Two answers to the same question, written five days apart.
A registered general nurse working in a CHPS compound in the Nanumba North Municipality of northern Ghana, Musah Iddrisu Naporow, was asked to imagine a new tool that would solve all his malaria problems.
He answered in one acronym.
“SPAQ.”
SPAQ is sulfadoxine-pyrimethamine plus amodiaquine, the two-drug combination given to young children once a month through the rainy season to stop malaria before it starts.
The World Health Organization recommended it in 2012.
Community health workers carry it door to door.
It reaches tens of millions of children a year.
Charlotte Temboum is a midwife at a district medical centre outside Yaoundé, in Cameroon.
Asked the same question, she designed something that does not exist.
Her team has artemisinin combination treatment.
What they lack, she wrote, is any way to know in advance whether it will work.
So she specified the instrument: a drop of blood, and in 10 minutes it tells you if the K13 mutation is present, predicting the risk of artemisinin failure, and identifies the alternative treatment to give.
A midwife had written a target product profile.
She did not use the term, and she had not yet read a word of the “new tools” curriculum.
Between those two responses lies much that is interesting about what the people who use malaria tools imagine about the next ones.
Nobody usually asks them
On 31 August 2026, The Geneva Learning Foundation opened “Malaria: New tools to turn the tide”, the second certification in its Malaria: Turning the tide programme, in English and in French.
The first week was introductions, and it was not a survey.
Nobody was sampled or scored.
Participants were asked to write for their colleagues, read what others had written, and reply.
Three questions.
- Who are you and what do you do.
- What are you missing to end malaria in your community.
- Imagine a new tool that would solve all your malaria problems, and tell us what it does.
The third question is the unusual one.
Operational malaria staff are asked to design, implement, and report on interventions.
They are rarely asked what they would build.
And this was week one, before participants began exploring a subset of new tools chosen for this certification.
Nobody had told them yet which 14 tools would be covered, how far along each one is, or how strong the evidence behind it is.
The answers are therefore what this workforce thinks a new tool should be.
In that first week, 656 people from 39 countries wrote 891 posts and 1,659 replies to one another.
The largest groups came from the Democratic Republic of the Congo, 192 people, and Nigeria, 97, which together supplied 44.1% of participants.
They came from every level of the health system.
Facility staff were the largest group, 229.
District level, 131.
Regional, 99.
National, 169.
International and multi-country, 28.
Among them 207 doctors, 148 public health workers, 86 nurses, 42 community health workers, 32 pharmacists, 9 midwives, and 132 in other roles.
They were also reading across geographic and linguistic borders.
Anglophone and francophone malaria work run on separate circuits, with separate meetings and separate networks.
Here, nearly two thirds of all replies (63.2%) crossed a national border, across 296 pairs of countries.
A nurse in Zambia answered a colleague from Ireland.
A doctor displaced from eastern Congo answered a student in Benin.
What they asked for, counted
The French posts were analysed in full for what people asked for. The most frequent requests were community education (147 of 652 posts), a vaccine (145), medicines (134), financing (129), and training (128), and the English posts showed the same order at the top. The French responses showed four shapes.
- Something that already exists. Of 100 answers, 14 asked for existing tools applied fully or combined, and 7 asked for a vaccine. Across all French posts, the vaccine appeared in 145. On the surface, this could be misconstrued as a failure of imagination. It is not, and we will return to this.
- A way to see their own district. In French, 33 of 100 answers described the same machine in different words, and in English 45 posts used the language of real time, hotspots, prediction, or early warning. It detects, maps, alerts, reminds, connects. They named it themselves: Palu-Alert. PaluGuard. MAL-SCAN. Radar Paludisme. Malaria Smart Surveillance. A PHC Malaria Stock and Tracking Hub. A community fever node.
- Permanence. In French, 44 posts used the language of a definitive or total solution, once and for all, zero cases, and some asked for immunity for life, protection that does not have to be renegotiated every evening.
- The mosquito gone, and nothing else harmed. Eight of the 100 answers imagined a tool that eliminates the mosquito, often on condition that it spare the rest of nature, and 16 French posts in all asked for one.
What almost nobody described was the pipeline.
Of 891 posts, 90 named even one of the 14 tools the certification teaches, about 10%.
Four tools out of the 14 drew no mention at all, including the first malaria medicine ever dosed for newborns and infants, added to WHO’s purchasing list on 24 April 2026, four months before the cohort was asked these questions.
Vaccines came up in 181 posts.
In 169 of those, more than 9 in 10, no product was named.
People wrote “the vaccine.”
RTS,S was named 7 times in 891 posts.
R21, 7 times.
All of them in French.
The gap follows position in the health system, not language.
At national and regional level, roughly 1 post in 8 named a tool.
At facility level, closer to 1 in 13.
Among community health workers, 1 post out of 62.
A chi-square test shows that the pattern is unlikely to be chance (p = 0.02).
We found no difference between the English and French groups (p = 0.68).
“New” means when a tool reaches your community
Francis Teye works for Ghana Health Service in the Eastern Region. Asked what tool he lacked, he gave a count and a border: “Seven (7) out Sixteen (16) regions in Ghana are currently implementing Malaria vaccination for children. My own region (Eastern) is not part of the implementing regions.”
Julien Kingombe, a doctor in Lubero health zone in North Kivu, described the malaria vaccine as the new tool his team had not yet experienced, because it is not yet available where he works.
Elie Noro Raholimalala, a laboratory technician in the parasitology unit at Institut Pasteur de Madagascar and a WHO-certified malaria microscopist, wrote five words: the vaccine does not exist here.
For these three, a recommended, prequalified, deployed vaccine is a new tool.
It exists.
It works.
It has not arrived.
This is one hinge in the exercise.
In a product pipeline, “new” means not yet approved.
At a CHPS compound in northern Ghana, “new” means it has not arrived.
Those two definitions do not overlap, and the people holding the second one are the people who will be asked to explain the first.
Musah Iddrisu Naporow’s one-word answer reads differently in that light.
SPAQ is not his failure to imagine.
It is a statement about supply.
The claim should not be pushed too far, and the full analysis behind this article says so.
These answers cannot be matched against deployment records.
Establishing that availability drives what people imagine would take a study nobody has done.
What can be said is that the pattern appears in both cohorts, and that several people said it outright.
They asked to be able to see
The most common imagined tool, in both languages, was not a molecule. It was sight. Here are five examples:
- Beman Ouattara Ali, a state nurse in Côte d’Ivoire, works outreach in remote villages. He has no dashboard: he does not know where the active foci are, which families used their nets, or who has not consulted in 6 months. His summary runs four words: “I work blind”.
- Stephen Olawore trains community health workers for the monthly SPAQ rounds in Nigeria. He described the limit of what he can see: “I can see our coverage numbers, but I cannot easily see which specific households were missed, which children received incomplete doses, or where community resistance is concentrated. Until it is too late to correct it within the same cycle.” A household nobody visited and a household that refused look identical in his report, and the report lands after the round has closed.
- Noé Patrick M’Bondoukwé has spent 13 years at the Mélen sentinel surveillance site in Libreville, Gabon. He located the failure precisely: it is not knowledge we lack, it is the connection between what we know. Case data, entomological data, resistance markers, climate variables, each in its own silo, months between collection and decision.
- Marlène Kapinga Mulumba, who works in continuing education at the Ministry of Public Health in the Democratic Republic of the Congo, wrote the sentence the others were circling: data that stays in a register does not change the situation.
- Derick Asare, a pharmacist and public health practitioner in Ghana, named the same broken circuit: “a feedback loop that data goes up and never comes back down to the community that produced it.” His own answer to the new-tool question was a community fever node, placed where people actually go first, the chemical seller and the community pharmacy: it reads the test, refuses to log an antimalarial against a negative result, checks the medicine pack is genuine, and texts the patient on days two and three. The point, he wrote, is that “It makes the right decision the easy one, and brings the informal first contact inside the surveillance system instead of leaving it outside.”
Five people at five levels of one system asked for the same thing.
That is a request to stop working in the dark.
This comes at a time when the global malaria community wishes there was more, better use of local data, where service delivery happens.
They asked to stop persuading
The second wish is harder to hear.
- Stellamaris Wanjiku, a medical social worker and community health volunteer in Kenya, wanted a tool that would work “instead of wrestling with supply shortages or begging people to remember daily prevention habits,” one that would interrupt the parasite’s life cycle “with zero ongoing human effort.” That sounds like a wish for magic until you read what the persuading involves.
- Emile Welo, a public health doctor in the Democratic Republic of the Congo who has run net distribution and independent monitoring across three provinces, reports that the population does not use the net. The commonest complaint is heat: under the net one suffocates, and it is genuinely hot where he works. In Haut-Lomami, as the fish grew scarce, nets went into the water to catch them.
Asare, in Ghana, described what happened when teams stopped asking households why they did not sleep under their nets and asked instead to see the net.
The answers were “the room was too hot, the sleeping mat was in a place with nowhere to tie the net, or the household had four nets for eleven people sleeping in shifts.”
Those are solvable problems, he wrote, but only if you ask in a way that lets people be honest.
Mercy Magwanga, a nurse in a refugee setting in Kenya, described the case where the standard tool cannot be used at all. Nets are often impossible to hang in temporary, roofless or transient shelters. She is the only person in the English cohort who named spatial repellents, the room devices WHO recommended in 2025, and she defined one precisely: a lightweight, passive, portable sheet or device that continuously releases an active ingredient into the air. She arrived at that product by reasoning from the absence of a roof.
Read Wanjiku’s wish against those three accounts and it changes character.
She is asking for a tool that does not depend on winning the same argument in the same household every night for twenty years.
That is a design requirement, and it is one the certification itself takes seriously.
What participants do after the primer is not memorise the 14 tools.
They write up one occasion when they introduced something that was new at the time, then plan what they will listen for in one real family, then draft the actual words they would say about a tool that has not arrived yet, including the sentence admitting it is not available and the sentence saying what it cannot do.
The specifications they wrote without being asked
Several answers were closer to engineering than to wishing.
- Ismail Abdullahi Ridwan, working in community health in Jos, Plateau State, Nigeria, imagined a handheld kit called MAL-SCAN that in two minutes would “test from a finger prick not just if it is malaria, but which species and drug resistance pattern,” then report the geolocated case automatically.
- Olubayode Akinwumi is a pharmacy technician with the Ekiti State Primary Health Care Development Agency, dispensing malaria treatment. His constraint is concrete: “ACTs and RDTs often run out mid-month at PHCs.” His tool is a PHC Malaria Stock and Tracking Hub that predicts the stockout before it happens.
- lys kuwa, a doctor at a health facility in Kinshasa, wrote a specification as a list of constraints rather than functions. The tool must not be expensive. It must be accessible to everyone. It must respect the environment, meaning the fauna, the flora, and people. It must be usable without electricity or solar panels. It must not be dangerous to the community.
Any procurement officer would recognise that document.
Safiyya Mustapha, a human physiologist in Nigeria waiting to begin a master’s in public health, reasoned from reservoir biology rather than from a product list: “If a vaccine can completely clear the parasite from human hosts, the mosquitoes lose their source.”
And two answers together reorganise where a new tool would even have to land. Nathan Binene Kayeye, a nurse with 20 years in malaria care who chairs the private health facility owners’ association in his zone of Lubumbashi, reports that in his area the private sector handles nearly 90% of this work. Noelly Zola Watusadisi, a doctor in Kinshasa’s Gombe health zone, explains why: given what hospitalisation costs, the community treats itself.
A tool introduced only through public facilities would, in those two accounts, miss most of the first contacts.
One field observation, and the system that cannot receive it
Roberta Nduka is a chief medical laboratory scientist in Nigeria, in low ground that floods after light rain. She recorded something and filed it as a curiosity: “In a surprising twist, I have noticed that even the mosquitoes have not been affected by insecticide treated nets in recent times.”
One person’s impression establishes nothing about insecticide resistance.
That is precisely what entomological sentinel surveillance exists to determine, with standardised bioassays, defined mosquito populations, and repeat measurement over time.
Her post is not evidence of resistance.
It is evidence of something else.
A laboratory scientist noticed a change in the field, had no route by which to report it into the system that could test it, and so wrote it in an introductions activity as a surprise.
Whatever is or is not happening to the mosquitoes in her district, the observation itself went nowhere.
That is the loop Asare, M’Bondoukwé, Ouattara Ali and Kapinga Mulumba had each described from a different angle.
The exchange that supplied what the pipeline had not
Faustin Alognon is a sociologist by training, now a monitoring and evaluation officer at a clinic in Togo. Asked what was missing, he wished for a preventive vaccine that would be available the way the meningitis vaccine is available.
Jean Bertrand Mekoulou A Ziem, who coordinates community health projects at the Protestant Hospital in Ngaoundéré, Cameroon, replied. The good news, he wrote, is that it already exists and is being rolled out. Two malaria vaccines are now recommended by WHO, RTS,S/AS01 and R21/Matrix-M, given in four doses from five months of age, cutting cases by more than half in the first year. More than 25 African countries are already using them. Cameroon began some years ago. He added the caveat unprompted: this is not the miracle solution, the vaccine mainly protects young children, and it complements nets and testing rather than replacing them.
The reply named both products that WHO recommends, which 169 of the 181 posts mentioning a vaccine had not done.
Exchanges like that were the exception.
Across 1,659 replies, 41 named a specific new tool, and 17 of those went to colleagues who had named none.
Most replies were short.
Nearly 4 in 10 ran to eight words or fewer.
A network of 656 people produced 17 such transfers in a week. The volume is low, but the mechanism is present and can be measured, so the course can see whether it grows.
Ahmed Rufai Shaibu, a nurse on an outreach team in Ghana, observed that hesitancy about the malaria vaccine is not limited to the general public but extends to healthcare workers including doctors, nurses and public health officers. His conclusion: “The advocacy must start among healthcare providers.”
The people who refused the question
Some of the sharpest answers declined to imagine anything.
- Tawase Rodrick Wehtuogenyi, an epidemiologist in Cameroon, wrote: “I can not really think of any new tool that can act as a game changer to eradicate malaria.” He added that he had come to have his doubts cleared.
- Ousmaila Bianpambe, a district medical officer in the Far North of Cameroon, went further. To think such a tool could exist, he wrote, is utopian. What he wants is an environment in which the female anopheles cannot survive, and in the meantime, vaccination alongside everything else.
- Fidèle Tshibanda Mulangu, a polio consultant in the Democratic Republic of the Congo, answered the question about what he lacks in five words: nothing is missing. Then he listed what he already has, tool by tool.
- Blaise-Pascal Bishweka Koroni is a Congolese government doctor from North Kivu, working now at a regional hospital across the border in Burundi. What we lack first, he wrote, is peace. An insecticide-treated net is of no use to a family that has to leave its house in the night to escape the fighting and go and sleep in the forest. The thing he named last is the thing he says war destroys: continuity.
These four are the boundary of any reading of this material.
A version of this story in which every participant is a frustrated visionary has to account for the epidemiologist who says no game changer exists and the consultant who says nothing is missing.
Patient Mbasha, a community health worker in the Democratic Republic of the Congo, wrote the line that holds the rest together without naming a single product: the persistence of malaria does not mean medicine has failed, it reveals the strengths and weaknesses of a society.
What they were telling us
Put the four shapes back together and a coherent brief emerges from 891 unconnected posts.
They asked for tools that arrive.
The vaccine, which exists and is recommended, was the second most common imagined tool, and the people who explained why were describing a map of where supply stops.
They asked for tools that let them see.
The most common imagined tool, in both languages, was a version of the same information system, designed independently, because the data they generate does not come back to them in time to use.
They asked for tools that do not depend on nightly persuasion, because the tool they have now loses an argument with a hot room.
They asked for tools that cost little, work without electricity, harm nothing, and reach the private clinics and drug sellers where most fevers actually present first.
None of that is a wish list.
It is a set of conditions any of the 14 tools will meet on arrival, written down by the people who will meet them first, in the week before anyone explained what those tools are.
Patrick Okello, a public health specialist in Uganda, wrote that the tools in use have not ended malaria where he works, not nets, not diagnosis and treatment, not repellents.
And so, he reports, “My community keeps asking why can’t we get rid of malaria?”
That question is now on its way back to the people who design the answers.
What arrives next will be judged, in a CHPS compound and a refugee settlement and a health zone in North Kivu, by whether it survives a hot room, an empty shelf, and a family that has heard a rumour.