Reducing Malaria in Mali: Effective Diagnostics and Treatment are Not Enough

This 32-page final report shares the experience, lessons learned, and assessment of a project to improve malaria control in Mali through more effective rapid diagnostic tests (RDTs) and artemisinin-based combination therapy (ACT). Medecins Sans Frontieres (MSF) worked with the Malian health authorities to improve access to effective diagnosis and treatment for children five years and under and pregnant women. According to the report, during the initial phase it was found that the availability of diagnostics and treatment were not enough to significantly impact malaria control. Following a mid-term evaluation, measures were introduced to remove financial barriers to treatment and to promote community-based responses, which the report notes significantly reduced mortality due to malaria.

During the first two years of the project (2005-2006), MSF worked with the Malian health authorities to improve diagnostics and treatment for children under five and pregnant women. The rates of attendance at the health centres rose compared to earlier years, but not as high as expected. MSF re-evaluated its strategy and concluded that there were significant financial and geographical barriers to access to effective care. Therefore, in the second phase of the project, from 2007 – 2010, all care for children five years and under and for pregnant women was provided for free, and a subsidised rate was applied to patients over five years. In addition, a new cadre of health workers was introduced, known as Agents Palu (Village Malaria Workers). They were chosen by their villages and after receiving training in malaria diagnosis and treatment, they provided free care for uncomplicated malaria in the more remote villages.

During the rainy season from July to December, the Agents Palu were particularly important as many villages were isolated due to blocked roads, leaving people without access to health care at the time of high malaria transmission. The Agents Palu (APs) were trained to diagnose and treat uncomplicated malaria in children between three months to 13 years of age. By 2010, 68 APs were covering 193 villages or hamlets and were being supervised by six MSF nurses. Based on MSF's evaluation, APs were providing coverage to 62% of the population living more than 5kms away from the community clinics. However, the report notes that this figure is not entirely precise due to incompatible age-group definitions between the national census data and the MSF programme.

During the second phase of the project a number of other initiatives were employed to reduce the morbidity and mortality of malaria. They included management support of the village health management associations (ASACOs), training and support for the referral centres, targeted financial support for laboratory investigations and ambulance services, sensitisation campaigns in the villages regarding free care and the new treatment protocol, and support for a widespread campaign to introduce insecticide-treated bednets into the villages. A second referral centre and four more health centres were added to the project.

The project also introduced the Relais, which was a community-based network under the supervision of the ASACOs and was responsible for health education and promotion in the villages regarding malaria, malnutrition, hygiene, and other preventive messages. Their job was to sensitise villages on the new malaria programme, including educating about the changes in diagnosis and treatment (including adherence), and promoting changes in health-seeking behaviour and prevention measures (follow-up on bednet usage). MSF provided training on malaria prevention and the signs of uncomplicated and severe malaria. A second component of the training was the use of different types of communication (story telling/theatre, group talks, school visits, radio, and later, video) in order to effectively pass on the messages.

According to the report, a knowledge, attitudes, and practices KAP survey on bednet utilisation performed in 2010 revealed that bednets were widely distributed in Kangaba district - 98% of all interviewed households had bednets, with an average possession of 2.96 bednets each, while 71% of people in these households reported sleeping under their bednets. Bednets had been distributed in various ways and the Relais supported these activities through health education. However, the report states that it is impossible to determine how much the Relais’ activities contributed to the high overall uptake of bednet usage and other changes in health-seeking behaviour. However, the changes were dramatic, as documented by a rise in attendance and according to the APs and ASACOs, so that it seems likely that they contributed to the changes.

The evaluation showed that the results in terms of clinic attendance and reduced mortality from malaria show a marked improvement after 2007 that continued until the end of the project in 2010. The report concludes that it is clear that the original goal of providing free RDTs and ACT was not enough to substantially improve malaria care in the district. Malaria management needed to be integrated into free primary health care for the key groups and care had to be extended to remote areas with Agents Palu. The report attributes the dramatic increase in clinic attendance and malaria cases treated from 2007 and the drop in mortality to multiple interventions including effective diagnosis and treatment, reduction in financial and geographical barriers, increased health care management skills in the community, and preventive measures including use of bednets and health promotion in the community.