Zambia's National Malaria Elimination Centre (NMEC) has set an ambitious objective: ensure that every suspected malaria case is tested by a rapid diagnostic test or microscopic examination of a blood smear.
To help reach this goal, PAMO Plus—led by PATH and funded by the U.S. President’s Malaria Initiative (PMI)—supported the NMEC in introducing an innovative approach to expanding access to prompt malaria testing and treatment: proactive community case management, or ProCCM.
In 2011, the National Malaria Elimination Program (NMEP) introduced malaria community case management (mCCM) as a step towards expanding access to essential malaria services, such as testing and prompt treatment. During mCCM, community members who suspect they have malaria seek out a trained community health worker to receive malaria testing and—if confirmed malaria positive—receive antimalarial treatment or (for severe cases) referal to a health facility. This approach has been found to successfully prevent severe malaria and contribute to parasite clearance at the community level, limiting further malaria transmission.
Due to the introduction of mCCM, identification of malaria cases has shifted away from health facilities—the traditional setting for malaria testing and treatment—and into communities. By 2021, approximately 60 percent of all malaria cases in the Eastern province were being identified at the community level. Despite the significant improvement in access to malaria testing within communities, still less than half of children under 5 years of age with fevers were being taken to a trained medical provider.
Community health worker Getrude Phiri delivers interventions as part of the ProCCM study. Photo: PATH/Marie-Reine Rutagwera
Building on the success of mCCM, PAMO Plus supported the national malaria program in running an 18-month pilot of ProCCM in Chadiza district in Zambia’s Eastern province. Unlike in mCCM where community members seek out community health workers when feeling ill, through ProCCM, health workers proactively conduct weekly visits to homes within their communities to identify people with malaria symptoms, offer diagnostic tests, and provide treatment or referral to a health facility to those with confirmed malaria cases.
In order to see if the addition of ProCCM would lead to a greater reduction in malaria parasite prevalence and case incidence, the study team compared the impact of mCCM alone to mCCM conducted in combination with ProCCM.
In October 2021, PAMO Plus trained 66 community health workers to participate in the trial. Half were trained to continue providing mCCM alone, while the other half were trained in the delivery of mCCM in combination with ProCCM. In addition to being trained to test and treat for malaria, the health workers were trained to collect quality data using smart phones. Data points included the number of people in the household, those found with signs and symptoms of malaria, the number of people tested, the number of people who tested positive for malaria, the number of people referred to a health facility, the number of visits that each worker conducted to the household, and the approximate time the health worker spent at the house.
Between December 2021 and May 2023, community health workers participating in the trial made 286,445 visits to more than 5,000 households. On average, they conducted approximately 57 visits per household over 70 weeks.
Community health worker Cosmas Bonny Ndlovu tests a child with signs and symptoms of malaria during a weekly community health visit. Photo: PATH/Webby Phiri
Although community health workers in the mCCM arm tested more people than those in the mCCM+ProCCM arm, incidence and prevalence of malaria decreased similarly in both arms of the study. However, community members favored receiving ProCCM over mCCM alone, saying that it reduces distance travelled to seek care and ensures that even those who do not regularly seek out health care receive lifesaving malaria services.
When asked about his thoughts on the new approach, one community member said, “This idea of visiting door to door is good because when [the health worker] visits he will test us and find us with malaria. [In the past,] I stayed home with it. Now, I will be helped even if I don’t go to the hospital.” But despite this favorable view from the community, there is a risk ProCCM may place a greater burden on community health workers than mCCM.
Through this study and the ongoing partnership between PAMO Plus and the Zambia NMEC, we are learning more every day about how to improve access to lifesaving malaria services and stop malaria starting at the community level. The valuable insights gained through this work will help inform policies to drive progress in the fight against malaria in Zambia.
