From Knowledge to Action: Towards Enhanced Malaria Elimination Strategies

What to do when you know that an intervention is useful and valuable, but you are not sure what strategy to use so that it reaches everybody in need? This is precisely the question addressed by the ADAM project, led by the Manhiça Health Research Centre (CISM) and ISGlobal, and funded by EDCTP. In collaboration with the National Malaria Control Programme (NMCP) in Mozambique, the project aims to assess how to programmatically deliver two malaria interventions that rely on reaching very high coverage to have real impact against the disease: Mass Drug Administration (MDA) and reactive focal drug administration (rFDA) with foci investigation.

The ADAM project aims to assess how to programmatically deliver two malaria interventions that rely on reaching very high coverage to have real impact against the disease

ADAM is the natural continuation of the Magude Project, which evaluated a package of interventions to advance towards malaria elimination, including MDA and rFDA, in an area with very low malaria transmission. Following two rounds per year of population-wide MDA for two consecutive years in the context of intensified vector control, Plasmodium falciparum (Pf) infection prevalence was reduced by 71.3% (from 9.1% to 2.6%). These interventions were followed by rFDA for one more year which resulted in an overall reduction of 84.7% in all-age Pf infection prevalence throughout the project, and averted 76.7% of expected clinical cases.

With the proven efficacy of MDA and rFDA, ADAM now aims to design and pilot a strategy to deliver these two interventions through the health system in Mozambique, in order to develop specific technical guidance for their implementation on a large scale. The rationale behind this study is the fact that when interventions that have been proven to be effective are scaled-up in the “real world”, their effectiveness is generally lower than what was observed in the trial setting.

When interventions that have been proven to be effective are scaled-up in the “real world”, their effectiveness is generally lower than what was observed in the trial setting

This “effectiveness decay” is due to several factors that range from limitations of the health system to adequately deliver the novel intervention, to cultural issues that may affect compliance and health-seeking behaviour, stocks-outs, or other supply chain issues that decrease the expected coverage and impact. Understanding how best to implement an intervention “in programmatic mode”, that is, within the regular health programs and systems, is critical to adapting implementation strategies to the specificities of each setting. These issues are generally addressed by the research field called Implementation Science.

Making informed decisions in this context is complex, as programmatic implementation entails all the components of the health system, from delivery and supply chain to leadership and governance. After months of discussions and planning, the district to conduct the MDA of the ADAM project has been selected. This has not been an easy choice since many factors needed to be considered, including the burden of malaria, other malaria control interventions in place, priority regions for the NMCP, budget constraints, operational and logistical issues.

ADAM’s first phase is currently focusing on the design and development of an optimized delivery strategy for MDA and rFDA. This is being done through meetings, consultations, and workshops engaging all parts of the health system, including relevant representatives of the government, civil society, and other stakeholders, such as non-governmental organizations and international agencies involved in the implementation of health interventions in Mozambique.

Following several online and face-to-face meetings and workshops on various aspects of the project like delivery strategies, target population, human resources needed for the implementation, drug supply, and community engagement activities, the team recently visited the selected district in what was the first “site visit”.

Distrit of Manjacaze, Mozambique.

The pilot of the agreed strategy will begin in November 2022, when the malaria season is expected to commence after the first rains of the season. After the pilot and the consequent evaluations of the acceptability and feasibility of the implementation approach, ADAM expects to translate lessons learned into policy and practice that can be effectively scaled up in other areas of the country.

In close collaboration with the NMCP, the ultimate objective is to optimize the implementation of malaria control strategies in Mozambique, decrease the burden of malaria in the country and increase health equity.

The ADAM project is funded by the EDCTP2 Programme supported by the European Union and partially funded by the Medical Research Council of South Africa (SAMRC).