Building a community wide malaria control programme: advantages, disadvantages and options.
Disadvantages of establishing a community-wide malaria control programme:
- Costs: malaria commodity costs can be considerable (WHO, 2012 and Wafula et al., 2010)
- LLINs cost around $2.7 - $4 per net if bought in bulk, often more if bought in smaller quantities.
- ACTs cost around $1.3 - $1.4 for an adult treatment course (for the most commonly procured brand which is an artemether-lumefantrine combination).
- RDTs cost around $0.7 for a multi-species test.
- IRS costs vary considerable in relation to economies of scale. Where more than 1 million people are protected, as in large national programmes, costs per person protected will be lower; but in smaller programmes, such as those likely to be supported by private companies, costs can be around $5.5 per person protected.
Expanding services beyond employees to employees’ families or to whole communities can therefore have important cost implications.
- Designing and implementing an effective community-wide malaria control strategy requires specialised skills in entomology, malaria vector control, case management, community health promotion and communication.
Advantages of establishing a community-wide malaria control programme:
Options for establishing a community-wide malaria control programme:
Some general options planners could consider are described here. Click the links to access more information on each of these possible options. [Option titles and text for the links are shown below (Options 1 - 8).
- Technical appropriateness - linked to:
- Disease epidemiology
- Potential for impact on disease
- Alignment with international and national priorities
- Operational appropriateness – linked to:
- Capacity of local health systems
- In-house capacity in relevant areas
- Capacity available through out-sourcing
- Size and life of operation and potential for sustainability
- Cost-effectiveness and efficiency
- Equity
- Feasibility (political, financial), including consideration of options using lobby and advocacy activities to increase political will and secure additional financing
- Potential for impact on:
- Disease burden
- Company finances
- Company reputation
This appraisal will inform detailed planning undertaken in the next step.
Option 1: One off focus on community-wide LLIN coverage
Rationale: Companies could fund and support mass insecticide treated net distribution if appropriate to the setting and if ownership of LLINs is low. Depending on the epidemiological context, this could provide good community protection as long as the nets remain in use.
Approach: A one-off distribution campaign with sufficient LLINs to provide total coverage in all households in the target community (usually one LLIN per two people) – either door-to-door or through community distribution points. This would need to be accompanied by a health communication component to promote use.
Pros: Few specialized skills are required aside from advice on whether LLINs are an effective control measure in the setting.
Can have a high and instant impact in areas where LLINs are appropriate and if coverage was previously low.
Cons: Ideally a mass distribution of nets should be accompanied by an approach for communities to access replacement nets as needed, otherwise coverage levels will gradually drop. Companies are therefore encouraged to think longer term than a single distribution campaign.
Option 2: On-going community-wide prevention
Rationale: Ensuring effective vector control measures are in place community-wide in all local communities would have a high impact and help to reduce the risk of infection in those people residing within the company compound, given the community-wide impact on transmission levels.
Approach: This would need to be tailored to the local setting but could include indoor residual spraying cycles or larval site mapping and removal / treatment programmes. Community involvement would be critical and long-term engagement required. Health promotion would be a necessary component to ensure support.
Pros: Can be high impact if a well-designed programme is put in place; based on the local epidemiological context and with quality assurance measures in place for its implementation.
Cons: Requires staff with specialized skills to be engaged in the activities on a long-term basis. Requires strong community involvement and support for success. Requires long-term commitment and a clear exit-strategy.
Option 3: Establishing new clinics
Rationale: Where there are no malaria case management services, establishing and maintaining high quality facilities would be an effective way to reduce the rates of serious illness and death from malaria.
Approach: This could involve making clinics inside compounds accessible to communities; or building, equipping, staffing and maintaining new clinics outside the compound to serve local communities. A range of levels of involvement are possible depending on the capacity of the local health authorities or other local organisations, for example the company could establish the clinics and hand over their management to others (see below). Health promotion would be a necessary component to ensure facilities are used.
Pros: Potential for extremely high impact. Appropriate to fulfil the responsibility of care to employees and their families. Good quality clinical services may be the highest priority need if these do not exist.
Cons: Requires staff with specialized skills to be engaged in the activities on a long-term basis. Requires long-term commitment and a clear exit strategy. There can be high initial costs if infrastructure and equipment is needed.
Option 4: Support existing clinics
Rationale: Where existing clinics are accessible, the company could consider supporting these. This may be a more cost-effective and sustainable approach.
Approach: Health facility assessments would be needed to examine existing infrastructure, equipment, supplies, personnel and services. These should include gathering community perspectives on their needs and the current services. As discussed above, partnership with the organizations responsible for the health facilities would be essential from early planning stages throughout assessment and design of the support package. The support package could be purely financial, or could see the company contracting groups to provide infrastructure, equipment improvements or training. If this approach is taken a quality assurance component would be needed to ensure that company support is resulting in better quality of care.
Pros: May be more cost-effective than establishing new clinics. May be more sustainable, though an exit strategy and measures to ensure sustainability would need to be included in the support package.
Cons: Working with partners may be problematic in some settings. Change in service provision and care approaches may be difficult to achieve in some settings. The company may have less control over quality than they had hoped. May be less opportunity than some other approaches for clear ‘branding’ of company support.
Option 5: Support other existing activities
Rationale: In some locations the local health authorities and other organisations may be very active in malaria control, or in public health with the possibility of expansion into malaria control. They may have clear plans and clear knowledge of resource gaps which the company could fill.
Approach: Discuss with all organizations working in health locally to determine if there are other activities that the company could support. The company will need to assess potential partners for capacity and appropriateness for support.
Pros: Fills an already identified need; leverages existing local skills and partnerships.
Cons: There may be few or no organisations active in the company’s location. Organisations that are active may not have the capacity to absorb additional funds or to manage expanded programmes. May be fewer opportunities than in some other approaches for clear ‘branding’ of company support.
Option 6: Contribute financially to the national malaria control programme
Rationale: All countries within this region have national malaria control programmes with clear malaria control strategies and often up to date gap analyses showing where they need additional support in order to fulfil their strategic aims. Companies with funds available to support malaria control could effectively leverage these existing national plans.
Approach: Discussion with national malaria control programmes should include: review of existing gaps; options for use of contributed funds; company interest in supporting specific geographical areas and likelihood of this being achieved. There could also be an additional component for more locally focused malaria control support.
Pros: Leverages existing national capacity and skills. Demonstrates company’s commitment to the country and its authorities. Fills an already identified need. Has potential for long-term and sustainable impact.
Cons: There may be extremely limited opportunities for clear ‘branding’ of company support. Assurances that funds will be used as planned may be difficult to attain or verify. May not lead to improvements in malaria control in the specific geographical areas in which the company works (which may or may not be the aim).
Option 7: Contribute financially to other initiatives in country, such as the private malaria control sector
Rationale: In the Asia-Pacific region there are many private companies working in the malaria industry, from Artemisia growers to drug manufacturers and distribution companies for malaria commodities. There may be opportunities to partner with such an organization to expand its role in the malaria industry, playing a useful role in the area of malaria commodities supply.
Approach: Review local private companies working in the field. Through meetings and discussions explore opportunities for support. This process should be led by or include expert advice from specialists in the field of malaria and malaria commodities.
Pros: The role of the private sector in the malaria industry is important at a number of levels but such companies often have few opportunities to access financial support to expand their role.
Cons: Requires specialist advice on needs and appropriate areas of support. May not lead to improvements in malaria control in the specific geographical areas in which the company works (which may or may not be the aim).
Option 8: Contribute financially to regional or global bodies
Rationale: Regional organizations such as WHO regional offices, the Asian Pacific Leaders Alliance and the Asia-Pacific Malaria Elimination Network are all credible organisations working to reduce malaria in the region with clear strategies and likely existing resource gap analyses. Companies that have funds available to support malaria control could effectively leverage these existing national plans.
Approach: Discussion with national malaria control programmes should include: a review of existing gaps; options for use of contributed funds; company interest in supporting specific geographical areas and the likelihood of this being achieved. There could be an additional component for more locally focused malaria control support.
Pros: Leverages existing national capacity and skills. Demonstrates company’s commitment to the country and its authorities. Fills an already identified need. Has potential for long-term and sustainable impact
Cons: There may be extremely limited opportunities for clear ‘branding’ of company support. Assurances that funds will be used as planned may be difficult to attain or verify. May not lead to improvements in malaria control in the specific geographical areas in which the company works (which may or may not be the aim).
Examples of successful industry malaria control programmes
Sources of technical support and advice
