Tackling malaria, Sierra Leone’s biggest killer

Malaria, a disease transmitted by mosquitoes, is the leading cause of death and illness in Sierra Leone. Children under five and pregnant women are especially vulnerable to the disease and the devastating complications it can cause, including maternal and foetal anaemia and stillbirths.

Ultimately, though, malaria is preventable – and there are a number of widely recognised ways to treat it. So why do millions of people across Sierra Leone still die from it every year?

The prevalence of malaria in Sierra Leone comes down to three main factors:

1. Low awareness

Across the country, there’s a lack of understanding and awareness of precautionary measures people can take to avoid contracting malaria, such as improved sanitation and the use of insecticide-treated nets. Many people don’t seek help from health services quickly enough, if at all. A study run at the start of the project revealed that only 54% of children were treated within 24 hours after the onset of a fever, one of the most common symptoms of malaria.

2. A shortage of resources

Sierra Leone is a low-resource country with a health budget that simply doesn’t meet the needs of the population. While the government has declared that treatment of malaria in health facilities is free, historically there have been shortages of testing equipment and treatment.

3. Distrust in health facilities

Rural communities prefer to seek health support from traditional healers and influential women (elders who support women through pregnancy and birth), rather than trained health professionals. This is due to the long distances to hospitals, the cost of transport and a longstanding distrust of healthcare workers, who have previously requested informal fees.

However, the traditional healers people turn to are ill equipped to handle the serious complications that can occur with malaria. They may treat people for malaria without testing them, or prescribe incorrect dosages. As a result of these complications, people can end up seeking formal health care when it’s too late.

In 2017, Concern received a generous grant from Comic Relief to launch the TAP (Treat and Prevent) Malaria project in 25 rural communities across Sierra Leone’s Tonkolili District. The project, which ran until 2021, aimed to:

• Increase people’s understanding of how to prevent and treat malaria
• Encourage pregnant women and mothers of children under 5 to seek healthcare
• Improve the quality of local health facilities to increase trust
• Build communities’ capacity to gather data, to inform decision-making and encourage a change in attitudes
• Save lives.

During TAP-Malaria’s four-year run, the project achieved each of these goals – and even exceeded expectations.

Traditional healers and influential women played an instrumental role in the project’s success. They used their reputations as trusted members of the community to act as ‘messengers’, identifying warning signs of malaria and referring people to hospitals. This innovative method - which was initially seen to be controversial - has been so effective that the Sierra Leone government now plans to embed it in their national malaria strategy.

Since 2017, clinical registers from hospitals across the Tonkolili district have shown a significant reduction in patient numbers and deaths from malaria – especially in pregnant women and young children. Community members are now more trusting of health facilities and have even started to self-refer, without consulting a traditional healer first. In one hospital, malaria-related deaths in March and April 2021 reduced from 91 in previous years to five.

When we surveyed communities on the most significant changes the project has made to their lives, we found:

1. People now know traditional herbs can’t cure malaria.

Communities’ knowledge of what causes malaria - and what helps to prevent and treat it - has increased drastically. They’ve learned that herbal treatments can’t cure malaria, and many traditional healers have now stopped offering them completely.

2. More than 90% of respondents were aware that malaria treatment is free.

The majority of people now know that they have a right to free malaria treatment at any public health facility. Before, the perceived cost implications of going to a hospital had long been a disincentive, with traditional healers considered a cheaper source of health care.

3. The community is now much cleaner.

Many people feel that a cleaner environment has been achieved over the lifetime of the project, as a result of recommendations on increased sanitation and the use of bed nets encouraged by traditional healers, influential women and local authorities.

TAP-Malaria evolved considerably in its four years and resulted in some other, unforeseen outcomes. For one, there’s been a positive shift in the way women are perceived and treated across these communities.

It’s now widely recognised that influential women and traditional healers have played a key role in changing attitudes and educating their communities. In turn, they’ve gained the respect of health staff, the local community and the national government. We’re hopeful that this is just the start of a more gender-inclusive approach to tackling other health challenges faced in Sierra Leone.

Antenatal care attendance and home births had previously been huge contributors to the high maternal mortality rate in Sierra Leone. The project evolved beyond malaria when influential women and traditional healers began to refer pregnant woman to hospitals. Since then, there’s been a significant increase in hospital births.

The project also responded to outbreaks of Lassa fever and Covid-19. Though, initially, there was a sharp drop in hospital attendance due to fear and misinformation about the pandemic, TAP-Malaria adapted to educate people on how to prevent and treat Covid-19 and encouraged them to seek help in hospitals. As a result, the recovery in hospital attendance was much quicker compared to the 2014 Ebola outbreak.

Due to the success of TAP-Malaria, we’re currently in talks with the National Malaria Control Programme and potential donors to support a nationwide expansion of some aspects of the project. This includes the model of working through traditional healers and influential women– something that could be easily replicated across the country. We’re also sharing our learnings and strategies with other NGOs who want to implement similar projects.

The recent successful trial of a malaria vaccine, which had an efficacy of 77%, could be transformative – but if TAP has taught us anything, it’s the value communities in Sierra Leone place on trust, information and the views of those they respect.