Rwanda reduced malaria by an astounding 88% in just a few years. Here's how

Over the past six years, Rwanda has achieved one of the largest and fastest reductions of malaria incidence in history, and the East-Central African country now appears within reach of eliminating the ancient scourge by 2030.

According to the latest data from the Rwanda Biomedical Centre, malaria cases in the country dropped by 88%, from more than five million cases in 2016/2017 to 623,000 in 2023. Deaths from malaria dropped by a similar margin over the same period, from 600 to 51 deaths last year. This decline has impacted a wide array of other health outcomes – including helping reduce maternal mortality by 72% over the past decade.

Rwanda’s success comes at a time when changing temperatures and rainfall patterns driven by climate change, as well as growing insecticide resistance around the world, are making malaria an even more formidable foe. As a result, progress against malaria has plateaued in many geographies. Rwanda demonstrates that progress is possible despite these headwinds.

Dr. Aimable Mbituyumuremyi, malaria program manager at the Rwanda Biomedical Centre, attributed the country’s success against malaria to its data-driven strategy, which allows health leaders to launch targeted interventions where they are needed the most and can have the greatest impact.

“Using sub-national data for decision-making has allowed us to target three key interventions and make good progress against malaria,” said Dr. Mbituyumuremyi. “Those three key interventions are vector control, increasing access to diagnosis and treatment, and community mobilization.”

“We don’t have a single protocol for tackling malaria,” added Dr. Mbituyumuremyi. “The key is understanding where the problem is and what the problem is in each area and using the data you have to design effective interventions for each area. And we must sustain those interventions if they work. You can’t stop or slow down.”

Analyzing local data about human health and the mosquitos also helped Rwanda track growing resistance to the standard insecticides used for vector control.

In areas where the standard protocol was losing its effectiveness, the country doubled down on indoor residual spraying (IRS) and distributed a new generation of bed nets – pyrethroid plus piperonyl butoxide synergist-treated nets – to counter pyrethroid resistance. The standard and cheaper insecticide-treated bed nets continue to be used in areas without surging insecticide resistance.

“IRS is expensive, yet effective, and so are the new nets,” said Dr. Mbituyumuremyi. “We kept these high-impact interventions more affordable by targeting their application.”

Health leaders also dramatically increased access to diagnosis and treatment by training and equipping the country’s 40,000-plus community health workers (CHWs) across the country. Previously, CHWs were equipped and trained to only diagnose and treat children under five. But in 2016/2017, the government expanded capacity building for the cohort and trained and equipped these frontline health workers to provide free diagnosis and treatment to all.

Today, CHWs manage 60% of all malaria cases. That is up from 8% in 2016, said Dr. Mbituyumuremyi. Cases are being diagnosed and treated faster, slowing the spread of malaria and ensuring treatment before complications arise.

Another critical tool has been community mobilization through local NGOs. “You absolutely need community engagement,” said Dr. Mbituyumuremyi. “It isn’t easy to make progress without community engagement. And for this, NGOs are key because they are close to local communities and have their trust.”

NGO partners deliver messages that extend well beyond merely health promotion. Communities are told that preventing malaria is about accountability and that it's their civic duty to ensure they do not infect their neighbors, colleagues, friends, and family with the disease.

“The government has been proactive in thinking outside the box, testing different approaches, and then communicating clearly with partners about what works,” said Manasseh Gihana Wandera, executive director of the Society for Family Health, an NGO working in Rwanda. In partnership with the Rwandan government, Society for Family Health supports social behavior change through mass media and peer education, mobilizing communities to engage in vector control, and building CHW capacity in 250 communities to diagnose and treat malaria.

To help NGOs and others maximize the impact of their limited resources in the fight against malaria, the government distributes an easy-to-read monthly malaria scorecard that breaks down the use of mosquito nets, malaria cases, and other key data points, at the district level. For example, when the data showed that farmers in areas with aquaculture farms were at increased risk of malaria, the ministries of health and agriculture partnered to take action – and eventually the ministry of agriculture was able to identify a small fish that eats mosquito larvae in fishponds and distributed them to farmers.

Likewise, when data showed that malaria cases were increasing in Kigali, the government used drones to spray insecticide over the parts of the capital most at risk. And when data showed that people who were active during the night – such as security guards, farmers, and sex workers – experienced higher rates of malaria, the government distributed personal mosquito repellent to these vulnerable populations.

Rwanda has also been quick to test and adopt promising new vector control innovations, said Thomas C. Putzer who works for SC Johnson on establishing collaborations with governments and NGOs in support of malaria elimination. SC Johnson has partnered with Rwanda to develop and test the “mosquito shield,” an easy-to-use mosquito repellent device that can be hung in a home and repels mosquitos for one month.

Already millions of Rwandans are using the device, which has not yet been approved by the WHO but has been subject to robust testing for approval in Rwanda. The government of Rwanda also partnered with SC Johnson to develop and test a new “guardian shield” which, like the mosquito shield, is an easy-to-use, filter-like device that hangs in a home and can repel mosquitos for a full year. The device is currently being tested by Rwanda’s government regulators and, if approved, could be distributed in the areas with stubbornly high levels of malaria as early as later this year.

“The government of Rwanda has adopted a more holistic approach,” said Putzer. “They are eager to develop, test, and roll out new innovations.”

Dr. Mbituyumuremyi acknowledges Rwanda has been here before. In 2011, the government had pushed malaria to extremely low levels. But vigilance proved hard to maintain and the disease surged again. Perseverance and flexibility are key parts of the fight against malaria, explained Dr. Mbituyumuremyi, “Mosquitos are adaptable. People can’t think the fight is over. People can’t relax. We have six years before 2030 and believe that we can eliminate malaria. But this isn’t going to be easy.”