For many years, the politics of malaria control have been such that IRS and the use of DDT have been discouraged either officially by WHO or de facto by donor agencies that have failed to provide funding for IRS programs.
WHO and donor agency policies against IRS stem in part from their unwillingness to challenge the often vocal environmentalist organizations that have campaigned against the use of insecticides in the control of insect borne diseases. During the 1990 and early 2000s most UN agencies, such as WHO and UNICEF and almost all donor agencies only supported insecticide treated nets (ITNs) as a means of malaria control. While ITNs are a useful and effective intervention, there is no evidence that they can be used as a replacement for other interventions, such as IRS. To date the malaria control efforts that rely solely on ITNs have not delivered the hoped for reductions in malaria cases and deaths.
A further problem with the large UN and donor agency supported malaria control efforts is that they have not been accompanied by rigorous monitoring and evaluation of results. Frequently success in donor run projects is not measured in terms of changes to malaria cases and deaths, but rather in terms of funds disbursed or commodities procured.
During the 1990s, the Zambian government began a process of privatizing its copper mines. The newly-privatized Konkola Copper Mine plc (KCM) which operates in Chingola, Chililabombwe and Kitwe in Copperbelt Province and Nampundwe in Central Province, re-started its malaria control program in 2000. KCM’s malaria control program focused on indoor residual house spraying (IRS) as the primary vector control strategy. KCM’s malaria control program covered an area of 834km2 in 2001 and 2002, which encompassed a 10km radius around the council-delineated towns of Chingola, Chililabombwe and Nampundwe. In 2003 and 2004 the malaria control area was increased to 842km2 by including KCM employee residences in Kitwe and Kalulushi.
The KCM malaria control program managed to achieve a very high spray coverage rate in 2001 (31,463 houses sprayed), 2002 (34,454 houses sprayed) and 2003 (33,419 houses sprayed). In 2004 spray coverage decreased to 74% (25,792 houses) largely due to delays in procuring insecticides in time for the start of the spraying season. Approximately 360,000 people live within the KCM malaria control program area.
Results of the Mozal malaria control program
The average malaria parasite prevalence rate in the Mozal area in Mozambique in 2000 was 86%. After the first spray round the malaria prevalence decreased to 62% in 2001, 36% in 2002 and 18% in 2003. The current malaria parasite prevalence is below 15% and the reported malaria cases amongst MOZAL employees decreased by 50%. The reduction in malaria prevalence has translated into significantly fewer cases, medical evacuations and fatalities at the Mozal smelter.
The regional approach to malaria vector control between South Africa, Swaziland and Mozambique, which extended malaria vector control to an area of over 100 000km2 in the three countries has resulted in significant reductions in malaria cases and malaria parasite prevalence. The average malaria parasite prevalence amongst children (2>15 years) in Maputo Province, Mozambique decreased from 64% in 1999 to under 10% in 2005 which contributed to the malaria control successes experienced at the Mozal smelter.
Rather than pandering to international pressures these private companies conducted research to determine which interventions are most effective at reducing the prevalence and incidence of malaria and improving the productivity of their employees. The Mozal and KCM malaria control programs, which are predominantly based on IRS, have been highly successful and effective interventions, reducing malaria cases and deaths consistently since the program was started in 2000.
Neither Mozal nor KCM had any real interest in the political agenda that determined which intervention would or would not be supported; rather they were determined to implement policies that would reduce the burden of disease fastest. Their self-interest in wanting to control a disease that affected their bottom line has generated significant community benefits and should be seen as a model for public-private partnerships in the future.
A further important feature of these programs has been the rigorous and ongoing monitoring and evaluation. Unlike many of the donor supported programs, both Mozal within the Lubombo Spatial Development Initiative (LSDI) and KCM were insistent on undertaking a proper baseline measurement of malaria cases and deaths and regularly assessing progress so that they could know whether or not success in malaria control was being achieved.
It is likely that the interventions have also been economically beneficial to the wider community and economy of the regions. The evidence based approaches taken by both Mozal within the LSDI and KCM have led to changes to malaria control programs in general. Thanks in part to the success shown by these programs, the WHO reversed its de facto refusal to support IRS and the use of DDT in September 2006. In addition, some major donor agencies, such as the US Agency for International Development has reversed its policies against the use of DDT in malaria control and is now procuring this insecticide for those malaria control programs that require it.
To date much of the involvement of private companies in malaria control has been limited to the supply of ITNs to affected communities. These two cases show that private companies can play a far more active role in malaria control supporting other interventions, such as IRS and provide an excellent model of a public-private partnership.