World Malaria Day 2022: Stories from the MAM@Scale programme
This World Malaria Day, we’re celebrating MAM@Scale, the innovative, community-led programme designed to address the lack of severe malaria case management capabilities and access to treatment options in rural Zambia. This programme included the delivery of quality assured pre-referral rectal artesunate suppositories (RAS), injectable artesunate at healthcare facilities and the implementation of bicycle ambulances as a form of emergency transport system (ETS).
MAM@Scale was implemented by a consortium comprising Development Data, DAI Global Health, Disacare, Medicines for Malaria (MMV) and Transaid, all working with the National Malaria Elimination Centre (NMEC) and the District Health Management Teams in Zambia. The consortium secured valuable funding from Grand Challenges Canada (GCC) and the Government of Canada to enable the scale up of the initial MAMaZ Against Malaria (MAM) pilot project, which achieved great success.
Africa carriers a disproportionately high share of the global malaria burden and is home to 95% of global malaria cases and 96% of malaria deaths, with children under five accounting for around 80% of all malaria deaths in the region (according to the WHO World Malaria Report, December 2021). Since its inception in 2017, MAMaZ Against Malaria (MAM) has been working to reduce severe malaria deaths in children by educating families on spotting its symptoms, administering a pre-treatment at the community level and enabling children to access the appropriate medical treatment quickly using bicycle ambulances to reach healthcare facilities.
At the end of 2018, the MAM pilot recorded a staggering 96% reduction in child mortality from malaria in Serenje District, serving a population of 54,000 people. Since then, the programme has been scaled up with investment and drug procurement from the Zambian Ministry of Health, and has now reached ten districts and more than one million people. One of these communities is Nyakanyaka, home to Betshebar Mwape, her son Best and baby Moses.
It was dawn when four year old Best screamed and said: “Mama, I am not feeling well, my stomach is hurting.” His mother Betshebar went to where he was sleeping, checked his temperature, and discovered that he had a high fever. She remembered what she had previously learnt from her local Community Health Volunteers (CHVs), having been taught to spot some of the dangers signs for severe malaria, such as fever, excessive vomiting, and refusing food. When Best’s condition started to deteriorate further, and he began to convulse, Betshebar knew that she needed to seek help immediately and put her son onto her back in preparation for the journey. She travelled as quickly as she could to the nearest CHV.
Betshebar first arrived at Minerva’s house – the custodian of the bicycle ambulance and ETS rider. Minerva took Best to Noah – the nearest CHV, he recognised the danger signs for severe malaria in Best and immediately completed a Rapid Diagnostic Test (RDT) to check whether Best had malaria. RDTs detect malaria antigens in a person’s blood. If the malaria antigen is present, the person will test positive. When Best’s RDT came back positive, Noah immediately administered two doses of RAS, and a referral note was written for the nearest healthcare facility.
They used the bicycle ambulance to travel to the healthcare facility, which was three kilometres away. Upon arrival, Best was rushed straight to the clinical officer, who examined him and administered the course of injectable artesunate. Best was later discharged with the appropriate follow up treatment, and recovered from severe malaria.
Best has three brothers and sisters, and his mother explained that all four of her children have suffered from severe malaria. In the past, when Betshebar’s eldest child fell ill at five years old, she did not know what to do, and nor did she suspect severe malaria. But this time, when she saw the condition that Best was in, and having witnessed the CHVs doing their severe malaria awareness training, she recognised the symptoms and rushed Best to the CHV for help.
Today, all four of Betshebar’s children are healthy. She says that life has changed dramatically since MAM arrived in her community: “The project is working well, because when my child was treated, he recovered well and has not had malaria since. It is working well in terms of RAS, but also how the CHVs are helping us in the community. The bicycle ambulance has really helped us in terms of reducing the transport costs, because it is free. We just ride it to the healthcare facility.”
Treating children with severe malaria
Andrew Mundala is a healthcare worker in Mulilima, he plays an essential role in treating children with severe malaria when they arrive at the healthcare facility. Below he tells the story of the programme in his community, explaining why in the case of severe malaria, when timing is critical, both pre-referral intervention at the community level and the bicycle ambulance, have a fundamental part to play.
“Before the project started, we lost a large number of children in the community to severe malaria.” Andrew explains that often children died on the way to the healthcare facility, or when they arrived. This was because the community is vast and there are some very isolated places at a great distance from healthcare facilities. For a parent to make a decision to take their child to the healthcare facility, they had to think twice about whether to walk or to wait for transport. This was a contributing factor to the high fatality rate, as the limited transport options in the area meant that by the time a decision was made, they might have stayed in the community for three or four days with malaria, and so the case becomes very severe.
Looking back to when the programme first started, Andrew says that there were 40 volunteers, covering around five healthcare centres.
As the number of volunteers increased, the numbers reaching the healthcare facility increased and a significant reduction in the number of deaths from severe malaria was seen.
“We managed to reduce deaths from severe malaria in the community to almost 0.5%.”
ETS provides a vital link between rural communities and healthcare services, as part of the MAM@Scale programme. ETS riders are volunteers who serve their communities by using bicycle ambulances to take people to healthcare facilities in medical emergencies.
As part of the project, Andrew assisted with the training of CHVs in tackling severe malaria. He taught them to educate families on the danger signs, administer RAS, and refer patients to a healthcare facility for further treatment. CHVs provide invaluable health advice to their communities, which are often located far from healthcare facilities.
In the past, if a parent came to the healthcare facility with their child, they would have to wait their turn to be attended to. With the arrival of MAM, and the training of CHVs to identify the signs and give a referral letter, the parent is no longer required to queue because the child is treated as an emergency.
Andrew explains that before MAM, when a child arrived at the healthcare facility cases were often quite difficult to handle, as the child would be very weak, convulsing and sometimes unconscious. “Previously, we had so many cases where nothing had been done in the community and by the time the patient arrived at the healthcare facility, it was too late.”
He says: “Now, because of the intervention that is being done in the community, we are smiling, because they have been taken care of very well and are normally in a stable condition on arrival. They have come to the facility in time, and we can handle it efficiently.”
“The work is super now! We feel very good when you attend to someone and save that life.”
“The arrival of the bicycle ambulance is very, very helpful.” He explains that when a parent sees that a child is not well, they will travel immediately to the nearest CHV who will assess the child, and the child will be put on the bicycle ambulance with the parent, and taken to the healthcare facility.
Reflecting on the MAM@Scale programme, Andrew said: “The project is doing very well. We refer in time, and we manage the case and then we discharge the child.”
Looking to the future, Andrew would like to see bicycle ambulances in every community because of the motivational effect that they have. He explains that communities mobilise quickly when they know that they have means of transport. He says: “If we scale up, it will be of great help. Not just in the case of severe malaria, but also in tackling barriers to healthcare for maternal and new-born situations.”