In one of the most fragile contexts in the world, a network of determined health workers reached 1.45 million children, proving that even amid political crisis, lifesaving care can go the distance.

In late July 2023, just as Niger's annual malaria season was reaching its peak, the country was plunged into political uncertainty. A military coup toppled the government, raising fears that public health systems, already stretched, would falter under the weight of disruption. But on the ground, in the Tahoua and Dosso regions, community health workers working under the direction of the National Malaria Control Program (NMCP) were already moving. Trained, equipped, and determined, they stepped into the moment with quiet clarity. The rains had come, the mosquitoes were biting, and Niger’s children needed protection.

"Malaria doesn’t wait for peace," says Paula Wood, Director of Malaria at Palladium. "And our teams didn’t wait for stability. They moved forward because they knew what was at stake."

A High-Stakes Fight in a Fragile Landscape

Malaria is Niger’s most serious public health threat. In 2022 alone, over 4.8 million cases were confirmed, with more than half of children under five testing positive for the disease. The malaria incidence is 144 per 1,000 population at risk, which means that nearly 15 percent of the at-risk population contracts malaria each year. Among children between six and fifty-nine months of age, nearly one in three is infected. These figures underscore how deeply entrenched the disease remains and why even modest progress is both hard-won and urgently necessary. Though the country has made modest gains in reducing prevalence and deaths, it remains locked in a seasonal battle against a disease that disproportionately affects its youngest and most vulnerable.

Complicating matters, mosquito resistance to pyrethroids, the insecticides used in bed nets, is rising. Service coverage in health facilities remains at just over 50 percent. In the Dosso and Tahoua regions alone, more than 3.6 million people live beyond a five-kilometer radius from the nearest clinic. For children already weakened by malnutrition, malaria can be a death sentence.

The Layered Defense: A Community-Led Campaign

Seasonal malaria chemoprevention, or SMC, has emerged as one of Niger’s most effective defenses. The approach involves administering preventive antimalarial drugs to children between three and fifty-nine months at monthly intervals during the rainy season. But SMC is just one part of a broader strategy.

The campaign complements the distribution of insecticide-treated mosquito nets, comprehensive testing and treatment and intermittent preventive treatment in pregnancy. Most recently, Niger has also begun introducing the RTS,S malaria vaccine, adding another layer to its prevention efforts. These tools, when layered, offer a comprehensive defense against the disease.

In 2024, despite catastrophic rains that washed out roads, the PMI Advancing Health and Malaria Services program in Niger (PMI AHMS Niger), led by Palladium worked with the NMCP to expand its efforts to reach 1.45 million children with the full SMC regimen.

"Each round was a logistical marathon," says Wood. "But the coverage held and, in many cases, improved. That’s a testament to the system we’ve built and to the people who power it."

The Frontline Force: CHWs as the Heart of the Response

At the center of that system are Niger’s distributors and community health workers (CHW), known as RComs. RComs provide integrated health care in remote areas that formal health systems cannot easily reach. In 2024, 618 RComs were deployed across five districts to reach up to 3.6 million people who cannot reach their nearest health facility. During SMC, an average of 7700 distributors were deployed each round, trained not only to deliver antimalarials but also to diagnose malaria cases, screen for malnutrition, and refer severe cases to clinics.

"These aren’t just volunteers. They’re the infrastructure," says Wood. "They’re trained, tracked, paid, and supported. And they’re trusted by their communities in a way that’s priceless."

Support for these workers came in many forms. Monthly stipends funded under the PMI AHMS Niger project provided financial compensation. Coordination was maintained through WhatsApp groups. Quarterly supervisory meetings reinforced quality and provided a feedback loop for continuous improvement.

Reaching the Unreachable: Radio Waves and Village Champions

With traditional communication channels disrupted by the coup, the program turned to its most reliable amplifier: local radio. Palladium partnered with 54 community and private stations to deliver thousands of public health messages in Hausa, Zarma, and Fulfulde. Scripts were adapted, verified, and broadcast at key moments during each SMC round.

More than 500 village leaders were also engaged through advocacy sessions. These leaders helped organize community campaigns that encouraged women to attend prenatal care visits, promoted household-level cleanups to reduce mosquito breeding grounds, and made sure children received all their scheduled doses.

"What we saw was real co-ownership," says Wood. "The system didn’t just survive. It evolved."

The Results Are In

More than 1.6 million children were reached during the 2024 SMC campaign, with 1.45 million completing the full four-dose regimen. Malaria mortality in PMI-supported regions dropped to just 0.31 percent. Utilization of community health services rose from 46 percent in 2022 to 49 percent in 2023. And 99 percent of confirmed malaria cases received appropriate treatment using artemisinin-based combination therapies, a rate that exceeded the national average.

Behind the numbers are quieter wins. Health facilities were less overwhelmed. Households were better informed. A health system learned how to operate even in the most uncertain conditions.

But this progress is precarious. A recent study modelling malaria trends in Zambia found that reductions in intervention coverage, especially SMC and indoor residual spraying, can result in a swift resurgence of malaria cases and deaths, often reversing years of gains in a matter of seasons. The same could happen in Niger if investment, coordination, or trust in the system were to falter.

A Blueprint for Resilience

The PMI AHMS Niger experience shows that resilience is not a buzzword. It is a structure. It is radio stations transmitting trusted messages. It is blister packs and reminder cards in local languages. It is training sessions and check-ins. It is community health workers walking village to village through the rain.

It is the product of long-term investment in systems that can adapt, not collapse, when the unexpected strikes.

"NMCP and PMI built this program to last," Wood reflects. "And in 2023, with the Palladium team, we proved that it could."

As the world marks another World Malaria Day, Niger offers a message that is as urgent as it is hopeful. Fragile does not mean helpless. With the right tools, partners, and people, even the most complex contexts can deliver life-saving care at scale.

Paula Wood is Director of Malaria at Palladium. With 25 years of experience in global development and a technical focus on malaria and vector-borne diseases, she leads strategy, partnerships, and implementation of integrated malaria programs. She supports country teams in designing locally led, data-driven approaches and works to strengthen systems for long-term disease prevention, outbreak response, and high-quality care.