Gokwe malaria project
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| GOKWE MALARIA PROJECT
Three Month Report Feasibility Study Of The Introduction Of Malaria Control And Prevention Commodities Into The Rural Areas Of Zimbabwe And Its Impact On Malaria Sponsored By Peter Carroll (EMNET (Pvt) Ltd - Harare, ZIMBABWE) Implemented By Tim Freeman (Ex - Blair Research Institute) November 1993 GOKWE MALARIA PROJECT Three Month Report INDEX Index...................................................... 1 Introduction............................................... 2 Objectives................................................. 4 Project Methodology........................................ 4 Background Information..................................... 6 Report On Weekly Activities................................ 8 Results.................................................... 12 Pricing Structure.......................................... 14 Observations............................................... 15 Comments On Commodities.................................... 17 Mosquito Nets....................... 17 Repellents.......................... 18 Residual Insecticides............... 19 Larvicides.......................... 19 Conclusions................................................ 20 Appendix 1 - Malaria Statistics For Gokwe.................. 21 Appendix 2 - Analysis Of Malarial Areas Of Gokwe........... 22 GOKWE MALARIA PROJECT Feasibility Study Of The Introduction Of Malaria Control And Prevention Commodities Into The Rural Areas Of Zimbabwe And Its Impact On Malaria Sponsored By - Peter Carroll (EMNET (Pvt) Ltd - Harare, ZIMBABWE) Implemented By - Tim Freeman (Ex - Blair Research Institute) Introduction The Ministry of Health of Zimbabwe as part of its National Malaria Control Campaign has a health education campaign which promotes the use of various malaria prevention methods. Work done by Tim Freeman over the last two years in Gokwe of Midlands Province suggests that despite this malaria health education most people living in rural areas remain largely ignorant of the disease and consequently few people practice any form of malaria prevention, even in areas in which malaria morbidity is very high. The second confounding factor is that even if the health education of malaria were reaching the remoter parts of the country, items being promoted such as mosquito nets and repellents are largely absent from rural areas, and where found, are sold at prohibitive prices due to high profit margins sort by many rural traders. A project done earlier in 1993 in Gokwe by Freeman suggests that once people were given health education about malaria, they would purchase anti-malaria products where they were available at a reasonable price. The project even appeared to show a localised reduction of malaria where this occurred. The situation has been exacerbated by the lack of mosquito nets suitable for people sleeping on floors, and the lack of knowledge about repellents. Emnet (Pvt) Ltd, Zimbabwe's leading manufacturer of mosquito nets, recently designed a new mosquito net for people sleeping on floors. The net needed to be evaluated for acceptance by the rural community with a view to expanding into a huge untapped market. For any anti-malaria product to be successfully marketed in the rural areas it was felt that they must be sold at an attractive and affordable price, while at the same time being profitable. To do this, alternative supply routes for the products needed to be found, which basically by-passed rural traders, but maintained extremely good credit control. Emnet and Freeman have recently come together in a joint project which is both a malaria control sustainability project and a marketing feasibility study. While Emnet is a manufacturer of mosquito nets, the study includes all antimalarial commodities from mosquito nets and repellents to insecticides for residual applications and larvicides and includes the promotion of both environmental and behavioral control. The project will evaluate whether it is possible to get anti-malaria products into the rural areas at a price which is affordable but also sustainable from a business point of view. At the same time the project will evaluate whether the activities of the project are having an impact on malaria by carrying out a health impact study on malaria. If it is possible to get the anti-malaria products into the rural areas on a profitable basis and have an impact on malaria, then a sustainable form of malaria control will have been achieved. The project is being carried out in Gokwe District of Midlands Province which is probably the worst malarial area in the country. While Gokwe has the climatological and geographical conditions eminently suitable for malaria transmission, it is felt that much of the malaria in the district is unnecessary and could be greatly curbed by individuals taking simple precautions in both behaviour and the use of simple anti-malaria measures such as mosquito nets, repellents and environmental precautions. To date, thirty two outlets of anti-malaria products have been recruited into the project in Gokwe. Each outlet is given a consignment of stock and sells on commission. Eleven of these outlets are mission hospitals and clinics, seventeen are council clinics belonging the Gokwe North and Gokwe South Rural Council, and four are private individuals including one shop keeper who have shown an interest in promoting malaria health education. The first recruited outlet of Sassame Mission has sold over 100 mosquito nets in nine weeks, 50% of the nets being sold to rural householders, the main target group of this project. Despite only a few outlets having being established for more than six weeks, about 600 mosquito nets and 500 repellents have been purchased to date, despite there being no real malaria or mosquito incidence, and the drawback that most rural farmers had not received their Cotton Marketing Board cheques until only a few weeks ago. It would appear that there is a huge potential market for anti-malaria products in the Gokwe rural area. However, the main logistical problem is getting to the people who wish to have the products at a time when they have money in their pockets. While all anti-malaria precautions have been promoted with no special attention to mosquito nets, mosquito nets have attracted the most interest and sales, despite having the highest price tag! The main restricting factor to the whole project is lack of funds and suitable equipment. The project sustains itself on the sale of stocks of mosquito nets. The vehicle in use is a two wheel drive pick up which is not really suitable for Gokwe roads, and totally unsuitable for the rainy season. The project is unlikely to become sustainable financially for at least six months, and only then if cutbacks are made in both transport and time spent in the field. These cutbacks could also jeopardise the project where sustained health education also sustains the sale of the products. Objectives 1) Evaluate the feasibility of getting anti-malaria products into the rural areas at a price which is affordable to rural people yet profitable. 2) Evaluate the impact on malaria where both health education and anti-malaria products are promoted and available at the same time. Project Methodology Two major problems faced the project. 1) It was felt unlikely that any local traders would commit any sizable resources to the promotion of health products which are not normally sold in the rural areas, and if they did would likely to charge exorbitant prices due to high profit margins. Both of these assumptions appeared to have held true over the last three months. 2) The alternative was to sell products on commission, i.e give out consignments and be paid as products were sold. This of course is fraught with difficulties. Even though people may be basically honest, many things can occur which means that payment does not occur. To overcome both problems, it was decided that the Mission Hospitals and Clinics were probably the only credit worthy institutions in the rural areas. While some of these institutions are under financed, it was felt that it would be unlikely that they would in any way be dishonest in any transaction. More importantly, as the products are health related, and malaria is a big problem in Gokwe, it was felt that the missions might appreciate the importance of the project, even though the selling of products in many cases is a new idea. In terms of selling health related products, clinics would be the most powerful selling medium possible. This rational has worked well, and all missions have agreed to take part in the project, apart from one mission outside the Gokwe District in Kwekwe, where the administrator had just died. However, Gokwe is a huge district of 18 140 km2, and contains only nine mission health centres in the whole district. The project wished to make these products accessible to even the remotest parts of the district, so alternative supply routes had to be found. When Freeman had originally carried out his health education project in Chireya is was with the idea of health centres selling anti-malaria products in the same way in which pharmacists sell drugs. However, he had been told that in terms of government institutions this was impossible. However, into the first week of the project it was realised that nearly 50% of the health centres in Gokwe were administered by Gokwe (now Gokwe North & Gokwe South) Rural Council. The council was approached and explained the project and immediately showed an interest to participate in the exercise. Nevertheless, even with all the mission and council clinics selling nets, there were still some pockets of Gokwe which are fairly inaccessible to these clinics, and in some of these areas private individuals have been recruited into the exercise. All these individuals have been known to Freeman for a period of over six months. As the project goes on, and different people are known better, this line of approach may be expanded. However, at the early stages of the project, while not being given commodities on consignment, it was hoped that shop-keepers would be willing to participate. As it would be logistically difficult and expensive to supply shops from Gokwe, it was hoped that the missions might be used as store houses, which would supply shops at a lower price than the general public, allowing shop keepers to make a small profit, but having to keep their profit margins down in order to compete with mission sales. With this in mind, a three tier pricing structure was set up, the lowest for the missions, next the shops and lastly for the general public. The idea was that the missions would get a small mark up for administrative costs by supplying to the shops, and a greater mark up for supplying to the public. It was expected/hoped that the missions would use the mark up to employ persons to go into the villages to carry out health education and be paid by getting commission on everything they sold. Lastly, if the missions did make a profit at the end of the day, then it was expected that this would be put into other development projects. However, despite the possible restraints of using shop keepers, an evaluation exercise was made of the feasibility of supplying shops directly where missions do not occur. While the project carried all products to do with malaria control, the majority of the missions felt that the nets and repellents would suffice for their purposes. Therefore, most missions have been supplied with the 'Rukukwe' mosquito nets and 'Mosbar' repellent, and recently the repellent vaseline. Where interest has been shown in other products, these have been supplied to the missions, or else the project team has dealt directly with the individuals showing interest. Since the project has to be same sustaining in terms of finances, other pest control products have been carried, including fly traps, rat poison (which has proved very popular) and spray pumps. Lastly, a small project evaluation in terms of health impact was negotiated with Midlands Provincial Directorate and Gokwe District Health Authorities. This has been agreed to, and is now starting at Sassame Mission where there is a full time microscopist. The area around Sassame Mission has been divided into control and intervention areas. The intervention areas are those in which intensive health education takes place, especially those individuals presenting themselves with malaria at the clinic. Special emphasis is being placed on the need of these cases to protect themselves from mosquito bites as they might be acting as a reservoir of infection for a period of up to two months. It is hoped that the results gained from Chireya earlier in the year can be replicated, and that a reduction in malaria incidence can be shown in the intervention areas. Background Information Gokwe District north of the escarpment is probably the worst malaria area in Zimbabwe except for possibly parts of Binga District in Matebeleland North Province. In the 1992/1993 malaria season at least 157 people died of the disease (Appendix 1) with 90 000 clinical cases of malaria officially reported by the Ministry of Health. Actual malaria cases may be much higher because of treatment by Village Community Workers (VCW) who are supplied chloroquine by the Ministry of Health and self treatment by individuals who can buy chloroquine tablets from most shops in the district. While these figures are for clinical malaria, many clinics taking slides during March, April and May of 1993 recorded positivity rates of 90% and over. Census figures of 1993 suggest that the population of Gokwe is in the region of 360 000 people which means that possibly up to 25% of the population of Gokwe suffered from malaria in the 1992/1993 season. The reason for the high figures of malaria is twofold. Firstly much of the district lies below 900 metres where malaria transmission is considered capable of existing for much of the year and secondly the abundance of water in the district which allows the mosquito vector to survive during the otherwise dry season and from which both parasite and mosquito can spread with the following rainy season (Appendix 2). Another little considered factor leading to high malaria figures in the District is that of ignorance. Considering that this is one of the worst affected malaria areas in the country, the population as a whole remain largely ignorant of the disease, leading to little being carried out in the way preventative measures. While the Ministry of Health promotes the use of mosquito nets and repellents, none of these commodities are readily available in the rural areas, and up to three months ago there was no mosquito net on the market which was suitable for people sleeping on the floor which is the sleeping habit of most people in the district. With repellents the story is a little different. Most people believe that repellents are mosquito coils only used in the house and the concept of being able to rub something onto the skin which is able to prevent mosquito bites is generally unknown. Similarly, activities such as environmental control are not carried out, and ironically, it appears that general health education in the district which encourages people to dig holes to get rid of refuse actually increases the sites in which mosquitoes breed, though these are largely culicine mosquito breeding sites. Work done earlier in the year by Tim Freeman in Chireya, Gokwe suggested that where health education of malaria was carried out, and commodities made available, people responded positively and bought the products. Health education in this case was carried out generally and targeted at malaria cases presenting themselves at the local clinic. Where this was done there was an apparent reduction of malaria in the area in which the health education was carried out. It is thought that potential malaria carriers took anti-mosquito methods thus reducing possible source of infection to vector mosquitoes and thus the community. At another centre, Sassame Baptist Mission, Gokwe, mosquito nets were put on offer for sale, and 60 nets were sold with very little promotion over a period of about two months. This was considered a remarkable achievement, since the area was suffering from the effects of drought from the previous year, and money was considered extremely scarce. The nets had been supplied on a consignment basis by Emnet (Pvt) Ltd and had been sold with a 5% mark-up to cover administrative costs. Emnet are the biggest manufacturer of mosquito nets in Zimbabwe. Nevertheless, their yearly output of mosquito nets to the Zimbabwean market amounts to about 20 000 nets a year for a population of nearly ten million people, which reflects a very small usage of mosquito nets in the country as a whole. This situation is reflected in Gokwe where yearly sales of mosquito nets total about 600 nets a year for a population of 360 000. Recently Emnet has designed a new mosquito net for people sleeping on the floor aptly named the 'Rukukwe' which is the Shona word for a sleeping mat. Emnet wishes to promote its net into the areas in which people sleep on the floor and increase it future sales. Emnet and Freeman decided to come together to carry out a joint exercise which encompassed both a business and malaria study. The project agreed upon would not only assess the feasibility of getting anti-malaria products into the rural area on a profitable basis, but also whether the presence of these products would actually have an impact on malaria, and would act as a follow up to the work already done in Chireya. While Emnet obviously wished to increase their mosquito net sales, it was decided that the exercise should include all anti-malaria products. As the exercise had to run on a very tight budget, various other companies were approached who manufacture or supply other anti-malaria products. Commodities were negotiated on a consignment basis with a two month credit extension to aid the initial funding of the project. These companies include 1) Lancaster Industrials who manufacture Mosbar, a repellent soap containing DEET and permethrin, and considered to be the most cost effective repellent on the Zimbabwean market. 2) Ecomark who supply deltamethrin marketed as Cislin 2.5% S.C and Crackdown 1.0% S.C. and Coopex larvicide which is 2% permethrin. 3) Shell Chemicals who supply Tabard (a roll on perfumed repellent containing DEET), alphacypermethrin marketed as Fendona 6% S.C., and Malariol larvicide which is a mixture of various oils. 4) Lever Brothers who have only very recently started manufacturing a repellent vaseline which contains both DEET and dimethylphalate. It was decided not to offer mosquito coils for sale as these are all readily available in rural areas and are not considered either cost effective or useful as they are only useful while in confined quarters. Other repellents available in Zimbabwe were also rejected either on a cost basis, not containing DEET or because of poor packaging leading to leakage etc. It was hoped also to sell prophylactics, but Zimbabwean law prohibits the sale of prophylactics except by pharmacists. To promote all anti-malaria products a brief malaria information sheet was produced in English, Shona and Ndebele which has been stencilled and duplicated (Appendix 3). Due to lack of finances this information sheet is not very attractive, but luckily, the Mission Malaria Campaign being carried out by CAPS to promote the use of its drugs has offered to reproduce the sheet in a more presentable format and make a thousand copies. Lastly, to help the project pay for itself, other commodities of a pest control nature have been taken which include insecticide sprayers, chemicals for other household pests, poison baits for rats and an environmentally friendly fly trap. The decision to carry out the study in Gokwe was threefold. 1) The area was well known to Freeman. 2) It is a very bad malaria area. 3) The area is relatively wealthy due to cotton production by rural farmers. If the study fails here it is unlikely to succeed elsewhere. In order to carry out a health impact study, the Provincial and District Health Authorities of the Ministry of Health were approached for approval and possible assistance. The main restricting factor to the whole project is finance. Emnet is cash strapped after investing in a lot of stock for the forthcoming rainy season when mosquito net sales are at their peak. The project needs at all times to be self financing, and pays for itself through the sales accrued. However, it is most unlikely that the project will realise any profits for at least a period of six months, if at all. The project must be regarded as a long term investment not only in mosquito nets sales, but also in the fight against malaria. Report Of Weekly Activities Weeks 1 & 2 - 2/8/93 - 13/8/93 Harare - This time was spent negotiating consignments with various companies and writing up health education material. Week 2 was broken up because 11th and 12th were Hero's Day and Defence Forces Day, both public holidays. Week 3 - 16/8/93 - 20/8/93 Gokwe - Initial contacts made with Sassame, Chireya, Mtora and Sanyati Missions. Only Sassame Mission agreed to start exercise immediately, and employed a person to sell the malaria products on a commission basis. During this time the idea of using other non-governmental health institutions came to mind so initial contacts made with Gokwe Council who have seventeen clinics in Gokwe. Contacts also made with shop keepers in Nemangwe, Chireya, Gokwe and Mtora areas. This involved shop to shop visits handing out health information sheets and explaining the use of products. At the end of the week someone was employed to move house to house for the following week in the Chireya region around certain villages giving health information and informing people about a mini market to be held in two weeks time. 1386 kilometres covered. Week 4 - 23/8/93 - 27/8/93 Harare - Week spent in further negotiations with companies for consignments. Health information printed and CAPS Ltd (Mission Malaria) showing interest in supporting the health education aspect. other team member in Gokwe doing house to house promotions. Week 5 - 30/8/93 - 3/9/93 Gokwe - Held three meetings/markets in villages of the Chireya area. All villagers showed great interest in the products but stated that they had no money to buy anything because their cotton marketing board checks had not come in. Chireya, Mtora and Sanyati Missions agree to take consignments of nets and repellents. Shops revisited from week 3 with very disappointing results. Despite promises of purchases, very little realised. Gokwe Council agree in principal to sell nets through clinics - final agreements to be left to the following week. First private individual to be recruited to promote and sell anti malaria products. 1395 kilometres covered. Week 6 - 6/9/93 - 10/9/93 Gokwe - Chidamoyo Mission in Mashonaland West which has many patients from Gokwe agrees to take a consignment of nets - already they were promoting the use of Mosbar as a repellent. Kana Mission in the south of Gokwe agrees to take a consignment of products. Final agreements are drawn up with Gokwe Council for six clinics in Gokwe South to sell nets and repellents on a trial basis. Shops were visited in the south of Gokwe with a greater response than those of northern Gokwe. The Ministry of Education in Gokwe is approached to help publicise project amongst schools - great enthusiasm from the education officers and one or two teachers had died of malaria this year. Zhombe Mission in Kwekwe District visited, but they turned down the offer to sell nets, citing bad crops and unlikely response from local community. 1378 kilometres covered. Week 7 - 13/9/93 - 17/9/93 Harare - Car in for service. Paperwork done, further negotiations with various companies. Consignments of nets and repellents sent to Gokwe Council. Week 8 - 20/9/93 - 24/9/93 Gokwe - Take part in Gokwe District malaria control planning meeting as an observer and malaria expert. Project explained to Gokwe Health Teams. Hold further meetings with education officers about distributing information to schools. Sanyati Mission agrees to distribute nets through its clinics in Gokwe, i.e Nyenyunga, Manyoni, Mutanke, Goredema and Denda. Larvicide trial carried out at Mutimutema with Malariol. Visit several schools and talk to teachers. 1357 kilometres covered. Week 9 - 27/9/93 - 1/10/93 Gokwe - Address headmasters meeting in Gokwe. Visit Kana Mission and some schools and shops in the south of Gokwe. Discover that council clinics have not yet received their mosquito nets. Return home through Omay visiting the north west of Gokwe and finally Chidamoyo Mission on follow up. 1485 kilometres covered. Week 10 - 4/10/93 - 8/10/93 Harare - Car repairs and paperwork. Week 11 - 11/10/93 - 15/10/93 Gokwe - Left notices of product range and prices in shops in southern Gokwe. Delivered mosquito nets to three council clinics of Nyamunga, Sai and Gawa. Visit Vumba Primary School at invitation of head master, where all teachers purchase mosquito nets. Vumba is situated at the northern end of Chirisa Game Park near Simuchembu - the area is cut off completely during the rainy season to buses - teachers must walk twenty kilometres to reach the nearest point at which buses can be caught. Other schools visited in the Nemangwe and Chireya areas. 1405 kilometres covered. Week 12 - 18/10/93 - 22/10/93 Gokwe - Start negotiations with Gokwe North District Council after realising that previous negotiations were with Gokwe South District Council only. Deliver nets to a further two council clinics of Musala and Jiri. Visit Chireya, Mtora and Sanyati Missions on follow up visits. Offered consignment to the only business so far in Chireya who was known for a long time and willing to sell at stipulated price. 1560 kilometres covered. Week 13 - 25/10/93 - 29/10/93 Gokwe - Address two groups of Gokwe headmasters in Gumunyu and Gokwe. Visits shops to which product range and prices had been given two weeks earlier - very poor response from shop keepers. Visit schools in the Nemangwe and Chireya areas again. Negotiate with some Gokwe businessmen about the possibility of having a anti-malaria promotion scheme from their shops. 1514 kilometres covered. Week 14 Gokwe - Address all Gokwe South Councillors about project in their clinics. Deliver nets to a further three council clinics of Gokwe South, Tongwe, Mangidhi and Musita. Gokwe North Council agrees to repeat exercise from the five clinics in Gokwe North. Visit two clinics from Sanyati Hospital on follow up - Mutanke and Goredema. 1062 kilometres covered. Results From a business point of view the success of the project depends on the number of sales and hence profitability. The performance of the various outlets is as follows. 1. Health Facilities All non-governmental clinics in Gokwe are or will be within two weeks selling mosquito nets and repellents. Also two missions in Mashonaland West - Sanyati and Chidamoyo who both receive substantial number of patients from Gokwe District. Operating Approx No Approx No Health Facility Time Of Nets Of Repellents (Weeks) Sold Sold MISSION
Sassame 10 116 109 Chireya 8 23 0 Mtora 8 20 35 Sanyati 8 52 0 Chidamoyo 7 36+ ND Kana 7 35 2 Nyenyunga 6 ND ND Denda 6 3 ND Goredema 6 1 ND Mutanke 6 10 2 Manyoni 6 10+ 0
Manoti 4 20+ ND Chemahororo 4 ND ND Masuka 4 14 ND Nyamunga 3 ND ND Sai 3 3 ND Gawa 3 ND ND Musala 2 ND ND Jiri 2 ND ND Tongwe 1 ND ND Mangidhi 1 ND ND Musita 1 ND ND Krima 0 NA NA
Zhombe 0 NA NA Gumunyu 0 NA NA Mashame 0 NA NA Kuwirirana 0 NA NA Kahobo 0 NA NA Apart from the mission hospitals where the hospital staff buy nets, sales to the public in the first month are generally very low. If the health centre has done some publicity as at Sassame, then sales have increased drastically in the second month. The level of sales is greatly increased where a person is employed to carry out health education and sell products on commission. This is the case at Sassame, and other missions are being encouraged to follow this idea. Gokwe Council has decided to make a ten percent mark-up for commissioned sales, 7% goes to the council and 3% to the clinic staff who are making the sales. 2. Private Individuals In the Nemangwe and Chireya area four private individuals including one shop keeper are also promoting and selling the mosquito nets. This type of exercise is being limited to the Nemangwe and Chireya areas as these areas have been worked in before by Freeman and the individuals have been known for a long time and are known to be trust-worthy. These individuals are selling on a commission basis. While it might be argued that they may not do much in the way of health education, the products themselves lend themselves to health promotion whether it is being emphasised or not. The use of private individuals may be expanded as people become known in other areas. These individuals have only been operating for about five weeks and have sold something in the region of about fifty mosquito nets. 3. Shop Keepers While it would have been good public relations to give nets on consignment to shops, this idea has been basically rejected because while some of the shop keepers are very honest, many are impoverished and it would be difficult to decide which shop keepers would be credit worthy and which are not. Only one exception has been made in Chireya where the shop keeper has been known for eight months and has always kept his promises in the past. Therefore shops have been offered products at very competitive wholesale rates. However, to date shop keepers have been found to be very unreliable in their promises to purchase items, and this was clearly demonstrated in an exercise carried out in weeks eleven and thirteen, where thirty one shops had been given notice in writing about the product range, prices and time of visit by the team. From the thirty one shops was purchased a total of $280 worth of items, most of this being the new repellent vaseline, with not one Mosbar or mosquito net purchased. It was decided at this point that the logistics of using shops keepers was not sustainable in the least, and should be abandoned unless actually approached by a shop keeper. However, the exercise has not been entirely wasted, as many of the shop keepers are now known, and some of these may be offered consignments in the future if the use of private individuals in Nemangwe and Chireya proves worthwhile. However, it must be said that much time has been spent talking health education to shop keepers, and the general response has been apathy. More concern has been whether they can sell the products at high profit margins. This is best demonstrated by one shop keeper in the Kahobo area who bought a net for $65 and is trying to sell it at $130. For the rest of the shop keepers, the few who have bought nets, seem to have used them for their own purposes, as few have been seen on the shelves of the shops. One or two shop keepers have bought Mosbar for re-sale, and many have purchased the new repellent vaseline. The vaseline is already available in the wholesalers, so their is little point in visiting shops to simply supply vaseline. Two large shops owned by indian traders were the only ones purchasing Tabard while refusing the cheaper repellents. Pricing Structure Originally it was hoped that once a mission or other outlet got going it would be able to deal directly with Harare, i.e once a month they would send a cheque to Harare, and new consignments sent by carrier to Gokwe to be picked up by the mission. However, the setting up of missions has proved much more difficult than originally realised with numerous teething problems which has necessitated much more travel than originally anticipated. The same applies to the council. While Gokwe South Council received the nets in week seven, due to transport problems none of these products had actually got to any clinic by week 9, and due to communication problems (i.e some clinics are very remote with no telephones), many of the clinics had even heard of the programme by week 12. It was therefore decided to aid the programme and get it going by making the first delivery to all the clinics concerned, thereafter the clinic staff would pick up further nets as required when they came into Gokwe. What this all meant was extra expenses which had not been originally anticipated. At the start of the project it was decided that the price of the 'Rukukwe' net to the end user should be kept at no more than eighty dollars, and therefore with a three tier pricing structure, the price to the missions was extremely low, with a maximum mark-up of two dollars a net. With all the travelling, this price was not sustainable by any means, unless huge quantities of nets were purchased. Gokwe Council on receiving their nets did something quite unexpected. They ignored the suggested pricing structure, and decided to sell the nets with only a ten percent mark-up, which in fact was the ethical thing to do. However, this meant that the council clinics were selling nets below the price of anyone else, and at about the same price that was being offered to shop keepers by the project. Since shop-keepers seemed reluctant to buy the nets, and since Gokwe Council had taken the moral lead in terms of pricing structure, it was felt that the pricing structure should revert to a two tier pricing structure, and the nets should be sold to the shops, missions or councils at the same price, without affecting the end user price by too much, but at the same time increasing the base price so that the project might have more chance of becoming sustainable, rather than be closed down due to lack of finance. The other factor which has been done is too increase the profit margins on the double nets which wealthier people tend to buy, while keeping the profit margins on the 'Rukukwe' lower for the lower income groups who would be attracted to the 'Rukukwe'. For the 'Rukukwe' the price structure before and after is as follows. Factory Price Missions/Council Shop End User Before $62.50 $65.00 $70.00 $78.50 After $63.50 $72.00 $72.00 $82.00 NB The difference in the factory prices quoted, is that sales tax needs to be paid on the price at which the net is sold. The new pricing structure should remain in price for at least the next four months. Already the work of changing the prices has proved very time consuming as the stock is out on consignment, and making price changes when stock is not actually in ones hand difficult. Some people may argue that the profit margins given to the missions and the council are still unnecessarily high. However, it is the strong belief of the project that the money must be used for the promotion of the nets and for the extra time that mission staff must spend on the project. At Sassame Mission, where a person has been employed purely on a commission basis to promote health education, mosquito nets and repellents have been sold extremely quickly. However, it must be noted that for this project to be sustainable even with the new price structure, at least 1200 nets must be sold a month to keep up with present expenditure. The objective of the project is therefore to sell at least 1200 mosquito nets a month. Observations It has been very gratifying to note that throughout the duration of the time spent in Gokwe the project has been greeted with great enthusiasm by all sectors of the community. Most individuals realise that malaria is a serious problem and welcome any initiative that may help combat the disease. While provincial staff of the Ministry of Health has shied away from giving any formal approval to the project, all health staff in the province and district have been helpful and encouraging. While the majority of people initially buying the nets have been professional people such as nurses and teachers, it is very encouraging to note that at Sassame Mission where clear records are being kept that out of the 116 people buying mosquito nets, at least 50 of these were villagers, who are the real target group of this exercise. Mosquito net sales were very low at the beginning of the project. This was due to the lateness of the arrival of the Cotton Marketing Board cheques. It is believed to date that at least 25% of these cheques have still to be paid out, and it is only when this is done that the project can make a real evaluation of the acceptability of the products on offer. The first six weeks of the project were basically dealing with people who had no money at all due to the drought of 1992. Even though this project is being supported by a company who manufactures mosquito net, no special emphasis has been made on mosquito nets. Where possible, a balanced approach has been given to all aspects of malaria control from the taking of prophylactics, to avoidance of mosquito bites by repellents and avoidance of breeding sites after dark, the use of residual insecticides, larviciding and environmental control. Despite this approach, for the first two months, mosquito nets have been the most sought after commodity on offer. It is thought that the reason for this is because a mosquito net is a barrier and it is easy to visualise its effectiveness. It is also believed that utmost in peoples mind is not malaria at all but rather a good nights sleep. The only product to supersede mosquito nets in popularity is the new vaseline repellent. Vaseline is in common usage in the area, and the benefits of repelling mosquito bites have been quickly visualised. School teachers in particular have shown a great interest in buying mosquito nets. At at least three schools every teacher has bought a net. There are 3000 teachers in Gokwe in about 200 schools. However, the logistics of actually getting to these schools (many are in very remote places) when they actually have money in their pockets has proved a logistical nightmare. However the problem is being worked on with the assistance of Education Officers in Gokwe. Each school has been distributed health information sheets and price lists. Special offers have been made to schools which purchase more than ten mosquito nets in order to encourage group participation. If they wish to take up the offer they are then asked to inform their local education officer. The response of this exercise will only be realised at the end of November. Another method for schools being considered is Mail Order. Comments On The Commodities An overall comment which is worth noting. The mere presence of mosquito nets and repellents has acted as a focus of health education on malaria. The fact that they are present has lead to debate on why they should be used, and consequently to malaria prevention. Mosquito Nets The Rukukwe mosquito net has proved extremely popular in terms of the perceived quality and price. While it has been aimed at people sleeping on the floor, many people using beds have purchased it because of its low price especially when they realise that it is actually large enough to fit over a double bed. A few people, namely professional people such as teachers and health workers have often bought the much more expensive double nets citing that they don't wish to purchase a net aimed for use with sleeping mats, even though they can see that there is nothing essentially different about the net. It was hoped to have impregnated mosquito nets for sale. This has proved impossible because not one single insecticide in the country is registered for this purpose. To get round this problem, deltamethrin and alphacypermethrin marketed as Crackdown 1% S.C and Fendona 6% S.C respectively have been offered for sale along side the nets. The only problem is that both these chemicals come in quantities that are able to impregnate several nets at one time (Crackdown in 200 ml bottles - able to impregnate 13 nets at a time and Fendona in 500 ml bottles able to impregnate 100 nets at a time). While a few bottles of both Crackdown and Fendona have been purchased, mainly to rid dwellings of cockroaches, and may be used incidentally on mosquito nets there has been little interest shown in the use of the impregnated net concept. However, to promote the use of impregnated mosquito nets, nets have been offered at a lower price to groups wishing to buy in large orders. Where this happens, they have been encouraged to buy the insecticide as well. Several schools have purchased over ten nets at a time, and though offers were made to show them how to impregnate the nets if they purchased the insecticide, none of the schools have taken up the offer, even though there would not have been any insecticide left over. The only real complaint that has been mentioned over the use of mosquito nets is that they make the user hotter than usual due to reduced ventilation. Where this complaint has been made, the concept of eave curtains has been mentioned. But experiences from Chireya earlier in the year, showed that most people preferred the idea of a mosquito net to that of an eave curtain. The main problem with selling mosquito nets that this project overcomes, is that it appears that mosquito nets are subject t 'impulse' buying rather than planned purchase; i.e people in the rural areas would rarely go shopping in towns with the purpose of buying a mosquito net in mind, and should they see mosquito nets it is unlikely that they would purchase because they would not have budgeted enough money for that purpose. The fact that the nets are now on sale close by means that people do not have to travel far to purchase the nets. Once seen it is not a great distance to return with money to finalise a purchase. Certainly the results seen so far, is that the target group (rural villagers) for the 'Rukukwe' mosquito net is actually buying the nets. While being initially expensive, mosquito nets are probably the cheapest form of malaria control in the long term, as a net if looked after properly can last indefinitely. However, it must be noted, that the general experience of the project so far, that uppermost in people minds when buying mosquito nets is not malaria, but mosquito bites! Repellents Three repellents have been offered for sale, Mosbar (repellent soap), Tabard (a relatively expensive perfumed roll on) and the newly introduced Repellent Vaseline. The main problem with marketing repellents is that most people associate repellents with mosquito coils, and few people have the concept that something can be rubbed into the skin which can deter mosquito bites. However, it is considered to be one of the more powerful anti-malarial tools as it is able to protect people from mosquito bite (albeit not 100% effectively) whether they are in or out doors. Emphasis is being placed on the use of repellents during night time activities such as fetching water, or going to beer halls or churches near water bodies. While Tabard is easily seen to be the nicest of the repellent on offer, few people have bought it due to its higher price. Mosbar sales depend on its promotion. The fact that is looks like soap and is generally called a soap, but is three times more expensive than a normal bar of soap has led to few sales in some centres where the health staff are not fully familiar with its usage. Vaseline however has been quickly accepted by most people. While it is effective, emphasis has been put in the health education of using repellents twice in a night, once before it gets dark, and once before going to bed. While the vaseline seduces peoples minds easily, vaseline is not a product that most people wish to use twice in a night. The other big problem with the vaseline is that when it gets hot it melts and leaks. It is therefore not the kind of repellent that a person is likely to walk around with in their back pocket. Therefore, generally the project is promoting Mosbar as the most cost effective repellent in the range, but it is the most difficult to market. While Tabard needs no water, Mosbar does. Where Repellent Vaseline serves two purposes, Mosbar doesn't, or at least people are persuaded not to use it as soap otherwise it quickly becomes wasted. However, once people realise the benefits of Mosbar, it sells well as seen at Sassame Mission where it was introduced to people at the beginning of the year in another project. Residual Insecticides A few people have bought insecticides, even though the insecticides being sold are comparatively more expensive than those usually found in the rural areas such as malathion and lindane. However, quite a few people have decided to purchase the synthetic pyrethoids, often to kill off cockroaches, but in some cases for mosquitoes. Crackdown (deltamethrin) has sold most, mainly because it is marketed in smaller packages, but where larger applications have been required, Fendona (alphacypermethrin) has been recommended because it is substantially cheaper per metre square. For use with bed nets, Chidamoyo Mission agreed to impregnate the nets of all hospital staff at the mission. The insecticide has been given free of charge by the respective companies. The main purpose of this exercise is to evaluate whether the staff perceive any real difference before and after impregnation. It is felt that if people are unable to actually feel a difference after spraying their nets, it is unlikely that impregnation of mosquito nets will become popular. The results of this exercise have yet to be collected, as Chidamoyo Mission has no telephone and is one of the remotest of the missions in terms of this project. Larvicides Two larvicides are being offered for sale, Malariol, which is a mixture of fuel oils and Coopex which is 2% permethrin. Both larvicides have their drawbacks. Permethrin is environmentally dangerous if used wrongly as it is likely to kill all other aquatic life, and Malariol, while probably environmentally safer is extremely difficult to apply at the recommended dosage rates of 3 litres per hectare with normal spraying equipment. Quite a few rural farmers are now using ULV equipment which might be ideal for Malariol application, but this has still to be verified by the project. For these reasons, environmental methods are usually promoted. However, there are certain situations where these larvicides are being strongly recommended, in particular at certain schools where artesian wells have been dug, and no other viable short term solutions can be seen, though generally the use of fish ponds are being promoted as a long term solution in this particular situation. Despite of this, only one bottle of larvicide has been purchased so far. Conclusions Apart from Sassame Mission, the project has yet to determine whether this exercise can be sustainable. However, the project has recieved no adverse critisism from anyone in the Gokwe area, and generally has been warmly recieved by all individuals dealt with. If the results from Sassame Mission can be replicated at all centres then the project has evry chance of success. To date there have be no problems with credit control, but it would be naive to think they there won't be. The project hoped to expand beyond the borders of Gokwe, as the project needs large sales of nets to be truly sustainable. However, due to financial restraints, the expansion of the project seems unsound until the performance of Gokwe can be measured. Emnet must be congratulated for their willingness to support the project, and it can only be hoped that they continue to do so as their resources are limited. While it might be argued that Emnet are investing in their own future, there are much safer ways to invest money than putting them into what might be best described as a rural development project. The idea of this project has been the subject of a project proposal of two years old. The project proposal has been presented to both commercial companies and non governmental organisations. Commercial companies have generally been unwilling to invest money in rural areas due to both lack of knowledge and the perceived instability of the rural areas. Non governmental organisations on the other hand seem unwilling to venture into anything that smacks of commercialism, even though they often sponsor many so called 'sustainable' projects which cost the donor organisations huge sums of money. This project is a attempt to produce real sustainable development. In an era when money for development is ever decreasing and third world countries like Zimbabwe are for ever cutting back on health and other developmental issues, this type of project must be seen as a possible model (in terms of principal though not necessarily in methodology) on ways in which things can and probably must be done in the future. While it is much nicer if everyone in the rural areas could be given a mosquito net and repellents, it is not fair that people should die in Gokwe or any other place while donors are sought who can give these things. While it is true that some people in the world may not be able to afford a mosquito net, those who do have the resources should be given both the knowledge and the means with which to improve their lot, and if necessary make a profit doing so! The scope of this project needs a bigger input than presently available in terms of personnel, transport and health education material. In some ways, considering the present resources available, the project is trying to do the impossible. It can only be hoped that the project might draw the attention of any organisation either commercial or non commercial with bigger resources than Emnet to give this project the greatest chance of survival. Tim Freeman - 9 November 1993 Appendix One Malaria Statistics For Gokwe (As Recorded From Gokwe Hospital) Malaria Deaths (As Recorded From Gokwe, Chireya, Mtora and Kana Hospitals only) 1992 42 1993 147 (Until September 1993) NB - Ten deaths were recorded in November and December of 1992, making the 1992/1993 malaria season total 157. However, this does not include figures from Sanyati Hospital where eighty deaths were recorded many from Gokwe, nor does it include any deaths that occurred at any other clinic or persons dying at home. It can only be assumed that the mortality figures for this season for Gokwe were much higher than 157. Clinical Malaria <5 5+ TOTAL 1988 Whole District 70 996 1989 Whole District 90 766 1990 Whole District 16 941 51 549 68 480 1991 Whole District Jan - June 30 964 1992 Gokwe Hospital 558 1 859 2 417 Rest Of District 7 346 18 860 26 206 TOTAL 7 904 20 719 28 623
Feb 1 904 6 255 8 159 Mar 3 459 12 045 15 504 Apr 6 820 20 763 27 583 May 4 639 17 617 22 256 Jun 1 728 7 105 8 833 Jul 631 2 737 3 368 TOTAL 19 989 69 370 89 359 Figures suggest that the 1992/1993 season has been as nearly as bad as 1989 when a huge outbreak was considered to have occurred. April figures for 1989 (28 699) are marginally higher than those of 1993 (27 583). Source - Sampson Mabwe - Statistician - Gokwe Hospital Appendix Two Analysis Of The Malarial Areas Of Gokwe The areas in which malaria is worst in Gokwe District are those with year round water supplies. In probable order of magnitude. 1) Nemangwe Ward from Svisvi to Madzivazvido - Here artesian wells have been dug along Gokwe's only tar road from 1987 to 1993. Each artesian well is a huge source of Anopheles gambiae complex. The area is very accessible due to the tar road and due to the high movement of people the parasite may easily spread out by carriers. The area is also fairly flat, with the formation of many semi permanent pools "Makawa" and rivers which leave numerous shallow pools when floods have receded. 2) Chireya - Three major sources in this area. A natural salt spring near Chireya business centre, an newly build artesian well at Shiridzinodya and the Ume River which forms many permanent ponds when not flowing. 3) Eastern Gokwe along the Sanyati River - The Sanyati is the biggest river in the area. When not flowing it forms many permanent pools. From a Gokwe perspective it is difficult to come up with conclusive figures about the area as many of the people in this area prefer to go to Sanyati Baptist Mission Hospital in Mashonaland West. This hospital recorded eighty deaths in 1993, and many of their cases come from Gokwe. 4) Denda and Goredema - This area has many older artesian wells which surprisingly enough do not appear to cause such a problem as the newer artesian wells in Nemangwe. One possible reason is that the area is more isolated and the movement of people more restricted. 5) Mtora (Nembudzia) - This area has a number of dams. 6) Mutanke/Tongwe area - This area has a large dam, a semi permanent river the Mudzongwe and is in close proximity to the Sanyati River. The permanent pools of water act as a reservoir for both parasite and mosquitoes. A survey carried out at Mutimutema (700 metres above sea level) in Nemangwe in the third week of July of 1993 revealed that 25% of school children living around an artesian well were carrying malaria parasites in the their blood. These results suggested two things, firstly the possibility of a semi-immune population around water bodies as not all the children sampled were ill, and secondly it showed clearly that the parasite could easily exist throughout the whole year. With the onset of rains, it is very easy for both parasite and mosquito to spread outwards to infect the surrounding area. The situation is further complicated by the general shortage of boreholes in the area. Many people utilise holes dug in river beds as a source of water (Mifuko). Often several holes will be dug at one point, but often certain holes are favoured leaving other holes abandoned and uncovered. Often these pools are found to be harbouring vector mosquitoes. A. gambiae complex usually bite during darkness. Due to the heat in Gokwe many people fetch water after darkness bringing themselves into direct contact with the malaria vectors when they are most active, often relieving the mosquitoes of the necessity of flying into people houses which are sprayed to feed. Watering points of all kinds therefore act as a reservoir and focal point of infection. In keeping with this general idea, settlements such as business centres tend to be built with ready access to water and night time activities as beer drinking at bottle stores may become centres of infection. Similarly, meetings such as church meetings which last for several days will usually be held with easy access to water. Once again a source of water can be a focal point of malaria transmission. Source - Tim Freeman - Personal Experience |