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A World Malaria Day Q&A with Project Director Ricki Orford

This year’s U.S. President’s Malaria Initiative (PMI) Annual Report to Congress highlights the substantial gains made in the fight against malaria in 2021. Through the generosity of the American people and Congress, PMI protected 5.4 million pregnant women and 8.4 million children from malaria using preventive antimalarial treatments and delivered 155 million malaria rapid diagnostics tests. As the flagship global service delivery project of PMI, PMI Impact Malaria is proud to contribute to these achievements by supporting national malaria programs across 18 PMI countries to strengthen malaria diagnosis, treatment, and drug-based prevention.

COVID-19 led to an increase in malaria cases and deaths in 2021, but the fight against this ancient and deadly disease can still be successful. Not only is it possible to eradicate malaria within our lifetime, but as this Annual Report cites, doing so “promises an almost 20-fold return on investment, could save 11 million lives, and could unlock $2 trillion in economic benefits by 2040”. In recognition of World Malaria Day, when global partners reflect on the progress made and commit to the last mile towards ending malaria, we spoke with our Senior Project Director, Ricki Orford, on how PMI Impact Malaria is contributing to life-saving impact and the future of malaria service delivery.

PMI Impact Malaria kicked off in April 2018 with an initial buy-in to support nine PMI countries in Sub-Saharan Africa. Today, we work in 18 different countries across the globe including the Greater Mekong subregion and support two USAID regional bureaus: Africa and Latin America and the Caribbean. With over four years of project implementation, what achievement(s) are you most proud of? What do you see as the legacy of PMI Impact Malaria?

The legacy of PMI Impact Malaria will have been our work on quality improvement of malaria service delivery. We’ve learned that the OTSS+* approach is 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. Our OTSS+ approach is built on PMI’s impressive and successful history of piloting, testing, and evolving on-the-job supportive supervision and training. We have been proud to take the baton from previous projects and continue the support to OTSS, introducing an upgrade with digital technologies and innovative strategies to improve the management of malaria in pregnancy and severe malaria. We’ve also supported PMI as they rolled out service delivery support to new countries that did not have a PMI presence before our project came along.

Our efforts to support national malaria control programs (NMCPs) to deliver Seasonal Malaria Chemoprevention** (SMC) is also something that really makes me smile. The sheer numbers of children reached and protected from malaria with this intervention is inspiring. The IM teams in country work hard under the leadership of the NMCPs to ensure that the campaigns are delivered on time and within budget, as part of a broader partnership to protect children from malaria before they can be infected. Thanks to the dedication of the IM and NMCPs teams working together, millions of children were protected from malaria last year.

*Outreach, Training, and Supportive Supervision Plus (OTSS+) is a facility level approach aimed at improving health facility and provider skills through on-site supportive supervision, troubleshooting, and on-the-job training.

**Seasonal malaria chemoprevention (SMC) is a campaign style intervention that involves giving antimalarial medicines each month during the rainy season when malaria transmission spikes.

We know that PMI-supported Seasonal Malaria Chemoprevention (SMC) campaigns reached 8.4 million children this year, as shown in the PMI Annual Report. In the past year, PMI Impact Malaria supported Burkina Faso, Cameroon, Mali, and Niger to reach more than five million children under the age of five with antimalarials through SMC. How did PMI Impact Malaria support of National Malaria Control Programs (NMCPs) in partner countries contribute to this lifesaving impact? 

It’s about partnering with the NMCP right from the planning stage, working out the priority areas for intervention, and determining the need. Planning together to make sure that we have the trained staff in place at the right time, and then of course making sure that the campaign happens as smoothly as possible whilst keeping resources flowing. We’re reducing the burden on NMCPs while supporting its lower tier levels – districts and provincial level teams – to execute.

For the districts that we support, we help them organize microplanning workshops before the seasonal campaign and debrief workshops afterwards, we buy everything except medicines, and we hire vehicles for the supervisors. We also help develop, execute, and pay for the social mobilization, including town criers and radio broadcasts to spread the word about prevention efforts. Beyond that, we support the campaign supervisors in each district to coordinate efforts, we help recruit, train, and pay community distributors, and support staff at every level to monitor their campaign daily.

Last year, we supported SMC campaigns across Burkina Faso, Cameroon, Niger, and Mali that treated over five million children with antimalarials, all in the face of the pandemic. COVID-19 taught us that we must adapt, and we did adapt to ensure public safety against the pandemic and prevention against malaria. Working with countries, we reduced the number of face-to-face meetings, switched from fixed post to 100% door-to-door delivery to avoid crowds, and went from administering the antimalarials to directly observing caregivers as they administer the drugs instead. This support helped SMC campaigns reach one million more children than last year – an incredible effort for every one of those lives, like Tata Wagué in western Mali.

Accurate diagnosis, appropriate treatment, referral, timely reporting, and tracking of malaria cases are the cornerstones of malaria service delivery. However, several barriers limit access to high-quality malaria services including inadequate health provider competencies and practices, slow or ineffective uptake of new global guidance, and shortages of commodities and supplies. How is PMI Impact Malaria supporting NMCPs to close the gaps in malaria prevention, diagnosis, and treatment and to improve the quality of health service delivery? 

PMI Impact Malaria is focused on a holistic quality improvement approach centered on OTSS+, which is combined with classroom training, mentorship, and peer-to-peer learning where appropriate. We’re adapting global standards to national contexts, supporting countries to go out and train, doing it on-the-job, and providing corrective training to staff in real time as they provide direct care to their communities. That is what’s key, it is all about going away from PowerPoint and going towards the patient – from PowerPoint to patient.

We have also worked hard to take quality improvement one step further. Not only are we supervising, but we are using digital algorithms that allow us to immediately correct errors that we see in the field, in a standardized way across our staff. In all our countries, and over the life of the project, we have seen the competency of health providers improve. Currently, an external evaluation is assessing the overall impact of OTSS+ on improvements in the quality of care provided in targeted countries. We look forward to publishing our results in the coming year.

The PMI Annual Report 2022 highlights the progress made over the last year in moving the needle against malaria. Despite consistent global progress since 2000, COVID-19 disruptions caused an increase in cases and deaths last year. Reaching an end to malaria is still possible but requires that we overcome setbacks from public health crises and outbreaks like this pandemic and as we saw with the Ebola crisis several years ago. In both cases, community health workers played a critical role pulling double duty as a fever finding network to identify illnesses and provide treatment quickly and accurately, thus strengthening the health system and increasing capacity at all levels. How is PMI Impact Malaria helping countries become stronger in their fight against malaria and fostering a more resilient health system capable of taking on other diseases? 

Community health workers, like Abdoulaye Bakary in Cameroon and Beatha Mukabucyana in Rwanda, are the frontline heroes. They’re the ones providing critical primary health services right at the doorsteps of their neighbors, who would otherwise have to travel hours if not days for care. As members of their community, they’re leading efforts face-to-face every day against endemic diseases like malaria and pandemic outbreaks like Ebola and COVID-19.

As we combat malaria, we’re facing many of the same problems that any pandemic illness would face, problems of access to diagnosis and quality treatment, problems of reporting, and problems of timely referral. Whether this is malaria, COVID-19, or the next zoonotic or pandemic disease we have some lessons learned, as many of the same people will be involved, perhaps the same community health worker, same district nurse, same facility, same supply chain. As PMI demonstrates in this Annual Report, “PMI’s investments in people and systems—including improving lab capacity, supply chains, distribution systems, data collection, fever surveillance, and quality assurance of health commodities—have done double duty, saving lives from malaria while working to fight the current pandemic and other infectious diseases.”

Strengthening the health system’s ability to fight one disease can have a positive spillover effect on other diseases, and it provides opportunity for learning. Malaria investments are strengthening health systems to cope beyond a single disease while using a single disease as a catalyst. The key is being able to treat fever when it is malaria and refer it or appropriately treat it when the fever is not malaria. That is why PMI Impact Malaria supports integrated Community Case Management – integrating malaria diagnosis and treatment with diarrhea, pneumonia, and malnutrition services.

 

Source: U.S. President’s Malaria Initiative 16th Annual Report to Congress, 11.

PMI and PMI Impact Malaria supports those working at the frontlines and community level to protect vulnerable groups, such as pregnant women and children under five, from malaria. Why should that be a focus for future projects working towards the ultimate goal of global eradication? 

Global malaria efforts, which were scaled up in the late 90s and early 2000s, focused on high-profile national-level initiatives to create massive gains in the malaria control fight. We scaled up prevention tools like insecticide–treated bed net coverage to interrupt malaria transmission; to combat drug resistance, we moved to artemisinin-based combination treatments (ACTs) which is now the standard, first line of defense antimalarial drug; and we scaled up treatment seeking behavior. We achieved these activities at national scale to significantly move the needle against malaria and bring elimination within reach in many countries. These were the low-hanging fruits that enabled us to achieve massive gains relatively quickly. The next step now is the last mile – the harder to reach geographic areas, those without reliable and consistent access to care.

The last mile is always the hardest. But the last mile to ending malaria includes community-based approaches that reach the people that need it most. As PMI recently commented in a global health journal, “reaching the unreached is an active extension of accessible health care…[and] requires a deeper understanding of the population to determine who is unreached, where they can be found, what characteristics they have, and how we can ensure the necessary prevention or care services are utilized. Local knowledge is critical. This means that people in communities help identify the unreached and identify options to establish reach.” To listen to those at the frontlines of this disease – community health workers – to understand the needs in their communities. To continue supporting districts on the verge of elimination so that countries can achieve subnational elimination which supports long-term national elimination efforts.

Ending malaria is not a one-size fits all approach. It requires adaptation and a toolbox of approaches, and it takes a village to deliver these services.

Header Photo Credit: Mwangi Kirubi, PMI Impact Malaria

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 JhpiegoMedical Care Development International (MCDI), and the Malaria Elimination Institute (MEI) at UCSF.

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