:: Programs - The PSI Response
PSI/Malawi tackles each of the country's most pressing health issues, with social marketing programs dealing with malaria prevention, HIV/AIDS prevention, childhood rehydration and safe drinking water. Figures are as of March 2004.
Malaria Prevention
The PSI response to Malaria in Malawi is set within the framework of the global 'Roll Back Malaria' movement (which aims to 60% of pregnant women and children under five covered by an ITN by 2005,as agreed by African heads of state in Abuja, Nigeria in 2000).
Insecticide Treated Nets (ITN), which repel and kill Anopheles mosquitoes (the carrier of the Malarial parasite), currently offer the best opportunity for malaria control. PSI/Malawi's efforts focus on the promotion of our Chitetezo brand net and M'wbezera Chitetezo re-treatment kit.
Challenges
- Malaria transmission is highest in rural areas, where purchasing power is lowest. Distribution outlets are sparse in rural areas.
- Harvest-derived rural income is available only after the peak period of malaria transmission.
- Young children and pregnant women do not have preferential access to ITNs within the household.
- Re-treatment rates for nets remain low - only 20%1
Solutions
- A three-pronged delivery strategy: for urban inhabitants who sleep in beds, PSI/Malawi markets and sells a blue conical net exclusively through commercial outlets at a market price - 395MK (US$3.65).
- For rural inhabitants who are most at risk for malaria infection (pregnant women and caregivers with children under the age of five), PSI/Malawi distributes a heavily subsidized green rectangular net (MK50 or US$0.46) through antenatal health clinics.
- Other rural inhabitants are sold the green nets through community-based initiatives at a price of MK100 (US$0.92).
- Sustainable malaria prevention is most effective when a net is treated annually. PSI/Malawi has effectively addresses this issue through promotion of the M'Bwezera Chitetezo brand ITN re-treatment kit. To make this product readily available to people throughout Malawi , it is sold at a subsidized price at both commercial outlets and public health centres - MK30 (US$0.28).
- Communications vehicles such as PSI/Malawi's Mobile Video Unit and Village Theatre Groups promote understanding of Malaria vulnerability and prevention to rural communities throughout Malawi .
- In order to combat the problem of low re-treatment rates, manufacturers are currently designing mosquito nets that contain insecticide treatment that can last for the life of the net. There is a range of candidate products that is currently undergoing field-testing.
Impact
- Over 2.3 million Chitetezo nets sold
- Over 1.1 million re-treatment kits sold
- Over 5.8 million person years of malaria protection delivered
- Over 10,000 child malaria deaths averted2
- 94% of Malawian have heard of Chitetezo ITNs and M'bwezera Chitetezo retreatment kits on the radio
- Over 90% of those surveyed agree that ITNs can prevent malaria
- 6.2% of surveyed outlets sell M'bwezera Chitetezo kits.
Read an article on preventing Malaria in Malawi.
HIV/AIDS Prevention
PSI/Malawi's HIV/AIDS prevention program aims at changing behavioural norms. Our branded condom social marketing activities are accompanied by generic communication campaigns that educate and induce such healthy behaviour such as abstinence, delay of sexual relations, mutual fidelity and correct and consistent condom use.
This commitment to the 'ABC' of HIV/AIDS/STI prevention is demonstrated by both the work of Youth Alert! and by the promotion of our Chishango brand condom.
Challenges
- Fear of public disclosure with the stigma associated with HIV/AIDS has been identified as a significant barrier to HIV testing and programs aimed at assisting people living with the disease.
- Half of all Malawians do not believe that persons with the AIDS virus should be allowed to continue with their work in an office, shop or on a farm.
- Major misconceptions and ignorance remain regarding condom use, with 24% of women and 16% of men believing that condoms are not safe to use.
- Risky sexual behaviour is widely prevalent, with 18% of men report extramarital sexual activity, and with 21% of all men paying for sex.
- Lack of education, particularly in rural Malawi, translates into poor knowledge of how to source condoms; more than half of women and one-quarter of men in the 15-19 age group report being unable to get a condom for themselves.
Solutions:
- Youth Alert! employs a range of mass media and inter-personal communications channels to promote effective and realistic strategies to avoid HIV/AIDS. For more information, click here.
- In order to assure across-the-board affordability, the mean price of a 3-pack of Chishango is MK7.00 (US$0.06)
- Chishango was relaunched in a new guise in 2002 to specifically appeal to sexually active men aged 14-25.
Impact:
- Over 58.8 million condoms sold
- Since 2001, over 44,000 primary and over 67,000 secondary cases of HIV averted 3
- Over 490,000 couple years of protection delivered 4
- Over 279,000 unplanned pregnancies averted 5
- 94% of adult Malawians have heard of Chishango condoms.
- The number of women buying condoms has increased since 1999 by 10%.
- 43% of all outlets in Malawi sell Chishango .
PSI/Malawi's oral rehydration program aims to reduce the number of deaths in children under five from dehydration caused by severe diarrhoea. The Thanzi brand of oral rehydration salts (ORS) were introduced to the Malawian market in May 1999, with the solution's formulation complying with the WHO specifications for ORS.
Challenges
- The public sector has found it increasingly difficult to deal with demand for ORS, with estimated availability standing at 50% at the time of Thanzi' s introduction.
- Because generic ORS were available only in public health outlets, they were therefore viewed as a prescription-only medical product requiring the advice of a health practitioner to use.
Solutions
- PSI/Malawi has spread distribution of its branded product to grocery stores, supermarkets, through hawkers and private clinics - moving the products to the nearest outlets at affordable prices.
- A single packet of Thanzi retails at MK5.00 (US$0.04)
- Messages are targeted at mothers and caregivers of children under five, through radio advertising, community Drama, Mobile video, Wall signs in populated commercial areas and the vernacular MONI magazine.
- Advertising is intensified during the peak diarrhoea season for relevance
- Packaged in the promotional campaigns are key health messages for the prevention of childhood diarrhoea
Impact
- Over 2.8 million sachets sold 6
- Over 482,000 child years of rehydration delivered 7
- Overall, 79% of respondents have heard of Thanzi
- 31% correctly identified Thanzi as ORS, with 30% stating that it is a dehydration treatment, a further 23% mentioned its use for the treatment of diarrhoea.
- 37% of outlets nationwide sell Thanzi
Safe Drinking Water
In order to reduce the prevalence of water-borne disease, in 2002 PSI/ Malawi introduced its WaterGuard product. WaterGuard is a bottled solution of liquid sodium hypochlorite, a chemical that kills the germs in drinking water. It is extremely easy to use, and when properly mixed, makes most water safe to drink. Sodium hypochlorite has been used all over the world for decades and has proven safe for consumption even over long periods of use.
Challenges
- 35% of Malawians source their drinking water from an unprotected source.
- Most contamination of drinking water in Malawi occurs after collection - during transport and storage.
- The only other way for an average Malawian to ensure that his/her drinking water is uncontaminated is to boil it just before drinking. This is hardly convenient since the person has to wait for the water to boil and then cool before consuming it - not something someone wants to do when thirsty.
- Peri-urban populations are often the most vulnerable - the government has had success in distributing chlorine during the rainy season to rural areas and in urban areas people do not store their water as frequently.
- The high population densities in peri-urban areas often lead to more contamination.
- WaterGuard is a new, unfamiliar product, lacking recognition among target consumers and retailers.
Solutions
- In order to assure affordability, a 200ml bottle retails at an average price of MK8.00 (US$0.07) - each such will ordinarily treat the drinking water for a family of four for one month (one cap-full effectively treats 10 litres of water).
- WaterGuard is in liquid form to allow for dosing flexibility and simplicity; once the solution has been added, the water must sit for only 30 minutes in order to keep the water safe for 24 hours.
- The label on the bottle provides pictorial directions for use, making it possible for everyone, even the illiterate, to understand.
- In order to create incentives for its sale, wholesalers enjoy 35% and 40% trade margins; encouraging shopkeepers to stock and actively promote WaterGuard to their consumers.
- A concerted advertising campaign was launched to include radio, billboards, suburb signs and branded minibuses.
- The Mobile Video Unit and village theatre groups advocate the use of WaterGuard in their educational films and dramatic sketches.
Impact
- Over 830,000 bottles sold
- Over 332,000 person years of treated water delivered8
- 25.7% of outlets nationwide sell WaterGuard
Footnotes
1. The main reason for low re-treatment rates is the discrepancy in consumer perception of effectiveness and the actual effectiveness of treatment against malaria. Consumers tend to judge the effectiveness of insecticide treatment on the noise and density of mosquitoes around the net. The problem is that the vast majority of biting mosquitoes in Malawi are Culex which are relatively resistant to pyrethroid insecticides but have no public health significance in Malawi . However, Anopheles mosquitoes, which transmit malaria, are extremely susceptible to pyrethroid insecticides. Therefore, although the net treatment is very effective at preventing malaria, in the eyes of the consumer it does not appear to make much difference to mosquito density in the sleeping room. For this reason demand for the product is low.
2. Child malaria deaths averted are based on 6 deaths averted per 1,000 children protected, with 0.75 children per net. Lengeler C. Insecticide treated bed nets and curtains for malaria control (Cochrane Review). In: The Cochrane Library 1998; 3. Oxford
3. PSI uses a model based upon the AVERT model, developed to account for a variety of interventions (such as behavior change communications, VCT clients, sales of STI Kits, etc.). The system models the complex AVERT variable relationships, including additional parameters, available epidemiological and behavioral data for country target populations. The model is dynamic, and estimates not only primary cases averted (number of cases directly prevented by program activity) but also tracks the future impact of activities by estimating the consequent number of infections averted over the following 12 months.
4. Couple years of protection are the amount of contraception necessary to protect one couple for one year [120 condoms, 15 cycles of oral contraceptives, 100 vaginal foaming tablets, .285 intrauterine devices, 4 injectables (3-month dose) or 6 injectables (2-month dose) and 13 doses of emergency contraception]. Based on an analysis done by the MEASURE Project in 1999.
5. Estimates for unwanted pregnancies averted due to provision of contraceptives are calculated based on a formula developed by the Alan Guttmacher Institute in 1996
6. ORS Social Marketing primarily compliments the public sector provision of the product; sales patterns are also affected by public sector availability of Generic ORS. More Thanzi ORS is sold in the absence of generic ORS in public hospitals. Donations of ORS improved in 2001 and 2002 thus less Thanzi ORS was sold in that period.
7. Child years of rehydration are the number of sachets of oral rehydration salts necessary to prevent dehydration of a child under five for a year. This figure assumes an average of 3 diarrhoea episodes per year over the first five years of life, with each episode treated with an average of two sachets of ORS. Based on UNICEF information.
8. Person years of treated water are based on the number of bottles of PSI safe water solution necessary to disinfect the drinking water of one person for one year. This figure is based on disinfection of 1,000 litres of water per bottle of safe water solution at an average consumption of 5.5 litres per day per person, 365 days per year, yielding a total of approximately 2,000 litres per year treated with two bottles per person. Based on UNICEF information.
