Community case management of malaria (CCMm) consists of treating patients with prepackaged anti-malarial drugs that are distributed by members of their own community. This study examines a CCMm programme that relies on rapid diagnostic tests (RDTs) for diagnosis and artemisinin-based combination therapy (ACT) for treatment in the district of Saraya, south-eastern Senegal. It assesses the programme’s acceptance by communities in Saraya, the effectiveness of the lay health worker training, and the availability of supplies in the field.
The World Health Organization (WHO) estimates global malaria incidence in 2010 at 216 million cases, of which 81% were in Africa . In the same year, mortality due to malaria is estimated to be from 655,000 to 1,238,00 deaths, 91% of which occurred in Africa and the majority among children under 5 years of age [1, 2]. Many of these deaths also occurred in rural areas where there is sparse health infrastructure [3–5].
In 2005, Senegal’s national malaria control programme reported that malaria accounted for 28% of mortality in health facilities and was the single largest contributor to documented mortality . Plasmodium falciparum accounts for the vast majority of infections, with fewer cases of Plasmodium ovale and Plasmodium malariae. Deaths from malaria in Senegal are projected to have increased over three-fold between 1980 and 2000 (4,888 to 15,125 deaths) due to increasing population size, and to have decreased by over a third between 2000 and 2010 (15,125 to 10,150 deaths), likely due to intensified prevention and treatment efforts .
Community case management of malaria (previously known as home management of malaria) consists of a lay health worker with no formal health training providing malarial diagnostic or therapeutic care outside of a formal health care establishment . The WHO recommends that CCMm be implemented in areas where a health facility is not accessible to the majority of people within 24 hours of illness onset . As of 2010, 42 countries, including Senegal, have implemented some form of CCMm with RDTs . Several studies have shown that CCMm is qualitatively acceptable to communities or providers [9–13]. Some researchers have assessed cure rates including a Ghana-, Nigeria-, and Uganda-based study that found greater than 90% parasitological cure rates in all sites where CCMm had been implemented . Despite these positive findings, other authors have raised concerns about CCMm. Some have questioned the ability of lay health workers who need but cannot afford eyeglasses to read RDTs correctly  based on a high rate of untreated ophthalmologic conditions in sub-Saharan Africa [15, 16]. Others have pointed out that the wide implementation of CCMm programmes is expensive and could accelerate the emergence of resistance to ACT . There is also controversy around the impact of CCMm programmes on morbidity or mortality, with a Cochrane Review identifying only one randomized control CCMm trial showing a decrease in mortality (Ethiopia) [17, 18]. Despite these concerns, CCMm with RDTs and ACT is endorsed by the WHO and widely accepted in areas where malaria is endemic and there is sparse health infrastructure .
Senegal’s national malaria control programme introduced ACT (artesunate-amodiaquine) as first-line treatment for uncomplicated malaria in 2006. In 2007, it began offering RDTs in most health centres, health posts, and operational health huts nationally . A recent study found that the prescription of ACT decreased from 73% to 32% of all malaria-like febrile illnesses three years after RDTs had been introduced .