Lusaka — As the rainy season descends in Zambia, hospital beds around the country will increasingly fill with patients suffering from malaria. The disease is Zambia's number one killer, accounting for 50,000 deaths a year, or 47 percent of all deaths in the country.
A vicious cycle has seen malaria incidence rates in Zambia triple in the last 30 years, while its economy has deteriorated in the same time period.
In a country where 73 percent of the population now lives below the poverty line, most households have lost breadwinners to malaria and struggle to support family members afflicted with the disease.
The public cost is also high. Malaria accounts for an estimated 40 percent of public health expenditures, draining a health system already overburdened by HIV/AIDS and a shortage of health workers. Lowered productivity as a result of malaria infections has further crippled the government's ability to implement measures to control the spread of the disease.
A new partnership between the government, international donors and the nongovernmental organisations that make up Zambia's existing Roll Back Malaria campaign aims to break the cycle, with an ambitious plan to reduce malaria deaths in Zambia by 75 percent over the next three years. It is hoped that the initiative, known as the Malaria Control and Evaluation Partnership in Africa (MACEPA), will serve as a model for other countries in the region.
"Malaria has been sadly overlooked," said Malama Muleba, executive director of the Zambia Malaria Foundation, an umbrella body for NGOs that are helping the government implement control efforts. "We're trying to remedy that."
Optimism about Zambia's chances of attaining its goal of reaching 80 percent of the population with prevention and treatment measures is seen in the level of cooperation taking place between government, local NGOs and international donors, which include the Global Fund to Fight AIDS, Tuberculosis and Malaria, the World Bank and the Bill & Melinda Gates Foundation.
Paul Libiszowski, a project-implementation specialist with PATH, the NGO charged with managing the Gates Foundation's $35 million contribution to MACEPA, explained that the choice of Zambia as the country to test-drive malaria control arose from its commitment to reducing malaria deaths and its willingness to work in conjunction with donors and other partners.
In the past, said Libiszowski, sporadic efforts by individual donors to implement malaria control projects lacked an integrated approach.
"What we've got going here is a national programme donors are buying into and contributing to rather than vertical projects," he said.
Technological advances such as rapid diagnostic test kits and the new artemisinin-based malaria drug, Coartem, have provided additional tools for tackling malaria.
But even low-tech solutions, such as awareness raising, insecticide spraying and the provision of insecticide-treated bed nets, have been beyond the means of the Zambian government until now. Nets are only affordable for a small portion of the population, but with the assistance of international donors free nets are now being delivered in huge numbers. PATH alone used its partnerships with local public health structures and NGOs to deliver half a million bed nets in 2005and will use another million in 2006.
Reaching the most remote rural communities with malaria prevention and treatment measures is again dependant on partnerships, this time with faith-based organisations and traditional healers, which provide the majority of healthcare services in those areas.
The Churches Health Association of Zambia (CHAZ) is an umbrella body of faith-based organisations that provides 50 percent of rural healthcare services in Zambia and is the primary recipient of Global Fund financing. With its existing network of clinics and home-based care workers, CHAZ is well positioned to distribute nets, give additional training to its health workers and help raise awareness.
CHAZ's malaria programme officer Charles Chiyama said that a surprising number of Zambians still do not know what causes malaria. A number of myths about how the disease is transmitted persist, including witchcraft, eating immature sugar cane and getting soaked in the rain.
Muleba described how previous efforts to distribute mosquito nets had failed because the recipients were not sufficiently educated about how the nets could protect them. Some nets were sold to more savvy town-dwellers or converted into fishing nets. Others were turned into wedding dresses.
The solution, said Muleba, is to work with local chiefs and traditional healers to educate communities about the proper use of mosquito nets. Through the Traditional Healers Association, healers are also being trained to recognise malaria symptoms and refer patients to clinics for treatment.
Muleba, like most Zambians, has suffered from bouts of malaria, as has his young son. It was an encounter with an elderly couple in a rural area, weak from malaria and struggling to walk the 12 km home from the nearest clinic, however, that drove home for him the necessity of broadening the reach of malaria treatment and control.
Muleba and his colleagues at the Zambia Malaria Foundation have applied an almost evangelical zeal to achieving the goals Zambia has set for itself. Malaria rates had already decreased by 10 percent in the last year. With more funds, said Muleba, his foundation and its partners could move forward more rapidly.
"We need to look at innovative and cost-effective means," he said.
One such approach is to integrate efforts with those already being used to combat HIV/AIDS. The foundation has several partners whose primary focus is HIV/AIDS, including RAPIDS, a consortium of six NGOs that is now training its extensive network of home-based caregivers to help raise awareness about malaria and to distribute nets donated by the foundation.
"We distributed 5,000 nets in 10 days, and we now have our caregivers checking to see if they're being used," reported Bruce Wilkinson, RAPIDS chief of party. "We could do 300,000 a year if someone gave us the nets and the cost would be minimal."
As malaria infection has been shown to increase viral load in those infected with HIV, and HIV infection can, in turn, increase the severity and likelihood of contracting malaria, this integrated approach has a medical basis.
"I think the nexus of TB, malaria and AIDS are the basis for making many Zambians vulnerable," Wilkinson said. "So it only makes sense to use and promote those tools available to deal with all three in an integrated fashion."
Considering the loss of earnings caused by malaria, Zambia's private sector also has a stake in malaria control.
Zambia Breweries is one of several companies that has instituted an employee malaria scheme with support from the Malaria Foundation. The scheme provides employees with free testing and treatment at on-site clinics as well as subsidised nets. Spraying of entire communities where employees are housed will begin with the rainy season.
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"It's in our interest that our employees are physically fit," explained Chimango Chikwanda, the company's human resources director. "If they have malaria, it's a minimum of three days they're off work, and that impacts our ability to deliver."
Figures showing that malaria cases are already decreasing in Zambia can be attributed in large part to the replacement of chloroquine as the primary drug for treating malaria with Coartem, an artemisinin-based combination therapy.
Increased resistance to chloroquine had resulted in treatment failure rates as high as 52 percent in most areas of the country before financing from the Global Fund made it possible for the government to switch to Coartem. Zambia was the first country in Africa to do so.
Macha Hospital, one of the first facilities to begin prescribing Coartem in 2003, saw its malaria caseload drop from nearly 1,000 a year in 2003 to under 100 cases in 2005.
"It may be we are seeing the actual future of what Roll Back Malaria is doing in Zambia," said Phil Thuma, a doctor who has been monitoring the impact of Coartem at Macha Hospital.
MACEPA partners across the board seemed to share Thuma's cautious optimism.
"We need a major success story for decreased incidence of malaria in Africa, and Zambia has the potential to achieve that," said Wilkinson.
[ This report does not necessarily reflect the views of the United Nations ]
