Effects of Disease Prevention Bundles and Delivery on Health in the Horn of Africa– A comprehensive study

Cover picture - UN News

Development Studies: Malaria and Gastro-intestinal diseases in the Horn of Africa Evidence suggests that providing bundles at no cost maximises accessibility, particularly for vulnerable groups like children under 5 and pregnant women. By using Community Health Workers (CHWs) to deliver preventative goods directly to households, the use of fixed facilities as a centre for goods would not be required, it creates trust, increases usage, and improves health outcomes.

Background Healthcare plays an essential role in allowing basic societies to function through the treatment of diseases and the maintenance of health. However, arguably more important than treatment in some regards, is the prevention of ill-health in the first place. This can be achieved through various means, and a prominent method is the use of mosquito nets to reduce the risks of infectious and gastrointestinal illnesses which are incredibly dangerous in hot, humid, equatorial climates. Diseases spread through vectors contribute to more than 700,000 deaths each year, where 95% of malaria induced deaths in 2022 were in the WHO Africa Region. (CDC, 2023) Those most vulnerable to malaria and other vector - borne - diseases include children under the age of 5 who have not yet developed partial immunity to malaria, and pregnant women whose immunity is altered during the pregnancy, especially during the first and second pregnancies. However, there has been a significant decline in multiple vector-borne diseases (UK Health Security Agency, 2023) , (The Royal Society, 2001), including those transmitted by Anopheles funestus, following the desertification of tropical regions, especially in the Sahel and Amazon Rainforest, due to human actions such as deforestation and agriculture. A decline in soil's water retention capacity and evapotranspiration creates a less humid environment, which sterilises the breeding grounds of these vectors The decline in illness following a decline in the population of vectors highlights the importance of them in disease transmission, as evidenced by the decline in the malaria parasite index in children from 40-80% in 1967 to 10% in 1991 and 1992. The substantial decrease in malaria transmission underscores the critical role vectors play in spreading disease, illustrating how environmental changes can directly impact public health by altering vector populations.

Preventative healthcare goods, such as bed nets, are vastly under-consumed. Regions in the midst of development contend with heightened vulnerability to an array of health hazards, including vector-borne diseases, diarrheal afflictions, and exposure to pathogens in contaminated water sources, in contrast to their counterparts in well-developed nations. The under-consumption of healthcare materials can be attributed to a range of factors, with psychological barriers and monetary constraints being the main drivers. People's reluctance to travel and the effort required to collect merit goods constitute significant impediments. Despite the advantages associated with such goods, the prevalence of quasi-hyperbolic discounting significantly influences decision-making processes, leading to less investment in long-term gains and increased spending on short-term benefits.

A proposed solution to this problem of under-consumption emerged while reading Esther Duflo and Abhijit Banerjee's "Poor Economics." They identified a discrepancy where people acknowledged the benefits of using healthcare materials but did not act on that knowledge. This gap between awareness and action suggests that financial and psychological struggles hinder individuals from taking necessary steps to achieve good health. The salience of benefits alone had not led to a significant increase in consumption, highlighting the need for strategies that address both financial constraints and psychological barriers.

To tackle this issue, a practical step is to introduce a system for delivering and bundling healthcare materials. This involves combining various goods into a single package sold as a single unit, while optimising the distribution of these bundles.

1. Introduction 1.1 Context of Absolute Poverty

Absolute poverty is defined as living on less than $1.90 PPP per day. Diseases significantly contribute to the persistence of poverty traps and exacerbate poverty, particularly in nations that under-consume healthcare goods. Vector-borne diseases and the consumption of contaminated water significantly hinder individuals' ability to work, resulting in a loss of income. This issue is particularly severe in low-income countries, where the absence of adequate social safety nets, such as sick leave and unemployment benefits, worsens the financial strain on affected households. Consequently, families may be forced to deplete their savings, if available, or resort to borrowing from predatory lenders to meet their basic needs.

1.2 Impact of Diseases on Poverty The adverse effects of disease on households in the absence of adequate welfare infrastructure can be illustrated by examining the impact of COVID-19 on highly developed countries such as the UK (M. Brewer, 2021) , (M Brewer et al., 2020). To measure the effectiveness of the welfare state in protecting household incomes, it is important to understand the extent to which the UK was affected by the pandemic due to its status as a developed nation. In 2021, the UK ranked among the top five countries globally for deaths per million and was in the top twenty for the highest number of infected cases (HM Treasury, 2020). The government implemented strict lockdown measures, resulting in household net income decreasing by an estimated average of 6.9%. To calculate the effectiveness of welfare policy, post-pandemic statistics can be compared to pre-pandemic levels of household net income. A 100% effectiveness rating would correspond to a return to pre-pandemic levels of household net income.

The changes in social security specifically included a £20 per week increase in the standard allowance of Universal Credit (UC) and Working Tax Credit (WTC). Additionally, the Job Retention Scheme (JRS) and the Self-Employment Income Support Scheme (SEISS) helped prevent sharp falls in household income. However, it is unreasonable to assume that household income changes are equivalent across all deciles of pre-pandemic income levels. Those with higher household incomes were affected more severely than those with lower pre-pandemic incomes. For ease of analysis, this paper will address the average change in household income in all working households between February 2020 and May 2020. Overall, net household income fell by roughly 7%. Without a social security net, households might have lost about 30% of their net income, indicating that these policies were around 77% effective in returning household net income to pre-pandemic levels. This highlights the importance of social security nets, which are often insufficient in developing nations. The parallel drawn between the UK during COVID-19 and developing nations arises from the rampant effect of the virus even in a cold climate, akin to the rapid spread of diseases like malaria in hot equatorial climates. Losses of income are not mitigated, and households bear the full brunt of unemployment and productivity declines due to illness. These effects can be illustrated by examining the impact of malaria on rural small farmers (RSF) and agri-business/industry labourers (AB/IL) in Kenya, excluding urban middle-income workers (C. Leighton et al., 1993). The losses experienced by urban middle-income workers are proportionately less, relative to their annual income, than those experienced by RSFs and AB/ILs. Assuming annual household incomes for RSFs and AB/ILs are 20,000 KES and 35,000 KES respectively, malaria results in a loss of 1,920 KES (£12 PPP) and 660 KES (£3.97 PPP), respectively. Including healthcare costs, these households may lose around 17.6% and 5.25% of their earnings, respectively, with similar figures reported in Nigeria and other sub-Saharan nations. Rampant inflation due to the pandemic and conflicts, such as Russia’s invasion of Ukraine, exacerbates these impacts by increasing food prices, which account for 20% of global caloric intake (World Gain, 2024)

Poor families in developing countries spend approximately 50-80% of their incomes on food. Consequently, when food prices increase, these families have less money available for savings and are often compelled to use their savings to cover essential expenses such as medicines and food (H. J. Brinkman et al., 2009).

The lack of savings is a critical issue for many in developing communities and even in the developed world. Without savings, families have no buffer against unexpected events, forcing them to borrow from loan sharks with rates of 50% APR or higher, as seen in the UK following the pandemic (BBC, 2023). High interest on loans increases the amount borrowers must repay, leading to psychological stress and reducing disposable income. This prevents low-income families from planning for the future and making investments, keeping them trapped in poverty.

1.2 Overview of Healthcare Consumption

Besides the effects of poverty on welfare and the cycle of poverty in developing nations, this paper focuses on the under-consumption of healthcare goods. This issue is evident in various unsuccessful campaigns aimed at promoting the use of chlorine tablets and bed nets. For example, door-to-door marketing efforts in India have led to some sales, but often these purchases were driven by guilt rather than genuine intent to use the products. As a result, the items were frequently never utilised, undermining the campaigns' effectiveness in improving public health (Royal Economic Society, 2018). Despite these challenges, there have been successes through co-selling more well-known products alongside health goods. This approach leverages a positive framing effect and an understanding of consumer behaviour, resulting in approximately double the free chlorine content detected in households' drinking water. Given the success of projects that focus on behavioural elements, the remainder of this paper will explore other methods to encourage the consumption of these health-promoting goods (S. Ahmed et al.,2011).

1.3 Hypotheses Hypothesis 1: The use of bundles to combine disease preventing commodities will increase consumption of them and therefore reduce the likelihood of disease in rural communities in the Horn of Africa Hypothesis 2: The use of a community health worker (CHW) led delivery system of the bundles will contribute to increasing uptake of the disease preventing technologies and therefore reduce the likelihood of disease in rural communities in the Horn of Africa 2. Challenges in Healthcare Access 2.1 Socioeconomic Factors Affecting Healthcare Access Rural communities in developing countries generally have less access to healthcare compared to their urban counterparts. This disparity arises from factors such as cost, educational gaps, and distance from medical facilities. A study conducted in Kenya revealed that 23.3% of participants did not seek healthcare during illness. Among these, 42.8% resorted to self-medication by purchasing non-prescription drugs from shops or pharmacies (A. Ngugi et al., 2017) , (A. Mehmood et al., 2016). Another 20% avoided healthcare facilities due to high costs or lack of funds, 9.9% considered their illness not serious enough to warrant a visit, and 8.1% found the nearest facility too far away or lacked transport

2.2 Transport as a Barrier to Seeking Healthcare Travel costs, especially in terms of time, pose a significant burden for the 8.1% who need to travel for healthcare. They forgo wages during this time, further diminishing their motivation to seek medical care. This travel time represents an opportunity cost, which could otherwise be spent on income generation or educational activities vital for lifting families out of poverty. Additionally, responsibilities such as childcare and household maintenance often take precedence over healthcare, as these are viewed as non-negotiable (J. Taber et al., 2014).

In contrast, developed nations benefit from well-established transport infrastructure, including rail, buses, and other public transport options. Unfortunately, such infrastructure is often limited to urban centres in developing countries. Furthermore, inadequate road infrastructure in rural areas can make travel difficult, whether that’s via walking, bike or car, discouraging the 8.1% from seeking necessary medical services due to distance and travel challenges.

2.3 Illness as a Barrier to Seeking Healthcare in Rural Areas The inability to access healthcare can be exacerbated by illnesses that cause immobility. Many infectious diseases prevalent in impoverished equatorial regions, such as Dengue fever, Chagas disease, Onchocerciasis, Schistosomiasis, Lymphatic Filariasis, and Polio, fall into this category. These vector-borne or sanitation-related diseases are preventable. As discussed earlier, prevention is crucial. Measures such as insecticide-treated bed nets (ITNs) and chlorine tablets can significantly reduce the risk of these diseases, helping individuals avoid the struggles associated with immobility and access to healthcare.

Figure 1: Regions in the Horn of Africa with high malaria prevalence (red) and poor infrastructure (blue). Overlapping areas indicate where healthcare delivery faces the greatest challenges. Adapted from (Mapsland,n/d)

3. Health Goods Utilisation 3.1 Overview of ITNs and Chlorine Tablets 3.1.1 Vector Resistance to Insecticides Pyrethroid and deltamethrin are insecticides commonly used to treat nets to kill vectors. However, more than 100 mosquito species worldwide have developed resistance to one or more insecticides, including 56 species of Anopheline and 39 species of Culicine mosquitoes. This resistance threatens the effectiveness of ITNs in preventing the transmission of infectious diseases (L. Smith et al., 2016), (N. Liu et al., 2006). Outside of insect resistance, the combined insecticidal and irritant effects of pyrethroids, along with the physical barrier of the bed net, have been found to reduce vector density, sporozoite rates (the first form of the malaria parasite entering the human body, with the rate being the number of mosquitoes infected with sporozoites divided by the total number of mosquitoes examined, expressed as a percentage), malaria parasite prevalence, disease incidence, and all-cause child mortality.

The success of ITNs in achieving these goals has led to the transportation of 300 million ITNs to Africa at a cost of more than US$1 billion for their purchase and distribution. While there is controversy over the effectiveness of foreign aid, this paper focuses solely on the effectiveness of prevention methods, including the use of ITNs, bundles, and delivery services

3.1.2 ITNs’ Impact on Malaria Transmission and Child Mortality Although mosquitoes are gradually developing resistance to pyrethroids, numerous studies have demonstrated that ITNs remain effective in protecting against malaria transmission in areas with pyrethroid-resistant mosquito populations when properly deployed (K. Lindblade, 2015). In Malawi, household ownership of at least one ITN increased from 27% in 2004 to 55% in 2012. The use of ITNs by children under the age of 5, one of the most vulnerable groups, contributed to a decrease in national malaria parasite prevalence from 43% in 2010 to 28% in 2012. In regions where deltamethrin killed only 38% of An. funestus (the main malaria vector) and 53% of An. gambiae s.l. (the secondary vector), ITNs reduced the incidence of malaria by 30% among children aged six to 59 months, even with the vectors' resistance to deltamethrin. Beyond individual protection, high ITN usage rates can suppress malaria transmission community-wide, benefiting even those who do not use bed nets through herd immunity. These findings demonstrate that ITNs continue to be effective in preventing malaria infections, even in areas where pyrethroid-resistant An. funestus is the dominant vector (M. Kilama et al.,2014).

The continued effectiveness of ITNs in the presence of insecticide resistance may be attributed to the sublethal effects of pyrethroids. For instance, increased irritancy upon contact with treated netting can reduce a mosquito's ability to find and feed on a host or incubate malaria parasites. Additionally, in the absence of insecticides, vector competence may decline, particularly affecting the survival of insecticide-resistant mosquitoes (SW Lindsay et al., 2021). While ITNs are still effective, their ability to kill mosquitoes and prevent disease transmission is declining due to rising resistance among mosquito populations. Understanding how mosquitoes are developing resistance, particularly to pyrethroids, is crucial. This knowledge could lead to new approaches for deploying ITNs to maintain their effectiveness despite these challenges.

3.1.3 Effects of Faecal Water Contamination and Diarrhoea While ITNs can mitigate the risk of infectious diseases spreading through vector transmission, humans have a need for water. In developing communities without access to a sanitary freshwater well or a pipeline, water may be taken and used for consumption and bathing in unsanitary static water sources where pathogens are able to grow and diversify. Contamination of water is not only at the source, however, can occur during transportation or when being stored at home or in the village.

In Africa and Latin America, studies indicate that a village child may have as many as 6 to 10 bouts of diarrhoea a year, each lasting an average of 3 days. Diarrhoea can cause death, and is also a significant contributor to malnourishment in the children that survive (J. Gasana, 2002). The primary source of microbial contamination is human faeces, and children may come into contact with these harmful agents indirectly, often through contaminated drinking water, bottle formula, or weaning foods. In Rwanda, diarrheal diseases rank as the second leading cause of morbidity after malaria with more than 89% of children affected by diarrhoea being between the ages of 0 and 2, and the greatest effects among those aged 6 to 11 months, likely due to this being the critical period when weaning begins (Palintest, 2020) , (Food Standards Scotland, n.d) , (K. Sankaranarayanan, 2014).

NGO guidelines suggest that 10-100 Colony Forming Units (CFU - a measure of viable colonogenic cell numbers in CFU/mL) per 100 mL is tolerable for short periods of time, but above 100 CFU per 100 mL the risk to life is too great (New Brunswick, n.d). With faecal coliforms, the WHO suggests that the CFU/100mL in irrigation water for crops to be eaten raw should be less than 1000 and for drinking water to be safe CFU/100mL should be at 0. Despite this, an average was taken from three different counties across Kenya, total coliforms per 100mL in boreholes were 982 and 1203 in river water which are both dangerous levels of total coliforms to human health when consumed (A. Onyango et al., 2018) , (R. Abila et al., 2012) , (M. Osiemo et al., 2019)

Elevated coliform levels in water are associated with a range of severe health implications, including typhoid fever, cholera, bacillary and amoebic dysenteries, various gastrointestinal disorders, respiratory illnesses, peripheral vascular diseases, and gangrene (A. Bhargava et al.,2003)