COMMENTARY

End Malaria Faster: Taking Lifesaving Tools Beyond “Access”

to “Reach” All People in Need
Courtney Emerson,a Jed Meline,b Anne Linn,b Julie Wallace,b Bryan K. Kapella,a Meera Venkatesan,b
Richard Steketeea

Key Messages sprays (IRS) on house walls that kill malaria parasite-
n To effectively address malaria control and carrying mosquitoes, preventive use of antimalarial
elimination worldwide, we must endeavor to drugs, and tests and medicines to diagnose and treat ma-
“reach the unreached,” to deliver malaria laria. PMI, along with these other key malaria actors,
services from the clinic to the community and also invests in strengthening the capacity of health
home. workers, laboratories, supply chains, surveillance, and
n Reach moves beyond access and requires that other health system pillars to control and eliminate ma-
we have the data to know who are unreached, laria, save lives, and strengthen global health security.6
where they are located, and how to ensure they Historic progress against malaria is threatened. The
receive malaria services. World Health Organization (WHO) estimates there
n Reach can only be achieved with community were 241 million malaria cases and 627,000 deaths
health workers that are adequately supported and worldwide in 2020—figures that had steadily declined
equipped to diagnose and treat malaria in every since 2000 but began to stagnate in 2015.1 Then, with
person in their communities regardless of age. the advent of the coronavirus disease (COVID-19) pan-
n Reach incorporates equity and responsibility for demic, malaria morbidity and mortality increased for
service delivery more expansively. the first time in this century. Efforts to achieve ambitious
global targets to reduce malaria have dramatically fallen
short. The resource gap grows each year with increasing
populations in endemic areas; WHO has noted that 2020
funding reached US$3.3 billion against an estimated
BACKGROUND need of US$6.8 billion.1 New threats are widening this
divide. The impacts of COVID-19 on communities, the
M alaria causes hundreds of millions of infections
and kills more than half a million people each
year.1 The U.S. President’s Malaria Initiative (PMI)
health workforce, supply chains, and health systems
may have further set malaria progress back by years.7
works in close partnership with National Malaria Increasing antimalarial drug and insecticide resistance
Control Programs (NMCPs) and other partners in and growing conflict and violence in malaria-affected
24 malaria-endemic African nations and 3 programs in the communities pose major challenges to progress.1 A
Greater Mekong subregion to change that.2 PMI recently reversal in progress against malaria could have dire conse-
released its 2021–2026 Strategy End Malaria Faster.3 The quences, resulting in hundreds of thousands of additional
Global Fund recently released its new Strategy 2023– deaths, potentially increasing the risk of outbreaks and
2028, which includes a malaria-specific technical strate- drug resistance, undermining economies, increasing pov-
gy for the first time.4 The World Health Assembly also erty, and weakening global health security.8
adopted the Update to the Global Technical Strategy Despite strong progress in scaling up malaria inter-
and Targets for Malaria 2016–2030 in May 2021.5 Each ventions across malaria-endemic sub-Saharan Africa,
of these strategies aims to support NMCPs and their by 2020, 35% of homes did not have at least 1 ITN, and
partners to deliver lifesaving interventions—such as care was not sought for more than 30% of children
insecticide-treated nets (ITNs) and indoor residual with fever.1 These individuals often represent families
experiencing poverty and living in rural areas, but signif-
a
U.S. President’s Malaria Initiative, U.S. Centers for Disease Control and icant numbers also live near health facilities. Where care
Prevention, Atlanta, GA, USA.
b is available, critical gaps persist in the quality of services
U.S. President’s Malaria Initiative, United States Agency for International
Development, Washington, DC, USA. including malaria testing and treatment practices, and in
Correspondence to Courtney Emerson ([email protected]). the deployment of optimal mosquito nets to address

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There is a need to insecticide resistance.9 Though we have existing communities both have and use their ITN; get test-
focus on ways to tools that are highly effective, coverage remains ed for their febrile illness; obtain the diagnostic re-
ensure that suboptimal. There is a need to focus on ways to en- sult, including the needed dose of medication; and
malaria services sure that preventive interventions like ITNs and receive their preventive antimalarial treatment
reach families seasonal malaria chemoprevention (SMC), as (e.g., intermittent preventive treatment during preg-
who are not yet well as prompt and effective malaria case manage- nancy [IPTp] or SMC). In addition, reaching the
using these ment services, reach families who are not yet us- unreached can sometimes refer to reaching adults
effective ing these effective interventions. in a community where government- or donor-
interventions. The global malaria community has been en- supported services target only young children.
gaged in dialogue regarding how to return to a Previous studies have shown the importance
course of progress, even “Rethinking Malaria.”10 of strong health systems to deliver preventative
The new PMI strategy calls for a focus to “Reach and curative malaria services,19,20 and this con-
the Unreached.” Strategic investments in commu- tinues to require focus. However, reach also
nity health systems and surveillance can better ex- emphasizes the importance of the quality of pre-
tend prevention and care to the unreached and vention, care, and treatment, recognizing that
strengthen pandemic preparedness and response. people receiving poor-quality services are not “ef-
While there is a need for new tools for malaria fectively covered” and are essentially unreached.9
control11 and the promise of new malaria vac- While there are few specific scientific references to
cines,12,13 existing tools, including ITNs, IRS, pre- reaching the unreached,21–23 efforts to extend ser-
ventive treatment, and case management, have vices to populations in need are evident in many
not yet achieved their full potential due to the programs, and evidence exists from large-scale in-
number of families and individuals not yet being tervention trials that the action of taking existing
reached by these lifesaving interventions.14,15 recommended interventions to high coverage in
populations can have a marked impact in prevent-
ing infection, illness, and death.24,25 By using the
By using the term DEFINING “REACHING THE term “reach” instead of “access,” the dialogue
“reach” instead of
UNREACHED” moves perceptibly further toward impact.
“access,” the
Access is defined in general terms as “permission, Community characteristics can determine the
dialogue moves
liberty, or ability to enter, approach, or pass to and best strategies to reach families and individuals.
perceptibly further
from a place or the freedom or ability to obtain Population characteristics such as rural/urban,
toward impact.
something.” By contrast, reach is defined as “to minority, migratory or mobile, and internally
extend to, to come to, to communicate with” and displaced/conflict-affected may lead to distinct
denotes a much more active, expansive approach and varying local needs and delivery require-
with close engagement and accompaniment.16,17 ments. As noted in the WHO Strategy, there is a
Within a global health context, care is accessible if need to address health disparities and inequities
it is available when and where people need it.18 to respond to populations experiencing disadvan-
Reaching the unreached is an active extension tage, discrimination, or exclusion.14
of accessible health care. Reach incorporates the Malaria services can be thought of as a package
utilization of prevention and care services, beyond of high-quality tools or interventions that can be
availability, and is the outcome of working to delivered to all of those in need when (1) com-
achieve, sustain, and tailor deployment and up- modities are appropriately resourced, procured,
take of high-quality, proven interventions with a distributed, and monitored; (2) personnel are suf-
focus on people who have been underserved. ficiently trained and compensated; and (3) benefi-
Reach builds on access and requires communities ciaries understand and have the desire and means
to have appropriate knowledge about care seeking to take advantage of each intervention. There is
and using preventive and treatment services, diversity in the strategies available to reach sus-
which necessitates identifying and addressing var- ceptible populations with these services. For ex-
ious barriers and facilitators experienced by speci- ample, with vector control tools, ITNs need to be
fic segments of the population that underuse in the home and used to cover sleeping spaces;
priority interventions. Reach addresses the critical IRS must be taken to every appropriately targeted
needs of all populations in and outside of commu- house and sprayed on walls; diagnostics and
nities (e.g., migrant and mobile populations) and artemisinin-based combination therapies for con-
requires overcoming economic and a myriad of firmed malaria must be delivered at the home,
other barriers to care. Reach has implications well health post, or clinic and used for the child with
beyond access to ensure that individuals and suspected malaria. For a child with fever to get

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tested promptly, families and providers must con- information systems report only on people who are
nect. IPTp must be actively delivered to pregnant reached at a health facility or sometimes by a com-
women, and young children in areas of highly sea- munity health worker (CHW) and typically exclude
sonal transmission must be reached repeatedly in those not accessing services in the public sector (also
their homes or communities with SMC. Social those using the private sector or military facilities).
and behavior change messaging and interventions Surveys (e.g., Demographic and Health Surveys,30
are a critical component of an effective malaria Multiple Indicator Cluster Surveys,31 Malaria
service package by helping ensure access is con- Indicator Surveys,32 and Malaria Behavior Surveys33)
verted into reach and services are used.26 Reach have provided important population-level infor-
requires a skilled and supplied workforce to deliv- mation on intervention coverage, infection and
er tools and an informed community to accept/ anemia rates, and certain knowledge and beha-
make use of them. Only then will the tools, exist- viors. However, these surveys are point-in-time
ing or new, be taken to those in need in a way that snapshots every few years, and sampling frame-
truly reaches that population. works only allow rate estimates at national or
regional levels, thereby offering limited local gran-
ularity. Hence, they can often miss mobile and
KNOWING WHO IS UNREACHED
otherwise unreached or undocumented popula-
AND HOW TO REACH THEM tions. These current tools have important value,
Understanding reached and unreached requires yet as we push to define the unreached, local
measurement and quantification of those who do efforts will benefit when they explore and ulti-
and those who do not use the necessary interven- mately adopt additional information opportuni-
tions (e.g., with ITN ownership of 70%, who are ties to assure that the unreached can be identified
the 30% with no ITN?). In fact, with our current and ultimately reached.
measurements of malaria intervention coverage, Newly available systems to collect district and lo- Newly available
we are often (but not always) measuring the scale cal data can be used to identify unreached popula- systems to collect
of population reach. Unreached populations are tions and measure progress in reaching them. district and local
different in each country and locality. To reach Systems such as the Geo-Referenced Infrastructure data can be used
them requires a deeper understanding of the pop- and Demographic Data for Development incorporat- to identify
ulation to determine who is unreached, where ed into the AKROS Reveal Platform, the Center for unreached
they can be found, what characteristics they International Earth Science Information Network, populations.
have, and how we can ensure the necessary pre- and Ecopia AI can combine satellite imagery and
vention or care services are utilized. Local knowledge geographic location including data on population,
is critical. This means that people in communities settlements, infrastructure, high-risk environments, Local knowledge
help identify the unreached and identify options to and boundaries to discover unreached places.34–36 is critical: people
establish reach. Data and information systems can As satellite data typically rely on census or vital regis- in communities
then be designed and made available locally to help try systems for validation, foundational investments can help identify
communities further plan and map their actions. in better vital registry systems in countries are also the unreached
Countries have made significant progress in required,37 noting that countries that do not have and identify
strengthening data systems. Many countries have these, have only an approximation of the number options to
adopted electronic health information systems, of individuals in their population.38 establish reach.
which have improved data collection and may Finding groups that have been economically
help to reduce stockouts.27,28 Malaria surveillance or socially marginalized will require different
is a key intervention component of the WHO types of information, potentially gathering knowl-
Global Technical Strategy.14 Recent advances in edge and data from private or nongovernmental
mobile technology have enabled health workers organizational providers that may not be well
in remote communities to communicate with connected to existing health systems. In addition,
supervisors, record and report data, receive on- internally displaced or conflict-affected people
the-spot virtual support, and even geo-map cases may require outreach to local organizations that
and prevention services. As the cost of such tools serve them and that may not be integrated into
continues to fall and connectivity improves, they district health information software reporting
can be used on a larger scale to improve both the systems.39
quality of services provided and the data for sur- Data collection and interpretation related to
veillance and planning.29 complex emergencies is often different from regu-
The common information systems may inherent- lar malaria programming and is a critical aspect of
ly miss the unreached. Routine health management reaching the unreached in these situations.40

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The unreached Ironically, the unreached can sometimes be to prevent importation of malaria through expo-
can sometimes be hidden in a community where government or sure to unique high-risk populations.43
hidden in a donor-supported services target only young chil-
community where dren or set other “specific coverage” targets.41 ENHANCING COMMUNITY HEALTH
government or Children aged 5 years and older, older adolescents,
and adults can often serve as reservoirs for malar-
SYSTEMS TO REACH THE
donor-supported
services target ia, not getting sick immediately or only modestly. UNREACHED
Adults who would quickly seek care for a febrile Bringing care to people helps ensure that no one
only young
child might defer their own care, risking their wel- remains unreached by lifesaving tools and ser-
children or set
fare and perpetuating malaria transmission in vices. Malaria tools do not deliver themselves—
other “specific
their communities. In many cases, child-focused health workers do.44 One proven approach for
coverage” targets.
services might be efficiently expanded to reach delivering malaria services closer to home is
Malaria tools do adults as well. CHWs, who, in many countries, are engaged in
not deliver Improved vital registration for all members of a campaign-style prevention interventions as well
themselves— population allows for better program planning by as in the delivery of routine case management ser-
health workers do. local health leaders. Data advances will allow na- vices.45 CHWs have demonstrated the ability to
tional programs to better track disease trends and provide testing and treatment for malaria, along
intervention effectiveness, identify coverage gaps, with diarrhea, pneumonia, and other childhood
monitor commodity stocks in more remote areas, diseases through an integrated community case
and identify populations requiring more commu- management (iCCM) platform, a proven approach
nity health services and the workforce to deliver for reducing child mortality when sufficient com-
them—in other words, help reach the unreached. modities for non-malaria ailments are available.46
In countries or specific areas where malaria
case rates are at lower levels, national programs
are implementing proactive community case
IMPLICATIONS OF REACH: TAILORED management where CHWs conduct regular
MALARIA CONTROL PROGRAMS household visits to actively seek out cases of fever
With differences in geography, climate, malaria and provide appropriate case management—
seasons, mosquito characteristics, cultural and so- proactively reaching community members where
cial norms, and human behavior, it is important to they reside rather than waiting for care to be
identify the most effective mix of interventions for sought.47 CHWs also play an active role in case
each setting.29 To truly reach communities with follow-up and investigation in elimination set-
the right services, it is critical to not only identify tings. In addition, evidence and experience show
areas of greatest malaria burden, greatest need, or that community-centered interventions can influ-
critical communities missed but also then ensure ence social norms, foster an environment for the
that the systems are strong enough to consistently practice of better health behaviors, and increase
deliver quality care and prevention services to demand for broader health services.48,49 Yet
those communities and households we are trying CHWs cannot deliver these services without in-
to reach. Fully reaching all susceptible people can vestment in systems to support them, which
lead to demonstrable reductions in malaria infec- includes relationships and processes to support
tion and burden and help address the stagnation health in communities and households outside
in global progress against malaria.24 but related to the formal health system.18
Countries can tailor the deployment of inter- There are many examples of system challenges
ventions and intervention packages subnationally that can limit the impact of CHWs. Weak and
so that the right tools are available in the right under-resourced systems for supervision leave
places at the right time. Evidence from operational CHWs without the support and mentorship they
research, evaluations, modeling, and other data need to work effectively. Health management infor-
can guide the selection of interventions and their mation systems that do not integrate community-
combinations. For example, tailoring includes us- level data or even numbers of CHWs50 leave the
ing local data to distribute mosquito nets effective true impact of CHWs unmeasured.46,51 Most
against insecticide resistance preferentially or CHWs are women, many are people experiencing
extending the length of chemoprevention cam- poverty, and most are not paid. Women on the
paigns in districts with a longer malaria season.42 front lines, including many at the community level,
In elimination settings, different interventions subsidize more than US$1 trillion of health care
may be used to target foci of local transmission or globally with their unpaid labor,52 and WHO

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End Malaria Faster: Beyond “Access” to “Reach” www.ghspjournal.org

recommends that CHWs be paid commensurate To address the plateau in progress against malaria,
with their work.53 the global malaria control community needs to
Frequent stockouts of commodities prevent ensure quality interventions reach the unreached.
CHWs from offering care for malaria, but in many Programs will benefit from learning who the
cases, even more so for the other childhood dis- unreached are, where they are located, and how
eases covered in the iCCM platform.54,55 Despite to best get the most effective malaria preventive
efforts by country governments and development and treatment services to them in their communi-
partners to scale up iCCM platforms, many coun- ties and homes. This requires better, timelier, and
tries have reported that supplies needed for the fully available data for communities. Malaria ser-
treatment of diarrhea, pneumonia, and malnutri- vices must be of sufficient quality and presented
tion are not consistently funded or available at the in a way that results in good use. Stronger
community level. It is important to extend the col- community health systems, involving CHWs, can
laboration with partners in child health to advo- provide prevention, diagnosis, and treatment of
cate at global, national, and local levels for the malaria for all ages and are central to successfully
provision of both malaria and nonmalaria com- reaching the unreached. PMI has committed to
modities56 together so CHWs can offer a truly inte- reaching the unreached as a critical component of
grated suite of lifesaving services and reach the its new strategy and will work with partners to
unreached for the full spectrum of health needs.57 again drive the malaria morbidity and mortality
It is also critical that this work is owned and coor- curves down and end malaria faster.
dinated by government leaders.58
Investment in communities and community Acknowledgments: The authors would like to acknowledge Dr. Raj
Panjabi, former U.S. Global Malaria Coordinator for his contributions to
health systems using iCCM has the potential to the U.S. President’s Malaria Initiative (PMI) Strategy, as well as PMI Staff
yield returns against malaria and more broadly and collaborating National Malaria Control Programs, Ministries of
Health, and partners. Financial support for this commentary was
against preventable and treatable diseases.46,57,59 provided by the U.S. President's Malaria Initiative.
Strengthening community health systems, from
the clinic to the community level, is a second focus Disclaimer: The contents are the responsibility of the authors and do not
area in PMI’s strategy, homing in on the “5 Ss” of necessarily reflect the official position of the U.S. Centers for Disease
Control and Prevention or the U.S. Agency for International
community health systems.60 Development.
These include a community health workforce
that is: Author contributions: MV led the development and writing of U.S.
President’s Malaria Initiative’s 2021–2026 Strategy. CE, JM, and RS
 Selected in the best way to get the right people developed the outline for the manuscript. CE drafted the manuscript. JM,
providing this service in all the communities of RS, MV, JW, AL, and BK provided critical intellectual feedback and
assisted in revising the manuscript. All authors read and approved the
need final manuscript.
 Skilled, either at the outset or through training
Competing interests: None declared.
 Supplied with the necessary tools and
equipment
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Peer Reviewed

Received: March 27, 2022; Accepted: April 4, 2022; First published online: April 20, 2022.

Cite this article as: Emerson C, Meline J, Linn A, et al. End malaria faster: taking lifesaving tools beyond “access” to “reach” all people in need. Glob
Health Sci Pract. 2022;10(2):e2200118. https://doi.org/10.9745/GHSP-D-22-00118

© Emerson et al. This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a
copy of the license, visit https://creativecommons.org/licenses/by/4.0/. When linking to this article, please use the following permanent link: https://
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