On a hot and sunny day in 2002 in Rukungiri, Uganda, Edward Mugwanya, a young and eager medical officer at Kisiizi Hospital was reviewing local disease morbidity rates with his colleagues. He noticed that malaria was ranked number one. “But what is incredible is that it doesn’t have to be,” he says. “That is why I pursued a career in public health. I was motivated to come up and really change this picture.”
Now, with another degree and over 16 years of malaria-related experience, Edward is a senior technical advisor on the JSI-managed PMI Uganda Malaria Reduction Activity. In this role, Edward guides the program team to tailor its approach to meet the needs of the people living in Lango, Acholi, Busoga, Karamoja, and West Nile, the regions with the highest malaria prevalence rates in the country.
Edward cites four key strategies to help Uganda and other malaria-endemic countries move closer to the coveted “malaria-free” designation: prevention, social and behavior change, integration, and sustainability.
“We know the problem, we know how prevalent it is, we know the distribution, and most importantly, we have the right interventions,” Edward says.
Prevention
Prevention is key in addressing any infectious disease. Malaria is ancient, and over the years countless tools such as insecticides, bed nets, preventative treatments, and environmental adaptations have mitigated malaria, in some places eradicating it. But as Edward explains, many malaria strains have evolved to evade the insecticides and treatments most commonly used where he works. To keep pace with — much less overcome — malaria, our clinical resources must evolve, too.
“We cannot just wait at the clinic until people fall sick. We must extend malaria programs beyond the context of the facility,” Edward says. “All the risk factors for malaria are at the household — they come to the facility to get treatment but then go right back to the same environment that exposed them to malaria in the first place.”
Through the Uganda Malaria Reduction Activity, JSI piloted household action against malaria (HAAM), an approach based on Ministry of Health guidance, which is now being implemented across Lango, Musoga, and West Nile regions. From December 2022 to June 2023, the portion of households enrolled in HAAM that stated use of at least three malaria prevention methods increased from 44% to 94%. Among these methods was use of nets in good condition, which increased from 50% to 78%. Next year the Activity will scale up HAAM to reach the final two regions.
Social and Behavior Change
Public perception and behavior, one of the greatest challenges in the malaria response, is also a great opportunity. Complacency and lack of prevention and treatment awareness and skills lead to surges in malaria cases. After recurrent infections, peoples’ immunity increases, making them less sick, less concerned, and therefore less likely to take precautionary measures for themselves and their families. Unfortunately, young children have low immunity; according to the World Health Organization (WHO) 78.9% of all malaria deaths in the African region in 2021 were among children under the age of 5.
However, if the public has the skills, knowledge, and ownership in the response, they can be the strongest agent of change. “That is why the bulk of the [PMI] Uganda Malaria Reduction Activity is working with the community,” Edward says. “They have the greatest power and opportunity to prevent the spread of malaria.”
The Malaria Reduction Activity uses human-centered design approaches to understand and align with community needs, interests, decision-making, and culture while integrating malaria prevention practices into daily lives. Using strategies like interpersonal communication and social mobilization through community dialogues at household level, staff tailor interventions to be evidence-based, gender-sensitive, and locally appropriate. The Activity then works with district and community health staff to improve malaria-related service delivery, health provider-client interactions, and social norms such as mosquito net use.
Integrated approach
One of the pillars of JSI’s programs worldwide is using a person-centered approach. In the Ugandan context, many people are not as worried about malaria as they are about other health, economic, and social challenges. This presents an opportunity to address the unique and intersecting needs of each family in one place: the household.
“Because our work requires us to be in the community, in their spaces and in their homes, we can partner with other community entities to promote disease prevention and control.” Children may need vaccination, young women family planning or antenatal care, and others HIV or TB testing. Service integration allows case managers to meet people where they are and improve health coverage even with limited resources. The Malaria Reduction Activity works with local council chairpersons and village health teams to cluster households and connect trained community members who assess malaria transmission drivers with malaria champions from those households to develop and implement an action plan to fill gaps. The village health teams can also use this infrastructure to meet other health needs.
Sustainability
In 2021, the WHO estimated 247 million cases of malaria worldwide, 2 million more than the year before, making it the first in more than 20 years that progress in malaria control not only stalled, but reverted. In 2020, Uganda had a resurgence of malaria cases and some districts experienced epidemic levels. “Many approaches that are working are also expensive and incredibly funder-driven. When the project is happening, you may make a dent in malaria prevalence for some time, but when the intervention ends and the money’s gone, the disease resurges,” Edward says.
Edward says that part of the solution lies in the community. “We need a mindset shift at the household so that people take malaria seriously but also understand that they can prevent it, and have the means to do so. This will help sustain good malaria prevention and control practices at the household beyond the project funding, and this is the focus of the HAAM approach that the [PMI] Uganda Malaria Activity is implementing.”
This strategy is showing promising results. The project is noting increased demand for nets and improved care, use, and repair of nets.
As the community strengthens ownership of the response, government and global malaria funders must sustain prevention efforts. The Malaria Reduction Activity is working with Uganda’s National Malaria Control Division and district health, political, executive, religious and cultural leaders to do just that by working to create an enabling political environment for HAAM through guideline development and resources for implementation.
Opportunities ahead
Edward is optimistic. With enrolled households showing a malaria episode reduction from 73% to 35%, he says that the Activity is on track to reach the Ministry of Health goal of reducing national malaria-related morbidity by 50% and mortality by 75% by 2025.
“We have made tremendous gains in this country,” says Edward. “Now, we are tasked to ensure that those gains are maintained.”
By Sarah Denison-Johnston, Edward Mugwanya, Angela Kateemu Nuwahereza, and Aliza Hasham
