Introduction

Malaria is one of humankind’s oldest and most persistent health challenges. As a result of its longevity, the morbidity and mortality malaria causes have, to a great extent, become normalized and accepted as inevitable in many countries, particularly in sub-Saharan Africa. Preventing malaria is widely treated as a voluntary matter of individual responsibility—through the use of bed nets or removing breeding sites from around homes; once these measures become routine they are often not pursued aggressively,. Among health care providers in endemic countries, treating malaria is considered “business as usual” rather than a crisis requiring urgent and society-wide interventions. Research into new approaches and tools for vector control and disease treatment is initiated and driven by academic questions and industry priorities, rather than by frontline malaria programs. In all, for most people living in malaria-endemic countries, as well as for most global health professionals, malaria is neither a new and interesting topic nor a particularly exciting or engaging challenge.

Yet as malaria experts and many others in global health are well aware, malaria should be a major and urgent cause of concern for governments, health care providers, global health policy advocates and local communities around the world. In this paper, we argue that in order to once again bring malaria to the forefront of health improvement and sustainable development efforts in endemic countries requires going beyond technically sound interventions or increasing funding levels. It also requires going beyond efforts to inform and educate people at risk of malaria. To truly have an impact on improving the malaria situation in the countries where it remains entrenched, malaria program staff and advocates must also utilize strategic communications in order to rally the full range of stakeholders to prioritize working effectively toward eliminating malaria. Effective communications can trigger improvements in malaria control by driving and supporting decision-making by individuals and leaders. It is a tool used to improve policy and mobilize resources. And it serves as the management glue that holds the malaria program and team together and supports them to maintain strategic interests, coherence and focus.

This concept of “strategic communications” related to malaria goes beyond how the term is traditionally used in malaria programming. Typically, malaria programs refer to communications as a program activity—namely through behavior change communication (BCC) or information, education and communication (IEC) campaigns designed to inform people in communities about malaria prevention and treatment options. We focus instead on communication as a “soft skill” that leaders can develop to use as a tool to make national malaria programs more effective in advocating for and carrying out their work. Throughout this essay, we draw on experiences from Uganda, where one of the authors leads the country’s National Malaria Control Division.

Ugandans experience 5% of all global malaria cases and 3% of all malaria deaths, despite accounting for less than 0.05% of the global population [1]. Estimates vary, but malaria infections are the cause of approximately 40% of outpatient visits to clinics around the country and up to 20% of hospitalizations [2, 3]. In a recent study conducted in five clinics in five high malaria-burden districts, malaria was suspected in over 73% of all outpatient visits and nearly 70% of those tested were positive for the disease. These proportions were slightly higher among children under the age of five years [4]. The deaths of more than 10,000 people in Uganda were attributable to severe malaria in 2019 [1]. The problems malaria causes persist despite notable progress made in previous years in controlling the disease, the existence of significant scientific, biomedical and traditional knowledge about preventing malaria by preventing mosquitoes from breeding near and biting humans, and the existence of effective treatments. Uganda’s experience shows that complex efforts to control, eliminate, and ultimately eradicate malaria must be long-term endeavors, not short-term interventions.

Why does malaria remain entrenched in Uganda, as in so many places, despite years of malaria control programming? Why have national malaria interventions not received sufficient and sustained attention and support from political and community leaders? Why are many national malaria programs understaffed and under-resourced, even when funding is available to countries from the Global Fund to Fight AIDS, Tuberculosis and Malaria and other bilateral and private donors? And why has global progress in reducing the burden of malaria slowed in recent years? We argue that these gaps represent failures in local, national, and global governance of malaria interventions. Malaria governance comprises the governmental and institutional structures and processes that: identify malaria as a priority; set ambitious but feasible goals for reducing the burden; and, equip and hold people and institutions accountable for accomplishing the defined objectives. The governance challenges that impede further progress on malaria elimination arise from many factors rooted in history, science, advocacy and culture.

We further argue that a key element of improving malaria governance is improving the strategic communications capacity of the staff of malaria programs. When we conducted a literature review on the topic, as described below, we found no examinations of such efforts. Thus in the rest of this paper we propose a framework for studying this topic further and present our case for prioritizing strategic communications for malaria governance. Among other shifts, malaria programs have to undertake stronger and more strategic communications to promote policies that would support meaningful progress towards the vision of eliminating malaria. The global COVID-19 experience has demonstrated these kinds of shifts are possible; once key stakeholders prioritize dealing with a disease and its societal consequences, the development of technology, provision of funding, deployment of human and other resources, and accountability structures all swiftly follow.

A gap in the literature

We conducted searches in the PubMed and Web of Science databases for peer-reviewed literature on strategic communications for improving malaria governance using various combinations of the terms “malaria”, “communication”, “policy”, “governance”, and “advocacy.” The vast majority of the articles we found focused on using BCC or IEC strategies with beneficiary communities, and the few we reviewed in detail proved to be only peripherally relevant. We also did a targeted search for the key terms in Malaria Journal. Again, the vast majority of the publications focused on BCC or IEC interventions. The remaining publications focused on advocating for policy changes in light of emerging research and global-level policy architecture.

We concluded that almost nothing has been published in the scientific literature about the use of strategic communications by malaria programs to engage stakeholders and foster long-term support and political commitment to the fight against malaria. This gap in the literature reflects our empirical observations about the priorities of malaria research and control programs in many endemic countries: they focus on using their resources on interventions, rather than on more nebulous concerns such as management and communications. However, we believe that in order to resume making progress towards malaria elimination, the malaria community must examine these issues. In the rest of this paper, we present a set of concepts and terms related to communications for malaria governance that we hope can become the subject of both additional research and capacity development among national malaria programs. We propose that utilizing and elaborating on this framework for strategic communications for malaria governance would enable national malaria programs to reach new levels of effectiveness.

Strategic communications for malaria governance

Throughout this essay, the term “strategic communication” goes beyond IEC, BCC, and means of communications to encompass the full range of both formal and informal activities and mediums by which human beings convey and receive information and messages. In our usage, strategic communications is the use of communication to promote an agenda—such as eliminating malaria morbidity and mortality—by engaging with current and potential stakeholders. Strategic communications is key to building a collective sense of purpose and urgency in a complex and dynamic world.

In Uganda, national malaria control strategies are created by technical experts at the Ministry of Health, often with technical support from international malaria experts. In recent years, these were codified in The Uganda Malaria Reduction Strategic Plan 2014–2020 [5]. A review completed in 2017 identified many shortcomings in the national malaria program and recommended a complete program reorientation to make it more focused, holistic and multi-sectoral, and therefore more effective.

Outlining good technical strategies, however, was only the first step. The program’s leadership realized that in order to make change, they had to move beyond asking only, “How should the national malaria control program achieve its objective: reducing malaria?” They also had to develop a more complex understanding of malaria governance. Getting the resources to implement the proposed new strategies required convincing national decision makers, who allocate the government’s budget, and the international donors that provide financial support. It also entailed convincing busy health care providers to adapt their practices, persuading stakeholders from other public sector agencies and the private sector to lend their support, encouraging political and traditional leaders to participate, and most of all, engaging with local communities—the intended beneficiaries of the strategies—to gain their trust and understand how malaria fit in with their other priorities. Communications also plays a role in building a strong team to implement malaria programming.

Components of communications for malaria governance

Constant and purposeful strategic communications is not a program that can be easily encapsulated or quantified. It requires soft skills, including tactical planning and leveraging network opportunities, that are not routinely taught in public health and civil administration training programs. However, it is an essential area for malaria program leadership. Broadly, the key elements of communications are:

• Audience: who needs to receive a given message
• Message: what the program wants the audience(s) and stakeholders to learn, understand, or do
• Medium: how the program delivers these messages to different audiences
• Messenger: who delivers the messages to targeted audiences
• Timing: when the audience is open to receiving messages

Regularly developing clarity about each of these is an important practice. For example, the message of this paper is that in order for malaria programs to be more effective in achieving their goals, they need to build their capacity to engage in strategic communications with a wide range of stakeholders. We want this message to be understood by malaria program managers and their supporters. Our medium is this essay. The messenger is the leader of Uganda’s malaria control efforts, whose experiences in his work have led him to understand this message. And by publishing this piece in conjunction with a global effort on “Rethinking Malaria in the Context of COVID–19,” we hope to reach an audience of people excited to consider new approaches to malaria control and elimination programming. So, how does a national malaria control program engage with the full range of stakeholders to “sell” them on supporting the program to pursue its preferred strategies and achieve its stated goals?

Discussion: Building a chorus of voices on malaria governance

“If a woman dies while delivering a baby, there will be an outcry from the community and an investigation into root causes. But if someone dies of malaria, it’s just normal business.”

Making malaria a “hot topic” will not happen overnight, nor will it happen if the national malaria program is the only advocate. Messages about the importance of focusing on malaria cannot come only from health professionals. Politicians and policy makers who only hear complaints about malaria from the staff of the malaria program may infer that it is not a major problem or that program staff are just angling to keep their jobs. Thus the malaria program must reach out to a wide array of stakeholders to include them in the program’s communications activities and empower them to undertake their own activities independently.

One key group in this effort is journalists, whose core mission is updating the public about pressing issues. In Uganda, the malaria program has provided trainings and information sessions for journalists to inform them about the state of malaria in the country. Following these formal engagements, journalists have come to understand the importance of a coordinated effort to address malaria as an urgent priority. They are now eager to answer informal phone calls from malaria program staff and attend their press conferences. Their coverage keeps malaria on the front pages for the public’s attention, and their questions to politicians keep the issue at the forefront of policy debates. Indeed, before the COVID-19 pandemic began, malaria was receiving the most coverage of any disease in Uganda, keeping it in the public eye and emphasizing its seriousness. While COVID-19 has altered global and national priorities around the world, malaria remains a major problem that, if it is not addressed, will experience an upsurge.

Finally, the most important strategic communications must come from the people directly affected by malaria. The malaria program must not only provide communities with services; it has to listen to their lived experiences, help them to identify likely solutions, and then organize to make their messages heard. As one Ugandan malaria advocate said: “When a clinic runs out of anti-malarial medicines, it should create the same uproar among patients and civil society groups as a stock out of HIV antiretrovirals does.” The malaria program cannot and should not do strategic communications in isolation. It has to recruit and engage other communicators—first to help them articulate the impact of malaria on their lives and health, and then to support them to do their own strategic communications about the disease. These stakeholders may include civil society organizations, patient and child rights advocates, labor unions and other industry partners, and local, religious, and traditional authorities. By developing messages and messengers collaboratively, the malaria program and its stakeholders can coordinate to make their voices heard.

Conclusion

Governance entails setting overarching goals, marshalling resources, and holding actors accountable for working towards achieving intended results. All of these governance activities involve human beings. And all human beings, and the systems we create, have our own interests. Strategic communications helps us to listen to and understand others’ interests so that we can explain to them where our interests intersect and overlap. By doing so, we can more effectively influence policy and decision making. In the case of malaria, national malaria programs need to communicate that malaria is both an urgent problem and that it has feasible solutions. Strategic communications help malaria programs “sell” the message about why and how best to address the complex challenges of malaria. Yet our literature review found no published papers examining strategic communications by national malaria programs. In response to this gap, we have therefore proposed a framework for developing and studying strategic communications for malaria governance in endemic countries.

Strategic communications for governance should be included in all leadership development opportunities for national malaria program managers. It is a natural extension of skills that are often included in leadership training, such as stakeholder analysis, decision making, change management, identifying multipolar dimensions of performance, and understanding the politics of organizations and their environment. Communication skills help bridge the gap between analysis and action by giving malaria program managers the capacity to persuade stakeholders to support the program to achieve its objectives. As mentioned, communications is a “soft skill.” There are no pat formulas for successful communication. Indeed, one feature of successful leadership is noticing what works and developing “gut feelings” about how and when to communicate with different stakeholders.

Malaria program managers need more routine opportunities to share their experiences with successful communications among themselves. Currently, most contact among national malaria program managers is mediated through international agencies and academic institutions. Efforts to support direct, “south-south” communication and learning should be fostered to enable a community of practice among practitioners that does not need to be facilitated or moderated by partners from non-endemic countries. For example, initiatives such as the ALMA Scorecard for Accountability and Action from the African Leaders Malaria Alliance (ALMA) provides senior leadership with up-to-date information on the fight against malaria, fostering transparency and accountability to stakeholders [6]. This and other efforts create opportunities to for strategic communications to improve governance at local, national, and regional level.

Ultimately, strategic communications for malaria governance represent a key approach to restoring global progress on the path to malaria elimination. We offer the framework and discussion presented in this paper as a first step towards strengthening and understanding the strategic communications approach.

Supporting information

Acknowledgments

The Working Group on Malaria Governance appreciates the comments from the “Rethinking Malaria in the Context of COVID-19” global engagement governance bodies who met with the Working Group and provided useful feedback and suggestions on this paper. For a list of individuals comprising the Steering Committee, Working Group Co-Chairs and contributing authors, and External Advisory Committee, see S1 Text.