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Success Without A Future? Two Lessons from Malaria Interventions in Madagascar

July 15, 2012

Under 5 mortality rate in Madagascar is 62 per 1000 live births. Malaria accounts for 6% of these deaths.  30% of the population lives in high transmission areas whereas 70% lives in low transmission areas: almost everybody in Madagascar is likely to get malaria sometimes during their lifetimes. For this reason, the government, backed up by the international community (i.e. Global Fund and President’s Malaria Initiative), has rolled out a panoply of interventions aiming to slash malaria mortality and morbidity: distribution of insecticide treated nets (ITNs), indoor insecticide spraying and increase in coverage of diagnostics facilities and medicines for treatment. This package of interventions worked, at least in the short term: they reduced the case of malaria infections from 90 per 100 in 2000 to 10 per 100 in 2010. Yet, there are now signs that malaria incidence could be rising again in some regions. A report by Jeune Afrique highlights two key facts which explain why this success is at risk of turning into failure: firstly,the social and political context is likely to influence or contain the spread of malaria as much as techincal interventions such as ITNs are . Secondly, because malaria is influenced by so many factors, foreign aid can realistically hope to contain malaria in the short run but not eliminate it in the long run.

1. The context

The Diversity of A Continent: Madagascar is not simply an island, it is a continent with incredible diversity. The malaria profile is no exception: the mosquito anopheles, main vector of the parasite, is present on the island in 5 different forms. A type of insecticide could be effective for one mosquito but not for the other. No single intervention can be rolled out uniformly on the island.

Poverty and Migration: the expansion of coverage of testing and early treatment has produced impressive results. Yet, late last year spikes of malaria infections were registered in some regions in the East and the South. The same interventions were implemented across the country and the access to testing and treatment was comparable across regions but some regions experienced a rise in malaria infections some others did not: why? The answer has to do with poverty, migration and hope of a better life. Mining companies recently started operation in the regions of the south and the east. With mining came jobs and with jobs came migrants from other regions. The main region of origin were the high plateau in the middle of the island where malaria prevalence is very low because of the altitude. People living in these areas have little immunity to the malaria parasite so once they migrate to high prevalence regions to work in the mining sector they get easily infected with malaria. New jobs and the migration which followed suit introduced a new, less immune human host which caused malaria incidence to spike. This was compounded by the cyclone Genevieve which increased humidity rates thus creating a conducive environment for the reproduction of mosquitoes.

2. Success Without A Future?

The second lesson has to do with the fate of any aid funded interventions. Take the example of ITNs: the initial distribution of bednets can bring down the incidence but then they need to be replaced. Other interventions which aim to control the vector such as indoor spraying stands to face the same bottlenecks. On the top of that what works today might not work in the future: vectors adapt to the insecticide and the more one extends the coverage of insecticide (through bed-nets or indoor spraying) the more insecticide resistant mosquitoes develop. The failure of tomorrow can be the child of the success of today.

The point is that interventions such as ITNs distribution and insecticide spraying can bring down malaria infections for a certain period as long as they are effective. They are not effective forever though. This implies that one should look into alternative solutions to replace them in the long run. The reasons why this does not happen is that donors look at the present without considering the future. They hope that what is implemented today can eradicate malaria. This is just not the case.  Any aid funded intervention rarely has the power to eliminate the disease: it can alleviate the burden of disease today but it does not promise a disease free environment. Malaria eradication is contingent on better housing, better environment management, better nutrition and all in all better income. Aid can hardly deliver all of them.

In sum, foreign aid in Madagascar achieved remarkable results: cases of malaria infections went down from 90 per 100 in 2000 to 10 per 100 in 2010. This success however is not forever: the environmental diversity of the island and the social dynamics which push people to migrate from malaria-free to malaria-ridden areas warns anyone from believing that malaria is defeated. This however is not to be read as a failure of foreign aid. It just goes beyond what foreign aid can be realistically expected to deliver: malaria containment.

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