Rusinga Island in Suba District is an excellent example of an isolated, underdeveloped and highly disadvantaged community in western Kenya where malaria poses a major health burden in close association with increasing poverty and environmental degradation. Rusinga is home to a growing population of approximately 14,000 people with rapidly increasing levels of irrigation, urbanization of market areas, modernization in house construction, deforestation, vegetation clearance and poorly planned infrastructure development 55, leading to abundant Anopheles larval habitats near human settlements and endemic malaria transmission 2956575859606162.

Mobilization of the Rusinga community in the development of their own healthcare and public health services was initially facilitated by the Rusinga Island Child and Family Programme (RICFP) of the Christian Children's Fund (CCF)-Kenya, an international non-governmental organization. The collaboration began at a health stakeholders meeting in Suba District, Western Kenya. RICFP engaged the academic partners directly and were provided, upon request, with access to the local research facilities, personnel and training through a series of open days (Figure 1). After a presentation by the academic partners on old-fashioned larval control techniques 1315213863, RICFP/CCF invited them to train volunteers on the island. Continuous and adaptive training efforts over two years culminated in the establishment of an active malaria surveillance and control programme on the island, directly supported by the University of Nairobi, which now acts as the community's link to the international research community.

It was clear that there was an active group on Rusinga Island trying very hard to combat malaria but that their access to information and training in relation to environmental management or larviciding of malaria vectors was negligible. A good example is the commonly quoted national policy which advocates clearing of bushes for a malaria control, despite evidence that it confers no lasting protection against African anophelines 64. Although forest clearance to expose breeding sites to sunlight can be highly effective for controlling shade-loving mosquitoes, this is very species-specific and can have the opposite effect if haphazardly applied in areas with vectors that prefer sunlit water 6566. Even the greatest advocates of environmental management at the height of its popularity concluded the following 65:

we know of no instance where a small radius of clearing about houses or inhabited centres has done any good but many instances where it has done great harm

Given that the most important malaria vectors in Kenya, An. gambiae and Anopheles arabiensis, proliferate avidly in small sunlit water bodies 3031, such clearing of vegetation typically increases malaria risk 25266768. Indeed CCF has recently found that vegetation clearance is associated with increased malaria risk on Rusinga Island 56 so this is a classic example of a policy that needs to be actively reformed 47. Broad issues of land ownership and governance in Kenya are clearly identified as targets for change in the national Poverty Reduction Strategy Paper (PRSP) 69 and Suba District's corresponding Consultation Report 70 but, like PRSPs of most tropical nations, environmental resource development strategies are conspicuously absent 4771.

At the outset of the collaboration, none of RICFP's 67 volunteers working with the community to address their malaria problems actually knew what aquatic stage mosquitoes looked like or where they could be found. Since then, RICFP/CCF has expanded it's collaborations to include local government and a number of national and international scientists through the University of Nairobi and an operational malaria surveillance based on community participation is active on Rusinga Island. Practical demonstrations using mosquito larvae and pupae taken from local habitats and allowed to emerge into cages allowed the community members to see for themselves (Figure 2). A special training course was introduced and completed which has enabled more than 70 community volunteers to distinguish Anopheles malaria vectors from non-vector species, to classify their larval habitats and to evaluate their productivity (Figure 3). Direct experience strongly suggests that community members find such active and tangible participation highly interesting and rewarding. It is envisaged that this will lead to rapid and sustainable changes in behaviour with knowledge transfer from children to adults and between families and friends.

The dissemination of information and adoption of appropriate malaria control activities requires all the elements of the classic theory of the Diffusion of Innovations by Everett Rogers 72: innovation, communications channels, time and social system. The community-based larval control of malaria mosquitoes (innovation) is communicated through personal interaction during training sessions focused on learning-by-doing (communication channels). Implementation of larval control happens directly with immediate visual effects (time). Community members and health stakeholders (social system) all participate in the decision-making, planning, action and evaluation of this project that aims to enable local people to take control over their own health situation. These central elements seem to favour the process of dissemination of the innovation represented by larval surveillance and control. Additionally, this approach addresses a felt community need and is not an imposed activity but rather responds to their interest and eagerness to solve their malaria problem. The information is easy to understand and apply with low financial input. There is no obvious risk involved and results are easily experienced. It is, therefore, possible to envisage a rapid dissemination of information about community-based larval malaria control activities among members of the community.

The experience on Rusinga bear a striking resemblance to those reported during the development of primary health care systems in nearby districts over two decades ago 73. The Saradidi Rural Health Development Programme 74 demonstrated that parasitaemia and anaemia in pregnant mothers could be effectively tackled by community volunteers 75, who were prepared to contribute substantial time and effort with little remuneration 73. These primary health care programmes are still operational today and it is notable that the academic support required to maintain them has been institutionalized in the form of the Teaching Institute for Community Health in Kisumu which continues to train community health workers. Although the academic side of the Rusinga Island collaboration was mainly initiated by international partners directly with the community, this is not a viable mechanism for scaling up to national levels. Therefore, responsibility for running the malaria control project has now been handed over to Kenyan scientists based at the University of Nairobi which acts as the link institute between the international partners and the community on Rusinga (Figure 4). Since then collaborative linkages have been established with a project with similar objectives but different origins in the quite different urban setting of Dar es Salaam in neighbouring Tanzania.

The history of malaria control in Dar es Salaam 76 dates back more than 100 years, commencing when the area was a German possession 777879 Larval control of mosquitoes, emphasizing environmental management has played an important role in malaria control in Dar es Salaam and other Tanzanian cities for much of the 20^th century 7677. Urban malaria control in Tanzania during the 1960s relied heavily upon larviciding and community-implemented environmental management such as drainage, filling, and other engineering works 40778081, resulting in malaria transmission that was considered to be of limited magnitude40778081 In 1972, adverse economic conditions, combined with poor restructuring during the transition to decentralization, resulted in the deterioration of the urban health system, and chemotherapy was the only anti-malaria intervention left in place. Additionally, policy shifts at that time encouraged the citizens of Tanzania, including urban dwellers, to engage in income-generating activities, notably agriculture, which led to intensified cultivation of rice, vegetables and other crops in peri-urban areas. This increased emphasis on urban cultivation may have contributed to a ten-fold increase in the density of Anopheles in Dar es Salaam by the early 1980s 82.

In 1987, the Government of Japan, through the Japan International Cooperation Agency (JICA), provided external assistance for urban malaria control in Dar es Salaam and Tanga to reinitiate mosquito abatement in these urban centres. This programme was successful in terms of community-implemented environmental management, particularly the rehabilitation of drainage infrastructure (Figure 5) 7683 but national ownership and capacity were not sufficiently developed by this programme to achieve sustainability and the programme ended in 1996. Although valuable lessons about working with the community were learned 84, the project retained a centralized structure as a vertical programme directly under the Ministry of Health and was poorly adapted to working in a participatory fashion, even to the extent that indoor residual spray programmes had to be abandoned in favour of bednet distribution because residents refused access to their houses 7683.

In recent years, the ten-year Dar es Salaam Urban Health Project 88586, has considerably strengthened healthcare and public health infrastructure within the city through a decentralized health system 7, which is also ideal for delivering community-based vector control interventions 15343987. This degree of autonomy enabled Ilala Municipal Council to independently conceive, fund and implement a community-based mosquito surveillance programme as an entirely local initiative in early 2002. Supplementing ongoing programmes for social marketing of ITNs and improved access to effective diagnosis and treatment 88, teams of community members were recruited to map and characterize the extensive breeding sites provided by intensive urban agriculture and poorly planned settlement (Figure 6) which abound in Dar es Salaam 7689 and many other African cities 192090919293. Weekly surveys for larval and adult mosquitoes were piloted in 7 of the 22 wards of Ilala Municipality as a preliminary step towards IVM by larviciding and environmental management. Furthermore, all three municipal councils had actively promoted a variety of locality-specific community-based environmental management schemes such as trench digging and collection of solid waste refuse to prevent obstruction of such drains (Figure 7). In June 2003 the City Medical Office of Health (CMOH) convened a stakeholders meeting for all concerned with malaria in Dar es Salaam, and invited a consortium of national and international scientific partners, including those involved with the Rusinga Island project in Kenya. Consensus was reached by all stakeholders that control of aquatic-stage mosquitoes, particularly source reduction through environmental management, was highly desirable and should be added to the national priority interventions to complete an integrated suite of interventions for the city. With support from the national and international academic partners, the City Medical Office then formulated a detailed implementation plan for evaluating the incremental effectiveness of larval control delivered by community members in 15 of the 73 wards of Dar es Salaam, in addition to the existing national programme interventions. Importantly, this demand-driven implementation plan for the UMCP built upon the community-based systems developed in Ilala, in which responsibility for routine mosquito surveillance is delegated to individual community members, known as Community-Owned Resource Persons (CORPs), appointed and managed through Street Health Committees.

The consensus view of the stakeholders was that it was essential to strengthen the capacity of research and training institutions in Tanzania, within the initial pilot period of the programme, to build the necessary academic support base required to maintain the essential skills base on an indefinite basis. The primary national institutes involved included the Ifakara Health Research and Development Centre and the Department of Zoology and Marine Biology at the University of Dar es Salaam. These institutes were identified as not only supporting institutes but also as targets for strengthening training capacity so that the quantity and quality of applied ecologists available at undergraduate and graduate levels for recruitment to mosquito control programmes could be improved. Although this community-academic collaboration differs considerably from Rusinga in its setting and origins, the partnership has already begun to address capacity deficits by bringing expertise in operational mosquito control to the Municipal and City teams, including over 100 CORPs (Figure 7). As on Rusinga, the academic partners observed that standards of training and practice were initially quite poor within the existing municipal health teams who had had no expert training or access to current training material relating to mosquito abatement.

In November 2003, the Centre for Enhancement of Effective Malaria Interventions (CEEMI 94) of the National Institute for Medical Research (NIMR) and the National Malaria Control Programme (NMCP) of Tanzania conducted a sensitization workshop with the country's Members of Parliament (MPs) aimed at soliciting for their support in promoting the use of ITNs in line with the National Medium-Term Strategic Plan 88. While the MPs generally endorsed the interventions prioritized by the national plan, particularly the use of ITNs, many requested reconsideration of mosquito abatement, which many of them remembered from previous programmes, and greater support for such activities. Immediately afterward, at a meeting held in Dar es Salaam and sponsored by Tanzania NGOs' Alliance Against Malaria (TaNAAM), it became apparent that, NGOs and CBOs, including scouts and girl guides, were willing and ready to undertake many tasks pertaining to malaria control at community level but lacked the necessary skills and coordination mechanism. Thus, although the local circumstances and mode of interaction proved quite different to the Rusinga scenario, the message from the community to ecologists, health scientists and policy makers was clear: the people of Tanzania requested help from their national institutes to develop mosquito abatement programmes similar to those they have experienced in the past (See references 768095 for reviews).