Malaria among primary school-age children has long been recognized as a threat to the health and education of this age group, but has attracted relatively little attention [1]. Recent surveys conducted across sub-Saharan Africa (SSA) have reported that the prevalence of Plasmodium falciparum in school-age children is consistently higher than all other age groups, but has significant variation across the region—from 4% of children in western Tanzania [2] to 60% or higher in Malawi and southern Mali [3]. In Malawi, primary school-aged children are at higher risk of Plasmodium infection than younger children, but their access to malaria prevention and formal case management services is lower than other age groups [4, 5]. The high prevalence of asymptomatic infection and associated morbidity has the potential for detrimental effects on educational achievement, through reduced school attendance and cognitive development [6, 7]. However, given the rapid increase in primary school participation across SSA [8], schools increasingly have the potential to be an efficient and effective delivery point to provide care for malaria.

Previous research has demonstrated that the delivery of anthelmintic treatment by school teachers is widely accepted by both parents and guardians, and school children, and that teachers view this additional role positively [9, 10]. Prior to recommendations that parasitological diagnosis (by rapid diagnostic test or microscopy) should be undertaken before artemisinin-based combination therapy (ACT) is given, past studies have also indicated that using trained school teachers in the provision of presumptive malaria treatment using chloroquine or sulfadoxine-pyrimethamine was feasible [11–13]. A study in coastal Kenya reported that community members would be satisfied with teachers overseeing the delivery of ACT treatments to primary school children following rapid diagnostic tests (RDTs) carried out by health workers, and that they would also be accepting of the teachers conducting RDTs following thorough training [14].

The Ministry of Health (MoH) in Malawi has recently explored the use of RDTs for community case management of malaria in children under 5 years of age [15]. With support from the Ministry of Education Science and Technology (MoEST), the MoH has been keen to expand a ‘test, treat and track’ service to children over 5 years of age, through school-based case management. As a result, the MoH and MoEST established a trial to train teachers to use malaria RDTs and ACT for the diagnosis and treatment of uncomplicated malaria in school children. A pre-implementation pilot workshop in June 2013 indicated that training school teachers to conduct RDTs and treat uncomplicated malaria as part of a basic first aid kit was feasible. Post-training interviews with participants (school teachers) and facilitators (district-, zonal- and national-level facilitators from the MoH) suggested that following sufficient training and practice, teachers felt confident to conduct RDTs and make decisions regarding treatment [16].

In total, eight FGDs and 20 IDIs were conducted. Five FGDs were carried out with adults (parents, guardians and teachers), and three FGDs conducted with school children who had recently sought care from an LTK dispenser.

In the case of our study, malaria testing using RDTs and treatment using ACT by trained school teachers was well received and perceived to be a valuable programme amongst both providers and users of the LTK. While presumptive malaria diagnosis and treatment has been shown to be feasible and acceptable when delivered by teachers [11–13], this study is the first to show that the use of RDTs and ACT by teachers can also be an acceptable way of delivering care for malaria. This finding is significant for malaria control, because whilst access to health facilities is limited in most African countries including Malawi, enrolment at primary school is high in most rural communities [8]. This provides an opportunity for the health and education sectors to collaborate in improving the health and learning environment for school-going children, and to ensure timely access to prompt diagnosis and treatment, one of the key strategies in malaria control [17]. It is important to highlight that as school-based malaria testing and treatment can only be done during term time and school hours, school children could still delay in receiving prompt care and treatment when sick outside these times. Therefore, ensuring that all individuals suffering from malaria have prompt access to effective treatment remains a priority for resource-constrained health systems, regardless of the availability of programmes such as the LTK.

For a programme where teachers use RDTs and ACT to diagnose and treat uncomplicated malaria to be successful, there is need for an effective collaboration between the health and education sectors. Although it is clear that teachers can safely and accurately test and treat malaria in school children [16], supervision and mentoring remain critical elements in the delivery of any community-based programme and thus LTK dispensers will require technical, logistical and supply chain support from healthcare workers in local health facilities. However, concerns regarding poor coordination between the health and education sectors were shared by local, district and national stakeholders. Teachers expressed concerns that they regularly failed to receive feedback on referred patients, or that their requests for drugs from the local health facility were not prioritized. Such issues were observed in a project training shopkeepers to use RDTs and placing this service in drug shops in Uganda, where the links between the informal drug shops and formal health sector were also perceived to be weak [18]. Similar to these results, health workers reported not being fully oriented on the newly introduced programme, and shopkeepers reported referral forms given to clients were not formally recognized or respected by health workers.

During the trial, facility-based healthcare workers were trained and designated as local supervisors of teachers, although additional supervision visits were conducted by both the implementation team and district taskforce. However, teachers reported that supportive supervision and mentoring to the LTK dispensers by healthcare workers was limited. Recent research corroborates these accounts, reporting that deployment of facility-based healthcare workers as supervisors of community-based health services is frequently unrealistic and unsustainable [19]. Whilst a lack of supervision of peripheral services and inadequate referral systems are not unfamiliar challenges to many low-income country’s health systems, it is important that these processes continue to be strengthened if the LTK was to be rolled out more widely.

Although calls for greater supervision of peripheral health services are frequently reported, little consensus exists of the best approach, effectiveness, or affordability of such strategies [20]. For the LTK in Malawi, community-based Health Surveillance Assistants (HSAs) would likely be the best supervisors for teachers given their experience in providing health services at community level. HSAs are currently responsible for treating common childhood diseases, including malaria, in children under five in hard-to-reach areas [21] and as such have good experience in dealing with the formal health sector, coordinating an effective supply chain and biowaste disposal. However, given current concerns regarding the detrimental effects of ‘overloading’ HSAs in both their responsibilities and scope, this should be approached cautiously [21]. Whatever the approach, future roll-out of any school-based malaria test and treat programme can only be successful if efforts are made to ensure effective support and supervision of the teachers by local health workers.

Establishing a robust, reliable and consistent supply chain is critical for a community-based case management intervention such as the LTK, but is a frequently reported challenge to such interventions [22]. In Malawi, more than one-third of all HSAs surveyed did not have all essential drugs in stock, and the majority of clinical errors were due to not having the required treatments. In this study, supplies such as ACT, RDTs and other LTK supplies were procured by the implementing partner and delivered to schools from local health centres through the district health office, limiting stock-outs in the study area because of this parallel supply provided for the study. Stock-outs are the most commonly reported obstacle to providing services to HSAs, followed by delays between requesting and receiving supplies and then transport-related obstacles [20], issues that were also raised by the LTK dispensers in this study. Ongoing disruption and stock-outs of essential drugs in Malawi [21] has significant implications for the entire health system, including a routine school-based programme where supplies would have to be integrated with the general supply. The unavailability of drugs, including at health facilities, was also reflected in concerns from school children, who reported that drugs meant for unwell school children were sometimes shared with other individuals. While strengthening the LTK supply chain at the last-mile is, therefore, a prerequisite of successful implementation, it must take place with attention to and in broader support of the entire supply chain system.

Due to the unexpected high levels of demand for the LTK, trained teachers and their head teachers described being put under significant strain, and that their time spent teaching was affected as they could not leave sick children unattended. The two biggest implications of this are overburdening of teachers and a negative impact on learning for school children. To address this concern, such a programme could train a greater number of teachers per school to reduce the workload on individual teachers and to minimize any disruption to teaching. In addition, LTK dispensers expressed an expectation that because they were doing an extra activity on top of teaching, they should be rewarded with an incentive. This finding is similar to what others have shown for school-based malaria programmes [14]. Whilst incentives have been shown to motivate, retain and increase the participation of workers [23] such an incentive would have to be thought of in the context of other school-based health programmes. Currently, programmes such as school feeding or routine deworming are generally facilitated by teachers without an incentive. Introduction of an incentive for a school-based malaria programme could potentially disrupt the success of other programmes, if the incentive is seen to be targeting only teachers working on the malaria programme.

There are several limitations to be considered when interpreting results from this study. The implementing partner has a long established and recognized presence in the study area, implementing child health programmes in support of government efforts. At the same time, the study was conducted at a time when the health facilities in Malawi faced critical shortages of drugs and supplies. In this environment, participants may have expressed their acceptability of the LTK programme from the perspective that schools are the only viable option for health for their children and for fear of jeopardizing future support from Save the Children.

The scope of this nested study was to explore the experiences and perceptions of those who had either sought, delivered or supervised the provision of care by school teachers at the school level, and thus all those who participated in the study had direct experience in the implementation of the LTK. Parents, guardians and school children were selected on the basis of recent (less than 6 weeks since) treatment, representing a specific population of all stakeholders who may not represent the broader views of those who have never required care from the LTK, or never chosen to seek care from the LTK. In addition, only children from senior classes (Standard 6–8) were involved in this study, who represent both the smallest overall enrolled population and the age group with the least number of total LTK consultations, and thus do not necessarily represent the opinions of the majority of children who ultimately seek treatment from the LTK. Finally, the study involved only community members from intervention schools, and did not include the views of parents, guardians, or children from schools not receiving the intervention.

Awareness of broader perspectives, including the acceptability of the intervention in naïve as well as non-participant community members would have reduced the chance of positive bias in the reported perceptions of the intervention. Including these groups in future qualitative research could also contribute important insights on pre-intervention expectations and concerns that could be prospectively addressed during early implementation activities such as community sensitization, training or supervision. Indeed, observations that a proportion of school children in intervention schools continued to seek care from other formal and informal sources despite the LTK being available (Halliday et al. submitted) should be a priority focus for future research regarding how the intervention is perceived by these individuals, and thus how the LTK and similar school-level health interventions could be refined.

Overall, the LTK was perceived by users and implementers to bean acceptable method of delivering care for malaria to school children by parents and guardians, teachers and district officers alike. For many, the LTK was considered a preferential choice for sick children due to its perceived convenience and reliability in terms of facilitating prompt treatment, saving time and money and allowing children to continue with their education. However, the perceived benefits of the programme created an unexpectedly high demand for the service, which led to concerns from providers such as maintaining the supply chain from local health facilities, overburden of additional work for teachers, and requests for treatment for ineligible community members at inappropriate hours. With careful consideration to appropriate capacity building, redeployment of resources and integration of services at school level to ensure sustainability and impact, there was strong support to scale-up the programme, and further evaluation of such scale-up is warranted.