Impact Evaluation of Malaria Control Interventions on Morbidity and All-Cause Child Mortality in Rwanda, 2000-2010

Abstract

The impressive decline in child mortality that occurred in Rwanda from 1996-2000 to 2006-2010 coincided with a period of rapid increase of malaria control interventions such as indoor residual spraying (IRS); insecticide-treated net (ITN) distribution and use, and improved malaria case management. The impact of these interventions was examined through ecological correlation analysis, and robust decomposition analysis of contextual factors on all-cause child mortality. Child mortality fell 61% during the evaluation period and prevalence of severe anemia in children 6-23 months declined 71% between 2005 and 2010. These changes in malaria morbidity and mortality occurred concurrently with a substantial increase in vector control activities. ITN use increased among children under five, from 4% to 70%. The IRS program began in 2007 and covered 1.3 million people in the highest burden districts by 2010. At the same time, diagnosis and treatment with an effective antimalarial expanded nationally, and included making services available to children under the age of 5 at the community level. The percentage of children under 5 who sought care for a fever increased from 26% in 2000 to 48% in 2010. Multivariable models of the change in child mortality between 2000 and 2010 using nationally representative data reveal the importance of increasing ITN ownership in explaining the observed mortality declines. Taken as a whole, the evidence supports the conclusion that malaria control interventions contributed to the observed decline in child mortality in Rwanda from 2000 to 2010, even in a context of improving socioeconomic, maternal, and child health conditions.

Figure 1.

Malaria risk strata in Rwanda. Source: Malaria and Other Parasitic Diseases Division 2013.

Figure 2.

Timeline of data sources and malaria control interventions, 1992–2010. This figure appears in color at www.ajtmh.org.

Figure 3.

Household ownership of insecticide-treated nets, 2000–2010. This figure appears in color at www.ajtmh.org.

Figure 4.

In all households, the proportion of children under five, pregnant women, and all household members who slept under at insecticide-treated net the previous night, 2000–2010. This figure appears in color at www.ajtmh.org.

Figure 5.

Trend in all-cause out-patient cases and in suspected malaria cases, Health Management Information System 2001–2010. This figure appears in color at www.ajtmh.org.

Figure 6.

Malaria incidence per 1,000 persons (all age groups), 2001–2010, Health Management Information System. This figure appears in color at www.ajtmh.org.

Figure 7.

Monthly proportional malaria morbidity in children under five, 2001–2010, Health Management Information System. This figure appears in color at www.ajtmh.org.

Figure 8.

Parasitemia prevalence in children 6–59 months, Rwanda, 2007/2008, 2010, stratified (A) by age, (B) by household residence, and (C) by household wealth. * Measured via microscopy. This figure appears in color at www.ajtmh.org.

Figure 9.

Annual all-cause under-five mortality rates from Demographic and Health Surveys data, 1989–2010. This figure appears in color at www.ajtmh.org.

Figure 10.

Relative percent change in age-specific childhood mortality in children in Rwanda; a comparison of 5-year estimates from the 1996, 2000, 2005, and 2010 Demographic and Health Surveys. Key: NN = neonatal mortality (first month), per 1,000 live births; PNN = postneonatal mortality (age 1–11 months), per 1,000 live births; ₁q₀ = infant mortality (first year), per 1,000 live births; ₄q₁ = child mortality between exact age 1 and exact age 5, per 1,000 children surviving to 12 months of age; ₅q₀ = under-five mortality, per 1,000 live births. This figure appears in color at www.ajtmh.org.

Figure 11.

Trends in all-cause child mortality by malaria risk, Rwanda 1996–2000 and 2006–2010. This figure appears in color at www.ajtmh.org.

Figure 12.

Proportional malaria mortality in children under five, 2001–2010, Health Management Information System. This figure appears in color at www.ajtmh.org.