Getting to Zero Malaria Starts with Building Stronger Health Systems

By Tarryn Haslam, Director Malaria and WASH, PSI; Dr. Christopher Lourenço, Deputy Director Malaria, PSI

No single tool available today will solve the problem of malaria. Reducing malaria case incidence and mortality risk by 90 percent globally by 2030 will require new approaches and greatly intensified efforts, aided by new tools and the better implementation of existing ones.

And while COVID-19 disruptions have led to an increase in malaria cases and deaths, eradicating this ancient and deadly disease is still a possibility within our lifetime. World Malaria Day reminds us to reflect on the scale of the challenge we still face—and the steps we must take to overcome setbacks and maintain the momentum of recent progress such as the first malaria vaccine recommended for broad use by the WHO, RTS,S.

At Population Services International (PSI), we are not just focusing on one building block of malaria prevention and control, rather, we’re looking at all that is needed—from vector control to chemoprevention, case management and surveillance—all within the context of building health system resilience, country ownership and long-term sustainability.

To get there, we’re bringing together consumer voices, government partners, donors, and the private and public sectors to ensure our programs are designed by and for the communities that are most impacted by malaria. Here’s how:

THE JOURNEY TO ELIMINATION STARTS WITH IMPROVED SURVEILLANCE

Despite the threat of drug resistance and COVID-19, cases in the Greater Mekong Subregion fell by 97 percent in the last two decades. These achievements would not have been possible without the refinement and use of robust malaria surveillance systems. Through the Bill & Melinda Gates-funded Greater Mekong Subregion Elimination of Malaria through Surveillance (GEMS+) project, PSI supports national malaria control programs (NMCPs) in Cambodia, Lao PDR, Myanmar and Vietnam to integrate private sector service providers into national systems. Between 2016 and 2019, the project supported 25,000 private outlets to provide quality malaria case management and timely case reporting into national health management information systems. The GEMS-supported network tested over 3.4 million suspected cases and detected nearly 100,000 malaria cases.

Through the GEMS+ project, PSI is also increasing country ownership. A key focus of the project is to transition private sector malaria programs to government oversight by the end of 2022. A successful transition would see the integration of the private sector into national malaria elimination strategies, surveillance systems, planning, and management structures. This will result in the availability of comprehensive malaria case data from all sectors; enable NMCPs to gain a more accurate understanding of the true burden and distribution of malaria in each locality; and allow for better tailoring and targeting of interventions in the pursuit of national elimination goals. Since the start of GEMS+, over 550 private providers have been transitioned and integrated into to government structures in the four countries.

USING EVERY EFFECTIVE TOOL TO REACH THE MOST VULNERABLE

Almost 70 percent of malaria deaths worldwide occurred in children under five years, making children the most vulnerable group. Through the Unitaid-funded Intermittent Preventive Treatment in Infants-Plus (IPTi+) Project, PSI supports widespread adoption of an effective but underutilized prevention method that could help avoid malaria infection and deaths by more than half a million young children.

Through a country-led co-design process, the project will develop, pilot and evaluate delivery models designed to scale-up intermittent preventive treatment of malaria for infants using sulfadoxine-pyrimethamine (‎SP-IPTi) in four focus countries—Benin, Cameroon, Côte d’Ivoire and Mozambique.

The IPTi+ Project is designed to work with and within the existing health system structure, leveraging existing points of contact between the health system and children under two to offer SP-IPTi. The models co-designed by the government and national stakeholders include utilizing routine vaccinations and Vitamin A contacts delivered both through facility and community channels. The models will help to strengthen these delivery channels through supervision, support to routine monitoring using national systems and by offering training to providers and community health workers. Evidence generated by our partner, the London School of Hygiene and Tropical Medicine (LSHTM) and their national research partners, on impact, cost-effectiveness and feasibility of SP-IPTi across variable settings will inform scale-up in target countries and beyond.

GAINS ARE FRAGILE WITHOUT IMPROVED SERVICE DELIVERY

Early diagnosis and treatment of malaria reduces disease, prevents deaths and contributes to reducing transmission. Under the U.S. President’s Malaria Initiative (PMI) flagship project Impact Malaria, PSI supports NMCPs across 18 countries in their efforts to strengthen diagnosis, treatment and drug-based prevention in health facility and community settings. Impact Malaria’s Outreach, Training and Supportive Supervision Plus (OTSS+) approach is contributing to improving health facility and provider skills through on-site supportive supervision, troubleshooting, and on-the-job training. Impact Malaria also incorporates the use of digital technologies and innovative strategies to improve the management of malaria in pregnancy and severe malaria. The OTSS+ approach has proven an effective strategy for improving the quality of health service delivery and that competency-based supervision of community health workers is not only possible but can improve the quality of community-based malaria services. To learn more about PMI Impact Malaria, click here.

INSECTICIDE-TREATED NETS REMAIN CRUCIAL AT SAVING LIVES

Despite the introduction of other interventions such as seasonal malaria chemoprevention, mass insecticide-treated bed net (ITN) distribution remains the most important prevention strategy to reduce malaria transmission. As part of PMI’s technical assistance to national malaria efforts in Angola, PSI’s Health for All (HFA) project leads mass ITN campaign across six provinces with the aims of distributing 3.6 million nets between February-July 2022, thus offering protection against malaria for approximately 6.6 million Angolans. To distribute ITNs in a safe and efficient manner during the COVID-19 pandemic, a single-phase door-to-door distribution of ITNs was devised where household registration and distribution stages of the campaign are combined to reduce mass gatherings. More than 3,000 people will be engaged in the provinces moving door-to-door promoting key malaria prevention messages and handing out nets to the households.

Furthermore, PSI has directly distributed over 440 million ITNs since 2004 and, in addition under PMI VectorLink, provided technical assistance to government-led distribution of a further 23 million ITNs.

PSI is also harnessing innovation through the use of digital tools to support malaria service delivery and data collection at the community level in both Burundi and Angola. Instead of paper-based vouchers and population registers, focal points use mobile application—to register the household and nets distributed. The application works on-line and off-line and can also be used to “read” or scan handwritten information in case paper-based vouchers are used in some locations. In Burundi, the digital solution “Connecting with SARA” allows consumers to learn more about the services and products available at the health center through the community health workers that visit them every day at home. From those visits, a pregnant woman learns that a net is provided for free after the first prenatal consultation. Digitization is critical to monitoring distribution with minimal delay of information from the field activities.

Eliminating Malaria is Within Reach

We’re at a pivotal moment in our journey to achieving zero malaria. Reaching the last mile calls for reinvigorating efforts to support our national malaria control program colleagues to build robust surveillance, prevention, and case management systems. Strengthening a health system’s ability to fight one disease can have a positive spillover effect in other disease areas. Surveillance solutions built for malaria are now being adapted and used for other needs such as COVID-19. Community health workers play a critical role wearing many hats as a fever finding network to identify illnesses and provide treatment quickly and accurately. There are plenty more opportunities for learning and innovation—from delivery methods to increase access to diagnosis and quality treatment, along with adapting digital tools for reporting and timely referral. We will not only be saving lives from malaria, but also working towards fostering more resilient health systems, capable of responding quickly and effectively to other diseases and in the fight against current and future pandemics.

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