Mary Achen l Palladium - Mar 19 2024
It Takes a Village and Then Some: Reducing Malaria by Strengthening Community Health Systems

Uganda has the world’s highest incidence of malaria—responsible for almost 40% of all health facility visits. Treating a single episode of malaria costs between US$8-13.50. If a family experiences multiple cases of malaria each year, it can significantly impact both their health and economic security.

Josephine knows first-hand the horrible personal burden malaria can place on a family. She lives in Budaka District, located in Eastern Uganda, where malaria is part of everyday life. At any one time, most of the population is infected with the malaria parasite, and it’s the leading cause of death in children under age five.

Last year, Josephine lost two children – ages 6 and 7 – to malaria. The cost of treatment and the funerals meant that she had to sell livestock and she couldn’t afford secondary school fees for her eldest son; malaria has been devastating to her family.

Change didn’t come quickly enough for Josephine, but in the past two years Budaka has seen an almost miraculous change in malaria conditions. “With funding from USAID and the President’s Malaria Initiative (PMI), the Uganda Health Systems Strengthening (UHSS) project, led by Palladium, is supporting Budaka District to implement an extremely effective and sustainable approach to combating malaria,” explains Dr. Betty Atai, Deputy Chief of Party for UHSS.

In October 2022, 75% of the people with malaria symptoms who were seen at Budaka health facilities tested positive for malaria, but by January 2024, this had dropped to 23%. This decrease is thanks to strengthening community health systems, including taking district-wide action; using data more effectively; and implementing action plans at the community and household levels.

Mobilising District-Wide Action

In Budaka, many see malaria symptoms as being the work of evil spirits, with not much that can be done beyond prayer or the intervention of a traditional healer. One of the first hurdles to combating malaria is shifting mindsets and igniting a collective belief that change is possible.

UHSS engaged leaders and champions – local politicians, government officers at all levels, health workers, religious and cultural leaders, women and youth groups, schools, and other community members – and brought them together for group work on a multi-sectoral approach to combating malaria called Mass Action Against Malaria.

“An essential first step was to foster collaboration among government structures, different sectors, and the local community leaders and oriented them on key interventions and messages that needed to be directed throughout the community and down to the household level,” says Dr. Atai.

Using Data More Effectively

UHSS introduced new tools and approaches to make routine data collection more relevant and useful to district managers. For example, they used malaria data ‘heat maps’ to visualise the geographic areas with the highest rates of malaria infection to target community engagements. Similarly, detailed health facility treatment data were used to identify the most affected households and provide them with tailored support from Village Health Teams.

The Budaka District Health Officer Dr Erisa Mulwana sees this new emphasis on data use as a major success factor. “Data was there, but you would only hear about it when cases were high; we didn’t have proactive weekly meetings to analyse trends.”

“Now on a monthly basis, we are able to understand the numbers…and also know where to focus our efforts in preventing malaria,” she says. “There is a focus on encouraging facilities to consume their data and use it to make decisions.”

Household-Level Action Plans

Community volunteers called Village Health Teams conduct meetings and household visits to promote health, including knowledge about childhood illnesses. The UHSS project strengthened the capacity of these volunteers to disseminate malaria information and spearhead behaviour-change efforts.

These Teams were pivotal to mapping and assessing households most at risk and making home visits. During these home visits, the village health worker would help household members to assess root causes of their malaria vulnerability and help them create individualised action plans to address their unique challenges.

This approach empowered households to undertake simple but meaningful steps to safeguard their health, such as removing stagnant water, sleeping under a treated mosquito net, and recognising early signs of malaria in children and taking them immediately to a health facility.
These household-level interventions led to the creation of “Malaria-Smart Homes,” which were highlighted in community dialogues to show other people small changes are within their power and can make a difference.

Sustainable Success

This approach of engaging the whole community has made an impact in the fight against malaria and resulted in lasting change in people’s mindsets. Now, the local politicians and technocrats are pulling together under one united, community-wide effort to combat malaria.

Other mutually-reinforcing interventions have also been embraced, such as indoor residual spraying, government distribution of insecticide-treated nets, treatment through integrated community case management, and strengthening the capacity of health workers on malaria treatment guidelines, supported by many development partners such as the USAID PMI Evolve project, the Clinton Health Access Initiative, The AIDS Support Organisation, and the Communication for Development Foundation Uganda, with additional funding from The Global Fund.

This collaboration has been critical to sustainably controlling malaria.

Impact on the Community

Successful households are now champions, dispelling myths and sharing evidence-based advice on how each family can take malaria control into their own hands. “Empowering the community has lasting effects,” says Isaac Kimbugwe, a medical clinical officer at the health facility.

Health facility workers are noting the reduced malaria case load, freeing their time to treat other health conditions. The emphasis on data use at the facility and district level has also had a spill-over effect – Budaka is now leveraging its new data use skills to combat HIV and TB.

After seeing this remarkable change, George Mukamba, Budaka District’s Secretary of Health proclaimed it a success. “We need to continue cementing the message of having malaria smart homes, because it is cheap and very convenient. If we can continue this effort with the partners, the government and the district, we will defeat malaria.”

Special thanks to article contributors George Barnett, Erin McGinn, and Andriana Barungi Nankasi. For more information, contact