Do Malaria Control Interventions Reach the Poor? A View through the Equity Lens
Lawrence M. Barat, Natasha Palmer, Suprotik Basu, EVE Worrall, Kara Hanson, and Anne Mills.

Malaria, more than any other disease of major public health importance in developing countries, disproportionately affects poor people, with 58% of malaria cases occurring in the poorest 20% of the world’s population. If malaria control interventions are to achieve their desired impact, they must reach the poorest segments of the populations of developing countries. Unfortunately, a growing body of evidence from benefit-incidence analyses has demonstrated that many public health interventions that were designed to aid the poor are not reaching their intended target. For example, the poorest 20% of people in selected developing countries were as much as 2.5 times less likely to receive basic public health services as the least-poor 20%. In the field of malaria control, a small number of studies have begun to shed light on differences by wealth status of malaria burden and of access to treatment and prevention services. These early studies found no clear difference in fever incidence based on wealth status, but did show significant disparities in both the consequences of malaria and in the use of malaria prevention and treatment services. Further study is needed to elucidate the underlying factors that contribute to these disparities, and to examine possible inequities related to gender, social class, or other factors. To achieve impact and overcome such inequities, malaria control efforts must begin to incorporate approaches relevant to equity in program design, implementation, and monitoring and evaluation.

Malaria: A Disease of Poverty
Malaria is confined almost exclusively to developing countries, particularly in sub-Saharan Africa and southern Asia, the poorest regions of the world. Gwatkin and Guillot demonstrated that 58% of the malaria deaths occurred in the poorest 20% of the world’s population, a higher percentage than for any other disease of major public health importance.
Within these poor countries, malaria disproportionately affects the poorest of the poor populations. Reaching the poorest of the poor with malaria control interventions poses great challenges, not solely because of financial barriers to accessing care and prevention services. The poorest populations in developing countries often live in the most remote areas and are socially or culturally marginalized.
In the global development community, concerns that public health interventions may not be reaching poor and marginalized populations have led investigators to examine the differences in the burden of disease and the coverage and impact of public health interventions among persons with differing socioeconomic status (SES). One of the primary tools in this line of investigation has been benefit-incidence analysis, in which the disease burden and the use of health care services and the government subsidies included in them are measured across different socioeconomic groups.2
The results of early studies have begun to demonstrate striking disparities in the use of public health services by the poorest when compared with less poor populations. Although these services are often intended to reach the poor, the poorest groups have been shown to be least likely to receive the benefits of those services. For example, analyses of Demographic and Health Survey (DHS) data have documented that the wealthiest 20% of the population of 44 developing countries were 1.25 to more than 2.5 times more likely than the poorest 20% to receive key public health services, including treatment of diarrhea, childhood immunization, and antenatal care (Gwatkin DR, unpublished data).
Because the negative consequences of malaria fall most heavily on the poorest segments of the population, such disparities in the use of public health services must be of particular concern to the malaria control community. If extra efforts are not made to reach the poorest of the poor with effective malaria control interventions, it is very likely that the Roll Back Malaria (RBM) target of reducing the global malaria burden by 50% by the year 2010 will not be reached. Interventions, therefore, must be designed to ensure that a large percentage of the most poor are using effective treatment, insecticide-treated bed nets (ITNs), and other essential malaria control interventions. This can only be accomplished with a broader understanding of what types of approaches are best at reaching the poor and what barriers limit access and use of essential malaria control services.

Definitions and Measurements
A working definition for inequities in health are differences that are “not only unnecessary and avoidable, but in addition, are considered unfair and unjust.”3 Although much of the work on inequities, to date, has focused on SES, other factors that might lead to inequities include sex, ethnicity, and social class. Although there are quantitative measures for SES and sex, measurement of factors like social status cannot be easily quantified. Qualitative research can be used to explore the role of these less tangible factors and thus help to identify underlying reasons why people do or do not use particular services […]
Research Findings
A small number of studies attempted to describe a relationship between malaria and poverty at the macroeconomic and geographic levels.4 The scientific basis of these findings, though, is as yet rather limited.
[…]
Whether the risk of infection varies by SES, current evidence suggests a much stronger correlation between wealth status and the consequences of malaria infection. In rural Tanzania, for instance, mortality in children less than five years old following acute fever was 39% higher among the poorest compared with the least poor (Mwageni E, unpublished data). The precise reasons for the higher risk of complications from malaria infection in the poor have yet to be elucidated. Many have pointed to the possibility that financial barriers limit access to both preventive and curative services and commodities. Non-financial barriers, including the educational status of the caretaker, distance from health services, and opportunity costs of lost time at work, may also be underlying factors […]
One factor that no doubt contributes to such disparities is the cost of commodities, such as bed nets and drugs. A study in Malawi found that expenditure on malaria prevention showed a positive correlation with income, indicating that the poorest households probably cannot afford commodities such as ITNs.8 Further evidence in Tanzania from an ITN social marketing program supports this argument, finding that the price of the net was the most common constraint on net ownership (Hanson K and others, unpublished data). This would suggest an important role for targeted subsidies to lower financial barriers to access.
Beyond the costs of commodities, other reasons why the poor have more negative health outcomes and use prevention and treatment less often may be more complex. Cultural, behavioral, and educational factors that lead to delayed treatment seeking may play important roles, but have yet to be fully defined by appropriate qualitative research. Lower levels of education may, for instance, be useful predictors of the type and timeliness of care-seeking behavior.9 Elucidation of these factors could suggest interventions for lowering these more complex barriers to the effective use of prevention and treatment services.
Discussion
Clearly in this new line of investigation, there is much that we do not know. For example, studies examining the relationship between malaria incidence and SES have yielded contradictory results. Filmer found no positive correlation between reported fever and SES in his analysis of DHS data.5 Other studies have contradicted these findings.
In contrast, some noticeable trends can be detected in studies looking at severe complications of malaria, and these findings could inform the implementation of malaria control programs. There appears to be a much stronger basis to conclude that the severe consequences of malaria are borne most heavily by the poorest. More limited access to both preventive measures and curative treatment may partially explain worse outcomes among the poorest.
Not surprisingly, studies looking at both use of ITNs and access and use of malaria treatment demonstrate lower coverage in the poorest compared with the least-poor. It remains to be clarified whether the barriers to preventive and treatment services are primarily financial or whether other factors (e.g., cultural practices and norms, sex roles, caretakers’ educational status, proximity to health services) play a significant role. Disentangling the myriad factors that might limit the accessibility and use of malaria control services by the poor will require additional quantitative and more importantly qualitative research […]
Full article available at Do Malaria Control Interventions Reach the Poor? A View through the Equity Lens - The Intolerable Burden of Malaria II: What's New, What's Needed - NCBI Bookshelf (nih.gov)

Acknowledgments
This paper is based on a review and analysis of the literature and a report on a meeting on Malaria and Equity carried out by the Health Economics and Financing Program, London School of Financing and Tropical Medicine, in collaboration with the World Bank, and funded by the World Bank.
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Footnotes
Received for publication August 21, 2003.Accepted for publication January 6, 2004.
Financial support: Natasha Palmer, Eve Worrall, Kara Hanson, and Anne Mills are members of the Health Economics and Financing Programme, which receives a research grant from the United Kingdom Department for International Development.
Authors’ addresses: Lawrence M. Barat, Academy for Education Development, 1825 Connecticut Avenue, Washington, DC 20009 and Suprotik Basu, Natasha Palmer, Eve Worrall, Kara Hanson, and Anne Mills, Health Economics and Financing Programme, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom.
Copyright © 2004, American Society of Tropical Medicine and Hygiene.
Bookshelf ID: NBK3767