This 25-page case study, published by the African Medical and Research Foundation (AMREF), shares the experience of the organisation's Malaria Prevention and Control Programme in the Afar region of Ethiopia which comprises mostly pastoralist communities. The main activities included training health care service providers, equipping health centres, training mother co-ordinators, distributing insecticide treated nets (ITNs), and sensitising local leaders on malaria prevention and control. According to AMREF, as a result of this programme, the skills of over 200 health care service providers on diagnosis and treatment improved. There was a 34% increase in knowledge about transmission of malaria, 62.5% increase in ITN possession, and 48% increase in treatment seeking behaviour at community level. The case study suggests that the programme demonstrated a reasonable and replicable model of malaria prevention and control by strengthening and linking the different segments of health systems in pastoralist communities.

Along with the activities mentioned above, AMREF developed and tested a Participatory Malaria Prevention and Treatment (PMPT) toolkit in 2006 in collaboration with the Afar Regional State Health Bureau, woreda health offices, and UNICEF. The major topics in the toolkit focused on signs and symptoms of malaria, appropriateness of early diagnosis, prompt treatment with effective antimalarial drugs (particularly among under-fives and pregnant women), traditional practices, and preventive measures. The toolkit used simple pictures designed to be easily understood by individuals at community level with little or no education. The toolkit was developed and tested after analysis of the cultural and traditional beliefs towards malaria prevention and treatment, based on the findings of a baseline survey and focus group discussions of studies carried out in 2005 and 2006 respectively.

According to the case study, as a result of the programme’s activities, the proportion of community members who correctly identified the transmission methods of malaria had increased from 27.4% in 2005 to 61.5% in 2007. In addition, knowledge of communities on the signs and symptoms of malaria had increased from 84.3% in 2005 to 88.4% in 2007 indicating an increase of 4.1%. On the other hand, knowledge on the prevention methods of malaria before and at the end of intervention remained at around 67.5%. However, comprehensive knowledge about the prevention and control of malaria is still low in the intended communities of Afar region.

As a result of the door-to-door distribution of Long Lasting Insecticide Treated Net (LLITNs), the coverage of at least one ITN in the intended communities had increased from 7.5% in 2005 to 70.2% in 2007. This has demonstrated the effectiveness of distributing LLITNs in conjunction with utilisation-focused health education. The proportion of pregnant mothers who slept under ITNs the previous night in Afar community increased from 27% in 2005 to 86.5% in 2007. Similarly, the proportion of children under five years who slept under ITNs the previous night had increased from 17% in 2005 to 84% at the end of 2007.

The report also states that treatment seeking behaviour for fever among the community increased to 48%. Of those who sought treatment for fever, 16.4% did so within 24 hours of onset of fever. However, only 14.3% of under-five children with fever sought treatment within 24 hours of onset. This indicated that there were improvements in treatment seeking behaviour, but that there were other limiting factors like long distances to access treatment services. During the years of AMREF’s presence in the area, the epidemic occurrences in malaria declined significantly.

The report identifies the following lessons learned:

• The need for concurrent actions on health workers and health facilities - Building the capacity of human resources for health cannot result in change if the health facilities’ capacity is not supporting the built capacity.
• Linking mother co-ordinators with the health system - The malaria programme in Afar region has implemented its community-based interventions using mother co-ordinators selected by the community, requiring the need to link them to the health facilities in the areas. The critical issue to sustaining the services of community-based mother co-ordinators is that they provide the services without payment, making it difficult to maintain their motivation.
• Involving local community leaders in health interventions - In pastoralist communities there are local traditional leadership systems that are deep-rooted and respected by the majority of community members. This programme recognised the role of the traditional leadership system and utilised it to reach and influence the behaviour of the community at large. Thus, the greatest lesson learned is that interventions can be facilitated if the local structure is recognised and well utilised.
• Involving the local health system in programme activities - The district, zonal, and regional structures play a crucial role in formulation and implementation of policies. The most effective strategy in influencing policy and practice is to involve policy makers during the early stages of programme implementation.
• Door-to-door distribution of insecticide treated nets - The most reliable method to ensure a service reaches and is used by households is to provide the service directly to the intended community and to educate them on the utilisation.
• Utilisation of locally applicable technology for intervention - Modern and electronic materials are hardly used in nomadic communities. The programme thus developed locally applicable and culturally-sensitive methods.

Based on the experiences in the implementation of the Malaria Prevention and Control Programme in Afar, the following recommendations were made:

• Given the high turnover of trained staff in Afar region, there is continuous need to provide in-service training for the new health workers. In addition, there should be a system in place to retain the trained staff.
• Since communities are the centre of a health system, the district health offices should utilise the community structures to narrow the gap between the communities and the health system. It would also be helpful to create networks and organise these structures for successful implementation.
• To effectively reach the community with user-friendly services the mother co-ordinators should have a greater role. Hence there is a need to integrate these co-ordinators’ activities with those of the rest of the health system to ensure appropriate follow up.

The case study concludes that this programme demonstrated a replicable model of malaria prevention and control. Key components of the programme were enhancing the capacities of health workers and health infrastructure at facility level, improving the capacity of the community to own their health, and creating a linkage between communities and the health facilities by community accepted agents.

AMREF website on January 13 2010.