KAMPALA, Uganda – After five years of focusing on malaria prevention through Seasonal Malaria Chemoprevention (SMC) in the Karamoja region in northeastern Uganda for children under the age of five, Uganda’s Health Ministry has decided to extend the intervention to children up to the age of 10.

SMC is the intermittent administration of a curative dose of antimalarial medicine to children at high risk of severe malaria living in areas with seasonal transmission, regardless of whether they are infected with malaria. 

Since it was introduced, there has been a modest 13% reduction in malaria cases in children aged three to 59 months, according to the Uganda Ministry of Health’s National Malaria Control Division.

Uganda is one of the worst-affected countries in Africa for malaria.

Dr André-Marie Tchouatieu, senior director of medical affairs at the Malaria Medicines Venture (MMV), described the extension of SMC to children older than five years old in Uganda as “one of the most impactful, evidence-backed strategies available to reduce the country’s malaria burden”. 

“By reducing the parasite reservoir, closing the immunity gap in older children and protecting this high-risk group, age-extended SMC could dramatically accelerate Uganda’s progress toward malaria control, and potentially elimination, in seasonal transmission zones,” said Tchouatieu.

“The combination of strong clinical evidence, WHO’s updated guidance on SMC and Uganda’s existing infrastructure makes this scale-up both feasible and urgently needed.

Lives saved

“Since SMC was introduced, many children’s lives have been saved in my region,” Lotee Paul Komol, chairperson of Kotido district, told the first-ever joint annual meeting of the SMC Alliance and the Alliance for Malaria Prevention (AMP) held in Kampala last week.

 In Africa, SMC has already been implemented at scale in 20 countries, 14 of which are in the Sahel region, according to the World Malaria Report 2025.

 “This intervention was delivered at the right time, and it has significantly reduced malaria deaths among children under five,” Komol told Health Policy Watch. 

“As leaders from Karamoja, we are extremely proud that we were prioritized and it was implemented in our region. We no longer see parents flooding health facilities with children suffering from malaria, as was once the case. SMC has put a smile on the faces of many mothers,” he said.

 In 2013, about a million children received SMC, but by 2024, this had risen to around 54 million. The success of SMC led WHO to recommend its expanded use for any child at high risk of severe malaria in Africa, irrespective of age and geography.  

In Uganda, the SMC program started in 2021 in Moroto and Kotido, with Nakapiripirit serving as a control during the evaluation phase. Once the government saw that it was feasible, the program was expanded to nine districts in the Karamoja region, including Moroto, Kotido, Nakapiripirit, Nabilatuk, Amudat, Abim, Napak, Karenga and Kaabong by 2023.

 “When we realized that it was feasible, we mobilized resources and began to scale up,” said Dr Jane Nabakooza, a senior medical officer and technical lead for Malaria Chemoprevention and Vaccines at the Uganda Ministry of Health’s National Malaria Control Division.

Integrated approach

The Uganda SMC programme also realised that the intervention could not be delivered in isolation, so it was included in the integrated Community Case Management (iCCM) being implemented by the Village Health Teams (VHTs). These had a strong module on referral.

“SMC is not a stand-alone,” Nabakooza said. “It has to be done with other methods.” For instance, VHTs under SMC were cautioned not to dispense medicines until they established that the children had no malaria.

“If they were infected, medicines were withheld until treatment was initiated. If they had malaria signs, referral to the nearest health centre was done,” said Nabakooza. As such, the relationship between VHTs and health facilities deepened.

“If you do not plan with the VHTs, you miss a lot because they have the solutions to most of the problems and their lived experiences shape how malaria interventions succeed or fail,” she explained.

At the community level, SMC teams confirmed that households had bed nets, were using them properly, and identified children who had missed routine vaccines.

They were referred to health facilities, but many did not follow through and visit the facilities. 

“Subsequently, the SMC teamed up with vaccination teams, not only for malaria but for all childhood vaccines,” Nabakooza said.

But as the project was rolling out, weaknesses quickly became visible. VHTs could identify sick children, yet stock-outs meant they often had no medicines. Reporting was weak, and their contributions went undocumented.

“This was solved by strengthening supply chains, improving supervision, and tightening reporting systems,” said Nabakooza. 

But still, the results were not good. Data appeared weak, partly because reporting tools were not robust enough and some health workers struggled with documentation. 

Digital dashboards

Digitisation was also introduced into SMC and staff were retrained and supplied with new tools and a robust surveillance system to identify problems and act accordingly.

Brenden Williams, co-chair of the Humanitarian and At-Risk Populations (HARP) Working Group, said national malaria programmes are leading the use of real-time digital dashboards to identify and correct registration errors mid-campaign, ensuring accurate data-driven decisions that were previously impossible with paper reporting.

Williams presented the meeting with data from national malaria programmes and partners in Burundi, Chad, Mali, Nigeria, Pakistan, Somalia, and South Sudan.

In Ghana, an electronic data system for all interventions – Insecticide Treated Nets (ITN) mass campaigns, SMC, and larviciding (killing mosquito larvae) – has been developed. All electronic community intervention data systems are in the process of being harmonised into one platform called the Ghana Malaria Interventions System (GMIS).

Moving to digital platforms generates long-term savings by reducing logistical costs and preventing over-procurement through more accurate population estimates, said Williams.

It also fosters national ownership by training local government staff to manage technical operations, reducing reliance on external support and improving the user experience for field volunteers.

But while SMC is designed for highly seasonal settings, Uganda wants to expand it beyond Karamoja’s single rainy season to regions like Lango and Acholi that have two rainy seasons and are more densely populated regions. This would mean reaching more children and lowering the cost of intervention per chil

The rationale is that children who survived malaria often carried infections that re-exposed younger children. So in 2025, SMC was extended to children aged five to 10 in Napak, Abim, Karenga and Kaabong.

While the results are still being analyzed, one outcome is already clear. “We reduced the cost per child from $4 to $1.71 over five years,” said Nabakooza.

In the Gambia, they also want to implement SMC for children up to 10 years old because they think it will enable them achieve elimination.

But Peter Olumese, the World Health Organisation (WHO) technical Lead of malaria case management in the Malaria and NTD Department, is sceptical.

“SMC has to be done in areas where the transmission is seasonal. In most parts of Uganda, you have perennial seasons. That means transmission happens all year,” he told Health Policy Watch. 

“During the rainy season, malaria cases go up. That is not seasonal transmission. That is perennial transmission with seasonal variation, which is different from the Sahel region, where you have malaria during the months of July to October, and after that, there is little or no malaria. Even when children have a fever, you do not think about malaria. So that is where you should be doing SMC,” he said.

“Technically, speaking from a WHO perspective, [Uganda] should not be implementing this, but a country has a right to choose to do what they want to do,” he said.

The meeting also served as a shared platform for countries and implementing partners to exchange experiences, innovations and best practices, particularly in light of the revised WHO malaria guidelines and the shifting funding landscape as nations prepare for Global Fund Grant Cycle 8.

“The beauty of it is having 29 African countries and combining the two meetings.  At the end of the day, country programs here are hearing from each other and learning, plus exchanging ideas. That is one of the best things,” said Olumese.

Image Credits: UNICEF.