Can malaria be controlled where basic health services are not used?

OBJECTIVE To assess the potential of integrating malaria control interventions in underused health services. METHODS Using the Piot predictive model, we estimated malaria cure rates by deriving parameters influencing treatment at home and in health facilities from the best-performing African malaria programmes and applying them to Yanfolila district, Mali. RESULTS Without any malaria control intervention, the population cure rate is 8.4% with home treatment, but would be 13% if access to timely treatment were improved (as in Kenya). A further 3.2% of malaria patients could be cured in institutional settings with more sensitive diagnosis, timely start of treatment, better compliance (as in Uganda, Tanzania, Ghana) and 80% chloroquine efficacy. Applied in a setting where 7.6% of malaria patients seek institutional care, these assumptions would result in a total population cure rate of 14.5%. Increasing the health service user rate from 0.17 in Yanfolila to 0.95 new cases/inhabitant/year (as in Namibia) would result in half of all malaria patients attending professional services, raising the cure rate to 26.1%. CONCLUSION If malaria patients are to be treated and followed-up early and appropriately, basic health services need to deliver integrated care and be attended by an adequate pool of users. Improved service user rates and case management can increase malaria cure rates far more than isolated control interventions can. This has implications for international policies endorsing a narrow disease-based approach.