Malaria remains a leading cause of death for children around the world, claiming half a million lives every year. In many rural areas, families live far from hospitals and struggle to get the right medicine.
My recent research – co-authored with Yoonjei Michell Dong, Sanghmitra Gautam, Marcus Holmlund, Costas Meghir and Edit Velenyi – explores whether we can save lives by training the people whom families already visit for help: local volunteers and small-scale medicine sellers. By equipping these informal providers with basic tools, we can bring life-saving care to the last mile of the health system (Carneiro et al, 2025).
Evidence from Nigeria
Our study examines the impact of a large-scale government programme in the state of Anambra in Nigeria – a country that is home to around a third of malaria deaths in sub-Saharan Africa. The experiment involved 280 different areas and followed over 42,00 households.
The programme tested three ways to help: training new community volunteers to visit homes; training existing private medicine shopkeepers; or doing both at once. All these providers were given modern anti-malarial drugs and rapid tests that can diagnose the disease in minutes.
Our results show that these local providers significantly improve the health of children. Two years after the programme started, the number of children under 12 with malaria fell by 3-4 percentage points. While that sounds small, it represents a 20-30% reduction in the total number of cases. The medicine shopkeepers were especially effective at reducing malaria for children under the age of 5.
We also find that the programme significantly improved what parents know about the disease. After the training, more families knew that fever is a danger sign and that modern drugs are the best treatment. But surprisingly, the programme did not change how often people used mosquito nets. Instead, the success came from better diagnosis and faster treatment when children fell ill.
Improving healthcare in developing countries
Our research shows that you do not always need a sophisticated hospital to improve health in lower-income communities. In many developing countries, private medicine sellers are the first place parents go when a child has a fever because they are close to home and stay open late. Our study suggests that these shopkeepers can be a vital part of the public health system if they are given the right training and supplies.
Our findings also update our understanding of how informal and formal health systems work together. Research shows that these local providers do not replace local clinics: they complement them. For example, the shopkeepers are trained to recognise complex cases and refer those children to the nearest public health facility for specialised care. This ensures that children get the right level of help before it is too late.
But our research also reveals a vital condition for success: the quality of the local public clinic matters immensely. The programme only worked in areas where the nearby public health facility was high quality. This is because the clinics are the institutions that supervise the volunteers and ensure that the medicine shops have a steady supply of drugs. If the local clinic is broken or empty, the volunteers and shopkeepers cannot do their jobs effectively.
Integrating informal health providers into national health strategies
Policy-makers should stop trying to bypass informal health providers and start integrating them into the national health strategy. Training local volunteers and medicine sellers is a cost-effective way to expand health services to rural areas that are hard to reach.
At the same time, governments around the world must also accept that training is not a magic bullet. To make these programmes work, policy-makers must also invest in the backbone of the system – the public health facilities. This means ensuring that clinics have reliable supply chains so they do not run out of drugs or tests. Without a steady supply, even the best-trained volunteer will have nothing to give a sick child.
Finally, more research is needed to see if these improvements last over many years. We also need to know if this model can be used to deliver other types of care, such as vaccines or basic nutrition for babies. If we can strengthen the link between local shops and public clinics, we might find a way to provide ‘last mile’ care for many other diseases beyond malaria.
