GMAP

[Full Table of Contents]
[Executive Summary]

[Part II: The Global Strategy] PDF version

  1. Introduction to the Global Strategy
  2. Control: Overcoming malaria
    1. Scale Up for Impact: Achieving Universal Coverage
    2. Sustained Control: Maintaining Coverage and Utilization
  3. Elimination and Eradication: Achieving Zero Transmission
  4. The Malaria Research Agenda
    1. Research & Development for New and Improved Tools
    2. Research to Inform Policy
    3. Operational and Implementation Research
  5. Costs and Benefits of Investment in Malaria Control

Part II: The Global Strategy

2. Control: Overcoming Malaria

Key messages

  • RBM's malaria control strategy aims to permanently reduce malaria mortality and morbidity by
    • Strengthening health systems to enable malaria control
    • Reaching universal coverage with appropriate interventions
  • This will require many countries to
    • First, scale-up their health systems and delivery capabilities
    • Second, sustain control for years until they move to elimination
  • Because of the variation between countries in epidemiology and control programs, no one global approach is recommended.
    • Appropriate interventions will differ by transmission levels, parasite type and vector behavior
    • Delivery strategies will need to be adapted to existing control programs and integrated with other disease and development programs
  • However, best practices in health system strengthening and delivery can provide guidance to countries and highlight areas where global support is needed
    • In the short term, substantial global support is needed to help the highest contributors to global burden scale-up rapidly to meet the 2010 targets
    • In the longer term, all countries will need support in moving towards elimination
  • Global support is needed to provide tools and resources required for malaria control and assistance in the following capabilities: policy and regulatory, planning, financing, procurement and supply chain management, communication and behavior change methodologies, monitoring and evaluation, management of humanitarian crises and appropriate research and development

Malaria control can be defined as reducing malaria morbidity and mortality to a locally acceptable level through deliberate efforts using the preventive and curative tools available today. WHO classifies 82 of the 109 countries or territories with malarious areas in the Control stage.

Malaria control relies on effective prevention and case management. Prevention with vector control interventions aims to reduce transmission and thus decrease the incidence and prevalence of parasite infection and clinical malaria. Prevention with intermittent preventive treatment for pregnant women reduces the impact of placental malaria infection and maternal malaria-associated anemia. Early and effective case management of malaria will shorten its duration and prevent complications and most deaths from malaria.[2]Malaria Control Today - Current WHO Recommendations, working document. Geneva, World Health Organization, 2005.

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Malaria Control: Different Settings, Different Approaches

Since most countries will contain multiple settings, countries need a tailored approach to control malaria with tools appropriate for the various settings.[3]An initiative called the Malaria Atlas Project (MAP) is working to develop a detailed model of the spatial limits of P. falciparum and P. vivax malaria at a global scale and its endemicity within this range. This information will be helpful to inform country burden estimates as well as the appropriate interventions.

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The decision of which intervention (or combination of interventions) to use depends heavily on epidemiological and logistical factors. Therefore the package of interventions to be implemented in each district is first and foremost a country decision, informed by WHO malaria control recommendations.[4]See WHO website (http://www.who.int/malaria/) and Appendix 6 Compilation of WHO references.

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As summarized below, different interventions are required for areas of high transmission of P. falciparum, areas of low to moderate transmission of P. falciparum, and areas with a high proportion of P. vivax or mixed transmission. See Part 3: Regional Strategies for a more detailed description of which interventions are appropriate within regions.

High transmission of P. falciparum. In areas of high transmission of P. falciparum as occurs in many sub-Saharan African countries, at least one of the two core vector control interventions (LLINs, IRS) should cover people at risk. IPTp is recommended to protect pregnant women; at present, this intervention is only recommended for sub-Saharan Africa, however, in highly endemic areas in Asia-Pacific, this intervention could also be appropriate, but its role still needs to be clarified. Where IPTp is not being implemented in a high transmission area, routine screening of pregnant women for malaria infection and appropriate treatment could be done. In areas of high stable malaria transmission[5]There is as yet no consensus on criteria for determining the thresholds between high and low to moderate transmission settings. Suggested criteria include: the proportion of all children under 5 years of age with patent parasitaemia, and the incidence of individuals with the spleen palpable below the umbilicus in children aged 2–9 years. The IMCI guidelines recommend that areas in which fewer than 5% of young children with fever have malaria parasitaemia should be considered as low-transmission settings., the probability of fever in a child being caused by malaria is high. Children under 5 years of age should therefore be treated on the basis of a clinical diagnosis of malaria. In older children and adults including pregnant women, a parasitological diagnosis (by quality-assured light microscopy or where unavailable RDTs) is recommended before treatment is started.[6]Guidelines for the Treatment of Malaria. Geneva, World Health Organization, 2006.

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Artemisinin-based Combination Therapies (ACTs) are the recommended first-line treatment against P. falciparum infections.

Low to moderate transmission of P. falciparum. In places where transmission is seasonal or localized in select areas, the use of targeted vector control measures such as IRS or other vector population reduction methods (environmental management, larviciding etc.) can be appropriate. LLINs can also be used. IPTp for pregnant women is currently not recommended. Prompt parasitological confirmation of the diagnosis is recommended before treatment is started in all age groups[7]Guidelines for the Treatment of Malaria. Geneva, World Health Organization, 2006.

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(microscopy or, where unavailable, RDTs).

P. vivax or mixed transmission. When both P. falciparum and P. vivax are prevalent (e.g. in Asia-Pacific, in the Americas or in the Middle East), diagnosis should distinguish P. falciparum from non-falciparum parasites, as the appropriate treatment differs. In many areas, chloroquine is still effective for P. vivax, but must be combined with primaquine to ensure clearance of liver-stage infection. If infections are mixed, then ACTs must be used to treat P. falciparum (which is widely resistant to chloroquine). In addition, the patient should receive primaquine for treatment of P. vivax liver-stage parasites.

Reaching and Sustaining Universal Coverage: Two Stages, Two Objectives

Malaria control in countries is a continuum consisting of two main stages with different, although complementary, objectives (Figure II.3):

Both the scale-up and sustained control stages share two primary activities: strengthen health systems to enable malaria control and scaling up and maintaining universal coverage with appropriate interventions. Both of these cross-cutting activities begin in the scale-up stage but continue in the sustained control stage to ensure that reduction in mortality and morbidity continues.

Figure II.3: Two primary activities supporting scale-up and sustained control

Strengthen health systems to enable malaria control. Controlling malaria through universal coverage is not only about increasing spending and the delivery of malaria interventions. It also requires building, expanding and continuously improving health systems supporting all interventions.

A health system is defined by WHO as the sum of all organizations, institutions, people and resources whose primary purpose is to improve health (Box II.1). It requires adequate staff, funds, information, supplies, transport, logistics, communication, overall guidance and direction. Strengthening health systems is not only a malaria specific issue: it is a global development issue deserving the support of the international donor community. Improving health systems related to malaria control is likely to benefit other diseases and contribute heavily to the achievement of development targets.

Box II.1: WHO Framework for Health Systems Strengthening

The framework for health systems strengthening defined by WHO comprises six major components:[8]Everybody's business: Strengthening health systems to improve health outcomes – WHO's framework for action. Geneva, World Health Organization, 2007. The framework presented is the generic WHO framework for Health Systems Strengthening. However the concrete examples for the 6 pillars presented here have been adapted to malaria.

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  1. Leadership and governance. This includes strong political commitment backing malaria efforts, clear definition of policy and financing frameworks in line with international recommendations, regulation, leadership and stewardship from national authorities to lead planning efforts and to coordinate and align all partners.
  2. Sustainable financing and social protection. It is essential for malaria control programs to have access to adequate and timely resources for activities planned, in ways that ensure populations at risk are covered by the required interventions without bearing undue personal cost.
  3. Health workforce. Sufficient, well trained, fairly distributed and productive staff is required to deliver interventions with the highest possible quality.
  4. Medical products, technologies, infrastructure and logistics. Efficient and cost effective tools for malaria prevention and case management need to be available for all populations at risk.
  5. Service delivery. Good health services are those which deliver effective, safe, quality interventions to those that need them, when and where needed, with minimum waste of resources.
  6. Health information system. The health information system ensures the production, analysis, dissemination and use of reliable and timely information. It includes monitoring and evaluation, disease and mortality surveillance, disease mapping and information technology.

Reach universal coverage with appropriate interventions. Scaling up and sustaining universal (100%) coverage of appropriate malaria interventions for the entire population at risk with a target of at least 80% utilization[9]This is in line with the Roll Back Malaria Harmonization Working Group's recommendations that countries should budget for universal coverage of all populations at risk with interventions to achieve 80% utilization as there will be a gap between coverage and utilization. will lead to a dramatic reduction in malaria morbidity and mortality.

Prevention. Universal coverage for prevention means that 100% of the population at risk is provided with locally appropriate preventive interventions. For these interventions, coverage is defined as follows:

Case management. Universal coverage means that 100% of patients receive locally appropriate case management interventions. For these interventions, coverage is defined as follows:

Particular attention is required to ensure that interventions reach the most vulnerable populations, and that gender, socio-economic status or geographic location are not barriers to access.

Strengthening health systems to enable malaria control and reaching and maintaining universal coverage both require substantial effort. The two following sections A. Scale-up for Impact: Achieving Universal Coverage and B. Sustained Control: Maintaining Coverage and Utilization focus on strategies to answer the following questions: