Is the scale up of malaria intervention coverage also achieving equity?

Abstract

Background and methods: Malaria in Africa is most severe in young children and pregnant women, particularly in rural and poor households. In many countries, malaria intervention coverage rates have increased as a result of scale up; but this may mask limited coverage in these highest-risk populations. Reports were reviewed from nationally representative surveys in African malaria-endemic countries from 2006 through 2008 to understand how reported intervention coverage rates reflect access by the most at-risk populations.

Results: Reports were available from 27 Demographic and Health Surveys (DHSs), Multiple Indicator Cluster Surveys (MICSs), and Malaria Indicator Surveys (MISs) during this interval with data on household intervention coverage by urban or rural setting, wealth quintile, and sex. Household ownership of insecticide-treated mosquito nets (ITNs) varied from 5% to greater than 60%, and was equitable by urban/rural and wealth quintile status among 13 (52%) of 25 countries. Malaria treatment rates for febrile children under five years of age varied from less than 10% to greater than 70%, and while equitable coverage was achieved in 8 (30%) of 27 countries, rates were generally higher in urban and richest quintile households. Use of intermittent preventive treatment in pregnant women varied from 2% to more than 60%, and again tended to be higher in urban and richest quintile households. Across all countries, there were no significant male/female inequalities seen for children sleeping under ITNs or receiving antimalarial treatment for febrile illness. Parasitemia and anemia rates from eight national surveys showed predominance in poor and rural populations.

Conclusions/significance: Recent efforts to scale up malaria intervention coverage have achieved equity in some countries (especially with ITNs), but delivery methods in other countries are not addressing the most at-risk populations. As countries seek universal malaria intervention coverage, their delivery systems must reach the rural and poor populations; this is not a small task, but it has been achieved in some countries.

Figure 1. Equity in household ownership of ITNs.

Percent household ownership of at least 1 ITN, by household residence and poorest versus wealthiest quintile, from national household surveys 2006–2008. Top group of countries are those achieving equity across rural-urban and wealth quintiles; bottom group are those not achieving equity across these categories. *Wealth statistically different (P-value<0.05); **Urban/rural statically different (P-value<0.05); ***Wealth and urban/rural statistically different (P-value<0.05); $Data not available for statistical test.

Figure 2. Equity in antimalarial treatment of fever in children.

Percent children with a fever in the past 2 weeks receiving any antimalarial, by household residence and poorest versus wealthiest quintile, from national household surveys 2006–2008. Top group of countries are those achieving equity across rural-urban and wealth quintiles; bottom group are those not achieving equity across these categories. *Wealth statistically different (P-value<0.05); **Urban/rural statically different (P-value<0.05); ***Wealth and urban/rural statistically different (P-value<0.05); $Data not available for statistical test.

Figure 3. Equity in use of intermittent preventive treatment in pregnancy (IPTp).

Percent women 15–49 who received 2 or more doses of sulfadoxine-pyrimethamine for IPTp during their last pregnancy, by rural versus urban residence and poorest versus wealthiest quintile, from national household surveys 2006–2008. Top group of countries are those achieving equity across rural-urban and wealth quintiles; bottom group are those not achieving equity across these categories. *Wealth statistically different (P-value<0.05); **Urban/rural statically different (P-value<0.05); ***Wealth and urban/rural statistically different (P-value<0.05); # Data are for sulfadoxine-pyrimethamine preventive use, but did not specify 2+ doses IPTp.

Figure 4. Equity among male and female children sleeping under an ITN.

Percent male and female children under-5 years of age sleeping under an ITN the previous night, national surveys between 2006 and 2008. All country male-to-female rates are similar with no statistically significantly differences (P-value>0.05).

Figure 5. Equity among male and female children receiving antimalarial treatment.

Percent of male and female children under-5 years of age with fever receiving any antimalarial medicines, national surveys between 2006 and 2008. *Statically different with P-value<0.05.

Figure 6. Malaria parasite prevalence in children.

Percent parasitemia in children under-5 years of age by urban or rural setting and by richest or poorest wealth quintile, national Malaria Indicator Surveys in African countries. *The Rwanda DHS report did not include parasitemia comparisons by wealth quintile. All urban-rural and richest-poorest differences are statistically significant at P-value<0.001 except for Rwanda urban versus rural (X² = 1.52, P-value = 0.2168). For Zambia, substantial increases in malaria intervention coverage occurred between the 2006 and 2008 surveys and likely accounts for the observed reduction in prevalence, predominantly in rural and poor populations.

Figure 7. Moderate-to-severe anemia rates in children.

Anemia rates (Hb<8gms/dl) in children under-5 years of age by urban or rural setting and by richest or poorest wealth quintile, national Malaria Indicator Surveys in African countries. *While testing was done in the Rwanda DHS, the comparisons were provided in different categories and are not comparable to the other studies. **Statically different with P-value<0.05. For Zambia, substantial increases in malaria intervention coverage occurred between the 2006 and 2008 surveys and likely accounts for the observed reduction in severe anemia, predominantly in rural and poor populations.