SUDAN: Mixed success on malaria control in the south
JUBA, 4 February 2010 (IRIN) - More than four million insecticide-treated nets (ITNs) have been distributed across Southern Sudan since 2007, but universal coverage of treatment remains a long way off, according to experts.
|Less than 10 percent of children currently receive malaria treatment within 24 hours of fever onset
The region is, however, likely to achieve preventive targets set by African heads of state in 2000 at a summit in Abuja, Nigeria. These include at least 80 percent of people at risk from malaria using locally appropriate vector control methods like ITNs and indoor residual spraying.
Other targets are 80 percent of malaria patients being diagnosed and treated with effective anti-malarial treatments; and in areas of high transmission, all pregnant women receiving intermittent preventive treatment.
"We can say that in areas where ITN distribution campaigns have taken place, there is already 80 percent coverage," Robert Azairwe, a senior adviser to the Ministry of Health's National Malaria Control Programme, told IRIN.
"By the end of 2010, nationwide nets’ distribution is likely to be achieved," he added.
The distribution programme - which so far has been run by the Health Ministry, the UN Development Programme and the social marketing NGO Population Services International (PSI) - has covered seven and a half of the 10 states in the south.
Central Equatoria and parts of Eastern Equatoria and Jonglei are yet to be reached.
The region, according to experts, is "hyper-endemic" for malaria. The disease, the UN Children's Fund says, is responsible for up to 29 percent of Southern Sudan's disease burden.
Lukasz Czerwinski, operations manager for PSI in Southern Sudan, said the distribution had succeeded largely because of a good relationship with the government, planning, and prepositioning of materials.
"Community sensitization on malaria prevention through the use of LLINs [long-lasting insecticide-treated mosquito nets] began several months before the nets arrived, with more than 10,500 community volunteers raising awareness at state, county and `payam’ [large village] level," he told IRIN.
PSI is currently the principal recipient for malaria grants from the Global Fund to fight HIV, Tuberculosis and Malaria in the region.
"PSI beefed up its community level activities by adoption of a mass media strategy using radio stations as a tool to urge people to use LLINs. The messaging focused on correct and consistent use of the distributed LLINs," he said.
Despite some success, Southern Sudan's poor road network and notoriously difficult natural terrain made distribution a challenge. Where possible, PSI used bicycles or people on foot to take nets to areas that were impassable for vehicles.
Sometimes, during the rainy season, teams were forced to postpone the distribution when rivers burst their banks, cutting off entire villages. Sporadic outbreaks of violence also delayed distribution to certain areas.
The programme has also faced some unexpected challenges, according to Azairwe, including reports that in some areas, the nets - which should usually have a shelf life of up to three years - are being destroyed by extreme environmental factors and have not even lasted one year.
"During the dry season, temperatures in some areas can go over 40 degrees Celsius, and reports from the field indicate that their use, and perhaps durability may be compromised" he said.
Czerwinski said the nets were being tested for durability as reports of heat damage continued to be investigated. Surveys, he said, were also under way to monitor actual use of the nets and their impact in terms of malaria incidence in the populations covered.
Treatment lagging behind
While distribution of nets has been largely successful, the same cannot be said for treatment. According to Azairwe, less than 10 percent of children with fever currently receive effective malaria treatment within 24 hours of fever onset.
"The Abuja targets require that by the end of 2010, 80 percent of malaria patients receive effective treatment within 24 hours of the first symptoms," he said. "In Southern Sudan, where only 25 percent of the population has access to a health facility, this is an extremely difficult target to achieve."
"Ensuring a constant supply of ACTs [Artemisinin-based combination therapy] is difficult - the drugs are expensive and we depend on partners, and efforts are not always well coordinated," he said. "In 2009 there was at least one quarter [of the year] where there were no ACTs here."
Logistical difficulties - including storage of rapid diagnostic tests - that most manufacturers recommend not be stored above 30 degrees Celsius - make diagnosis, and in turn, treatment, difficult.
Human resource shortages mean that even when the drugs were available, there was not always a trained medical professional on hand to dispense them. Even when both drugs and health workers were available, patients often did not actively seek health services.
"We also need to build the capacity of the private sector - used by much of the population for their drugs - to follow the government's malaria policies," he said. "A dose of Coartem [a brand of ACT] costs US$7-10, so many outlets don't stock it because people won't buy it; instead they stock less costly ineffective drugs that are not in line with the government's policy."
"If we manage to improve the supply of medicines, see some improvements in health systems and implement home-based care on a larger scale, we could see about 50 percent treatment coverage by the end of 2010," he added.