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Reality Bites – Tanzania
In sub-Saharan Africa, over two million people die every year as a result of Malaria. The majority of victims are pregnant women and children under five years old. There is already an effective means of prevention: insecticide-treated nets (ITNs) have been shown to decrease the incidence of severe malaria by 45 per cent, reduce premature births by 42 per cent and cut all-cause child mortality by up to 63 per cent.
However, access to nets in sub-Saharan African is problematic and simply giving away nets is ineffective. In Tanzania, a social marketing approach has been adopted. Pregnant women are given a discount voucher worth more than 80 per cent of the commercial price of a net on their first visit to an ante-natal clinic. They can use this voucher to purchase an ITN in selected retail outlets.
Malaria in Southern Africa
Almost 90 per cent of malaria deaths occur in Africa, south of the Sahara. Each year there are over 300 million clinical cases of malaria; that is five times as many as combined cases of TB, AIDS, measles and leprosy. Malaria is responsible for a quarter of all childhood deaths in Africa.
The contribution of malaria to mortality varies considerably between countries, partly because malaria is more endemic in some countries than in others, but also because of differences in prevention and treatment, and in the incidence of other infectious diseases (e.g. HIV/AIDS), local health service provision and socio-economic conditions. Even in countries where malaria is confined to limited areas, malaria mortality can be high among vulnerable groups, particularly in epidemic years. The people at greatest risk of malaria are those with low or no immunity to malaria. In non-endemic areas, all age groups are at risk of malaria. However, in endemic areas children under five and pregnant women form the two main risk groups due to their low immunity to the disease.
Malaria is Tanzania’s leading cause of morbidity and mortality, with an estimated 16 million cases and about 100,000 malaria-related deaths occurring each year. In Tanzania 90 per cent of the population lives in what is called a malarious area. All 21 regions in Tanzania are considered to be malarious, and in 1998 a total of very nearly 34 million people were considered at risk. Malaria transmission is intense but stable in low-lying areas of the country (e.g. the coastal areas of Lake Victoria). The high altitudes of the Northern and Southern highlands appear to contain pockets that are malaria-free with adjacent epidemic-prone areas. In Tanzania, malaria consumes an estimated US$119 million of national resources per year through direct expenditures by the state and households, reductions in economic productivity, and losses in economic opportunities.
Malaria Explained
Plasmodium is a group of one-celled animal parasites that lives on the red cells in the blood of many birds, reptiles and mammals. There are four human malaria species – P. falciparum, P. ovale, P. vivax and P. malariae – of which the first is by far the most dangerous. Unfortunately, it is also the most common in Africa. Malaria is transmitted by certain Anopheles mosquitoes. The parasite has to undergo a crucial development process in the mosquito, and this can only happen in certain mosquitoes.
In humans, the parasite multiplies in two stages: first in the liver cells, then in the blood cells.
The liver stage
Parasite forms (sporozoites), which are injected into a human from an infectious mosquito, first travel to the liver where they undergo an initial multiplication phase. One parasite cell in the liver stage produces 10,000 (in P. vivax) to 30,000 (in P. falciparum) merozoites. These then enter the blood system where they start multiplying further.
The liver stage of the parasite can become dormant, and re-emerge after 1-18 months (in P. vivax and P. ovale). Recurrence in P. falciparum (in less than a year) and P. malariae (up to 50 years) is due to the re-emergence of parasites living at very low levels in the blood.
The blood cycle
In the blood stream, the parasites invade red blood cells, feeding on them as they grow and divide, until they finally break free and destroy the cells. Each parasite produces 12-32 new parasites (in P. falciparum; slightly less in other species). Each new parasite then invades another red blood cell and starts dividing. This multiplication can quickly result in severe disease and death.
Fever is caused by the release of waste material when infected cells rupture in the blood. Cerebral malaria is caused by the clotting of red blood cells in the brain’s blood capillaries as a result of the malaria infection. Severe anaemia is caused by the destruction of both infected and uninfected cells by the parasite or by the body itself. The failure of other organs, such as kidneys, liver and spleen, is caused by the flood of waste materials and the clotting of blood capillaries, to the point where the body can no longer cope.
The blood cycle in P. falciparum occurs in ‘deep circulation’, i.e. in the blood vessels of the inner organs. Only when the cells rupture do parasites appear in peripheral blood (where they can be picked up through a finger prick). That is why it is sometimes difficult to pick up parasites with the microscope, unless the blood was taken during a fever spell.
The maximum parasite density achieved by P. falciparum is 2,000,000 parasites per micro litre (μl); 50,000 per μl in P. vivax; 30,000 per μl in P. ovale; and 20,000 per μl in P. malariae. On average there are 5,000,000 red blood cells per μl of blood, so P. falciparum can infect 40 per cent of all red blood cells before death.
Immunity
Immunity is only acquired under conditions of frequent infection. The more frequently a person is infected, the greater the immunity. It does not prevent infection, but decreases the rate and severity of the disease, and increases the rate of recovery. Immunity can be lost when a person leaves the malaria area. Immunity is also specific to a particular species and stage of the parasite. It is transferred from the mother to the infant but remains active only for three to six months. Fetal haemoglobin also partially protects babies during the first few months.
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Beating Malaria
Drugs have been developed against malaria, but these have adverse side effects and do not always prevent malaria. The cheapest and safest (chloroquine) is rapidly losing its effectiveness against malaria. In some parts of the world, malaria is resistant to the four leading front-line drugs. Malaria quickly rebounded from the mass insecticide spraying campaigns in the 1950s and 1960s. It then eluded mass treatment strategies based on a single drug, such as chloroquine.
In Tanzania, following progressively increased resistance to chloroquine in the 1980s and 1990s, an interim front-line drug, sulfdoxine-pyrimethamine (SP) was introduced in 2001. But after three years of implementing this new antimalarial drug policy, failure of this treatment is showing an alarming increase. These warning signs are showing that this front-line treatment should be discontinued. Resistance to the second-line antimalarial drug, amodiaquine, varies, but its useful therapeutic life also appears limited. When treatment failure become so frequent, malaria deaths rise greatly, especially in children. The demise of chloroquine and sulfdoxine-pyrimethamine leaves artemisinin-class combination therapies (ACT) as the best treatment option. The main reasons for treating malaria with combination therapy is that patients, given two robust and highly effective drugs, are less likely to encounter drug resistance and fail treatment – which brings both clinical and public health benefits. There is a proposal to introduce ACT therapy for the treatment of uncomplicated malaria. The plan is to introduce this over the next 5 years, with the long term goal of reducing malaria mortality and morbidity in all 121 districts of Tanzania by 50 per cent by 2010.
The best method of prevention is personal protection against the mosquito. Malaria mosquitoes generally bite after dark. The first steps to prevent being bitten are:
- Wearing long sleeves and trousers in the afternoon and evening;
- Staying indoors if possible;
- Using insect repellent on exposed skin;
- Sleeping under an insecticide treated bed net - insecticide treated nets are about twice as effective as non-treated nets;
- Closing windows and doors at night;
- Spraying insecticide aerosol and/or burning mosquito coil at night.
These measures are not always possible for many marginalised groups in Tanzania, who are unable to afford insecticides, door screens etc. The Government of Tanzania is a strong proponent of the Public Private Partnership (PPP) approach to scale up the use of ITNs. The PPP approach is considered to be a more long-term sustainable solution to a short-term free net distribution approach.
The National Insecticide Treated Nets (NATNETS) programme was formed to implement this strategy and promote the national use of ITNs by making nets affordable, accessible and acceptable.
- Affordability: by ensuring that groups most at risk from malaria (i.e. pregnant women and their infants) have access to an ITN at virtually no cost through the voucher scheme;
- Accessibility: by stimulating demand in even the most remote rural areas and hence promoting private sector development and growth of the ITN sector;
- Acceptability: b y creating a sustained national awareness and behaviour change on malaria prevention and the use of ITNs.
Free distribution also undermines efforts to establish ITNs as an accepted and commonly used consumer good. Tanzania is unique in the region because of its strong net use culture and the existence of a strong private sector manufacturing, distributing and selling ITNs. Although distributing free nets might seem like a quick-win solution it is a less attractive option for Tanzania because it jeopardizes accessibility of ITNs to the non-target groups since there will not be retail outlets selling nets. As seen with free food distribution, free distribution of ITNs would seriously damage private sector expansion which provides a sustainable distribution model.
The Poverty-Malaria Link
Poverty affects malaria. Communities with low incomes, limited education and poor access to health care are least able to engage in malaria control activities. Prevention of malaria may not be affordable or properly understood. Equally, treatment-seeking behaviour may be influenced by lack of education as well as inability to pay transport, consultation and treatment fees at health facilities.
At the same time, malaria affects poverty. In poor households, a greater proportion of income is likely to be spent on malaria treatment than in richer households. The malaria disease can cause absenteeism from work and school, a reduction in labour for cultivation, and a decline in childcare; malaria deaths can lead to funeral costs, loss of an income-earner and a rise in orphanhood. A negative spiral can develop with malaria, which causes and deepens poverty. This, in turn, worsens inequalities in society. Within Southern Africa the burden of malaria is greatest within poor communities located in malarious areas. Such communities are resource-poor, have limited access to health and other social services, and have low levels of literacy.
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NATNETS
The use of insecticide-treated nets is cost-effective as a malaria prevention tool. The nets have become important in the prevention of malaria in highly endemic areas. Studies have shown a 19-24 per cent reduction in child mortality as a result of ITN trials. The probability of a child dying before its fifth birthday was reduced from 240 per 1000 to 170 per 1000, an improvement of 29 per cent.
Currently, in Tanzania, 40 per cent of children under five years old sleep under nets, and 50 per cent of these nets are treated with insecticide. The availability and use of mosquito nets in the country varies according to location (rural/urban), malaria transmission patterns and the presence of an ITN project in the area. It is possible to significantly increase the coverage of mosquito nets and ITNs in a fairly short time frame, but re-treatment of ITNs remains a major challenge.
The main aim of the NATNETS programme has been to scale up this use of ITNs in Tanzania. It is made up of four components:
1. The Tanzania National Voucher Scheme (TNVS) is supported by the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) to enable groups most at risk from malaria (i.e. pregnant women and their infants) to have access to an ITN at virtually no cost. Pregnant woman are issued a discount voucher worth more than 80 per cent of the commercial price of a net on their first visit to a Reproductive and Child Health (RCH) Clinic. Pregnant women can use the voucher to purchase an ITN from selected retail outlets. In addition, insecticide re-treatment kits are given out free of charge to mothers (or those taking care of the infants) on subsequent visits to the clinics at the first and second vaccination milestone of the child. In short, the public sector provides a targeted price subsidy to the most vulnerable groups while the private sector carries out the distribution and sale of ITNs.
2. The SMARTNET (Strategic Social Marketing for expanding the Commercial Market of ITNs in Tanzania) project was implemented by Population Services International, and supported by the UK Department for International Development (DFID) and the Royal Netherlands Embassy. The SMARTNET project aims at changing behaviour through mass promotion campaigns and supporting rapid development of a commercial distribution system for ITNs and insecticide re-treatment kits.
3. The ITN Cell, within the National Malaria Control Programme, is supported by the Swiss Agency for Development and Cooperation through the Swiss Tropical Institute. The ITN cell is responsible for the overall coordination of all ITN activities in Tanzania, and for establishing and managing the Tanzania National Voucher Scheme (TNVS).
4. Complementary ITN scaling-up activities are supported by Development Cooperation Ireland. The main areas to which support is being provided are:
- Promotion of long-lasting nets;
- Communication and advocacy;
- Training and institutional strengthening, specifically at district and community level;
- Review of the TNVS.
Achievements
The TNVS was launched in October 2004 and is now operating in over half of the country. National coverage will be reached by the first quarter of 2006. The main achievements to date are:
- Over 220,000 vouchers have been redeemed. Once the programme is operating on a national scale the projections are that over 1 million nets will be bought with vouchers per year, in addition to the existing commercial sales;
- Redemption rate is 87 per cent, i.e. for every 100 women that received a voucher 87 women have used it to purchase an ITN;
- As a result of the TNVS, clinics are seeing an earlier attendance to Ante Natal Clinics (ANC) as well as an increase in attendance.
- A small household survey to assess coverage has been carried out in four districts by the contractors. Main results are:
- Overall net use by pregnant women is estimated at 34 per cent (results from HH survey) to 66 per cent (results from exit survey) and 50-60 per cent of these nets are treated.
- The utilisation of ANC services is high (58 per cent of currently pregnant women, 100 per cent of those who gave birth in 2004/5)
- Awareness and use of HP is high (93 per cent of exit survey; 64 per cent of women aged 15-49 in HH survey).
- Over 1300 retailers signed up to the voucher scheme, of which 80 per cent are new to the ITN business;
- The number of non voucher sales has increased as people are able to buy nets for the first time in their community. Regions are reporting and increase in net sales (pre-TNVS compared to current sales minus TNVS sales) of between 10-25 per cent.
- With assistance from SMARTNET commercial sales of nets in 2004 reached 2 million. In addition, 2.3 million insecticide retreatment kits were sold.
- The commercial sales of nets in the first 2 quarters of 2005 when the TNVS was rolling out has already been 42 per cent higher than last years sales during the same period, before the TNVS started. The sales forecast for next year when the TNVS will be operational in the entire country are therefore very optimistic.
“It’s great they’ve introduced these vouchers – it means a net costs us a lot less to buy.”
Asha Ismail, first-time mother
“When I came I was told about the scheme, so I just went to the clinic, picked up my voucher and bought my net – it was really easy.”
Fatma Mohamed, mother of three-month-old Najma Mohamed |
The economy is also benefiting from the local production and sale of ITNs.
“From a business point of view, it would be hopeless because there would be no employment. This voucher scheme has clearly created jobs. It’s given us something to do that helps put food on our tables.”
Herman Kimambo, mosquito net wholesaler |
Mosquito nets are now marketed in many parts of the country through existing commercial markets at highly competitive prices. Nearly two million good quality and inexpensive nets reach households every year. Usually two people sleep under one net, meaning an extra 10 per cent of the population gain access to ITNs.
Acknowledgements
Hands On would like to thank Karen Kramer of Nat Nets for help and advice in putting together this case study.
Further Information
Contact
Karen Kramer: natnets@natnets.org Further Information
References
BBC News (2005) Photojournal: Burden of Malaria. Available from:
http://news.bbc.co.uk/1/shared/spl/hi/picture_gallery/
05/world_burden_of_malaria/html/1.stm
Lengeler, C., Kramer, K., Mwita, A. and Wyss, K. (2005). The National Upscaling of Insecticide Treated Nets in Tanzania and the NETCELL Project. Tanzania: National Malaria Control Programme.
Malaria in Southern Africa: General Information. Available from: http://www.malaria.org.za/Malaria_Risk/index.html
Report on Insecticide Treated Nets in the 21st Century. Available from: http://www.liv.ac.uk/lstm/malaria/itncont.html
Participating Organisations
Roll Back Malaria
World Health Organisation:
Beatriz Martinez Garcia
Communications Officer
Tel: +41 22 791 2891
E-mail: martinezgarciab@who.int
World Bank:
Ms Julie Mclaughlin
RBM Direction and all WB Operational issues
Team Leader, Health Sector Specialist, Africa Region
Tel: +1 202 458 4679
Fax: +1 202 473 8299
E-mail: jmclaughlin@worldbank.org
UNICEF:
Dr Kopano Mukelabai
Senior Health Advisor, Health Section, Programme Division
Tel: +1 212 824 6318
Fax: +1 212 824 6460
E-mail: kmukelabai@unicef.org
Website: http://www.rbm.who.int/cgi-bin/rbm/rbmportal/
custom/rbm/home.do
Donor and Supporting Organisations
Department for International Development (DFID)
1 Palace Street
London SW1E 5HE
UK
Tel: +44 (0)20 7023 0000
Fax: +44 (0)20 7023 0019
E-mail: enquiry@dfid.gov.uk
Website: http://www.dfid.gov.uk/
USAID
Information Centre
Ronald Reagan Building
Washington, DC 20523-1000
USA
Tel: +1 202 712 4320
Fax: +1 202 216 3524
Website: http://www.usaid.gov
Swiss Tropical Institute
Socinstrasse 57
Postfach
CH-4002 Basel
Switzerland
Tel: + 061 284 81 11
Fax: + 061 271 86 54
Telex: 962 508
Website: www.sti.ch
Population Services International (PSI)
1120 19th Street, NW
Suite 600
Washington, DC 20036
USA
Tel: +1 202 785-0072
Fax: +1 202 785-0120
Website: www.psi.org
Resources
Africa Fighting Malaria
P.O. Box 783348
Sandton 2146
South Africa
Tel: +27 11 884 9578
E-mail: rtren@fightingmalaria.org
Website: http://www.fightingmalaria.org/
Practical Action Technical Information Service
Schumacher Centre for Technology & Development
Bourton Hall
Bourton-on-Dunsmore
Warwickshire CV23 9QZ
UK
Tel: +44 (0)1926 634462
Fax: +44 (0)1926 634401
Website: http://www.practicalaction.org/
?id=technical_information_service
ITDG Publishing
Schumacher Centre for Technology & Development
Bourton Hall
Bourton-on-Dunsmore
Warwickshire CV23 9QZ
UK
Tel: +44 (0)1926 634501
Fax: +44 (0)1926 634502
E-mail: marketing@itpubs.org.uk
Website: www.itdgpublishing.org
Malaria in Southern Africa
Website: http://www.malaria.org.za/
Mapping Malaria Risk in Africa
Website: http://www.mara.org.za/
NetMark
Academy for Educational Development
1875 Connecticut Ave, NW
Washington, DC 20009
USA
Tel: +1 (202) 884-8000
E-mail: ssomashe@aed.org
Website: http://www.netmarkafrica.org/index.html
Southern Africa Malaria Control
P.O. Box CY348
Causeway
Harare
Zimbabwe
Tel: +263 4 253 724 30
Fax: +263 4 253 731 2
E-mail: shivamal@samara.co.zw
Website: http://www.malaria.org.zw/public_mgt.html
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http://www.handsontv.info/series3/
fairtradefairprofit_reports/netprofit_tanzania.html
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http://www.handsontv.info/series1/reports_24-31/Stop_The_Bite_Papua_New_Guinea.html
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