by Leith Greenslade

Malaria – a child survival success story…

The fight against malaria has contributed significantly to the decline in child deaths. The World Malaria Report in 2013 found that between 2000 and 2010 three million fewer children died from malaria.  According to UNICEF, malaria now accounts for just 7 percent of all child deaths – an estimated 460,000 in 2012 – and is dwarfed by other causes including newborn (38 percent), pneumonia (17 percent) and malnutrition which contributes to a massive 45 percent of all under 5 deaths. Deaths from malaria among children are now on a par with deaths from diarrhea (9 percent) and injuries (5 percent).

Success in controlling malaria means that the problem is becoming more concentrated in specific countries.  The vast majority of child malaria deaths now occur in a handful of countries in sub-Saharan Africa.  Ten countries account for 70 percent of all child deaths with just two – Nigeria and the Democratic Republic of Congo – accounting for a massive 40 percent of the burden.

Table 1: Child Malaria Deaths are Concentrated in 10 Countries…

Country	Number of Child Malaria Deaths (UNICEF, 2012)
NigeriaDemocratic Republic of Congo Cote d’Ivoire Mozambique Angola Chad Niger Mali Uganda Burkina Faso	143,00064,000 18,000 16,000 15,000 15,000 15,000 14,000 13,000 13,000

The impressive progress in reducing child malaria deaths appears to be largely the result of massive increases in prevention, specifically the wide distribution and use of insecticide-treated bed nets.  The proportion of children under five sleeping under one of these nets has increased from 5 to 40 percent since 2000.  Although access to the recommended treatment – artemisinin-based combination therapy (ACT) – did increase over the same period, the gains were not as great and the proportion of children receiving this therapy still remains very low in many of the countries with the greatest challenges.  The rates of confirmed diagnosis of malaria among children with fever are even lower in many countries, however on the rise as rapid diagnostic tests are being rapidly rolled out aggressively.

Table 2: Prevention Coverage is High but Diagnosis and Treatment Rates for Children with Malaria Remain Spotty…

Ten Countries with Highest Numbers of Child Deaths from Malaria	% Children Sleeping under Insecticide-Treated Nets(UNICEF, 2011-12)	% Children with Malaria Receiving ACT (UNICEF, 2010-12)	% Children with Fever with Confirmed Malaria Diagnosis (UNICEF, 2010-12)
-Nigeria-Democratic Republic of Congo -Cote d’Ivoire -Mozambique -Angola -Chad -Niger -Mali -Uganda -Burkina Faso	1638 37 36 26 10 20 46 43 47	114 17 60 77 2 80 5 69 25	817 11 30 26 9 No data 6 26 5

This increased usage of bed nets and malaria diagnosis and treatment has come at a hefty price.  International donors increased their support for malaria 20 fold between 2000 and 2010, from an estimated $100 million to over $2 billion.  In addition, many African governments increased the proportion of national health budgets allocated to malaria prevention and treatment.  Despite these large increases, it is estimated that a minimum of $5 billion is needed to deliver on the promise of universal coverage of malaria prevention and treatment and so greater investment in malaria will be needed to drive child malaria deaths close to zero.

The remarkable progress in reducing childhood malaria deaths has generated a massive opportunity in the countries where malaria is endemic to build on the advocacy, delivery and outreach platforms to deliver other high impact child survival interventions.

Going for greater impact by integrating malaria, maternal and child health programs…

Why is it imperative that we do this?  There are four reasons.  First and foremost, by increasing coverage of the highest impact maternal and child survival interventions more children’s lives can be saved.  Bundling additional interventions onto existing, effective health outreach platforms like malaria is a highly effective way of increasing coverage of other interventions and has the potential to at least double the impact on lives saved of existing outreach platforms.  A recent evaluation of a program in Mali that delivered malaria, pneumonia and diarrhea prevention and treatment programs together found that child deaths fell tenfold over three years.  Dramatic results like this are not seen in programs that pursue a single disease or intervention focus.

Second, using existing health outreach platforms like malaria that often deliver interventions door to door and reach the children who are least likely to visit health services ensures that the children who will benefit most from health interventions, receive them first.  This is the equity argument and it is vitally important to the achievement of global health goals, as deaths are so often concentrated among children who are the hardest to reach.  This is so often the achilles heel of routine health platforms and programs where the benefits accrue disproportionately to the children who are least likely to suffer from severe illness or death. The malaria bed net distribution network particularly with its engagement of local civil society and faith communities has been very successful at reaching the most vulnerable children.

Third, delivering more than one intervention at a time using the same service platform increases the efficiency or cost effectiveness of health investments – something that we all should be seeking to maximize with scarce global health dollars only becoming scarcer.   Examples abound in donor financed health systems of parallel supply chains, competing workforces, multiple donor reporting requirements and training duplication as each disease or intervention-specific program attempts to construct its own autonomous operating environment.  When interventions are bundled the cost falls as an evaluation of a program in Western Kenya demonstrated when they distributed bed nets alongside condoms, HIV tests and medicines and water filters to 47,000 people in 7 days, averting more deaths, disability and future medical costs compared to  individual interventions alone.

Finally, delivering integrated packages of services to families increases “patient value” by minimizing the costs of seeking health care – measured in money and time.  This is why parents and communities are so supportive of platforms that deliver a package of interventions to their doors (e.g. child health weeks and multiple vaccination campaigns), because they spend less time and money getting their children fully protected against the leading threats to their health and survival. Patient value is not something we talk enough about in public health and more work is needed to quantify the benefits of integrated delivery to populations and governments.

With about 600 days to the Millennium Development Goal deadline, and more than 2 million child deaths to prevent to achieve MDG4, now is the time to pursue every opportunity to accelerate child mortality reductions.  Missed opportunities will be measured in children’s lives lost and our own analysis at the Office of the UN Special Envoy for Financing the Health MDGs shows that an estimated 300,000 additional child deaths could be prevented over a two year period by simply delivering a package of maternal and child health interventions to nine sub-populations of the most vulnerable children.

Let’s start with malaria programs tackling pneumonia, newborn and nutrition…

As a matter of urgency, three areas are crying out for greater coordination and integration of malaria with broader maternal and child health efforts. First, if malaria diagnosis and treatment services were able to respond to children who presented with fever but who tested negative for malaria, fewer children would die from undiagnosed and mistreated or untreated pneumonia. Studies are now emerging showing malaria now accounts for a minority of children who present with fever in malaria endemic settings – some as low as 10 percent – and are being dwarfed by children presenting with acute respiratory infections.  If malaria services could diagnose and treat suspected child pneumonia appropriately they could potentially double their impact on children’s lives saved.

Second, malaria in pregnancy contributes to an estimated 11 percent of newborn deaths and hundreds of thousands of stillbirths in Africa.  Despite relatively high rates of prenatal care in many countries coverage with the recommended doses of intermittent preventive malaria treatment (IPTp) is dismally low. If prenatal services routinely tested pregnant women for malaria and provided the recommended treatment many hundreds of thousands of newborn deaths and stillbirths could be prevented.  As newborn deaths and stillbirths now account for an estimated 5 million deaths globally, IPTp deserves to be front and center of an integrated malaria/RMNCH effort to prevent these tragedies by reducing the risk of low birth weight, premature birth and stillbirth.

Third, malnutrition is an underlying cause of almost half of all child deaths and there is growing evidence from emergency settings that when malaria prevention and treatment services are combined with screening and treatment for moderate and severe malnutrition, the impact on lives saved could dramatically increase.  A recent evaluation of a program in Niger that distributed a ready-to-use supplementary food to children alongside malaria and other child prevention and treatment interventions reported that mortality rates were cut in half.

If we all marched to the same drum…

If all organizations active in child health measured their impact in terms of child deaths prevented examples of integrated child health programs would abound and we would be closer to achieving global child health goals. But instead we have many programs measuring success by the number of individual products procured or distributed, or by the number of children diagnosed or treated with a specific intervention. In some cases organizations committed to child survival can deliver on their specific goals while having very limited impact on child survival or Millennium Development Goal 4.

This needs to change and it will be up to the post-2015 environment to better align the new global health goal of eliminating preventable child deaths with the performance measurement of the agencies charged with implementing it.  We’ll need a better match too between funding and the burden of disease with the largest shares of funding going to fight the diseases that cause the most deaths.  Donors will need to press agencies to deliver integrated services to maximize the life-saving impact of every dollar.

But it is not just donors and their implementing agencies that need to demand the greater impact that integrated services can deliver.  The populations who stand to benefit from these services need to demand the same.  Families and communities need to petition their health services and their governments to protect their children against all of the leading threats to their health in such a way that reduces the money and time they spend on healthcare.  This is part of the democratic conversation that each government needs to have with its citizenry on what kind of health system the people support and ultimately agree to invest their own tax dollars in.  With many countries in Africa and South Asia growing relatively strongly with a growing middle class, this conversation is already happening or just around the corner.

If this all works, the international development community will be much more on the sidelines in many countries, only acting when governments ask or in the case of dysfunctional governments, when the people and their civil society representatives call for external support and partnership.  The global health community can play a constructive role in this transition by ensuring that the support it provides is in line with the vision Jim Kim, Paul Farmer and Michael Porter outlined so powerfully in their 2013 Lancet commentary, “Redefining Global Healthcare Delivery”, namely to build health systems that, “use shared delivery infrastructure to create patient value by capturing synergies in care for related pathologies, by improving reach and access for patients, by enabling better utilization of scarce personnel and facilities, and by allowing care activities to take place in the most cost effective setting while integrating care”.

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Leith Greenslade is Co-Chair of Child Health at the MDG Health Alliance and Vice-Chair at the Office of the United Nations Special Envoy for Financing the Health Millennium Development Goals, which works in partnership with governments, non-government organizations, academic institutions and corporations to accelerate achievement of the health related Millennium Development Goals. The Alliance operates in support of Every Woman, Every Child, an unprecedented movement spearheaded by the United Nations Secretary-General to intensify global action to improve the health of women and children.