How can we build on the success of seasonal malaria chemoprevention?
Over the past decade, global efforts to reduce malaria incidence have stalled, largely due to inadequate funding, disruptions from the COVID-19 pandemic, and emerging threats such as drug and insecticide resistance. These challenges have hindered progress in regions most affected by the disease, where weakened health systems can struggle to maintain prevention and treatment programmes. However, the inception and growth of seasonal malaria chemoprevention (SMC) has been a source of optimism that the gains made against malaria can be saved and built upon. Through the leadership of national malaria programmes and the support of implementing partners including Malaria Consortium, SMC has grown to reach over 50 million children per year as of 2023.
Leveraging a proven platform like SMC, which consistently reaches so many children, can lead to the expanded delivery of other health interventions, increasing health coverage and reducing overall cost.
What does SMC integration look like?
Since it was first recommended by the World Health Organization (WHO) in 2012, the priority for SMC was to scale up to reach as many children as possible. In recent years, as the scale has grown and communities have become familiar with SMC as a campaign-based intervention, governments and implementing organisations have explored how to use SMC as a platform, integrating SMC campaigns with other health services where it makes sense to do so. This can take several different forms:
Full integration
The full integration of SMC campaigns with other health interventions means combining SMC delivery with other essential health services to maximise efficiency and impact. For example, when SMC medicines are administered to children, it can be done alongside the distribution of vitamin A supplementation (VAS). This approach ensures that during SMC distribution, children also receive vitamin A, which is crucial for their overall health and immune system function. By integrating these services, healthcare providers can reach more children with multiple health interventions in a single visit, improving health outcomes and optimising the use of resources and personnel.
Malaria Consortium has found, through its experience of working with Nigeria’s National Malaria Elimination Programme, that the full integration of SMC campaigns with VAS can be achieved at a minimal additional unit cost to the existing SMC campaign. Moreover, the integrated campaign is safe, equitable and does not compromise the quality or coverage of SMC delivery. As a result of this integration, Nigeria has seen a substantial increase in VAS coverage.
Partial integration
There is also the potential for partial integration where components of SMC, such as joint planning, community engagement or monitoring and evaluation, are utilised to strengthen the delivery of other health interventions. This means that selected components of the SMC programme (see Figure 1) can be leveraged to support another intervention, but that the delivery of this intervention does not take place through SMC. For example, Malaria Consortium is working with authorities in Togo to test the use of SMC as a platform to enhance routine childhood immunisation coverage. This will involve adaptations to training that enable SMC community distributors to identify and refer children who have not received routine vaccinations. As a result, health authorities will be supported to reach under-immunised children outside of the SMC programme.
Partial integration can also be thought of in different terms: maximising impact by capitalising on the complementarity of SMC and other health interventions, even though their delivery mechanisms may be separate. For example, in areas where malaria transmission is seasonal, studies have demonstrated that maximum benefit can be achieved by coordinating the timing of seasonal malaria vaccination and SMC.
The reverse case: Integrating SMC into other interventions
Another approach to minimising cost and ensuring the sustainability of an intervention could involve embedding SMC within other, established community-delivery platforms or into routine community health service delivery. This would mean SMC would no longer be delivered through stand-alone campaigns. It would be delivered either through another programme that offers reliably high coverage at the community level, or through routine activities such as household visits by community health workers (an approach being tested by Malaria Consortium in Togo).
When integration does not make sense
The different models of integration outlined above have the potential to provide significant value to health systems, enabling an increase in coverage across different health interventions. However, this does not mean that integration is always beneficial. Malaria Consortium works closely with health authorities to understand where value-add is possible. There are circumstances in which SMC integration may not be suitable, including in relation to the following areas:
- Quality: Malaria Consortium maintains an SMC quality framework to serve as a benchmark for how SMC should be delivered, based on international and national SMC policies and guidelines. This framework ensures that campaigns are safe, effective, timely, equitable and people-centred. The integration of a health intervention with SMC campaigns could negatively impact on the quality of one or more components of an SMC campaign. SMC quality is routinely monitored within Malaria Consortium-supported SMC campaigns, but the impact on quality should also be factored into initial pilots of any integration.
- Cost: As seen in the example of SMC and VAS integration in Nigeria, the coverage of the latter can be significantly increased at minimal additional cost. This may not always be the case and cost-effectiveness should be assessed during the initial pilots of any integration.
- Novelty: Where SMC campaigns are already an embedded and acceptable intervention in a community, it may be simpler to achieve the successful integration of an additional health intervention. However, in areas where SMC campaigns are new to a community or wider geography, it may not be beneficial to integrate an additional service immediately.
- Health system strength: The integration of health campaigns like SMC with other interventions makes particular sense in settings where the primary healthcare system is weak or resource constrained, such as in humanitarian crises. Conversely, integration would not make sense if the health system is already achieving high coverage with an intervention such as VAS. Removing the intervention from routine delivery and integrating it with SMC campaigns would be counterproductive if integration does not result in significantly higher coverage.
Examples of other health campaign integration
The concept of integrating health services or using successful health platforms to provide additional support for people in need of health services is not entirely new. Other examples of successful campaign integrations include the integration of measles and meningitis immunisation campaigns in Guinea, lymphatic filariasis and deworming mass drug administrations in India and polio immunisation and vitamin A supplementation in Ghana.
Maximising the impact of proven health platforms and integrating additional services into well-established delivery mechanisms offers an efficient and effective way to reach more children and communities in need. In leveraging SMC’s consistent and wide-reaching coverage, we can expand access to vital health interventions such as immunisations, nutrition supplements and preventive treatments. As we continue to build on these successes, such integration holds the potential to significantly improve child health outcomes and strengthen health systems in the long term.
Ashley Giles is External Relations Manager for Malaria Consortium’s SMC programme.
Find out more about our work on SMC and other projects:
- Project brief: Seasonal malaria chemoprevention
- Learning brief: Integrating seasonal malaria chemoprevention and vitamin A supplementation: Lessons learnt from Nigeria
Cover image: Edward Echwalu/Malaria Consortium