Malaria control for Afghans in Pakistan and Afghanistan (1990-2005): a mixed-methods assessment considering effectiveness, efficiency, equity, and humanity

Abstract

Increased global attention and funding has provided opportunities to strengthen malaria control. One cross-border control programme researched a range of prevention and treatment interventions over twenty years to reduce the malaria burden for Afghans in Pakistan and Afghanistan. Malaria in these areas is unstable and seasonal. Primary vectors include Anopheles culicifacies, An. fluviatilis, and An. stephensi. Objectives were to evaluate malaria control interventions in refugee settlements in Northwest Pakistan and returnee settlements in Eastern Afghanistan. Findings offer lessons for programmes in other fragile and conflict-affected settings, while helping inform regional and global malaria control efforts. A mixed-methods study design included two study sites. The northwest Pakistan site covered 248 camps on malarious land near the Afghan border. The eastern Afghanistan site covered 200 villages near Jalalabad. As the national border separating study sites was relatively porous and both populations mobile, there were no notable sociodemographic differences between sites. Notable differences related to national malaria control policies, infrastructure, and priorities. Data were collected as part of operational research by HealthNet-Transcultural Psychosocial Organisation (HNTPO) between 1990 and 2005. Economic and quantitative data were analysed using Microsoft Excel™ and Stata®11-14. Qualitative data were analysed thematically using inductive and deductive coding. Cost-effectiveness analysis of adding indoor residual spraying to case management in Pakistan (1990-95) showed favourable incremental cost-effectiveness ratios per case prevented and DALY averted. A clinical trial of extended-dose chloroquine in Pakistan (1998) showed that while increasing chloroquine dosage reduced recrudescence, approximately 50% failure was still too high for first-line treatment. Qualitative analysis of men’s and women’s perspectives on malaria prevention during the Taliban regime in Afghanistan (2000), showed women and men had similar knowledge, while lack of money was a major disincentive to ITN purchasing. Clinical and epidemiological analysis of pregnant and reproductive-age women in Afghanistan (2004-2005), showed malaria prevalence was much lower than anaemia prevalence in pregnancy and women were well-informed about malaria risks, but their autonomy was limited. Key findings are discussed in relation to the study framework, providing overall lessons, implications, and potential limitations.