Nongovernmental organizations (NGOs) are playing a critical role in helping countries move toward those Millennium Development Goals that seek significant reductions in child and maternal mortality and progress in combating HIV/AIDS, malaria, and other major diseases. In Rwanda, three NGOs have teamed with the national government to introduce effective community-based care for malaria.

Julia Ross is communications manager for the CORE Group, a Washington, D.C.-based coalition of NGOs working in child health and development.

Malaria continues to take a huge toll on global health. More than one million lives are lost to the mosquito-borne illness each year, with the vast majority of deaths occurring in Africa among children under age five.

In the central African country of Rwanda, malaria is the leading cause of morbidity and mortality, accounting for 43 percent of all deaths and 40 percent of health center visits. But the use of health facilities in Rwanda is low, and many children with malaria end up dying at home, without proper treatment. In the Rwinkwavu district, for example, community health workers reported 588 deaths of children under age 5 in 2002, almost three-quarters of which were attributed to malarial fever. Only 42 of these deaths occurred in health facilities.

In a survey conducted in two health districts by Rwanda's National Malaria Control Program, children less than 5 years of age were found to get appropriate treatment for malaria an average of three days after the onset of fever, much later than the World Health Organization-recommended treatment window of 24 hours after onset.

Mothers and children being trained through the antimalarial program in Rwanda.
Courtesy of The CORE Group

The reasons for this delay include distance from a local health center and the cost of treatment. Many Rwandan parents or caregivers prefer to purchase treatment from local pharmacists and pill sellers who are close by and charge less than health centers for medication, but who often do not provide high-quality medication or proper advice regarding dosing and duration of treatment. These factors account for Rwanda's low use of government-sanctioned health facilities: less than 0.24 visits per person per year.

Additional surveys conducted in 2004 by three NGOs working in Rwanda—Concern Worldwide, the International Rescue Committee (IRC), and World Relief—showed that few young children with fever receive antimalarial treatment as recommended by Rwanda's Ministry of Health. Only 16 percent of children included in the study in the Kibilizi district, 9 percent in the Kirehe district, and 20 percent in the Kibogora district received timely and appropriate treatment. About one-third of children received no treatment.

FIVE-DISTRICT PILOT PROGRAM

In response to these surveys and the evident gap in delivering treatment to young children with malarial fever, Rwanda's National Malaria Control Program in 2004 teamed with the three NGOs to launch a pilot program for community-based distribution of antimalarial medication in five districts.

The initiative—funded by the CORE Group; the U.S. Agency for International Development (USAID); and the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM)—aims to educate parents to identify danger signs associated with malarial fever and treat the illness with help from a nearby community drug distributor within hours of onset, when the chances of saving a child's life are at their highest. For more complicated cases, parents are advised to seek help at a health center.

With support from the government of Belgium, Rwanda's National Malaria Control Program last fall purchased about 450,000 blister packs of malaria drugs to treat children under age five. Local distribution began in November 2004, with the packs offered at very low cost (10 cents) or on credit. While the Rwandan government provides program oversight, the NGOs and their local partners implement and monitor the drug distribution efforts. Community health workers, chosen by communities and trained by health districts and their NGO partners, are responsible for distributing the drugs.

PROMISING RESULTS

As of April 2005, program results were promising. In the initiative's first five months, more than 85 percent of children in the five districts were treated within 24 hours of the onset of fever. World Relief trained 329 local drug distributors and reported no deaths among children receiving treatment through these distributors. From November 2004 to February 2005 in the Kibilizi district, Concern Worldwide reported that cases of children successfully treated for fever in the community rose from zero to 795.

The International Rescue Committee reported that, as of May 2005, 280 community distributors in the Kirehe district were treating more than 3,000 cases of childhood fever per month. Dr. Emmanuel d'Harcourt, the IRC's senior technical adviser for child survival, says Kirehe's program has been embraced equally by parents, drug distributors, and health facility staff. According to d'Harcourt, "Health center staff say they have been pleasantly surprised at the care that distributors have put into their work. They say they have full confidence in the distributors and can concentrate on sicker children now that simple malaria is being treated in the community."

"Community-based distribution of antimalarial drugs is a key way to reach the Abuja target of treating 60 percent of kids under 5 within 24 hours," says Dr. Jules Mihigo, former maternal and child health specialist with USAID in Rwanda.

The Abuja targets for malaria reduction were set as part of the African Summit on Roll Back Malaria held in Abuja, Nigeria, in 2000.

Rwanda has received funding from GFATM to scale up the five-district pilot program nationwide, beginning with five additional districts in September 2005.

The opinions expressed in this article do not necessarily reflect the views or policies of the U.S. government.

The CORE Group, a membership association of international nongovernmental organizations based in Washington, D.C., promotes and improves the health and well-being of children and women in developing countries through collaborative action and learning. Collectively, the CORE Group's 38 member organizations work in more than 140 countries.