Policy Brief on Scaling up Malaria Control Interventions in Cameroon Initiative of Cameroon Coalition Against Malaria (Ccam) And

CCAM IN PARTNERSHIP WITH CDBPH

POLICY BRIEF ON SCALING UP MALARIA CONTROL INTERVENTIONS IN CAMEROON INITIATIVE OF CAMEROON COALITION AGAINST MALARIA (CCAM) AND

CENTRE FOR DEVELOPMENT AND BEST PRACTICES in HEALTH (CDBPH)

CORDINATED AND WRITTEN BY

Dr. John NGUM Wonghi, MD, MPH, Public Health Adviser within the Technical Secretariat of the Steering and Follow-up Committee of the Health Sector Strategy;

Dr. Pierre Ongolo-Zogo, MD, MSc, Head of the Centre for Development of Best Practices in Health – Yaoundé Central Hospital, Faculty of Medicine and Biomedical Sciences University of Yaoundé 1

Dr Esther Tallah, MD Pediatrician, Manager of Cameroon Coalition Against Malaria, Board Member UNITAID Executive Board, Alternate Board Member RBM Partnership, Communities Delegation GFATM

Pr Rose LEKE, PhD, Immunologist, Director Biotechnology Centre – University Yaoundé 1 and Executive Director of Cameroon Coalition Against Malaria,

Pr Wilfred MBACHAM, Microbiologist, Public Health, Biotechnology Centre – University Yaoundé 1 and Executive Secretary of Cameroon Coalition Against Malaria

The following participated at the deliberative forum during which this paper was finalised and validated.

Preface

The concept of Evidence Informed Policy Making is new and has come into focus in recent years, as a result of the observation that in the past, many a policy has been based on impression or how the boss sees it or what we think should be, to the extent that some policies are based on fallacy and ideology which when tested prove to be contrary to the reality.

It is therefore of utmost importance that policy-makers should use as basis proven facts in order to make policies. The example of the belief that Sudden Infant Death Syndrome (SIDS) was thought to be due to the situation whereby a baby is made to lie on their back which therefore made paediatricians to advise caretakers that babies should be laid instead on their bellies, which later on, following scientific studies, it was demonstrated that there is a predisposition at the brain of such babies who do not survive low oxygen level in their brains, and most of them die when lying on their bellies because breathing is compromised to some extent and therefore oxygen level in the body/brain, and that fewer deaths occurred when such children lie on their backs, completely reversed the attitude that was advised by paediatricians to the caretakers of young babies. This is just one among several examples and just to emphasis the importance of evidence to inform policy.

It is in this perspective that CCAM and partner CDBPH embarked on this project funded by WHO to research and write a policy brief on Scaling Up malaria Control interventions in Cameroon, which is aimed at providing evidence in line with the problem of these interventions not effectively reaching the people, such that these facts shall be taken into consideration when Cameroon engages in the universal coverage with malaria control interventions.

This comes at a time when the world has engaged to support all malaria endemic countries to achieve universal coverage, sustain it and move towards malaria elimination with the magic target of achieving universal coverage in all countries by December 2010.

Cameroon is ready to join the other endemic countries in achieving this target thanks to double funding from the Global Fund to Fight HIV, TB and Malaria in the 6th round in 2004 and the 9th round in 2009.

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This policy brief is therefore timely and it is our hope that it will contribute in helping the policy-makers in Cameroon ensure that all malaria control interventions are reaching the people in an equitable manner and with their active participation to ensure sustainability, while addressing all the bottlenecks that may refrain this from being achieved.

Table of contents

Preface……………………………………………………………………………………………………iii Key messages ...... vi Executive summary ...... viii Acronyms ...... xiv 1 The problem ...... 1 Background ...... 1 1.1.1 Epidemiological profile of Malaria in Cameroon ...... 1 1.1.2 Parasite and vector Resistance profile ...... 6 1.1.2.1 Parasite Resistance Profile...... 6 1.1.2.2 Vector resistance profile ...... 8 1.1.3 Poverty profile ...... 8 1.1.4 Historical Facts and Perspectives of the Malaria Control Interventions in Cameroon ...... 11 1.1.4.1 Historical Facts: The past and the Present ...... 11 1.1.4.2 Perspectives ...... 13 1.2 Size of the problem ...... 13 1.3 Causes of the problem ...... 16 1.3.2 Insufficient access of the population to MCI: ...... 16 1.3.3 Low utilisation of available services ...... 17 1.4 Framing of the problem ...... 17 2 Policy options of Evidenced-based Strategies for Scaling Up Malaria Control Interventions in Cameroon ...... 19 3 Implementation considerations ...... 24 3.1 Global Considerations related to Malaria control Interventions: ...... 24 3.1.2 Malaria Prevention Interventions ...... 24 3.1.3 Malaria Case Management ...... 25 3.2 Strategy-specific Considerations: ...... 27 4 References ...... 29 4.1 The epidemiological profiles ...... 29 4.2 The poverty profile...... 29 4.3 The malaria services coverage ...... 29 4.4 Effective interventions ...... 30 4.5 Implementation considerations ...... 31

Key messages

Cameroon, Africa in miniature, presents diversified epidemiological strata of malaria transmission along with the corresponding parasites and vectors. Malaria continues to be endemic and the first major cause of morbidity and mortality among the most vulnerable groups - children under 5 years pregnant women People Living With HIV/Aids (PLWHA) and the poor accounting respectively for 18, 5, 5.5, and 40 percent of the total population estimated at 19 million.

In spite of the efforts deployed by the National Malaria Control Program and its partners, the actual coverage and use of malaria services and commodities are dramatically below the national targets set in line with the Global Malaria Action Plan. Households with children aged below 5 years and pregnant women have benefited from free Insecticide treated Nets (ITNs) and the entire population from highly subsidized Artemisinin-based Combination Therapy (ACTs). However, the subsidized ACTs and SP for IPTp are unevenly available due to inadequate prescription by providers, multiplicity of licensed anti malarial drugs (over 90 in circulation) and frequent stock-outs. LLINs are not available for purchase for the non targeted groups. Recently proven effective control interventions are not available. Control strategies are not customised to epidemiological profiles of malaria and are mostly health facility based.

Financial barriers, low utilisation rate of available interventions and low utilisation rate of health facilities stand as immediate causes to the low coverage of Malaria Control interventions (MCI).

This evidence-based policy brief proposes remedial strategies to increase the coverage and utilization rates of the effective malaria control interventions targeting the whole population at risk as appropriate. These strategies include: o Governance arrangements: (i) Clearing the drug market of all antimalarials that are not in the national policy (Artesunate-Amodiaquin and Artemether-Lumefantrin for uncomplicated malaria and Quinine for complicated, Sulfadoxine Pyrimethamine for IPTp), (ii) Enforcing regulation through reinforced inspection and supervision activities, (iii) Shifting from the current unified approach to specific strategies according to epidemiological profiles and the emerging trends such as co-morbidity with HIV/Aids and, (iv) Transferring greater

responsibilities to and empowering municipalities-communities for comprehensive and integrated malaria control interventions o Delivery arrangements: (i) Shifting from the current unified approach to specific strategies according to epidemiological profiles and the emerging trends in the epidemiology of diseases for example: Introduce the Intermittent Preventive Treatment for infants and preschool children living in high and moderate transmission zones and for PLWHA, (ii) Distribution of LLINs, IPTp, IPTi, IPTc by the communities supported by NGOs, CSOs, Community Health Workers (CHW) and Community Based Associations (CBAs) as it is the case with CDTI and , (iii) Fostering public private partnerships through Service Level Agreements (SLA) or Performance Based Contracting (PBF) as appropriate e.g. pharmacists selling only commodities and drugs recommended by the national policies, Effective private marketing approaches for LLINs distribution. o Financial arrangements: (i) Secure and sustain subsidies for IPT, LLINs and ACTs and, (ii) Financial incentives for pharmacists and prescribers who comply with regulations. o Implementation considerations: (i) Barriers such as resistance to change, low budget allocation to health, failure of the procurement chain, and inadequate knowledge among the stakeholders both on malaria and its effective control strategies, insufficient capacities of community stakeholders to take ownership; and (ii) Effective Strategies such as communication, education, advocacy building on the “malaria competence approach”.

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Executive summary

In Cameroon, malaria continues to be endemic and the first major cause of morbidity and mortality among the most vulnerable groups - children under 5 years pregnant women People Living With HIV/Aids (PLWHA) and the poor accounting respectively for 18, 5, 5.5, and 40 percent of the total population estimated at 19 million. This means that 2/3 of the population is vulnerable to malaria

In spite of the efforts deployed by the NMCP and partners, the burden of malaria has remained the same over the past decade and the actual coverage and use of malaria services and commodities are still significantly behind the targets set in line with the Abuja commitments and the Global Malaria Action Plan goals on universal coverage for 2010.

According to Demographic Health Surveys 2004, MICS 2006, NMCP 2008 annual report, malaria accounts for 35 to 43% of all deaths in health units, 50 to 56% of morbidity among children under the age of 5, 40 to 45% of medical consultations and 30% to 47% of hospitalizations. It is also the cause of 26% of absences in the workplace and 40% of the health expenditure of households. Malaria is responsible for 49 % consultations and 59% of hospitalisations during pregnancy leading to abortions and premature labour and deliveries as well as low birth weight all exposing the babies to early deaths and mothers to death during delivery.

Data on coverage on malaria control interventions show that only 13.1 % of children aged under five years sleep under insecticide-treated mosquito nets, 37% of pregnant women received the second dose of Sulfadoxine Pyrimethamine and only 58% of complicated cases of malaria are promptly and properly managed. In a recent study in Obala Health District, the coverage was as follows: 15.1% for ACTs, 41% for LLINs, 67% for IPT2.

The burden of malaria stems from the epidemiological and poverty profiles that are inappropriately addressed in the formulation of the national strategies. The latter are not customised to local needs and are mostly health facilities based, consequently not reaching those most in need. In addition, some recently proven effective control interventions are not included within these strategies.

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Based on the transmission pattern, the epidemiologic profile of malaria can be further categorised into 3 types: (i) Endemic and perennial zones of continuous transmission (7 to 12 months) covering the South Cameroonian Equatorial forest, the High western plateaux altitude and the Coastal region where about a hundred infective bites per man per month can be registered, (ii) Endemic and seasonal zones of long seasonal transmission (4-6 months) covering High inland plateaux (Adamawa) and the Savannah-forest transition regions where about twenty infective bites per man per month can be registered and, (iii) Epidemic or strongly seasonal zones of short seasonal transmission (1-3 months) covering the Sudano- sahelian region where about ten infective bites per man per month can be registered.

According to the last House Hold Survey (INS, 2007), 40% of the population are living under the poverty line with 55% in rural as against 12.2% in urban. The low purchasing power of this poor section of the population contributes to reduce their access to malaria control services.

From the results of Systemic Quality Improvement assessment of the performance of Health districts and regional health facilities carried out in 2007/08, service organisation and delivery is generally not satisfactory. Further more, LLINs are not available for purchase for the non targeted groups and also absence of an in-built mechanism within the health system to stimulate demand.

The subsidized ACTs and SP for IPTp are unevenly available due to inadequate prescription by providers coupled with the frequent stock-outs related to some failures in the Procurement and Supply Management Chain.

There is low acceptability of proposed interventions by the targeted populations leading to a low utilisation of the available services. The use of ITNs is not commensurate with their possession due to insufficient knowledge on recommended malaria treatment and preventive interventions. As a consequence patients indulge in inappropriate health seeking behaviours including auto medication with wrong drugs.

With regards to governance, the malaria control drugs and commodities have been liberalised favouring therefore their high commercialisation in a poorly regulated set up. The consequence is a multiplicity of licensed anti malarial drugs (over 90 in circulation) and insufficient popularisation and enforcement of regulatory texts exonerating drugs and medical commodities from taxation. The multiplicity of licensed

ix drugs besides favouring the circulation of sub standard drugs, act as a catalyser to inappropriate prescription, self medication and poor compliance which all expose to the emergence of drug resistance.

The community organisations and municipalities are not adequately equipped (not empowered) to take the lead in the design, the implementation and the evaluation of malaria control measures relevant to their communities. The lack of specific strategies to empower communities has lead to and made them passive recipients of services.

In summary, the malaria control interventions are not reaching those most in need. Insufficiently decentralised programme with poor sense of ownership at the implementation level both by service providers and users are the main causes. This policy brief has been prepared to inform policy and decision makers, health workers and community to face this challenge by implementing effective malaria control interventions targeting the whole population at risk as appropriate. These strategies include:

Governance arrangements: (i) Clearing the drug market of all antimalarials that are not in the national policy (Artesunate-Amodiaquin and Artemether-Lumefantrin for uncomplicated malaria and Quinine for complicated, Sulfadoxine Pyrimethamine for IPTp), (ii) Enforcing regulation through reinforced inspection and supervision activities, (iii) Shifting from the current unified approach to specific strategies according to epidemiological profiles and the emerging trends such as co-morbidity with HIV/Aids and, (iv) Transferring greater responsibilities to municipalities- communities for comprehensive and integrated malaria control interventions

Delivery arrangements: (i) Shifting from the current unified approach to specific strategies according to epidemiological profiles and the emerging trends in the epidemiology of diseases for example: Introduce the Intermittent Preventive Treatment for infants and preschool children living in high and moderate transmission zones and for PLWHA, (ii) Distribution of LLINs, IPTp, IPTi, IPTc by the communities supported by NGOs, CSOs, Community Health Workers (CHW) and Community Based Associations (CBAs) as it is the case with CDTI and , (iii) Fostering public private partnerships through Service Level Agreements (SLA) or Performance Based Contracting (PBF) as appropriate e.g. pharmacists selling only commodities and drugs within the national policies, Effective private marketing approaches for LLINs distribution. Financial arrangements: (i) Secure and sustain subsidies for IPT, LLINs and ACTs and, (ii) Financial incentives for pharmacists and prescribers who comply to regulations.

Implementation considerations: (i) Barriers such as resistance to change, low budget allocation to health, failure of the procurement chain, and inadequate knowledge among the stakeholders on malaria and effective intervention strategies, insufficient capacities of community stakeholders to take ownership; and (ii) Effective Strategies such as communication, education, advocacy building on the “malaria competence approach”. The table below presents a summary of these policy options and their respective implementation considerations .

Summary of policy options and their implementation considerations towards scaling up malaria control interventions in Cameroon Policy Option Governance arrangements Delivery arrangements Financial arrangements Description (i) Clear the drug market of antimalarials that (i) Shift from the current unified approach to specific strategies (i) Secure and sustain Title and Activities are not in the national policy (Artesunate- according to epidemiological profiles and the emerging trends subsidies for IPT, LLINs and in the strategic Amodiaquin and Artemether-Lumefantrin for in the epidemiology of diseases for example: Introduce the ACTs and, (ii) Financial options uncomplicated malaria and Quinine for Intermittent Preventive Treatment for infants and preschool incentives for pharmacists complicated, Sulfadoxine Pyrimethamine for children living in high and moderate transmission zones and for and prescribers who comply IPTp), (ii) Enforce regulation through PLWHA, (ii) Distribute LLINs, IPTp, IPTi, IPTc by the with regulations. reinforced inspection and supervision communities supported by NGOs, CSOs, Community Health activities, (iii) Shift from the current unified Workers (CHW) and Community Based Associations (CBAs) as it approach to specific strategies according to is the case with CDTI and , (iii) Foster public private epidemiological profiles and the emerging partnerships through Service Level Agreements (SLA) or trends such as co-morbidity with HIV/Aids Performance Based Contracting (PBF) as appropriate e.g. and, (iv) Transfer greater responsibilities to pharmacists selling only commodities and drugs recommended and empower municipalities-communities for by the national policies, Effective private marketing approaches comprehensive and integrated malaria for LLINs distribution. control interventions Barriers to Resistance to change, inadequate knowledge The State supply chain fails to deal with private pharmacies and Low budget allocation to implementation among the stakeholders on both malaria and sales of other licensed antimalarials are often more profitable. health, Poverty, insufficient its effective control strategies, insufficient IPTi is not part of the national policy because of the fear that regulation leading to high capacities of community stakeholders to take S/P will lead to resistance as is the case in other countries e.g. commercialization of malaria ownership. Tanzania control

Challenges for Presence of strong leadership and previous Developing partnerships between communities, policy makers and experts. Developing local adaptability community empowerment strategies organisational capacity and financial empowerment Implementation Information, education and communication, ” Communication, education, promotional campaigns, communication, strategies malaria competence approach”, Promotional management and leadership training and careful selection to decentralisation and campaigns1, Use existing social structures ensure only ACTs on MOH policy circulate in the market and Promotional campaigns, and community groups are used, empowerment of parents, resources mobilisation management and leadership training

1 Advocacy targeting private and public, political and scientific spheres as well as the general population who should be encouraged to become partners and even actors of vector and malaria control at their household level.

Acronyms

ACT Artemisinin Combination Therapies AL Artemisinin + lumefantrine AM-LM Artemether-Lumefantrine AS+AQ Artemisinin + Amodiaquine CBA Community Based Association CDTI Community Directed Treatment with Ivermectine CHW Community Health Worker CSO Civil Society Organisation DDT Dichlorodiphenyltrichloroethane DH-PP Dihydroartemisinin-Peoeraquine DHS Demographic and Health Survey IPT2 Intermetent Preventive Treatment IPTi Intermetent Preventive Treatment for Infants IPTp Intermetent Preventive Treatment for Pregnant women IRS Indoor Residual Spray ITMN Insecticide Treated Mosquito Nets ITN Insecticide Treated Nets LLIN Long Lasting Insecticide Treatment Nets MCI Malaria Control Interventions MDG Mellinium development Goals MICS Multi Indicator Cluster Survey MoH Ministry of Health NGO Non Governmental Organisation NMCP National Malaria Control Programme PBF Performance Based Financing PLWHA People Living with HIV/ Aids SLA Service Level Agreements SP Sulfadoxine-Pyrimethamine SQI Systemic Quality Improvement

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SWAp Sector Wide Approach UNICEF United Nations of International Children's Emergency Fund WHO World Health Organisation

“...In comparison to the current funding trajectory rapid scale up could safe two and half million additional lives, prevent more than 430 million additional malaria cases and help generate $ 50 billion more in economic output over five years. What’s more, it will safe twice as many lives for each dollar spent...” (34)

Malaria No More and McKinsey & Company on behalf of the Roll Back malaria Partnership, January 2008

1 The problem

Background

1.1.1 Epidemiological profile of Malaria in Cameroon

Figure 1: Mapping of the Epidemiological strata of Malaria in Cameroon

It is commonly held that Cameroon is Africa in miniature. This is certainly true with regards to the epidemiological strata almost all of which are represented. Seven epidemiological strata have been identified in Cameroon (1) as illustrated in figure 1 above and details of which, including the description of corresponding parasitological and vector profiles for each strata, are presented in table 1 below

The mapping of the vector profile is further illustrated in fig 2.

Table 1: Synthesis of the malaria geographical strata, transmission patterns and parasitology and main vectors in Cameroon Geographic Characteristics defining Transmission pattern and parasitology Main vectors ecological zones I-Sudano-sahelian strata. dry Savannah zones and Malaria here is unstable with a risk of epidemic and In addition to Anopheles gambiae a major the steppes to the north of the country, between severe clinical forms at all ages. Here, malaria is malaria vector, Anopheles arabiensis along with latitudes 13°N and 8°N. From west to east caused by Pl. Falciparum (93.6-98.7%) , Pl. Malariae Anopheles funestus have been identified here. (0-6.4%) and Pl. Ovale (0-1.3%) The first two are both resistant to DDT and pyrethrinoides II-High inland plateaux strata (Adamaoua). Situated Malaria is tropical and stable with seasonal Relative immunity starts appearing as of the age in the very heart of Cameroon between latitudes outbreaks, caused by Plasmodium falciparum of 10. Anopheles gambiae gambiaeis a major 8°N and 6°N, the Sudani-Guinean tropical climate is uniquely malaria vector tempered by the altitude (1,100 m on average). III-Savannah-forest transition strata. the transition The malaria here is equatorial and stable with Relative immunity is achieved by the age of 5. zone that separates the forest Savannah from the seasonal outbreaks, caused by Pl. Falciparum (89.8- Anopheles gambiae gambiaeis a major malaria forested plateaux to the south. Located between 100%) , Pl. Malariae (4.3-8.4%) and Pl. Ovale (0-1.8%) vector latitudes 6°N and 4°N, with the exception of the mountain regions to the west IV-South Cameroonian Equatorial forest strata. Malaria is equatorial holo-endemic, caused by Pl. Relative immunity is achieved early in life, Situated between latitudes 5°N and 2°N, and at an Falciparum (62.0-96.3%), Pl. Malariae (0.6-3.0%) and before the age of 5. Anopheles gambiae altitude of 600 m to 900 m the region is watered by Pl. Ovale (1.1-35.0%) gambiaeis a major malaria vector but also the Sanaga, Nyong, Ntem and Sangha rivers. The Anopheles moucheti that comes in contact with forest is dense, heterogeneous. humans at sun set. Anopheles moucheti is found here too along the sananga

Geographic Characteristics defining Transmission pattern and parasitology Main vectors ecological zones V-High western plateaux altitude strata. This The transmission of malaria is permanent, occurring This area is one of the most densely populated polygon shaped region stretching 300km by 200km all year long, sometimes lessened by altitude though regions of Cameroon Anopheles gambiae is composed of the Bamoun and Bamiléké plateaux, never totally absent. Here malaria is caused by Pl. gambiaeis a major malaria vector. the Mbos plain, the Manengouba, Bamboutos and Falciparum (95.5-96.0%), Pl. Malariae (1.7-7.0%) and Oku mountains, volcanic plateaux of Bamenda and Pl. Ovale (0.1-6.8%) An. gambiae is more resistant to DDT than is An. grassfields arabiensis in the tropical zone VI-Coastal strata. This corresponds to Cameroon’s In this zone of dense hygrophile forest (Biafrican Anopheles gambiae gambiaeis a major malaria only coastal region, from Campo to Mamfé. The forest) and mangrove swamp the transmission of vector altitude is inferior to 300 m and it is a veritable cul- malaria is the highest for all the country, caused by de-sac often swallowed up by the monsoon Pl. Falciparum (97.7-100%), Pl. Malariae (0-0.7%) and Pl. Ovale (0-2.3%)

Based on the transmission pattern, the epidemiologic profile of malaria can be further categorised into 3 types:

1. Endemic and perennial: Zone of continuous transmission (7 to 12 months) covering the South Cameroonian Equatorial forest strata, the High western plateaux altitude strata and the Coastal strata where about a hundred infective bites per man per month can be registered 2. Endemic and seasonal: Zone of long seasonal transmission (4-6 months) covering High inland plateaux strata (Adamawa) and the Savannah-forest transition strata where about twenty infective bites per man per month can be registered 3. Epidemic or strongly seasonal: Zone of short seasonal transmission (1-3 months) covering the Sudano-sahelian strata where about ten infective bites per man per month can be register

The results Presentation in table 1 and figure two reveal that the intensity of malaria transmission reduces as one moves inland suggesting a potential risk of malaria epidemic in highlands and thus the need for a continuous epidemiological surveillance (33) in zones of seasonal transmission.

Figure 2: Mapping of transmission pattern

Figure 3: Mapping of vector species

1.1.2 Parasite and vector Resistance profile

1.1.2.1 Parasite Resistance Profile

Resistance to antimalarial drugs is proving to be a challenging problem in malaria control in most parts of the world (2). Since early 60s the sensitivity of the parasites to chloroquine, the best and most widely used drug for treating malaria, has been on the decline. Newer antimalarials were discovered in an effort to tackle this problem, but all these drugs are either expensive or have undesirable side effects. Moreover after a variable length of time, the parasites, especially the falciparum species, have started showing resistance to these drugs also.

6 Accoording to John Ehrenberg (2), WHO regional adviser on malaria and other vector borne and parasitic diseases, the Asia Pacific region has traditionally been the focus of resistance to antimalarial drugs and now we have artemisinin resistance primarily on the Thai-Cambodian border. If it is not contained, it can have global implications and the most serious one would be in Africa which has a high disease burden and the highest mortality rates. The best way to prolong the use of the drug would be to use it in combination with other anti malarial drugs (23).

In Cameroon, resistance to anti malarial drugs has been reported (19). Chloroquine which was most accessible and used as the first line treatment for uncomplicated malaria, developed resistance which was depicted for the first time in 1985 in the Limbe Township and later in other localities in the country with high rates of therapeutic failures observed.

Confronted with this situation, other molecules (Amodiaquine, Sulfadoxine -pyrimethamine as well as more recent artemisinine associated therapies) were proposed for use in chloroquine resistant areas (23). However, therapeutic failures to Artemisinine Combination Therapies (ACT) are now being registered in some towns in Cameroon as presented in Table 2 below:

Table 2: Rate of therapeutic failure related to combination of Atesunuate and amodiaquine + sulfadoxine-pyrimethamine in Cameroon (2004-2006)

Site Year Age group Total No of cases of Failure rate number treatment treated failure reported Akom II 2002 0-5 years 59 0 0 Limbe 2004 0-5 years 250 35 14 Yaoundé 2004 0-5 years 250 50 20 Garoua 2004 0-5 years 250 42 17 Yaoundé 2006 6months-5 62 7 11.3 years

Source: NMCP Strategic Plan

7 Resistance develops most rapidly when a population of parasite encounters sub-therapeutic concentration of antimalarial drugs (2). The following points will be helpful in reducing the emergence of resistance:

1. Selection of drugs - Use conventional drugs first in uncomplicated cases. Greater the exposure, higher will be the emergence of resistance. 2. Avoid drugs with longer half-life if possible. 3. Avoid basic antimalarials for non-malarial indications (e.g. Chloroquine for rheumatoid arthritis in a malarial endemic area). 4. Ensure compliance. 5. Monitoring for resistance and early treatment of these cases to prevent their spread. 6. Clear policy of using newer antimalarials. 7. Use of combinations to inhibit emergence of resistance.

1.1.2.2 Vector resistance profile

The prevention of malaria in Cameroon is based essentially on vector control through use of Insecticide Treated Mosquito Nets (ITN) and Indoor Residual Spray (IRS) (19). A number of insecticide sensitivity studies have been carried out by the NMCP as well by other research institutions in different parts of the country. The results derived through these studies show that there is optimum sensitivity of An. Gambiae s. I. to cabamites and organophosphorates. However, An. gambiae is more resistant to DDT than is An. arabiensis in the tropical zone. No vector resistance, what so ever, has been noticed in Maga and Tiko for all insecticides tested.

Resistance to DDT and to pyrethrinoides has been observed both in An. Gambiae (s.s. M&S forms) and in An. arabiensis.

1.1.3 Poverty profile

With the average monetary threshold of 269.443 francs FCFA per adult equivalent and per year in 2007, the incidence of poverty has not changed significantly between 1996 and 2007, national average has dropped from 53.3% to 39.9%; the objective haven been set at 25% by 2015. The disparities between urban and rural settlements are aggravating. Between 2001 and 2007: the incidence of poverty dropped in the urban area from 17.9% to 12.2% while increasing in the

8 rural areas from 52.1% to 55% (3, 5, 15). The cities of Douala and Yaoundé where the poverty incidence in 2007 stood at 6% is draining the rural population that are seeking greener pasture. The socio economic status, level of education and the size of the family tend to influence the poverty levels within the Cameroonian society (5). The poverty profile by region is presented in table 3 below.

Table 3: Evolution of the incidence of poverty between 1996 and 2007, and distribution of the poor population 2001 by milieu of residence

Milieu of Incidence Incidence Incidence Difference Poor population in Residence in 1996 in 2001 in 2007 2001 Number % Douala 37.3 10.9 5.5 -5.4 163 437 2.6 Yaoundé 49 13.3 5.9 -7.4 179 974 2.9 Total Douala Yaoundé 343 411 5.5 Adamawa 48.4 52.9 4.5 334 696 5.4 Centre (Outside Yaoundé) 48.2 41.2 -7 584 963 9.4 East 44 50.4 6.4. 327 642 5.3 Far North 56.3 65.9 9.6 1 545 349 24.9 Littoral (outside Douala) 35.5 30.8 4.7 267 671 4.3 North 50.1 63.7 13.6 562 503 9 North West 52.5 51 -1.5 935 409 15 West 40.3 28.9 -11.4 752 781 12.1 South 31.5 29.3 -2.2 168 602 2.7 South West 33.8 27.5 -6.3 394 032 6.3 Total regions 5 873 647 94.5 Urban 41.4 17.9 12.2 -5.7 962 415 15.5 Rural 59.6 52.1 55 2.9 5 254 643 84.5 Country level 53.3 40.2 39.9 -0.3 6 217 058 100 Source : Rapport National sur le Développement Humain 2008/2009

Substantial in-kind welfare transfer payments allocated to households by government (3) have resulted in an improvement in the access to health and education services for the poor and also the vulnerable groups. In the domain of the health sector, for instance, these transfers have been

9 carried out via programmes such as initiatives launched to combat HIV/aids, the extended programme of immunization and the fight against malaria programme.

Through the fight against malaria programme, the population, particularly pregnant women and households with children aged under-5, have benefited from free ITNs. Further more, because of the high poverty rate (40 percent of all Cameroonians and 55 percent in rural communities) (20), the Government, with the support of the Global Fund to fight Aids, Tuberculosis and Malaria decided beginning in January 2007 to partially subsidize ACT for malaria treatment in public and not-for-profit health facilities and in private pharmacies.

In spite of this partial subsidy, the cost of treatment of uncomplicated malaria with ACTs is still above the purchasing power of most of the population. To make it worse, these ACTs are regularly out of stock and the agreement signed by the Minister of Health and private pharmacists’ representatives to allow them to sell subsidized, ACTs is also not adequately implemented for several reasons, including (20):

a) AS+AQ and AL are among approximately 100 licensed anti-malarials in Cameroon, including monotherapies. b) Many of those are actively marketed by the pharmaceutical industry. c) The State supply chain fails to deal with private pharmacies. d) Sales of other licensed antimalarials are often more profitable.

In conclusion, poverty has contributed to inaccessibility of malaria control interventions for the majority of the population thus fostering the persistence of malaria which further aggravates poverty. To be successful, programmes oriented toward providing minimal access by poor households to better health, nutrition, and educational opportunities require that target groups be well identified (4). Understanding the likely effects of policy interventions on different groups in society allows for the possibility of fine tuning or developing mitigative actions.

10 1.1.4 Historical Facts and Perspectives of the Malaria Control Interventions in Cameroon

1.1.4.1 Historical Facts: The past and the Present During the fifties (9), large scale malaria vector control projects based upon house spraying were implemented in Southern and Northern parts of Cameroon in line with malaria eradication concept. In the South, the pilot zone of Yaoundé gathered about 150,000 inhabitants, in the forest area. First operations started in 1953 but the programme became actually operational in 1956. The South was divided in two parts: the western part was treated with DDT, while the eastern one was treated with dieldrin. At the same time, the whole forested area was also treated with dieldrin until 1960. Yaoundé itself was not treated because it was free of anopheles and malaria. House spraying in the pilot area of Yaoundé was a complete success and plasmodic index dropped below 1%. The same success was observed in most of the southern treated areas. Unfortunately dieldrin resistance of An. gambiae hampered this programme which stopped in 1960. The northem pilot project dealt with some 250,000 inhabitants around Maroua, in a savanna area. To avoid dieldrin resistance observed in 1956, DDT was selected and house spraying started in 1959. From a strictly operational point of view, the campaign was considered as a success. But after two years, it was noticed that plasmodic index remained still around the same value of 35% and the programme stopped. It was thus stated that according to available techniques it was not possible to reach the ultimate goal of eradication even when chemoprophylaxis (chloroquin + pyrimethamin) was added. Vector control was then stopped for a while.

The comparison between South (= success) and North (= failure) was very interesting as it underlined the big differences between epidemiological strata, an unaccepted concept at that time. Now ecological and epidemiological diversity is well acknowledged. It also underlined the need of diversity of strategies according to the epidemiology of the disease and the ecology of its vector.

In the eighties, Primary Health Care was promoted and malaria control shifted from vector to parasite control, vector control remaining as a prevention method. But chemo-resistance of Plasmodium falciparum appeared and quickly spread, at different levels, across the country. A

11 new emphasis was therefore given to vector control thanks to the newly developed technique of insecticide impregnated mosquito nets. Two kinds of studies were undertaken: - what people were actually doing in terms of mosquito control at family level, the main reason and the costs as well as current use of mosquito nets - the efficacy of pyrethroid treated mosquito nets (ITMN) in different areas of southern forested area against different malaria vectors: An. gambiae, An. nili, An. moucheti.

It thus clearly appeared that ITMN were very successful in sharply reducing malaria transmission and morbidity. But its promotion is limited by the current poor use of mosquito nets.

1995 was a turning point in the history of malaria control marked by the drafting of the first Malaria Control Programme (MCP) document in line with the 1992 Ministerial conference that held in Amsterdam. This was followed in 1997 by the declaration of the national policy for the control of malaria as approved by Government. In December 1998, the Central Technical Group for the Malaria Control was created. The President of the Republic was personally committed to this new drive towards malaria control activities through the letter he sent to the WHO Director General on the 28th April 1999. Following the signing of the Abuja Declaration on the 24th of April 2000 by the African Heads of States, this initiative was launched in Cameroon on the 25th July 2000 by the Minister of Public Health. These initiatives were concretised in 2002 with a National Malaria Control Strategy Plan which has given rise to what prevails today. According to this plan, Artemisinin Combination Therapy (ACT) is the treatment of choice for uncomplicated malaria (8, 15, and 20). The implementation of this plan is financed by multiple sources: state, Global Fund to fight HIV/Aids, Tuberculosis and Malaria (GFATM), WHO, UNICEF and Bill and Melinda Gates Foundation. Households contribute the largest share of financing through malaria prevention and home based care.

The NMCP has been restructured to make it more operational. In that light, the 2007-2010 strategy plan aims at contributing towards the achievement of MDG 6 through prevention, improving case management, behaviour change communication in favour of malaria, training and operational research, capacity building and partnership development.

12 1.1.4.2 Perspectives

The Government's objective over the next decade, with regard to malaria control, is to significantly reduce the prevalence rate of this disease which, with a rate of 40 per cent, is the leading cause of morbidity and consequently mortality in Cameroon (6, 7). A more coordinated approach of malaria control will be systematically sought and established at all levels in order to make the initiatives of stakeholders involved in this fight more complementary and better harmonized, especially health services, hygiene and sanitation services, the education system and information and communication services. Decentralized local authorities (councils notably) will increasingly be entrusted with the responsibility of managing integrated malaria control at the local level. In the medium term, (by 2015), the following goals will be pursued by the Government: (i) 80 per cent of children under 5 will sleep in long lasting insecticide treated mosquito nets; (ii) 80 per cent of community relays will apply the malaria community management package in at least 4/5 health areas of each district and (iii) 60 per cent of health units will apply the malaria management norms and standards in at least 4/5 health districts in each region.

1.2 Size of the problem Cameroon, Africa in miniature, presents diversified epidemiological strata of malaria transmission along with the corresponding parasites and vectors. Malaria continues to be endemic and the first major cause of morbidity and mortality among the most vulnerable groups - children under 5 years pregnant women People Living With HIV/Aids (PLWHA) and the poor accounting respectively for 18, 5, 5.5, and 40 percent of the total population estimated at 19 million.

Although malaria is preventable and treatable, there were still between 189 million to 327 million cases in 2006, resulting in between 610,000 to 1.2 million deaths. Half the world's population is at risk, particularly the poor and those living in remote areas with limited healthcare access. A child dies from malaria every 30 seconds. In Cameroon, more than 930 000 cases were reported in 2005. According to the NMCP 2008 annual report (10), more than 1 650 749 cases were reported and this is most predominant

13 amongst pregnant women and children below 5 years. The clinical morbidity rate estimated at 41%, the mortality rate at 2.2%

Data on coverage on malaria control interventions show that only 13.1 % of children aged under five years sleep under insecticide-treated mosquito nets, 37% of pregnant women received the second dose of Sulfadoxine Pyrimethamine and only 58% of complicated cases of malaria are promptly and properly managed. In a recent study in Obala Health District (17), the coverage was as follows: 15.1% for ACTs, 41% for LLINs, 67% for IPT2.

Based on the Systemic Quality Improvement (SQI) 2007/2008 data base (12) the number of cases of malaria registered in the regional and operational levels of the national health system alone is even higher (2 055 543 compared to the 1 650 749 cases reported through the NMCP), and varies from one region to another as presented in table 4 below (in decreasing order of the total population column).

Table 4: Burden of malaria in the operational and regional levels of the national health system Region Children under 5 Pregnant women Total population Number % Number % Number % NORD 180 457 44% 27 011 7% 409 346 20% NORD OUEST 97 033 33% 8 785 3% 291 552 14% EXTREME - NORD 116 732 43% 11 897 4% 268 638 13% OUEST 98 048 38% 12 177 5% 259 582 13% CENTRE 77 347 34% 18 551 8% 227 008 11% SUD OUEST 99 687 65% 5 191 3% 154 535 8%

14 LITTORAL 52 492 34% 21 159 14% 152 433 7% ADAMAOUA 52 972 37% 9 927 7% 145 009 7% EST 45 585 40% 7 405 6% 114 007 6% SUD 12 713 38% 2 030 6% 33 433 2% Total for Operational and 833 066 41% 124 133 6% 2 055 543 100% Regional levels Source: ST/CP-SSS: Situation analysis associated to Systemic Quality Improvement (SQI) 2008

When the same data is analysed in function of the level of care (first line, 1st level of referral, and 2nd level of referral) the trend of the burden of malaria disease is presented in figure 2 below.

Source: ST/CP-SSS: Situation analysis associated to Systemic Quality Improvement (SQI) 2008.

As presented in figure 2: 1. Malaria affects mostly women and children < 5 years old, 2. Malaria is the main cause for consultation at the operational level (integrated Health Centres as well as in District Hospitals) than it is at the regional level, 3. Malaria is the main cause of hospitalisation in the regional Hospitals than it is in the district hospitals, 4. Malaria as a main cause of mortality at all the levels analysed. It however, kills more at the operational level,

15 5. Though pregnant women no longer die from malaria at Regional Hospitals children < 5 continue to die from Malaria even at this level of care.

1.3 Causes of the problem

Upon critical analysis, the causes why malaria control interventions are not reaching the population are numerous and diversified. The said causes can accordingly be categorised under accessibility related on the one hand and to utilisation related on the other hand.

1.3.2 Insufficient access of the population to MCI: The causes of inaccessibility are largely related to governance, organisation and delivery of services, financing and regulation of the health system. Poor governance within the system: This is manifested by inadequate management of stock of drugs and commodities with resulting stockouts of ACT and LLINs in the authorised distribution points. It is not uncommon to find the same ACTs and LLINs being sold in the black market.

Unsatisfactory organisation and delivery of services: 50% population in Cameroon lives more than 5km from health facility thus limiting accessibility to facility based MCI. This is further made worse by the limited functionality of home management approach. At health facility level, there arise problems of the quality of service delivery as the majority of health staff tend not to prescribe ACT for simple malaria and delay in referring complicated cases to ensure continuity of care (fig. 1 shows high proportions of mortality from malaria in Health Centres). Just as well, they do not systematically seize the opportunity of Antenatal Consultations (80%, DHS III) to integrate malaria control interventions for pregnant women such as IPTp (47%, DHS III).

Low purchasing power: As mentioned earlier, close to 40% of the population lives below the poverty line (cf. poverty profile). Even though drugs and commodities have been subsidised to improve access to the most vulnerable and the poor, a good portion of the population cannot still afford the cost for the treatment of uncomplicated malaria with ACT (16), not to mention affording the cost (social and economic) of footing bills of treatment of complicated malaria Furthermore, there are no effective social protection measures that

16 can ensure equitable access to quality health services for the section of the population with a low purchasing power (6, 23). Insufficient popularisation of regulatory texts: In spite of the law exonerating medical commodities from taxes, malaria control commodities are being taxed thereby leading to LLINs being expensive and rare. The corollary is uncontrolled proliferation of non- recommended medical commodities

1.3.3 Low utilisation of available services The available services are under utilised. This may be explained by Low acceptability of proposed interventions due to lack of ACT and LLIN culture among population as only 11.5% of children <5 years and pregnant women sleep under a mosquito net (11). Acceptability of commodities is influenced by the milieu of residence, by the level of education as well as income levels: 8% use mosquito nets in rural areas compared to 15% in urban. Use of mosquito nets is more common amongst educated women and amongst women in well to do families. Inappropriate health seeking behaviours with over dependence on traditional healers for wrong indications resulting in unnecessary delays to getting quality health care, and as a bitter consequence, preventable deaths arise. In addition, there is frequent auto medication with inappropriate drugs or without respect of the dosage if the drug where appropriate. This obviously leads to development of resistance to recommended anti malarial medicines (2). Lack of empowerment of the population resulting in the later remaining a passive recipient of services. No in-built mechanism within the health system to stimulate demand

1.4 Framing of the problem With regards to the implementation of malaria control policy, there is still a significant disparity between the interventions hitherto carried out and the Global Malaria Action Plan goals set for 2015. Only 13% of children below the age of five sleep under insecticide-treated mosquito nets, 37% of pregnant women are on IPT2 and 58% of complicated cases of malaria are promptly and properly managed (6, 7, 13).

In a recent study in Obala Health District, the coverage was as follows: 15.1% for ACTs, 41% for LLINs, 67% for IPT2.

IPTi has not been included in national malaria control policy though there is substantial evidence (22) that it can reduce about 20- 30% the incidence of clinical malaria in infants living in areas of high and moderate intensity of transmission, comparable to results obtainable from mass use of insecticide treated nets.

In spite of the diversity in the epidemiologic profile, this malaria control policy that entails prevention interventions (LLIN, IPTp, IRS) and curative regimens (ACT for uncomplicated malaria, Quinine for severe malaria) is unique for the whole country and its implementation fails to respond to contextual needs (2). Further more, in practice, a multitude of anti malarial drugs are commercialised and even so, some as monotherapies (20) thereby increasing the risk to parasite resistance on one hand and rendering difficult the regulation, supervision and control of the PSM chain of all the drugs and commodities homologated on the other hand.

This coverage in MCI is clearly not promising if the goal of reaching the malaria prevalence rate of 3 per cent by 2015 is maintained. The consequence of this low coverage of malaria control interventions (commodities and medicines) is that malaria still persists as a major public health problem, resulting in high malaria related morbidity and mortality affecting women and children.

There is enough evidence to inform policy and decision makers, health workers and community to face this challenge through remedial strategies in the march towards malaria elimination in Cameroon. This policy brief proposes contextual solutions towards scaling up malaria control interventions in Cameroon.

18 2 Policy options of Evidenced-based Strategies for Scaling Up Malaria Control Interventions in Cameroon

The philosophy of evidence based policy brief is to propose sound options where there are problems and for which, sufficient relevant evidence is available. The options hereby proposed put through the message that to scale up malaria control interventions, prevention strategies need to be adapted to the main epidemiological strata in function of the transmission pattern. The options proposed in table 3 below are not mutually exclusive. As a matter of fact they are complementary and are tailored to context.

19 Table 5: Summary table of policy options Policy Governance arrangements Delivery arrangements Financial arrangements Option Description (i) Clear the drug market of antimalarials that (i) Shift from the current unified approach to specific (i) Secure and sustain subsidies for are not in the national policy (Artesunate- strategies according to epidemiological profiles and IPT, LLINs and ACTs and, (ii) Financial Title and Amodiaquin and Artemether-Lumefantrin for the emerging trends in the epidemiology of diseases incentives for pharmacists and Activities in the uncomplicated malaria and Quinine for for example: Introduce the Intermittent Preventive prescribers who comply with strategic complicated, Sulfadoxine Pyrimethamine for Treatment (22, 26), for infants and preschool children regulations. options IPTp), (ii) Enforce regulation through living in high and moderate transmission zones and for reinforced inspection and supervision PLWHA, (ii) Distribute LLINs, IPTp, IPTi, IPTc by the activities (31), (iii) Shift from the current communities supported by NGOs, CSOs (30), unified approach to specific strategies Community Health Workers (CHW) and Community according to epidemiological profiles and the Based Associations (CBAs) as it is the case with CDTI emerging trends such as co-morbidity with and , (iii) Foster public private partnerships through HIV/Aids and, (iv) Transfer greater Incentives/budget support (32), for example Service responsibilities to and empower Level Agreements (SLA) or Performance Based municipalities-communities for Contracting (PBF) as appropriate with pharmacists to comprehensive and integrated malaria sell only commodities and drugs recommended by the control interventions (28, 29) national policies, with business people for effective private marketing approaches for LLINs distribution. Barriers to Resistance to change, inadequate knowledge The State supply chain fails to deal with private Low budget allocation to health, implementation among the stakeholders on both malaria and pharmacies and sales of other licensed antimalarials Poverty, insufficient regulation its effective control strategies, insufficient are often more profitable. IPTi is not part of the leading to high commercialization of capacities of community stakeholders to take national policy because of the fear that S/P will lead to malaria control ownership. resistance as is the case in other countries e.g.

20 Policy Governance arrangements Delivery arrangements Financial arrangements Option Tanzania Challenges for Presence of strong leadership and previous Developing partnerships between communities, policy makers and experts. Developing local adaptability community empowerment strategies organisational capacity and financial empowerment Implementatio Information, education and communication, ” Communication, education, promotional campaigns, communication, decentralisation and n strategies malaria competence approach”, Promotional management and leadership training and careful Promotional campaigns, campaigns2, Use existing social structures and selection to ensure only ACTs on MOH policy circulate management and leadership training community groups in the market and are used, empowerment of parents, resources mobilisation Advantages introduction of incentive schemes is already Cost-effective interventions are available (24) and all introduction of incentive schemes is part of the Health Policy (7) and performance the interventions to be scaled up have proven high already part of the Health Policy (7) based contracting is ongoing at pilot scale in impact on MDG 4 and 5 (6, 7, 21). A 20-30 percent and performance based contracting some health districts within the context of reduction in incidence of clinical malaria in high and is ongoing at pilot scale in some SWAp moderate transmission epidemiologic settings using health districts within the context of IPTi is comparable to the levels of efficacy observed SW for the massive use of impregnated mosquito nets (22). Disadvantages In spite of the relative advantage3 that Artemether- A package of interventions to lumefantrine [AM-LM] has over the other ACTs, it decrease the bulk of the malaria

2 Advocacy targeting private and public, political and scientific spheres as well as the general population who should be encouraged to become partners and even actors of vector and malaria control at their household level

3 AM-LM has potential advantage over other forms of Act as it has registered no treatment failure due to recrudescence, closely followed by dihydoartemisinin- piperaquine (DH-PP)

21 Policy Governance arrangements Delivery arrangements Financial arrangements Option requires six doses, rather than three doses for other burden is not, however, affordable in artemisinin-based combinations (23). very-low income countries. Coverage of the most vulnerable groups in In northern Tanzania, as in many other parts of Africa Africa will require substantial where the drug has been used extensively, resistance assistance from external d o n o r s 4 to S/P is frequent , and is expected to increase after (24) S/P has become first line treatment (25). Costs According to a systematic review conducted by Goodman CA, Coleman PG, Mills AJ on the Cost-effectiveness of malaria control in sub-Saharan Africa (24), the cost-effectiveness range of insecticide-treated nets was US$19-85. If only insecticide treatment was required, the range would (unit cost) be decreased to US$4-10 per DALY averted. Cost effectiveness was $32-58 for residual spraying (two rounds per year), $3-12 for children's chemoprophylaxis, $4-29 for intermittent treatment of pregnant women, and $1-8 for improvement in case management. The global costs linked to the deployment of each strategy, based on the Cameroonian context, still need to be analysed to enable stakeholders ascertain feasibility Additional The monitoring and evaluation of the impact In view of the limited resources, universal access Malaria prevention and treatment considerations : of the governance arrangements to could target pregnant women, Children < 5 and should continue to benefit from Equity, gender strengthen the process of extending MCI with PLWHA as priority groups. Routine Data on coverage government subsidies and partner approach, the community at the fore front is should be disaggregated to identify all aspects of funding. Human rights fundamental in the justification of the choices discrimination: sex, milieu of residence, education, approach made in this policy brief. This requires the income levels where possible. In the approach to Demand side schemes should cover Monitoring and development of specific governance empowering communities, the participation of the cost of treating malaria for the evaluation, indicators to tract the effectiveness and the women and especially women groups should be target group identified: pregnant PSM efficiency of each strategy taken in context as encouraged as they are the first concerned for the

4In Cameroon, IPTi with Sulfadoxine Pyrimethamine (S/P) is preferable to IPTi with amodiaquine because the later is already in use for IPTp (3).

22 Policy Governance arrangements Delivery arrangements Financial arrangements Option evidence points to the need to adapt any continuum of mother and child health. women, children < 5 years and PLWHA strategy to the local context. As a matter of fact, reviews found a weak evidence base for Where and when the above is achieved, coverage The at risk population other than the claiming success of any particular health should systematically be extended to the whole identified priority groups should have services strengthening strategy in one LMIC population at risk. access (availability, affordability) to (34). There is even less evidence to expect the malaria prevention products such as The CDTI experience should serve as entry point same results in another country. LLINs through social marketing towards the integration of public health Delivery at channels the level of the community

23 3 Implementation considerations

According to the systematic reviews edited by David H. Peters et al (34), strategies relying on government oversight, strengthening human resources, strengthening management systems, public sector reorganization, community empowerment, and financing systems have all been shown to work. The same editors state that there is moderate evidence that most interventions require local adaptation. Leaders will need detailed advice/consultations from local experts to formulate the implementation process.

The strategic options considered in this policy brief rely on government oversight, strengthening management financing systems and should therefore work. Regarding Governance arrangements government oversight shall enhance leadership, stewardship and regulation while at the same time ensuring community empowerment through training and participation. Similarly regarding Delivery and financial arrangements, the strengthening of their management systems should entail adaptation to the local context. For example, the epidemiological profile of malaria in Cameroon reveals that the intensity of malaria transmission reduces as one moves inland and as such, there is need to adapt policy implementation to the epidemiologic profile (table 4). Other situations to take into consideration include the poverty profile and the HIV-malaria co-mobidity. This chapter summarises the implementation considerations into two categories: Global and Strategy specific.

3.1 Global Considerations related to Malaria control Interventions:

3.1.2 Malaria Prevention Interventions According to WHO (36) neither LLINs nor indoor residual spraying (IRS) may be sufficiently effective alone to achieve and maintain interruption of transmission in holo-endemic areas of Africa. Operational research is needed to determine the extent to which combining the two interventions would maximize the public health impact of malaria vector control and offer opportunities for management of insecticide resistance.

The way in which full coverage should be achieved may vary with particular epidemiological and operational situations. Where young children and pregnant women are the most vulnerable

24 groups, their protection is the immediate priority while progress is made towards achieving full coverage. Apart from the use of LLINs, cchemoprophylaxis or IPT reduces antenatal parasite prevalence and placental malaria when given to women in all parity groups. They also have positive effects on birth weight and possibly on perinatal death in low-parity women (27). IPT also reduces clinical malaria and severe anaemia in preschool children (22, 26). In Cameroon, due to co-morbidity of HIV-malaria, PLWHA should automatically be the third priority group. In areas of low transmission, where all age-groups are vulnerable, national programmes should establish priorities on the basis of the geographical distribution of the malaria burden (cf. epidemiological sub facies, table 1)

3.1.3 Malaria Case Management According to a study conducted by Wilfred F Mbacham (38) the prevalence of molecular markers for quinoline and anti-folate resistances showed high levels and differed between the south and north of Cameroon. AQ, SP and AQ+SP treatments were well tolerated but with low levels of efficacy that suggested alternative treatments were needed in Cameroon since 2005. According to Whegang et al (39), further studies are needed to evaluate the clinical efficacy and tolerance of ACT in different epidemiological contexts; artemether-lumefantrine [AM-LM], AM-LM appears to be the most effective with no treatment failure due to recrudescence, closely followed by dihydroartemisinin-piperaquine [DH-PP]. In Cameroon more than one ACT is being used (20) without that this is based on proven efficacy for each given epidemiological Strata. Acces to subsidised ACT is not equitable (16).

Table 4 summarises the malaria control interventions that may apply with respect to given epidemiological profile.

Table 6: Implementation considerations based on the main epidemiological strata Major epidemiological profile Malaria Control Intervention Endemic and perennial: Zone of continous 1. Universal coverage with LLINs5 transmission covering the South Cameroonian 2. IPTp and IPTi (35) are useful to combine Equatorial forest strata, the High western (29) with LLIN use given that the coverage plateaux altitude strata and the Coastal strata in Cameroon is still very low for both where about a hundred infective bites per man target groups per month can be registered. Most of the 3. Malaria case management for the general malaria burden occurs in children under the age population (37), which shall be covered of 5 years and pregnant women with LLIN and IRS progressively. Endemic and seasonal: Zone of long seasonal 1. Systematic case management6 transmission (6-9 months) covering High inland 2. Operational research (36): plateaux strata (Adamaoua) and the Savannah- IRS coupled with LLIN to the general forest transition strata where about twenty population infective bites per man per month can be impact of systematic treatment of non registered clinical forms of malaria presenting with positive smear with ACT Epidemic or strongly seasonal: Zone of short 1. continuous epidemiological surveillance seasonal transmission (3-4 months) covering the (33) Sudano-sahelian strata where about ten 2. effective case management (home as well infective bites per man per month can be as clinic based) (37) registered. High risk of epidemics

5 4–5 times cheaper than IRS which, cannot be targeted to children only. 6 Establish priorities based on the geographical distribution of the malaria burden (28)

26 3.2 Strategy-specific Considerations: Table 5 below summarises, for each strategic option (cf. table 3), the expected barriers to implementation, challenges for adaptability and Implementation strategies in the context of Cameroon.

Table 7: Summary of implementation consideration for each strategic option Policy Governance arrangements Delivery arrangements Financial Option arrangements Description: (i) Clear the drug market of antimalarials that are (i) Shift from the current unified approach to specific (i) Secure and sustain not in the national policy (ii) Enforce regulation strategies, (ii) Distribute LLINs, IPTp, IPTi, IPTc by the subsidies for IPT, LLINs and through reinforced inspection and supervision communities supported by NGOs, CSOs, CHW CBAs and ACTs and, (ii) Financial activities, (iii) Shift from the current unified Community Based Associations, (iii) Foster public private incentives for pharmacists approach to specific strategies (iv) Transfer greater partnerships through Service Level Agreements (SLA) or and prescribers who comply responsibilities to and empower municipalities- Performance Based Contracting (PBF) as appropriate with regulations. communities Barriers to Resistance to change, inadequate knowledge The State supply chain fails to deal with private Low budget allocation to implementation among the stakeholders on both malaria and its pharmacies and sales of other licensed antimalarials are health, Poverty, insufficient effective control strategies, insufficient capacities often more profitable. IPTi is not part of the national regulation leading to high of community stakeholders to take ownership. policy because of the fear that S/P will lead to resistance commercialization of malaria as is the case in other countries e.g. Tanzania control Challenges for Presence of strong leadership and previous Developing partnerships between communities, policy makers and experts. Developing adaptability community empowerment strategies local organisational capacity and financial empowerment Implementation Information, education and communication, ” Communication, education, promotional campaigns, communication, strategies malaria competence approach”, Promotional management and leadership training and careful decentralisation and

27 campaigns7, Use existing social structures and selection to ensure only ACTs on MOH policy circulate in Promotional campaigns, community groups the market and are used, empowerment of parents, management and leadership resources mobilisation training

7 Advocacy targeting private and public, political and scientific spheres as well as the general population who should be encouraged to become partners and even actors of vector and malaria control at their household level.

4 References

4.1 The epidemiological profiles

1. Francis LOUIS, Armel REFFET, Dominique LOUIS-LUTINIER. Malaria in Cameroon : http:/www.impact-malaria.com

2. WHO :Drug Resistance.http://www.who.int/tdr/research/progress9900/methods/malaria-resistance.htm

4.2 The poverty profile

3. INS: Trends, profile and determinants of poverty in Cameroon in 2007 4. Sarah G. Lynch: Income distribution, poverty, and consumer preferences in Cameroon, 1991 5. INS : Résultats préliminaires de l’ECAM3 en 2007

4.3 The malaria services coverage

6. Government of Cameroon: Growth and Employment Strategy Paper 2010-2020, 7. Ministry of Health: Health Sector Strategy 2001-2015. 8. National Malaria Control Programme: Plan Stratégique National de Lutte contre le Paludisme au Cameroun 2007-2010.

9. P Carnevale, J Mouchet : http://www.anopheles.org/showcitationlist.php

10. Ministry of Health : Rapport d’activités 2008 du Programme National de Lutte Contre le Paludisme 11. INS: Demographic Health Surveys, 2004 12. ST/CP-SSS: Systemic Quality Improvement (SQI) 2007/2008 data base 13. INS:MICS 2006 14. NMCP: Rapport 2008 15. PNUD/MINEPAT: Rapport National sur le Développement Humain 2008/2009, Cameroun/ Le défi de la réalisation des Objectifs du Millénaire pour le Développement. 16. Literature review Cameroon. Access to, and Delivery of, malaria Treatment in Cameroon

29 17. Cameroon Coalition Against Malaria: Obala Malaria Campaign Baseline Survey, Feb 2010 18. Malaria No More and McKinsey & Company on behalf of the Roll Back malaria Partnership: We can’t Afford to Wait: The business Case for Rapid Scale-up of Malaria in Africa, January 2008

4.4 Effective interventions

19. David H. Peters, Sameh El-Saharty, Banafsheh Siadat, Katja Janovsky, Marko Vujicic, (Editors): Improving Health Service Delivery in Developing Countries: From Evidence to Action. World Bank, 2009. 20. Pierre Ongolo-Zogo, Renee-Cecile Bonono. Policy brief on improving access to artemisinin-based combination therapies for malaria in Cameroon. 21. MoH: Marginal Budgeting for bottlenecks 22. IOM: Assessment of the Role of Intermittent Preventive Treatment for Malaria in Infants: Letter Report, http://www.nap.edu/catalog/12180.html 23. Whegang et al. Malaria Journal 2010, 9:56: http://www.malariajournal.com/content/9/1/56 24. Goodman CA, Coleman PG, Mills AJ., Cost-effectiveness of malaria control in sub- Saharan Africa: Lancet 1999 Jul 31; 354(9176):378-85. 25. Julius J Massaga: Effect of intermittent treatment with amodiaquine on anaemia and malarial fevers in infants in Tanzania: a randomised placebo controlled trialLancet 2003; 361: 1853–60 26. Meremikwu MM, Donegan S, Esu E. Chemoprophylaxis and intermittent treatment for preventing malaria in children. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD003756. DOI: 10.1002/14651858.CD003756.pub3. 27. Garner P, Gülmezoglu AM. Drugs for preventing malaria in pregnant women. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD000169. DOI: 10.1002/14651858.CD000169.pub2.4 28. Wallerstein N (2006). What is the evidence on effectiveness of empowerment to improve health? Copenhagen, WHO Regional Office for Europe (Halth Evidence Network report; http://www.euro.who.int/Document/E88086. pdf accessed 19 april 2010

30 29. Rassekh B and Segaren N (2009). Review of community empowerment strategies for health in Improving health service delivery in developing countries: from evidence to action. pp 127-171. Edited by David H. Peters ... [et al.]. DOI: 10.1596/978-0-8213-7888-5. World Bank 30. Vega-Romero R, Tovar MT (2007). The role of civil society in building an equitable health system. Paper prepared for the Health Systems Knowledge Network of the WHO Commission on the Social Determinants of Health. June 2007. 31. Gilson L (2007). What sort of stewardship and health system management is needed to tackle health inequity and how can it be developed and sustained? Centre of Health Policy, University of Witwatersrand, South Africa. 32. Alexander K. Rowe, Samantha Y. Rowe, Marko, Vujicic, Dennis Ross-Degnan, John Chalker, Kathleen A. Holloway, and David H. Peters (2009): Review of Strategies to Improve Health Care Provider Performance. Pp 103-109, Edited by David H. Peters ... [et al.]. World Bank

4.5 Implementation considerations

33. Tomoléon Tchuinkam et al: http://www.biomedcentral.com/1471-2334/10/119 34. David H. Peters, Sameh El-Saharty, Banafsheh Siadat, Katja Janovsky, Marko Vujicic: Improving Health Service Delivery in Developing Countries: From Evidence to Action. World Bank, 2009. 35. D Houeto, W D'Hoore, EM Ouendo, D Charlier, A Deccache: Malaria control among children under five in sub-Saharan Africa: the role of empowerment and parents’ participation besides the clinical strategies, Rural and Remote Health 7: 840. 36. WHO: INSECTICIDE-TREATED MOSQUITO NETS: a WHO Position Statement, 2007 37. Bernard J Brabin, Marian Wasame, Ulrika Uddenfeldt-Wort, Stephanie Dellicour, Jenny Hill and Sabine Gies: Monitoring and evaluation of malaria in pregnancy – developing a rational basis for control, Malaria Journal 2008, 7(Suppl 1):S6 doi:10.1186/1475-2875-7- S1-S6 38. Wilfred F Mbacham et al, Efficacy of amodiaquine, sulphadoxinepyrimethamine and their combination for the treatment of uncomplicated Plasmodium falciparum malaria in children in Cameroon at the time of policy change to artemisinin-based combination therapy

39. Whegang et al. Malaria Journal 2010, 9:56 http://www.malariajournal.com/content/9/1/56