humanitarian news and analysis

Malaria costs Africa alone an estimated $ 12 billion a year, impeding the growth and prosperity of many sub-Saharan countries. Credit: IRIN

The economic cost of malaria to individuals, communities and nations has been a neglected area of study for decades. Because millions of Africans appear to accept this devastating disease as part of their local living reality – and because the international community has failed to prioritise the issue of malaria – it is perhaps not surprising that little is known of the full economic impact of the disease. This has begun to change recently, with increased research and attention being paid to combating malaria.

According to the World Health Organization (WHO), malaria costs Africa alone approximately US $12 billion a year. It is a social and economic weight that burdens most tropical nations – particularly those in sub-Saharan Africa – and impedes their growth and prosperity.

Peering over his computer in a corner office in Nairobi, Kenya, Manase Lomole, executive director of Humanitarian Assistance for South Sudan - a relief, development and rehabilitation agency for south Sudan recalled an incident involving his cattle, a young herder and malaria.

“It all started when this young man had a sudden attack of malaria while he was herding the animals,” he explained. Instead of watching the herd, the sick man decided to lie down in the shade of a tree. While he was resting, the cows ate part of someone else’s crops, which started a dispute. To resolve it, Lomole had to compensate the farmer for his losses. it didn’t end there, however. One of Lomole’s cows fell into a snare and died. Consequently, Lomole himself lost on two counts: the loss of his cow and the loss of having to pay the farmer for the crops his wayward herd had consumed.

Lomole’s story is a brief illustration of the detrimental repercussions of malaria in rural life, both on the individual, by reducing his level of performance, and on communities, by increasing the overall bite of poverty.

Lomole, who comes from a malaria-endemic area of Sudan, has suffered several attacks of malaria himself. He argues that the correlation between poverty and malaria is strong. The physical and mental effects of the disease – blurred vision, fatigue, body aches, weakness, the inability to concentrate – reduce a person’s productivity level. For farmers this means fewer days in the field, leading to fewer crops and meagre harvests. For young people, malaria means fewer days in school, poor performance in class and a greater chance of dropping out.

“The bottom line is that all these people lose days to malaria that could have been spent furthering themselves, their families, their community and their nation,” Lomole said.

The link between poverty and malaria

The global burden of malaria is unevenly distributed, and malaria-endemic countries must absorb large economic and social penalties. Studies show that the growth rate of per capita gross domestic product (GDP) in countries with malaria is markedly lower than those countries that do not have to contend with the disease. The difference appears modest – malaria-endemic countries have a rate that is between 0.25 to 1.3 percent lower than non-malarial countries – but when extrapolated over a period of 25 years, for example, this difference can add up to almost half the per capita GDP of poor countries.

Economists such as Jeffery Sachs and Pia Malaney, both formerly of the Center for International Development at Harvard University, have examined the relationship between malaria and poverty in an attempt to better understand the influence each has on the other. They observed that countries that have eliminated malaria happen to be outside the tropics or on the fringes. In other words, these countries did not have to face head-on the lethal impact of the mosquito species Anopheles gambiae and the parasite Plasmodium falciparum, a combination that thrives in sub-Saharan Africa. “With respect to the relationship between malaria and poverty, it is difficult to disaggregate the direction of causation, i.e., to what extent malaria causes poverty and poverty causes malaria,” Malaney said.

Studies have proven that up to 50 percent of medically related school absenteeism in the sub-Saharan region is due to malaria. This is just another way in which the disease diminishes a country’s human capital. Credit: IRIN

According to reports, approximately 500 million clinical cases of P. falciparum malaria occurred worldwide in 2002, and Africa accounted for almost 350 million of these cases. One million people in sub-Saharan Africa die of malaria each year, which accounts for 90 percent of malaria mortality globally. According to WHO, most of the victims are children under age five.

“All the risk factors are here,” said Daniel Feikin, a medical epidemiologist at the Kenya branch of the Centers for Disease Control (CDC). “Crowding, malnutrition, no access to safe water, living in an area with a lot of mosquitoes carrying malaria, and HIV epidemics -- they’re all here.” In western Kenya, where Feikin works, life expectancy is 38 years of age.

Studies consider fertility rates, premature mortality, demographic shifts, medical costs, saving and investment habits, productivity and absenteeism as typical factors caused by malaria that impede development and, when aggregated, create huge GDP losses.

Despite an absence of statistics to directly corroborate most of these connections, economists have developed compelling arguments. They suggest that a high-fertility/high-mortality environment can shape behaviour in a way that impoverishes both households and nations. During the 1990s, sub-Saharan Africa witnessed a median childhood-malaria-specific mortality count of approximately 10 per 1,000 in children from birth to age four. Additionally, malaria accounts for about 25 percent of all-cause mortality in this age group in regions where the disease enjoys stable endemic transmission.

Changing people’s attitude

The mind-set that has developed as a result of this grim environment is captured in an old African proverb: “You can’t hold your children like eggs.”

“I’ve heard mothers here say you have to have six children, so that you get one who will be educated and take care of you financially and one who will stay home and take care for you when you are old,” said Mary Hamel, chief of the malaria branch at the joint CDC/Kenya Medical Research Institute (KEMRI), also based in western Kenya.

“You have six, so two survive,” she explained. “It’s what we used to do in the US around the turn of the century. It wasn’t until child mortality declined that then you saw a decline in the fertility rate. The impact of this disease is tremendous.”

High fertility rates can create a string of consequences adverse to economic development. There is the likelihood of reduced investment per child, especially for girl children. Daughters, who probably spend most of their prime working years involved in child rearing, might be seen as a bad educational investment. This results in women having limited employment opportunities and work experiences. Their long-term absence from a nation’s labour pool can have a significant impact on an economy.

Furthermore, if parents compensate for high child mortality by having larger families and their children beat the odds and survive, they must struggle to provide for their dependents. Large numbers of children severely limit a family’s ability to accumulate household savings. The burden extends beyond individual households to impact the health, education and employment sectors and lowers the gross national product.

Absenteeism is another way malaria drains an economy. Kenya, for example, loses approximately 170 million working days annually to the disease. Malaria forces Kenyan primary school students to miss 11 percent of school days per year. Secondary students miss 4.3 percent. Other studies have suggested that 13 percent to 50 percent of medically related school absenteeism is due to malaria. A side effect of missing class so often can be higher drop-out rates, which further diminish a country’s human capital.

Heavy opportunity costs

On-going campaigns to eradicate malaria cost African countries, and their donors, many millions of dollars every year and represent a high opportunity cost from an economic perspective. Money that should be invested in development is instead used to combat disease and create the pre-conditions for development to occur. The expected benefits of this huge on-going investment in control and prevention, however, are not always realised.

Malaria control efforts in sub-Saharan Africa are widely regarded as having achieved little if any success. Infection rates in particular countries or regions may have fallen, but the overall number of deaths from malaria is increasing. In the 1960s, WHO sponsored an intensive malaria control and research project in the district of Garki, Nigeria. Over the course of seven years, the Nigerian government and WHO spent over $6 million on malaria-eradication efforts in 164 villages. People were given mass drug administration, and insecticide was sprayed in every hut during the time of the study. Despite the apparent reduction of mosquitoes in the area, there was no substantial change in the rate of villagers contracting malaria. The control efforts in this project, like many others in sub-Saharan Africa, failed due to the vectorial capacity of the mosquitoes carrying the parasite, which greatly exceeded what was required to halt transmission of malaria.

A costly burden on health services

Malaria also robs the wealth of a country through the strain it places on the health system. WHO estimates that malaria accounts for 25 percent to 40 percent of outpatient visits and 20 percent to 50 percent of hospital admissions in African countries where the disease is endemic.

Juliana Otieno, a doctor at a provincial hospital in Nyanza in western Kenya, cannot say precisely what proportion of the facility’s budget is spent on fighting malaria, but she knows it is high. "We've never figured it out, but it is a giant expense. Certainly, malaria takes the majority of our budget," said Otieno, who is the head of the paediatric ward and one of only two paediatricians on staff. "The economic impact on the community is immense, and devastating on families."

From April through June, the worst months for malaria in Nyanza, the 40-bed paediatric ward admits up to 130 patients a day. The patient overflow not only places a huge burden on staff, it also leads to additional costs for parents, as they are left with the responsibility of buying the necessary medicines. This scenario is repeated in thousands of rural communities across the continent.

Poverty fuelling the parasitic infection

In 2002, the government of Malawi launched one of the largest insecticide-treated bed net (ITN) distribution programmes in Africa. ITNs were subsidised to the highest levels possible and distributed through child health clinics, community networks and the private sector. The programme proved to be successful to a significant degree and reduced the number of people infected with malaria. Yet the poorest of the poor, who lived in some of the most isolated and malaria-infested areas, still could not afford to buy ITNs, despite the reduced prices. Malaria in those areas continues to thrive.

Many experts believe that if any progress in fighting malaria in the poorest countries – where populations place food and water atop any priority list – is to be made, medicines and ITNs must be distributed free of charge.

Affecting development choices

Julius Mono, a native of southern Sudan, is a senior administrative officer with GTZ, a German development company that is building roads in south Sudan. Having just returned from Bor, in the greater Upper Nile region, where malaria is hyper-endemic, Mono is under no illusion of the impediment that the disease poses to his company's plans.

A smile to get through it all. Because of the connection between poverty and malaria, and the nature of climate and ecology of tropical Africa, the parasitic infection delivers its heaviest blow on the African continent. Credit: Stephenie Hollyman/WHO

From May through July, he said, malaria affects about three-quarters of the breadwinners in Bor, a region that can only be reached by airplane during certain periods of the year. There is no hospital. Within this context, malaria makes building a road in Bor at least 10 times more expensive than building one in other parts of south Sudan. The costs of a team of health workers – as well as the provision of basic medical supplies and equipment – need to be factored into any project in Bor. If workers fall seriously ill, developers have to be prepared to transport them to hospitals as far away as Nairobi, well over 1,000 km away.

"This is a disease that affects large economies and small,” said Mono. “It affects the economies of nations and households. It has an impact on everything -- from building roads to building a fire at home. Its impact runs from top to bottom."

Mono notes that these additional costs have not been lost on donors. When it comes to investment in other parts of south Sudan, the figures illustrate the donors’ preferences. Places like Yei and Narus, which are closer to the border with Uganda and the Democratic Republic of Congo and have some infrastructure and malaria control, become more obvious choices compared with Bor, which is riddled with malaria and far more inaccessible.

"What happens when you get this sort of cost-benefit approach to donorship is that isolated areas, areas that often have the greatest needs, are left behind," he said.

Malaria remains a significant obstacle to development. In the most malaria-endemic areas, poverty and insufficient healthcare have diminished control and treatment efforts that have had a positive impact elsewhere in the world. According to WHO, over three billion people live under the threat of malaria globally. It kills more than one million people each year, mostly children. Because of the close connection between poverty and the parasitic infection, and the nature of the climate and ecology of tropical Africa, malaria delivers its heaviest blow on the African continent.

"Different diseases do different things to Africa.” Mono said. “Malaria keeps Africa down."