By Brittany Gardner

Introduction

Malaria is an incredibly difficult disease to combat, especially in high-transmission zones. A plethora of complex, multifaceted issues contribute to the pervasive nature of malaria in Sub-Saharan Africa, and oftentimes these issues merely isolate poverty as the single cause of high malaria transmission rates. Most societies choose to treat malaria directly through the use of antimalarial commodities rather than addressing the root causes, because the root causes are often difficult to determine and unrelated to the disease itself. This is especially true in Africa, where the malaria burden remains the highest globally. The Democratic Republic of the Congo (DRC), a large country located in central Africa, constitutes 10% of the approximate 407,000 annual malaria-related deaths in Sub-Saharan Africa.¹ Factors such as socio-economic turmoil and lack of infrastructure impair malaria prevention and treatment access. Consequently, an increase in mortality levels due to malaria results in economic repercussions, including but not limited to reduced working time, productivity, and family income.² Currently, aid organizations such as the President’s Malaria Initiative focus on improving the supply chain movement of antimalarial commodities so that supplies reach the desired locations when required. However, this current method of supply chain design does not account for the majority of challenges facing the DRC regarding malaria. Failure to focus on the holistic spectrum of issues surrounding the causal factors related to malaria results in a narrowly-focused methodology that ultimately hinders effective aid. These issues are critical to understand because malaria-related mortality is preventable and impairs the industrialization of the DRC.

MOST SOCIETIES CHOOSE TO TREAT MALARIA DIRECTLY THROUGH ANTIMALARIAL COMMODITIES RATHER THAN ADDRESSING THE ROOT CAUSES...

Often transmitted through the bites of female Anopheles mosquitoes, malaria is a treatable and avertable infectious disease caused by unicellular organisms of the genus plasmodium. Once malaria transmission occurs, the host will begin displaying flu-like symptoms after 10–28 days; although, in some cases symptoms may remain dormant for months or even years. In geographic locations where malaria is pervasive, it is rare that individuals live their whole lives without serious complications. Instead, most victims exhibit significant malaria-induced maladies, sometimes resulting in death. Not only are approximately 32% of outpatient visits in the DRC directly attributable to malaria, but 36% of deaths are caused by malaria-related illness.³ Only a mere 30% of the Congolese people have access to medical aid.⁴ The scarcity of accessible health care causes these entirely preventable malaria-related deaths.

Mainstream opinion suggests that the issue of malaria will be effectively resolved through the continued donations of antimalarial commodities and the eventual elimination of poverty in the DRC.⁵ However, this model is unrealistic. Poverty is too large of an issue to readily combat because it is the result of larger socio-economic and political issues. Antimalarial commodities are effective and have led to the drastic decline–from 52.5% in 2005 to just 24.6% in 2015–in the incidence of malaria in the DRC.⁶ Nevertheless, the decline in malaria mortality has only further complicated the Congolese people’s desire to prevent malaria. A factor contributing to this complication is that malaria in the DRC is viewed as part of everyday life, no differently than how we view contracting the flu in the United States. The debilitating mindset of malaria as just another everyday disease causes new victims not to seek treatment. Because of this, plasmodium is spread to more vulnerable populations and results in a higher mortality rate. This research seeks to identify the causal factors inhibiting the current success of cost-effective, long-term malaria aid in the DRC while focusing on the distribution of effective aid in order to redefine the structural method to combat malaria.

THIS RESEARCH... USES INTERVIEWS WITH SUBJECT MATTER EXPERTS ALONGSIDE A SEMANTIC ANALYSIS...

Methodology

This research employs a qualitative knowledge-based interview with subject matter experts alongside a semantic analysis to aggregate the factors and conditions that have an effect on the cost of malaria prevention and treatment efforts within the DRC. The aim of this research is to optimize humanitarian aid by eliminating repetitive data accumulation processes in order to create a more holistic view of supply chain improvement in the DRC. As part of this study, ten individuals experienced with malaria-aid and DRC-centric issues out of a recruitment pool of 30 people were interviewed via email and phone calls.

Fifty percent of the participants were involved in the DRC for more than ten years, and 70% of the participants were doctors and malaria aid workers. The questions utilized in this study had three purposes: to verify the interviewees’ practical knowledge on the current state of malaria, to gauge interviewee opinion on the current antimalarial supply chain processes, and to investigate the availability and effectiveness of current prevention and treatment efforts from a sociological and cultural perspective. The data were subsequently inputted into a program for the purposes of information analysis, conclusion development, and juxtaposition of results with the literature review.

Results

Ninety percent of the participants stated that treatment and prevention methods for malaria were adequate to meet demand. Currently, the rate of malaria mortality remains high even though the antimalarial commodities are sufficient to meet demand. While the treatment methods are available, too often they are inaccessible to the people who need them. Some of the issues contributing to this disparity between the availability of the commodities and the demand include inability of the population to follow the guidelines given by the DRC Ministry of Health, lack of funded means to access care, stock-out rate, and the physical distance between those populations needing services and the existing health structures. One interviewee said:

“Most people don’t live within access of effective malaria cures or treatments. A lot of times the government health centers usually didn’t have much medicine. It would often get sold out on the side when it would first arrive, and so medicine was not readily available.”

Figure 1. Root cause analysis of the causal factors of malaria.

Additionally, the few roads that exist remain in a state of disrepair, and electricity and cell phone reception are inaccessible in parts of the country. Interviewee three noted that if the goods and supplies somehow do get delivered, it is “usually from the capital city distributed by air, which is expensive, just because the roads aren’t passable.” The equatorial forest inhibits transit, and the lack of urbanization throughout the country leads to externalities that impede the management of the disease. Financial inaccessibility demotivates the population, as wages in many sectors outside of public health are insufficient. Politically, the DRC has a history of violence that has given rise to dozens of armed groups, leading to an unstable government incapable of attaining order. Historically, poverty accompanies malaria and creates a mentality of short-term gain where individuals focus more on their day-to-day lives instead of a long-term perspective where people focus on their future well-being. This exacerbates the current in-country issues because those who have developed a resistance to plasmodium do not seek treatment and, instead, decide to live with malaria, expediting malaria transmission. Furthermore, the DRC does not have the capital to fund necessary malaria aid; instead, it relies almost entirely on foreign aid. These foreign entities may place restrictions on the money by only allocating it for a predetermined set of initiatives that may not align culturally with the DRC. Interconnectivity between health structure layers is severely lacking. Communication disparities and dozens of concurrently-operating supply chains lead to the inability to meet demand, a lack of historical use data, and increased cost of providing aid.

From the key findings of the research, the team discovered that malaria was a systemic challenge comprised of self-sustaining issues rather than, solely, a supply chain issue. An endeavor to fix the supply chain issue would be inefficacious in decreasing the rate of malaria mortality in the DRC because it is a societal problem that necessitates an approach focusing on the root causes. Figure 1 indicates the root causes of the challenges to eliminating malaria in the DRC. The DRC’s impoverished conditions lead to violence that, in turn, destabilizes effective government and renders the government incapable of funding malaria aid. This reliance on foreign aid becomes ingrained in the country and weakens the culture, promoting poverty by inhibiting self-sufficiency. This is a departure from the traditionally-held belief that malaria will be solved through the elimination of poverty and the use of antimalarial commodities and, instead, pinpoints five systemic issues—socio-economic turmoil, foreign reliance, poor government, cultural issues, and violence—that create a self-propelling cycle of malaria in the DRC. Antimalarial commodities merely treat the symptoms of malaria; however, malaria can be best combated through addressing the five root causes of malaria in the DRC.

Analysis

Although the current approach to eliminating malaria focuses on poverty, this is difficult and ultimately ineffective because of the deep associations between malaria and poverty. To eliminate malaria, humanitarian aid must migrate from a platform of simply providing supplies to one which stimulates intra-country aid efforts and spearheads economic independence. This can be done by heavily subsidizing antimalarial commodities, enabling in-country production, and offering the commodities in exchange for an alternative form of payment if an individual cannot afford the cost.

TO ELIMINATE MALARIA, HUMANITARIAN AID MUST MIGRATE... TO (AID) THAT STIMULATES INTRA-COUNTRY AID EFFORTS...

Currently, value is not attached to antimalarial commodities in the DRC, which decreases the usage and adoption of these items. The mentality of the Congolese people that antimalarial commodities will continue to be provided at no cost to them creates a systematic reliance that detaches value from the commodity. For example, the government has made it illegal to sell insecticide-treated mosquito bed nets because it does not want citizens to sell the cost-free nets provided by aid organizations. Not only does this prevent people from buying the nets when needed, it inhibits in-country production. Malaria is a systemic societal problem from which a supply chain issue is created, meaning that if the supply chain issue were to be eliminated, malaria-related mortality would hardly be impacted. The current mortality rate is a consequence of combined issues (Figure 1), and in order to break the cycle, we must begin to eliminate these systemic issues. When one of the issues is eliminated, the rest become infinitely easier to tackle.

Helping the Congolese people adopt a long-term mindset by expanding their understanding of normalcy—a life without malaria—can heighten resolve and induce the citizens to seek and manage malaria-related illness, thereby reducing the exposure rate. Mitigating violence has great potential to stabilize governmental power and reprioritize the country’s resources. Furthermore, reducing poverty can create prosperity by allowing the Congolese people to have options when spending, thus leading to increased economic independence and reductions in violence. These actions would ultimately reattach value to antimalarial commodities and enable the country to become self-sufficient. Finally, a non-corrupt government would possess an increased ability to enforce law and order, enhancing their ability to make long-term decisions to better the Congolese people.

The common wetland mosquito.

Discussion and Conclusion

In conclusion, this root cause analysis moves the current approach of combating malaria-related mortality from a mindset that forces an overreliance on external aid and cripples the country’s ability to become self-sufficient to a mindset that focuses on increasing in-country production and antimalarial commodity usage. Although antimalarial commodities contribute to the decline of malaria, malaria in the DRC will only be eradicated upon the elimination of the country’s societal challenges. The results of the study demonstrate the interrelation between supply chain and non-supply chain issues, provide key insight for malaria aid organizations on the spectrum of challenges affecting the DRC malaria, and assist in creating a holistic approach to reduce malaria-related mortality. The aforementioned approach incorporates an integrated view of the supply chain in conjunction with socioeconomic, cultural, and political issues. This model may beget the government’s capability to enforce law, provide education, promote gainful employment, and, ultimately, reduce reliance on foreign aid. When the Congolese people reprioritize malaria as a significant systemic issue and begin to target the operational inefficiencies that exist in the DRC, more than 40,000 preventable malaria-related deaths annually will drastically decline.¹

This decrease in unnecessary deaths will allow the DRC to become a more industrialized nation, ultimately bettering the Congolese people by increasing the country’s stability and presence on the international stage.

Acknowledgments

Special thanks to Dr. Malini Natarajarathinam and Dr. Wei Lu for their willingness to become my research advisors and their untiring guidance and direction without which this study would not have been possible.

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Brittany Gardner '18

Brittany Gardner is a senior supply chain management student with a certificate in professional development from Spring, Texas. Brittany completed the work for this article while participating in the 2017–2018 class of the Undergraduate Research Scholars under the guidance of Dr. Malini Natarajarathinam and Dr. Wei Lu. Upon graduation, Brittany will begin work as a management consultant for PricewaterhouseCoopers.

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References

1. World Health Organization. 2017. World Malaria Report. Geneva: World Health Organization.

2. Nkohkwo, Quinta Nven-akeng, and M. Sirajul Islam. 2013. “Challenges to the Successful Implementation of e-Government Initiatives in Sub-Saharan Africa: A Literature Review.” Electronic Journal of e-Government 11, (1): 253–267.

3. U.S. Aid, CDC, U.S. Department of State, and USA Department of Health and Human Services. 2017. “Malaria Operational Plan FY 2017.” PMI.https://www.pmi.gov/docs/default-source/default-document-library/malaria-operational-plans/fy17/fy-2017-democratic-republic-of-congo-malaria-operational-plan.pdf?sfvrsn=19.

4. U.S. Aid. January 25, 2018. “Health Fact Sheet | Fact Sheet | Democratic Republic of the Congo.” U.S. Agency for International Development.https://www.usaid.gov/democratic-republic-congo/fact-sheets/usaiddrc-fact-sheet-health.

5. Teklehaimanot and Paola Mejia, Awash. 2008.”Malaria and poverty.” Annals of the New York Academy of Sciences 1136 (1): 32–37.

World Health Organization, Global Health Observatory Data Repository. “Incidence of Malaria in the Democratic Republic of the Congo.” Incidence of Malaria Data.https://data.worldbank.org/indicator/SH.MLR.INCD.P3?locations=CD.