Community health workers lead the fight against malaria in Rwanda

Esther Urimubenshi, a 50-year-old farmer from the Bugesera district of Rwanda’s Eastern Province, used to dread the rainy season, when the constant threat of malaria loomed over her family.

In 2016, Esther fell ill with malaria three times in just two months, despite taking medication. “The fever, chills, and weakness left me bedridden and unable to care of my family or tend to my crops. It was a dark time,” she says.

But Esther’s fortunes have changed. Theoneste Nezehose, a community health worker in Esther’s area, has for the past 12 years dedicated efforts to support Esther and her community to combat malaria.

Theoneste educated Esther and her family on the importance of good practices to avert malaria transmission and on other prevention measures including the removal of mosquito breeding sites and the proper use of mosquito nets. It has now been more than two years since Esther had malaria.

“Malaria was constantly haunting us, but Theoneste has been our beacon of light,” she says.

In addition to disseminating critical information on malaria prevention, community health workers like Theoneste provide early diagnosis and treatment, distribute insecticide-treated bed nets and conduct indoor residual spraying to help prevent transmission. They also monitor and report all cases to the nearest health facility.

“I receive supplies and training support from Mayange Health Centre, seven kilometres from here. I send weekly updates and they help with referral cases,” says Theoneste. “Being able to make a difference in the lives of people like Esther and other fellow community members is a privilege I cherish every day.”

“Community health workers are the unsung heroes of the fight against malaria in the country,” says Dr Emmanuel Hakizimana, acting head of the malaria division at the Rwanda Biomedical Centre (RBC), the Ministry of Health’s implementing wing. “Thanks to them, we have been able to bring malaria prevention, diagnosis and treatment into the heart of the community, which has also reduced the strain on health facilities.”

This approach of community case management has worked in tandem with other interventions. This includes the distribution of more than 6 million bed nets, with one net for every two household members. A ratio of at least one net for every two household members is considered typically sufficient to achieve universal coverage in a population. In addition, indoor residual spraying has been scaled up from three to 12 districts which usually represent the highest burden of malaria cases.

The country has also increased access to health services for all through its Community Based Health Insurance scheme, helping to ensure that people receive free, prompt malaria treatment.

WHO has been a key partner in the country’s fight against malaria. The Organization has supported community health worker trainings the development of technical guidelines as well as the development and implementation of a national strategic plan for 2020‒2024, with the primary goal of reducing malaria morbidity and mortality by at least 50% compared with the 2019 levels.

“Community health workers are the backbone of community health programmes and contribute immensely to managing diseases like malaria,” says Dr Jules Mugabo Semahore, Head of Malaria and Neglected Tropical Diseases at WHO Rwanda. “They play a crucial role in reaching remote and underserved communities with life-saving interventions. WHO continues to partner with the Ministry of Health to capacitate this cornerstone of the fight against malaria.”

The diagnosis and treatment of malaria was decentralized to improve the prompt treatment of malaria cases and target all age groups, says Dr Hakizimana.

He adds that in the coming years, the country plans to tackle the primary challenges to Rwanda’s malaria control programme. This includes the effective management of forms malaria transmission that can persist after achieving full universal coverage with nets and indoor residual spraying, for example, when mosquitoes feed on people who are active or outdoors, or feed on livestock. The country will enhance operational research and digitalize data on malaria cases at village and household levels, addressing the lack of aggregated data this level.

The programme intends to sustain the capacity of community health workers like Theoneste. He is proud of his ongoing contribution towards this fight. "What keeps me going is seeing first-hand the difference that my work makes in my community,” he says. “It’s an incredible feeling.”