Linking disease control programmes in rural Africa: a pro-poor strategy to reach Abuja targets and millennium development goals
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7448.1129 (Published 06 May 2004) Cite this as: BMJ 2004;328:1129All rapid responses
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Sir,
To control several diseases, Molyneux and Nantulya (1) propose to
link bed nets to mass drugs’ distribution and to co-ordinate programmes’
administrations. They argue that “such strategy would have a rapid effect
on malaria morbidity and mortality among under-served populations». At
first glance, the proposal sounds reasonable as:
- programme managers (of AIDS, tuberculosis, malaria, onchocerciasis,
immunisations, family planning, acute respiratory diseases, acute
diarrhoeal diseases, poliomyelitis, leprosy, chagas, Guinea worm, …)
- and managers of programmes-to-be (soil transmitted helminths,
schistosomiasis, lymphatic filariasis, visceral leishmaniasis,
trypanosomiasis, trachoma, cholera, Buruli Ulcer, Rabies, echinococcosis,
cardio vascular and cerebrovascular diseases in transition epidemiology
areas…)
cannot cope with the inefficiency generated by so many disease-
specific operational teams and administrations.
In fact, Molyneux and Nantulya carefully keep health care delivery
services out of disease control policies, while suggesting that mere
administrative and operational linkages would suffice to successfully
tackle the failure of Roll Back Malaria (2) and other control programmes.
This is debatable:
- First, malaria requires medical treatment (3) because of superior
efficiency (4), even if bed nets have a role in control strategies. In
fact, virtually all of the above mentioned diseases, except
onchocerciasis, require diagnosis and treatment, or simple surgery.
- Second, programmes linkages increase the bureaucratic burden while
improving in some instances distribution efficiency. However, the too many
programmes’ bureaucracies already deteriorated both acceptability and
accessibility of health services (5).
- Third, the proposed community health workers (CHW) are limited in
their capacity to tackle jointly numerous disease programme activities –
though they could probably deliver lymphatic filariasis and some malaria
interventions. Therefore, numerous programmes will have to train their own
CHW, inasmuch as they don’t often overlap geographically.
- Finally, with their own objectives, resources and information
systems, vertical programmes are not prone to linkages between each other.
The best linkages between programmes are those made by health
professionals – be they nurses or medical assistants. They can establish
them at the right time - when the patient’s health status requires it,
while meeting their demand for suffering alleviation. It would be an
illusion to believe that diseases could generally be controlled in
developing countries without decent health services.
1. Molyneux DH and Nantulya VM. Linking disease control programmes in
rural Africa: a pro-poor strategy to reach Abuja targets and millennium
development goals. BMJ 2004; 328: 1129 -1132
2. Roll Back Malaria : a failing global health campaign. Editorial.
BMJ 2004;328: 1986-1087
3. Moerman F, Lengeler C, Chimumbwa J, Talisuna A, Erhart A,
Coosemans M et al. The contribution of health-care services to a sound and
sustainable malaria-control policy. Lancet Infect.Dis. 2003; 3(2): 99-102
4. Goodman CA, Coleman PG, Mills AJ. Cost-effectiveness of malaria
control in sub-Saharan Africa. Lancet 1999; 354: 378-385
5. Unger JP, De Paepe P, Green A. A code of best practice for disease
control programmes to avoid damaging health care services in developing
countries Int J Health Planning and Management 2003; 18: S27-S39
Competing interests:
None declared
Competing interests: No competing interests
Strengthening the potential of health systems in rural Africa
Molyneux and Nantulya (M&N) suggest increasing progress towards
the RBM goal and Abuja Targets by linking malaria control programmes to
community directed health initiatives and elimination programmes(1). Their
approach underestimates achievements by health systems, and risks
diverting resources needed to strengthen and support these systems. Some
of the evidence they cite to support their claims and to reject other
approaches lacks validity and scientific rigour; other important studies
are not cited.
M&N state that voucher schemes for pregnant women are the
recommended approach for ITN distribution in sub-Saharan Africa (SSA). The
source of this claim is not provided. In fact, the WHO spearheaded a call
for coordinated national action with two key components: the sustained
provision of subsidies to vulnerable groups and private sector growth, in
an effort to achieve a balance between equity and sustainability(2).
Vouchers are just one of the mechanisms identified.
Dismissal of antenatal clinic (ANC) systems as a means of delivery is
not justified by an examination of the evidence. Our calculations using
recent Demographic and Health Surveys (DHS) across 26 countries of SSA
show that 75% of women attend ANC at least once. This is very close to the
76% coverage achieved during the first annual mass drug administration for
lymphatic filariasis in Zanzibar 2001, which albeit implemented on a much
smaller scale, is hailed as a success by M&N. By comparison, Malawi
has already achieved the Abuja target for Intermittent Preventive
Treatment in pregnancy (IPTp) using ANCs(3), demonstrating the potential
of using routine health services.
The cost data presented by M&N is not consistent with published
studies that have costed alternative distribution strategies in a rigorous
manner, such as in Tanzania(4). They include only the marginal costs of
adding ITN distribution to an existing programme, and the full opportunity
or economic cost of the activity has not been quantified(5).
1. Molyneux DH, Nantulya VM. Linking disease control programmes in
rural Africa: a pro-poor strategy to reach Abuja targets and millennium
development goals. British Medical Journal 2004;328(7448):1129-32.
2. World Health Organization. Scaling-up insecticide-treated netting
programmes in Africa: A Strategic Framework for Coordinated National
Action. Geneva: World Health Organization, Roll Back Malaria, 2002:12.
3. Malawi Ministry of Health / UNICEF National Community Malaria
Survey, February – April, 2004, Malawi.
4. Hanson, K., Kikumbih, N., Armstrong Schellenberg, J., Mponda, H.,
Nathan, R., Lake, S. et al Cost-effectiveness of social marketing of
insecticide-treated
nets for malaria control in the United Republic of Tanzania. Bull World
Health Organ 2003; 81(4): 269-76.
5. Linking ITN distribution to measles campaigns achieves high and
rapid coverage at low cost. Proceedings of the annual meeting of the
American society of Tropical Medicine and Hygiene; 2003 4 December 2002;
Philadelphia.
Competing interests:
None declared
Competing interests: No competing interests