Beating Malaria: Moving beyond Clinics and into Affected Communities

World Malaria Day: A Conversation with Dr. Bernard Nahlen

The theme for World Malaria Day this year is #readytobeatmalaria. MSH’s newest Board Member, Dr. Bernard Nahlen, recently spoke with Thomas Hall, MSH’s Senior Principal Technical Advisor for Malaria, about reducing the malaria burden in developing countries most affected by the disease. Dr. Nahlen, Director of the University of Notre Dame’s Eck Institute for Global Health, has decades of experience in research and disease elimination programs worldwide. Prior to his recent appointment at the Eck Institute, Dr. Nahlen served as Deputy Coordinator of the US President’s Malaria Initiative from 2007 to 2017. From 2005 to 2006, he was Senior Advisor, Monitoring and Evaluation, at the Global Fund to Fight AIDS, Tuberculosis and Malaria.  

Thomas Hall and Dr. Bernard Nahlen discuss health systems interventions that must be undertaken by malaria-affected countries, as crucial measures to complement critical international donations of commodities and technical assistance resources: 

African countries are still the most-affected countries and incur the heaviest malaria burden globally. What are some of the most significant health system gaps you see that may slow down or impede the efforts to reduce malaria burden, particularly in Africa?

Dr. Nahlen: In Africa, there was a remarkable reduction in malaria cases and deaths between 2000 and 2015, but progress has slowed since then. Africa continues to account for more than 90 percent of malaria cases and deaths. Significant progress needs to be made in the ten highest burden countries if we are to reach the ambitious targets of the WHO Global Technical Strategy. These countries are: Nigeria, Democratic Republic of the Congo, Burkina Faso, Mali, Tanzania, Niger, Mozambique, Ghana, Uganda, and Angola (WHO World Malaria Report 2017). WHO aims for 90 percent reductions in malaria morbidity and mortality and 35 countries eliminating malaria by 2030, compared to 2015 levels. The major reason for stagnation in progress is not due to failure of the interventions for prevention and case management but, rather, major gaps in coverage of populations most at risk of malaria.

These ongoing coverage gaps are due to inadequate financial and human resources, along with other challenges, such as weak procurement and supply chain systems of needed medicines. In many of these countries, governance and financial management of the health system also urgently need improvement.

Improved surveillance and health information systems will also be key components of efforts to reduce the risk of malaria. Since malaria primarily affects the poorest of the poor in rural areas, which are frequently beyond the reach of the routine health system, efforts to drive down the burden of malaria will need to move beyond clinics into affected communities. This will also require a greater focus on prevention, in addition to case management.

Bernard Nahlen: We Can Beat Malaria with Simple Interventions

MSH is long recognized as a global leader in supporting efforts to strengthen health systems (supply chain, governance, monitoring and evaluation). What role do you see for MSH in assisting affected countries to address health system gaps related to malaria?

Dr. Nahlen: There is no organization that has done as much as MSH to partner with countries to improve the supply chain system for malaria and other health products. The USAID-funded, MSH-led Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program recently published results in a report, Defeating Malaria through Pharmaceutical Systems Strengthening. Before SIAPS, MSH was doing this work through its Strengthening Pharmaceutical Systems and Supply Chain Management System projects.

MSH also has a long history of experience and expertise in providing technical assistance in 1) the improvement of quality malaria case management in public health facilities, 2) delivery of malaria services at the community level, 3) integration of malaria services with other maternal and child health services, where it makes sense to do so, and 4) engagement of the private sector for service delivery.

Closing the coverage gaps for malaria prevention, diagnosis, and treatment over the next decade will require expansion of community-based platforms to bring prevention tools and case management—the diagnosis and treatment of malaria infection cases—as close as possible to those most at risk, especially the poorest living in rural, often remote, areas. Delivery of insecticide-treated nets and indoor residual spraying at the household level can only be accomplished with strong community involvement.

Diagnosis and treatment for non-severe malaria are simple enough to be readily deliverable at the community level. Effective implementation of case management, as close to the household as possible, will prevent severe disease and deaths. While these community-based platforms are not malaria-specific, in many African countries malaria has been the pathfinder for establishment and improvement of these systems.

In particular, MSH supports community health workers in DRC, Madagascar, Malawi, and Nigeria by supporting training on rapid diagnostic tests for malaria and treatment using artemisinin-based combination therapy, as well as in knowing when to refer potential severe cases of malaria. MSH also supports local health workers by building their capacity for data recording and transmission, either using paper data sheets or using electronic means, such as smartphones or regular phones using SMS to transmit malaria cases and malaria commodity stock information.

Dr. Nahlen: Correct. But coverage gaps for malaria diagnosis and treatment cannot be addressed solely by the public sector. In many high-burden countries, private sector health providers and shops will continue to play a major role in malaria treatment. Such as MSH’s work with accredited drug shops in Tanzania, Uganda, Liberia, Nigeria, Zambia, and Bangladesh

MSH should continue to play a role addressing health systems gaps overall, such as the work we have been doing in Madagascar, where we support community surveillance of malaria, which assists in the tracking and recording of the disease.

Research played a prominent role in producing much of the evidence used to identify the main interventions the global community has been scaling up for the last 15 years in the fight against malaria. What role do you see academia playing in identifying solutions to health system challenges, as they relate to global objectives to eliminate malaria?

Dr. Nahlen: The bulk of research has centered on improvement of existing tools for malaria prevention and treatment and the development of new vector control tools, diagnostics, drugs, and vaccines. Fewer academic institutions have been involved in the area of implementation research, yet most recognize the importance of this research agenda.

Do you see any potential partnerships for MSH with academic institutions?

Dr. Nahlen: MSH has a long track record in implementation research related to improvement of delivery and health information systems, and there will continue to be important opportunities for MSH to collaborate with academic institutions on this research agenda.

Great progress has been made in reducing the burden of malaria in the last decade, but, there is a great deal of work left, as morbidity and mortality reductions may be slowing. What newest programmatic trends is MSH well-positioned to take the lead on?

Dr. Nahlen: While hospitals and clinics with highly-trained staff will always be a key component of any health system, if our goal is healthy people, we need to push beyond brick and mortar facilities and their staff, which have all too often been the singular focus of improvement efforts. We need to have an equal focus on preventing illness, which is the only sustainable path for Universal Health Coverage in most settings—as well as for meeting the Sustainable Development Goals for health.

In Madagascar, for example, the MSH-led USAID Mikolo Project supports improved performance of community health workers who provide health data that is then fed into data-information reporting systems; conduct malaria surveillance; alert authorities on outbreaks; report malaria commodity stock issues; and, collaborate with district and national health authorities to respond effectively to issues related to these interventions. When reporting by community health workers reveals abnormally high cases of malaria, the central and district levels send teams to investigate and ensure availability of malaria commodities, such as rapid diagnostic tests, artemisinin-based combination therapy for treatment, and even insecticide-treated nets.

MSH is well-positioned to lead effective prevention, case management, and treatment. These require a deep, sustained community engagement, including a paid cadre of workers providing support to deliver prevention and health services. This community platform must include support for an efficient procurement and supply chain system, a health information system that focuses on health outcomes, and attention to human resources and training, as well as financial management. And MSH is prepared to do all that.