Introduction

Long-lasting insecticide-treated nets (LLINs) and indoor residual spraying (IRS) are the core malaria vector control tools and interventions in the global fight against malaria recommended by the World Health Organization (WHO).¹ Unfortunately, their effectiveness has been threatened due to the development of insecticide resistance of malaria vectors (female Anopheles mosquitoes) and its (malaria vector) behavioral change (outdoor biting and resting) as well as increasing concern as a result of the longstanding ecological effect of certain insecticides being used.² Due to a possible increase in outdoor transmission heightened by the increasing resistance of Anopheles species to insecticidal chemistries used on LLINs.¹ In tackling the adverse public health impact of outdoor biting (outdoor resting and feeding) of the Anopheles species, additional vector control interventions that target the mosquitoes outside of the home are needed.¹ The growing challenge of insecticide resistance in adult mosquitoes, as well as high levels of outdoor transmission may however lessen the effectiveness of LLINs thereby shifting the problem of control to larval control strategies aimed at preventing the occurrence of adult mosquitoes. In this regard, interventions/strategies that can serve as supplementary methods that would tackle outdoor transmission and insecticide resistance are needed immediately.^3,4

Globally, controlling malaria by relying on the current core vector control methods (LLINs and IRS) recommended by the World Health Organization (WHO) has proved not to be sufficient because the sustainability of these malaria control strategies has been challenged by the development of resistance as well as increasing worries about the long-standing environmental impact of some insecticides.^2,5 The majority of these malaria cases during 2018 were in the WHO African Region which is 213 million representing 93%.⁶

There were an estimated 241 million malaria cases in 2020 in 85 malaria endemic countries (including the territory of French Guiana), increasing from 227 million in 2019, with most of this increase coming from countries in the WHO African Region.⁶ In 2020, malaria deaths increased by 12% compared with 2019, to an estimated 627 000; an estimated 47 000 (68%) of the additional 69 000 deaths were due to service disruptions during the COVID-19 pandemic.⁶ About 96% of malaria deaths globally were in 29 countries. Six countries Nigeria (27%), the Democratic Republic of the Congo (12%), Uganda (5%), Mozambique (4%), Angola (3%), and Burkina Faso (3%)—accounted for just over half of all malaria deaths globally in 2020.⁶

The total number of deaths attributable to malaria in 2017 in Ghana was 599 representing a reduction of about 54.6% over 1264 malaria deaths recorded in 2016. Out of these malaria deaths, 327 occurred among children under five (U5) years in 2017 compared to 590 in 2016.⁷ In 2016, Ghana recorded 10.4 million suspected malaria cases in its Outpatient departments which denotes a 2.5% increase compared to the same period in 2015. Conversely, there was a reduction in the number of malaria-attributed deaths from 2137 in 2015 to 1264 in 2016 representing a 40.9% reduction. In 2017, the country recorded approximately 10.2 million suspected malaria cases representing about 34% of OPD cases. About 19.0% and 2.0% of total admission and total death respectively were attributable to malaria.⁷

The entire country of Ghana has been declared a high risk for malaria infection. Ghana accounts for 4% of the global malaria burden and in West Africa, 7% of the malaria burden.⁸ In 2016, Ghana recorded 10.4 million suspected malaria cases in its Outpatient departments which denotes a 2.5% increase compared to the same period in 2015. Conversely, there was a reduction in the number of malaria-attributed deaths from 2137 in 2015 to 1264 in 2016 representing a 40.9% reduction. In 2017, the country recorded approximately 10.2 million suspected malaria cases representing about 34% of OPD cases. About 19.0% and 2.0% of total admission and total death respectively were attributable to malaria.⁷ In 2018, nearly half of all populace at risk of malaria in Africa had protection from the use of insecticide-treated net (ITN), compared to 29% in 2010. Nonetheless, increases in ITN usage is thought to have been stalled ever since 2016.⁹

According to Sherrard-Smith et al¹ in a modeling study which shows that, whilst the ratio of mosquitoes biting indoors has declined, mosquito biting taking place outdoors has amplified by 10% in the year 2018 as compared with the year 2003. The findings from the study forecast an additional 12.2 million malaria cases across the Sub-Saharan Africa (SSA) region yearly, even with an anticipation of 100% coverage with the current malaria vector control tools that can be achieved.¹ The possible reasons for the alteration in mosquito behaviors could be a result of mosquitoes biting earlier in the evening and avoiding the LLITNs which people sleep under during the night, and perhaps that householders are staying outdoors longer in the evening.¹

Environmental management is the altering of the environment to avoid or reduce vector proliferation to prevent human-vector-pathogen contact through the destruction, changing, eliminating, or salvaging of empty receptacles providing conducive environment developmental stages of the mosquito vector such as eggs, larvae, pupa, and adult whereas these activities must form the backbone of vector control¹⁰ Environmental Management is in 3-folds namely: Environmental Modification: permanent carnal alterations to reduce vector larval habitats for example, consistent network water supply to communities as well as domestic connections. Environmental Manipulation: momentary changing/altering of vector habitations concerning the controlling of receptacles including regular draining and housekeeping by washing water-storage containers, flower pots, desilting of gutters, hiding or discarding empty lorry tires to prevent accumulation of water, recovering or appropriate disposal of discarded containers and tires. Modification and Manipulation: human habitat and behavioral changes as well as activities to shrink human–vector contact, that is, fixing mosquito screening on windows and doors as well as other entrances and use of mosquito nets during sleeping time either day/night time.¹⁰

The environmental management of malaria vectors could be an operational means for malaria control. Ever since the unearthing of the Anopheles mosquitoes in malaria transmission over 100 years ago, malaria control professionals have acknowledged the significance of altering mosquito larval habitats to lessen or eliminate malaria transmission. Elimination of habitats or alteration efforts have been incorporated into general programs to shrink the abundance of all mosquitoes and targeted more projects of species sanitation focused on the primary malaria vectors. The concept of modifying vector habitat to discourage larval development or human contact is generally termed environmental management (EM).¹¹

Interestingly, in East Asia and the Pacific, during the 1900s malaria was controlled in several fragments of the region by employing environmental management (EM) as a vector control strategy. Environmental management is termed as the modification and manipulation of the environment or both, serving as breeding grounds, to lessen malaria transmission by killing local malaria mosquito vectors. However, to employ this strategy one must understand the habitats of the mosquito species involved to be successful.²

There are indications environmental measures should be given increasing prominence, anthropogenic or man-made causes (such as reasonably preventable breeding sites, stagnant waters, uncovered water receptacles, encroachment, and settlement on swampy/marshy areas) should have man-made solutions, about 40% is the estimated proportion of Anopheles mosquito breeding sites (and malaria cases) which could be eliminated through environmental management (EM).¹² Strategies such as screening of doors and windows to prevent mosquitoes from entering buildings as well as environmental changes like engineering projects to limit or remove mosquito breeding sites such as draining marshes, swamps, and other areas mosquitoes may laid their eggs, that is, efforts known as species sanitation that seeks to control both the larval stages of the mosquitoes and the adults.¹¹

By 1984, the development of immature stages of (breeding) Anopheles funestus had almost disappeared from Accra as a result of the loss of natural habitats such as ponds, swamps, marshes, tree holes and resting places (trees and shrubs), as well as the adoption of mosquito control measures (screening of houses, aerosol spraying of insecticides, use of coils, control of domestic water containers (by covering receptacles with lid, removal and /or proper disposal where possible), and intermittent larvicidal campaigns with kerosene and dichloro-diphenyl-trichloroethane (DDT).¹³

Controlling the mosquitoes that transmit the malaria infection by tackling the Anophelines larval stage is an essential element of malaria control program globally through eliminating the breeding sites by way of source reduction, which is attacking the larval habitats as well as incorporating adult vector control measures, could greatly help this fight. This study was carried out to assess the prospects of Environmental Management and Sanitation (EMS) as a vector control strategy to control malaria mosquitoes outside/outdoor among stakeholders (since EMS seems to be an effective, workable, and communally conventional vector control strategy) to reduce drastically the transmission of malaria.

Materials and Methods

Results

In all, 12 people participated in the FGD discussions across the stakeholder groups, 8 of them were males whereas 4 were females. The lack of gender balance among the participants is due to the Coronavirus (COVID-19) pandemic restriction of movement in Ghana which prevented the researchers from contacting the rest of the participants. The demographic characteristics of the FGD participants are presented in Table 1 above.

Table 1.

Gender distribution of the participants of the focus group discussions.

Responses and /or opinions of key stakeholders involved in and/or concerned with malaria prevention and control in the study area are presented with regard to the FGD guide questions enumerated in the specific research questions above.

Discussion

This study explored the knowledge and opinions of key stakeholders on the prospects of environmental management and sanitation (EMS) as a malaria vector control strategy. The stakeholders’ discussion focused on EMS as a supplementary or alternative malaria prevention and control strategy amid insecticide resistance and vector behavior change.

The findings show considerable agreement across the stakeholders on stagnant water being the main breeding site for mosquitoes. The health professionals indicated stagnant waters that are relatively clean as well as rice fields, and pools of water are where Anopheles (female) mosquitoes breed whereas the Honourable Assembly Members identified leaves of trees that accumulate water in bushy areas around our houses, uncovered water receptacles and polluted waters. These responses are consistent with findings from other studies which stated that larval habitats such as impermanent, standing, or slowly moving water under a shadow are known breeding sites of Anopheles.² While principal sites ensue year-round and tend to be connected with the stream system in a deep forests, mosquito habitats can include freshwater wetlands (swamps, flood plains, riverine forests, and swamp forests), mangroves, and coastal wetlands (lagoons, estuaries, and tidal mudflats).²³ However, they differ in nature with regards to the season where there are stream beds, pools connected with streams, or meanders of slow-moving streams in the dry season.^24,25 The malaria epidemic might emanate as result of the development of dams, and irrigation schemes, which alter the local environment and subsequently the preceding ecological balance.²⁶ It is noted that Anopheles breeds in wells near houses in certain areas all over the year even when densities of these wells are declined in the dry season²⁷ and secondary larval habitats occur in the rainy season and can be found closer to human settlement at the forest fringe such as shallow, temporary, shaded water-holding depressions and in long marshy areas (swamps).²⁸

Environmental factors such as rainfall, humidity, and temperature have been mentioned by the health professionals while mainly poor sanitation (presence of empty gallons, empty cans, and plastic containers) and lack of drainage systems were considered the main factors contributing to mosquitoes breeding addressed as the main factors that were raised by the Honourable Assembly Members. This agrees with a study by Kyi,²⁹ which indicated that moderate, warm temperatures, high humidity, and wetlands/swampy areas within the tropical zones serve as environmental conditions and factors that provide a readily available receptive environments which is responsible for mosquito breeding and proliferation and malaria transmission differs seasonally due to mosquito populations’ densities during these periods. According to Obsomer et al,²⁶ the commonest causative element in malaria epidemics is abnormal climatological settings which alter the environmental balance between human hosts and parasites. The breeding sites (place of laying of eggs) of mosquitoes is influenced by many environmental factors such as climatic conditions which includes temperature, rainfall, vegetation, salinity and turbidity of the water, the size of the breeding habitat, and the amount of sunlight.³⁰ The ability of mosquito larvae to survive depends on the temperature of the larval habitats which could impact larval development, pupation rate and time.³¹ Discrepancy in respect of rainfall patterns as well as changes in seasons (dry and rainy) is noted to influence the presence of larval habitats and its proliferation.³² Landscape features such as topography, land cover, and land use influence the formation, distribution, and microclimate conditions of larval habitats, which in turn influence the distribution of adult Anopheles vectors.^33,34 Bugoro et al,³⁵ in a study demonstrated that, the presence and abundance Anopheles farauti larvae were influenced by environmental factors (ie, floating filamentous algae, aquatic emergent plants, sun exposure, salinity and rainfall) within the large streams and a good understanding these parameters will allow for targeted cost effective implementation of source reduction and larviciding to supplement the core malaria vector methods IRS and LLINs.

There was a consensus among all the participants, on settlement around wetlands (swampy or marshy areas) area could significantly contribute to malaria prevalence in the community because Anopheles species such as female Anopheles gambiae, Anopheles funestus, etc. breeds in these areas). This findings agrees with a study conducted by Hinne et al³⁶ in Ghana, shows that swamps and furrows ranked the most prolific larval habitats of Anopheles mosquitoes in the Sahel savannah zone during the dry and rainy seasons, respectively whilst larval habitat types were influenced by the presence of larvae as well as larval density. Also, the land-use type affected the presence of Anopheles larvae whereas vegetation cover influenced larval density. Further, the researchers concluded that, the abundance of Anopheles breeding habitats and larvae were influenced by anthropogenic activities and therefore the involvement of community members whose actions and activities turned to produce larval habitats to participate in larval source management including habitat manipulation with the aim of stopping mosquito breeding is paramount for malaria prevention and control.³⁶

According to Celli,³⁷ aside from genetic adaptation, the most common human strategy for limiting malaria infections historically was geographic and avoiding mosquito breeding sites such as swampy areas and clean stagnant waters. Avoiding malaria is the reason that the United States Congress and Supreme Courts had a summer recess to avoid Philadelphia and Washington DC during the months when malaria was most common; similarly, communities of British in Colonial India moved to Hill stations in summer believing them to be healthier than lower elevations. Larvae of Anopheline species can be found in a wide diversity of habitats, ranging from small, temporary pools and puddles to large and more permanent water bodies. The aquatic life cycle of Anopheles species starts when a gravid female mosquito deposits her eggs on or very near the water in swampy areas or around stagnant waters.³⁸ Complementary interventions might be suitable in a particular situation, for example, larval source management in situations where mosquitoes’ aquatic habitats are insufficient, immovable as well as visible.³⁹

On the types of vector control strategies employed in the Municipality, according to the Regional Malaria Focal Person, Sunyani, the National Malaria Control Programme (NMCP) employed integrated vector management (IVM) (ie, use of, prompt and effective case management (test, treat, and track), Intermittent preventive treatment for pregnant women (IPTp) (Sulphadoxine pyrimethamine (SP), LLITNs, IRS, and larviciding/bio-control). It was noted that the NMCP has started a piloting programme implementation on malaria vaccine among children up to 6 to 24 months. The Environmental Health Officers and Honourable Assembly Members called on community members to consider taking responsibility for cleaning their environment to eliminate mosquito breeding sites and advised community members to use LLITNs and IRS. Interestingly, the Honourable assembly members stressed the need to employ local biological control methods such as the pouring of dirty oil or kerosene on the surfaces of stagnant waters to prevent mosquito breeding and larvae survival. The development of biological control agents such as natural enemies and organisms pathogenic to the larval and adult stages such as the use of kerosene has helped to reduce the larval populations.³

The participants highlighted 3 supplementary or alternative options as an anti-malarial prevention method. The use of social and behavior change communication (SBCC), strengthening the previous environmental management (EM) options, and social mobilization (communal labor) of the local community to embark on clean-up exercises (to remove mosquito breeding sites). These opinions or suggestions of the participants corroborated with findings of research conducted in urban Tanzania where the majority of participants stressed the importance of environmental management to remove mosquito-breeding sites as the most effective strategies for controlling outdoor-biting mosquitoes and malaria.⁴⁰ Except intermittent preventive treatment of pregnant women, IPTp (currently the use of sulfadoxine-pyrimethamine was mentioned), other important and sensitive supplementary or alternatives methods such as mass drug administration for the general population, gene drive technology (ie, genetically modified mosquitoes), and biological control methods such as the use of Bacillus thuringiensis var. israelensis (Bti) as a novel biological control agent for malaria and its vector control in the community that was mentioned by another research study from Tanzania^41-43 were not mentioned by the participants of this current study. This could be due to either the lack of knowledge and/or the non-availability of such options in our study area. The majority of the participants unanimously agreed extra efforts and additional interventions are required other than the current interventions to reduce the burden of malaria, which was consistent with findings from malaria endemic areas of Africa.⁴⁴ One of the missing links regarding the implementation of environmental management and sanitation as a vector prevention and control mechanism was the recognition that different types of mosquitoes might have different habitats for breeding as stated in Finda et al.⁴⁵ For malaria eradication to succeed, all elements in the transmission cycle must be sufficiently targeted, taken into consideration with the current vector control tools where only indoor- and late-biting, and indoor-resting vectors are tackled. However, there is a gap in protection, not only before sleeping time but also for people that remain outdoors during the night. A specific mosquito behavior assuring its vectorial status is only relevant concerning specific human behavior and the relation people have with their surrounding environment. According to Durnez and Coosemans,⁴⁶ larval control must be included as part of the integrated vector management (IVM) programs on the condition that malaria elimination remains the ultimate goal whilst the prominence of larval interventions has newly re-claimed consideration in malaria control.⁴⁷ Ferguson et al⁴⁸ indicated that other tools not relying on the host-vector contact (such as larval control and environmental sanitation measures) can supplement ITNs and IRS as they are not specific for indoor biting and indoor resting mosquito populations.

The participants mentioned that they worked with local and international organizations and institutions such as development partners, non-governmental organization, and government agencies who are responsible for malaria control as well as religious bodies who have demonstrated a keen interest in environmental care or cleanliness, and traditional and opinion leaders (Chiefs and Unit Committee). These views expressed by the respondents rightly corroborate with the findings of a similar study conducted in Rwanda where the participants considered the involvement of various stakeholders as key to success in malaria elimination, including stakeholders at the national level, community grassroots level, and partnership between the national and local level as well as other community.⁴⁹ According to National Malaria Control Programme,⁷ a project that was implemented based on processes of mass education and stakeholders engagement and involvement was very successful with some modest achievements (ie, 60, 200 audiences were reached in 172 remote communities, 90 schools and 43 Districts from 10 Regions in Ghana) where major stakeholders in the health sector such as Community Health Workers, District Health Officers, Honourable Assembly Members, Traditional Authorities, the Clergy, and Teachers to use a single platform to address social and behavioral change against the burden of malaria among community members.

Despite stressing the important of stakeholder collaboration, it was noted in the current study that there was lack of effective collaboration among the stakeholders especially National Malaria Control Programme (NMCP), Environmental Health Officers (EHOs), and Honourable Assembly Members (HAMs) that is serving as a major challenge against fighting malaria. In most malaria-endemic countries, there is lack of effective collaboration among local experts such as public health officers, medical entomologists and engineers from different sectors to plan, implement, monitor, and evaluate control interventions including conducting health impact assessments (HIAs).^50,51

The stakeholders stressed the importance of robust educational campaigns on environmental management and sanitation on different media platforms and educational levels from nursery through to universities. It was noted that stakeholders organize discussions on malaria control and educate the community on environmental management and sanitation on radio/TV, in churches, mosques, and information centers. This was consistent with findings from a study conducted in Tanzania which focused on the effectiveness of mass behavior change communication (BCC) campaigns on the importance of environmental management and sanitation as the main tool for sustainable, community-led malaria control⁵². According to National Malaria Control Programme,⁷ community radio stations were used, whereby some of them had a listening audiences beyond the selected districts which were used for mass education on malaria prevention and control in local languages. However, this helped the team to reach the audience who could not come to see the cinema shows during the mass education campaign. According to Ingabire et al⁴⁹ in a study conducted in Rwanda, participants expressed the need for repeated intensive education with a focus on malaria prevention methods, malaria symptoms, and correct use of bed nets, the benefits of indoor residual spraying, and hygiene and environmental cleaning. A study conducted by Ahmed and Isaac in the Volta Region of Ghana, recommended sensitizing or educating the inhabitants as well as the general public on sanitation in basic schools to create some level of awareness as well as strengthening and equipping the Municipal Assembly in the area by the Government would help ensure frequent monitoring and regulate waste management in the area.⁵³

The findings showed considerable agreement amongst participants on the importance of law enforcement regarding environmental and sanitation bye-laws in the prevention and control of malaria. The stakeholders stressed that even if the law exists, the lack of implementation or enforcement would not encourage or force people to keep their environment clean thereby removing mosquito breeding sites to prevent and control malaria transmission in the community. However, among the reasons given by the stakeholders as to why there seems to be a difficulty in the enforcement of environmental sanitation bye-laws are (a) Political interference, (b) Lack of commitment and political will from government, (c) Indiscipline, (d) Low charges/fines and non-prosecution of sanitary offenders, and (e) Lack of empowerment and inadequate resourcing of the Health Inspectors (EHOs). According to Sangoro et al⁴² a major issue voiced out by all stakeholder groups in a similar qualitative study was the lack of clear regulations and enforcement on environmental management (EM) regulations though EM look like a malaria prevention method which is not supported by the law although it seems to be cost-effective method. Environmental management and sanitation (EMS) interventions could be implemented because a higher chance of exposure from outdoor biting can occur in breeding sites known for female Anopheles mosquitoes that are left without any intervention supported by law enforcement.⁵⁴ Law enforcement may support the implementation and sustainability of EMS for malaria control as a supplementary tool against malaria, by reducing overall vector populations including those that may bite outdoors.⁵⁵ The importance of law enforcement regarding Environmental management and sanitation interventions is vital during summer times, when a great proportion of people are forced to spend more time outdoors because of higher temperatures.⁵⁶ The finding of this study regarding law enforcement practice was different from other findings from eastern Rwanda, where a community-based initiative where local communities were engaged in monthly community clean-up activities or works aimed at destroying mosquito-breeding sites around homes was successfully implemented. This activity was then promoted and maintained to regulate environmental conditions at the community level and later was found to have help in the reduction of the malaria disease burden.⁵⁷

One interesting finding of this study was the issue of the high government support/political will. The majority of the stakeholders believed that the government has not been giving enough support and political will in the allocation of funds for the prevention tasks as well as the inclusion of the prevention tasks in the objective of projects that are under way such as road projects. The stakeholders emphasized that central and local government authorities must avoid political interference to allow the Health Inspectors to strictly enforce the environmental sanitation bye-laws. Environmental Health Officer stressed that there is allocation of funds (though inadequate) to the EHSD but the funds are not reaching the intended purpose (them). The Government support was addressed as funds and supports were not only inadequate but also adequate and being misused. As indicated by Sande et al in a study conducted in Zimbabwe,⁵⁸ lack of capacity building mainly due to lack of human resources and inadequate infrastructure is the main reason put forward for the little government support for malaria prevention and control. According to Dr. Margaret Chan, a former Director General of WHO, “Recent progress on malaria has shown that, with adequate investments and the right mix of strategies, remarkable results could be achieved if strong political commitment and expanded financing are in place.”⁵⁹

There were many challenges raised regarding the stakeholders’ collaboration in malaria prevention and control in the Sunyani Municipality. The stakeholders were many but their actual integration was restricted at the Regional level. It was characterized by seasonal involvement mostly on occasions such as “World Malaria Day” and “environmental care campaigns” but the involvement was relatively stronger at the lower level where the community significant others such as Chiefs and Unit Committee Members, Pastors, Religious Leaders are included in the malaria prevention and control tasks. It was also stressed that the collaboration between the Malaria Control Focal Persons and concerned professionals at the grass root level is very poor. The issue of inadequate financial support, access to LLINs by community members, and poor attitudes of residents (community members) with regard to ownership and usage were described as key challenges. Lack of reliable funding opportunities for mosquito control operations and the lack of initiatives to apply leverage in support of mosquito control by other government and community agencies are common problems being faced with malaria control in Africa, the Middle East, and the Americas.⁶⁰ Further, findings from this study highlighted political interference, lack of educational materials (teaching and learning) to carry out health education and promotion activities in the community, lack of means of transportation, and recognition by government authorities were outlined as part of the challenges being faced by the various stakeholders (especially the EHOs and HAMs) in the fight against malaria in the Municipality. According to Lemon et al,⁶¹ deterioration of public health infrastructure, lack of adequate funding, lack of adequate training and training models, over-specialization in the biomedical sciences, driven by emerging technology and emphasis on the basic sciences, and bureaucratization were identified as key bottlenecks affecting finding lasting solutions for vector-borne disease (VBDs). However, for a successful implementation of malaria control programs, the National Malaria Control Programmes must address these bottlenecks.

This weak integration and /or involvement was identified as one of the threats to the strategy of malaria prevention and control in sub-Saharan Africa in addition to weak advocacy and inadequate promotion.^62,63 According to a study conducted by Nganga et al in western Kenya, stakeholder collaboration in the management of malaria prevention and control programs should not only target the prevention and control of malaria, rather it shall integrate other vector-borne diseases to maximize the outcome.⁶⁴ An innovative country-driven response, dubbed High burden to high impact has been launched in Mozambique in November 2018. This new line of attack is presently under implementation and driven by 11 nations that are malaria endemic and carries the highest burden of the infection i.e., Burkina Faso, Cameroon, the Democratic Republic of the Congo, Ghana, India, Mali, Mozambique, Niger, Nigeria, Uganda and the United Republic of Tanzania). Important fundamentals of this novel approach include (1) Political will to reduce the toll of malaria, (2) Strategic information to drive impact, (3) Better guidance, policies, and strategies, and (4) a coordinated national malaria response.⁶⁵ In addition, maintaining high coverage levels will require effective distribution approaches aimed at strengthening all routine delivery mechanisms and improving integration with other disease programs where appropriate. Increased decentralization of decision-making and budgeting will facilitate strengthened community participation in the delivery of interventions.⁶⁶

The study had limitations. Due to the Coronavirus (COVID-19) pandemic and its restrictions on human movement in March 2020, the researchers could not reach the set target sample size of conducting 16 focus group discussions as well as causing a gender balance bias (recorded more males than females) among the participants.

Conclusions

Due to current documented reports of malaria vector behavioral change (outdoor biting and resting) and insecticides resistance that seems to help malarial vectors to evade the core vector control methods (LLINs and IRS), alternative vector control interventions are needed to further reduce malaria transmission. Findings from this study shows the prospects of environmental management and sanitation (EMS) as a vector control strategy and/or supplementary option that would help in the fight against malaria due to the residual transmission that is happening outdoors.

However, EMS could be employed as a vector control strategy and/or supplementary option if the following conditions and bottlenecks are addressed and in place: (a) Effective collaboration among key stakeholders such as National Malaria Control Programme (NMCP), Environmental Health and Sanitation Department (EHSD), Honourable Assembly Members (HAMs), Non-Governmental Organizations (NGOs), Private Sector, Traditional Leaders, and Religious Bodies; (b) High Government (central and local) support and political will through the adequate allocation of funds to the Environmental Health and Sanitation Department (with a dedicated account to reach them) and Honourable Assembly Members (HAMs); (c) Enactment /instituting of robust educational campaigns across all educational levels and via different media (Radio/TV, Information Centres, Churches, and Mosques) on environmental management and sanitation; (d) Recognition, empowerment, and adequate resourcing of Health Inspectors (Environmental Health Officers) to effectively and efficiently enforce the environmental sanitation bye-laws to ensure residents remove or eliminate mosquito breeding sites; (e) Adherence to settlement away (building and living around) from natural wetlands (swampy/marshy) where there are high Anopheles mosquito population densities; (f) Revision of fees/charges/fines and strict prosecution of sanitary offenders and reinforcement of communal labor exercises; and (g) Enactment /instituting Environmental Sanitation Day (ESD), adequate provision of sanitary infrastructure (proper drainage systems), and the establishment of the Environmental Health and Sanitation Fund (EHSF).