Malaria and Health Promotion Approach

1Health Promotion As a Contribution toEffective Malaria Control: An Analytical CaseStudyDavid Houeto and Alain Deccahe

SummaryOne of the disease burdens that weigh heavily on sub-Saharan Africa is malaria.Children under five years of age constitute the principal victims with morethan three million deaths annually. Effective therapeutic measures (preventiveand curative) are available and many activities are carried out in countriesof the region in the fight against malaria. However, malaria continues tobe the first reason for consultation and death for the children under five.This paper addresses the socio-cultural characteristics, beliefs, perceptions,representations and practices associated with child fever before proposingcontrol strategies that aim to empower the populations by taking into accountthese characteristics. In other words, advocate for health promotion strategiesfor effective childhood malaria control in sub-Saharan Africa.

1.0 IntroductionMalaria is a major public health problem in Africa (Traore, 2005). It remainsthe leading cause of death in children under five accounting for 94% of allmalaria deaths globally (Black et al., 2003, Bryce et al., 2005). There aremany efforts at the international and national levels to control and preventmalaria. For example, the African Heads of States formulated an ambitiousproject within the framework of the 'Roll Back Malaria' initiative at the AfricanSummit in Abuja, Nigeria, in 2000 (WHO, 2000). Accordirig to them, it was asuitable and sustainable action to reinforce the health systems and to controlmalaria. The objectives of 'Roll Back Malaria' were that by 2005: at least 60%of those suffering from malaria have prompt access to, and are able to correctIyuse affordable and appropriate treatment within 24 hours of the symptoms'onset; and at least 60% of those at risk of malaria, benefit from the mostsuitable combination of personal and community protective measures such as

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insecticide treated bed-nets and other interventions which are accessible andaffordable to prevent infection and suffering.

In 2007, two years after the expiry of the Abuja declaration, the reporton the situation of malaria in the region remained unchanged. There was noevidence that malaria has been controlled in iny country in the region. Ina study undertaken in Benin, only 4% of children under five years receivedadequate treatment within 24 hours from the onset of fever (Houéto et al.,2007). According to the same study, of 80% of the households that had bed-nets, only 10% had used them in the 24 hours preceding the survey. It is dear,from this study and others that the objectives of Abuja were not achieved(Traoré, 2005) in spite of the fact that the <RollBack Malaria' initiative wasimplemented in all the countries of the region.

Our concern in this chapter is to understand the reasons for this failure andto formulate proposals for the re-dimensioning of the strategies for effectiveunder-five malaria control. Why is the region unable to control malariadespite the large amounts of resources, development partners, hard workingprofessionals involved in the interventions? Are health professionals using theright tools to address malaria? What gaps exist in controlling malaria and howcan they be closed? What role can health promotion play in re-dimensioningmalaria control? Before answering these questions, below is a review of thewidespread consequences of malaria for the African populations and thevarious interventions in place.

2.0 Malaria in sub-Saharan AfricaMalaria remains one of the major health concerns worldwide (Samba, 2004).The populations at the greatest risk of malaria are children under five andpregnant women (Bryce et al., 2005). More than 515 million cases of malariaare reported worldwide annually, with 75% occurring in sub-Saharan Africa(Reaney, 2005). The annual deaths due to malaria are estimated at 3 to 5million,with over 90% of them in sub-Saharan Mrka (Bryce et al., 2005). In addition,malaria causes economie losses for African families that depletes the resourcebase of poor households. It is estimated that each household spends an averageof about 25% of its annual income on malaria (Russel, 2004). Malaria costsAfrica over US$12 billion annually (exduding the indirect effects on tourism,

E F FEe T 1 V E MAL A RIA CON T R 0 l. 159

international trade, etc). Malaria, thus, constitutes one of the major çonstraintsto the development of Africa.

The persistence of this burden is difficult to understand because thereare effective therapeutic and preventive measures in place that are capable ofcontrolling the disease (Traore, 2005). In addition to the 'Roll Back Malaria'initiative, there are interventions through other programmes such as theGlobal Funds, the Multilateral Initiative on Malaria (MIM), the IntegratedManagement of Children IIIness CIMCI), etc (Traoré, 2005; Were, 2004). AlIthe countries in sub-Saharan Africa are involved in these programmes. Itshould be noted that malaria programmes, based in the ministries of health,are managed mainly by health professionals who shouI~ ideally be not theonly ones concerned based on the multiple determinants of the disease. Thecommunityaspects remain weak (Houéto et al., 2007; Muhe, 2002).

Morbidity and mortality related to malaria remain in constant progression(Traoré, 2005). One continues to observe each year, during the rainy seasonmore specifically, the same pattern of malaria transmission with the sarnetherapeutic routes (Greenwood, 2000), which cause unwanted expenditureand negative outcomes (Baume, 2002; Lubanga et al., 1997). In 2006, a studyundertaken in Benin revealed that 4% of the children un der five years ofage received adequate care within 24 hours from the onset of fever, which isessentially a failure of the Abuja declaration that had aimed at 60% (Houétoet al., 2007).

Several authors have discussed the reasons for the persistence of malariadespite the various global and national efforts. They have also identified factorsthat are relevant to the African region. For example, there exists a differencebetween the terminologies indicating malaria and those qualifying fever(Lubanga et al., 1997). For certain populations, there is no link between feverand malaria {Mwenesiet al., 1995). Severe malaria, in the form ofconvulsions,coma and severe anaemia, is associated with witchcraft or bewitchment, andthis perception determines the care seeking behaviour of sorne communities(Deressa et al., 2003). In sorne cases, people have a sense of competence withrespect to managing fever because it is regarded as a cornmon and banalinfection not requiring recourse to healthcare. This situation partly explainsthe strong prévalence of self-medication in the region (Ryan, 1998). The

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therapeutic attitudes of the parents in case of child malaria are thus linked tothese perceptions and representations of fever and malaria. Recourse to healthfacilities is thus very little or none in the event of fever, thus the medical systemis often the last resort for severe malaria (Baume, 2002). This poses a trueproblem in the statistics used by malaria programmes which do not reflect thereal prevalence (Agyepong & Kangeya-Kayondo, 2004; Houéto et al., 2007).

For child malaria, it is necessary to note the precocity of home treatrnentof fever by parents (Baume, 2002; Deressa et al., 2003; Houéto et al., 2007,Amuyunzu-Nyamongo & Nyamongo, 2006). This treatment is inadequate anddoes not prevent the evolution of malaria (Lubanga et al., 1997; Pillai et al.,2003). The observations by these authors confirm McCombie's (1996) studywhich reported that seeking care in the event of fever is very poor with 19% inKenya and 24% in Gambia. When there is recourse to the health facilities, thetime parents take to seek the services is often long and varies on average betweenthree to seven days after fever onset in the child. This study recommended thathome-based management of malaria must be improved in order to reduce theprogression of cases to severe forms. The author further recommended theinvolvement of non-health professionals in malaria' management, especiallyamong children.Although the WHO also prornotes malaria home managementinitiatives (Were, 2004), it is doubtful that these initiatives address the peoples'interests.

Williams and Jones .(2004) contend that the community based approachhelps to understand that it is not only the people's lack of knowledge thatdetermines their health care seeking behaviour in the event of fever, but severalother factors come into play. These indude economie (poverty, accessibiiityto health services and treatment), socio-political and social factors thathave significant influence. They further observe that communities are fullyresponsible in deciding where to receive care and they use several sources ofcare. The decisions on diagnosis and treatment, which are deeply embeddedin the local culture, are the subject of systematic and logical choices (from thepoint of view of the population) even if they do not foHow biomedicallogic.One of the conclusions of this study is not just to ask the question and not toknow"how can we get them (communities) to ... ': but rather - and what seemsmost important for us is - "we should be pressing to find ways to increase

E F FEe T 1 V E MAL A RIA CON T R 0 L. 161

people's capacity to have access to complete and effective treatments".The problem posed by under five children is that malaria control goes

beyond the simple biomedical vision of health. Malaria prevention andcontrol should not be the business of the health professionals only because itis underpinned by several other factors, which are beyond the competences ofmedicine alone as illustrated bylones & Williams (2004) and others. Malariacontrol for children un der five should involve parents and other sectors in amuItidisciplinary way, giving power to parents to manage fever in their specifiecontexts, using multiple strategies, and dealing with the social inequities {seefigure 1).

3.0 An Example of Benin Malaria ControlProgramme and National Health Systems

The intervention took place in Benin from January200S to May 2007 (Houéto& Deocache, 2008). It was a community-based intervention that involved thestudy community in developing a malaria control programme for childrenunder five years, based on the health promotion approach and using theprinciples of: participation, empowerment, contextualism, intersectorality,multistrategy, equity, and sustainability (WHO, 1998). The process consistedof eight steps, namely: (i) Identification and description of the health priorityproblem - several meetings were held with the village leader, the notables andthe whole community in a general assembly (GA) of the village. This led tothe planning and implementation of a baseline study. (ii) Expressed problems- a feedback session was organized on the results of the baseline study withthe aim of establishing a general community understanding the cause of feverin children. The various health or non-health factors of fever, in connectionwith the realities of the village, were identified. The problems to he resolvedfor a coordinated approach in the fight against fever were discussed. (iii)Reformulation of problems - the main problems identified were reformulatedafter validation, according to the community's understanding and based onlocally available means. (iv) Prioritisation - the problems identified wereranked according to the weight placed on them by the community members.(v). Resource inventory - the community memhers discussed the availability ofresources necessary for solving the identiâed problems as well as the potential

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Faclors 1/ \ \\ \\ \~ \

Fogure 1 : ~tation of the interactions in the child maIatio conIroI.

collaboration with professionals (health or non-bealth). (vi) Desirable andfeasible changes - the community identified various actions to be taken. Asteering committee was set up. which identified seven main Unes of actionas shown further below. (vii) Implementation - the steering. committeeplayed the leading role during the implementation of the activities identified.It created and maintained informal relations with the community mainlythrough the community leaders, the notables, and periodic village meetings.(viii) Assessment - an evaluation of the intervention was carried out after 27months. This involvedthe steering committee and the community members asweil as the authors of this chapter.

The seven main actions undertaken by the community are out1inedbelow.(i) Barly home .tceatment of child fever by mothers. Training was


organized for mothers in hamlets. The training was facilitated by thefirst author, with material support from the department of healthmanagement. At the end of each meeting, mothers establishedtheir criteria and unanimously chose a community health worker(CHW) as the nearest source of health care. Mothers proposed thatvermifuge be included in the home-management kitty because ofthe belief that intestinal worms worsen child fever. The doses oftreatment were pre-packaged in reconditioned sachets. The supplyof medicines and priees were managed by the steering committee.

(ii) Use of impregnated mosquito nets (IMN). The Ministry of Healthallowed the project to get 300 IMNs at a reduced cost. The IMNswere purchased within a one-week period - these are the sameIMNs they had refused to use in the pasto

(iii) Parents' income improvement. Two very important income-generating activities came into force. There was the installation oftwo grain mills for processing corn, beans and other cereals, as weIlas cassava. For the farming activities, contacts were made with theInternational Institute of Tropical Agriculture (lITA) in order toimprove agricultural practices.

(iv) Setting up of a micro-insurance scherne for health. The-communityagreed upon sorne methods of micro-insurance: 1OOFCFA ($USO.2)as membership fees and a monthly 'Contribution. of 200F CFA($USOA) byeach household ($US4.8) per year. The contributioncovered 100% of care at the CHW level and at the district healthcentre. The steering committee committed itself to supervising aregular (quarterly) deworming programme through the micro-insurance schème, in order to reduce children's 's1lSCeptibility' tofever according to the belief in the village.

(v) Environmental deanliness and 'Creation of mosquito-me habitat.Community members adopted a new model of habitat withappropriate measures to maintain their environment dean. Thestructure of the new model was registered with the chief of thevillage who would give a .copy to any member who intended tobuild a house.

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(vi) Systematic schooling of children and adult literacy. The systematicschooling of children was agreed upon by members in order forthe community to change behaviour towards fever and malaria.Mobilization of children for school started from the followingacademie year (2006). The elimination of adult illiteracy wasplanned for the following year (2007).

Results, at the individuallevel: the cognitive aspects, correct attributionsbefore and after intervention were 6 and 15among 18 interviewees, respectively.Knowledge of prevention practices before and after intervention was 8 and16 among 18 interviewees. For the latter, they knew malaria prevention andpractised it. Parents' practices of recourse to health centres in the case of childfever changed notably within the project period. Before intervention thesentiments induded: "it is normal to go to health facility with child fever afterat least three days, because if it is natural it will dedine or give up with use ofhousehold remedies". But after intervention the views changed to: "withouthealth professionals' remedies, child fever involves anaemia, expenditureand even the loss of the child. The recourse to health facility is withoutconditions':

At the community level: about 80% of the community membersparticipated in the intervention through the different actions implementedthrough the project. This induded participation in meetings, decision makingand readiness to he engaged in the project activities. Compet-ence to adequatelytreat child fever was developed fairly quickly, contributing to the developmentof the people's self-esteem, while skills to establish partnerships were developed.Communication, through positive interactions, tolerance of divergent pointsof view, was also developed during the intervention. One could, in addition,note the maturity of the critical conscience through the manifestation ofcollective, social, political consciousness and engagement with other membersof the community as well as the acceptance of a personalliability for change.

In relation to health data, changes were observed through the activescreening of malaria as well as analysis of registers. The prevalence of feverand other signs of malaria were significantly reduced from 34% to 20%. Therecourse to the health facilities, in the case of fever, increased especially on early

E F FEe T 1 V E MAL A RIA CON T R 0 L· 165

and adequate home treatment of fever. Consequently, the severe cases of feverreduced from 13% to 7%. Deaths caused by malaria were significanjly reducedfrom 15, the year before the intervention, to 4 in 27 months of intervention.The process used in this intervention is summarized below:

(i) no action was taken without considering the local context of theintervention community;

(ii) the issue approached was a priority for the interventioncommunity;

{iii) participation, through giving voice to the community to take allthe possible and suitable actions for fever control, was effectivelydone;

(iv) health professionals played a guiding role as resource persons andproposed actions for community consideration;

(v) the use of multiple strategies of actions that addressed variousaspects of the community's life without limiting them to the healthsector;

(vi) confidence by the community in the intervention played the role of"motivator" that increased the members' self-esteem.

There is evidence, as stated by Raeburn (2005), that communityparticipation, as experienced during this intervention, is the core processof empowerment. It makes it possible for the community to discover thebiomedical reality of child fever and to adopt behaviours favourable for its'Control. This form of participation is possible, only when programmes focuson the local contextual factors and not on sorne generic actions, as is thecase with many national malaria control programmes in SSA (Houéto et al.,2007). These conditions are necessary for ensuring equity in health care, andthe sustainability of any health action with the people concerned being at thecentre of the action (Raeburn, 200S). The role of the reseaecher/actor appearsto us as a critical factor in such an approach - the ability to be (present andnot present' at the same time for the sake of 'indigenous knowledge', and bymaintaining only a status of a guide and a resourœ person,


4.0 DiscussionVarious programmes have been formulated and implemented in collaborationwith the African States through the health systems towards the control of malaria.Generally, these programmes are the initiatives of the medical hierarchy of thecountries or the development partners with activities that neither fit with thecharacteristics nor the needs of the targeted communities. The concerns of thepopulation, their perceptions and their systems of management of the diseasesare by no means taken into account. More surprisingly is the fact that theseprogrammes do not even refer (or refer very little) to the research on malaria(Attaran et al., 2006). The example of the free distribution of the IMNs is a caseamong so many others that ignore deliberately the problems created by theexemption From user fees, e.g. iniquity and sustainability, The programmes aremost of the time implemented in a vertical way and are rarely integrated intothe existing systems. The activities are planned by the national malaria controlprogrammes that train the agents off ground and carry out the supervisionwithout a true appreciation of the decentralized structures of the health system(Houéto et al., 2007).

The Bamako initiative (cost recoverysystem, essentialdrugs under genericname and community participation) adopted in 1987 was not implementedsuitably because of the difficulties that resulted from lack of responsibilitysharing between health professionals and populations, conflicts and suspicions(MSP/Bénin, 2004; Ridde et al., 2005). The introduction of the direct paymentof user Fees generated an exclusion of access to health care for the poorand vulnerable. The system of health insurance in place in the majority ofthe countries in the region generally covers the civil servants who do notrepresent more than S to 10% of the population. The health micro-insurancecompanies are very recent and still cover a negligible part of the population.AlI these occur in an economie context of recession that -constitutes one ofthe factors explaining the use of un-prescribed drugs (MSP/Bénin, 2004). Thecommunity participation in question into these programmes does not aim atthe autonomy of the communities, because health professionals aiways holdthe leadership of the ideas and the actions. One notes a lack of systematizationin the approaches used and which are ofien not updated. No link is establishedbetween the practioe and research in the programmes in order to learn from

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'! j) rWiheJ1j anal~1Ïn§4nten'!entiQnS rrqlatFd ..JQ J.n~iétNQnlJ:<)l~Q.n~.can observetliatr oefttinr ,.sp.ec.t.s -of ~Îprohl~;jprinqipl~~jcw.~ f~~é!legi~sare; takeniBtolaeœ.nn.t~4Pd·,w.heo.~'J.o.mt uWJQf;ptratëgi~Jbi ftbstmt1'.ml}{ ..ean observethatiiatnumpen[bf:)iIlte~ns.·JjS~r k#lnm}lJÙt}trp~cip_ati~~'i~mmunitycap:am~[builclio.g~tccreatio1i'Jcti suppomYei enViw.MlMi~;·t~jthé: adoption ofpromoted beb.aviàUJJ:}, ·advooaâyran.dlpmnt!rshipir~er" iti iSh<rHÙdbe notedthat rthe oolicq>:tl(~wacl'<l)Us(;coimnunicatioimfmethods ~d~pproaches usedm-;pr~ate ·in1el.iVmti~~lnmyalways.'pm;.qm.dm,{the-· Bartltl;~ithe aspectsusèrllU"eJlot!tomFeh.~nsive: iarseme Gàst:s~as fo.JlttoqamUDi~:parti(lipation fordmmp16jh<talth! pr.o.œssÎfm~tilre;&Omttimes!tBe·maini adQIi$Jin5tœd of being"technical advisers" It is also necessary to note the im~iftainœ!OflPolitical willNRYrlds9 Inf!!h~')Ytélf!~~iS~~if<MIJh~0=r'jlJJ~ ~f(JtnilJ?Jmgl~trclition~. Forexample, wim.; m~)aJ1qui~h~9"J?f.)m~llMN ~l§f!J~wJC9~t~~~Cf'rnobilizationof the development partners at international as weIl as nationallevels, it wase~~w.~(wJ.wpl~~J}~&ft~ç&My'çfPP.!fP~iJj>fQGHYJM!lAIDr »~in·; j ;:Hi ') (Ü rn(rd' The pe~~~IJ\ÇN.9..(mâJiP.'i*,,)Wr~.P!t~.<?~tP~'(v:Mj~~mi~§~iYAh~JlJJftf9§4~

examinatiQn9,ftm~,DtÇ.~f~mweÂhipJ?atticI1J,arthec~oJJ~aclr MlIJ!JI•.i.a' initiative.-11-f)-'ffl) .. ,-'(u~;-'''clli '09 ..~ '-}d' u1i,f .Gl,J':ii ";êJDtJt)'l,o.'1rr)TTn[T)T~r . .~?hWm~~~!hfJH~()).'f~?H&"lf,t~P1~W,H~8{fV8~ltW,l~HYfP,rrfh~/~~~ammes fail~R..;~A~mctfF.I~J~iW\~fi~;cf,qttHb!JH;lLo~N,r,~~~tJfi~~ m~~Y;~~u§Jadors thatwHffiflh~JJbetRf~lqm f?~I?!WIN4~~,~é lfjÜmHiJ~~'~mffm,a!h~f'iW:4 integrated'rnZ'iJ~!li~%*,~jnwlP!J\};fq\"tB~lêG~C?RAptiPHk~ ~ffimt:W~1programmesare enveloped in ~~~\qm6~~c~-)m!9R\Mffi~~J.P~~aJMtÎ?ROm~sipnals' logic,

m~v~~~l~W~J~f![~f~if81~~~1~1~1~~f~t:J&~~~?~~~~~f~~!l:!~:~~~~~~ffi~sJ5Jigri~l~hJa h~16~bY;~ddfe'(~6»~'y~r~iJ.!1~~~JYJ~~~'n:~systematicway in many malaria control programmè~~'" "~ :n ,.",.").",, ,<.1, ',':

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Aptitudes/competencies - in order to ensure a true anchoring ofthe activities in the partner population, an important stage in theirdevelopment is that of sharing of knowledge between professionalsand communities. Through this knowledge sharing, professionalsshouId learn from the communities with regard to their perceptionsand representations in relation to malaria or fever. In the samemanner, communities should learn from the professionals currentknowledge about malaria as well as the appropriate controlmechanisms. By this process of exchange, the two parties by wayof negotiation, should reach a consensus on the choice of theactivities to becarried out that wouId guarantee effectiveness andsustainability.Communication, based on the local principles and equality,identifying the channels most listened to by the community.

From the activities undertaken in the Benin malaria programme the followingcan be concluded regarding the health systems at the nationallevel.

Development of policies, legislation and dear regulations - for aneffective malaria control programme, political commitment mustbe expressed by ruIes dearly announced and diffused at all levelsamong all the stakeholders. Mobilization for the Abuja declarationwas temporal without a future and without obvious repercussionsin the health systems of the concerned countries.Communication of information - the information flow inrelation to scientific realities, expressing issues in a manner that isunderstandable at allieveis.Provision of services and reinforcement of human resources - it isimportant to give priority, at the nationallevel, to hum an resourcetraining in the fields lik.ely to facilitate malaria control. Theprogrammes are ofsen managed without adequate competences andcontinuo us training for the personnel. Possibilities of training existin the countries, provided by the development partners withoutreaUy serving the interests of the nations. Political oommitmentshould thus take into account this kind of planning which places


at the disposaI of the programmes, qualified human resources, andsystems of continuous training weIl codified and sysfematized incollaboration with the other sectors of the states coordinating theopportunities for scholarships and short training courses (inter-sectoral partnership). We make a difference between the trainingthat is proposed here and what occurred in the sub-Saharan Africancountries called by Smith (2003) "the perdiemity" or "per diemtrainings".

Inter-sectoral shared responsibilities - the process must includea systematic mechanism of building partnerships with the keysectors concerned with malaria control, starting from the inventoryof the factors that underlie it. One should be able to bring togetherthe various actors concerned, according to the list of the factorsidentified including ministry of health, envkonrnental specialistsand local entrepreneurs.

Community mobilization - nothing should be done without thecommunities. The principle must be "to make with them" and not"to make for them':

Creation of a system of information gathering - data should makeit possible to acquire the true picture of the burden of malaria.Consequently, research must accompany ail the interventionprooesses in order to know how to answer questions on thedisease.

Health systems in sub-Saharan Africa have sorne particular .characteristicsthat constrain effective implementation of malaria control. A critical factor isthat the national health systems remain organized in a vertical way. In 'Sornecountries, there has been an attempt to decentralize the system by creating theHealth Districts but without a true autonomy of intervention. The decisionson disease management, as weIl as the resouroes, are managed at the helm ofthe health pyramid without sufficient regional specificity, thus being unawareof the characteristics, perceptions and the representations of each area withr-egard to malaria. Thus, one could simply say that malaria control and inparticular, the Abuja declaration, failed because, as noted by Chavez (1991;


p.4), the following was not taken into account: "never suppose that you knowthe needs and the priorities of the populations; admit your total ignorance oftheir context, the way in which their spirits work, the reasons of their attitudes,and ask them rather how they would like that you help them:'

5.0 Proposais for an Effective Malaria Control:Health Promotion Contributions

Due to the fact parents hesitate to seek care at health facilities for childhoodfever, but treat it at home, it appears useful to address malaria control withtheir collaboration, through community dialogue which brings about mutualunderstanding (between health professionals and communities) for actionsthat have positive impact in reducing malaria prevalence (Baume, 2002;Deressa et al., 2003). In other words, developing community knowledge andskills for malaria control may lead to the people's empowerment and increasedinvolvement in planning and implementing effective interventions (Houéto etal., 2007; Lévesque, 2002; WHO, 2002). This was not fully taken into accountby the WHO's Home Malaria Management initiative (HMMI), which couldpartly explain why the initiative failed. .

According to the health promotion concept, interventions should, asgeneral principles: tackle the various factors which influence malaria (broaddeterminants of malaria) as mentioned above; use in an integrated way variouscommunication approaches and methods (health edu<:ation, communicationfor behaviour change, social mobilization, social marketing, mediation,publicity campaigns) that reach the target populations; ensure participationof the community mernbers in devdoping malaria programmes; establishmechanisrns to facilitate multi-sectoral collaboration at all levels of the society(linked to the identified malaria determinants); and develop and implementactivities within the context of the general proeess of the health sector reform(WHO, 2002). Strategies must be used simultaneously to achieve optimum

effe<:tiveness.It would he desirable that child malaria interventions take into account

systematically health promotion principles and strategies because theseconsider individual/community capacity to play an active role, The conceptof participation reorients interventions in a horizontal direction at all levels.


Populations' perceptions and representations are taken into account onlywhen health professionals act as technical advisers in such a process whichpresupposes that communities share, plan and implement their commonvision to address the health problems in question. The core aspect of theprocess is community participation, which would ensure the sustainabilityof interventions implemented through the health promotion concept. Withreal participation, where communities make decisions <:oncerning their healthproblerns, it would be easyto identifythe means and methods of communicationto be used, enabling conditions to he set up, partnerships to be established forbetter management of the intervention and levels requiring the use of advocacy.Another aspect, which is central to suocessful malaria interventions, is thecreation of supportive environments to the adoption of promoted behaviours(Kidane & Morrow, 2000). As developed by Gr-eenand Kreuser (2005), creationof supportive environments to behaviour adoption (called enabling factors) isone of the major elements to the success of behaviour change. These enablingfactors facilitate the implementation of actions at individual and communitylevels. They include resource availability and accessibility, supportive laws/policies (healthy public policies), governmental priorities and commitmenttowards health, individual and collective skills. It is thus understood thatfor child malaria control to be effective, certain 'Conditions according tocomrnunities' perceptions and representations, Me essential to obtaining theirsupport (Jones & Williams, 2004).

It is often argued that a powerful health system that gives early and correctdiagnosis with prompt and adequate care would he enough to reduce theburden of malaria (Were, 2004). Contrary to this, malaria control strategiesrequire research into community interpretations in order to capture theirspecificities in setting up conditions that faciHtate the adoption of goodpractices. Of course, this cannet be done without a reorganized bealth system,providing health services very close to the served populations. Also, if it isrecognized that there are several factors underlying childhood malaria, it isneœssary to work in collaboration with other sectors (as shown in Figure 1),since it is obvious that one sector cannot achieve much independently (Jones& Williams, 2004; Williams & Jones, 2004). This emphasizes the importance ofadvocacy when implementing interventions according to the health promotionconcept (WHO, 2002).


6.0 Conclusion and RecommendationsWould it have been possible to achieve Abuja's goals if we continued with thebiomedical vision ofinterventions? It seems to us that there isa need to widen ourvision of health by adopting a bio-psychosocial approach and thus addressingother factors induding social, cultural, economie, environmental, political, etc,that underlie malaria. This will lead to active community engagement whilestrengthening the members' capacity to act while health professionals take therole of'technical advisers'. The "power" given to populations would certainly beused for the resolution of other health problems (e.g. HIV lAIDS, tuberculosis,water and sanitation and cholera) in the community and would thus constitutean entry point towards their development (social empowerment). The Abujadedaration has failed but the MDGs are another milestone that can be used toillustrate what the host of the Abuja Summit, Oiusegun Obasanjo, Presidentof Nigeria, referred to: "Today we have begun to write the final chapter of thehistory of malaria. We have raised the hopes and expectations of our people -we must not let them down. We cannot afford to let them down. May malariabe rolled out and development rolled in ail African countries." We recommendthe recognition of the health promotion approach as a -leading process in thehealth systems. There is also a need to produce sufficient critical mass of healthpromotion practitioners in the region. Health promotion needs to be integratedin malaria programmes in particular and in ail programmes in general.

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