Throughout Central America, a traditional malaria control strategy (depending on heavy use of organic pesticides) became less effective during the 1970s. In Nicaragua, an alternative strategy, based on frequent local epidemiological assessments and community participation, was developed in the 1980s. Despite war-related social instability, and continuing vector resistance, this approach was highly successful. By the end of the contra war, there finally existed organisational and ecological conditions that favoured improved malaria control. Yet the expected improvements did not occur. In the 1990s, Nicaragua experienced its worst recorded malaria epidemics. This situation was partly caused by the country's macroeconomic structural adjustment programme. Volunteers now take fewer slides and provide less treatment, malaria control workers are less motivated by the spirit of public service, and some malaria control stations charge for diagnosis or treatment. To "roll back malaria", in Nicaragua at least, will require the roll-back of some erroneous aspects of structural adjustment.
PIP: This paper examines the social and political influences on malaria transmission and control activities in Nicaragua. In politically unstable Central America, methods that depend on community participation and planning on the basis of routine surveillance data may be sufficient to control malaria transmission. The Nicaraguan experience in the 1980s and 1990s shows how an integrated approach can prove to be effective where social stability, health education, and strong program administration exists. During the Contra war in the 1980s, implementation of the community-based strategy was limited, resulting in increasing rates of P. vivax transmission in the war zone. The loss of timely epidemiological reporting and the decrease in use of local volunteers for blood slide detection and directly observed therapy resulted in a greater epidemic. More recently, WHO has initiated "Roll Back Malaria" and "Roll Back Structural Adjustment" programs which aim to make more efficient use of limited resources in the health sector to help eradicate malaria. Several components were needed for the strategy: the technical capacity of the national staff needed strengthening, the staff needed to be re-evaluated, additional funds were needed to assure competitive salaries, and malaria control programs needed to be identified for appropriation of funds as essential components to national development planning during structural adjustment. National leadership and the establishment of public service and social solidarity will help mobilize volunteers to work toward the goal of preventing malaria transmission.