Children under five years of age are the most vulnerable group affected by malaria. In 2017, they accounted for about 60% of all malaria deaths worldwide. Fortunately, there are proven ways to prevent malaria in this population. One is seasonal malaria chemoprevention (SMC)—a campaign style public health intervention to prevent and treat malaria infection in young children living in the Sahel region of Africa. SMC involves giving an antimalarial medicine at monthly intervals for a maximum of four months during the rainy season when malaria incidence dramatically increases. The World Health Organization (WHO) has recommended SMC since 2012. (For those unfamiliar with SMC, learn more here: https://www.pmi.gov/how-we-work/technical-areas/seasonal-malaria-chemoprevention.)

This year, PMI Impact Malaria (IM) has been supporting National Malaria Control Programs (NMCPs) in Cameroon, Mali, and Niger in their work to plan and implement SMC campaigns. Cameroon held its second SMC cycle from August 1-5 and both Mali and Niger are running their second cycles this week. Within these three countries, SMC in IM’s target intervention areas will reach an estimated 3.6 million children altogether. Simply put, this intervention will save the lives of many children.

Because SMC is resource-intensive with children’s lives at stake, it’s imperative that countries consistently improve their delivery of the intervention. IM works closely with NMCPs to support them in this endeavor. Together, we think about how to improve access, efficiency, and quality through these three overarching questions:

• How do we ensure access to SMC treatment for all eligible children throughout all cycles of the campaign?
• How do we promote the highest level of efficiency possible so that limited resources are used wisely?
• How do we foster the use of quality assurance systems surrounding the campaign in the forms of supervision, coverage surveys, and pharmacovigilance?

In getting ready for this year’s campaigns, our IM teams in Cameroon, Mali, and Niger reflected on what the NMCPs and other partners did in previous years. This review of past campaigns through coordination meetings, discussions, and analyses of reports and data allowed IM and NMCPs to get up to speed on lessons learned and use these to strengthen planning for 2019 campaigns. Here are the three big lessons that have helped to plan for SMC success:

The early bird catches the worm

It’s vitally important to start planning early. Really early—almost a full year ahead of the campaign. With the seasonality of rainfall determining when SMC can be most impactful, the NMCP must work backwards and ensure that all key steps can be carried out in plenty of time ahead of the campaign. (See the key activities and timeline mapped out in the graphic below.) Planning early involves thinking carefully about competing priorities because the district health teams supporting the campaign also work on a wide variety of other health areas. If strategic planning doesn’t happen in advance, these teams could be pulled into other health activities when the campaign needs them most.

It’s crucial that the NMCP work with district health teams and implementing partners, such as IM, to identify any gaps and come up with solutions far in advance of the campaign. One area that benefits from significant attention during the “microplanning and validation” stage is data. Key elements for a successful campaign include a map of data flow, identification of entry points where data quality can be enhanced, a robust data analysis framework, and a plan to ensure there will be enough staff to handle data entry, management, and analysis—both during and after the campaign. Teams must anticipate potential weak points in the data flow (which could lead to poor quality of data) and develop a coherent data quality plan at the community, district, regional, and national levels to mitigate the possibility of these weak links and ensure that data will be processed in a timely manner.

Community health workers plan visits and review data during the first cycle of Cameroon's SMC campaign during July 2019 in the regions of Garoua and Maroua. Credit: PMI Impact Malaria

All hands on deck

SMC success is impossible without a workforce that is sufficient in size and well trained. We know from all campaign style activities that it takes a huge collection of actors to make it all happen. The NMCP must be able to readily recruit SMC staff that can mobilize communities, deliver the intervention, and supervise and troubleshoot in communities and at the district level.

In planning for the campaigns that started in July across all three countries, IM closely supported NMCPs in training hundreds of community level distributors—most often community health workers—who go door-to-door during each campaign cycle to administer antimalarial medication. In addition, IM recruited a small group of temporary district-based SMC staff who have been working hand-in-hand with IM team members and NMCPs to ensure a successful campaign. One of their most significant tasks is conducting supervision visits. During these visits, temporary SMC staff follow up with community level distributors to help ensure that distributors are following through on all the practices they were trained in—for example, sharing information about SMC in an effective way so that families are clear on how the campaign will benefit their children.

In Mali, temporary SMC consultants work at the district level to respond to immediate technical and operational needs during SMC implementation. According to Dr. Beh Kamate, IM Technical Advisor in Mali, the SMC consultants are crucial because “they provide a strong linkage between the district and community distribution activities, enhance quality assurance, and work alongside national health providers to review SMC data reporting.”

A community health worker (CHW) administers antimalarial medicine to a child during the first cycle of Niger’s SMC campaign in July 2019. The CHW is also providing guidance to the mother regarding follow up care. One full treatment of SMC medicine is for three days: on the first day, the child is given the medicine on the spot and observed; then the child’s caregiver receives the other two doses and gives each dose daily at home for the following two days. Credit: PMI Impact Malaria

It takes a village

Communities need to know what to expect. For this reason, community mobilization campaigns must be both highly visible and targeted. For some communities this means using radio promotions to get out key messages. In others, the most effective messengers are community mobilizers (i.e., town criers) who remind young children’s caregivers that SMC is coming soon. Trusted faith leaders also play an important role in getting out the message. NMCPs have been working to ensure that everyone involved is aware of the value of SMC as a lifesaving intervention and understands the importance of taking all three doses of antimalarial medication during each of the four campaign waves.

A community health worker administers antimalarial medicine to a child during the first cycle of Mali's SMC campaign in July. Credit: PMI Impact Malaria

Cameroon, Mali, and Niger all launched their SMC campaigns in July and will conduct four cycles in total, finishing in October. NMCPs in these countries have built their SMC planning and implementation upon a solid foundation of past SMC campaigns, enabling them to carry out this vital intervention better than ever before. IM is partnering with these three countries to look more deeply at what’s working well, what isn’t, and why—while also helping the NMCPs to distill and apply cross-country learnings. We look forward to taking you along on our journey through SMC as we share the impact of this lifesaving intervention on children and families in Cameroon, Mali, and Niger!

Written by Kathryn Malhotra, PMI Impact Malaria Technical Advisor, and Anne Bulchis, PMI Impact Malaria Communications Manager. Contributions from Tabitha Kibuka, PMI Impact Malaria M&E Advisor, and Gladys Tetteh, Malaria Director at Jhpiego and Malaria Technical Leader with PMI Impact Malaria.

Sources: World Health Organization—Malaria Key Facts and SMC

Header Photo Credit: Natalie Hendler for PMI Impact Malaria. Caption: Community health worker Fatimatou Ibrahim administers antimalarial medicine during the second cycle of Cameroon’s SMC campaign in August 2019.

PMI Impact Malaria is funded and technically assisted by the U.S. President's Malaria Initiative (PMI) and is led by Population Services International (PSI) in partnership with Jhpiego, Medical Care Development International (MCDI), and the Malaria Elimination Initiative (MEI) at UC San Francisco.