors and other stakeholders to provide free ITNs, IRS, intermittent preventive treatment for pregnant women (IPTp) using sulfadoxine-pyrimethamine and free diagnosis. The ITNs are particularly issued to pregnant mothers during antenatal visits. Another important government policy/regulation is the fight against substandard and counterfeit antimalaria drugs. As earlier stated, the trade in such drugs is very prevalent in Benin. The use of the counterfeit and substandard drugs has negatively affected the treatment outcomes because the drugs are ineffective and often contribute to drug resistance. The government has moved to regulate and limit the trade in antimalaria drugs.
As much as the above initiatives are commendable and effective, there is room for improvement. The policies are effective because they specifically target the vulnerable groups (pregnant women and children under the age of five) and they encompass all the necessary components of the antimalaria war i.e. prevention, prompt diagnosis and effective treatment. However, there is need to improve on the regulation of trade in antimalaria drugs. The government should introduce legislation with stiffer penalties for those caught trading with counterfeit and substandard drugs. The government should also introduce a policy to guide collaboration with home-based health providers to reach those who are far from the government health facilities. The providers should be trained by the government, registered and provided with RDTs, ITNs and the free drugs to help in the distribution. As earlier stated, stated the collaboration should be strictly monitored to ensure the protection of those receiving services of home-based health providers. Another important regulation is one to guide the empowerment of the communities in the antimalaria war. Even with the best policies and regulation, community support and participation is paramount. Finally, there is need to increase surveillance to help monitor and evaluate the effectiveness of other policies introduced by the government.
Resources
It is accurate to say that the resources allocated to the antimalaria war is inadequate. A majority of the poor continue to sleep without the protection of ITNs or IRS and have very low access to malaria treatment. As such, more resources are needed to expand the government driven initiatives of providing free ITNs, IRS, IPTp and education. In addition more resources are required to construct more health facilities, especially in the rural areas, to help facilitate higher access to healthcare. With regard to healthcare, I would recommended allocation of funds to facilitate mobile diagnosis and treatment units. The government should allocate some funds to every hospital for mobile clinics to visit the villages in their vicinity. There is also need to increase resources for the provision of RDTs to healthcare facilities and home-based healthcare providers. By and large the budgetary allocation for health should be increased to 10% of the country’s GDP. I would also propose that some money be set aside for training and equipping home-based healthcare providers because they are closer to the communities and could help the government in implementation of some of the nontechnical policies like distribution of ITNs, awareness creation and community education, free and accurate diagnosis with RDTs.
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