Viewpoint: Evaluating the impact of malaria control efforts on mortality in sub-Saharan Africa

OBJECTIVE To describe an approach for evaluating the impact of malaria control efforts on malaria-associated mortality in sub-Saharan Africa, where disease-specific mortality trends usually cannot be measured directly and most malaria deaths occur among young children. METHODS Methods for evaluating changes in malaria-associated mortality are examined; advantages and disadvantages are presented. RESULTS All methods require a plausibility argument - i.e., an assumption that mortality reductions can be attributed to programmatic efforts if improvements are found in steps of the causal pathway between intervention scale-up and mortality trends. As different methods provide complementary information, they can be used together. We recommend following trends in the coverage of malaria control interventions, other factors influencing childhood mortality, malaria-associated morbidity (especially anaemia), and all-cause childhood mortality. This approach reflects decreases in malaria's direct and indirect mortality burden and can be examined in nearly all countries. Adding other information can strengthen the plausibility argument: trends in indicators of malaria transmission, information from demographic surveillance systems and sentinel sites where malaria diagnostics are systematically used, and verbal autopsies linked to representative household surveys. Health facility data on malaria deaths have well-recognized limitations; however, in specific circumstances, they could produce reliable trends. Model-based predictions can help describe changes in malaria-specific burden and assist with program management and advocacy. CONCLUSIONS Despite challenges, efforts to reduce malaria-associated mortality in Africa can be evaluated with trends in malaria intervention coverage and all-cause childhood mortality. Where there are resources and interest, complementary data on malaria morbidity and malaria-specific mortality could be added

Do malaria control interventions reach the poor? A view through the equity lens.

Malaria, more than any other disease of major public health importance in developing countries, disproportionately affects poor people, with 58% of malaria cases occurring in the poorest 20% of the world's population. If malaria control interventions are to achieve their desired impact, they must reach the poorest segments of the populations of developing countries. Unfortunately, a growing body of evidence from benefit-incidence analyses has demonstrated that many public health interventions that were designed to aid the poor are not reaching their intended target. For example, the poorest 20% of people in selected developing countries were as much as 2.5 times less likely to receive basic public health services as the least-poor 20%. In the field of malaria control, a small number of studies have begun to shed light on differences by wealth status of malaria burden and of access to treatment and prevention services. These early studies found no clear difference in fever incidence based on wealth status, but did show significant disparities in both the consequences of malaria and in the use of malaria prevention and treatment services. Further study is needed to elucidate the underlying factors that contribute to these disparities, and to examine possible inequities related to gender, social class, or other factors. To achieve impact and overcome such inequities, malaria control efforts must begin to incorporate approaches relevant to equity in program design, implementation, and monitoring and evaluation

Is malaria a disease of poverty? A review of the literature.

OBJECTIVE: To review the evidence on the link between malaria and poverty. METHODS: Review of the published and grey literature to identify (i) the data available on the socio-economic distribution of malaria incidence and vulnerability, and (ii) the uptake of malaria control interventions. RESULTS: We found mixed evidence on malaria incidence, with a number of studies identifying no relationship between socio-economic status and incidence, although a larger number of studies do find a link. There is strong evidence that uptake of preventive and treatment interventions is closely related to proxies for socio-economic status. More generally, the quality of the literature examining this issue is highly variable, with many different measures of socio-economic status and often inadequate descriptions of methods of data collection and analysis in relation to socio-economic status. CONCLUSIONS: Important socio-economic differentials exist in access to malaria interventions, increasing the vulnerability of the poorest. More information is needed about how other methods of delivering malaria treatment and prevention can redress these inequalities

The Relationship Between Socio-Economic Status and Malaria: A Review of the Literature

Malaria is frequently referred to as a disease of the poor or a disease of poverty. A better understanding of the linkages between malaria and poverty is needed to guide the design of coherent and effective policies and tools to tackle malaria and poverty together. While recognising that there are a large number of dimensions of potential vulnerability to malaria that encompass social, demographic and geographic elements, the key focus of this work is on differences among socio-economic groups. The aim of this review was to document and review critically the evidence available on two key issues: malaria incidence or vulnerability to the effects of malaria by socio-economic status (SES); and the utilisation, effectiveness and accessibility of malaria control interventions by SES.[HEFP WP NO 01/03]Demographic surveillance system; Focus group discussions; Chloroquine; Insecticide treated nets; London School of Hygiene and Tropical Medicine; Demographic and health survey; Inter-American Development Bank; Gross domestic product; Disability adjusted life years; Pan American Health Organization

The costs of interpersonal violence - An international review

This article reviews evidence of the economic impact of interpersonal violence internationally. In the United States, estimates of the costs of interpersonal violence reach 3.3% of GDP. The public sector - and thus society in general - bears the majority of these costs. Interpersonal violence is defined to include violence between family members and intimate partners, and violence between acquaintances and strangers that is not intended to further the aims of any formally defined group or cause. Although these types of violence disproportionately affect poorer countries, there is a scarcity of studies of their economic impact in these countries. International comparisons are complicated by the calculation of economic losses based on foregone wages and income, thus undervaluing economic losses in poorer countries