Ruth Seleman and Godfrey Bahati, a young couple in Northern Tanzania listen carefully to nurse Damari Kipondya as she counsels them on reproductive health.  Although none of the two appear sick, they have every reason to come to the Ngumo Dispensary in Kwimba, Mwanza region. They are expecting a baby as Ruth is five months pregnant. Moreover, she and her husband live in an area with one of the highest malaria infection rates in the country.

“My neighbor’s daughter died a few months ago. She was pregnant [and] people say it was because of malaria, but she never went to the hospital for a checkup. She only used herbs,” said Ruth who knows too well how dangerous malaria can be because she has suffered from the infection in the past. When Ruth knew she was pregnant with her first baby, she felt both joy and fear in equal measure.

“I told my husband, look, you know we live in an area with a lot of malaria illness. Someone once said to me that pregnant women like me are more prone to malaria compared to others, so we must get checked and take prevention measures.”

Her instincts were right. Although Tanzania has made progress in addressing its malaria burden, between 10 and 12 million people contract the infection each year, and over 80,000 people—mostly children and pregnant women— die needlessly from it. Pregnancy reduces a woman’s immunity to malaria, making her more susceptible to infection and at greater risk of illness, severe anaemia and death. Malaria during pregnancy also interferes with the growth of the fetus, increasing the risk of premature delivery and low birth weight – a leading cause of child death.

Although health providers like Nurse Damari felt prepared to manage patients with malaria, there was a problem. Health facilities were recording too many malaria cases, leading to overuse of antimalarial medicines and rapid depletion of the regional drug stock.

“This is because [health providers] treated clients with fevers, symptoms or infections that mimic malaria symptoms as malaria patients,” said Mwanza Region Medical Officer Thomas Dr Rutachunzibwa. “We ended up having more clinical malaria cases [on paper] that had not been verified by malaria rapid diagnostic tests.”

This practice denied timely and appropriate care to the patients, wasted medicines and increased the risk of drug resistance. Also, it made it difficult for the region to track malaria cases and to allocate resources more effectively.

“Mwanza’s Kwimba District is well known for the high number of malaria cases. For many years we were doing clinical management for malaria cases. It was difficult to decide on what will be the right means to manage them because we didn’t have reliable data,” said Nurse Damari. “For example, it was difficult to know whether the challenge was drugs or competence of providers until we developed a [malaria] checklist to guide us because we were attending to clients based on the history of presenting illness only.”

To improve the care and treatment of malaria, the U.S. President’s Malaria Initiative (PMI) supports Tanzania’s National Malaria Control Program, through the USAID Boresha Afya activity. The activity has worked to develop and roll out the Malaria Service and Data Quality Improvement (MSDQI) checklist in Mwanza and six other regions in the Lake and Western zone. This approach is helping regional health administrators like Dr. Rutachunzibwa and mentoring teams manage the quality of malaria case management services at the facility level and take corrective measures. The new mechanism also helps nurses like Damari collect, monitor, and review facility-based malaria performance indicators and use the information to improve the quality of the care. 

By using the MSDQI approach, the project has improved malaria case management reviews of outpatients and antenatal care clients in over 1,800 health facilities in the Lake and Western zone. To reduce the impact of malaria, pregnant women like Ruth are required to take malaria rapid diagnostic tests on their first visit to the antenatal care clinic. Women who are diagnosed with malaria are managed per national guidelines. Pregnant women are also required to take a minimum of 3 doses or more of Intermittent Preventive Treatment during pregnancy with Sulfadoxine-Pyrimethamine to protect them against malaria. Through the USAID Boresha Afya activity partnership, malaria testing among pregnant women during the first antenatal care visit increased from 68% in 2016 to 98% in 2020 in supported health facilities. When MSDQI was being introduced in the Mwanza in 2016, only 2 out of 100 pregnant women completed the three required doses of Sulfadoxine-Pyrimethamine for the intermittent preventive treatment of malaria.  By October 2016, thanks to the region’s commitment to improving services through the MSDQI approach, 57 out of every 100 pregnant women are completing all three doses, a remarkable achievement over a short period to an age-old disease.

“As we continue rolling out MSDQI and strengthening malaria case management, the trend we are now seeing in our region is that malaria is going down,” said Dr Rutachunzibwa. “This success has galvanized and inspired us to focus beyond malaria case management by expanding our efforts in prevention and making sure the two interventions go hand in hand.”

When USAID Boresha Afya first introduced MSDQI  in Dr. Rutachunzibwa’s region,  he was concerned. He worried it was going to be business as usual: a top-down standalone approach where a few health administrators made all the decisions and sent mentors around to coach and supervise lower-level facilities’ health providers,  expecting them to provide better services.  Instead, the partnership has been a great success.

“We have made a huge leap with MSDQI in my region. I thank Jhpiego and the USAID Boresha Afya team for the fruitful collaboration,” said Dr. Rutachunzibwa. He said the secret behind their MSDQI success and rollout was in how they co-designed and engaged council health management teams and mentors throughout. This approach instilled a sense of ownership and increased acceptance and coverage."

“The greatest support the activity has done to our region is in the creation of a competent team of health providers. The mentorship teams we have used are not from Boresha Afya. They are government employees, they work in our councils, right here in Mwanza region.”

With such an improved health system and timely access to health care close to where they live, women like Ruth Seleman are now less worried. They are assured of quality malaria care--diagnosis and appropriate treatment--and prevention services like insecticide-treated mosquito bed nets.

As for Godfrey Bahati, who was escorting his wife to the antenatal clinic for the first time, he could not be more pleased with the reception and service they received.

“She is carrying our first baby, so we are taking all precautions, so she does not get malaria. Thanks to the providers here, we received a thorough and comprehensive malaria screening and counselling process. They also gave us a mosquito net to sleep under at night. We feel so lucky” he said.

And indeed, lucky they are, and so are thousands of other women in the region. Given the self-reliance the Mwanza team has demonstrated, Godfrey and his wife Ruth are on a journey to experience an assured, safe motherhood experience that is also malaria-free.