Health equity is fundamental to success in the fight against malaria. Everyone everywhere must have access to affordable, high-quality health care or the parasite will find a way to return even to places where we thought it had been eliminated.
To help address obstacles to health equity and accelerate progress in the fight against malaria, PATH is collaborating with national malaria programs and partners around the world to develop innovative ways to ensure that even the most hard-to-reach communities receive the malaria prevention, testing, and treatment they need to fight back against this deadly disease. Together, we’re working to reach the unreached by reducing the distance to health, taking a smarter approach to community case management (CCM), and understanding barriers to accessing health care.
Reducing the distance to health care
In many parts of the world, distance between a person and the health system can be the primary reason preventing access to malaria services. 646 million people around the world live more than an hour away from a health facility even if they have access to a motor vehicle. More than 40% of the world’s population—3.16 billion people—are more than an hour away from the nearest health facility by foot. Translate that distance to time spent not earning wages at work, not attending classes at school, or not helping care for the rest of your family at home, and that distance can become an insurmountable barrier to accessing malaria prevention, diagnosis, and treatment.
“We’ve faced recurrent bouts of malaria, especially during the rainy seasons,” says Rosa Namukonde, who lives with her family in Isoka District, Zambia. She says the long distance required to travel to a health facility takes a toll not only on her family’s health but also on their time and money.
“It often leads to days of missed work or school, and sometimes even hospital visits, which strains our finances.”
Rosa Namukonde, a caregiver in Isoka District, Zambia. Photo: PATH/Emma Lwando.
Having ready access to services to fight malaria is incredibly important for a community’s well-being. By having malaria services available within a community, malaria cases can be detected and treated early, preventing severe disease and saving lives. It also contributes to a community’s overall health and productivity, as fewer of its members are left too sick to work or go to school.
Through the U.S. President’s Malaria Initiative-funded PAMO Plus project and in collaboration with Zambia’s National Malaria Elimination Centre (NMEC), PATH has been working to help address this issue by bringing the lifesaving malaria services that health centers provide into the communities where they are needed most.
“Access to malaria services through the presence of community health workers in our community has been a lifesaver for my family. It's not just about convenience; it's about saving lives and ensuring a healthier future for our community.”— Rosa Namukonde
At the backbone of this work is Zambia’s network of trained community health workers (CHWs), who help bridge the gap between the health system and unreached populations by delivering malaria services within their own communities. CHWs make it possible for even remote or hard-to-reach communities to readily access high-quality, free health care, such as malaria testing and treatment of positive cases. CHWs also educate community members on what they can do to prevent malaria in their own homes, encouraging their neighbors to take an active role in preventing malaria transmission in their community.
Through PMI PAMO Plus, more than 4,000 CHWs have been trained to deliver malaria services directly to communities like Rosa’s.
“Access to malaria services has been a game changer for us,” said Rosa. “Now, thanks to the dedication of CHWs, we can receive prompt diagnosis and treatment right at our doorstep. No longer do we have to endure long and costly trips to the health facility when someone falls ill with malaria.”
Margret Chalo, a Data Community Health Worker in Petauke, Zambia, tests a community member for malaria. Photo: PATH/Mukomela Banda.
A smarter approach to expanding community case management
Community case management (CCM) using community health workers (CHWs) is a game changer for reducing the distance to care for many communities. But how do you know where these health care heroes are needed most? With limited financial and human resources at their disposal, ministries of health often require more and better data—especially health data for rural populations—in order to effectively deploy CHWs to the people and places that need them most.
PATH's Malaria Control and Elimination Partnership in Africa (MACEPA) has been working across Africa to help answer key questions that can help expand access to quality health care even among remote or underserved communities.
“There has been a growing challenge in ensuring access to health care by underserved populations, especially with high disease burden, workload, and geographical areas that impact access to health care,” said Prudence Malama, MACEPA Senior Integrated Community Case Manager in Zambia. “CCM benchmarking is a data-driven, integrated approach that provides support to guide CHW expansion in such communities in Zambia.”
MACEPA conducted analyses at two different scales—continental or Africa-wide, and country specific—to develop a benchmarking tool that national malaria programs (NMPs) could use to inform decisions on where and how to expand CCM in their countries.
MACEPA used data on walking time to access health care, malaria burden, population size, and health facility locations to identify where malaria burden is highest but access to health care is lowest, shown on this map in dark burgundy. Image: PATH MACEPA.
The continental analysis used publicly available data on malaria burden, health facility locations, and the amount of time it takes to walk to health facilities to identify spots across Africa where malaria burden was high but access to health care was low. These areas were pinpointed as places where the services CHWs provide are needed most, as the need for malaria services was high but the people who lived there currently have limited ability to access them. This information will be integrated into an open-access, interactive dashboard where stakeholders can indicate specific criteria they are interested in and generate information on how many CHWs are needed to reach those targets in different geographies.
The second approach is more tailored, using country-owned national and subnational data. The MACEPA team works in close collaboration with NMPs, ministries of health, local partners, and other key stakeholders to analyze these data to better understand a country’s specific goals and identify geographical targets for CCM expansion.
“There has been a growing challenge in ensuring access to health care by underserved populations. CCM benchmarking is a data-driven, integrated approach that provides support to guide CHW expansion in such communities in Zambia.”— Prudence Malama, MACEPA Senior Integrated Community Case Manager
In addition to the types of data used in the continent-wide analysis, this analysis also incorporates country-specific information, such as whether a district had enough CHWs per person to meet national targets, the proportion of people in a district living more than an hour away from a health facility or a CHW, and the subnational burden of severe malaria. The team will use these data to answer several questions important for planning the expansion and deployment of CHWs, such as where and how many additional CHWs are needed to achieve national malaria control targets.
In Zambia, these analyses provide essential information not only for NMPs but also for those leading programs in other health areas.
“This support is provided to all stakeholders using an integrated approach to include all disease areas and provides visualization tools like dashboards and reports to illustrate CHW expansion activity and gaps in Zambia,” said Prudence.
With the outputs provided by the CCM benchmarking tool, NMPs are better equipped to develop and deploy evidence-driven, targeted community health programs to ensure equitable access to high-quality malaria services across their countries.
CCM benchmarking guides CHW expansion efforts in Zambia. In this map overlaying CHW coverage and malaria burden across Zambia, areas with high malaria transmission but insufficient numbers of CHWs to satisfy health needs are in red. Image: PATH MACEPA.
Understanding barriers to care
Distance to care and availability of local health services are critical factors in ensuring equitable access to malaria prevention and treatment—but they’re not the only ones. So how can we figure out what other barriers are standing between unreached communities and lifesaving malaria interventions?
Through the PMI Insights project, a research team at the Université Cheikh Anta Diop (UCAD) in Senegal is working to address this question to help the Senegal NMP better understand what determines whether a patient seeks out and receives appropriate malaria care during both low and high malaria transmission seasons.
The UCAD team conducted a study with two primary activities across four different malaria transmission settings in Senegal. First, they visited health facilities and CHWs to gather information on the quality of malaria care they are providing. Critically, they looked to see whether suspected malaria cases are being confirmed with a diagnostic test and if so, whether appropriate treatment is being provided based on their test results. The UCAD team also conducted focus group discussions with community members to learn more about how they make decisions about seeking care when they’re sick.
UCAD (far left) and PMI Insights (far right) staff conducting a site visit at a health center in Yeumbeul, Senegal in May 2023. Photo: PMI Insights
Preliminary results suggest that cost of transport and seasonal movements of key populations seeking care are barriers to early access to care for malaria. Additionally, home-based care provided by CHWs helped improve access to early diagnosis and treatment in many communities. In the coming weeks, UCAD plans to organize a national dissemination meeting to share high-level results from this study and discuss conclusions and recommendations based on what they found.
The team hopes that the results of this study will help guide the design and targeting of interventions to improve care-seeking for malaria and ensure quality health care is provided by health facilities and CHWs.
