New community-based approaches in treating and preventing malaria are starting to bear fruit. Malaria continues to take a huge toll on global health. More than one million lives are lost to the mosquito-borne illness each year, with the vast majority of deaths occurring in Africa among children under age five.

The use of mosquito nets is still one of the main elements in preventing malaria. (photo Timothy Kisambira).

In Rwanda, malaria is the leading cause of morbidity and mortality, accounting for 43% of all deaths and 40% of health center visits. But the use of health facilities in Rwanda is low, and many children with malaria end up dying at home, without proper treatment.

"Many Rwandan parents or caregivers prefer to purchase treatment from local pharmacists and pill sellers who are close by and charge less than health centers for medication, but who often do not provide high-quality medication or proper advice regarding dosing and duration of treatment", Paul Safari of the malaria control program says.

In Rwinkwavu district, for example, community health workers reported 588 deaths of children under age 5 in 2002, almost three-quarters of which were attributed to malarial fever. Only 42 of these deaths occurred in health facilities.

In a survey conducted in two health districts by the National Malaria Control Program, children less than 5 years of age were found to get appropriate treatment for malaria an average of three days after the onset of fever, much later than the World Health Organization-recommended treatment window of 24 hours after onset.

These factors account for Rwanda's low use of government-sanctioned health facilities, less than 0.24 visits per person per year. Additional surveys conducted in 2004 by three NGOs - Concern Worldwide, the International Rescue Committee (IRC), and World Relief - showed that few young children with fever receive ant malarial treatment as recommended by the Ministry of Health.

Only 16% of children included in the study in Kibilizi district, 9% in Kirehe district, and 20% in Kibogora district received timely and appropriate treatment. About one-third of children received no treatment.

Danger signs

In response to these surveys and the evident gap in delivering treatment to young children with malarial fever, the National Malaria Control Program in 2004 teamed with the three NGOs to launch a pilot program for community-based distribution of ant malarial medication in five districts.

The initiative aims to educate parents to identify danger signs associated with malarial fever and treat the illness with help from a nearby community drug distributor within hours of onset, when the chances of saving a child's life are at their highest.

For more complicated cases, parents are advised to seek help at a health center. With support from the government of Belgium, the National Malaria Control Program last fall purchased about 450,000 blister packs of malaria drugs to treat children under age five. Local distribution began in November 2004, with the packs offered at very low cost (10 cents) or on credit.

While the government provides program oversight, the NGOs and their local partners implement and monitor the drug distribution efforts. Community health workers, chosen by communities and trained by health districts and their NGO partners, are responsible for distributing the drugs.

Promising results

As of April 2005, the program results were promising. In the initiative's first five months, more than 85% of children in the five districts were treated within 24 hours of the onset of fever.

World Relief trained 329 local drug distributors and reported no deaths among children receiving treatment through these distributors. From November 2004 to February 2005 in Kibilizi district, Concern Worldwide reported that cases of children successfully treated for fever in the community rose from zero to 795.

The International Rescue Committee reported that, as of May 2005, 280 community distributors in Kirehe district were treating more than 3,000 cases of childhood fever per month.

Dr. Emmanuel d'Harcourt, the IRC's senior technical adviser for child survival, says Kirehe's program has been embraced equally by parents, drug distributors, and health facility staff.

"Health center staff says they have been pleasantly surprised at the care that distributors have put into their work," says d'Harcourt. "They say they have full confidence in the distributors and can concentrate on sicker children now that simple malaria is being treated in the community."

Community-based distribution of ant malarial drugs is a key way to reach the Rwanda target of treating 85% of kids under 5 within 24 hours," says Dr. Jules Mihigo, former maternal and child health specialist with USAID in Rwanda.

However, major efforts are also made in preventing the disease. Recently, a new national campaign was launched under the theme "Free Rwanda from malaria now".

"The new strategy includes the use of coartem, a newly recommended malaria drug, by children below the age of five years," health minister said Jean Damascene Ntawukuriryayo explains. "It also includes a new health approach called Malaria Home Based Management and the distribution of free long lasting mosquito nets to people living with HIV/AIDS."

About three million insecticide-treated mosquitoes were distributed between 2005 and 2008. Last year the ministry of health distributed 80,000 mosquito nets to people living with HIV/AIDS. More than 65% of children below five years, and pregnant women now sleep under treated mosquito nets.