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ObjectiveTo determine whether the administration of rectal artesunate by trained community health volunteers before referral to a health-care facility reduces the case fatality rate of severe malaria in young children in hard-to-reach communities in Zambia.MethodsWe implemented a pilot project in Serenje District between July 2017 and July 2018. The project involved: (i) training community health volunteers to administer rectal artesunate to children with suspected severe malaria and refer them to a health facility; (ii) ensuring emergency transport with bicycle ambulances was available; (iii) ensuring adequate drug supplies; and (iv) ensuring health-care workers could treat severe malaria with injectable artesunate. Surveys of health facilities, volunteers and bicycle ambulance riders were performed near the beginning and end of the intervention period. In addition, data on severe malaria cases and associated deaths were obtained from health facilities and a community monitoring system.FindingsIn the year before the intervention, 18 deaths occurred in 224 cases of confirmed severe malaria among children younger than 5 years seen at intervention health facilities (case fatality rate: 8%); during the intervention, 3 of 619 comparable children with severe malaria died (case fatality rate: 0.5%).ConclusionThe administration of pre-referral rectal artesunate treatment to young children with severe malaria by community health volunteers was feasible, safe and effective in hard-to-reach communities in Zambia and was associated with a substantial decrease in the case fatality rate. The project’s approach is highly adaptable and could be used in other countries with a high malaria burden.

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This paper examines a demand-side intervention that significantly increased access to maternal health services in rural Zambia in a context where skilled birth attendance rates had been stagnant for over two decades. Aspects of the intervention design that were crucial to the programme's success were the participatory and adult learning-centred approach used to mobilise intervention communities, the use of a community volunteer model, and the design's sensitivity and responsiveness to underlying social factors and problems. The demand-side intervention is already being scaled up in six districts, and is highly suitable for national level scale-up.Cet article examine une intervention axée sur le côté de la demande qui a considérablement amélioré l'accès aux services de santé maternelle en milieu rural en Zambie dans un contexte dans lequel le taux de naissances en présence d'accoucheuses qualifiées stagnait depuis plus de vingt ans. Parmi les aspects de la conception de l'intervention qui s'étaient révélés cruciaux pour le succès du programme figuraient l'approche participative et centrée sur l'apprentissage parmi les adultes employée pour mobiliser les communautés au sein desquelles était menée l'intervention, l'utilisation d'un modèle de volontaires communautaires et la sensibilité et réactivité de la conception aux facteurs et problèmes sociaux sous-jacents. L'intervention axée sur le côté demande est d'ores et déjà en cours d'élargissement dans six districts, et elle est tout à fait adaptée à un élargissement au niveau national.El presente artículo examina una intervención determinada por la demanda que ayudó a aumentar el acceso a los servicios de salud materna en el área rural de Zambia, en un contexto en que la tasa de asistencia de personal capacitado en los partos se había estancado durante dos décadas. En este sentido, se hace referencia a algunos aspectos del programa que determinaron su éxito, a saber: el enfoque participativo, centrado en el aprendizaje de los adultos, utilizado para movilizar a las comunidades donde se llevó a cabo la intervención; el uso de un modelo de voluntarios comunitarios; y la sensibilidad del modelo y su capacidad de respuesta a los factores y los problemas subyacentes. La intervención determinada por la demanda se ha extendido a seis distritos, mostrando ser muy adecuada para su uso a nivel nacional.

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