Malaria and Poverty
Address for correspondence: Awash Teklehaimanot, Malaria Program, The Earth Institute at Columbia University, 2910 Broadway, Hogan Hall, Rm. 110, New York, NY 10027. Voice: 212-854-8157; fax: 212-854-3637.
Malaria is one of the most important challenges to global public health. African countries south of the Sahara bear today the heaviest burden of malaria. The relationship between poverty and malaria has long been recognized but its paths are multiple and complex. Recent studies suggest that causality works both ways, trapping communities in reinforcing cycles of poverty and disease. If malaria is to be controlled or eventually eliminated, the social and economic conditions that fuel malaria transmission need to be addressed. At the same time, malaria control should be seen as a poverty reduction strategy.
Malaria is one of the most important challenges to global public health. Every year, there are between 300 million and 500 million cases of malaria worldwide, and more than 1 million people die from the disease, most of them children younger than 5 years. Ninety percent of the cases and 75% of the deaths occur in sub-Saharan Africa. These childhood deaths, resulting mainly from cerebral malaria and anemia, constitute somewhere between 20% and 25% of child mortality in Africa.1
Today, malaria is a tropical disease of poor countries. But for centuries, malaria was present in temperate regions of the world, some as far north as Russia and Canada. By the mid-20th century, the disease was already decreasing in many areas of the world, partly due to general improvements in housing and nutrition. The World Health Organization (WHO) Global Malaria Eradication Campaign (1958–1969)—which did not include tropical Africa—interrupted malaria transmission in many of these temperate regions.
African countries south of the Sahara bear today the heaviest burden of malaria. Ecological and climatic conditions in tropical Africa are particularly favorable for an intense transmission of malaria: The Anopheles gambiae mosquito, the most efficient malaria vector, is widely distributed in Africa, and most infections are caused by the Plasmodium falciparum parasite, which produces a much more severe disease than the other three Plasmodium species that infect humans. But while acknowledging the importance of these factors, we cannot ignore that these countries are among the poorest in the world and that widespread poverty on the continent plays a role in the continuing burden of malaria.
Malaria cases and deaths have risen steadily in sub-Saharan Africa since the late 1970s. The emergence of resistance to insecticides and chloroquine, the cheap antimalarial treatment widely used for clinical management of uncomplicated malaria, has been held as a major factor in this trend, aided by a general weakening of health systems.2 This effect was exacerbated by economic stagnation and decline: According to the World Bank, from 1980 to 1987 per capita gross national product declined by 2.8% in sub-Saharan Africa, whereas it grew by 4% among all low-income economies.3 Per capita gross national product for sub-Saharan Africa declined by 44.3% between 1960 and 1999. According to the World Bank, malaria deaths in Africa rose from roughly 100 to 160 per 100,000 over this same period.4
The links between malaria and poverty are multiple and complex. A strong correlation between malaria and poverty has long been recognized, but understanding the direction and magnitude of the correlation is more difficult. Most likely, causality works both ways: Poverty sustains the conditions where malaria thrives, and malaria impedes economic growth and keeps communities in poverty.5 With a potential dual causation between poverty and malaria, where poor households experience high malaria prevalence that in turn maintains them in poverty, these households are trapped in reinforcing cycles.6
There are many pathways through which the relationship between malaria and poverty operates. Poor housing does not protect people from contact with infective mosquitoes. Simple preventive measures such as insecticide-treated bednets are unaffordable to the poorest if they must pay for them. Lack of resources prevents people from seeking timely health care. Often, peak malaria transmission coincides with harvesting time, and a few days of work lost to illness can mean food insecurity for the entire family. Malaria infections are more frequent and severe in undernourished children. Little or no schooling is associated with less knowledge about malaria prevention and the early recognition of symptoms.
The above-mentioned factors operate at an individual or household level, but they do not capture a wider social level, where poor communities cannot protect themselves or invest in control measures, governmental control programs, or development programs. Moreover, there are intangible costs that malaria taxes on communities: Malaria endemicity discourages investment because it makes labor more costly. Understanding the economic effect of malaria is important for health policy and for development policy more generally, but it is also critical for targeting malaria control interventions toward the poor and vulnerable.7
The malaria burden is concentrated largely on the poor. On the basis of country-level data, Gwatkin and Guillot25 estimated that 57.9% of all deaths from malaria in the world in 1990 occurred among the poorest 20% of the world's population. But within the poor countries, there is evidence that the costs of malaria fall more heavily on the very poor. In Malawi, for instance, very-low-income households carried a disproportionate share of the economic burden of malaria, with total direct and indirect cost of malaria among these households consuming 32% of annual household income, compared with 4.2% among households in the low-to-high income categories.8 In Tanzania, mortality in children younger than 5 years after acute fever was 39% higher among the poorest than in the least poor. 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%.12
Cost of Malaria
Attempts to estimate the economic burden of malaria have traditionally used two different approaches. Microeconomic studies assess the direct costs of prevention and treatment of the disease at individual, household, and health services levels, and to these add the estimated indirect cost of work time lost because of illness or death or to the need to care for others sick with malaria. These studies aim to document the cost-effectiveness of controlling malaria for the sake of productivity, conceptualizing malaria as an obstacle for development and a factor in keeping people in poverty.
A different approach, from macroeconomics, attempts to measure the effect of malaria at country-level scale, assessing its effect in long-term economic growth and development. The influential 2001 report of Gallup and Sachs9 has brought this approach to the forefront of the policy arena in recent years. Cross-country regressions for 1965–1990 estimate that countries with intensive malaria grew 1.3% less per person per year than nonmalarious countries, even after controlling for factors such as initial poverty, economic policy, tropical location, and life expectancy. A 10% reduction in malaria was associated with 0.3% higher growth. Over 25 years, this can amount to almost half of the per capita gross domestic product (GDP) of poor countries.9
Recent studies to estimate the economic burden of malaria in endemic countries showed that the direct cost of one episode of malaria to a household was US$6.87 in Ghana, US$4.80 in Uganda, and US$4.50 in Mali. In Nigeria, it costs about US$1 to treat malaria by self-medication and about US$10 to treat it by the use of an orthodox health care provider when admission is not involved.
Estimates of the burden of malaria on the overall economies of Ghana, Mali, Nigeria, and Uganda reveal that malaria impedes economic growth in countries ranging from 0.067% in Uganda to as much as 3.8% in Nigeria. The GDP loss caused by malaria in Uganda in 2003 was equivalent to US$11 million, which is a substantive loss to the economy for a country like Uganda. This estimated GDP loss caused by malaria translates into US$0.43 per capita, which is about 5% of health per capita expenditure. The same studies in Ghana, Nigeria, Mali, Uganda, and Guinea found that indirect costs make up more than 70% of household malaria costs. These studies found that sick adults lost 1–7 days per malaria episode, depending on severity. The value of days lost because of malaria is estimated at US$8.92 in Uganda. Monthly household expenditures on malaria prevention ranged from US$0.32 to US$10 in the five countries.
At the household level, a study in Ghana found that costs of malaria consume 34% of the income of poor households, whereas the richer ones spend only 1% of their wealth.
Inequity in access to health services and malaria interventions is a further disadvantage to the poor.10
In Tanzania, malaria is a significant burden on society, both in health and economic terms. Almost 1.1% of Tanzania's GDP, or US$2.2 per capita, is devoted to tackling the disease, whereas 39% of all health expenditures are on malaria. Government facilities devote almost one-third of their resources to the disease. Private expenditures represent 71% of the total expenditures. Individuals allocate, on average, 0.7% of their annual income to preventing and treating the disease. For poorer households, this figure is probably significantly higher.11
The costs of malaria in terms of human capital are enormous. Studies tend to ignore short- and long-run cost implications of a wide spectrum of other morbidities and disabilities associated with malaria, including severe disease, anemia, pregnancy outcomes, and intellectual development.
Malaria takes a particularly high toll in children younger than 5 years and in pregnant women. Although adult women usually have developed immunity in areas of high transmission, they lose it with pregnancy, becoming highly susceptible to infection. Placental infection with malaria has a strong effect on intrauterine nutrition of the fetus. Malaria in pregnancy is associated with low birth weight, which in turn is one of the main causes of infant mortality. Low birth weight has also been associated with diminished intellectual development. Malaria is also a frequent cause of anemia in the mother, an important risk factor in maternal mortality.
A particularly burdensome consequence of chronic malaria is the anemia that directly results from this infection, particularly in children. In adults, such anemia markedly reduces worker productivity. In children, malaria-related anemia may be severe and potentially fatal, often requiring blood transfusions, which in turn may result in iatrogenic transmission of bloodborne diseases. Somewhere between 10% and 15% of overall human immunodeficiency virus infections and as much as 25% of pediatric infections in sub-Saharan Africa result from blood transfusions.12
Malaria probably significantly affects intellectual development through severe anemia, epileptic seizures, and school absenteeism. Variations in reasoning ability, cognitive skill, and years of schooling are considered important determinants of future variations in productivity and earnings of individuals, so the effect is likely to be significant.13 The long-term effects of severe malaria, which affect a proportion of those that survive, have not been well studied.
Poverty as a Cause of Malaria
By exposing people to infection, poverty can be considered a cause of malaria. Poor people live in dwellings prone to mosquito proliferation. It has been shown that the characteristics of wall construction are associated with malaria prevalence.26 Preventive measures such as insecticide-treated bednets are unaffordable to the poorest if they must pay for them.14,15
Household expenditure on malaria includes out-of-pocket expenses in transportation, consultation fees, drugs, and the cost of subsistence at a distant health facility. These costs may be prohibitive to poor families, so they would postpone seeking care in the hope that the sick will get better, or they might give up seeking care altogether. Other strategies to cope when appropriate treatment is unaffordable is to use drugs obtained from friends and neighbors, sharing drugs among siblings that are simultaneously ill, or once the child gets better, save some drug for the next disease episode. This strategy is common among households with many young children: Usually the younger or more seriously ill child is taken to a health facility and the drugs used to treat siblings.7 Not only does this approach affect treatment outcome; it is also a way to favor the emergence of drug resistance.
The poorest people often have limited access to health services, particularly in rural settings. There are financial barriers to access, but also geographical barriers, because they tend to live in remote areas with scant roads. But money and distance are not the only obstacles in accessing prevention and treatment for malaria. Social and cultural marginalization is also a powerful factor in favoring infection and impeding access to health care.16 The implementation of health care models that require patients to pay for services to reduce government expenditures also affects access to health care. The imposition of user fees for health services has limited access for the poorest people.
Poverty is often behind migration from rural to urban areas. Rapid and unplanned urban growth in tropical areas creates suitable conditions for malaria transmission, mainly at the periphery of towns and cities. People who migrate from rural areas generally settle in poorly constructed houses in densely populated and underdeveloped periurban areas and bring along their traditional rural practices that may favor mosquito breeding.27,28
Poverty pushes people every day to forests and jungles where malaria vectors are abundant to make a living in agriculture, road construction, timbering, and gem mining. For instance, colonization projects in the Brazilian Amazon have drawn nonimmune people into the region for agricultural settlement, resulting in a proliferation of the malaria vector in artificial habitats. The situation is made worse by poor shelter, logistical problems for disease control, high population mobility, lack of knowledge of the disease and poverty of the new settlers, providing favorable conditions for explosive epidemics.29 Poor nutritional status is often a contributing factor in making these epidemics more severe.
Malaria as a Cause of Poverty
In many areas of rural Africa, where most people are engaged in subsistence agriculture, time lost to work because of malaria can mean less food for consumption. In general, seasons of high transmission coincide with those of planting or harvesting; a brief period of illness can have enormous consequences for the economy and nutritional status of households and communities.17 Protein-energy malnutrition, in turn, is associated with greater malaria morbidity and mortality.18
There is evidence that the perceived risk of malaria can determine crop choices, favoring less labor-intensive crops instead of more profitable ones, as a coping mechanism in case of labor shortage caused by malaria.19
Malaria's effect on households has usually been measured on a short-term basis, but it is likely to affect poverty and vulnerability at the household level over time.
Many studies fail to take into account the ways in which households and businesses adapt their productive activities or cope in response to the malaria disease burden. In a study in rural Kenya, the most commonly used strategy was intrahousehold labor substitution in response to lost work time of household members. Households most often coped with direct costs by mobilizing cash reserves and savings, selling livestock, or receiving gifts from other households. These strategies can have negative implications, influencing household ability to withstand other contingencies in the future.7
The risk of malaria may have a pervasive effect on economic incentives, behavior, and strategies. Some of the costs deriving from the ubiquitous nature of malaria is to be reduced or eventually eliminated: Housing conditions that expose more than protect, warfare that displace millions and destroy scant infrastructure, unhealthy working conditions and poverty that makes prevention measures and appropriate health care unaffordable for people and nations. In such a situation, the very existence of malaria in a community imposes a cost on the entire community by modifying social and economic decisions taken in response to the perceived risk of infection. It has been widely observed in the descriptive literature that decision making in such diverse areas as crop choice, trade, investment, and fertility is affected by the risk of acquiring malaria, with a potentially sizeable negative effect on economic productivity and growth. Standard household-based studies naturally fail to capture these effects. One example of such a cost is the effect that fear of malaria may have on discouraging foreign trade and investment. In a rapidly globalizing economy, malaria's burden can turn heavier than ever, leaving Africa yet more isolated and impoverished.
Cost of Controlling Malaria
After decades of almost null multilateral funding for malaria control, by the early 1990s the global resurgence of malaria was a reality that could no longer be ignored. In 1992 the Ministerial Conference on Malaria brought together ministers of health from 102 countries who endorsed a Global Malaria Control Strategy based on the following:
- • Provision of early diagnosis and prompt treatment
- • Selective and sustainable use of preventive measures, including vector control
- • Prevention, early detection, and containment of epidemics
- • Strengthening local abilities and applied research
These principles were integrated into the Roll Back Malaria (RBM) program, proposed in 1998 by the incoming WHO director general and sponsored by UNICEF, the United Nations Development Programme, and the World Bank. RBM has promoted the deployment of an integrated package of effective malaria control interventions, tailored to the local context, along with effective program monitoring and evaluation.
Strong political commitment converged in the African Summit on the RBM initiative, held in Abuja, Nigeria, in 2000. Participating countries committed to provide access to effective and affordable treatment within 8 h of the onset of symptoms for at least 60% of those suffering from malaria. In the area of prevention, a target was set to achieve at least 60% coverage of those at risk of malaria. In 2006, African Union governments renewed their commitment to the goals adopted in 2000, calling for accelerated action toward universal access to human immunodeficiency virus/AIDS, tuberculosis, and malaria services. It was recognized that sustainable and predictable financing needs the mobilization of local resources, including the implementation of the Abuja Declaration call for the allocation of 15% of the national budget to health. Malaria programs also are to be integrated into poverty reduction strategies.20
The Global Fund to fight AIDS, Tuberculosis, and Malaria, created by United Nations Secretary-General Kofi Annan in 2002, has been a major source of funding for national malaria control programs. In Round 7 of the Global Fund in 2007, US$471 million was approved for 28 malaria control programs in 27 countries. This is a remarkable increase from the first round in 2002, where US$68 million was approved for malaria programs in 12 countries.
International funding for malaria control has increased in recent years, with estimated annual contributions from development agencies rising to US$600 million in 2005 from less than US$50 million in 2000. In 2005, estimated disbursements for malaria from bilateral donors, WHO, and the Global Fund were approximately US$841 million. New major funding initiatives launched by the World Bank and the United States of America in 2005 suggest that resources for malaria control will continue to increase. However, current international funding from malaria control represents only a fraction of the estimated total needs for gradual scale-up.21
My group estimated the financial resources needed for scaling up malaria control in Africa. A costing exercise based on the United Nations Millennium Project puts the cost of scale-up in US$1.3 billion per year in the next 5 years.24 A different calculation sets the average costs for Africa at US$1.7 billion and US$2.2 billion per year in the optimistic and pessimistic scenarios, respectively; outside Africa, the corresponding costs are US$2.1 billion and US$2.4 billion.21
Aside from the magnitude, the continuity of funding is also of concern. A total of US$38 billion to $45 billion will be required from 2006 to 2015. In most places, high levels of coverage and particularly preventive interventions will need to be maintained beyond 2015.
There are now many examples of successful scale-up of malaria control programs around the world, including African countries that pose particular challenges owing to the intensity of transmission. A common feature of these programs is sufficient and flexible financing.22,23
In the long term, the social and economic conditions that fuel malaria transmission need to be addressed if malaria is to be reduced or even eliminated: housing conditions that expose people to infection, labor conditions that put workers at risk, warfare that dispossess and displaces millions of people while disrupting precarious health services, and poverty that prevents individuals and nations from adopting and sustaining appropriate preventive measures and delivering appropriate health care for the sick.
Conflicts of Interest
The author declares no conflicts of interest.