Malaria Consortium’s
seasonal malaria
chemoprevention
programme:
Philanthropy report 2022i

April 2023
Report compiled by: Christian Rassi
Contributors and reviewers: Junior Achia, Dickson Awah, Kevin Baker, Craig Bonnington, Liberty
Bunce, Cheick Compaore, Louise Cook, Simon Cordery, Michelle Davis, Monica Anna de Cola, Ashley
Giles, Sam Gudoi, Tom Heslop, Maxwell Kolawole, Maurice Kwizera, Chuks Nnaji, Nkoli Nnamonu,
Anthony Nuwa, Musa Odongo, Chibuzo Oguoma, Joshua Okafor, Samantha Rothbart, David Salandini
Odong, Clotaire Tapsoba, James Tibenderana, Yakouba Zoungrana, Albertino Zunza
Established in 2003, Malaria Consortium is one of the world’s leading
non-profit organisations specialising in the prevention, control andtreatment of malaria and other communicable diseases among
vulnerable populations. Our mission is to save lives and improvehealth in Asia and Africa through evidence-based programs that
combat targeted diseases and promote universal health coverage.
Malaria Consortium
The Green House, 244–254 Cambridge Heath Road, London E2 9DA

www.malariaconsortium.org
info@malariaconsortium.org
UK Registered Charity No: 1099776
US EIN: 98-0627052

2

Executive summary
This report summarises how Malaria Consortium used philanthropic funding for seasonal malaria
chemoprevention (SMC), either exclusively or in combination with other funding sources, in 2022.
SMC is a highly effective community-based intervention to prevent malaria infections in areas wheremalaria morbidity and mortality are high and malaria transmission is seasonal. In those areas,malaria cases peak over a period of a few months every year, typically coinciding with the rainyseason. SMC involves the intermittent administration of antimalarial medicines to populations at risk
from malaria during this peak transmission season. The objective is to maintain therapeutic
antimalarial drug concentrations in the blood throughout the period of greatest risk.
2022 marked 10 years since the initial recommendation to scale up its use by the World HealthOrganization in 2012. The intervention has since been scaled up successfully, reaching around 48
million children in 2022. New global guidelines for malaria emphasise the importance of local
evidence and determining the optimal mix of interventions at the subnational level. For SMC, theguidelines no longer define geographic restrictions and provide greater flexibility in recognising agebased risk. Malaria Consortium believes that, for the foreseeable future, SMC is likely to remain acornerstone of malaria prevention and control in areas where malaria transmission is seasonal.
However, we are likely to see fundamental changes to how and where SMC is implemented. Keyquestions that will need to be addressed to ensure its longer-term effectiveness and shape thefuture of SMC relate to seasonality and age range; SMC in new geographies; parasite resistance andalternative drug regimens; integration; and innovation.
Malaria Consortium is a leading implementer of SMC. In 2022, we supported SMC delivery to almost
24 million children in seven countries: Burkina Faso, Chad, Mozambique, Nigeria, South Sudan, Togo
and Uganda. This means around half of all children reached with SMC that year were supported by
Malaria Consortium. The majority of Malaria Consortium’s funding for SMC comes fromphilanthropic sources. In 2022, philanthropic funding or co-funding enabled us to deliver SMC to
16.08 million children in the seven countries we supported. This compares with 12.19 million
reached with philanthropic support in 2021 and 7.14 million in 2020. The increased number ofchildren reached in 2022 was primarily due to the expansion of SMC to new areas in Nigeria andMozambique. We used philanthropic funding to procure around 77.5 million blister packs of SMC
medicines and to support more than 150,000 SMC implementers involved in the delivery of SMC.
SMC campaigns are implemented under the leadership of national malaria programmes and throughcountries’ existing health system structures. Consequently, Malaria Consortium’s role in supporting
SMC varies from country to country. However, we generally provide technical and operational
support on all the components that together make up SMC as a public health intervention:
administration of SMC medicines; planning and enumeration; procurement and supply
management; community engagement; training; case management and pharmacovigilance;
supervision; and monitoring and evaluation. Quality of SMC delivery, campaign digitalisation andmitigating risk are themes that cut across intervention components.
As both a leading implementer of SMC and a research organisation, Malaria Consortium is uniquelyplaced to develop and evaluate solutions to operational problems that can improve the quality of
SMC delivery; assess the extent to which SMC impacts estimates of the burden of malaria; and test
innovations that will shape the future of SMC. The scope and scale of Malaria Consortium’s SMC
research has grown substantially over the last few years. In 2022, Malaria Consortium’s SMC
research was published in seven peer-reviewed articles. We also presented our findings at3

prestigious academic conferences. Research studies we conducted in 2022 included testing different
community engagement strategies to increase the effectiveness of SMC by strengthening caregivers’
adherence to SMC protocol in Burkina Faso, Chad, Nigeria and Togo; and an ecological analysis
drawing on a range of data sets from Burkina Faso and Nigeria to estimate the impact of SMC interms of preventing malaria cases among children during the high transmission season. Some of ourmost exciting and groundbreaking research in 2022 explored the feasibility, acceptability and impactof SMC in East and southern Africa, where SMC had not previously been tested due to concerns overwidespread parasite resistance to the SMC medicines in this region. Those studies involved
assessments of the feasibility and acceptability of SMC in those new settings; assessments of thechemoprevention efficacy of SMC medicines and the effectiveness of SMC in terms of preventing
malaria cases during the high transmission season; as well as monitoring of common resistancemarkers associated with parasite resistance to the SMC medicines. We generally found SMC in the
new locations to be feasible and highly acceptable. Effectiveness results so far have been promising,but we do not yet have results from the chemoprevention efficacy and resistance markers studies,
which will become available over the course of 2023. We will only be able to draw robust
conclusions on the suitability of SMC in the locations where we have tested the intervention once
we have the full results from all study elements.
As a global leader on SMC, Malaria Consortium wants to contribute to relevant debates about SMC
policy and practice. We also want to ensure sustainable financing for SMC from three core channels:
governments, institutional donors andphilanthropists. Our external relations
outputs in 2022 included a technical brief
describing our monitoring and evaluation
framework; a summary of our insights from
implementing the first SMC campaign inMozambique; and an advocacy brief thatlobbies for the inclusion of policy guidance on
the co-implementation of SMC and vitamin A
supplementation in Nigeria.
We regularly engage with national, regionaland global malaria stakeholders and are
active members of the SMC Alliance, aworkstream under the RBM Partnership to
End Malaria’s Country/Regional Support
Partner Committee. In 2022, we served as thesecretariat of the SMC Alliance subgroups on
research and communications and advocacy.
This has included leading on the compilationof a report that celebrates 10 years of SMC
on behalf of the SMC Alliance.
The total philanthropic expenditure in 2022
was 62.26 million United States dollars.
Photo 1: A caregiver and children holding their SMC record
cards, where SMC doses are recorded, Mozambique4

Contents
1.

Introduction ............................................................................................................................ 8

2.

Malaria Consortium’s SMC portfolio 2022 ............................................................................... 93.

Seasonal malaria chemoprevention: Past, present and future ............................................... 11

4.

5.

6.

3.1

From concept to scale: Ten years of SMC ............................................................................ 11

3.2

SMC and malaria chemoprevention in the WHO’s updated Guidelines for Malaria............ 12

3.3

The future of SMC ................................................................................................................ 14

Malaria Consortium as an implementing partner for SMC ..................................................... 20
4.1

SMC intervention components ............................................................................................ 20

4.2

Quality of SMC delivery ........................................................................................................ 28

4.3

Digitalising SMC .................................................................................................................... 29

4.4

Mitigating risk....................................................................................................................... 32

Philanthropically supported SMC delivery in 2022................................................................. 35
5.1

Burkina Faso ......................................................................................................................... 35

5.2

Chad ..................................................................................................................................... 38

5.3

Mozambique ........................................................................................................................ 41

5.4

Nigeria .................................................................................................................................. 46

5.5South Sudan ......................................................................................................................... 53

5.6

Togo...................................................................................................................................... 56

5.7

Uganda ................................................................................................................................. 58

Malaria Consortium’s SMC research ...................................................................................... 64
6.1

Scope and scale of Malaria Consortium’s SMC research ..................................................... 64

6.2

Developing and evaluating solutions to operational challenges .......................................... 66

6.3

Assessing impact .................................................................................................................. 69

6.4

Shaping the future of SMC ................................................................................................... 71

7.

External relations .................................................................................................................. 79

8.

Philanthropic SMC expenditure 2022 .................................................................................... 82

9.

Concluding remarks .............................................................................................................. 85

References ................................................................................................................................... 86

5

Acronyms and abbreviations
ACCESS-SMC

Achieving Catalytic Expansion of Seasonal Malaria Chemoprevention
in the SahelAL

artemether-lumefantrine

AQ

amodiaquine

ASAQ

artesunate-amodiaquine

ASTMH

American Society of Tropical Medicine and Hygiene

CHIPS

Community Health Influencers, Promoters and Services

CHW

community health worker

CI

confidence interval

COVID-19

coronavirus diseasecRCTcluster-randomised controlled trial

DOT

directly observed treatment

DPdihydroartemisinin-piperaquine

EPI

Essential Programme on Immunization

FGD

focus group discussion

Global Fund

Global Fund to Fight AIDS, Tuberculosis and MalariaHRhazard ratio

iCCM

integrated community case management

IDPs

internally displaced people

IPTiintermittent preventive treatment of malaria in infants

IPTpintermittent preventive treatment of malaria in pregnancy

IPTscintermittent preventive treatment of malaria in school-aged children

KII

key informant interview

KOICA

Korea International Cooperation Agency

LGA

local government area

LQAS

lot quality assurance sampling

M&E

monitoring and evaluation

MDA

mass drug administration

MSF

Médecins Sans Frontières

NMCD

National Malaria Control Division

NMEP

National Malaria Elimination Programme

nRCT

non-randomised controlled trialOR

odds ratio

PDMC

post-discharge malaria chemoprevention

PhD

Doctor of Philosophy

PMC

perennial malaria chemoprevention

PMI

U.S. President’s Malaria Initiative

6

PNCM

Programa Nacional de Controlo da Malária

PNLP

Programme National de Lutte contre le Paludisme

PReS

Project Results System

RDT

rapid diagnostic test

SMC

seasonal malaria chemoprevention

SP

sulfadoxine-pyrimethamine

SPAQ

sulfadoxine-pyrimethamine plus amodiaquine

UK

United Kingdom

UNICEF

United Nations Children’s FundUS

United States

USD

United States dollar

VHT

village health team

WHO

World Health Organization

7

1. Introduction
Malaria Consortium is a leading implementer of seasonal malaria chemoprevention (SMC), a highly
effective community-based intervention to prevent malaria infections in areas where malaria
morbidity and mortality are high and malaria transmission is seasonal. In those areas, malaria cases
peak over a period of a few months every year, typically coinciding with the rainy season. SMC
involves the intermittent administration of antimalarial medicines to populations at risk frommalaria during this peak transmission season. The objective is to maintain therapeutic antimalarial
drug concentrations in the blood throughout the period of greatest risk.
The majority of Malaria Consortium’s funding for SMC comes from philanthropic sources. This
includes grants and donations to Malaria Consortium’s entities in the United Kingdom (UK) and theUnited States (US), primarily as a result of being awarded Top Charity status by GiveWell,[1,2] a nonprofit dedicated to finding outstanding giving opportunities and publishing the full details of its
analysis to help donors decide where to give.
In this report, we summarise how Malaria Consortium used philanthropic funding for SMC, either
exclusively or in combination with other funding sources, in 2022. Section 2 presents an overview ofthe scale and scope of Malaria Consortium’s current SMC portfolio. In section 3, we trace the scaleup of SMC over the past ten years and outline the adaptations and innovations that we believe will
shape its future. Section 4
discusses Malaria Consortium’srole as an SMC implementing
partner, describing how we work inclose partnership with nationalmalaria programmes to implement
SMC campaigns. Achievements andchallenges in each of the countries
where philanthropic funding wasused to support SMC in 2022 aresummarised in section 5. Section 6
discusses Malaria Consortium’srole as a research organisation andsummarises philanthropicallyfunded SMC research activities
conducted in 2022. In section 7, we
describe our approach to external
relations and how philanthropic
SMC funding was used to engage
with external stakeholders andaudiences. Finally, section 8
presents an overview ofphilanthropic SMC expenditure in
2022.
Photo 2: A community health worker in Uganda provides SMC to eligible children
alongside other services including malaria testing8

2. Malaria Consortium’s SMC portfolio 2022
In 2022, Malaria Consortium supported SMC delivery to almost 24 million children in sevencountries: Burkina Faso, Chad, Mozambique, Nigeria, South Sudan, Togo and Uganda (Figure 1).
Figure 1: Countries where Malaria Consortium supported SMC delivery, 2022

Out of a total of 23.78 million children targeted with Malaria Consortium’s support in 2022, 15.10
million were reached exclusively with philanthropic funding. An additional 970,000 children were
supported through co-funding arrangements with the Global Fund to Fight AIDS, Tuberculosis andMalaria (Global Fund), the United Nations Children’s Fund (UNICEF) and the Korea International
Cooperation Agency (KOICA). Global Fund funding exclusively was used to support SMC delivery to
the remaining 7.71 million children (Table 1).

9Table 1: SMC target population supported by Malaria Consortium by funding source, 2022

Funding source
Philanthropic

Number of children
targeted
15,100,000

Countries
Burkina Faso, Chad, Mozambique,
Nigeria, South Sudan, Uganda

Philanthropic andGlobal Fund

390,000

Togo, Uganda

Philanthropic and
UNICEF

300,000

Burkina Faso, Togo

Philanthropic andKOICA

280,000

Nigeria

Global Fund

7,710,000

Nigeria

TOTAL

23,780,000

103. Seasonal malaria chemoprevention: Past, present andfuture2022 marked 10 years since the initial recommendation to scale up the use of SMC by the World
Health Organization (WHO) in 2012. In this section, we recount the journey of SMC from concept toscale; discuss the current WHO guidelines for the deployment of SMC; and outline key
considerations that will shape the future of the intervention.

3.1 From concept to scale: Ten years of SMC

Photo 3: Boxes containing blister packs of the two antimalarials for use in SMC: sulfadoxinepyrimethamine and amodiaquine

In 2012, the WHO recommended the scale-up of SMC as a strategy for the prevention of malaria
caused by Plasmodium falciparum in children 3–59 months.[3] Children under five were targetedbecause young children are most at risk from severe malaria disease and death. Based on a metaanalysis of trials conducted over the previous decade,[4] the WHO expected that SMC could prevent
75 percent of uncomplicated and severe malaria cases in children under five. The policy
recommended a combination of two antimalarials for use in SMC: sulfadoxine-pyrimethamine (SP)and amodiaquine (AQ). A full therapeutic course of SP plus AQ (SPAQ) confers a high degree ofprotection for approximately 28 days.[5] Annual SMC rounds comprising four monthly SMC cycles —beginning at the start of the transmission season and comprising a full therapeutic course of SPAQ
each cycle — were recommended in areas where more than 60 percent of clinical malaria cases
occur during a maximum of four months, and where the clinical attack rate of malaria is greater than
0.1 attack per transmission season among children under five. SMC was not recommended in areas
where the therapeutic efficacy of SPAQ is below 90 percent due to parasite resistance, which is
widespread across East and southern Africa.[6] Consequently, the Sahel region of West and Central
Africa was prioritised for the scale-up of SMC. To support national malaria programmes in rolling out
the intervention, the WHO published a field guide in 2013, which provided technical information andoperational tools to inform decision-making on how and where SMC should be implemented.[7] The

11

recommendation to deploy SMC in suitable areas was reinforced in the WHO’s Global TechnicalStrategy for Malaria 2016 – 2030.[8]By 2014, eight Sahelian countries were implementing SMC, reaching about 2.5 million children.
Between 2015 and 2017, the Achieving Catalytic Expansion of SMC in the Sahel (ACCESS-SMC)
project, funded by Unitaid and led by Malaria Consortium, accelerated the scale-up of SMC acrossthe region. At its peak, ACCESS-SMC reached close to seven million children in Burkina Faso, Chad,
The Gambia, Guinea, Mali, Niger and Nigeria. The project also contributed towards building theevidence base of SMC as a safe and effective intervention when implemented at scale.[9] Casecontrol studies in the seven ACCESS-SMC countries showed that SMC under programmaticconditions provides high levels of protection comparable to those found in trial settings, with anaverage protective effectiveness of 88 percent against clinical malaria over a 28-day period.[10] A
study in Mali found that SMC reduced hospital admissions among children under five by 39
percent.[11] The weighted average economic cost of administering four monthly SMC cycles wasestimated at 3.63 United States dollars (USD) per child, with economic cost savings to ACCESS-SMC
countries’ health systems totalling 66 million US dollars by reducing the cost of malaria diagnosis,
treatment and hospital admissions.[12]SMC has since been embraced and further scaled up by governments, with support from donors
such as the Global Fund, the U.S. President’s Malaria Initiative (PMI), UNICEF, UK aid from the UK
government, Médecins Sans Frontières (MSF), KOICA and philanthropic funding for Malaria
Consortium’s SMC programme. In 2021, SMC was implemented in 15 countries, targeting around 45
million children,[13] up from 33.5 million children in 13 countries the year before.[14] The increase intargeted children was primarily due to the expansion of SMC to new states in Nigeria, while theincreased number of countries implementing SMC was a result of SMC pilot projects in Mozambiqueand Uganda — the first countries outside of the Sahel to test the use of SMC as a malaria prevention
strategy. According to unpublished data compiled by the SMC Alliance, a workstream under the RBM
Partnership to End Malaria’s Country/Regional Support Partner Committee, the number of children
targeted globally was just under 48 million in 2022. This means around half of all children reachedwith SMC that year were supported by Malaria Consortium.

3.2 SMC and malaria chemoprevention in the WHO’s updated Guidelines for
Malaria
The successful scale-up of SMC in the Sahel over the last decade has invigorated the global malaria
community’s interest in chemoprevention strategies for at-risk populations. This is reflected in the
WHO’s revised Guidelines for Malaria,[15] published in 2022, which encourage national malaria
programmes to expand access to chemoprevention, including a range of different strategies(Spotlight 1). The consolidated guidelines provide greater flexibility to malaria-endemic countries toadapt malaria strategies to their specific context and epidemiology, emphasising the importance of
local evidence and determining the optimal mix of interventions at the subnational level. Somecountries have conducted systematic, evidence-based stratification exercises to determine theoptimal mix of malaria interventions in different locations, taking into account epidemiologicalcharacteristics such as malaria prevalence, incidence and all-cause mortality among children under
five, as well as measures of seasonality, urbanisation and access to health care.

12

Spotlight 1: Chemoprevention strategies recommended in the 2022 WHO Guidelines for Malaria

The WHO defines chemoprevention as the use of medicines, either alone or in combination,
to prevent malaria infection and its consequences. The consolidated WHO Guidelines for
Malaria recommend the following chemoprevention strategies:
•

•

•

•

•

•

Intermittent preventive treatment of malaria in pregnancy (IPTp) involves giving
pregnant women monthly courses of SP beginning in the second trimester ofpregnancy. Doses should be given at least one month apart, with the objective ofensuring that at least three doses are received over the course of the pregnancy. IPTp
is typically delivered through countries’ antenatal care platforms. The WHO strongly
recommends the use of IPTp in all malaria-endemic areas.
Perennial malaria chemoprevention (PMC), formerly known as intermittent
preventive treatment of malaria in infants (IPTi), involves the regular administration of
antimalarials in areas where malaria transmission is high throughout the year. No
parameters have been defined for the age range of PMC, but the WHO advises thateligibility should be informed by the age pattern of severe malaria admissions. Where
PMC has been deployed to date, typically children under 24 months have beentargeted. Similarly, no specific drug regimen is recommended but, in practice, SP iscommonly used. Delivery is typically integrated into countries’ Essential Programmeon Immunization (EPI) programmes. The WHO have issued a conditional
recommendation for the scale-up of PMC.
Seasonal malaria chemoprevention (SMC) involves the administration of antimalarial
medicines (typically SPAQ) during peak malaria transmission seasons to reduce
disease burden. Commonly, children 3–59 months are targeted through communitybased door-to-door campaigns. The WHO strongly recommends the use of SMC insuitable areas.
Intermittent preventive treatment of malaria in school-aged children (IPTsc) involves
the administration of antimalarials to children 5–15 years at predetermined intervals.
The intervention can be implemented both in areas of perennial and seasonal malariatransmission. IPTsc should only be introduced if it does not compromise
chemoprevention interventions for younger children. Delivery is typically school
based. No specific drug regimen has been defined. The WHO conditionally
recommends IPTsc in malaria-endemic settings with moderate to high transmission.
Post-discharge malaria chemoprevention (PDMC) involves the repeatedadministration of antimalarials to children with severe anaemia caused by malaria
following their discharge from hospital. This is a new intervention that has not yet
been clearly defined or operationalised. The WHO has issued a conditional
recommendation for the use of PDMC in in settings with moderate to high malariatransmission.
IPTp, PMC, SMC, IPTsc and PDMC all target specific at-risk groups and are intended to
be implemented over several years. Those approaches are distinguished from mass
drug administration (MDA), which has a broader target population and is often
implemented as a one-off, stand-alone campaign. The WHO guidelines conditionally
recommend MDA for burden reduction; MDA for burden reduction in emergency
settings; and MDA to reduce transmission in low-transmission settings. MDA toreduce transmission in moderate and high transmission settings is not recommended.

13

For SMC, the consolidated WHO guidelines no longer define geographic restrictions and they provide
greater flexibility in recognising age-based risk.[16] Malaria Consortium welcomed these new
guidelines, acknowledging that in the face of limited resources and cross-border challenges such asparasite resistance and the global climate crisis, a coordinated approach will be needed to guide thefuture deployment of SMC.[17] An updated SMC field manual will provide further guidance on where
and how SMC should be implemented. Malaria Consortium was invited by the WHO to participate ina technical consultation to inform the revisions to the manual, which will be published in 2023.

3.3 The future of SMC
For the foreseeable future, SMC is likely to remain a cornerstone of malaria prevention and control
in areas where malaria transmission is seasonal, but we are likely to see several fundamental
changes to how and where SMC is implemented. Key questions the global malaria community willneed to address to maintain the longer-term effectiveness of SMC relate to seasonality and age
range; SMC in new geographies; parasite resistance and alternative drug regimens; integration; andinnovation.
i.

Seasonality and age range
In recent years, we have seen countries varying the number of monthly SMC cycles to betterreflect the duration of the peak malaria transmission season. A study conducted by Malaria
Consortium in Burkina Faso showed that adding a fifth cycle is feasible and acceptable, withsimilar SMC coverage achieved across all cycles.[18] Following a recommendation from asystematic stratification exercise, Burkina Faso’s National Malaria Control Programme —Programme National de Lutte contre le Paludisme (PNLP) — adopted the implementation of five
SMC cycles in 19 of the country’s 70 health districts, starting in 2019 (Figure 2). Of the countries
supported by Malaria Consortium, some states in Nigeria and all SMC-implementing areas inSouth Sudan and Uganda also implement five cycles. It is likely that varying the number of SMC
cycles between three and five per year will become the norm over the coming years. It is also
possible that seasonality patterns will change as a result of the global climate crisis. There is aneed to collaborate more closely with climate scientists to evaluate when and where SMC canbe used to maximum effect, including determining the optimal start and end points of SMC
campaigns based on local malaria transmission patterns.

14Figure 2: Number of SMC cycles implemented by health district, Burkina Fasoii.

Another parameter some countries have experimented with is the age range that is targeted forSMC. For example, a study conducted in Senegal found that SMC in children up to 10 years iswell tolerated and effective.[19] The WHO’s consolidated malaria guidelines stipulate that theage group targeted for SMC should be informed by the local age pattern of severe malaria
admissions, but also point out that cost-effectiveness of SMC will become less favourable as theintervention is extended to older age groups at lower risk of severe disease.[15] A study
conducted by Malaria Consortium in Chad found that extending the age range of SMC to older
children is generally acceptable to both policy makers and caregivers. However, there was also astrong preference for prioritising younger children.[20]SMC in new geographies
Greater flexibility and subnational tailoring will result in SMC being expanded to newgeographies, thus reaching children that have not so far benefited from SMC. In Nigeria, forexample, nine Sahelian states were targeted for the initial scale-up of SMC. In 2021, asystematic stratification exercise resulted in the National Malaria Elimination Programme(NMEP) considering an additional 11 states plus the Federal Capital Territory (FCT) eligible for
SMC (Figure 3). Similar stratification exercises in other countries may result in the identificationof additional locations that could benefit from SMC. Those exercises may, however, also
conclude that SMC is not needed in some areas that currently receive the intervention. In linewith the general paradigm shift away from one-size-fits-all approaches and towards subnational
tailoring, there is a need for closer coordination between SMC and other malaria interventions,
including net distribution and the other chemoprevention strategies recommended in therevised WHO malaria guidelines.

15

Figure 3: Areas considered eligible for SMC before 2021 and since 2021, Nigeria*Only 10 local government areas (LGAs) in Bauchi were considered eligible for SMC pre-2021. The remaining 10 LGAs havebeen considered eligible since 2021.
‡Only 11 out of 16 LGAs in Kwara are considered eligible for SMC.
†Only six out of 33 LGAs in Oyo are considered eligible for SMC.

The 2022 WHO malaria guidelines recommend SMC in all areas of seasonal malaria transmission
and no longer specify a therapeutic efficacy threshold for SPAQ.[15] This recognises that SMC
with SPAQ may still work for malaria prevention even in areas where the medicines are nolonger efficacious in terms of curing clinical malaria cases due to parasite resistance. Malaria
Consortium has supported the national malaria programmes in Mozambique, South Sudan and
Uganda in conducting implementation research to test the use of SMC in areas where malariatransmission is highly seasonal, but parasite resistance to the SMC medicines is assumed to behigh. Early results are promising, with one study in Uganda finding a 92 percent reduced risk ofdeveloping clinical malaria during the high transmission season among children in a district
where SMC was implemented, compared with children in a control district with no SMC.[21] In
2022, Malaria Consortium hosted a webinar to share emerging results from those studies,[22,23]
chaired a session on this topic at the annual meeting of the SMC Alliance and co-chaired a
symposium at the annual meeting of the American Society of Tropical Medicine and Hygiene(ASTMH). Study designs and results to date are presented in section 6 of this report.
Compared with West and Central Africa, there is much greater heterogeneity across East andsouthern Africa in terms of parasite resistance profiles, malaria transmission and prevalence,
population immunity and human genetic polymorphisms. All of those factors are likely to affecthow, where and when SMC can be deployed safely and effectively in this region. Moreover,
SMC intersects with other malaria prevention and control interventions and strategies, which
will also be affected by greater heterogeneity in East and southern Africa. It is, therefore,
16

important to carefully assess how introducing SMC would affect malaria prevention and control
more generally. Further research is needed to assess the chemoprevention efficacy of the
medicines — their ability to clear existing infections and prevent new ones — in the context ofhigh parasite resistance. This will tell us how long the medicines are likely to remain efficacious,and if there is a risk of negatively affecting other chemoprevention strategies such as IPTp andPCM, which use the same medicines. In 2022, the WHO published a standard protocol for theassessment of the chemoprevention efficacy for monitoring and evaluating the efficacy of
medicines used for malaria chemoprevention.[24] Malaria Consortium is working with the WHOto field test and validate the protocol (Spotlight 2).
Spotlight 2: Chemoprevention efficacy studies

So far, Malaria Consortium has conducted chemoprevention efficacy studies in Burkina
Faso, Mozambique, South Sudan and Uganda. Those studies involve taking blood samples
from children who have received a full course of SMC medicines under the supervision ofa trained distributor at different time points during the 28-day period during which SPAQ
is assumed to confer protection from malaria. Typically, samples are taken on the day
when the first doses of SP and AQ are administered (day 0) and then again on days 7, 14
and 28. The presence of malaria parasites in the blood is determined through microscopy
and quantitative polymerase chain reaction. This method allows us to detect thepresence of genetic markers commonly associated with parasite resistance to the SMC
medicines. In addition, pharmacometric analyses are performed on samples taken ondays 7 and 28 to determine drug concentrations, which allows us to understand how well
the medicines are metabolised and eliminated over time. Taken together, the results
enable us to assess not only if the medicines in the dosage provided are efficacious inclearing existing infections and preventing new ones, but also, where parasites survive
and breakthrough infections occur, whether this is a result of parasite resistance orsuboptimal dosing. This is an important distinction when considering the deployment of
SMC, especially in areas where parasite resistance is high. Without measuring drug levels,
breakthrough infections could be erroneously ascribed to parasite resistance and thedeployment of SMC might not be recommended; when, in reality, the parasites survived
due to suboptimal drug exposure, which could be addressed by increasing drug dosage.
Results from Malaria Consortium’s chemoprevention efficacy studies will be available in
2023. Similar studies are planned in a range of locations. Increasing our understanding of
the interplay between resistance and chemoprevention efficacy will allow us to makepredictions about the longer-term effectiveness of SMC, which will provide context for
global efforts to find alternative or complementary drug regimens for SMC.

iii. Resistance and alternative drug regimens
While the available evidence suggests that SPAQ remains efficacious for use in SMC, there is aneed to develop sustainable methods to monitor parasite resistance and the chemoprevention
efficacy of SMC medicines over time. This is because the large-scale administration of medicines
over a long period of time is likely to result in reduced efficacy of those medicines at some pointin the future. It is possible that the chemoprevention efficacy of SPAQ might decline faster in
East and southern Africa due to parasite resistance than what has been observed in the Sahel. It
is, therefore, imperative to develop and test alternative drug regimens that could replace orcomplement SPAQ. To be suitable for the use in SMC, alternative medicines will need to be safe,
17efficacious and inexpensive. In addition to clinical research, it is likely that developing
commercially viable medicines in the dosage and formulation required for SMC will involve
working closely with pharmaceutical companies.
iv. Integration
SMC is a community-based platform that consistently reaches a large number of children. This
platform could potentially be used for the delivery of other interventions. For example, Burkina
Faso has successfully integrated malnutrition screening into SMC delivery. In Nigeria, a study
conducted by Malaria Consortium showed that integrating vitamin A supplementation (VAS)
with SMC substantially increased vitamin A coverage.[25] In some cases, interventions may not
be delivered through the same mechanisms as SMC, but a partially integrated or synchronised
approach can maximise the combined public health impact. For example, SMC campaigns could
be used to check on household use of mosquito nets and promote uptake of services formalaria in pregnancy. Utilising the successful SMC platform for other community-based
interventions and coordinating across health programmes has the potential to unlock
efficiencies at the health system level, maximising coverage and reducing overall cost.
Another approach to minimising cost and ensuring the sustainability of the intervention could
involve embedding SMC within routine community health service delivery. This would mean
SMC would no longer be delivered through a dedicated campaign, but through routine activities
such as household visits by community health workers (CHWs), community-based primary
healthcare workers who typically receive a small stipend from the government and who provide
basic health services in their communities. However, this raises questions in terms of workload,
task shifting and respecting the 28-day rhythm between SMC cycles.
v. Innovation
Innovations such as malaria vaccines or monoclonal antibodies are likely to affect how andwhere SMC is deployed in the future. Malaria vaccines in particular have received considerable
attention recently, following the WHO’s recommendation to scale up the use of the RTS,S/AS01
vaccine among children in sub-Saharan Africa.[26] This vaccine should be provided in a scheduleof four doses in children from five months of age. After administration of a series of three
primer doses, the vaccine has been found to reduce clinical malaria cases in children 5–17
months by 51 percent over a 12-month period following the first three doses. Following
administration of a fourth ‘booster’ dose 18 months after the first dose, it reduces clinicalmalaria cases by 39 percent over a median of 46 months’ follow-up after the third dose.[27]Other promising malaria vaccine candidates that are designed to prevent disease are likely toreceive WHO approval in the near future. They offer similar levels of protection for acomparable period of time. Malaria Consortium believes that vaccines have the potential to
make a substantial contribution to the reduction of malaria, but need to be used in combination
with other effective control measures.[28] In areas where malaria transmission is seasonal,
maximum benefit can be achieved by combining seasonal vaccination with SMC (Spotlight 3). A
study conducted in Burkina Faso and Mali showed that seasonal vaccination using RTS,S/AS01
was as effective as SMC in preventing malaria among young children. The study also showedthat a combination of seasonal vaccination plus SMC provided a higher level of protection thaneither of those interventions alone, indicating an additive effect.[29]18Spotlight 3: Seasonal vaccination and SMC‘Seasonal vaccination’ refers to the administration of a malaria vaccine as an annual
booster dose, given just prior to the peak malaria season to children who have received
vaccine priming doses in the first year of their life. Childhood vaccines, such as those formeasles, diphtheria or hepatitis B, are typically provided through EPI programmes and it
is likely that EPI programmes will be the primary delivery platform for malaria vaccines,
especially for the primer doses. The optimal delivery mechanism for the booster dose has
not yet been determined. Either eligible children will need to attend a routine EPI
vaccination centre in the month prior to the onset of the malaria season, or the booster
dose could be given though an annual community-based campaign. The latter option is
likely to achieve higher coverage. However, community-based vaccination campaigns will
be more expensive and complex than SMC. For example, while SMC involves theadministration of dispersible tablets that can be overseen by implementers with minimal
training, the vaccine is administered through an injection and, therefore, requires
medical expertise. Likewise, the medicines used in SMC are relatively stable and do nothave complex storage requirements, while a cold chain needs to be maintained during
the deployment of the RTS,S/AS01 vaccine. It may be possible to leverage efficiencies byintegrating vaccination campaign activities into the SMC platform, for example planning,community engagement, training, supervision, monitoring and evaluation (M&E). This
will require close coordination across several Ministry of Health departments — mostimportantly the EPI and national malaria control programmes — which comes with arange of operational challenges. More research is needed on how seasonal vaccination
can best be operationalised, as well as on its cost-effectiveness and safety underprogrammatic conditions. This need is particularly urgent, since global manufacturing
capacity is likely to remain a bottleneck for the large-scale deployment of malaria
vaccines for the next two years, at least. Implementation research should be conductedon how to optimise the delivery of the malaria vaccine while supply remains an issue. This
will ensure that programmes are adequately informed to maximise reach andeffectiveness once sufficient quantities of vaccine are prequalified and available for largescale deployment.

19

4. Malaria Consortium as an implementing partner for SMC
SMC campaigns are implemented under the leadership of national malaria programmes and throughcountries’ existing health system structures. Consequently, Malaria Consortium’s role in supporting
SMC varies from country to country. However, we generally provide technical and operational
support on all the components that together make up SMC as a complex public health intervention:
administration of SMC medicines; planning and enumeration; procurement and supply
management; community engagement; training; case management and pharmacovigilance;
supervision; and M&E (Figure 4). We refer to all of those activities in a given location as annual SMC‘campaigns’. In this section, we describe how we work with our partners on delivering SMC
campaigns. We also describe our efforts to strengthen quality of SMC delivery, support thedigitalisation of health campaigns and mitigate risk for everyone involved in SMC, which cut acrossintervention components.
Figure 4: SMC intervention components

4.1 SMC intervention componentsi.

Administration of SMC medicines
The community-based distribution of SMC medicines is at the heart of SMC. Some community
distributors are CHWs who are trained to provide basic health services at the community level.
In most countries, however, most community distributors are volunteers recruited and trained
specifically for the SMC campaign. Community distributors typically work in pairs, going doorto-door in the communities with whom they work to identify eligible children and administer
SMC medicines.
There are two age-based SPAQ dosing regimens: a lower-strength regimen for infants 3–<12
months and a higher-strength regimen for children 12–59 months. A full course of SPAQ is given
over three consecutive days. On the day of the community distributor’s visit to a household,one tablet of SP and one tablet of AQ are dispersed in water and administered under thesupervision of a community distributor. This is called directly observed treatment (DOT). The
remaining two doses of AQ are given to the caregiver to administer once daily over the next two
20

ii.

days. Children who spit out or vomit the medicines within 30 minutes of SPAQ administration
should be re-dosed once. All healthy children 3–59 months are eligible for SMC, except those
who are allergic to SP, AQ or any other sulfa-containing medicines. Children who received SP or
AQ within the past month should also not receive SMC. Those who have a fever or are unable totake oral medication should not receive SPAQ from community distributors but will be referred
to a qualified health worker for further assessment and testing for malaria infection using a
rapid diagnostic test (RDT). Children who test negative for malaria should receive SPAQ if
deemed safe by a health worker.
In a given area, SMC medicines are typically distributed over a period of four or five days. This iscalled the ‘distribution period’. SMC distribution is repeated in four or five monthly cycles overthe course of the high transmission season. All SMC cycles in a given year are referred to as a‘round’ of SMC.
Planning and enumeration
Planning for SMC campaigns typically begins around five months before the start of the annual
SMC round. This involves agreeing campaign dates and modalities at the central level, as well as
reflecting on lessons learnt in previous years to inform adaptations to the SMC intervention
tools and protocols. Micro-planning at the subnational level is conducted about four months
before the start of the SMC round, including budgeting based on detailed enumeration of thetarget population (Spotlight 4), required personnel and commodities.

Photo 4: Community distributor uses a bicycle to travel between communities to distribute SMC medicines, Burkina Faso

21

Spotlight 4: Estimating the SMC target population in Burkina Faso

Burkina Faso is divided into 13 regions. For administrative purposes, each region is further
subdivided into provinces and communities (communes). Official census-based population
data make reference to those administrative units. The most recent census was conducted in
2019. Within the health system, health districts play an important role in coordinating healthservice delivery, including overseeing health centres and the implementation of masscampaigns like SMC. Health districts are generally smaller than, or equal to, provinces andlarger than communities in terms of population size. As census data are not disaggregated at
the health district level, the Ministry of Health and Public Hygiene, with support from the
National Institute of Statistics and Demography, created a reference document withpopulation figures at the health district level. The figures in this reference document are
projections for the years 2011 to 2020, based on a census conducted in 2006. They guide theallocation of resources within the health system and are also used as the basis for estimating
the SMC target population in Burkina Faso. The reference document contains projected
population figures for children under one and children between one and five. The SMC target
population of children 3–<12 months, that is, children who should receive the lower-strength
SPAQ regimen, is estimated at 2.75 percent of the total population in the district as advised by
the National Institute of Statistics and Demography. Since the reference document does notprovide projections beyond 2020, an annual population growth factor is applied for eachsubsequent year. This factor is determined by calculating the average annual population
growth per health district for the years 2015 to 2020 according to the reference document.
Target population estimates are then reviewed during SMC micro-planning meetings that areheld in each health district, about four months before the scheduled start of the annual SMC
round. The meetings are led by the National Malaria Control Programme, with involvementfrom regional and district health authorities and implementing partners like Malaria
Consortium. In some cases, population estimates are adjusted to reflect the local context. For
example, in districts that have experienced an influx of internally displaced people (IDPs) inrecent years, data obtained from the National Council for Emergency Relief and Rehabilitation
are reviewed to determine by how much SMC target population estimates should be
increased. For some districts that have seen substantial population changes in the recent past,
projections based on the 2006 census are considered inadequate. This is the case in
Ouagadougou and Bobo Dioulasso, urban centres that have been subject to rapid
urbanisation, and certain districts in the south of the country, where the population has
increased substantially due to migration from agricultural labourers caused by climate change
in other parts of the country. For those areas, data from a household enumeration exercise
conducted in preparation for a mosquito net distribution campaign in 2019 are used as thebasis for estimating the SMC target population. To calculate the SMC target population by age
band, the share of children 12–59 months among the total population is assumed to be 14
percent and the proportion of children 3–<12 months is estimated at 2.75 percent.

iii. Procurement and supply management
The medicines are packaged in co-formulated blister packs containing one full course of SPAQ.
Currently, there are three manufacturers with the capacity to produce quality-assured SPAQ in
the required formulation, dosing and packaging — one in China and two in India. While22

manufacturers’ production capacity has increased over the years, so has the global demand for
SPAQ. The manufacturing lead time can be up to 10 months and, consequently, orders should
ideally be placed around one year before the start of the annual SMC round. To determine therequired quantities of SPAQ, approximate target population estimates need to be used. This isbecause, when more granular local figures are compiled, micro-planning will only take place
later. Assumptions about wastage — for example, when a blister pack is damaged during SMC
distribution — and an appropriate buffer to mitigate the risk of stock-outs due to, for example,
population movement, are also considered.
Once the medicines have been produced, they need to be transported to Africa, preferably bysea owing to the lower freight cost, or by air at a higher cost if the consignment is more urgent.
The process of procuring the medicines and coordinating the transport to central-level
warehouses in the countries we support is led by Malaria Consortium’s global operations team(Spotlight 5). As a UK-based organisation, our drug and medical supply chain management issubject to Good Distribution Practice regulations and standards set out by the UK Medicinesand Healthcare Products Regulatory Agency. Once the medicines have passed customs andquality assurance procedures, they are distributed further using country-level supply chain
mechanisms, typically to the district level, the lowest administrative level where suitablestorage facilities exist.
Spotlight 5: A reefer’s journey from India to Chad

From engaging manufacturers of quality-assured medicines several months before delivery, toensuring Good Distribution Practice, Malaria Consortium’s global operations team coordinates
several moving parts towards achieving the success of SMC. Malaria Consortium uses
refrigerated containers (also referred to as ‘reefers’) to transport medicines frommanufacturers’ sites in China and India to various locations across Africa. These reefers,
usually 40 feet long, must be powered by generator sets to maintain an active cold chain
throughout the trip. This is necessary as the SMC medicines must be stored within atemperature range of 15–25 degrees Celsius. Our team monitors the transport of the
medicines using data loggers, some of which provide real-time information on light, relative
humidity and geolocation, in addition to temperature.
The journey of a reefer containing SMC medicines from the Indian manufacturers’ production
plant to the central warehouse in Chad takes about two months, on average. After customs
export clearance, a ‘stuffed and loaded’ reefer (one containing medicines, onboard a vessel)
setting out from Nhava Sheva Port, India, will take between 28 and 45 days to get to the portof Douala in Cameroon by sea. This is the preferred sea route to get to Chad, a landlocked
country. On arrival at the port, the reefer is offloaded from the ship and customs clearance
commences. Upon completion, the reefer is loaded onto a delivery truck and travels from
Douala to N’Djamena, the capital of Chad, by road. This journey spans seven to 10 days. At the
Cameroon-Chad border, export and import customs clearance is carried out again, confirming
all the shipment information provided prior to commencement of the journey. Once customs
clearance has been obtained, the remaining journey by road to the central warehouse in
N’Djamena will take just one more day. At the central warehouse, the medicines will bereceived and checked by the government-approved national supply chain service provider for
medicines – Centrale d’Achats des Médicaments Essentiels Génériques et des Consommables
Médicaux – and Malaria Consortium staff.

23

These processes and timelines are affected by several factors — weather, sea level, port
congestion, availability of equipment such as generator sets or reefers, and country-specificcustoms requirements. Effective and proactive communication between programmemanagers, commodity managers, global and country-level operations teams, third-party
logistics providers, government agencies, drug regulatory bodies, customs duty officials andconsignees also contributes to timely delivery of SMC medicines.

Photo 5: Data loggers are placed in reefers and provide real-time information including
temperature

In 2021–22, SPAQ manufacturers experienced production delays, in part due to shortages ofsome of the pharmaceutical ingredients. In addition, global supply chains were constrained dueto the coronavirus disease 2019 (COVID-19) and other global crises. While we generally
managed to ship the required quantities of SPAQ on time to the countries we support, wesometimes had to split orders into several consignments. On a few occasions, we also had totransport the medicines by air to ensure their timely availability for SMC campaigns.
In addition to antimalarial medicines, SMC commodities include, for example, branded T-shirts,
hijabs, bags and pens, as well as items required to minimise the risk of COVID-19 among SMC
implementers and communities, such as face masks and hand sanitiser. Last-mile distribution —the transport of commodities to the health facilities that serve as functional units for the SMC
campaign — usually happens just before the start of SMC distribution. This can be challenging
due to poor infrastructure (especially during the rainy season) and limited storage facilities.
Supply management also involves reverse logistics, which is the process of transporting SMC
commodities back to a central warehouse at the end of the cycle or annual round.
iv. Community engagement
Community engagement refers to the active participation of people and communities in healthcampaigns. The aim is to ensure that their voices are heard and their active contribution todecision-making is safe, equitable and effective. Community engagement is an importantcomponent of SMC campaigns to ensure high acceptability of the intervention amongcommunities, as well as to encourage adherence to the three-day SPAQ administration protocol
by caregivers. Activities typically include sensitisation meetings with local leaders, radio spots,
and town announcers disseminating relevant information before and during the campaign. The

24

process of selecting community distributors is led by the community and distributors typicallyserve the communities in which they live.
v. Training
SMC implementers are trained through a cascade model beginning at the central level about
two months before the start of the annual SMC round, with each cadre of trainers subsequently
training the next lower level of trainers and learners. Community distributors, field supervisors
and town announcers are typically trained at the health facility level just before the start of theround. SMC training includes modules on identifying eligible children, referring sick children to ahealth facility, administering SPAQ safely, recording SPAQ administration, interpersonalcommunication and safeguarding. In some countries, separate trainings are conducted on
supply chain management and health education. Community representatives are also often
included in the training cascade.
vi. Case management and pharmacovigilanceChildren who are referred to a qualified health worker by community distributors and who test
positive for malaria infection should not receive SPAQ. They should, however, be treated witheffective antimalarial medicines according to country guidelines for the case management ofmalaria in children. Often, the health workers performing the RDT and deciding on appropriatecase management of children who test positive are based at the health facilities that serve asfunctional units for SMC. In some countries, this function is provided by CHWs. While severe
adverse events following administration of SPAQ are rare, they do occur. Affected children need
to be seen and assessed by a health worker. Mild side effects such as vomiting are morecommon. All adverse events should be reported via countries’ pharmacovigilance systems andfollowed up according to country guidelines.
vii. SupervisionDuring SMC distribution, community distributors are assisted by field supervisors who receive
more in-depth training on supervision and mentoring skills. Supervision is coordinated by healthworkers at the health facilities that serve as functional units for SMC distribution, sometimes
with support from CHWs. Malaria Consortium staff and local, regional and central healthauthorities also support the supervision of community distributors.
viii. Monitoring and evaluation
We undertake M&E activities to track the performance of our SMC portfolio and to inform
decision-making and priority-setting. Our M&E approach is guided by a comprehensive M&E
framework for SMC, which facilitates the assessment of the outcomes of our work and theeffectiveness of our processes.[30] The framework assesses the relationship between different
aspects of SMC implementation (inputs, processes and outputs) and the expected results(outcomes and impacts), while also accounting for external factors that can affect SMC or ourability to measure impact.
M&E data are collected through a variety of methods, including administrative programme
data, household surveys and routine national health system databases. Administrative
programme data — including on households visited, SPAQ administered to eligible children, andchildren referred to health facilities — are collected by community distributors on tally sheets,
which are compiled at health facilities at the end of each cycle and reported upwards to the
local, regional and central health authorities. Stock reconciliation data — including physicalcounts — are collected through the national supply management systems. To identify areas that
do not meet certain coverage or quality targets, Malaria Consortium routinely conducts rapid
end-of-cycle household surveys using the lot quality assurance sampling (LQAS) methodology,
following all but the final SMC cycle. The objective of those surveys is to identify issues in SMC
25

delivery and provide a starting point to engage with local and national stakeholders to takecorrective actions to improve SMC delivery in subsequent cycles. Following the end of theannual SMC round, we commission more comprehensive and nationally representative
independent end-of-round household surveys to estimate SMC coverage and measure aspectsof the quality of SMC implementation across all cycles. Note that detailed 2022 SMC coveragedata in areas supported by Malaria Consortium have been compiled in a separate report.[31]M&E framework indicators for SMC have been set up in Malaria Consortium’s online Project
Results System (PReS), which was launched in 2021 to collect and compile data from all theorganisation’s programmes and projects and to facilitate data-driven decision-making (Spotlight6).
Spotlight 6: Using PReS to operationalise the SMC M&E framework

In 2019, colleagues with relevant expertise from across Malaria Consortium’s SMC programme
formed a task force to develop an SMC M&E framework. The task force has since beentransformed into an M&E working group that meets regularly to guide the collection of SMC
framework indicator data from all the countries Malaria Consortium supports. Those data arecollated into the PReS database, a cloud-based M&E platform developed by LogAlto. Within
PReS, we have created custom forms based on four main routine data collection tools that
contain the variables needed to calculate the indicators defined within our log frame. The
forms are linked to a PowerBI file with pre-populated indicators formatted into dashboards fordata visualisation.
The introduction of PReS required some change management, which came with its own
unique challenges. First, data from routine household surveys are collected using a different
platform, SurveyCTO. Those data need to be formatted to fit the custom forms within PReS,
which can be a lengthy process given the volume of data that needs to be processed. We are
exploring the introduction of Application Programming Interface endpoints, which allows a‘bridge’ software to download, aggregate, clean and process data from SurveyCTO andtranslate those data into the format needed for PReS. Additionally, PReS does not yet havethe functionality to automatically calculate the required indicators from the input variables.
For this reason, we use PowerBI for this step, then download the populated indicators andthen reupload them to PReS. Another challenge is staff turnover. New M&E colleagues need
to be trained quickly on PReS, so they can participate effectively in the M&E working group.
We are working on a PReS user handbook and standard operating procedures, which will
facilitate training and inductions, as well as serve as reference materials for all colleagues
working on the SMC programme.
The vision is for PReS to become a widely used, one-stop shop for reliable, actionable, andevidence-based results tracking and data-driven decision-making within Malaria Consortium.
Having easy access to a wide range of programme data will also facilitate communication withstakeholders and external relations.

26

Photo 6: Screenshot of an SMC dashboard from Malaria Consortium's PReS database

Malaria Consortium actively participates in the SMC Alliance M&E subgroup. The subgroup
comprises representatives from national malaria programmes, implementing partners andresearchers. It serves as a platform where the SMC community can share challenges and bestpractices in measuring and tracking SMC indicators. The subgroup has published an M&E toolkit
for SMC as a resource for national malaria programmes in SMC-implementing countries.[32]Malaria Consortium’s M&E framework informed the content of the toolkit, which will beincorporated into the revised WHO field manual that will be published in 2023.

27

Photo 7: Caregivers, like the woman pictured here, are tasked with providing subsequent SMC doses after the childreceives the first doses under supervision from community distributors

4.2 Quality of SMC delivery
Malaria Consortium conceptualises the quality of SMC delivery as the extent to which it is safe,
efficacious, timely, efficient, equitable and people centred.[33] We think of quality as a theme thatcuts across all SMC intervention components and have developed an SMC quality framework thatdefines 10 quality standards (Figure 5). While the standards are operationalised differently in
different countries, they serve as benchmarks that, if followed well and consistently, ensure highquality delivery of SMC.

28

Figure 5: Malaria Consortium’s SMC quality standards

Continuous quality improvement requires that quality be measured, and lessons learnt be
documented and shared. At the country level, this includes regular review meetings that bring
together SMC stakeholders to review available M&E data and determine actions required to improve
quality of SMC delivery. Malaria Consortium has developed tools for annual end-of-round quality
assessment workshops, which are attended by national malaria programme staff, representatives
from subnational health authorities and implementing partners. Participants are invited to reachgroup consensus on scores for a range of quality indicators and to determine top priorities for
quality improvements in subsequent SMC rounds. Malaria Consortium SMC country teams areencouraged to establish and monitor quality improvement plans.
In 2022, we commissioned a consultancy to develop tools and methods of an external SMC quality
audit as an additional method for assessing quality of SMC delivery. The audit was piloted in eight
local government areas (LGAs) in four Nigerian states and involved both a retrospective review of
documents, as well as direct observations by independent auditors. In 2023, we will review thequality audit methods and processes to determine if, and how, we will take this approach forward.

4.3 Digitalising SMC
Digital tools have the potential to transform the way health campaigns like SMC are delivered, bystrengthening campaign quality, efficiency, accountability, equity and cost-effectiveness. There are
multiple use cases for digital tools in SMC (Table 2), cutting across most intervention components
29and supporting overall campaign management and oversight. However, despite a broad consensus
on the potential benefits of campaign digitalisation, the adoption of digital tools in SMC has so far
been slow. A key bottleneck is the need to better define scalable and sustainable implementationand financing models, ideally enabling multi-use, integrated approaches across different healthcampaigns, case management and routine surveillance. Other challenges include a lack of
coordination between partners, a tendency to develop digital tools in silos rather than through acoordinated multi-partner effort, concerns over data protection and ownership, as well as challenges
in ensuring interoperability with routine health system data platforms, such as the widely used
District Health Information Software. Many of those challenges are not specific to SMC — they are
typical across the public health community. As a result, we have seen many small pilots, but few
digital solutions that have been successfully deployed at scale.
Table 2: Potential benefits of digitalising SMC

SMC intervention component

Potential benefits of digitalisation

Administration of SMC medicines

More reliable collection of administrative data; track
administration of SMC medicines to individual
children over time; increase coverage and equity byidentifying areas with low coverage during SMC
delivery; improved campaign management throughdashboards and real-time reports

Planning and enumeration

More accurate target population estimates; ensure
plan completeness and relevance; minimise
duplication across health campaigns

Procurement and supply
management

More precise stock inventory; prevent stock-outs oroverstocking

Community engagement

Reach larger audience

Training

Measure and track knowledge improvements;
remote access of training materials

Case management andpharmacovigilanceTracking of patient referral and treatment

Supervision

Better quality control

M&E

Real-time availability of data for decision-making

Payments

Build a database of trained SMC implementers;
cashless payment solutions; with the help ofbiometric verifiers, ensure that payments are madeonly to individuals who participated in SMC activities
and only for days when they were actively involvedin the SMC campaign

The best-established use of digital tools in SMC at Malaria Consortium is the electronic collection ofsurvey data for M&E and research using software such as SurveyCTO. As described above, we also
use platforms such as PReS to operationalise and visualise our SMC M&E framework.
30

In 2020 and 2021, Malaria Consortium piloted Reveal, a geospatial platform developed by Akros, foruse in SMC in Nigeria. The tool uses spatial intelligence and satellite imagery to enumerate
residential structures and guide field staff during SMC delivery. It has three main components: i) the
web user interface supports planning and enumeration and is used by higher-level implementers; ii)
the mobile client allows community distributors to navigate in their catchment area and record
administration of SMC medicines; iii) web-based dashboards are used by higher-level implementers
to monitor field activities and collect reports. Scaling up the use of Reveal would require thedevelopment of a refined data model for the core platform, which would substantially improve theprocess of identifying residential structures on satellite images, making it less dependent on human
input. As the refined data model was not ready for the 2022 campaign, we decided to pause ourwork on Reveal. Nevertheless, Malaria Consortium remains particularly interested in the geospatial
functionality of the platform, which could transform SMC campaign planning and coordination. We
are also excited about the role a geospatial tool could play in ensuring that hard-to-reach andvulnerable populations can benefit from SMC. In addition to Reveal, we have also supported thenational malaria programmes in Burkina Faso, Chad and Nigeria in digitalising SMC activities, inparticular the collection of administrative data, building databases of SMC implementers andsupporting supervision of community distributors.
Another important area where efforts have been made to introduce the use of digital tools is
payments to SMC implementers. Most of our SMC countries use mobile payment systems, typicallyworking with mobile service providers to register SMC implementers and paying implementers for
SMC activities through their mobile phones. While we have made progress over the last few years interms of embedding mobile payments in SMC, the process remains challenging. Common issues arethat implementers do not have an account with the service provider, that their accounts are notregistered in their own name, or that the phone numbers provided for the payments are incorrect.
There are also challenges relating to the exchange of information between health authorities,
mobile service providers and Malaria Consortium. Roles and responsibilities are not always clearly
defined, understood or accepted by all parties involved. In the absence of biometric verification, theverification of an implementer’s identity, checking of mobile account details and validation of
documents justifying payment — such as meeting attendance lists — for tens of thousands of
implementers is cumbersome and requires substantial effort from Malaria Consortium programme,
operations and finance staff. As a result, payment delays are not uncommon, which can affect SMC
implementers’ morale and willingness to participate in the campaign. Developing robust standard
operating procedures that are accepted among all parties involved and reducing payment delays
remain operational priorities in many of the countries where Malaria Consortium supports SMC
delivery.
To help Malaria Consortium adopt a more comprehensive and systematic approach to SMC
digitalisation, we formulated a digital road map for SMC in 2022. An important insight from theinternal and external consultations we conducted to inform the roadmap is that there is currently nosingle tool that offers all the functionalities that could potentially strengthen SMC delivery. The
roadmap recommends that campaign digitalisation should be rolled out through a structured andsystematic process (Figure 6) and calls for action in three areas: build integrated tools and digital
capacity; design with scalability in mind; and establish strong governance mechanisms. Operational
research will be needed to define implementation models that work at scale and that blend in
seamlessly with the established SMC delivery model. In 2023, we will continue to support nationalmalaria programmes in exploring how SMC delivery can be strengthened through the use of digital31

tools and to engage with global stakeholders on the development of coordinated approaches tosustainable health campaign digitalisation.
Figure 6: Process for digitalising SMC set out in Malaria Consortium’s digital roadmap for SMC

4.4 Mitigating risk
Minimising risk to everyone involved in SMC campaigns, including communities, SMC implementers
and Malaria Consortium staff is an important part of our work. We tend to look at the safety andsafeguarding of communities through the SMC quality lens as described above. In this section, we
focus on the safety of SMC implementers and Malaria Consortium staff, especially with regard to
three types of risk: insecurity, natural disasters and COVID-19.
i.

Insecurity
Over the last few years, security threats in many of the areas where Malaria Consortium
supports SMC implementation have increased substantially, including from armed groups andcriminals, as well as from intercommunal violence. It is generally accepted that insecurity islikely to increase further over the coming years. To manage the risk, Malaria Consortium’s
teams have put in place safety and security plans, staff movement protocols and standard
operating procedures. We have invested in enabling team communication, security awarenessand security training. We also enhanced our capacity to manage security risks by recruiting staff
with a security focus in many of our SMC countries. With support from the global operations
team, country teams continuously assess the security situation in the areas where we operate.
This involves security mapping and assigning areas to different levels of risk: low, medium andhigh.
Malaria Consortium has developed security adaptation principles, which outline how SMC
needs to be adapted in medium- and high-risk areas to minimise risk to communities, SMC
implementers and Malaria Consortium staff, while ensuring maximum accountability, coverageand quality of SMC implementation. Recognising that security risks can never be mitigatedagainst completely and that some residual risk will always remain, the principles outline
32

adaptations for each SMC intervention component. The principles draw on learning from all
SMC countries with the aim of defining a comprehensive and harmonised approach that can
inform our work across Malaria Consortium’s SMC portfolio. A core principle is that Malaria
Consortium staff can operate in medium-risk areas if approved by senior country management.
However, Malaria Consortium staff cannot enter high-risk areas. In those areas, we work with
our partners to identify how we can continue to deliver SMC within acceptable risk thresholds;
for example, by making use of government structures, with support and oversight provided by
Malaria Consortium remotely. In some of the most severely affected areas, that may involve
transporting SMC commodities with the support of countries’ security forces, sometimes byhelicopter.
ii. Natural disasters
Other security risks that have gained prominence over the last few years are heavy rains,
tropical storms and severe flooding. While SMC is, by its very nature, an intervention that is
implemented during the rainy season, flooding seems to have become more common, possiblyas a result of the global climate crisis. In 2022, floods and storms affected SMC delivery in Chad,
Mozambique, Nigeria and South Sudan. Mitigating measures to minimise risk to SMC
implementers and Malaria Consortium staff include the provision of life vests and suspending
SMC activities, where necessary. This was the case in March 2022, when a tropical cyclone hit
northern Mozambique and humanitarian efforts to assist those affected took priority overhealth campaigns like SMC.
iii. COVID-19
Since 2020, the COVID-19 pandemic has presented novel challenges to implementing
community-based malaria control interventions. The pandemic has posed a significant risk oftransmission to SMC implementers and communities. Minimising this risk has required
adaptations to the SMC delivery model. For example, more training events have beenscheduled to limit the number of participants per event. Physical distancing has also been
facilitated by encouraging caregivers to administer the medicines to their children, with
community distributors supervising from a safe distance. In addition, large quantities of COVID19-related commodities, such as face masks and hand sanitiser, have been made available to
SMC implementers. At the same time, it has been found that SMC can be a useful platform toshare public health information among communities. A study conducted by Malaria Consortiumin Nigeria found that community distributors can be an important source of knowledge of
COVID-19 infection prevention and control behaviours among caregivers.[34] Malaria
Consortium’s insights from implementing SMC during the first year of the pandemic, based oncomprehensive consultations with colleagues from across Malaria Consortium’s SMC portfolio
and external partners, were published in a learning paper.[35]In preparation for the 2022 SMC campaigns, we reviewed and updated our internal COVID-19
guidance in light of lessons learnt during the previous two years, as well as the emergence of
the Omicron variant at the time. We also took into account the findings of a study conducted by
Malaria Consortium in Burkina Faso, Chad, Nigeria and Togo in 2021, which found thatadherence to COVID-19 infection prevention and control measures was low among SMC
implementers,[36] highlighting the need to promote adherence though training and supervision.
Changes to the guidance included a requirement to use three-ply medical face masks(previously, fabric masks were considered sufficient), dropping the requirement to cleansurfaces with bleach at meeting venues and health facilities, and asking SMC implementers to
confirm that they do not have symptoms of COVID-19 before participating in SMC activities.
Although there are positive signs and the global community has made significant strides in the33fight against COVID-19, Malaria Consortium believes that the pandemic will still pose a threat to
SMC in 2023, especially since vaccination rates have remained low across Africa. We therefore
expect that infection prevention and control measures will remain necessary. However, we areplanning to move to a risk-based approach, where minimal measures will be in place in settings
where the disease is considered endemic and more stringent measures will be in place inepidemic settings.

Photo 8: A child receives SMC medicines, Mozambique34

5. Philanthropically supported SMC delivery in 2022
In 2022, philanthropic funding or co-funding enabled Malaria Consortium to deliver SMC to 16.08
million children in Burkina Faso, Chad, Mozambique, Nigeria, South Sudan, Togo and Uganda (Table3). This compares with 12.19 million reached with philanthropic support in 2021[37] and 7.14 million
in 2020.[38] Out of all children supported with philanthropic funding in 2022, 21 percent lived in areasthat received SMC for the first time that year, primarily in Nigeria and Mozambique. Just under twothirds of the philanthropically supported target population (62 percent) lived in areas where four
SMC cycles were implemented. The remaining 38 percent received five cycles.
Table 3: SMC target population supported with philanthropic funding or co-funding, 2020–2022

Country
Burkina Faso

2020

2021

2022

1,620,000

2,020,000

2,110,000

Chad

960,000

1,080,000

1,200,000

Mozambiquea

70,000110,000

1,300,000

4,310,000

8,400,000

10,720,000

0020,000180,000

490,000

500,000

Uganda0

90,000230,000

TOTAL

7,140,000

12,190,000

16,080,000

NigeriaSouth Sudan
TogoaAs the peak malaria transmission season cuts across calendar years in Mozambique, target population figures are reported

for the calendar year in which the transmission season started. This does not necessarily coincide with the calendar year
when the SMC round started. Both in the 2021/22 and the 2022/23 season, the start of the round was delayed until
January.

Malaria Consortium used philanthropic funding to procure around 77.5 million blister packs of SPAQ
in 2022. Philanthropic funding or co-funding supported more than 150,000 SMC implementers
involved in the delivery of SMC campaigns. Below, we provide a detailed summary of achievements
and challenges in each of the countries where philanthropic funding was used to support SMC in
2022, as well as an overview of support Malaria Consortium expects to provide with philanthropic
funding in 2023.

5.1 Burkina Fasoi.

Setting
Burkina Faso’s total population was estimated at 22.10 million in 2021.[39] Malaria is endemic
throughout the country, with a seasonal upsurge from June to October.[40] There were 8.33
million cases and 19,000 deaths from malaria in 2021, accounting for 3.3 percent of global casesand 3.4 percent of global deaths.[13] Security deteriorated further in 2022, with frequent attacks
by armed groups against civilians and intense counterterrorism operations. Large parts of thecountry were affected and there are an estimated two million IDPs. Political instability
deepened as a result of two military coups, one of which resulted in the overthrow of the
President.[41]

35

ii.

Scale-up of SMC and funding support
SMC implementation in Burkina Faso started in 2014 in seven health districts. Funding support
for SMC gradually increased over the following years. In 2019, Burkina Faso achieved 100
percent geographical SMC coverage, with all of the country’s 70 health districts reached. Fullgeographical coverage has been maintained in subsequent years. The total SMC target
population in 2022 was 4.39 million children (Table 4). The slight target population increase
compared with 2021 was due to population growth. As in previous years, funding for SMC wasprovided by Malaria Consortium’s philanthropic funding, the Global Fund, PMI and UNICEF.

Table 4: SMC target population by funding source, Burkina Faso, 2021–2022

Number ofhealth districts(2021)

Targetpopulation(2021)

Number ofhealth districts(2022)

Targetpopulation(2022)

Philanthropic

27

1,920,000

27

2,000,000

Global Fund22

1,400,000

22

1,450,000

PMI

19810,000

19

830,000

UNICEF andphilanthropic

2

100,000

2

110,000

TOTAL

70

4,230,000

70

4,390,000

Funding source

In Burkina Faso, SMC community distributors screen children for signs of malnutrition during
SMC distribution. In 2022, Malaria Consortium received funding from UNICEF to coordinate
malnutrition screening during SMC delivery in all 70 health districts.
iii. Philanthropically supported SMC delivery in 2022
The health districts supported by Malaria Consortium in 2022 (Figure 7) remained unchanged
compared with the previous year. A total of 2.00 million children in 27 health districts were
supported exclusively with philanthropic funding. As in the previous year, Malaria Consortium
also used philanthropic funding to procure SPAQ for 110,000 children in two additional healthdistricts, where all other SMC-related costs were covered by UNICEF.

36

Figure 7. Health districts supported with Malaria Consortium’s philanthropic funding for SMC, Burkina Faso, 2022

A total of 10,560,000 blister packs of SPAQ was procured with philanthropic funding andshipped to Burkina Faso by sea. The medicines arrived at the central warehouse in March.
Transport of SMC commodities from the central to the district level was provided free of charge
by Atlas Logistique, an operational arm of Humanity & Inclusion. All commodities arrived before
the scheduled start of the round and no stock-outs were experienced.
In preparation for the 2022 SMC campaign, Malaria Consortium supported the PNLP in updatingsocial and behaviour change communication materials for SMC. We also successfully advocatedfor the adoption of new content embedding safeguarding principles in the SMC training
cascade. Over 32,000 SMC implementers were trained with philanthropic support between May
and June, including almost 23,000 volunteers who served as community distributors (Table 5).
Table 5: SMC implementers trained with philanthropic support, Burkina Faso, 2022

Number of SMC
implementers

Number of days per
training

Number of training
eventsNational-level trainers

125

2

4

Supply chain managers

40

3

1

Regional-level trainers
and supervisors

129

1

6

District health staff

229

1

27

Health workers

3,127

1

95

Community distributors

22,822

1

1,110

Town announcers

6,041

1

926

TOTAL

32,513

Cadre

2,169
37

In the 11 health districts supported by Malaria Consortium where five SMC cycles were
implemented, the annual round commenced on 10 June. The remaining 18 health districts
implemented four SMC cycles and started the annual round on 10 July. All subsequent cycles
were implemented as scheduled. The final distribution day in all health districts was 7 October.
One case of a serious adverse event was reported. A child who had experienced convulsions
following the administration of SPAQ was treated at a health facility the same day and fully
recovered.
iv. Plans for 2023
In 2023, Burkina Faso’s National Malaria Control Programme was upgraded to permanent
secretary status and is now called the Secrétariat Permanent pour l'Élimination du Paludisme.
Malaria Consortium will continue to work with the permanent secretary to support the same
health districts as in 2022, including procuring SPAQ for two districts that are otherwise
supported by UNICEF. The total target population supported with philanthropic funding in
Burkina Faso in 2023 will be approximately 2.18 million children. Operational priorities will
include applying lessons from previous years to further improve the payment process for SMC
implementers, developing tools to strengthen SMC-related advocacy at all levels, and ensuring
timely availability of SMC commodities at the district level.

5.2 Chadi.

ii.

Setting
Chad’s total population stood at 17.18 million in 2021.[42] About two-thirds of Chad’s population
live in areas of high malaria transmission, principally in the southern half of the country,[43] witha seasonal peak between July and October in many of those areas. In 2021, there were 3.51
million cases of malaria and 11,700 deaths. Chad accounted for 1.4 percent of global malaria
cases and 2.0 percent of deaths.[13] Following the death of the President in 2021 and thedeclaration of his son as head of a Transitional Military Council, there were violent protests anddemonstrations in urban centres throughout 2022. Protests were particularly noticeable aroundthe anniversary of the transition in April, the opening of a ‘national dialogue’ — a series of talks
involving all segments of Chadian society to define a timeline and rules for presidential elections— in August, and the decision to extend the transition by 24 months in October. Armed groups
continue to carry out attacks against civilians and security forces in the Lake Chad area.[41]
SMC scale-up and funding support
Starting with four health districts in 2013, SMC was gradually scaled up, reaching 68 healthdistricts in 2022, with a total SMC target population of 2.60 million children. As in the previous
year, funding for SMC was provided by Malaria Consortium’s philanthropic funding, the Global
Fund, UNICEF, and MSF (Table 6). In addition to population growth, the increased target
population compared with 2021 was primarily due to the expansion of Global Fund and MSF
support to previously unreached areas.

38

Table 6: Table 6: SMC target population by funding source, Chad, 2021–2022

Funding source

Number ofhealth districts(2021)

Targetpopulation(2021)

Number ofhealth districts(2022)

Targetpopulation(2022)

Philanthropica

26

1,080,000

27

1,200,000

Global Fund32

940,00035

1,180,000

UNICEFa

4120,000

5

120,000

MSFb

1

40,0001

100,000

TOTAL

63

2,180,000

68

2,600,000

aThe increase in the number of districts covered by Malaria Consortium’s philanthropic funding and UNICEF compared with

2021 was a result of the creation of new health districts within areas previously reached by SMC. The geographical reach
therefore remained unchanged.
bThe increased target population supported by MSF in 2022 compared with 2021 was due to the expansion to areas in thesame health district not previously reached by SMC.

iii. Philanthropically supported SMC delivery in 2022
Malaria Consortium used philanthropic funding to deliver SMC to 1.20 million children in 27
health districts (Figure 8). The geographical reach of Malaria Consortium’s support for SMC in
Chad in 2022 was the same as in the previous year. The additional health district covered is a
result of one of the health districts in the area supported by Malaria Consortium being divided
into two in 2022.

39

Figure 8: Regions supported with Malaria Consortium’s philanthropic funding for SMC, Chad 2022

A total of 5,280,000 blister packs of SPAQ was shipped to Chad by sea. The shipment arrived at
the central warehouse in May. Training was conducted in June and July, including for more than
12,000 volunteer community distributors (Table 7).
Table 7: SMC implementers trained with philanthropic support, Chad, 2022

Number of SMC
implementers

Number of days
per training

Number of training
eventsNational- and provincelevel trainers andsupervisors

74

2

4

District-leveltrainers/supervisors andhealth workers

633

2

27

Field supervisors andcommunity distributors

13,564

1435

Town announcers

2,175

1

435

TOTAL

16,446

Cadre

901

40

Four SMC cycles were implemented, starting on 15 July, in the majority of the health districts
supported by Malaria Consortium. Nine health districts started cycle one distribution with adelay of one day and one health district started two days later, primarily due to conflicting
COVID-19 vaccination activities in those areas. All health districts completed the annual SMC
round by 15 October. While this did not significantly delay SMC delivery, the annual SMC roundin 2022 was affected by the challenging security situation as well as severe flooding.
The PNLP in Chad aims to digitalise the collection of administrative SMC data over the coming
years. In 2022, a digital tool was piloted in several districts, including one supported by Malaria
Consortium with philanthropic funding. The pilot in this district involved around 300 community
distributors. In general, the pilot went well, but issues were reported with faulty mobile devices
and synchronisation issues due to poor connectivity.
iv. Plans for 2023
In 2023, we will continue to support SMC in the same health districts as in 2022, with a target
population of around 1.24 million children. Programmatic priorities include developing
contingency strategies to better respond to severe flooding during SMC delivery, strengthening
the mobile payment process, and identifying further cost efficiencies to reduce the cost per
child. Following GiveWell’s decision to phase out philanthropic SMC funding for Chad because,
following the revision of its 2022 funding projections,[44] it is below its current cost-effectivenessthreshold,[45] we will also discuss an appropriate transition strategy for the period 2024–25 with
the PNLP.

Photo 9: A community distributor records the number of SMC treatments delivered on a tally sheet, Mozambique

5.3 Mozambiquei.

Setting
Mozambique had a total population of 32.08 million in 2021.[46] Malaria is highly endemic in theentire country, with the highest prevalence in the north and along the coast.[47] While
41

ii.

transmission is perennial in the south, there is a seasonal peak between December or January
and March or April in many areas in the northern half of the country. Mozambique ranks fourthin terms of global malaria cases (4.1 percent) and accounts for 3.8 percent of global malaria
deaths. In 2021, there were 10.28 million malaria cases and 22,300 deaths.[13] The humanitariansituation in Mozambique worsened in 2022, with attacks by armed groups, primarily in Cabo
Delgado province, and increased presence of Mozambican security forces in the area. The
violence has led to about 950,000 IDPs seeking refuge in other provinces of northern
Mozambique. In September, attacks on civilians occurred in two villages in Nampula
province.[41]
Scale-up of SMC and funding support
A mid-term review of Mozambique’s Malaria Strategic Plan 2017–2022[48] recommended SMC
as a strategy to accelerate impact in the highest-burden locations. In 2020, the National Malaria
Control Programme — Programa Nacional de Controlo da Malária (PNCM) — approached
Malaria Consortium about the possibility of exploring the use of SMC in Nampula province(Figure 9), where under-five mortality is high and malaria transmission is seasonal. Since 2020,
Malaria Consortium and the PNCM have been conducting a two-phase implementation study totest if SMC can be a viable malaria prevention strategy in northern Mozambique despite highresistance to SP.[49] The study is described in more detail in section 6. An insight briefsummarising lessons learnt from the first phase of the project during the 2020/21 season, when
SMC was implemented in two districts of Nampula, targeting 70,000 children, was published on
Malaria Consortium’s website.[50] A key learning was that the benefits of employing more SMC
implementers to strengthen community engagement need to be weighed up against budget
implications. The second phase of the project involved SMC delivery to 110,000 children during
the 2021/22 season. With support from GiveWell,[51] SMC was further scaled up to all 23
districts in Nampula during the 2022/23 season, with a total target population of 1.30 million
children.

42Figure 9: Location of Nampula province within Mozambique

Based on the promising early results from the SMC implementation study in Nampula (seesection 6), Malaria Consortium believes that the scale-up of SMC to the entire province isjustified while the research is ongoing. However, decisions on the longer-term deployment of
SMC in Nampula or other provinces of northern Mozambique will only be possible once the full
results from the study are available in 2023. To date, all SMC implementation activities in
Mozambique have been supported by Malaria Consortium’s philanthropic funding for SMC.
iii. Philanthropically supported SMC delivery in 2022
Unlike in all other countries supported by Malaria Consortium, the SMC season in Mozambique
cuts across calendar years. Activities conducted in the calendar year 2021 in preparation for the2021/22 SMC campaign were described in last year’s SMC philanthropy report, including thequantity of SPAQ procured and number of SMC implementers trained.[38] Due to delays in
obtaining ethical approval for phase two of the SMC implementation study, the 2021/22 round,which was scheduled to start in November 2021, did not commence until 18 January 2022 in all
four of the districts covered (Figure 10). Cycle 3 was delayed by about one week due to theimpact of tropical cyclone Gombe, which made landfall in Nampula on 11 March and affected
more than 700,000 people.[52] The annual SMC round concluded after four cycles on 21 April.

43

Figure 10: Districts supported with Malaria Consortium’s philanthropic funding for SMC by high transmission season
when SMC was introduced, Nampula province, Mozambique

In preparation for the 2022/23 SMC round and the scale-up to all 23 districts in Nampula
province, a health economist worked with Malaria Consortium’s Mozambique team to identify
opportunities for reducing the unit cost of SMC as the project transitioned from a tightly
controlled research project to at-scale implementation. Examples included leveraging
economies of scale in the procurement of larger quantities of SMC commodities and using
health system mechanisms for the transport of commodities to the district level. In August, adelegation comprising representatives from the PNCM, the provincial health authority andMalaria Consortium’s Mozambique team visited Nigeria to learn about the successes andchallenges of the Nigeria SMC programme, especially in terms of embedding large-scale SMC
delivery in the national health system (Spotlight 7).
Spotlight 7: Learning from Nigeria about implementing SMC at scale

In August 2022, a four-strong delegation from Mozambique visited Nigeria to learn from
Nigeria’s experience of implementing SMC at a large scale. The delegation included the Headof Social and Behaviour Change at the PNCM, the head of the Public Health Department at theprovincial health authority in Nampula, the project manager of Malaria Consortium’s
Mozambique SMC project and Malaria Consortium’s Mozambique Country Technical
Coordinator. The agenda of the learning visit included observing SMC distribution in Nasarawa
state, meetings with health authorities at the LGA and state level, discussions with the NMEP
and an exchange of learning with Malaria Consortium’s Nigeria team.
On their return to Mozambique, the delegation reflected on a number of important insightsthat will inform the potential scale-up of SMC in Mozambique. For example, the need to start

44

internal planning as early as possible — up to eight months before the scheduled start of theannual round — was noted as a major difference between a small-scale research project andan at-scale implementation project. The Mozambique delegation also learned about the
integration of last-mile distribution into national supply chain mechanisms in Nigeria — aprocess that had been coordinated by Malaria Consortium in Mozambique in previous years.
At small scale, formal review meetings had only been conducted after each cycle in previous
years in Mozambique — the Malaria Consortium team were aware of developments because
they were closely involved in all activities. However, it was recognised that this would not be
feasible at scale; hence, daily review meetings would be needed, with Malaria Consortium andsenior health authority staff focusing on managing from a distance. A pragmatic suggestionthat will be adopted in Mozambique going forward was to distribute SMC over the weekend,
if possible, as that is when caregivers are most likely to be at home with their children. The
NMEP emphasised the need to embed SMC in the national health system and to havededicated SMC focal persons at the central and state level. The PNCM plans to emulate thisstructure in Mozambique, if the research conducted by Malaria Consortium and the PNCM
confirms that SMC is a viable malaria prevention strategy in the country.
The delegation that visited Nigeria shared their observations and learnings with a broader
group of SMC stakeholders in Mozambique. Several adaptations to the SMC delivery modelfor the 2022/23 campaign were made. We plan to publish our reflections on how thoseadaptations have strengthened SMC in Mozambique in 2023.

A total of 5,598,000 blister packs of SPAQ was procured with philanthropic funding for the2022/23 SMC round in Mozambique and shipped to the country by sea. The medicines arrived
in Nampula in November, in time for the scheduled start of the round in December. However,at the request of the Ministry of Health, the campaign was postponed to January 2023 due to
conflicting health campaigns in December. While community-level trainings were conducted in
January and will be reported in next year’s philanthropy report, almost 700 national, provinceand district-level trainers and supervisors were trained in November and December 2022 (Table
8).
Table 8: SMC implementers trained for the 2022/23 SMC round with philanthropic support, Mozambique, 2022

Number of SMC
implementers

Number of days
per training

Number of training
eventsNational-level mastertrainers30

22District-level trainers andsupervisors

97

2

5

District-level trainers andsupervisors

563

2

35

TOTAL

690

Cadre

42

45

iv. Plans for 2023
The 2022/23 SMC round will conclude in April 2023. We expect to use philanthropic funding tosupport SMC delivery in the same 23 districts of Nampula province during the 2023/24
transmission season. The 2023/24 round is scheduled to start in December, targeting 1.57
million children. We will work closely with the PNCM and other stakeholders to ensure thetimely start of the SMC round.

5.4 Nigeriai.

ii.

Setting
Nigeria is Africa’s most populous country, with an estimated 213.40 million inhabitants in
2021.[53] Malaria is endemic in the majority of the country and 97 percent of the population are
considered to be at risk. In the south, malaria transmission is perennial, whereas in the north,
there are seasonal peaks of four to five months between June and November.[54] Nigeria has thehighest malaria burden globally. In 2021, there were 65.40 million malaria cases and 193,500
deaths, accounting for 26.6 percent of global cases and 31.3 percent of global deaths.[13]Insecurity has worsened with threats and frequent attacks from multiple armed groups. In thenortheast, the main threat comes from armed groups attacking government facilities, including
health centres. Areas not previously affected by insecurity were the target of attacks in 2022. In
the northwest, armed groups, known previously as bandits but now categorised by thegovernment as terrorists, are responsible for frequent killings and kidnappings for ransom. The
Nigerian military responded with airstrikes. Political tensions also increased as Nigeria prepared
for the 2023 general elections.[41] The number of IDPs is increasing and is currently estimated to
be around three million.[55]
Scale-up of SMC and funding support
Nigeria started implementing SMC in five LGAs in Katsina state in 2013. The first scale-up phasetargeted nine Sahelian states in the north of the country. In 2020, all LGAs in those nine states
were reached for the first time. As of 2021, the NMEP considers 20 states plus the FCT eligible
for SMC. Out of these, 18 were reached in 2021, with a total target population of 21.70 million
children and funding support from the Global Fund, Malaria Consortium’s philanthropic
funding, PMI and KOICA. (Table 9). Thanks to increased support from philanthropic funding and
PMI, all 20 eligible states and the FCT were covered in 2022. The total SMC target population
grew to 26.97 million.

46

Table 9: SMC target population by funding source, Nigeria, 2021–2022

Number of
LGAs (2021)

Target population(2021)

Number of
LGAs (2022)

Target population(2022)

Global Fund

225

12,320,000

220a

13,590,000

Philanthropic

127

8,130,000

152

10,440,000

PMI

14

990,00037

2,650,000

KOICA andphilanthropic

2

260,000

2

280,000

TOTAL

368

21,700,000

411

26,969,000

Funding source

aThe reduction in the number of LGAs covered by the Global Fund in 2022 is due to several LGAs in Kwara state no longer

being considered eligible. Malaria Consortium has been unable to ascertain why the total target population supported with
Global Fund funding still increased considerably compared with 2021.

iii. Philanthropically supported SMC delivery in 2022
The target population supported with philanthropic funding exclusively increased from 8.13
million in seven states (127 LGAs) in 2021 to 10.44 million children in eight states and the FCT(152 LGAs) in 2022 (Figure 11). The increased target population was due to the expansion of
Malaria Consortium’s support to eligible LGAs in Oyo state, the FCT and 12 additional LGAs in
Kogi. This expansion was supported by GiveWell.[56] While our support for SMC in Borno wasintended as a one-year stopgap to cover a funding gap that emerged only a few months before
the planned start of the 2021 round,[57] Malaria Consortium continued to support SMC in thestate with philanthropic funding in 2022, as the expected World Bank loan had not been
finalised in time for the 2022 round. One LGA in Borno, which had previously been considered
inaccessible, was included in the SMC campaign for the first time in 2022. As in the previous
year, an additional 280,000 children in two LGAs were supported by Malaria Consortium in
Bauchi state in 2022, where the KOICA-funded SMC IMPACT project[58] covered the majority of
costs. However, philanthropic funding was used to cover SPAQ for one cycle, as well as around40 percent of the cost of allowances paid to SMC implementers during the annual round. The
SMC IMPACT project budget was fixed in 2020, before the decision was made to implement fiverather than four SMC cycles in Bauchi. Philanthropic co-funding ensures that the two SMC
IMPACT LGAs receive the same number of SMC cycles as the remaining, fully philanthropicallysupported, LGAs in the state.

47

Figure 11: States supported with Malaria Consortium’s philanthropic funding for SMC, Nigeria, 2022

*Two LGAs in Bauchi are co-funded by KOICA and philanthropic funding; the remaining 18 LGAs are fully fundedphilanthropically.
‡Only six LGAs in Oyo are considered eligible for SMC.

Early in 2022, Malaria Consortium’s Nigeria team held engagement meetings with stakeholders,
including the state malaria elimination programmes and public health departments, in Oyo and
FCT, the two areas where we had not previously supported SMC delivery. Warehousing, healthfacility and in-depth security assessments were also conducted, and a new local office was
opened in Oyo. A Malaria Consortium SMC project management handbook facilitated theorientation of staff supporting SMC in Nigeria.
A total of 54,843,000 blister packs of SPAQ was procured for the philanthropically supported
states in Nigeria. This includes 1,593,000 blister packs initially intended for Borno in 2021, when
Malaria Consortium agreed to provide support to this state at short notice and an order wasplaced based on a rough population estimate. Once a more accurate population estimate wasavailable, only the required quantity of SPAQ was air freighted for use in the 2021 SMC
campaign in Borno and the surplus quantity was shipped to Nigeria by sea for use in 2022. The
total also includes SPAQ for the two SMC IMPACT LGAs in Bauchi, as philanthropic funding wasused to cover the cost of SPAQ for one cycle in those LGAs. As a result of the large quantity of
SPAQ procured with philanthropic funding for use in Nigeria in 2022, as well as global
production constraints, orders had to be split into seven consignments, which arrived at thedestined state-level warehouses between March and July (Table 10). Most consignments wereshipped by sea, but one consignment had to be air freighted to ensure availability of sufficientquantities of SPAQ for the scheduled start of the annual SMC round in Kogi state. In September,Malaria Consortium agreed to loan 1,522,200 blister packs of SPAQ to PMI to help avoid stockouts in the two states supported by this funder. At that point, we were confident that we had48

enough SPAQ in stock for the remaining cycles in philanthropically supported states. The loaned
quantity of SPAQ will be returned to Malaria Consortium before the 2023 SMC round.
Table 10: SPAQ consignments for philanthropically supported states in Nigeria, 2022

Consignment

Number of
SPAQ
blisterpacks

Mode oftransport

Arrival atwarehouse

1

1,593,000

Sea

March

Surplus quantity originallyintended for Borno

Notes

2

2,403,400

Air

May

Air freighted to ensure availabilityof sufficient SPAQ in Kogi forscheduled start of the annual
round

3

15,834,000

Sea

June

Includes SPAQ for SMC IMPACT
LGAs in Bauchi

413,206,000

Sea

June

-

5

7,650,000

Sea

June

-

6

10,560,000

Sea

June

-

7

3,596,600

Sea

July

-

TOTAL

54,843,000

As Nigeria is the only country supported by Malaria Consortium where SMC medicines fromdifferent manufacturers of quality-assured SPAQ are used, training materials were updated toreflect the slightly different packaging and labelling of the products. Malaria Consortium also
supported the inclusion of content on safeguarding in national SMC training materials. Morethan 110,000 SMC implementers were trained with philanthropic support for the 2022 annual
round between May and July (Table 11), including over 73,000 volunteers who served ascommunity distributors. At the central and state level, the trainings included participation fromthe National Primary Health Care Development Agency and the National Agency for Food andDrug Administration and Control to strengthen coordination between Ministry of Healthdepartments and avoid clashes with conflicting health activities, which had frequently resulted
in delays to SMC campaigns in the past. Other cadres involved in SMC delivery in Nigeria include
health educators, who coordinate SMC-related community engagement activities at the LGAlevel, and lead mothers. This cadre of female volunteers is tasked with sharing information
about SMC within their communities and visiting households over the two days following
community distributors’ visits, to encourage adherence to the three-day SPAQ regimen.
Because of the challenging security situation in Borno, the SMC training cascade in this state
differed somewhat from that in other states. For example, many health facilities in Borno are
not functional. To make up for the lack of health workers who typically coordinate SMC
delivery, additional implementers were drawn from the state level and focal persons
representing each ward, the administrative level below the LGA, were appointed. Instead ofcommunity leaders — a cadre of traditional leaders who are formally recognised by the49

government and typically support community sensitisation for health activities in most states —this function was adopted by a government-recognised cadre of LGA employees in Borno. Leadmothers were not used in Borno.
Table 11: SMC implementers trained with philanthropic support,a Nigeria, 2022

Number of SMC
implementers

Number of days
per training

Number of training
eventsNational-level mastertrainers

54

2

1

State-level master trainers

27

2

9

State-level supply chain
specialists

9

2

9

State-level health educators

9

2

9

LGA-level trainers andsupervisors

464

2

16

LGA-level supply chain
specialists

156

2

10

LGA-level health educators

127

2

9

Health workers

13,0382

402

Ward focal persons andadditional state-levelsupervisorsb

291

2

10

Community distributors

73,0472

2,467Community leaders

7,395

1

247

LGA representativesb

135

1

5

Town announcers

9,319

1

313

Lead mothers

7,846

1

261

TOTAL

111,917

Cadre

3,768

aAs KOICA funding was used for training in the two SMC IMPACT LGAs in Bauchi, SMC implementers trained in those LGAs

have not been included in the figures presented here.
bBorno only

Borno, Kebbi, Sokoto and 10 LGAs in the north of Bauchi continued to implement four SMC
cycles as in previous years. Ten LGAs in the south of Bauchi changed to implementing five cycles
for the first time in 2022, in line with a recommendation from the above-mentioned
stratification exercise. Five cycles were implemented in all other philanthropically supported
states. The Nigerian Meteorological Agency predicted that the rainy season would start
unusually early in 2022. Starting SMC delivery as early as May was considered. However, given
the supply chain constraints, this was not possible, with actual implementation dates varying
between states (Table 12). The first states to start cycle 1 distribution, on 25 June, were Bauchi,
Kogi, Nasarawa and Oyo. Abuja Municipal Council in the FCT was the last area to complete the50

SMC round, on 30 October. Bauchi, Borno, Kebbi, Kogi, Nasarawa and Sokoto were all affectedby severe flooding in 2022.[60] In some cases, the distribution period of SMC cycles had to beextended in the worst-affected areas to ensure all communities were reached. SMC delivery in
hard-to-reach areas of Borno was further affected by fuel shortages, which resulted in fewer
WHO-supported airlifts of SMC commodities into those areas. A learning brief summarising ourinsights from implementing SMC in conflict-affected areas of Borno has been published on
Malaria Consortium’s website.[61] A key learning was that strong collaborations with partners
that have an established presence and expertise on the ground were crucial for the accurate
assessment of operations in this volatile setting. Despite the challenges, SMC was safely
delivered to hard-to-reach populations, including many IDPs, at a cost comparable to that inareas that are less affected by insecurity.
Table 12: SMC distribution dates in philanthropically supported states, Nigeria, 2022

State
Bauchi (five-cycle
LGAs)

Implementation dates
Cycle 1: 25 June
Cycle 2: 23 July
Cycle 3: 20 August
Cycle 4: 17 September
Cycle 5: 15 October

Bauchi (four-cycle
LGAs)

Cycle 1: 2 July
Cycle 2: 4 August
Cycle 3: 1 September
Cycle 4: 29 September

Borno

Cycle 1: 15 July
Cycle 2: 13 August
Cycle 3: 10 September

FCT (Abuja
Municipal Council)

Delays and challenges
Parts of Bauchi were affected by severe
flooding between the end of July and
September. In some affected areas, thedistribution period was extended, especiallyin cycle 3, in order to reach the target
population, including those who weredisplaced because of the floods.
Cycle 2 was delayed by five days due to
conflicting Maternal, Newborn and Child
Health Week activities.
Parts of Bauchi were affected by severe
flooding between the end of July and
September. In some affected areas, thedistribution period was extended by a few
days, especially in cycle 3, in order to reachthe target population, including those who
were displaced because of the floods.
The SMC round started about two weeks
later than planned due to delays in agreeing
a memorandum of understanding with thestate malaria elimination programme.

Cycle 4: 8 OctoberCycle 2 was delayed by one day due to a lackof fuel to enable helicopter transport ofcommodities into hard-to-reach areas.

Cycle 1: 1 JulyIn the urban areas of Abuja, delays wereexperienced throughout the round due tochallenges in collaborating with health

Cycle 2: 29 July
Cycle 3: 30 August51

Cycle 4: 29 September
Cycle 5: 27 October
FTC (other area
councils)

Cycle 1: 30 June

workers, for example because of disputes
over payments.
-

Cycle 2: 28 July
Cycle 3: 26 August
Cycle 4: 23 September
Cycle 5: 21 October

Kebbi

Cycle 1: 1 July-

Cycle 2: 30 July
Cycle 3: 27 August
Cycle 4: 24 September
Kogi, Nasarawa
and OyoCycle 1: 25 June

Cycle 5: 15 OctoberParts of Kogi were affected by severe flooding
between June and September. In some
affected areas, the distribution period was
extended by a few days, especially in cycles 3
and 4, in order to reach the target population,
including those who were displaced becauseof the floods.

Cycle 1: 26 June-

Cycle 2: 23 July
Cycle 3: 20 August
Cycle 4: 17 September

Plateau

Cycle 2: 24 July
Cycle 3: 21 August
Cycle 4: 18 September
Cycle 5: 16 October
SokotoCycle 1: 1 July-

Cycle 2: 29 July
Cycle 3: 26 August
Cycle 4: 23 September
Several SMC processes, including for administrative data collection and supportive supervision,
have been digitalised in Nigeria. Digitalisation has been facilitated by the existence ofEmergency Operation Centers, government-led initiatives in seven northern Nigerian states thatare managed by the National Primary Health Care Development Agency. The centres aim to
improve public health emergency management by strengthening information sharing and joint
programming, including the collection, storage, and visualisation of relevant public health anddemographic information. In 2022, Malaria Consortium worked with the state malaria
elimination programmes of Bauchi, Borno and Sokoto to utilise the centres for daily reporting52

during SMC distribution, which informed frequent review meetings and supportive supervisionof SMC implementers in those states. In all states, Malaria Consortium introduced an electronic
attendance registration process for SMC meetings, trainings and SMC distribution days. Due toa lack of suitable providers, mobile payments are not used in Nigeria. Instead, payments areprocessed via bank transfer.
iv. Plans for 2023
In 2023, we expect to continue to use philanthropic funding to support the same states and
LGAs as in 2022. At the request of the NMEP, this includes Borno, where funding arrangements
through the World Bank loan had not been finalised at the end of 2022. We also expect tocontinue to use philanthropic funding to co-fund SMC in the two KOICA-funded SMC IMPACT
LGAs in Bauchi. The total target population supported with philanthropic funding in Nigeria in
2023 will be approximately 11.28 million children. Programmatic priorities include improving
SMC coverage in the highly urbanised areas of FCT, further embedding digital tools in SMC
delivery, and increasing timeliness of cashless payments.

5.5 South Sudani.

ii.

Setting
South Sudan has a total population of 10.75 million.[62] Malaria is endemic throughout thecountry, with transmission peaking during the rainy season between May and October.[63] In
2021, South Sudan reported 2.95 million cases of malaria and 7,300 deaths, which accounted
for 1.2 percent of both global cases and deaths. Malaria incidence is thought to have doubled
since 2015 due to conflict, poverty, malnutrition and climate change.[64] In 2022, thegovernment declared malaria a national emergency and launched a Zero Malaria campaign.
Violence between armed groups affects many parts of the country. The United Nations Officefor the Coordination of Humanitarian Affairs estimates that more than half of the population
insecure due to conflict, chronic underdevelopment and severe weather conditions.[65] There
are over two million IDPs in South Sudan.[66]Scale-up of SMC and funding support
The country’s Malaria Strategic Plan 2021–2025 recommends SMC as a prevention strategy inareas where the malaria burden is high and malaria transmission is seasonal.[67] To test if SMC
can be a feasible, acceptable and impactful intervention in South Sudan, Malaria Consortiumand the National Malaria Control Programme conducted an implementation study in 2022,
which is described in more detail in section 6. As part of the study, SMC was implemented
targeting just under 20,000 children in one county of Northern Bahr el Ghazal state (Figure 12)
in 2022, supported with Malaria Consortium’s philanthropic funding. The location for the study
was selected based on the seasonal malaria transmission pattern in the region, high malaria
incidence according to routine health system data and the state’s relative stability comparedwith other potentially suitable states where the security risk is greater. In addition, Malaria
Consortium had well-established working relationships with the state and county-level healthauthorities through previous non-SMC-related projects. While MSF had experimented withintermittent malaria chemoprevention for children in the area in the past, the pilot project was
the first time SMC was implemented using the standard door-to-door distribution model. A
news article announcing the expansion of Malaria Consortium’s SMC portfolio to South Sudan
was published on Malaria Consortium’s website.[68]53Figure 12: Location of Northern Bahr el Ghazal state within South Sudaniii. Philanthropically supported SMC delivery in 2022
The pilot project was implemented in Aweil South county (Figure 13). A total of 105,000 blister
packs of SPAQ were procured with philanthropic funding for the SMC pilot. At the time theproject received ethical approval in-country, shipment by sea was no longer possible and theconsignment was, therefore, air freighted to South Sudan. It arrived in Aweil in June. South
Sudan uses artesunate-amodiaquine (ASAQ) as the first-line treatment of breakthrough malaria
cases. There is a risk of overdosing on AQ if children who receive SPAQ for SMC subsequently
receive ASAQ for the treatment of malaria. For this reason, the first-line treatment in the study
area had to be changed to artemether-lumefantrine (AL). As this was not routinely available athealth centres, 78,300 AL tablets were procured with philanthropic funding, air freighted toSouth Sudan and distributed to health facilities in the study area in July. More than 300 SMC
implementers were trained in June and July, including around 290 Boma Health Workers, asalaried cadre of community health workers who serve as community distributors in South
Sudan (Table 13). Given the small scale of the project, only one training was conducted fortrainers and supervisors at the national, state and county-level, as well as for health workers.

54

Figure 13: Counties supported with Malaria Consortium’s philanthropic funding for SMC, Northern Bahr el Ghazal, South
Sudan, 2022

Table 13: SMC implementers trained with philanthropic support, South Sudan, 2022

Number of SMC
implementers

Number of days
per training

Number of training
eventsNational, state andcounty-leveltrainer/supervisors andhealth workers

23

3

1

Supervisors

18

3

1

Boma Health Workers

288

3

4

TOTAL

329

Cadre

6

Five monthly SMC cycles were implemented, starting on 22 July. This was about one month
later than planned due to delays in obtaining ethical approval for the study. Subsequent cycles
were implemented as scheduled and SMC distribution ended on 20 November. Throughout the
campaign, there was strong support and involvement from central, state and county healthauthorities. Communities in the study area also expressed strong support for the intervention.
iv. Plans for 2023
We will use philanthropic funding to continue the SMC project to further build the evidencebase for SMC in the complex environment of South Sudan. In 2023, we plan to implement SMC
in two counties of Northern Bahr el Ghazal state, targeting around 60,000 children.

55

5.6 Togoi.

ii.

Setting
In 2021, Togo had a total population of 8.64 million.[69] Malaria is highly endemic in the entire
country.[70] In the north, there is a seasonal transmission peak between June and September.
There were an estimated 2.05 million malaria cases and 3,700 deaths in 2021, accounting for
0.8 percent of global cases and 0.6 percent of global deaths.[13] Though Togo has not been
affected by the same levels of violence and insecurity as many of its Sahelian neighbours, 2022
saw a deterioration of the security situation in the north of the country. The government
declared a state of security emergency in Savanes region in June, following an attack by armed
militants.[71]Scale-up of SMC and funding support
SMC has been implemented in Togo since 2013. The three northernmost regions of Centrale,
Kara and Savanes are considered eligible for SMC. Geographical coverage increased from five
districts initially to all districts in the eligible regions from 2016 onwards. Full geographic
coverage was maintained in 2022 with funding from the Global Fund, Malaria Consortium’s
philanthropic funding and UNICEF, with a total target population of 510,000 (Table 14). The
slight increase in the SMC target population compared with the previous year was due topopulation growth.

Table 14: SMC target population by funding source, Togo, 2021–2022

Funding source

Number of
districts (2021)

Targetpopulation(2021)

Number of
districts (2022)

Targetpopulation(2022)

Global Fund andphilanthropic

12

300,000

12

310,000

Philanthropic
and UNICEF

7

190,000

7

200,000

TOTAL

19490,000

19

510,000

iii. Philanthropically supported SMC delivery in 2022
SMC in the three eligible regions is supported by Malaria Consortium’s philanthropic funding
through co-funding arrangements with the Global Fund and UNICEF (Figure 14). In the 12
districts of Centrale and Kara regions, the Global Fund covers SPAQ and the majority of SMC
implementation costs. Some activities, including training and household surveys, were
supported with philanthropic funding, as insufficient funds were available from the Global Fundto cover those activities. In the seven districts of Savanes region, UNICEF covered SPAQ, whilephilanthropic funding was used for all SMC implementation costs. Those arrangements havebeen in place since 2021. Because of the co-funding arrangements with the Global Fund and
UNICEF, Malaria Consortium does not procure SPAQ for Togo.

56

Figure 14: Regions supported with Malaria Consortium’s philanthropic funding for SMC, Togo, 2021

The training flipbook Malaria Consortium had introduced in 2021 was further refined based on
lessons from the previous year. All the national- and regional-level trainers involved in the 2022
SMC campaign had been involved in previous years and hence no trainings were conducted atthose levels in preparation for the 2022 round. Consequently, trainings were only conducted at
the district and community level, including for almost 6,000 volunteers serving as community
distributors (Table 15).
Table 15: SMC implementers trained with philanthropic support,a Togo, 2022

Number of SMC
implementers

Number of days
per training

Number of training
eventsSupervisors

624

2

19

Community distributors

5,996

2

258

TOTAL

6,620

Cadre

277

aIn the districts where co-funding arrangements are in place with the Global Fund, Global Fund funding was used to co-finance training activities.

All districts implemented four SMC cycles. While SMC distribution was initially scheduled tostart in June, micro-planning was delayed due to conflicting priorities affecting the capacity of
the PNLP. Cycle 1 distribution started on 1 July in all districts. Cycles 2 and 3 were implemented
as scheduled, but cycle 4 was delayed because a SPAQ consignment did not arrive on time. The
57

PNLP arranged to borrow SPAQ from neighbouring Benin, resulting in a relatively short delay of
three days. SMC distribution ended on 6 October in all districts. One severe adverse event wasreported during the 2022 SMC campaign in Togo. A child had developed a rash, lesions andswellings following the administration of SPAQ and had to be treated in a local hospital. The
incident was followed up through the national pharmacovigilance system and the childrecovered.
Malaria Consortium’s key role as an implementing partner in Togo is to advise on quality
implementation of SMC. In 2022, we rolled out the end-of-cycle surveys that had been piloted
in three districts in the previous year to all SMC-implementing districts. Processes were
established to ensure survey data are reviewed and used to inform improvements insubsequent cycles. Feedback on the approach from stakeholders at the different levels of thehealth system has been positive.
iv. Plans for 2023
In 2023, Malaria Consortium expects to support SMC in all provinces through the same cofunding arrangements as in 2022. Priorities for the year include agreeing the timescale for the2022 SMC campaign with all stakeholders well in advance of campaign activities, ensuring
timely availability of SMC medicines, and improving the timeliness of mobile payments.

5.7 Ugandai.

ii.

Setting
Uganda’s population was estimated at 45.85 million in 2021.[72] Malaria is highly endemic in theentire country.[73] Transmission is perennial in much of the country, but there are areas with aseasonal transmission peak between May and September in the northeastern parts of thecountry. In 2021, there were 13.02 million cases and 19,700 deaths. Uganda ranks third in termsof malaria cases globally, accounting for 5.1 percent of global cases. The country also accounts
for 3.2 percent of global malaria deaths.[13] Uganda is relatively stable and not affected by thesame level of violence as other countries where Malaria Consortium supports SMC. However,there is an ongoing military operation in the Karamoja subregion against intercommunal
violence.[74]
Scale-up of SMC and funding support
The Uganda Malaria Reduction and Elimination Strategic Plan 2021–2025[75] aims to move thecountry into the malaria pre-elimination stage and proposes new, innovative chemoprevention
approaches to combat malaria, especially in children. Modelling conducted by the Swiss
Tropical and Public Health Institute suggested that SMC could be a viable malaria prevention
strategy in the Karamoja subregion (Figure 15),[76] where malaria transmission is seasonal andthe highest prevalence rates in the country are consistently reported. However, SP resistance ishigh in Uganda.[77] In 2020, the National Malaria Control Division (NMCD) approached Malaria
Consortium with a request to support an SMC implementation study in Karamoja to investigate
the feasibility, acceptability and impact of SMC. The study commenced in 2021 and employs asimilar two-phase design as the study Malaria Consortium is conducting in Mozambique. It is
described in more detail in section 6. An article discussing the use of modelling data to informthe rollout of SMC in Uganda was published on Malaria Consortium’s website.[78]58Figure 15: Location of Karamoja subregion within Uganda

In 2021, the first year of SMC implementation in Uganda, philanthropic funding was used todeliver SMC to 90,000 children in two districts of Karamoja. In 2022, philanthropic funding
supported SMC delivery in eight districts of Karamoja, with a total target population of 230,000
children (Figure 16). Philanthropic funding was used exclusively to implement SMC in four
districts of Karamoja, targeting 150,000 children as part of phase two of the SMC
implementation study. This figure excludes around 3,000 children who lived in control
communities in Amudat, where a cluster-randomised controlled trial (cRCT) to assess theeffectiveness of SMC was implemented. SMC was not delivered in control communities. In a
fifth district, around 18,000 children were targeted, primarily with philanthropic funding.
However, the initial plan had been to only cover about 1,500 children enrolled in a cohort study
to determine the chemoprevention efficacy of SMC medicines in this district. It was later
decided to extend SMC to children beyond the study population, except around 19,000 who
lived in three subcounties that were kept as buffer zones to minimise contamination with
communities where the study was implemented. Children who lived in communities where SMC
was not delivered are not included in the target population figure. The additional quantity of
SPAQ needed was provided from stock procured by the Global Fund. The majority of children in
the five research districts received SMC with SPAQ, but around 15,000 children received SMC
with dihydro-artemisinin-piperaquine (DP), an alternative drug regimen tested as part of theresearch. SMC was also implemented by Malaria Consortium with funding from the Global Fundin an additional three districts, where no research was conducted. The total target population in
those three districts was 70,000 children. Philanthropic funding was used to support project
management and Malaria Consortium operational costs in those districts, which is why top-level
achievements have been included in this report. To date, SMC has not been implemented
elsewhere in Uganda.

59

Figure 16: Districts supported with Malaria Consortium’s philanthropic funding for SMC, Karamoja subregion, Uganda,
2022

iii. Philanthropically supported SMC delivery in 2022
In preparation for the 2023 campaign, the Malaria Consortium Uganda team carried out
assessments of storage facilities and health facilities in the new districts where SMC had notpreviously been implemented. A total of 723,600 blister packs of SPAQ and 174,000 tablets of
DP was procured with philanthropic funding. The SPAQ was shipped by sea and arrived in
March. DP was more challenging to source. To minimise delays to the research, theconsignment had to be air freighted. It arrived in Karamoja in late April. Between September
2022 and January 2023, Uganda experienced an outbreak of Ebola in the central part of thecountry.[79] While Karamoja was not affected, Malaria Consortium donated 93,125 tablets ofleft-over DP to the Ministry of Health for MDA in areas where the outbreak occurred in
November.
The SMC training cascade for the 2023 round was conducted between April and June for thefive districts that were primarily supported with philanthropic funding. This included more than
1,300 village health team (VHT) members, a recognised cadre of salaried community healthworkers, who serve as community distributors in Uganda (Table 16) (Spotlight 8). In areas
where DP was used, the trainings had a strong focus on the protocol for administration of DP,
which differs from that for SPAQ. For example, dosing is based on weight rather than age and all
children had to be weighed prior to DP administration.

60

Table 16: SMC implementers trained with philanthropic support,a Uganda, 2022

Number of SMC
implementers

Number of days
per training

Number of training
eventsNational trainers andsupervisors

7

4

1

Regional- and district-leveltrainers and supervisors

23

3

3

Health workers (SPAQ and
DP)

28

2.5

1

Health workers (SPAQ
only)

34

2

2

VHTs

1,322

2

43

TOTAL

1,414

Cadre

50

aAs Global Fund funding was used for training in the three districts primarily supported by the Global Fund, SMC

implementers trained in those districts have not been included in the figures presented here.

Spotlight 8: The role of village health teams in SMC delivery in Uganda

Uganda’s national CHW programme involves volunteer VHTs, who are selected by theircommunities to serve as the first point of contact for basic health services at the village level.
They are supervised by facility-based health workers and have close ties with theircommunities. Their responsibilities include community health promotion and education,
distribution of health commodities, follow-up of patients after their discharge from a healthfacility, mothers during pregnancy and after birth, and community-level health information
management and surveillance. Each village has an average of four VHTs. In some districts, twoof those VHTs have been trained to provide integrated community case management (iCCM)
of malaria, pneumonia and diarrhoea in children under five. For malaria treatment, they are
equipped with RDTs and antimalarial medicines.
At the recommendation of Uganda’s Ministry of Health, VHTs trained on iCCM serve as SMC
community distributors. Many people in Karamoja are nomadic pastoralists, but VHTs areaware of seasonal migration patterns and the population’s health-seeking behaviours. They
are familiar with the best times and locations to deliver services to the population, including
market days, religious gatherings or community meetings. VHTs also command a high level oftrust within their communities and, because of their role in iCCM, it is well known that they
can hand out antimalarials. Moreover, when they identify a child with malaria symptoms
during SMC distribution, they can perform a rapid diagnostic test (RDT) and administer malaria
treatment on the spot. This eliminates the need to refer those children to a health facility andensures that all sick children are indeed tested and treated as appropriate, including thoseoutside of the SMC-eligible age range who live in households visited for SMC. In most othercountries, SMC community distributors are volunteers who cannot perform RDTs or provide
antimalarials for the treatment of malaria. They, therefore, have to refer children withsymptoms of malaria to the nearest health facility; however, not all caregivers are able tofollow this advice, often because of the time and cost involved in travelling to a health centre.
The same health workers who supervise VHTs also serve as supervisors during SMC

61

distribution, which acts as a quality assurance mechanism for supportive supervision in SMC.
Because VHTs are a recognised cadre of community health workers who receive a stipend fortheir work, payment mechanisms are well established, which minimises the risk of payment
delays and low motivation.
Malaria Consortium believes that the use of VHTs in SMC has been a main contributor to thehigh acceptance of SMC among the population and the very good coverage results achieved inthis challenging setting.

Photo 10: A VHT member performs a malaria rapid diagnostic test, Uganda

Five SMC cycles were implemented in all philanthropically supported districts. To facilitate thecoordination of various research activities, SMC implementation dates were staggered and varied by
district (Table 17). Some resentment was reported from communities in control areas who felt leftout because they did not receive SMC. The Malaria Consortium team stepped up community
engagement activities in the control areas in response. Global Fund support for the three districts
was only confirmed in June; hence, the start of implementation was delayed until July and only fourcycles were implemented. In Uganda, a mobile app is used to strengthen supportive supervision of
VHTs.

62

Table 17: SMC distribution dates in philanthropically supported districts, Uganda, 2022

District

Implementation dates

Delays and challenges

Kotido and Moroto

Cycle 1: 17 May
Cycle 2: June
Cycle 3: 14 July
Cycle 4: 12 August
Cycle 5: 8 September-

Nabilatuk

Cycle 1: 22 May
Cycle 2: 18 June
Cycle 3: 17 July
Cycle 4: 17 August
Cycle 5: 14 September

Cycle 1 was delayed by about one week due
to a conflicting COVID-19 vaccination
campaign.

AmudatCycle 1: 18 June
Cycle 2: 19 July
Cycle 3: 21 August
Cycle 4: 26 September
Cycle 5: 25 October

An effectiveness cRCT with a SPAQ, a DP anda control arm was implemented in this
district. SMC distribution started about one
month later than planned due to delays inthe delivery of DP and because training(including on administration of DP) took
longer than anticipated.

Nakapiripirit

Cycle 1: 20 June
Cycle 2: 20 July
Cycle 3: 21 August
Cycle 4: 20 September
Cycle 5: 18 October

A chemoprevention efficacy study with a
SPAQ, a DP and a control arm was
implemented in this district. SMC distribution
started about one month later than planned
as approval was needed from the NMCD for
the use of SPAQ procured by the Global Fundto ensure SMC distribution across the entire
district, rather than just for children enrolled
in the study as initially planned. Approval
was only received in June.

In October, towards the end of the 2023 round in Uganda, the NMCD and Malaria Consortium
hosted an event to celebrate the successful rollout of SMC in Karamoja, with participation from
the Minister of State for Health, the Permanent Secretary, and several Members of Parliament.
A news article about the event was published on Malaria Consortium’s website.[80]iv. Plans for 2023
In 2023, Malaria Consortium expects to implement SMC with philanthropic support in the same
five districts as in 2022, but including children who lived in control or buffer communities andthus did not receive SMC in 2022. The philanthropic SMC target population will beapproximately 190,000. We expect that the remaining four districts of Karamoja, with a
combined target population of 100,000 children will be reached with support from the Global
Fund. Based on the good effectiveness measures found in the first study phase,[21] Malaria
Consortium believes that the use of SMC in the entire subregion is justified while the research is
ongoing. As in Mozambique, conclusions on the longer-term viability of SMC in Karamoja orelsewhere in Uganda can only be drawn once all study results are available.

636. Malaria Consortium’s SMC research
Malaria Consortium is one of a small number of non-governmental organisations in the UK that has
been awarded independent research organisation status by Research Councils UK.[81] We arecommitted to evidence-based interventions and to contributing towards building the evidence basefor the interventions we implement. In this section, we describe Malaria Consortium’s role as a
research organisation and how philanthropic funding was used for SMC research in 2022. We alsopresent emerging results from our studies.

6.1 Scope and scale of Malaria Consortium’s SMC research
As a both a leading implementer of SMC and a research organisation, Malaria Consortium is uniquelyplaced to develop and evaluate solutions to operational problems that can improve the quality of
SMC delivery; assess the extent to which SMC impacts estimates of the burden of malaria; and test
innovations that will shape the future of SMC.
The scope and scale of Malaria Consortium’s SMC research has grown substantially over the last few
years. For example, in 2018, we had no peer-reviewed publications and no SMC-relatedpresentations or posters at the annual meeting of the ASTMH, one of the most prestigious academic
conferences for malaria researchers. In 2022, Malaria Consortium’s SMC research was published inseven peer-reviewed articles (Spotlight 9).[18,20,25,36,76,82,83] We also co-hosted an SMC-themed
symposium at ASTMH and shared our research findings in five oral presentations and 12 conference
posters.[84-100] Academic publications with contributions from Malaria Consortium’s SMC research arereferenced throughout this report.
Spotlight 9: Malaria Consortium’s SMC-themed peer-reviewed publications, ASTMH presentations and posters,
2022

Malaria Consortium staff authored or co-authored the following SMC-themed peer-reviewed
articles that were published in 2022:
1. Co-implementing vitamin A supplementation with seasonal malaria chemoprevention
in Sokoto State, Nigeria: A feasibility and acceptability study. BMC Health Services
Research.
2. Delivery of seasonal malaria chemoprevention with enhanced infection prevention
and control measures during the COVID-19 pandemic in Nigeria, Burkina Faso andChad: A cross-sectional study. Malaria Journal.
3. Dynamical malaria modeling as a tool for bold policy-making. Nature Medicine.
4. Extending delivery of seasonal malaria chemoprevention to children aged 5–10 years
in Chad: A mixed-methods study. Global Health: Science and Practice.
5. Extending seasonal malaria chemoprevention to five cycles: A pilot study of feasibility
and acceptability in Mangodara district, Burkina Faso. BMC Public Health.
6. Feasibility, acceptability, and protective efficacy of seasonal malaria chemoprevention
implementation in Nampula province, Mozambique: Protocol for a hybrid
effectiveness-implementation study. JMIR Research Protocols.
7. Impact of seasonal malaria chemoprevention on prevalence of malaria infection in
malaria indicator surveys in Burkina Faso and Nigeria. BMJ Global Health.

64

At the 71st annual meeting of the ASTMH in Seattle 2022, our research was shared in five oralpresentations:
1. A cross-sectional survey to assess the feasibility and acceptability of seasonal malaria
chemoprevention among nomadic pastoralist population: The case of Karamoja,
region in Uganda.
2. A non-randomised controlled trial to assess the protective effect of seasonal malaria
chemoprevention in the context of high parasite resistance in Uganda.
3. Results from an implementation study to assess the impact, feasibility andacceptability of implementing seasonal malaria chemoprevention in Karamoja region.
4. Seasonal malaria chemoprevention: Mozambique implementation study 2020–22.
5. Seasonal malaria chemoprevention (SMC): New geographies in Nigeria and quality of
SMC delivery.
In addition, Malaria Consortium colleagues presented 12 SMC-themed ASTMH conference
posters:
1. Acceptability of seasonal malaria chemoprevention among children under five inMozambique: A qualitative study.
2. Assessing the quality of SMC delivery by village health teams in Uganda.
3. Evaluating the adaptation of seasonal malaria chemoprevention implementation
during COVID-19 in Karamoja, Uganda.
4. Exploring the role model approach to strengthen the administration of SMC medicines
in Chad.
5. Facilitators of, and barriers to, fully integrating seasonal malaria chemoprevention
with vitamin A supplementation: A qualitative enquiry.
6. Feasibility and acceptability of extending delivery of seasonal malaria
chemoprevention to children aged 5–10 years in Chad.
7. Harnessing the seasonal malaria chemoprevention campaign in Nigeria: Safety, equity
and cost of fully integrating vitamin A supplementation.
8. Impact assessment of seasonal malaria chemoprevention using routine healthsurveillance data in Kogi state, Nigeria.
9. Integrating gender into the process evaluation of seasonal malaria chemopreventionin Karamoja, Uganda: Results and future directions.
10. Measuring the impact of SMC on malaria prevalence and case distribution compared
to predicted estimates from a transmission model in Burkina Faso.
11. Optimising the role of lead mothers in seasonal malaria chemoprevention campaigns:
Insights from formative research in Kano state, northern Nigeria.
12. Using the role model approach to identify best practices and challenges duringseasonal malaria chemoprevention drug administration in Burkina Faso.

Our commitment to SMC research is illustrated by our participation in the SMC Alliance research
subgroup, which aims to provide a platform for national malaria programmes, implementing
partners and researchers to present study protocols and research findings, discuss evidence gaps
and research priorities, and promote the use of evidence to inform SMC implementation. Malaria
Consortium serves as the subgroup’s secretariat. On behalf of the subgroup, Malaria Consortium iscurrently coordinating a global SMC research priority-setting exercise using the eDelphi method. This
involves asking a large group of different SMC stakeholders to define and rank SMC-related research
priorities. Results and a peer-reviewed publication are expected in 2023.
65

6.2 Developing and evaluating solutions to operational challenges
In 2022, we worked on a number of studies that aimed to resolve operational challenges andimprove the quality of service delivery. The studies we conducted focused on how SMC could be
implemented more efficiently, effectively and equitably.
i.

Increasing efficiency
We explored two different approaches to increasing the efficiency of service delivery byintegrating SMC with other health services. A study in Nigeria looked at leveraging the SMC
platform for the delivery of another health intervention, VAS. We demonstrated that leveraging
the SMC campaign for VAS can substantially increase VAS coverage without negatively affecting
SMC delivery. In Togo, our research is looking at the opposite approach, exploring if SMC can be
integrated into routine community healthcare delivery; that is, moving away from SMC being
delivered through a dedicated campaign.
a) Co-implementing VAS with SMC, Nigeria
Building on a study conducted by Malaria Consortium in 2019 to explore if delivering VAS tochildren 6–59 months via SMC is feasible and acceptable,[101] we carried out further
research on this topic at a larger scale in 2021. The follow-up study targeted around
165,000 children during SMC cycle 4 in two LGAs of Bauchi state. A convergent mixedmethods design, including 12 key informant interviews (KIIs) and 12 focus group discussions(FGDs), as well as baseline and cross-sectional endline household surveys with 540 children
6–59 months, was used to explore the feasibility and acceptability of integrating VAS with
SMC among caregivers, community distributors, health workers and policymakers, as wellas to assess the effectiveness and safety of the approach. Baseline was defined as cycle 3(SMC only) and endline as cycle 4 (SMC plus VAS). The study also included a cost analysis.
The study was primarily funded through a grant from the Health Campaign Effectivenessprogramme at the Task Force for Global Health. Philanthropic funding was used to support
dissemination and publication of research results in 2022. A project brief describing thestudy methods can be found on Malaria Consortium’s website.[102]At endline, the proportion of children who received at least one dose of VAS in the last six
months increased significantly from two to 59 percent. There were no adverse effects on
the coverage of SMC delivery, with 70 percent of eligible children reached at baseline,
increasing to 76 percent at endline. VAS did not appear to negatively affect the quality of
SMC delivery, measured by proportion of children receiving their first dose as DOT, with 54
percent at baseline compared to 68 percent at endline. Adverse drug reactions wereconsistent between baseline and endline. Intervention costs were determined at 0.94 USD
per child and cycle for SMC only, and 1.18 USD per child for SMC and VAS. Caregivers liked
the intervention because of the perceived health benefits to their children. Facilitating
factors included knowledge of the benefits of VAS among caregivers and intensive
community mobilisation. Political influence in the recruitment of community distributors,
delayed payments to community distributors and their supervisors, and poor
communication with communities were reported as barriers to the successful coimplementation of SMC and VAS. The study concluded that full integration of SMC and VAS
is feasible, with minimal incremental cost, and is acceptable to implementers andcommunities. Study findings were published in BMC Health Services Research[25] andpresented as posters at the 2022 annual ASTMH meeting.[93,95]
A key learning from the study was that co-design and collaborative planning of theintegrated SMC and VAS campaign with stakeholders at all levels promoted active
66

ii.

participation and ownership by the National Malaria Elimination Programme. Utilisingexisting health system and programme delivery structures and mechanisms during design
and planning facilitated stakeholder buy-in.[103] An advocacy brief was produced in supportof efforts to lobby for the inclusion of policy guidance on VAS integration in the NMEP’s
SMC strategy.[104]b) Integrating SMC into routine community health service delivery, Togo
The PNLP in Togo is interested in integrating SMC into routine health service delivery toensure the intervention’s long-term sustainability. Malaria Consortium worked with Togo’s
Cabinet d’Expertise en Recherche-Action to conduct formative qualitative research to
explore the feasibility and acceptability of the closer integration of SMC with routine
community health services such as iCCM. The research protocol involves KIIs and FGDs withkey stakeholders to explore how the integration of SMC into routine community healthservices could be achieved. Results will be available in 2023 and will feed into a co-design
workshop with stakeholders to develop processes and tools for the integrated delivery of
SMC, which could then be evaluated through further research. A blog post describing how
researchers were trained for this study was published on Malaria Consortium’s website.[105]A peer-reviewed publication is in preparation.
Increasing effectiveness
SMC relies on caregivers administering the full course of SMC medicines to their children over athree-day period each cycle. In 2022, our research explored two different strategies tostrengthen caregivers’ adherence to the three-day SPAQ regimen. In Burkina Faso, Chad andTogo, we tested the role model approach, a community-driven behaviour change strategy that
identifies existing strengths and solutions among individuals in a community, which are thenshared with other community members to bring about positive behaviour change. Malaria
Consortium has previously used the approach successfully as a novel tool in malaria control andelimination in other projects.[106] In Nigeria, we conducted a study to optimise the role of leadmothers. Both studies confirmed that context-appropriate community engagement approaches
can play an important role in strengthening caregiver adherence to the SMC protocol. While wehave not yet demonstrated the cost-effectiveness of those approaches, Malaria Consortium
believes that appropriate community engagement is preferable to providing all SPAQ doses as
DOT, which would have significant implications in terms of the required resources and cost.
a) Using the role model approach to improve administration of SPAQ in Burkina Faso, Chadand Togo
In 2021, a formative study was conducted in Burkina Faso, Chad and Togo to identify
positive caregiver behaviours around the administration of SMC medicines.[107] Thosebehaviours included incentivising children with treats; spouses, family members orneighbours reminding caregivers to administer day 2 and 3 AQ; and placing blister packs ina prominent place such as near utensils or ingredients used for cooking. Some negative
behaviours that should be discouraged were also identified, including mixing SPAQ withfood or drink, often with porridge or tea, when it should only be mixed with water; andusing force to make the child take the medicines. Findings from the formative research
stage were shared at the 2022 ASTMH meeting.[92,100]
In 2022, role models were trained to deliver interactive monthly sessions within theircommunities, with the goal of sharing behaviours and reinforcing key messages. Social andbehaviour change tools, such as posters exhibited at health facilities, were also developed
to reinforce positive behaviours. The impact of promoting the identified role model67

behaviours on SMC outcomes was assessed at the end of the 2022 SMC campaign. Data
analysis is ongoing, and results will be published in 2023.
b) Optimising the role of lead mothers in SMC, Nigeria
Although lead mothers have been involved in SMC for several years, their role and how it
impacts on SMC delivery has so far not been evaluated. In 2021 and 2022, Malaria
Consortium and the NMEP conducted a study in one LGA in Kano that aimed to develop,
implement and evaluate an intervention to optimise the role of lead mothers in SMC. The
study comprised three phases. During the formative stage, a literature review and KIIs with
community leaders and national, state and local government health officials provided
insights that were used during the development phase to define the role of lead mothersand enhance their capacity to strengthen high-quality SMC delivery. The development
phase included a co-design workshop with key stakeholders. The evaluation phase involved
baseline and endline household surveys to assess the impact of lead mothers on SMC
outcomes, as well KIIs and FGDs with key stakeholders. The study methods are described in
more detail in a synopsis that was published on Malaria Consortium’s website.[108]The formative research conducted for this study concluded that lead mothers influencecaregivers to adopt healthy malaria prevention behaviours during SMC campaigns due totheir close ties with the community. Attributes and skills of lead mothers that werereported to strengthen relationships with caregivers were shared customs and beliefs,
being known by caregivers, and good communication skills. Areas for improvement
identified included recruitment criteria, training, work planning and supervision, and timely
payment of lead mothers. Concrete suggestions included increasing the number of leadmothers and giving a supportive or supervisory role to Community Health Influencers,
Promoters and Services (CHIPS) agents, a cadre of community agents established by the
National Primary Health Care Development Agency to bridge gaps in access to healthcare at
the community level. It was also suggested that the selection criteria for lead mothers
should be reviewed and that tailored training for lead mothers should be provided. There isa need to improve lead mothers’ knowledge and skills and provide supporting materials, sothey can better deliver targeted health messages to caregivers. Policymakers need to find away of transitioning the role of lead mothers into the existing community health worker
infrastructure, for example the CHIPS programme, to ensure the sustainability of theapproach. Findings from the formative phase were published in the Malaria Journal[109] andat the 2022 ASTMH meeting.[99]In 2022, the lead mothers approach was adapted based on the formative phase. In
particular, this involved strengthening the key messages lead mothers share with
community members, as well as developing targeted training materials for lead mothers.
The improved lead mothers approach was assessed using a mixed-methods approach,including KIIs and FGDs, and before and after household surveys. Data analysis is ongoing.
Results will be published in 2023.
iii. Promoting equity
While SMC campaigns generally achieve high coverage, it has been speculated that some
populations may not be optimally served through door-to-door campaigns because of theirmobility. Our research in 2022 addressed the needs of one such group: nomadic populations in
Chad. This study aimed to assess the feasibility and acceptability of SMC among nomadic
populations, determine factors affecting the administration of SPAQ in those populations, anddevelop strategies to strengthen access to SMC among eligible children in nomadic populations.

68A study protocol was developed that involved a mixed-methods design, including KIIs, crosssectional surveys and geospatial analysis. Malaria Consortium signed an agreement with the
Ministry of Health department in charge of services for hard-to-reach populations with the aimof improving access to SMC services for nomadic populations. Results were intended to feed
into a co-design workshop with key stakeholders and community members to develop
strategies to increase access to SMC among nomadic populations. The planned study site was ina health district in Chari Baguirmi province, where a large number of nomads lives. However,
due to several factors, including flooding and a decline in the security situation in this area, thestudy could not be implemented as planned and had to be stopped before data collection could
take place. We will review the feasibility of resuming the study in 2023, if conditions allow.

6.3 Assessing impact
Evidence of the impact of SMC has been growing over recent years, including through the studies
conducted as part of ACCESS-SMC.[9,10,12] Our research employs a variety of methods to monitor
impact over time and at scale. In 2022, our work included assessments of the chemoprevention
efficacy of SPAQ in different locations, as well as secondary analyses of a range of data sets to assess
the effectiveness of SMC.
i.

ii.

Assessing the chemoprevention efficacy of SMC medicines
SMC has now been deployed for several years in the Sahel. While the evidence generated
through the ACCESS-SMC project suggests that parasite resistance to SPAQ remains low,[9]Malaria Consortium believes that there is a need to corroborate those findings now SMC has
been fully scaled up in the region. There is also a need to assess the chemoprevention efficacyof the SMC medicines after a decade of their use. If the continued chemoprevention efficacy ofthe medicines can be confirmed, we can confidently predict that SMC will remain a viablemalaria prevention strategy for the foreseeable future.
In 2022, we conducted a chemoprevention efficacy study in one health district of Burkina Faso,
using Malaria Consortium’s chemoprevention efficacy study protocol. A description of the study
methods can be found in Spotlight 2 above. This was the first time this study protocol was
implemented in West and Central Africa to assess the chemoprevention efficacy of SPAQ after
several years of SMC implementation at scale. In total, 500 children were enrolled in the study
and received a full course of SPAQ as DOT. The presence of malaria parasites, resistancemarkers and drug concentrations in the blood was determined through microscopy,
quantitative polymerase chain reaction and pharmacometric analyses at different time points.
Data have been collected and analysis of the samples is ongoing. Results will be available in2023.
Chemoprevention efficacy studies were also conducted in Mozambique, Uganda and South
Sudan as part of the SMC wider implementation studies in those countries and are described in
more detail in the section below on shaping the future of SMC.
Evaluating the effectiveness of SMC at scale
SMC aims to prevent malaria disease in eligible children during the peak malaria transmission
season. The effectiveness of the intervention is well documented in research settings, butmonitoring effectiveness under programmatic conditions at scale can be challenging, forexample, due to varying quality of available routine data or changes in health-seeking
behaviour. In addition to evaluating a range of impact measures, we are also interested in theuse of malaria modelling and in contributing to the establishment of standardised
methodologies, especially those using routine health system data or other readily available data69

sets. Our work on measuring the impact of SMC in 2022 included an ecological impact analysis
drawing on a range of data sets from Burkina Faso and Nigeria, as well as an analysis of routine
health surveillance data to assess the impact of SMC in Kogi state, Nigeria.
a) Ecological impact analysis
This project explores how the impact of SMC could be measured by using multiple available
data sources, which may be a more sustainable approach than conducting primaryresearch, especially in areas where the effectiveness of SMC has been established inprinciple. Prevalence data from nationally representative household surveys, such as the
Demographic and Health Surveys and Malaria Indicator Surveys, which are routinely andregularly conducted in many countries, provide reliable representative estimates of malaria
prevalence at a specific time and place. They could potentially be used as an alternative,
sustainable data source to assess the impact of SMC. To test this hypothesis, an ecologicalstudy based on analysis of survey, rainfall, geographical and SMC programme data fromBurkina Faso (2010–2017) and Nigeria (2010–2018) was undertaken to assess the impact of
SMC. Mixed-effects logistic regression was performed to predict presence of malaria
infection in children 6–59 months. In Burkina Faso, there was a substantial decrease in theodds of RDT-positive malaria infection in children living in areas where SMC was
implemented during the months when SMC is delivered (odds ratio [OR]: 0.28, 95 percent
confidence interval [CI] 0.21–0.37, p<0.001). The same trend was found in Nigeria (OR: 0.40;
95 percent CI: 0.30–0.55, p<0.001). The odds of malaria were lower up to two months postSMC in Burkina Faso (OR: 0.33; 95 percent CI: 0.17–0.64, p<0.001). In Nigeria, the odds ofmalaria were lower up to one month post-SMC, but this was not statistically significant (OR:0.49; 95 percent CI: 0.23–1.05, p=0.07). The analysis showed that impact of SMC can bedetected in reduced prevalence of malaria from data collected through household surveys if
conducted during SMC administration or within months afterwards. These results were
published in BMJ Global Health.[83]Building on this work, we proceeded to calibrate a malaria transmission model[110] to survey
prevalence over time for selected health districts in Burkina Faso. The model had previously
been shown to replicate SMC efficacy in trials.[111] We simulated the introduction of SMC inchildren under five in each district at the time of SMC implementation, including data on
rainfall, net use and treatment seeking, fitting to microscopy-confirmed malaria prevalenceusing maximum likelihood by varying mosquito density. Model outputs of the proportion ofclinical malaria cases in under-fives out of all children below 15 years were compared forthe years 2013–2018. We also assessed the impact of SMC upon this proportion, using
district-level case data confirmed by RDT. Mixed-effects logistic regression models withrandom intercepts for district were conducted to test for the impact of SMC on the
proportion of clinical cases in children under five, adjusting for the removal of user fees forchildren under five in Burkina Faso.
This work forms part of a Doctor of Philosophy (PhD) project at Imperial College London.
Preliminary results were presented at the 2022 annual ASTMH meeting.[98] They show thatdrops in prevalence for children 6–59 months following SMC implementation match modelpredicted impact, assuming 70 percent coverage and full adherence. The proportion ofcases in under-fives aligns well with model simulations prior to SMC. However, the change
in the model predictions following SMC is more extreme than in case data. This suggeststhat SMC is having the expected impact upon prevalence, but impact in routine data was
obscured by the implementation of the removal of user fees for under-fives. Further
analysis will attempt to account for this effect.
70b) Impact assessment of seasonal malaria chemoprevention using routine healthsurveillance data in Kogi state, Nigeria
This analysis used propensity score matching to select three intervention and three control
LGAs in Kogi state, Nigeria, with similar meteorological characteristics, population size andmalaria epidemiology. Data for 2021 were extracted from outpatient daily registers atselected primary health facilities, and monthly incidence rates of confirmed malaria cases in
the intervention and control LGAs were compared. SMC impact was estimated by fitting anegative binomial regression model to measure outcomes.
Data were extracted from a total of 4,067 outpatient records — 2,206 and 1,861 fromintervention and control health facilities, respectively. After adjusting for rainfall, monthand age, the rate of confirmed malaria cases was almost two times lower among children
3–59 months in the SMC implementing LGAs, compared to non-implementing LGAs
(incidence rate ratio=0.508, 95 percent CI: 0.407–0.64, p<0.001). Incidence of confirmed
malaria among under-fives in the intervention LGAs was significantly lower during months
when SMC was implemented. We did not observe a similar reduction in control LGAs. The
findings were presented at the 2022 annual meeting of the ASTMH.[96]Photo 11: A child receives SMC medicines from a VHT member, to be administered by their caregiver, Uganda

6.4 Shaping the future of SMC
Due to the organisation’s global reach, Malaria Consortium is particularly interested in informing
policy and practice regarding SMC in new geographies that were not prioritised for the initial scaleup of SMC in both West and Central and East and southern Africa. Some of our most exciting andgroundbreaking research in 2022 explored the feasibility, acceptability and impact of SMC in those
new locations.

71

i.

ii.

Expanding SMC to new geographies in West and Central Africa
Several countries in West and Central Africa, where SMC has been deployed for many years,
recently expanded the geographical reach of SMC beyond the areas targeted for the initialscale-up of SMC, often based on recommendations from systematic stratification exercises.
Frequently, the transmission season in those areas is slightly longer and five monthly SMC
cycles are implemented. The expansion of SMC to those areas is now well established, but there
is a need to monitor impact and assess if the SMC delivery model used in the areas where SMC
was initially rolled out is applicable in those new areas.
In 2022, we examined results from the 2021 end-of-round household surveys conducted in fourstates that had implemented SMC in previous years (Bauchi, Borno, Kebbi, Sokoto) and three
new states that implemented SMC for the first time that year (Kogi, Nasarawa, Plateau) toassess if there was a difference in the quality of SMC implementation in those two states. Fourquality-related indicators were assessed: community distributor adherence to DOT; caregiveradherence to day 2 and day 3 administration of AQ; perception of the efficacy of SMC
medicines by caregivers; and caregiver satisfaction with service delivery.
No difference between old and new states was observed on any of the indicators assessed,
which suggests that the delivery model works equally well in both ‘old’ and ‘new’ SMC
locations. In new states, community distributor adherence to DOT was 89.5 percent; caregiveradherence to day 2 and day 3 DOT was 98.3 percent; 98.2 percent of caregivers believed in theefficacy of SMC medicines; and 99.5 percent were happy with the service community
distributors had provided. For old states, those figures were 89.3 percent, 99.0 percent, 96.8
percent and 99.3 percent respectively. Household coverage was also comparable across allstates, ranging from 94.5 percent in Bauchi to 98.9 percent in Kebbi. Results were presented
during a symposium on Taking SMC to New Geographies at the 2022 annual ASTMH meeting.[88]Assessing SMC in East and southern Africa
The 2012 WHO policy recommendation called for the scale-up of SMC in the Sahel region ofWest and Central Africa. SMC in East and southern Africa was not prioritised because ofconcerns over parasite resistance to SPAQ in this region. However, there are many areas in Eastand southern Africa where malaria transmission is seasonal, and the most recent WHO
guidelines no longer place any geographic restrictions on the deployment of SMC. Assessing if
SMC can be a viable malaria prevention strategy in this region despite parasite resistance is,therefore, of the highest priority. In 2022, Malaria Consortium continued the SMC
implementation studies we started in previous years in Mozambique and Uganda. We also
conducted an implementation study in South Sudan. All those studies included assessments ofthe feasibility and acceptability of SMC in this new setting; assessments of thechemoprevention efficacy of SMC medicines and the effectiveness of SMC in terms of
preventing malaria cases during the high transmission season; as well as monitoring of common
resistance markers associated with parasite resistance to the SMC medicines. We generally
found SMC in the new locations to be feasible and highly acceptable. Effectiveness results so far
have been promising, but we do not yet have results from the chemoprevention efficacy andresistance markers studies, which will become available over the course of 2023. We will only
be able to draw robust conclusions on the suitability of SMC in the locations where we havetested the intervention once we have the full results from all study elements.
We also started a new research project in 2022, which we refer to as ‘rapid assessments’. The
aim of the project is to determine the extent to which the results from the implementation
studies in Mozambique and Uganda are generalisable to other geographies in East and southern
Africa.
72a) Assessing the feasibility, acceptability and impact of SMC in Nampula, Mozambique
The SMC study in Mozambique was designed as a two-phase hybrid effectivenessimplementation study. The first phase focused on acceptability and feasibility, followed bymore rigorous assessments of the effectiveness of the intervention and chemoprevention
efficacy of SPAQ in phase 2. Detailed methods for both phases have been published in JMIR
Research Protocols.[82,112]
Phase 1 of the study was implemented alongside SMC implementation during the 2020/21
season in two districts of Nampula: Malema and Mecubúri. A third district, Lalaua, served asa control for some of the study components. Phase 2 of the study was conducted during the2021/22 season in four districts: the three districts involved in phase 1 plus a new district,
Muecate.
Acceptability and feasibility of SMC were assessed through KIIs and FGDs, as well as end-ofround household surveys in both research phases. Both phases also involved resistancemarkers surveys before and after SMC delivery to determine the prevalence of Plasmodium
falciparum parasites with common markers of resistance to SP and AQ, as well as any
increase in resistance due to SMC implementation. To assess the effectiveness of SMC interms of preventing clinical malaria cases, a non-randomised controlled trial (nRCT) was
conducted in phase 1, while phase 2 involved a cRCT. In addition, a cohort study was
conducted to determine the chemoprevention efficacy of SPAQ and whether drugconcentrations or resistance influence the duration of protection.
The study was conducted in collaboration with the PNCM and the Centro de Investigação em
Saúde de Manhiça. It was co-funded by the Bill & Melinda Gates Foundation. A scientificadvisory committee comprising malaria experts, the donor community and national
stakeholders guides the study to ensure scientific rigour and support research uptake. An
article published in Science magazine about how research in Mozambique could get the fightagainst malaria back on track featured the study.[113] Phase 1 results were presented at theannual ASTMH meeting in 2021. Preliminary results from phase 2 were shared at a
symposium on Taking SMC to New Geographies at the 2022 annual ASTMH meeting.[87] Final
results from all study elements will be available in 2023 and will be published in a peerreviewed journal.
• Feasibility and acceptability
The intervention was successfully delivered with only minor delays and at the anticipatedscale. No serious adverse events were reported. High coverage was achieved. In phase 1,
85.2 percent (95 percent CI: 82.1–88.9) of eligible children were reached. Caregivers’
adherence to administration of AQ on days 2 and 3 was high at 98.3 percent (95 percent
CI: 98.5–99.7).[114]
Acceptability of the intervention among the population was high. Caregivers, community
members and health officials all felt that introducing SMC had helped to reduce cases ofmalaria and improved caregivers’ lives, as they did not have to look after sick children.
Community engagement, the involvement of local and religious leaders, and coordination
between local authorities and implementing partners were mentioned as success factors.
A challenge reported was that some female caregivers could not allow their children to
take the SMC medicines because they did not have their male partner’s permission.
Acceptability results were presented at the 2022 annual meeting of the ASTMH.[89]• EffectivenessThe nRCT conducted in phase 1 suggested that SMC was effective in preventing malaria
cases in children under five during the high transmission season, with SMC conferring a73

protective effect of 83 percent.[87] In phase 2, a two-arm cRCT was conducted to assess
the effectiveness of SMC (on an intention-to-treat basis) for prevention of clinicallysignificant cases of malaria among children 3–59 months. The primary outcome was theincidence of confirmed malaria using RDTs in SMC-eligible children who visited a clinic orcontacted a community health worker for suspected malaria during the study period(January–May 2022) in the two districts where the study was conducted. The study was
powered to have an 80 percent chance to detect a 40 percent effect size at the 95
percent confidence level.
Clusters were selected at the community level from a list of all communities, withprobability for inclusion proportional to population size. A total of 76 communities was
randomly selected for inclusion in the intervention arm. From the remaining
communities, 114 were randomly selected for inclusion in the control arm. SMC was
implemented as per the standard protocol in communities in the intervention arm. In
communities in the control arm, community health workers visited households monthly
to disseminate similar health messages as those provided to caregivers by SMC
community distributors. In each selected community, 15 households were selected at
random from a list of all households in the community. One eligible child was selected at
random from among all eligible children in each selected household. In households where
no eligible children were identified, additional households were randomly selected until
15 children had been recruited in each community.
Once children had been recruited into the study, a questionnaire was administered tocaregivers to establish covariates, including sex, age, socioeconomic status, parental
education, use of mosquito nets and indoor residual spraying. Children enrolled in the
study were visited monthly by researchers to ascertain if, since the researchers’ last visit,
they had experienced a fever episode. For children who had experienced a fever episode,caregivers were asked if they had visited a clinic or contacted a community healthworker, whether a malaria RDT had been performed and what the outcome of the RDT
was. In the intervention arm, caregivers were also asked if the child had received SMC in
the previous cycle and if the child had experienced any adverse reactions to SPAQ.
In the first instance, multiple logistic regression was performed to calculate odds ratios.
This analysis did not account for the duration of follow-up. Covariates were tested using
the likelihood ratio test to determine whether model fit was improved. The protective
effect of SMC was estimated using multiple Cox proportional hazards regression models
to account for duration of follow-up. Children in both arms were right-censored when
they were lost to follow-up or experienced their first RDT-confirmed malaria event after
the date of recruitment at baseline. The likelihood ratio tests showed that none of thecovariates considered improved model fit. Results from the unadjusted model arepresented here, expressed in terms of hazard ratio (HR).
Data from 1,338 children were included in the final analysis: 710 in the intervention arm
and 628 in the control arm. In the intervention arm, 181 children experienced a malaria
episode confirmed by an RDT, while in the control arm, 431 children had an RDTconfirmed malaria episode. Cox regression analysis revealed that children in theintervention arm had a 77 percent lower risk of having an RDT-confirmed malaria episodethan children in the control arm (HR=0.2; 95 percent CI: 0.19–0.28)
This means that the study found approximately 80 percent effect size, which was highly
statistically significant at the 95 percent confidence level (p<0.001). Although our sample
was smaller than the original sample size calculation required, the larger effect size74

meant that the smaller sample was sufficient to provide statistical power to detect asignificant association. Additional data cleaning and analyses for the cRCT are ongoing,
including efforts to reduce loss to follow-up, descriptive analyses of baseline data withsurvey weights and analysis for recurrent events within each cycle. Final results may
differ from the preliminary results presented here.
• SPAQ resistance
While there was high prevalence of SP resistance, one annual round of SMC did notappear to have had a negative impact on the resistance profile.[115] Analysis of resistancedata from phase 2 is ongoing.
• Chemoprevention efficacy of SPAQ
A chemoprevention efficacy study as described in Spotlight 2 above was conducted in
2022. Data analysis is ongoing.
b) Assessing the feasibility, acceptability and impact of SMC in Karamoja, Uganda
A two-phase hybrid implementation effectiveness study was conducted in the Karamoja
subregion in 2021 and 2022, in collaboration with the NMCD and the Infectious Diseases
Research Collaboration. Phase 1 of the study was conducted in two districts, with a third
district serving as a control. Phase 2 involved research activities in five districts. The study
closely mirrored the design of the Mozambique study described above. In addition to
exploring the effectiveness of SMC using SPAQ and the chemoprevention efficacy of SPAQ,
phase 2 in Uganda also explored the use of DP as an alternative drug regimen for SMC,
including a safety study of the use of DP in children under six months. Phase 2 of the study
was co-funded by a grant from the Bill & Melinda Gates Foundation. The phase 2 study
protocol was published in Gates Open Research.[116] A summary of available results from bothstudy phases was presented at a symposium on Taking SMC to New Geographies at the 2022
annual ASTMH meeting.[86] Final results will be available in 2023 and will be published in apeer-reviewed journal.
• Feasibility and acceptability
SMC in Karamoja was found to be feasible and safe. The end-of-round household survey
at the end of phase 1 showed that a minimum of 87.2 percent of eligible children
received SMC per cycle, with the highest coverage (99.6 percent) achieved in cycle 5. A
household survey conducted in phase 2 found that 93.1 percent of eligible children had
received SMC. Few adverse events were reported. Structured observations by district
supervisors and health workers of over 2,000 instances of VHTs administering SMC
medicines found that SMC delivery by VHTs was of high quality. The active engagementof stakeholders through training, supervision and political buy-in were critical successfactors.
Acceptability was high, including among nomadic pastoralists. All stakeholders perceived
SMC as a highly relevant intervention in Karamoja. Female caregivers reported that theyneeded to visit the health facilities less often, which gave them more time for housework.
While male caregivers felt that they have joint responsibility for the health of theirchildren, most respondents reported that female caregivers primarily care for children. It
was also reported that many mothers delegate the administration of SMC medicines toolder children, extended family or neighbours, suggesting that community networks play
an important role in supporting primary caregivers with SMC. Phase 2 feasibility andacceptability results were presented at the 2022 annual ASTMH meeting.[84,86,90,91,97]75

•

EffectivenessThe nRCT conducted in phase 1 found that the malaria incidence rate was 3.0 and 38.8
per 100 person-months in the intervention and control groups, respectively. In theintervention areas 90.0 percent of children did not experience any malaria episodes
during the study period, compared to 15 percent in the control area. The incidence rate
ratio was 0.078 (95 percent CI: 0.063–0.096), which corresponds to a protective
effectiveness of 92 percent (95 percent CI: 90.0–94.0) among children in the intervention
area. Results from the phase 1 nRCT have been published in the Malaria Journal[21] andwere presented at the 2022 annual ASTMH meeting.[85]The cRCT in phase 2 was conducted in one district. There are 427 village clusters in this
district, of which 190 were randomised for each SMC intervention arm (SPAQ and DP),leaving 47 as control villages. The study had 80 percent power to detect this difference
using a two-sided test at the five percent significance level. In each selected village, 10households were selected at random from a list of all households in the community. One
eligible child was selected at random from among all eligible children in each selectedhousehold.
Upon enrolment into the study, a questionnaire was administered to caregivers toestablish child- caregiver- and household-level covariates, including sex, age,socioeconomic status, parental education, use of mosquito nets and indoor residual
spraying. Children enrolled in the study were visited monthly by research assistants and
VHTs to ascertain if, since the researchers’ last visit, they had experienced a fever
episode. At enrolment and at each follow-up visit, caretakers were encouraged to taketheir children to the VHTs or nearest health facility whenever the children were sick or
unwell. All the health facilities and VHTs were provided with lists of the children enrolled
in the study for easy identification when they visited. Children who presented with ahistory of fever had an RDT for malaria. If this was positive, they were treated as pernational guidelines or referred to the nearest health facility. Additionally, the research
assistants collected data pertaining to the health of the children, previous clinic visits,
mosquito net usage, any medication taken and if they took the right SMC regimen in theright dose for those in the intervention arm. In addition, research assistants shared
messages designed to ensure adherence to the study protocol and avoid contamination
between study arms.
Data were initially analysed using mixed-effects logistic regression models adjusted forcovariates, with ORs to assess the association between study arm allocations and theprimary outcome of interest (RDT-confirmed malaria cases) at any point during the study
period, converted to a percentage estimate of protective effect. The likelihood ratio test
was used to determine models’ goodness of fit. The protective effect of SMC wasestimated using random-effects Cox proportional hazards regression models to accountfor duration of follow-up, in an intention-to-treat analysis. This analysis was based onrecurrent events, with a new period of follow-up defined after a child has developed aconfirmed case of malaria (under the assumption that the child recovers from malaria on
the date of case confirmation and is subsequently at risk of developing a recurrent case)or when a child is lost to follow-up but subsequently re-joins the study.
Data from 3,749 children (1,698 in the SPAQ arm, 1,667 in the DP arm and 384 in thecontrol arm) were included in the analysis, contributing a total of 554,155 person-days(251,414 in the SPAQ arm, 249,069 in the DP arm and 53,672 in the control arm) to theanalysis. There were 464 events of clinical malaria (76 in the SPAQ arm, 66 in the DP arm
76

and 322 in the control arm). Compared with children in the control arm, those in the
SPAQ arm had a 94 percent lower risk of having an RDT-confirmed malaria episode (HR:0.06; 95 percent CI: 0.04–0.08, p<0.001), while those in the DP arm had a 96 percent
lower risk (HR: 0.04; 95 percent CI: 0.03–0.06, p<0.001). The HR for the protective
effectiveness of SPAQ was non-inferior to that of DP.
The cRCT results suggest that both SPAQ and DP are highly effective in reducing theincidence of clinically significant malaria. Further data cleaning and analyses are ongoing,
including more detailed descriptive analyses across cycles and analyses of secondary
outcomes. Final results may differ from the preliminary data presented here.
• Resistance
The resistance markers surveys that were carried out before and after the phase 1 SMC
round involved analysis of 300 blood samples, taken as dry blood spots, fromsymptomatic children 3–59 months who had a positive malaria test in the two study
districts and the control district. Five mutations of concern associated with SP resistance(PfDHPS437G, 540E and DHFR 51I, 59R 108N) were prevalent, but remained unchanged
between baseline and endline. DHFR 164L and DHPS 581G mutations, which mediatehigh-level SP resistance, were rare at both baseline and endline. Mutations associatedwith AQ resistance (PfCRTand PfMDR1 including copy number) were also rare. The
results, presented at the Conference on Public Health in Africa, which was held in Kigali in
December 2022,[117] indicate that one round of SMC with SPAQ did not appear to selectfor an observable change in resistance markers for SP and AQ. Data analysis of resistancemarkers samples collected before and after SMC delivery in phase 2 is ongoing.
• Chemoprevention efficacy of SPAQ and DP and safety of DP in children under six
monthsAll data were collected in 2022. Data analysis is ongoing.
c) Exploring the use of SMC in South Sudan
Like the implementation studies conducted in Mozambique and Uganda, this study aims totest the feasibility, acceptability and impact of SMC in South Sudan. Because of thecomplexity of conducting research in a region affected by years of conflict, we opted for aless rigorous one-year design in South Sudan, compared with the complex two-year studies in
Mozambique and Uganda. Research was conducted alongside SMC distribution in one countyof Northern Bahr el Ghazal state. Control communities in the county did not receive SMC.
Research activities included two cross-sectional surveys (before and after the SMC round) toestablish confirmed malaria cases in the intervention and control areas; a chemoprevention
efficacy cohort study to determine if SPAQ provides 28 days of protection from infection;baseline and endline resistance markers prevalence surveys; an end-of-round household
survey to determine coverage and quality of SMC implementation; as well as KIIs and FGDs to
assess acceptability. A synopsis of the study design was published on Malaria Consortium’s
website.[118] Oversight was provided by a scientific advisory committee comprising members
from the WHO, the Ministry of Health and implementing partners. All data were collected in
2022. Results will be published in 2023.
d) Rapid assessments
Malaria Consortium plans to conduct rapid assessments of SMC in a series of locations in Eastand southern Africa over the next two years. The rapid assessments are intended to inform
decisions about the potential scale-up of SMC in those locations. In addition, and together
with results from the implementation studies in Mozambique and Uganda, the rapid
assessments will inform a calibrated malaria model that can predict the impact of SMC in77

those geographies, thus eliminating the need to conduct elaborate primary research in each
new location. To develop the model, Malaria Consortium is partnering with Imperial College
London. Study design and planning started in 2022. The first assessments will be carried out
in 2023.
Locations for the rapid assessments will be selected based on seasonality of malariatransmission, malaria incidence among children under five, potential size of the target
population, inclusion of SMC in national malaria plans or strategies, buy-in from the nationalmalaria programme, and operational considerations such as the security situation and thefeasibility of importing SPAQ to those new locations. Likely locations for rapid assessments
include Niassa province in Mozambique — which differs from Nampula in terms of theparasite resistance profile and the intensity of malaria transmission — the Democratic
Republic of the Congo and Malawi.
The mix of research methods used in the rapid assessments will differ between different
locations, for example, depending on what data are already available in a given location. In
principle, each rapid assessment will include intervention and control areas. Eachintervention area will involve distribution of one cycle of SMC using SPAQ to a sample ofchildren under five during the high transmission season. There will be no SMC
implementation in the control area. The specific number of children for the intervention andcontrol areas will be determined for each location using age-specific incidence data. Table 18
shows the mix of research components that may be included in a rapid assessment.
Table 18: Potential rapid assessment study components

Objective
EffectivenessChemoprevention
efficacy

Resistance to SPAQ

MethodOutcomes

Approximate
sample sizecRCT (one cycle) withfollow-up extended to 42
days

Primary outcome:incidence of clinicalmalaria in the target
population

500 children perarm(intervention
and control)

Chemoprevention
efficacy of SPAQ

500 children perarm(intervention
and control)

Parasite resistancemarkers prevalenceand profile

300 RDTpositive
childrenCohort Study with followup extended to 42 days
Cross-sectional descriptive
before and after genetic
resistance markers surveys

Feasibility andacceptability

Feasibility andacceptability
KIIs and process evaluation

2 FGDs, 10 KIIs
and record ofprogramme
adaptations

We expect that each rapid assessment will take about six months and result in a set ofrecommendations regarding the potential scale-up of SMC in the location where theassessment was conducted. Recommendations will be discussed with local stakeholders,
especially the respective national malaria programmes, as well as the global SMC community.
78

7. External relations
Malaria Consortium’s external relations strategy for SMC underlines two core objectives: i) tomaintain Malaria Consortium’s position as a global leader on SMC by contributing to relevant
debates about SMC policy and practice; ii) to contribute to ensuring sustainable financing for SMC
from three core channels: governments, institutional donors and philanthropists.
Over the course of 2022, we produced various communications and publications outputs, including
blogs, news pieces and non-peer-reviewed publications to highlight Malaria Consortium’s work on
SMC and its impact. These outputs are referenced throughout this report and are also available on
Malaria Consortium’s website,[119] including pages specifically about our SMC portfolio.[120] Many ofthese resources were translated into French and Portuguese to increase their reach and impact. Twophotography assignments were also arranged in which a photographer visited our SMC projects in
Karamoja, Uganda, and Nampula, Mozambique. Two special newsletters marking World Malaria Day
and the end-of-year festive period were sent to our SMC newsletter audience of around 1,600
subscribers. We introduced a new format for the newsletters, which are now introduced by different
Malaria Consortium colleagues working on SMC with reflections on their role and their work. Malaria
Consortium’s SMC work was also featured in the organisational impact report,[121] underlining its
contribution to Malaria Consortium’s mission of saving lives and improving health through evidencebased programmes that combat targeted diseases and promote universal health coverage. We also
regularly engage with the effective altruism community, including foundations in Europe, Australia
and the US. For example, the SMC Programme Director presented Malaria Consortium’s SMC
portfolio at an event organised by effective altruism university groups based at the University of
London. SMC was also discussed by Malaria Consortium Technical Director on the 80,000 Hours
podcast as part of a wider conversation on malaria control and elimination.[122] Through these
relationships and networks, we can communicate the impact of SMC to large communities ofindividuals worldwide. They, in turn, continue to advocate for, and invest in, SMC.
Our external relations team amplified SMC research findings, especially the early results thatemerged from our implementation studies in Uganda and Mozambique. To advocate for SMC andinfluence SMC policy and practice, we held meetings with global stakeholders, including the WHO
Global Malaria Programme, the Global Fund and Unitaid, in which those results were presented anddiscussed (Spotlight 10). We supported SMC colleagues who attended the annual ASTMH meeting indesigning posters and preparing presentations. The conference was also an important platform formeetings with representatives from US-based SMC stakeholders such as the Bill & Melinda Gates
Foundation, the US Agency for International Development, PMI and the Centers for Disease Control
and Prevention. A blog post that discusses how we used our presence at ASTMH to advance theconversation on SMC was published on Malaria Consortium’s website.[123]Spotlight 10: Advocating for SMC though our external relations

Our external relations activities for SMC have focused on advancing the conversation on the
future of SMC following the publication of the WHO’s new Guidelines for Malaria. The debate
around SMC — how and where it is deployed, which drugs are used and what its ongoing
scale-up means for drug resistance — is not settled. Malaria Consortium’s role as a leading
implementer of the intervention across seven countries puts us in a unique position to share
our learning and contribute to SMC policy and practice.

79

The ASTMH Annual Meeting 2022 was a key outlet for these activities. We used the meeting
to advance the conversation with the wider SMC and tropical medicine community. Here aresome of the highlights from the meeting:
•

•

•

•

Through the SMC Alliance, we co-chaired a symposium on Implementing SMC in New
Geographies’ including the presentation of findings from implementation studies in
Mozambique and Uganda from representatives of the national malaria programmes
from both countries.
The new WHO Guidelines for Malaria no longer specify strict criteria on seasonality,
number and timing of cycles, age range or drug choice. The SMC symposium was aforum for discussion on these issues and underlined the importance of collaboration
between health authorities, SMC implementers and researchers as the pathway for
future implementation is agreed.
Malaria Consortium’s Senior Country Technical Coordinator in Nigeria presented
observations from Nigeria where we have worked with partners to expand the reachof SMC from the Sahelian states in the north of the country to states further south,
which also experience a rainy season. This work contrasts with the studies in
Mozambique, South Sudan and Uganda, as it expands on how new geographies within
Nigeria can benefit from SMC.
The Annual Meeting’s scientific programme also reflected other exciting malaria
innovations on the horizon, including malaria vaccines, post-discharge malaria
chemoprevention and next-generation monoclonal antibody treatments. Malaria
Consortium will look to contribute its learning on SMC to upcoming policy andpractice debates around these novel interventions, including how they may be
implemented alongside SMC.

Our SMC research was also an important part of Malaria Consortium’s wider external relations
activities around the ASTMH conference, which focused on three core themes: innovation,
equity and partnerships. Through the insights from our SMC implementation and researchpresented during the Annual Meeting, we showcased our experience across these themes, forexample, in our studies assessing the feasibility of SMC in new geographies, research tointegrate gender into evaluation processes and underlining the role of lead mothers in SMC
implementation. At the meeting, Malaria Consortium also engaged in a workshop to define an
advocacy agenda for the Global Gender and Malaria Community of Practice.
The malaria community also came together in 2022 at the Kigali Summit on Malaria andNeglected Tropical Diseases, held on the side of the Commonwealth Heads of Government
Meeting (CHOGM). Malaria Consortium was represented at the meeting by the Regional
Director for East and Southern Africa and the SMC External Relations Manager. The summit
ended with new spending commitments worth USD 4 billion and served as a valuable platform
for conversations with other malaria stakeholders.
Through these activities, we have looked to share our experiences as a leading SMC
implementing organisation to inform SMC policy and practice worldwide, and ultimately help
to improve the intervention for the benefit of the children who receive it. Malaria Consortium
will continue to use our external relations to make a positive contribution to the global SMC
community.

Malaria Consortium is an active member of the SMC Alliance, which holds monthly calls to discuss
80emerging issues. In 2022, this has included discussions about harmonising the labelling and brandingof SPAQ from different manufacturers, as well as preparations for the Global Fund replenishment
conference. The annual meeting of the SMC Alliance was held as a virtual event and included
presentations from the national malaria programmes of all SMC-implementing countries on theirachievements in 2021 and plans for 2023. Malaria Consortium hosted a session on Taking SMC to
New Geographies, where the directors of the malaria programmes in Mozambique and Ugandapresented results from the SMC implementation studies in those countries. Other topics discussed
included strategies to monitor parasite resistance and ensuring sustainable financing for SMC.
Within the SMC Alliance, we initiated the formation of a subgroup focusing on communications andadvocacy. The subgroup currently has about 15 members representing nine organisations. Malaria
Consortium serves as the subgroup’s secretariat. The subgroup supported several outputs in 2022,
including infographics and social media content and a placement of an article in Health Policy Watch
to mark the Day of the African Child.[124] To mark the tenth anniversary of the rollout of SMC
following the WHO’s initial policy recommendation in 2012, the subgroup compiled a report thatrecounts how SMC progressed from concept to scale, and recognises the contributions from nationalmalaria programmes, bilateral agencies, donors, implementing partners and researchers.[125]In 2023, we will continue to engage with global SMC stakeholders and proactively support the SMC
Alliance and its subgroups. We will also prioritise the dissemination of results from theimplementation studies in Mozambique and Uganda, along with a learning output charting the storyof the expansion of SMC in Mozambique.

818. Philanthropic SMC expenditure 2022
The total expenditure of philanthropic funding used for SMC in 2022 was approximately 62.26
million USD, around 17 percent less than the forecast submitted to GiveWell in June 2022 (Table 19).
Table 19: Philanthropic expenditure for SMC, 2022

Budget line

Forecast(USD)

Expenditure(USD)

Variance(USD)

Variance(percent)

Burkina Faso

8,795,149

7,655,837-1,139,312

-13

Chad

5,331,304

4,660,553-670,751-13

Mozambique

6,807,913

4,374,633-2,433,280-36

Nigeria

46,040,079

39,181,345-6,858,734-15South Sudan

1,153,479

847,919-305,560

-26

Togo

1,407,601

1,248,922-158,679-11

Uganda1,583,832

1,682,710

98,878

6

New country

100,000

0-100,000

-100

Rapid
assessmentsa

051,13951,139n/aAbove-country

886,791

839,929-46,862-5

Research

2,448,640

1,560,037-888,603-36

External relations

243,329

157,341-85,988

-35

TOTAL

74,798,117

62,260,365-12,537,752-17

aOperational costs associated with the rapid assessments had been included in the research forecast. Those costs areshown on a separate budget line in the actual expenditure. Only the costs of rapid assessment research activities areincluded on the research line.

Compared with the forecast, substantial cost savings were made in several countries. For example,
in Nigeria, training materials produced in previous years were reused, and specifications forprintouts were adapted to reduce costs. Further savings were made by combining procurement forareas where Malaria Consortium uses philanthropic funding and those where Global Fund funding isused, resulting in lower unit costs overall. In addition, some of the budgeted stock management andcommunity engagement costs were covered by state governments. In Chad, South Sudan and Togo,
adaptations made over the course of the SMC round resulted in lower costs compared with theforecast, for example by reducing the number of SMC implementers, training events, vehicle hireand quantity of SMC commodities. We also spent less than budgeted on international freight for
SMC medicines by largely avoiding air freight. Another reason for the underspend compared withthe forecast was that some costs that had been included in the forecast have shifted to 2023,
especially in Mozambique, where the start of the 2022/23 round had to be postponed to January2023, and in Burkina Faso, where many payments for 2022 SMC delivery were only made in January2023 because of the delayed submission of supporting documents. The forecast also included costsof potentially expanding Malaria Consortium’s support on SMC to a new country, which did not
happen in 2022. Research costs were overestimated primarily because payments for the analysis of82

chemoprevention efficacy samples had been forecast for 2022. However, as sample analysis isongoing, those costs will now only be incurred in 2023. Research costs were also lower thanbudgeted because a study exploring access to SMC among nomadic populations in Chad had to becancelled due to security concerns. Finally, there is an underspend on the external relations budget
line because the forecast included the cost of an SMC policy project; this was discussed at the timewith other global SMC stakeholders but, in the end, did not materialise. The only country wherecosts were underestimated in the forecast was Uganda. At the request of the local healthauthorities, SMC was extended to all children in the district where the chemoprevention efficacy
study was conducted, rather than only delivering SMC to children enrolled in the study as originallyplanned.
In addition to philanthropic funding for SMC, Malaria Consortium received co-funding for SMC fromthe Bill & Melinda Gates Foundation, the Global Fund, KOICA and the Task Force for Global Health to
implement the activities described in this report (Table 20). Co-funding provided by the Global Fundor UNICEF in Burkina Faso and Togo is not reported here, as those contributions are provided
directly to the respective national malaria programmes.

83

Table 20: Malaria Consortium’s SMC expenditure using third-party co-funding, 2022

Funding source

Expenditure (USD)

Notes

Bill & Melinda Gates
Foundation

771,627

Grant for an end-of-round household
survey, chemoprevention efficacy cohort
study and resistance markers study as partof phase 2 of the SMC implementation
study in Mozambique (INV-033337).
This grant ends in 2023.

Bill & Melinda Gates
Foundation

496,009

Grant for an end-of-round household
survey, chemoprevention efficacy cohort
study, resistance markers study andqualitative research as part of phase 2 of
the SMC implementation study in Uganda(INV- 039889).
This grant ends in 2023.

Global Fund

547,434

Funding received from Global Fund to
implement SMC in three districts of
Karamoja subregion. This does not include
the cost of SPAQ, which was procured
directly by the Global Fund.

KOICA

618,256

SMC IMPACT project.
This funding covered SPAQ for four out offive cycles implemented in two LGAs in
Bauchi, targeting 280,000 children, as well
the majority of SMC implementation costsin those LGAs. The SMC IMPACT project willend in 2024.

Task Force for Global Health

44,653Grant for implementation of an operational
research study exploring the coimplementation of SMC and VAS in Nigeria.
This grant ended in 2022. Somephilanthropic funding was used to support
the publication of results in a peerreviewed journal and at academic
conferences.

Malaria Consortium also received funding from the Global Fund to implement SMC in four states in
Nigeria in 2022 and from UNICEF to coordinate malnutrition screening during SMC delivery in all 70
health districts of Burkina Faso. As no philanthropic funding was used to co-finance those activities,
the costs are not included in this report.

84

9. Concluding remarks
2022 was a record year for SMC at Malaria Consortium. In total, 24 million children have beenreached across seven countries with Malaria Consortium support, representing around half of allchildren reached with the intervention globally. Around 16 million of this total were reached thanks
to philanthropic support. Implementing SMC differs from country to country, but thanks to theleadership of national malaria control programmes and strong collaboration with other national,
regional and local partners, Malaria Consortium continues to successfully support SMC deployment
in a range of geographies and against the backdrop of various operational challenges.
Malaria Consortium has also used this extensive reach to continue research activities designed to
improve the quality of SMC delivery, assess its impact on malaria cases and produce evidence thatwill shape the future of SMC, including its potential use in new geographies. Malaria Consortium’s
position as a large-scale implementer and research organisation has underlined its unique position
to contribute to global debates on SMC policy and practice and advocacy efforts to ensure theintervention’s sustainability.
As we move through 2023, Malaria Consortium aims to maintain the scale of its SMC activities
despite challenging economic circumstances and a difficult security landscape. Ten years on from theWHO’s initial recommendation to scale up SMC in the Sahel, the intervention continues to prove
itself to be an important part of the malaria prevention toolkit. Thanks to philanthropic support,
Malaria Consortium can continue its efforts to reach as many eligible children as possible with lifesaving SMC medicines.

85References
1. GiveWell. Our top charities; last updated: 2022 Dec [cited 2023 Feb 17]. Available from:https://www.givewell.org/charities/top-charities.
2. Kaplan, Miranda. Our recommendations for giving in 2022; 2022 Nov 23 [cited 2023 Feb 17].
Available from: https://blog.givewell.org/2022/11/23/giving-recommendations-2022.
3. World Health Organization. WHO policy recommendation: Seasonal malaria chemoprevention(SMC) for Plasmodium falciparum malaria control in highly seasonal transmission areas of the
Sahel sub-region in Africa. Geneva: WHO; 2012.
4. Meremikwu MM, Donegan S, Sinclair D, Esu E, Oringanje C. Intermittent preventive treatment formalaria in children living in areas with seasonal transmission. Cochrane Database of Systematic
Reviews, 2012; (2): CD003756.
5. Cairns M, Carneiro I, Milligan P, Owusu-Agyei S, Awine T, Gosling R, et al. Duration of protection
against malaria and anaemia provided by intermittent preventive treatment in infants inNavrongo, Ghana. PLoS One, 2008; 3(5): e2227.
6. Amimo F, Lambert B, Magit A, Sacarlal J, Hashizume M, Shibuya K. Plasmodium falciparum
resistance to sulfadoxine-pyrimethamine in Africa: A systematic analysis of national trends. BMJ
Global Health, 2020; 5(11): e003217.
7. World Health Organization. Seasonal malaria chemoprevention with sulfadoxine-pyrimethamine
plus amodiaquine in children: A field guide. Geneva: WHO; 2013.
8. World Health Organization. Global technical strategy for malaria 2016–2030: 2021 update.
Geneva: WHO; 2021.
9. ACCESS-SMC Partnership. Effectiveness of seasonal malaria chemoprevention at scale in west andcentral Africa: An observational study. The Lancet, 2020; 396(10265): 1829–40.
10. Cairns M, Ceesay SJ, Sagara I, Zongo I, Kessely H, Gamougam K, et al. Effectiveness of seasonalmalaria chemoprevention (SMC) treatments when SMC is implemented at scale: Case-control
studies in 5 countries. PLoS Medicine, 2021; 18(9): e1003727.
11. Issiaka D, Barry A, Traore T, Diarra B, Cook D, Keita M, et al. Impact of seasonal malaria
chemoprevention on hospital admissions and mortality in children under 5 years of age in
Ouelessebougou, Mali. Malaria Journal, 2020; 19(1): 103.
12. Gilmartin C, Nonvignon J, Cairns M, Milligan P, Bocoum F, Winskill P, et al. Seasonal malaria
chemoprevention in the Sahel subregion of Africa: A cost-effectiveness and cost-savings analysis.
Lancet Global Health, 2021; 9(2): e199-e208.
13. World Health Organization. World malaria report 2022. Geneva: WHO; 2022.
14. World Health Organization. World malaria report 2021. Geneva: WHO; 2021.
15. World Health Organization. WHO guidelines for malaria. Geneva: WHO; 2022.
16. World Health Organization. Updated WHO recommendations for malaria chemoprevention
among children and pregnant women. 2022 Jun 03 [cited 2023 Feb 17]. Available from:https://www.who.int/news/item/03-06-2022-Updated-WHO-recommendations-for-malariachemoprevention-among-children-and-pregnant-women.
17. Malaria Consortium. WHO issue new guidelines on seasonal malaria chemoprevention
implementation — our response. 2022 June 08 [cited 2023 Feb 17]. Available from:https://www.malariaconsortium.org/news-centre/who-issue-new-guidelines-on-seasonalmalaria-chemoprevention-implementation-andndash-our-response.htm.
18. Traore A, Donovan L, Sawadogo B, Ward C, Smith H, Rassi C, et al. Extending seasonal malaria
chemoprevention to five cycles: A pilot study of feasibility and acceptability in Mangodara
district, Burkina Faso. BMC Public Health, 2022; 22(1): 442.
8619. Cissé B, Ba EH, Sokhna C, NDiaye JL, Gomis JF, Dial Y, et al. Effectiveness of seasonal malaria
chemoprevention in children under ten years of age in Senegal: A stepped-wedge clusterrandomised trial. PLoS Medicie. 2016; 13(11): e1002175.
20. Moukénet A, Donovan L, Honoré B, Baker K, Smith H, Richardson S, et al. Extending delivery ofseasonal malaria chemoprevention to children aged 5–10 years in Chad: A mixed-methods study.
Global Health: Science and Practice, 2022; 10(1): e2100161.
21. Nuwa A, Baker K, Bonnington C, Odongo M, Kyagulanyi T, Bwanika JB, et al. A non-randomized
controlled trial to assess the protective effect of SMC in the context of high parasite resistance in
Uganda. Malaria Journal; 2023: 63.
22. Malaria Consortium. The future of SMC: Taking seasonal malaria chemoprevention to newgeographies [video]; 2021 Dec 6 [cited 2023 Mar 05]. Available from:https://www.youtube.com/watch?v=44M4uJhwxuM&t=14s.
23. Malaria Consortium. Webinar: Taking seasonal malaria chemoprevention to new geographies.
Infographic. London: Malaria Consortium; 2021. Available from:https://www.malariaconsortium.org/resources/publications/1521/webinar-taking-seasonalmalaria-chemoprevention-to-new-geographies.
24. World Health Organization. Malaria chemoprevention efficacy study protocol. Geneva: WHO;2022.
25. Oresanya O, Phillips A, Okereke E, Ahmadu A, Ibinaiye T, Marasciulo M, et al. Co-implementing
vitamin A supplementation with seasonal malaria chemoprevention in Sokoto State, Nigeria: A
feasibility and acceptability study. BMC Health Services Research, 2022; 22(1): 871.
26. World Health Organization. WHO recommends groundbreaking malaria vaccine for children at
risk; 2021 Oct 06 [cited 2023 Mar 04]. Available from: https://www.who.int/news/item/06-102021-who-recommends-groundbreaking-malaria-vaccine-for-children-at-risk.
27. World Health Organization. Malaria vaccine: WHO position paper – March 2022. Weekly
Epidemiological Record, 2022; 97(09): 60–78.
28. Malaria Consortium. Vaccines: The cornerstone of disease burden reduction. Position statement.
London: Malaria Consortium; 2022. Available from:https://www.malariaconsortium.org/resources/publications/1333/vaccines-the-cornerstone-ofdisease-burden-reduction.
29. Chandramohan D, Zongo I, Sagara I, Cairns M, Yerbanga RS, Diarra M, et al. Seasonal malaria
vaccination with or without seasonal malaria chemoprevention. New England Journal of
Medicine, 2021; 385(11): 1005–1017.
30. Malaria Consortium. Monitoring and evaluating seasonal malaria chemoprevention using a
logical framework approach. Technical brief. London: Malaria Consortium; 2022. Available from:https://www.malariaconsortium.org/resources/publications/1538/monitoring-and-evaluatingseasonal-malaria-chemoprevention-using-a-logical-framework-approach.
31. Malaria Consortium. Coverage and quality of seasonal malaria chemoprevention supported by
Malaria Consortium in 2022: Results from Burkina Faso, Chad, Mozambique, Nigeria, South
Sudan, Togo and Uganda. London: Malaria Consortium; 2023. Available from:https://www.malariaconsortium.org/resources/publications/1679/Coverage-and-quality-ofseasonal-malaria-chemoprevention-supported-by-Malaria-Consortium-in-2022.
32. SMC Alliance. Seasonal malaria chemoprevention monitoring & evaluation toolkit; 2021 Nov 09[cited 2023 Mar 05]. Available from: https://www.smc-alliance.org/resources/seasonal-malariachemoprevention-monitoring-evaluation-toolkit.
33. World Health Organization. Quality of care; no date [cited 2023 Mar 04]. Available from:https://www.who.int/health-topics/quality-of-care#tab=tab_1.
8734. Richardson S, Ibinaiye T, Nikau J, Oresanya O, Marasciulo M, Roca-Feltrer A, et al. COVID-19
knowledge, beliefs, prevention behaviours and misinformation in the context of an adapted
seasonal malaria chemoprevention campaign in six northern Nigerian states. Tropical Medicine
and Health, 2020; 48(1): 101.
35. Malaria Consortium. Implementing mass campaigns during a pandemic: What we learnt fromsupporting seasonal malaria chemoprevention during COVID-19. Learning paper. London: Malaria
Consortium; 2021. Available from:https://www.malariaconsortium.org/resources/publications/1432/implementing-masscampaigns-during-a-pandemic-what-we-learnt-from-supporting-seasonal-malariachemoprevention-during-covid-19.
36. Ward C, Phillips A, Oresanya O, Olisenekwu G, Arogunade E, Moukénet A, et al. Delivery ofseasonal malaria chemoprevention with enhanced infection prevention and control measuresduring the COVID-19 pandemic in Nigeria, Burkina Faso and Chad: A cross-sectional study.
Malaria Journal, 2022; 21(1): 103.
37. Malaria Consortium. Malaria Consortium’s seasonal malaria chemoprevention program:Philanthropy report 2021. London: Malaria Consortium; 2022.
38. Malaria Consortium. Malaria Consortium’s seasonal malaria chemoprevention program:Philanthropy report 2020. London: Malaria Consortium; 2021.
39. World Bank. World Bank open data: Population, total — Burkina Faso; no date [cited 2023 Mar
04]. Available from: https://data.worldbank.org/indicator/SP.POP.TOTL?locations=BF.
40. Severe Malaria Observatory. Burkina Faso: Malaria facts; no date [cited 2023 Mar 05]. Available
from: https://www.severemalaria.org/countries/burkina-faso.
41. Human Rights Watch. World report 2023: Events of 2022. New York: Human Rights Watch; 2023.
42. World Bank. World Bank open data: Population, total — Chad; no date [cited 2023 Mar 04].
Available from: https://data.worldbank.org/indicator/SP.POP.TOTL?locations=TD.
43. Malaria Consortium. Where we work: Chad; no date [cited 2023 Mar 05]. Available from:https://www.malariaconsortium.org/where-we-work/chad.htm.
44. GiveWell. An update on GiveWell’s funding projections; 2022 Jul 05 [cited 2023 mar 05].
Available from: https://blog.givewell.org/2022/07/05/update-on-givewells-funding-projections/.
45. GiveWell. Malaria Consortium — SMC Renewal in Nigeria, Burkina Faso, Chad, and Togo (January2023); 2023 Apr [cited 2023 Apr 04]. Available from:https://www.givewell.org/research/grants/Malaria-Consortium-SMC-renewal-Nigeria-BurkinaChad-Togo-January-2023.
46. World Bank. World Bank open data: Population, total — Mozambique; no date [cited 2023 Mar
04]. Available from: https://data.worldbank.org/indicator/SP.POP.TOTL?locations=MZ.
47. Malaria Consortium. Where we work: Mozambique; no date [cited 2023 Mar 05]. Available from:https://www.malariaconsortium.org/where-we-work/mozambique.htm.
48. Programa Nacional de Controlo da Malária [Republic of Mozambique]. Plano estratégico damalária 2017–2022. Maputo: PNCM; 2017.
49. Gupta H, Macete E, Bulo H, Salvador C, Warsame M, Carvalho E, et al. Drug-resistantpolymorphisms and copy numbers in Plasmodium falciparum, Mozambique, 2015. Emerging
Infectious Diseases, 2018; 24(1): 40–48.
50. Malaria Consortium. Insights from implementing the first seasonal malaria chemoprevention
campaign in Mozambique. Insight brief. London: Malaria Consortium; 2022. Available from:https://www.malariaconsortium.org/resources/publications/1565/insights-from-implementingthe-first-seasonal-malaria-chemoprevention-campaign-in-mozambique.

8851. GiveWell. Malaria Consortium — Seasonal Malaria Chemoprevention, Nampula, Mozambique.
2022 February [cited 2023 March 02]. Available from:https://www.givewell.org/research/grants/Malaria-Consortium-SMC-Mozambique-February2022.
52. ReliefWeb. Tropical Cyclone Gombe — Mar 2022; no date [cited 2023 Mar 05]. Available from:https://reliefweb.int/disaster/tc-2022-000184-moz.
53. World Bank. World Bank open data: Population, total — Nigeria; no date [cited 2023 Mar 04].
Available from: https://data.worldbank.org/indicator/SP.POP.TOTL?locations=NG.
54. Severe Malaria Observatory. Nigeria: Malaria facts; no date [cited 2023 mar 05]. Available from:https://www.severemalaria.org/countries/nigeria.
55. United Nations High Commissioner for Refugees, Nigeria. Internally displaced people; no date[cited 2023 March 05]. Available from: https://www.unhcr.org/ng/idps.
56. GiveWell. Malaria Consortium — Support for SMC in FCT and Oyo States, Nigeria (Oct 2021);
2021 Dec [cited 2023 Mar 05]. Available from: https://www.givewell.org/research/incubationgrants/Malaria-Consortium-SMC-FCT-Oyo-states-October-2021.
57. Malaria Consortium. Malaria Consortium responds to urgent call to deliver SMC to two million
children in Borno state; 2021 July 30 [cited 2023 Mar 05]. Available from:https://www.malariaconsortium.org/news-centre/malaria-consortium-responds-to-urgent-callto-deliver-smc-to-two-million-children-in-borno-state.htm.
58. Malaria Consortium. SMC extended to more countries thanks to SMC-IMPACT project; 2021 Feb
19 [cited 2023 Mar 05]. Available from: https://www.malariaconsortium.org/news-centre/smcextended-to-more-countries-thanks-to-smc-impact-project.htm.
59. Malaria Consortium. Implementing seasonal malaria chemoprevention in conflict-affected areasin Borno state. Learning brief. London: Malaria Consortium; 2023. Available from:https://www.malariaconsortium.org/resources/publications/1677/implementing-seasonalmalaria-chemoprevention-in-conflict-affected-areas-in-borno-state.
60. ReliefWeb. Nigeria: Floods — Jun 2022; no date [cited 2023 Mar 05]. Available from:https://reliefweb.int/disaster/fl-2022-000271-nga.
61. Malaria Consortium. Implementing seasonal malaria chemoprevention in conflict-affected areasin Borno state: Lessons learnt from Nigeria. London: Malaria Consortium; 2022. Available from:https://www.malariaconsortium.org/resources/publications/1677/implementing-seasonalmalaria-chemoprevention-in-conflict-affected-areas-in-borno-state.
62. World Bank. World Bank open data: Population, total — South Sudan; no date [cited 2023 Mar
04]. Available from: https://data.worldbank.org/indicator/SP.POP.TOTL?locations=SS.
63. Severe Malaria Observatory. South Sudan: Malaria facts; no date [cited 2023 mar 05]. Available
from: https://www.severemalaria.org/countries/south-sudan-0.
64. Pasquale HA. Malaria prevention strategies in South Sudan. South Sudan Medical Journal, 2020;13(5): 187– 90.
65. United Nations Office for the Coordination of Humanitarian Affairs. 2022 humanitarian response
in review: South Sudan. New York: OCHA; 2023.
66. ReliefWeb. South Sudan: Overview of the IDPs population per county (April 2022); 2022 May 13[cited 2023 Mar 05]. Available from: https://reliefweb.int/report/south-sudan/south-sudanoverview-idps-population-county-april2022#:~:text=The%20conflict%20and%20violence%20which,people%20as%20of%20March%2020
22.
67. National Malaria Control Programme [Republic of South Sudan]. Malaria Strategic Plan 2021–
2025. Juba: Ministry of Health; 2020.
89

68. Malaria Consortium. Malaria Consortium announces expansion of seasonal malaria
chemoprevention to South Sudan; 2022 Apr 25 [cited 2023 Mar 05]. Available from:https://www.malariaconsortium.org/news-centre/malaria-consortium-announces-expansion-ofseasonal-malaria-chemoprevention-to-south-sudan.htm.
69. World Bank. World Bank open data: Population, total — Togo; no date [cited 2023 Mar 04].
Available from: https://data.worldbank.org/indicator/SP.POP.TOTL?locations=TG.
70. Malaria Consortium. Where we work: Togo; no date [cited 2023 Mar 05]. Available from:https://www.malariaconsortium.org/pages/togo.htm.
71. ReliefWeb. Togo — State of emergency (DG ECHO, Government, Le Monde, The Guardian)(ECHO Daily Flash of 15 June 2022); 2022 Jun 15 [cited 2023 Mar 05]. Available from:https://reliefweb.int/report/togo/togo-state-emergency-dg-echo-government-le-mondeguardian-echo-daily-flash-15-june-2022.
72. World Bank. World Bank open data: Population, total — Uganda; no date [cited 2023 Mar 04].
Available from: https://data.worldbank.org/indicator/SP.POP.TOTL?locations=UG.
73. Severe Malaria Observatory. Uganda: Malaria facts; no date [cited 2023 mar 05]. Available from:https://www.severemalaria.org/countries/uganda.
74. UK Government. Foreign travel advice Uganda: Safety and security; no date [cited 2023 Mar 05].
Available from: https://www.gov.uk/foreign-travel-advice/uganda/safety-and-security.
75. Ministry of Health [Republic of Uganda]. The Uganda malaria reduction and elimination strategicplan 2021–2025. Kampala: Ministry of Health; 2020.
76. Owen BN, Winkel M, Bonnington C, Nuwa A, Achan J, Opigo J, et al. Dynamical malaria modelingas a tool for bold policy-making. Nature Medicine, 2022.
77. Mbonye AK, Birungi J, Yanow SK, Shokoples S, Malamba S, Alifrangis M, et al. Prevalence ofPlasmodium falciparum resistance markers to sulfadoxine-pyrimethamine among pregnant
women receiving intermittent preventive treatment for Malaria in Uganda. Antimicrobial Agentsand Chemotherapy, 2015; 59(9): 5475–82.
78. Malaria Consortium. Scientific modelling for malaria policymaking; 2022 Apr 20 [cited 2023 Mar
05]. Available from: https://www.malariaconsortium.org/news-centre/scientific-modelling-formalaria-policymaking.htm.
79. World Health Organization. Ebola outbreak 2022 — Uganda: Overview; no date [cited 2023 Mar
05]. Available from: https://www.who.int/emergencies/situations/ebola-uganda-2022.
80. Malaria Consortium. Uganda celebrates launch of SMC as part of roadmap to achieve zeromalaria status by 2030; 2022 Oct 26 {cited 2023 Mar 05]. Available from:https://www.malariaconsortium.org/news-centre/uganda-celebrates-launch-of-smc-as-part-ofroadmap-to-achieve-zero-malaria-status-by-2030.htm.
81. Malaria Consortium. Malaria Consortium awarded prestigious independent researchorganisation status; 2021 Feb 12 [cited 2023 Mar 05]. Available from:https://www.malariaconsortium.org/news-centre/malaria-consortium-awarded-prestigiousindependent-research-organisation-status.htm.
82. Baker K, Aide P, Bonnington CA, Rassi C, Richardson S, Roca-Feltrer A at al. Feasibility,
acceptability, and protective efficacy of seasonal malaria chemoprevention implementation in
Nampula province, Mozambique: Protocol for a hybrid effectiveness-implementation study. JMIR
Research Protocols, 2022; 11(9): e36403.
83. de Cola MA, Sawadogo B, Richardson S, Ibinaiye T, Traoré A, Compaoré CS et al. Impact of
seasonal malaria chemoprevention on prevalence of malaria infection in malaria indicatorsurveys in Burkina Faso and Nigeria. BMJ Global Health, 2022; 7(5): e008021.

90

84. Nuwa A. A cross-sectional survey to assess the feasibility and acceptability of seasonal malaria
chemoprevention among nomadic pastoralist population: The case of Karamoja, region in Uganda[presentation]. 71st American Society of Tropical Medicine and Hygiene Annual Meeting. 30
October – 03 Nov 2022. Available from:https://www.malariaconsortium.org/resources/publications/1628/a-cross-sectional-survey-toassess-the-feasibility-and-acceptability-of-seasonal-malaria-chemoprevention-among-nomadicpastoralist-population-the-case-of-karamoja-region-in-uganda.
85. Nuwa A. A non-randomised controlled trial to assess the protective effect of seasonal malaria
chemoprevention in the context of high parasite resistance in Uganda [presentation]. 71st
American Society of Tropical Medicine and Hygiene Annual Meeting. 30 October – 03 Nov 2022.
Available from: https://www.malariaconsortium.org/resources/publications/1627/a-nonrandomised-controlled-trial-to-assess-the-protective-effect-of-seasonal-malariachemoprevention-in-the-context-of-high-parasite-resistance-in-uganda.
86. Nabakooza J. Results from an implementation study to assess the impact, feasibility andacceptability of implementing seasonal malaria chemoprevention in Karamoja region[presentation]. 71st American Society of Tropical Medicine and Hygiene Annual Meeting. 30
October – 03 Nov 2022. Available from: https://www.malariaconsortium.org/galleryfile/12010535-21/drjanenabakoozasmcalliancesymposiumastmh2022slides.pdf.
87. Candrinho B. Seasonal malaria chemoprevention: Mozambique implementation study 2020-22[presentation]. 71st American Society of Tropical Medicine and Hygiene Annual Meeting. 30
October – 03 Nov 2022. Available from: https://www.malariaconsortium.org/galleryfile/12010557-90/astmh2022drbcandrinho2.pdf.
88. Oresanya O, Aidenagbon A. Seasonal malaria chemoprevention (SMC): New geographies in
Nigeria and quality of SMC delivery [presentation]. 71st American Society of Tropical Medicine
and Hygiene Annual Meeting. 30 October – 03 Nov 2022. Available from:https://www.malariaconsortium.org/resources/publications/1649/seasonal-malariachemoprevention-smc--new-geographies-in-nigeria-and-quality-of-smc-delivery.
89. Sitoe M, Zunza A, Tarquino I, Rodrigues M, Enosse S, Richardson S, et al. Acceptability of seasonalmalaria chemoprevention among children under five in Mozambique: A qualitative study[poster]. 71st American Society of Tropical Medicine and Hygiene Annual Meeting. 30 October –03 Nov 2022. Available from:https://www.malariaconsortium.org/resources/publications/1632/acceptability-of-seasonalmalaria-chemoprevention-among-children-under-five-in-mozambique-a-qualitative-study.
90. Odongo M, Nuwa A, Marasciulo M, Salandini Odong D, Achuma T, Dilla A. Assessing the qualityof SMC delivery by village health teams in Uganda [poster]. 71st American Society of Tropical
Medicine and Hygiene Annual Meeting. 30 October – 03 Nov 2022. Available from:https://www.malariaconsortium.org/resources/publications/1617/assessing-the-quality-of-smcdelivery-by-village-health-teams-in-uganda.
91. Salandini Odong D, Nuwa A, Odongo M, Tibenderana J, Baker K, Rassi C, et al. Evaluating theadaptation of seasonal malaria chemoprevention implementation during COVID-19 in Karamoja,
Uganda [poster]. 71st American Society of Tropical Medicine and Hygiene Annual Meeting. 30
October – 03 Nov 2022. Available from:https://www.malariaconsortium.org/resources/publications/1623/evaluating-the-adaptation-ofseasonal-malaria-chemoprevention-implementation-during-covid-19-in-karamoja-uganda.
92. Tounaikok N, Donovan L, Diar MSI, Baker K, Viganò E, Honore B, et al. Exploring the role model
approach to strengthen the administration of SMC medicines in Chad [poster]. 71st American
Society of Tropical Medicine and Hygiene Annual Meeting. 30 October – 03 Nov 2022. Available
91

from: https://www.malariaconsortium.org/resources/publications/1631/exploring-the-rolemodel-approach-to-strengthen-the-administration-of-smc-medicines-in-chad.
93. Fadipe JJ, Olusola O, Okechukwu E, Ibinaiye T, Ogunmola O, Achan J, et al. Facilitators of, andbarriers to, fully integrating seasonal malaria chemoprevention with vitamin A supplementation:
A qualitative enquiry [poster]. 71st American Society of Tropical Medicine and Hygiene Annual
Meeting. 30 October – 03 Nov 2022. Available from:https://www.malariaconsortium.org/resources/publications/1629/facilitators-of-and-barriers-tofully-integrating-seasonal-malaria-chemoprevention-with-vitamin-a-supplementation-aqualitative-enquiry.
94. Tounaikok N, Moukénet A, Diar MSI, Donovan L, Awah D, Dingamtel N, et al. Feasibility andacceptability of extending delivery of seasonal malaria chemoprevention to children aged 5–10
years in Chad [poster]. 71st American Society of Tropical Medicine and Hygiene Annual Meeting.
30 October – 03 Nov 2022. Available from:https://www.malariaconsortium.org/resources/publications/1636/feasibility-and-acceptabilityof-extending-delivery-of-smc-to-children-aged-5--10-years-in-chad.
95. Oresanya O, Phillips A, Ihechukwu E, Ogunmola O, Ibinaiye T, Muhammad K, et al. Harnessing theseasonal malaria chemoprevention campaign in Nigeria: Safety, equity and cost of fully
integrating vitamin A supplementation [poster]. 71st American Society of Tropical Medicine andHygiene Annual Meeting. 30 October – 03 Nov 2022. Available from:https://www.malariaconsortium.org/resources/publications/1621/harnessing-the-seasonalmalaria-chemoprevention-campaign-in-nigeria-safety-equity-and-cost-of-fully-integratingvitamin-a-supplementation.
96. Ibinaiye T, Ogunmola O, Salifu E, Okwulu A, Maduka K, Oguoma C. Impact assessment of
seasonal malaria chemoprevention using routine health surveillance data in Kogi state, Nigeria[poster]. 71st American Society of Tropical Medicine and Hygiene Annual Meeting. 30 October –03 Nov 2022. Available from:https://www.malariaconsortium.org/resources/publications/1637/impact-assessment-ofseasonal-malaria-chemoprevention-using-routine-health-surveillance-data-in-kogi-state-nigeria.
97. Viganò E, Nakirunda M, Richardson S, Nuwa A, Bonnington C, Baker K. Integrating gender into
the process evaluation of seasonal malaria chemoprevention in Karamoja, Uganda: Results andfuture directions [poster]. 71st American Society of Tropical Medicine and Hygiene Annual
Meeting. 30 October – 03 Nov 2022. Available from:https://www.malariaconsortium.org/resources/publications/1638/integrating-gender-into-theprocess-evaluation-of-seasonal-malaria-chemoprevention-in-karamoja-uganda-results-andfuture-directions.
98. de Cola MA, Sawadogo B, Compaore C, Tougri G, Richardson S, Roca-Feltrer A, et al. Measuring
the impact of SMC on malaria prevalence and case distribution compared to predicted estimatesfrom a transmission model in Burkina Faso [poster]. 71st American Society of Tropical Medicine
and Hygiene Annual Meeting. 30 October – 03 Nov 2022. Available from:https://www.malariaconsortium.org/resources/publications/1635/measuring-the-impact-of-smcon-malaria-prevalence-and-case-distribution-compared-to-predicted-estimates-from-atransmission-model-in-burkina-faso.
99. Okereke E, Smith H, Oguoma C, Oresanya O, Kolawole M, Rajab A, et al. Optimising the role oflead mothers in seasonal malaria chemoprevention campaigns: Insights from formative researchin Kano state, northern Nigeria [poster]. 71st American Society of Tropical Medicine and Hygiene
Annual Meeting. 30 October – 03 Nov 2022. Available from:https://www.malariaconsortium.org/resources/publications/1633/optimising-the-role-of-lead92

mothers-in-seasonal-malaria-chemoprevention-campaigns-insights-from-formative-research-inkano-state-northern-nigeria.
100. Compaore C, Traore A, Sawadogo B, Tapsoba C, Donovan L, Baker K, et al. Using the role model
approach to identify best practices and challenges during seasonal malaria chemoprevention
drug administration in Burkina Faso [poster]. 71st American Society of Tropical Medicine andHygiene Annual Meeting. 30 October – 03 Nov 2022. Available from:https://www.malariaconsortium.org/resources/publications/1630/using-the-role-modelapproach-to-identify-best-practices-and-challenges-during-seasonal-malaria-chemopreventiondrug-administration-in-burkina-faso.
101. Malaria Consortium. Co-implementing vitamin A supplementation with seasonal malaria
chemoprevention: A pilot implementation study in Sokoto state, Nigeria. Research brief. London:
Malaria Consortium; 2020. Available from:https://www.malariaconsortium.org/resources/publications/1365/co-implementing-vitamin-asupplementation-with-seasonal-malaria-chemoprevention-a-pilot-implementation-study-insokoto-state-nigeria.
102. Malaria Consortium. Improving vitamin A coverage through co-implementation with seasonalmalaria chemoprevention: Applying an effective, integrated health campaign in Nigeria. Project
brief. London: Malaria Consortium; 2021. Available from:https://www.malariaconsortium.org/resources/publications/1529/improving-vitamin-acoverage-through-co-implementation-with-seasonal-malaria-chemoprevention-applying-aneffective-integrated-health-campaign-in-nigeria.
103. Malaria Consortium. Integrating seasonal malaria chemoprevention and vitamin A
supplementation: Lessons learnt from Nigeria. Learning brief. London: Malaria Consortium; 2022.
Available from: https://www.malariaconsortium.org/resources/publications/1579/integratingseasonal-malaria-chemoprevention-and-vitamin-a-supplementation-lessons-learnt-from-nigeria.
104. Malaria Consortium. Maximising resources for healthcare: Integrating vitamin A
supplementation with seasonal malaria chemoprevention. Advocacy brief. Malaria Consortium;
2022. Available from:https://www.malariaconsortium.org/resources/publications/1580/maximising-resources-forhealthcare-integrating-vitamin-a-supplementation-with-seasonal-malaria-chemoprevention.
105. Pfurtscheller T, Ainsworth J. Defining the future of SMC in Togo: exploring new delivery
strategies; 2022 Dec 19 [cited 2023 Mar 05]. Available from:https://www.malariaconsortium.org/blog/defining-the-future-of-smc-in-togo-exploring-newdelivery-strategies.
106. Shafique M, Edwards HM, de Beyl CZ, Thavrin BK, Min M, Roca-Feltrer A. Positive deviance as anovel tool in malaria control and elimination: Methodology, qualitative assessment and future
potential. Malaria Journal, 2016; 15: 91.
107. Malaria Consortium. Using the role model approach to improve administration of seasonalmalaria chemoprevention drugs in Burkina Faso, Chad and Togo. Synopsis. London: Malaria
Consortium; 2021. Available from:https://www.malariaconsortium.org/resources/publications/1484/using-the-role-modelapproach-to-improve-administration-of-seasonal-malaria-chemoprevention-drugs-in-burkinafaso-chad-and-togo.
108. Malaria Consortium. Optimising the role of lead mothers during the seasonal malaria
chemoprevention campaign in Kano state, Nigeria: A mixed-methods study. Synopsis. London:
Malaria Consortium; 2021. Available from:https://www.malariaconsortium.org/resources/publications/1525/optimising-the-role-of-lead93

mothers-during-the-seasonal-malaria-chemoprevention-campaign-in-kano-state-nigeria-a-mixedmethods-study.
109. Okereke E, Smith H, Oguoma C, Oresanya O, Maxwell K, Anikwe C, et al. Optimizing the role of‘lead mothers’ in seasonal malaria chemoprevention (SMC) campaigns: Formative research in
Kano State, northern Nigeria. Malaria Journal, 2023; 22(1): 13.
110. Griffin JT, Ferguson NM, Ghani AC. Estimates of the changing age-burden of Plasmodium
falciparum malaria disease in sub-Saharan Africa. Nature Communications, 2014; 5(3136).
111. Thompson H. Modelling the public health impact of second-generation malaria vaccines; 2022.
PhD thesis, Imperial College London, UK.
112. Wharton-Smith A, Baker K, Roca-Feltrer A, Rodrigues M, Richardson S, Bonnington CA, et al.
Assessment of the feasibility, acceptability, and impact of implementing seasonal malaria
chemoprevention in Nampula province, Mozambique: Protocol for a hybrid effectivenessimplementation study. JMIR Research Protocols, 2021; 10(9): e27855.
113. Roberts L. Lingering fever: The battle against malaria in Africa has stalled. Can research inMozambique explain why — and how to get it back on track? Science; 09 September 2022: 1139–
1143.
114. Malaria Consortium. Exploring the implementation of seasonal malaria chemoprevention in
Mozambique: Results from an end-of-round coverage survey in Nampula province, 2020–2021.
Research brief. London: Malaria Consortium; 2021. Available from:https://www.malariaconsortium.org/resources/publications/1483/exploring-theimplementation-of-seasonal-malaria-chemoprevention-in-mozambique.
115. Candrinho B. Seasonal malaria chemoprevention: Results from Mozambique implementation
study 2020–2021 [presentation]. 70th American Society of Tropical Medicine and Hygiene Annual
Meeting. 17–21 Nov 2021. Available from:https://www.malariaconsortium.org/resources/publications/1514/seasonal-malariachemoprevention-results-from-mozambique-implementation-study-2020--2021.
116. Kajubi R, Ainsworth J, Baker K, Richardson S, Bonnington C, Rassi C, et al. A hybrid effectivenessimplementation study protocol to assess the effectiveness and chemoprevention efficacy of
implementing seasonal malaria chemoprevention in five districts in Karamoja region, Uganda[version 1; peer review: awaiting peer review]. Gates Open Research, 2023; 7: 14.
117. Nuwa A, Bonnington C, Baker K, Odongo M, Kyagulanyi T, Nabakooza J. Evaluation of the impact
of one round of seasonal malaria chemoprevention on resistance markers associated withsulfadoxine-pyrimethamine and amodiaquine in Karamoja, Uganda, March 2022 [poster]. 2nd
Conference on Public Health in Africa. 13–15 December 2022. Available from:https://www.malariaconsortium.org/resources/publications/1658/evaluation-of-the-impact-ofone-round-of-seasonal-malaria-chemoprevention-on-resistance-markers-associated-withsulfadoxine-pyrimethamine-and-amodiaquine-in-karamoja-uganda-march-2022.
118. Malaria Consortium. Exploring the use of seasonal malaria chemoprevention in South Sudan.
Synopsis. London: Malaria Consortium; 2022. Available from:https://www.malariaconsortium.org/resources/publications/1604/exploring-the-use-of-seasonalmalaria-chemoprevention-in-south-sudan.
119. Malaria Consortium. SMC Publications; no date [cited 2023 Mar 9]. Available from:https://www.malariaconsortium.org/resources/publications/search/SMC
120. Malaria Consortium. Seasonal malaria chemoprevention; no date [cited 2023 Mar 9]. Available
from: https://www.malariaconsortium.org/pages/preventive_treatments/seasonalmalariachemoprevention.htm.

94121. Malaria Consortium. Unlocking universal health coverage — Impact report 2022. London:
Malaria Consortium; 2022. Available from: https://www.malariaconsortium.org/pages/unlockinguniversal-health-coverage.htm
122. Wiblin R, Harris K. Dr James Tibenderana on the state of the art in malaria control andelimination. 80,000 Hours podcast. 2022 May 09. Available from:https://80000hours.org/podcast/episodes/james-tibenderana-malaria-control-andelimination/?msclkid=02ed36d1d03411eca8cbdd5671e07b57.
123. Giles A. Advancing the conversation on SMC at ASTMH 2022; 2022 Nov 25 [cited 2023 Mar 05].
Available from: https://www.malariaconsortium.org/blog/advancing-the-conversation-on-smcat-astmh-2022.
124. Tchouatieu AM, Poku-Awuku A. Protecting Children: 10 Years of seasonal malaria
chemoprevention. Geneva: Health Policy Watch; 2022. Available from: https://healthpolicywatch.news/97669-2/.
125. SMC Alliance. From concept to scale: Celebrating 10 years of seasonal malaria
chemoprevention. London: Malaria Consortium; 2023. Available from: https://www.smcalliance.org/resources/from-concept-to-scale-celebrating-10-years-of-seasonal-malariachemoprevention.

95

© Malaria Consortium / April 2023

No images from this publication may be used without prior permission from Malaria Consortium.
UK Registered Charity No: 1099776
Contact: info@malariaconsortium.org