Rapidly increasing national coverage of ITNs is central to Malawi's strategy of malaria control [8]. The challenge is in finding a distribution model that would ensure high and equitable ownership of ITNs. In Malawi, ITNs are distributed through the social marketing program. By definition, social marketing discriminates against the poor who may not have disposable income needed to afford health products [9]. Not surprisingly, by 2004, only 24% of households in the lowest socio-economic quintile (poorest) had ITNs compared to 71% in the least poor quintile. Alternative distribution methods are therefore urgently needed if Malawi is to scale up ITNs for impact, especially amongst the very poor. Because surveys have shown that poverty is the main reason for not owning an ITN [10], future distribution methods should include free distribution of ITNs at least to the vulnerable groups, including the very poor. There is evidence to show that targeted free distribution of ITNs is equitable. In Ghana, overall household ITN ownership increased from 4.4 percent to 94.4 percent when free distribution of ITNs was linked to a measles campaign with households in the poorest quintile achieving a post-campaign coverage ten times higher than the pre-campaign coverage of households in the wealthiest quintile [11]. Distribution of 100% subsidized ITNs to pregnant women and under-five children could also be linked antenatal and Expanded Program on Immunization (EPI) services. In fact, free distribution through antenatal clinics has been shown to be a simple, cheap and equitable approach to delivering ITNs to pregnant women [12]. However, more operational research is required to assess the feasibility of linking ITN distribution to routine EPI services.
Other observers have called for the free distribution of ITNs amongst the poorest of the poor. Unfortunately, proxies for the identification of the poorest of the poor are difficult to define under operational settings and have not been defined in Malawi. In our view, free distribution of ITNs should focus on the already identifiable vulnerable populations: pregnant women and children under five years of age. Only when very high coverage and equity is achieved in these groups, will the burden of malaria morbidity and mortality be significantly reduced.
In 2000, only 17% of children with fever were promptly treated (within 24 hours) with an effective antimalarial drug. About 60% of all the fevers were managed at home with drugs bought at pharmacies or local shops. Although there was no income related inequality across the wealth quintiles both in prompt treatment and home management of fever, the least poor group were more likely to have treated fever in children with an effective antimalaria drug than the poorest group. These statistics are more worrying because untreated or delayed treatment of falciparum malaria contributes both directly and indirectly to the death of non-immune individuals, sometimes within hours of the onset of symptoms [13]. The lack of inequality could be attributed to the fact that in 2000, the effective antimalarial drug (SP) in Malawi was locally manufactured and widely accessible at a minimal fee. However, the Government of Malawi is now changing its treatment policy to an artemisin-based combination therapy which will require visits to a health center and if available in local shops or pharmacies will be prohibitively expensive. With this new policy, it's more likely that income related inequalities will hinder access to effective treatment by the poor. It is important therefore that new distribution methods, which deliberately target the poor, be put in place to counter these potential inequalities. One such method could involve the empowerment community health workers to distribute effective treatment at community level, a method that has been proven to significantly reduce malaria morbidity and mortality in children, and to increase equity in access [14, 15]. However, the establishment of such a distribution method would depend on the cost implication of the program to the country. It is our view though that a drug policy which fails to address equity issues will lead to increased malaria morbidity and mortality.
In 2000, only 29% of pregnant women had received the recommended two doses or more of SP/Fansidar during the last pregnancy. Although there was no income related inequalities across the wealth quintiles, this figure is well below the Abuja recommendation of 60% of pregnant women using IPT. In Malawi, barriers to increasing IPT include inadequate knowledge or confusion among health staff regarding the proper timing of the second dose of SP, stock shortages of SP at health facilities and apprehension among pregnant women to take SP [16]. To avoid the confusion as to when to administer the second dose, IPT could be given at every antenatal contact with the pregnant woman. To date there is no evidence that shows that women who receive more than two doses of SP have an increased adverse drug reactions or increased number of adverse pregnancy outcomes than those on the recommended two doses [17]. In the event that a combination therapy is recommended to replace SP for IPT, then further research on the effective distribution channels to ensure equitable access to IPT will be needed. The lack of inequalities in IPT could be explained by the fact that in Malawi, antenatal attendance is very high across all socioeconomic quintiles, providing a great opportunity to reach all pregnant women with IPT.
