Kicking Malaria out
By Eunice Menka
The push by health officials is now to encourage people to sleep under treated bed nets by allowing volunteers in communities into bedrooms to hang the nets and educate people on usage.
In the past, people took delivery of the free bed nets and misappropriated them. Officials say although distribution of bed nets has been around for a long time, people were not using them partly because they did not know how to hang them.
The National Malaria Control Programme (MNCP) of the Ghana Health Service has currently moved away from just distributing free insecticide treated bed nets ((ITNs) to actually hanging them correctly in the sleeping quarters of beneficiaries.
This is to break transmission in the spread of the disease, as part of efforts to scale-up the prevention of malaria through a nation-wide campaign dubbed “hang up”. This is being done under a universal coverage programme, where two people in a household, get a bed net. And this has not gone down well with some beneficiaries, who feel everyone should be given one each.
It may appear easy to hang these nets in a simple exercise that takes only 5-minutes in the bed rooms of beneficiaries. However, it is no easy task gaining access to the bedchambers of households. Even the description of a sleeping place is a sensitive issue, not to mention the uncomfortable experience of beneficiaries about the invasion of their privacy.
Back 1998, the distribution of ITNs began on a small scale and targeted pregnant women and children under-5 because they were the most vulnerable. After a decade of implementation, it was realized that people were not using the nets properly.
A survey by NetMark, a USAID agency in 2008 showed that net usage rate was very low and a Demographic Health Survey (DHS) report also indicated that among pregnant women usage was around 20 per cent and 28 percent among under-5 children.
The current hang-up campaign, which began in 2010 in the Northern region, was therefore to address the shortcomings of the initial free bed net distribution exercise carried out in1998 by NMCP and its partners.
Ahead of the current exercise, registration was carried out to record persons in every household and in May 2010, with the few bed nets available to the NMCP, the door-to-door distribution and hang up to pregnant women and under-5 began in the Northern Region.
In April 2011, NMCP and partners including the United States Agency for International Development (USAID) and its agency- President’s Malaria Initiative (PMI), Department for International Development, Global Fund, United Nations International Children’s Fund (UNICEF) and the World Health Organization (WHO) covered the Eastern Region.
From Eastern region, attention was turned to the Volta region, which had bed net use culture because of the many water bodies and the need for protection against mosquito bites. Almost all the regions have been covered with the Ashanti Region beneficiaries having their share of the nets in February this year. People in the Brong Ahafo have also recently benefited from the exercise.
There have been challenges to this simple exercise to protect communities from mosquitoes and these have come in the form of politics, gaining access to bed rooms and inadequate supplies of the bed nets, among others.
During the exercise in the Brong Ahafo region for instance, a group of volunteers on their way to hang some nets in a large compound house with over 24 families, had to contend with a contentious beneficiary.
The resident of the New Krobo community in the Techiman Municipality of the Brong Ahafo region was not happy about the two-to-one approach. Mr Akwasi Addai Bosompem, on a bike on his way out of his compound, did not miss the opportunity to vent his spleen on the volunteers who had come to hang his net. He was furious and emphatic that it is not prevention because not everyone in his family of four was going to benefit from the exercise.
With the two nets he received, he and his wife would understandably share one of the nets but he was in a dilemma about how his two children, a boy and girl, aged 12 and 18,could share the other bed net as they do not sleep together.
“Which one of us should die? If the plan is two is to one, I’m repeating that it is not prevention. I have not asked anyone to give me any net. You can’t prevent one person from getting malaria and leave the others to die,” an angry Bosompem shouted at the team headed by Alhassan Ahmed, from the Disease Control Unit in the Techiman Municipality. Fortunately, Mr Ahmed quickly got in touch with the Field Supervisor in charge of the area to sort the confusion and ensure the volunteers got back to correct the situation by explaining matters to them.
According to Mr Ahmed, a lot of education had gone on in the local FM stations but issues of misunderstanding had become a problem.
Prince Charles Osei, one of the volunteers, said he had been told when he got to Mr Bosompem’s house that he will not be allowed access to the veranda much less the bed rooms to hang the net.
Some inmates of the compound house, in an interview, said they had received the nets but had insisted they will hang it themselves. Upon entering the house, one could see the nets on the drying line and the volunteers had left without ensuring that it was all going to be hanged correctly, despite the fact that volunteers had received strict instructions to ensure that the net were actually hanged to ensure proper usage.
“Do not just hand over the nets to recipients because it is a hang-up exercise. It is against the principle of the hang up. If beneficiaries will not let you enter their rooms, volunteers are expected to give the tools to the person to hang the net and the volunteer will then peep into the room to see if the nets have been properly hanged. Then the recipient will thumb-print in the registration book,” an official of the NMCP had sounded this warning to the volunteers at the start of the programme.
“We told them we’re from the Ghana Health Service and a Non Governmental Organisation. We are not here for politics.” Osei had explained in an interview.
Of course, all sorts of opposition were expected and even politics could not be ruled out in matters as simple as mosquito nets, especially when the hang up exercise in the Brong Ahafo region took place this year. Anything is possible in an election year and a drama unfolded at a durbar to launch the exercise in the region.
With this in mind, stakeholders resolved to avoid any political play at the mini durbar attended by chiefs, elders, community members, health officials and political appointees in the Yawhimah Krom community in the Sunyani Municipality, where the launch took place.
Mr Kwasi Lampo, the National Disaster Management Organisation (NADMO) Regional Coordinator, who addressed the durbar, told the gathering that what they were seeing was part of the “Better Ghana Agenda” being pursued by government.
Later in an interview to explain what he meant as this was not government doing the hang-up, he had a simple explanation: “A government in power can support or cancel any programme it comes to meet and once the government has given its support, then the hang-up campaign is part of the Better Ghana Agenda.” This almost stirred the hornet’s nest.
Madam Theresa Addae, a Principal Community Health Nurse of the Sunyani Municipal Health Directorate, also present at the durbar, however, did not let politics have its way to the new approach to protect households from mosquito bites.
“No! This is not politics as usual.” This summed up her militant stance against what she called “the politicization of the bed net distribution.”
Being concerned about the challenges facing national exercise, Theresa Addae, who works as a districts nurse, ceased the opportunity to educate the gathering that this was a national exercise with no political parties involved and as such community members should embrace the programme and allow volunteers into their bedrooms to hang up free bed nets made available by the Ghana Health Service and partners.
Other challenges also came in the form of deviant volunteers extorting monies from the beneficiaries before hanging the nets even though the nets were for free.
The hang up campaign was not all bad news. During rounds in some districts and municipalities in Brong Ahafo region, many residents were very cooperative.
Mary Takyiwaa, a beneficiary in the New Krobo community, was more than happy with the exercise and threw her doors wide open for the volunteers to again access to her bed room. Mary had a mat neatly spread out in the corner in her thread-bare room in an uncompleted building.
“I was buying spray and mosquito coil every now and then… I thank all who gave us the net. Everybody should use it,” she said with joy.
And it was also gratifying that chiefs like the Nkosuohene (Chief) of Yawhimah krom, Nana Kwaku Agyir, embraced the new preventive strategy as he told his people to make good use of the nets and deplored instances where bed nets were used as wardrobes, cover cloth or partition for rooms.
“Malaria is a killer and expensive. We are farmers and we work hard. Without strength, we cannot work”, he said in an interview. “We have spoken to everyone to accept the volunteers when they come in to hang the nets and we have used the FM stations to educate them and will continue with the education.”
Fortunately, the hang up exercise has been a private-public and community partnership deal thus ensuring that a large army of volunteers, health officials, chiefs, media and donors were all on the war path to keep malaria away.
During the Brong Ahafo campaign, health officials in the region gave the needed leadership to ensure the success of the programme.
Dr Timothy Letsa, Regional Director of Health Services, said leadership and community support were given to the exercise at every stage and even the Ghana Private Road Transport Union (GPRTU) was involved by helping to cart the nets to the Pre Positioning Sites, (PPS), which serves as the collection point where the nets are stored for collection and onward distributions to the districts and communities.
Despite the modest gains made in bringing malaria cases down across the country, there are still daunting realities to dislodge the disease from its top position as the common cause of OPD attendance.
During the hang up exercise health officials expressed dissatisfaction with the gains made about malaria.
Mr Anthony Ofori, Brong-Ahafo, Regional Malaria Focal Person, said malaria sat high on the list of diseases in the region with some districts such as Sene being critical areas because of the stagnant waters and other breeding sites for mosquitoes.
Indeed the statistics spoke for themselves. A visit to the Techiman Municipal Health Directorate told a story of not just statistics but the lives involved and the sufferings that malaria had caused over the years.
Madam Clementia Bagrmwin, the Malaria Focal Person in the Municipality, said in the first quarter of 2012, there were 34,282 reported malaria cases in the Techiman Municipality, although she acknowledges that during this time, there were “no rapid diagnostics test kits so cases may be higher. This can come down if we have kits.”
She said in 2011, malaria cases were 129, 582, because there were many more reporting centers such as the CHPS compound and maternity homes.
The current roll-out of the nation-wide hang up exercise could help bring down the Techiman statistics and others across the country if communities would make good use of the exercise, which could well complement other preventive and control tools to serve as a cocktail of strategies to kick out malaria.
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