In Malawi, a country of 10 million people, 90 percent live in rural areas. Because malaria is transmitted by a mosquito vector, rural communities are particularly affected. The Secretary of Health recently announced that on average, Malawians spend at least $35 every year on malaria, a significant amount where per capita income is below $200. A 1994 study found that overall direct expenditure on treatment of malaria among very low income household members surveyed was 28 percent of their annual income. Not only the poor but also the young carry a disproportionate share of the burden of malaria. At least 40 percent of all deaths of children under the age of two in Malawi result from malaria. To improve service delivery and quality for malaria, the Ministry of Health and Population (MOHP) began the Blantyre Integrated Malaria Initiative (BIMI) in 1996 to pilot test methods in malaria prevention and treatment for pregnant women and children under five years of age. Blantyre, a largely urban district with a population of nearly 500,000, was chosen as the launch site for the initiative. The BIMI built on prior malaria control work in the country and on new national malaria guidelines developed by the MOHP