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 5 and pregnant women are especially vulnerable to the disease and the devastating complications it can cause, including maternal and fetal anaemia and stillbirths.

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

Malaria in Sierra Leone: Behind the numbers

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.

The Treat and Prevent Malaria project

In 2017, Concern received a generous grant from the UK nonprofit Comic Relief to launch TAP Malaria in 25 rural communities across Sierra Leone’s Tonkolili District. The project (short for Treat and Prevent Malaria) concluded earlier this year. Our goals were 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.

The power of women and indigenous knowledge

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 for TAP. They identified warning signs of malaria and referred people to hospitals. While originally considered controversial, this innovative method 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 just five.

In one hospital, malaria-related deaths in March and April 2021 reduced from 91 in previous years to just five.

Local Nurse Rugiatu Fornah explains:

"Mine was one of the health facilities with the highest burden of malaria. After the project, cases have dropped to the lowest level. The data review meetings with community stakeholders, traditional healers and influential women have unearthed many challenges, as well as solving them through the use of data. I’m satisfied with the hospital attendance and the reduction in malaria cases."

Changing attitudes, saving lives

When we surveyed communities on the most significant changes the project has made to their lives, we found that a lot of the project's success came down to correcting a few pieces of fake news:

1. Herbs can't cure malaria

Knowledge of what causes malaria — and what helps to prevent and treat it — has increased dramatically among communities participating in TAP Malaria. One of the most popular misconceptions was that herbal treatments could cure malaria, which is simply not true. Many traditional healers have now stopped offering these herbs completely.

2. Malaria treatment is free

The majority of people (over 90%) now know that they have a right to free malaria treatment at any public health facility in Sierra Leone. Before, the perceived cost implications of going to a hospital had long been a drawback, with traditional healers considered a cheaper source of health care.

3. A cleaner community is a healthier community

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

Surprise outcomes

TAP-Malaria evolved considerably in its four years and resulted in some other, unforeseen outcomes. That's a good thing.

For one, there’s been a positive shift in the way women are perceived and treated across these communities. It’s now widely recognized 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.

Prenatal 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.

Practical use in a pandemic

The project also responded to outbreaks of Lassa fever and COVID-19. While there was an initial 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. Part of that was also thanks to women such as one mother from the Marunia community:

"I noticed my daughter had a fever and knew I needed to take her to the hospital, but neighbors warned me that if I brought COVID-19 into the community I would have serious issues. However, I wanted to lead by example. The nurse tested her and announced she was malaria positive. After three days of treatment, my daughter was back on her feet. I paraded her around the village to show them she had recovered and that the hospital is not the cause of COVID-19. In the weeks that followed, more people started coming for treatment at hospital."

Malaria in Sierra Leone: A potential vaccine and what else lies ahead

Due to the success of TAP Malaria, Concern is currently in talks with the country's 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.

Concern is 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 that communities in Sierra Leone place on trust, information, and the views of those they respect. The introduction of a malaria vaccine could be a game-changer for the people of Sierra Leone. Until then, and in tandem with that, we’re confident in the lasting legacy of TAP Malaria and its potential to save countless lives.

Support projects like this