Malaria is endemic in 13 of 64 districts in Bangladesh. About 14 million people are at risk. Some evidence suggests that the prevalence of malaria in Bangladesh has decreased since the the Global Fund to Fight AIDS, Tuberculosis and Malaria started to support the National Malaria Control Program (NMCP) in 2007. We did an epidemiological and economic assessment of malaria control in Bangladesh.
Methods
We obtained annually reported, district-level aggregated malaria case data and information about disbursed funds from the NMCP. We used a Poisson regression model to examine the associations between total malaria, severe malaria, malaria-attributable mortality, and insecticide-treated net coverage. We identified and mapped malaria hotspots using the Getis-Ord Gi* statistic. We estimated the cost-effectiveness of the NMCP by estimating the cost per confirmed case, cost per treated case, and cost per person of insecticide-treated net coverage.
Findings
During the study period (from Jan 1, 2008, to Dec 31, 2012) there were 285?731 confirmed malaria cases. Malaria decreased from 6·2 cases per 1000 population in 2008, to 2·1 cases per 1000 population in 2012. Prevalence of all malaria decreased by 65% (95% CI 65–66), severe malaria decreased by 79% (78–80), and malaria-associated mortality decreased by 91% (83–95). By 2012, there was one insecticide-treated net for every 2·6 individuals (SD 0·20). Districts with more than 0·5 insecticide-treated nets per person had a decrease in prevalence of 21% (95% CI 19–23) for all malaria, 25% (17–32) for severe malaria, and 76% (35–91) for malaria-associated mortality among all age groups. Malaria hotspots remained in the highly endemic districts in the Chittagong Hill Tracts. The cost per diagnosed case was US$0·39 (SD 0·02) and per treated case was $0·51 (0·27); $0·05 (0·04) was invested per person per year for health education and $0·68 (0·30) was spent per person per year for insecticide-treated net coverage.
Interpretation
Malaria elimination is an achievable prospect in Bangladesh and failure to push for elimination nearly ensures a resurgence of disease. Consistent financing is needed to avoid resurgence and maintain elimination goals.
Funding
None.
Introduction
Go
Bangladesh has a history of endemic malaria transmission in 13 of 64 districts. Up to 70?000 laboratory-confirmed and 900?000 clinical cases (appendix p 1), with more than 500 deaths per year, were reported in the late 1990s.1, 2, 3 Unreported cases might have been as high as 250?000 each year.4 A cross-sectional survey in 2007 reported a crude prevalence of 4% in the 13 malaria-endemic districts.5 More than 90% of cases were Plasmodium falciparum.5 The highest prevalence (>10%) was identified in three districts of the Chittagong Hill Tracts in southeastern Bangladesh.5
The Global Fund to fight AIDS, Tuberculosis and Malaria (Global Fund) approved funds in 20064 (Round 6) and 20096 (Round 9) to support the Bangladesh National Malaria Control Program (NMCP). The NMCP was implemented by the Bangladesh Ministry of Health with BRAC (a national non-governmental development organisation). The goals were to: (1) reduce malaria morbidity and mortality; (2) provide community-based services that increased access to diagnosis and treatment with artemisinin-based combination therapies in hard-to-reach regions; (3) provide longlasting insecticidal nets (LLINs) to 100% of households in the three malaria-endemic districts with the highest malaria burden and 80% coverage in the other ten malaria-endemic districts; (4) strengthen the malaria epidemiological surveillance system; (5) strengthen partnerships in malaria control; and (6) provide periodic (every 3 years) treatment of non-LLIN with suitable insecticides.4, 6
These interventions started in late 2007, and were fully implemented in the 13 malaria-endemic districts in 2008. There has been a general reduction in malaria cases, presumably through high coverage of and increased use of insecticide-treated nets, increased use of rapid diagnostic tests and antimalarial treatments, and a high number of community health workers and health facilities.7, 8, 9 The interventions have also reached marginalised populations.8 Bangladesh is moving from control to elimination in parts of the country, but evidence in favour of these actions has been more descriptive than quantitative so a robust cost–benefit analysis is crucial. Cost-effectiveness analysis is needed to maintain sustainable control programmes and assess the future needs for malaria elimination.
Malaria elimination also has substantial indirect benefits and economic attractiveness.10, 11 A systematic assessment of the effect of the programme has not been done in Bangladesh. Both donors and policy makers should have information about the costs and benefits of interventions. To address this gap, we did an epidemiological and economic analysis using the country's number of malaria episodes, total costs of the programme, and disbursed funds from 2008 to 2012 in the 13 malaria-endemic districts. We compared international donor assistance to control malaria in Bangladesh with other malaria-endemic countries.
Methods
Go
Study area
The population of Bangladesh is about 150 million; 14 million people live in the 13 malaria-endemic districts.12 Eight of these districts are in the north of Bangladesh, sharing a border with India, and five districts are in southeast Bangladesh, sharing borders with India and Myanmar (Burma).
Data sources
The main methods of malaria surveillance in Bangladesh are passive case detection at hospitals and rapid diagnosis and treatment at the community level by community health workers. We obtained annually reported, district-level aggregated malaria case data from the NMCP. Uncomplicated malaria, severe malaria (defined by clinical and laboratory variables associated with an increased risk of death and the presence of P falciparum parasitaemia)13, 14 involving admission to hospital, and malaria-associated mortality, were confirmed by microscopy or rapid diagnostic tests done in hospitals or by community health workers. Appendix p 2 shows the malaria reporting system in Bangladesh in more detail. We obtained data for the number of LLINs distributed and nets treated (new available non-LLIN) with K-O-tab 12315 (together designated as insecticide-treated nets) annually from the NMCP. LLINs were costed at $6·00 per net, and insecticide treatment of nets at $0·50 per net. We took demographic data from the Bangladesh Bureau of Statistics.16 Populations were projected for 2008, 2009, 2010, and 2012 using an exponential population growth model based on Bangladesh Bureau of Statistics 2001 and 2011 data.16
We obtained detailed data from the Bangladesh NMCP for funds disbursed to the NMCP from the donors (Global Fund, Bangladesh Government). Once the investments from the Global Fund arrived in Bangladesh, they were deposited in the Ministry of Health according to the US dollar rate. Inflation rates were calculated on the basis of differences between the rate at the time the funds were received and the reporting time at the end of the fiscal year. We obtained cost data in US dollars from the Bangladesh NMCP manager. All costs were cross-checked with budgets outlined in the original proposals submitted to the Global Fund and through reviews of available reports.
Data analysis
We analysed yearly aggregated district-level age (0·0–4·0 years, 4·1–14·0 years, and >14·0 years) and sex-specific malaria data for all 13 malaria-endemic districts. We used detailed demographic data from the Bangladesh Bureau of Statistics as the denominator. We calculated the prevalence17 of any malaria, severe malaria, and malaria-associated mortality per 1000 population. For all 13 districts, we calculated coverage of insecticide-treated nets per 1000 population, assuming an average net life of 3 years.18 We used Poisson regression to explore the association between malaria prevalence and insecticide-treated net coverage at the district level. We used STATA (version 11) for all statistical analyses.
Yearly malaria data (total number of malaria episodes, P falciparum, Plasmodium vivax, and mixed infections) were linked with district shape files (geographic data). District-level malaria prevalence in each year and the percentage of P falciparum, P vivax, and mixed infections were mapped separately and analysed for spatial clustering using the Getis-Ord Gi* statistic19 in ArcGIS software (version 10). This statistic established whether differences between the local mean (ie, the prevalence for a district and its nearest neighbouring districts) was significantly different from the global mean (ie, the prevalence for all districts).20 A significant positive Z score identified a hotspot for high prevalence and a significant negative Z score for a district identified local clustering of low prevalence.21, 22, 23
For the economic analyses, all costs were treated as capital costs (eg, transportation, human resources, training, infrastructures, institutional overhead, operational research), except costs for drugs, diagnoses, health education (information education communication or behaviour change communication), LLINs, and impregnation of nets to prevent malaria, which were treated as operating costs. The population (14 million people) living in malaria-endemic districts of the country was used as the denominator.
Methods
We obtained annually reported, district-level aggregated malaria case data and information about disbursed funds from the NMCP. We used a Poisson regression model to examine the associations between total malaria, severe malaria, malaria-attributable mortality, and insecticide-treated net coverage. We identified and mapped malaria hotspots using the Getis-Ord Gi* statistic. We estimated the cost-effectiveness of the NMCP by estimating the cost per confirmed case, cost per treated case, and cost per person of insecticide-treated net coverage.
Findings
During the study period (from Jan 1, 2008, to Dec 31, 2012) there were 285?731 confirmed malaria cases. Malaria decreased from 6·2 cases per 1000 population in 2008, to 2·1 cases per 1000 population in 2012. Prevalence of all malaria decreased by 65% (95% CI 65–66), severe malaria decreased by 79% (78–80), and malaria-associated mortality decreased by 91% (83–95). By 2012, there was one insecticide-treated net for every 2·6 individuals (SD 0·20). Districts with more than 0·5 insecticide-treated nets per person had a decrease in prevalence of 21% (95% CI 19–23) for all malaria, 25% (17–32) for severe malaria, and 76% (35–91) for malaria-associated mortality among all age groups. Malaria hotspots remained in the highly endemic districts in the Chittagong Hill Tracts. The cost per diagnosed case was US$0·39 (SD 0·02) and per treated case was $0·51 (0·27); $0·05 (0·04) was invested per person per year for health education and $0·68 (0·30) was spent per person per year for insecticide-treated net coverage.
Interpretation
Malaria elimination is an achievable prospect in Bangladesh and failure to push for elimination nearly ensures a resurgence of disease. Consistent financing is needed to avoid resurgence and maintain elimination goals.
Funding
None.
Introduction
Go
Bangladesh has a history of endemic malaria transmission in 13 of 64 districts. Up to 70?000 laboratory-confirmed and 900?000 clinical cases (appendix p 1), with more than 500 deaths per year, were reported in the late 1990s.1, 2, 3 Unreported cases might have been as high as 250?000 each year.4 A cross-sectional survey in 2007 reported a crude prevalence of 4% in the 13 malaria-endemic districts.5 More than 90% of cases were Plasmodium falciparum.5 The highest prevalence (>10%) was identified in three districts of the Chittagong Hill Tracts in southeastern Bangladesh.5
The Global Fund to fight AIDS, Tuberculosis and Malaria (Global Fund) approved funds in 20064 (Round 6) and 20096 (Round 9) to support the Bangladesh National Malaria Control Program (NMCP). The NMCP was implemented by the Bangladesh Ministry of Health with BRAC (a national non-governmental development organisation). The goals were to: (1) reduce malaria morbidity and mortality; (2) provide community-based services that increased access to diagnosis and treatment with artemisinin-based combination therapies in hard-to-reach regions; (3) provide longlasting insecticidal nets (LLINs) to 100% of households in the three malaria-endemic districts with the highest malaria burden and 80% coverage in the other ten malaria-endemic districts; (4) strengthen the malaria epidemiological surveillance system; (5) strengthen partnerships in malaria control; and (6) provide periodic (every 3 years) treatment of non-LLIN with suitable insecticides.4, 6
These interventions started in late 2007, and were fully implemented in the 13 malaria-endemic districts in 2008. There has been a general reduction in malaria cases, presumably through high coverage of and increased use of insecticide-treated nets, increased use of rapid diagnostic tests and antimalarial treatments, and a high number of community health workers and health facilities.7, 8, 9 The interventions have also reached marginalised populations.8 Bangladesh is moving from control to elimination in parts of the country, but evidence in favour of these actions has been more descriptive than quantitative so a robust cost–benefit analysis is crucial. Cost-effectiveness analysis is needed to maintain sustainable control programmes and assess the future needs for malaria elimination.
Malaria elimination also has substantial indirect benefits and economic attractiveness.10, 11 A systematic assessment of the effect of the programme has not been done in Bangladesh. Both donors and policy makers should have information about the costs and benefits of interventions. To address this gap, we did an epidemiological and economic analysis using the country's number of malaria episodes, total costs of the programme, and disbursed funds from 2008 to 2012 in the 13 malaria-endemic districts. We compared international donor assistance to control malaria in Bangladesh with other malaria-endemic countries.
Methods
Go
Study area
The population of Bangladesh is about 150 million; 14 million people live in the 13 malaria-endemic districts.12 Eight of these districts are in the north of Bangladesh, sharing a border with India, and five districts are in southeast Bangladesh, sharing borders with India and Myanmar (Burma).
Data sources
The main methods of malaria surveillance in Bangladesh are passive case detection at hospitals and rapid diagnosis and treatment at the community level by community health workers. We obtained annually reported, district-level aggregated malaria case data from the NMCP. Uncomplicated malaria, severe malaria (defined by clinical and laboratory variables associated with an increased risk of death and the presence of P falciparum parasitaemia)13, 14 involving admission to hospital, and malaria-associated mortality, were confirmed by microscopy or rapid diagnostic tests done in hospitals or by community health workers. Appendix p 2 shows the malaria reporting system in Bangladesh in more detail. We obtained data for the number of LLINs distributed and nets treated (new available non-LLIN) with K-O-tab 12315 (together designated as insecticide-treated nets) annually from the NMCP. LLINs were costed at $6·00 per net, and insecticide treatment of nets at $0·50 per net. We took demographic data from the Bangladesh Bureau of Statistics.16 Populations were projected for 2008, 2009, 2010, and 2012 using an exponential population growth model based on Bangladesh Bureau of Statistics 2001 and 2011 data.16
We obtained detailed data from the Bangladesh NMCP for funds disbursed to the NMCP from the donors (Global Fund, Bangladesh Government). Once the investments from the Global Fund arrived in Bangladesh, they were deposited in the Ministry of Health according to the US dollar rate. Inflation rates were calculated on the basis of differences between the rate at the time the funds were received and the reporting time at the end of the fiscal year. We obtained cost data in US dollars from the Bangladesh NMCP manager. All costs were cross-checked with budgets outlined in the original proposals submitted to the Global Fund and through reviews of available reports.
Data analysis
We analysed yearly aggregated district-level age (0·0–4·0 years, 4·1–14·0 years, and >14·0 years) and sex-specific malaria data for all 13 malaria-endemic districts. We used detailed demographic data from the Bangladesh Bureau of Statistics as the denominator. We calculated the prevalence17 of any malaria, severe malaria, and malaria-associated mortality per 1000 population. For all 13 districts, we calculated coverage of insecticide-treated nets per 1000 population, assuming an average net life of 3 years.18 We used Poisson regression to explore the association between malaria prevalence and insecticide-treated net coverage at the district level. We used STATA (version 11) for all statistical analyses.
Yearly malaria data (total number of malaria episodes, P falciparum, Plasmodium vivax, and mixed infections) were linked with district shape files (geographic data). District-level malaria prevalence in each year and the percentage of P falciparum, P vivax, and mixed infections were mapped separately and analysed for spatial clustering using the Getis-Ord Gi* statistic19 in ArcGIS software (version 10). This statistic established whether differences between the local mean (ie, the prevalence for a district and its nearest neighbouring districts) was significantly different from the global mean (ie, the prevalence for all districts).20 A significant positive Z score identified a hotspot for high prevalence and a significant negative Z score for a district identified local clustering of low prevalence.21, 22, 23
For the economic analyses, all costs were treated as capital costs (eg, transportation, human resources, training, infrastructures, institutional overhead, operational research), except costs for drugs, diagnoses, health education (information education communication or behaviour change communication), LLINs, and impregnation of nets to prevent malaria, which were treated as operating costs. The population (14 million people) living in malaria-endemic districts of the country was used as the denominator.
Knowledge Acquisition
Knowledge acquisition refers to the knowledge that a firm can try to obtain from external sources. External knowledge sources are important and one should therefore take a holistic view of the value chain (Gamble & Blackwell 2001). Sources include suppliers, competitors, partners/alliances, customers, and external experts. Communities of practice can extend well outside the firm.
http://www.knowledge-management-tools.net/knowledge-acquisition.html
Knowledge acquisition is a topic that could fill books and extend well outside the knowledge management (KM) focus. For this reason, detailed descriptions of how to manage external relationships are beyond the scope of this topic. However, since KM is inextricably linked to corporate strategy, an overview of the options available to the organization will be helpful to understanding the full potential KM role.
This subsection will discuss the knowledge available from the different sources, and the managerial issues that must be considered. In the subsection titled "External Knowledge Network", I will tie this back to the overall strategic level and look at the process behind external knowledge acquisition.
The main sources are of knowledge acquisition are:
Customers
Customer knowledge comes in different forms. Gerbert et al (2002) identify three different types:
Knowledge for customer: The knowledge that the customers can gain in order to satisfy their knowledge needs.. It can include product, market, and supplier knowledge. It can be sourced from our company or from other external sources like other customers and competitors (Zanjani 2008).
Knowledge about customer: The kind of knowledge that enables us to know the customer better, to understand their motivations, and to address them better. Includes requirements, expectations, and purchasing activities.
Knowledge from customer: The kind of knowledge that deals with products, suppliers, and markets. It can be used to improve our products and services.
These three categories apply to actual knowledge acquisition as well as to data and information, which can be processed and used to create knowledge (Zanjani 2008); e.g. data on purchasing habits could be analyzed to create knowledge that could improve marketing or design decisions.
Knowledge sharing is thus important, although it may take many different forms depending on the area of business. KM is particularly important for B2B relationships where the buyers are usually more prominent (i.e. either buy many products or buy expensive products) and the products are more likely to be customized to the needs of the customer. This can, and often should result in a closer relationship with more detailed communication and feedback, where the customers are involved as partners when discussing modifications and improvements (Gerbert et al 2002).
Some possible KM initiatives thus include:
Collecting feedback
Collecting and processing marketing related information
Collecting suggestions
Involvement in development/design
Effective acquisition of customer knowledge is dependent on customer relationship management. IT can be used in this context both as a means of collecting feedback and enhancing communication and cooperation between partners (the principles of knowledge sharing apply here within the confines of the specific relationship). It is also useful as a way to gather data and information regarding sales, trends, feedback, and so on, which can then be used to create new knowledge within the organization.
Subscribe to:
Posts (Atom)
