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EDUCATION AND DEBATE: David H Molyneux and Vinand M Nantulya Linking disease control programmes in rural Africa: a pro-poor strategy to reach Abuja targets and millennium development goals BMJ 2004; 328: 1129-1132 [Full text]

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HEALTH SERVICES ARE BADLY NEEDED TO CONTROL MALARIA (AND OTHER DISEASES)

Monique Van Dormael, Jean-Pierre Unger, Pierre De Paepe   (25 May 2004)

Strengthening the potential of health systems in rural Africa

Jayne Webster, Eve Worrall, Jenny Hill, Kara Hanson, Jo Lines   (4 November 2004)

HEALTH SERVICES ARE BADLY NEEDED TO CONTROL MALARIA (AND OTHER DISEASES) 25 May 2004
Monique Van Dormael, lecturer Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium, Jean-Pierre Unger, Pierre De Paepe Send response to journal: Re: HEALTH SERVICES ARE BADLY NEEDED TO CONTROL MALARIA (AND OTHER DISEASES)	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
Strengthening the potential of health systems in rural Africa 4 November 2004
Jayne Webster, Research Fellow London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, Eve Worrall, Jenny Hill, Kara Hanson, Jo Lines Send response to journal: Re: 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