Part III: Regional Strategies
Introduction to Malaria in the Region
Africa is composed of 50 countries or territories with malarious areas. Forty-seven of these are located in sub-Saharan Africa, which bears most of the global malaria burden. The three malarious North African countries have only residual malaria transmission and occasional imported cases. Therefore, this chapter focuses mainly on the 47 countries of sub-Saharan Africa (SSA).
Central Africa (8): Democratic Republic of Congo (DRC), Cameroon, Chad, Congo, Central African Republic (CAR), Gabon, Equatorial Guinea and Sao Tome and Principe
East Africa (12): Burundi, Comoros, Djibouti, Eritrea, Ethiopia, Kenya, Mayotte, Rwanda, Somalia, Sudan, Tanzania and Uganda
Southern Africa (11): Angola, Botswana, Madagascar, Malawi, Mauritius, Mozambique, Namibia, South Africa, Swaziland, Zambia and Zimbabwe
West Africa (16): Nigeria, Niger, Burkina Faso, Ghana, Mali, Côte d'Ivoire, Guinea, Senegal, Benin, Sierra Leone, Togo, Liberia, Guinea-Bissau, Mauritania, Gambia and Cape Verde
North Africa (3): Algeria, Egypt and Morocco
Population at risk. Approximately ~694 million people are estimated to be at risk of malaria in African countries, which represents 21% of the global population at risk. 30% of the total population at risk in this region is concentrated in two countries: Nigeria and the Democratic Republic of Congo.
Malaria transmission. Malaria transmission in sub-Saharan Africa is heterogeneous, both across and within countries. Many parts of sub-Saharan Africa have high transmission areas where infection is common and the population has developed immunity. In these areas, children and pregnant women are at high risk of developing severe symptoms or dying from malaria. Each year, approximately 25 million African women become pregnant and are at risk of P. falciparum malaria during their pregnancy.A strategic framework for malaria prevention and control during pregnancy in the African Region. Brazzaville, Congo, OMS-AFRO, Bureau régional pour l’Afrique, AFR/MAL/04/01, 2004. L’estimation présentée est basée sur un modèle développé par Snow et ses collègues, utilisant l’atlas du risque du paludisme en Afrique (Snow RW and al. Estimating mortality, morbidity and disability due to malaria among Africa’s non-pregnant population, Bulletin de l’Organisation mondiale de la Santé 1999; 77, 624-640) et son application aux données de l’UNICEF sur les naissances vivantes (UNICEF, State of the World’s children, Oxford University Press, 1998) ajustées pour l’année 2000.
Click for source Approximately 86% of Africa’s total population at risk is located in areas of high transmission. Other parts of sub-Saharan Africa are epidemic-prone with unstable and low malaria transmission; in these settings, few people develop immunity so adults as well as children are at high risk of contracting malaria.
The size and intractability of the malaria burden in Africa is partly due to the dominance of the highly efficient Anopheles gambiae mosquito as the primary vector and of P. falciparum. Sub-Saharan Africa bears an estimated 93% of P. falciparum estimated cases in the world. Although P. vivax transmission should not be overlooked, about 98% of cases in Africa are estimated to be P. falciparum.
Malaria burden. Africa remains the region with the highest burden of malaria cases and deaths in the world. See Figure III.2. In sub-Saharan Africa, approximately 365 million cases occurred in 2002 and 963 thousand deaths in 2000, equating to 71% of worldwide cases and 85.7% of worldwide deaths.Breman JG et al. Conquering Malaria. In: Jamison DT, Breman JG et al, eds. Disease Control Priorities in Developing Countries Conquering Malaria. Oxford University Press and the World Bank; 2006. p 415.
Click for source Almost 1 out of 5 deaths of children under 5 in Africa is due to malaria.18% of under-5 deaths in Rowe AK et al. The burden of malaria mortality among African children in the year 2000. International Journal of Epidemiology, 2006, 35:691-704.
Click for source In addition, malaria during pregnancy often contributes to maternal anemia, premature delivery and low birth weight thereby leading to increased child mortality. Severe maternal infection contributes significantly to maternal deaths in sub-Saharan Africa. Countries in North Africa have only a few imported malaria cases and no deaths.
Several factors have made malaria control difficult in sub-Saharan Africa and led to substantial increases in malaria burden on the continent during the 1980s and 1990s. The first was the widespread emergence of resistance of P. falciparumWhite NJ. Antimalarial drug resistance. Journal of Clinical Investigation, 2004. 113.
Click for source to chloroquine (CQ), then the most commonly used anti-malarial drug. This has been managed by changing treatment policy to ACTs in most sub-Saharan African countries.
Second, weaknesses in socioeconomic development, such as poverty, poor quality of housing and limited access to health care limit the feasibility and effectiveness of malaria control strategies. At the national level, there are often only limited financial resources for malaria-control interventions Rapport mondial sur le paludisme 2005, Genève, Organisation mondiale de la Santé, 2005; Roll Back Malaria; OMS; UNICEF.
Click for source which, compounded with the human resource crisis in the public health sector, have led to fragmented implementation of control strategies that were limited in scale and in the populations targeted. The societal and health burden of the HIV/AIDS pandemic and numerous humanitarian crises during the past decades also contributed to the challenges of controlling malaria in the region.
Figure III.2: Malaria cases and deaths in Africa
Note: Countries with negligible burden are not shown (Algeria, Botswana, Cape Verde, Egypt, Eritrea, Mauritius, Mayotte, Morrocco, South Africa, Swaziland)
Source: World Malaria Report 2008. Geneva, World Health Organization, 2008, 2006 data
Adapted Approaches and Current Levels of Coverage
Forty-six countries or territories with malarious areas in sub-Saharan Africa (the 47 malarious countries in sub-Saharan Africa except Mauritius)
Mauritius has interrupted local transmission and is currently in the prevention of reintroduction stage.
are currently in the control stage and need to scale-up preventive and case management interventions to all populations at risk and to sustain this level of control. Some countries with effective control programs in place have seen their burden reduced substantially and some others (e.g. Ethiopia, Rwanda, Eritrea, etc.) recently achieved tremendous progress in increasing coverage levels of select interventions. Therefore, these countries need to sustain the interventions which are deployed, and continue the scale-up of all other interventions. In North Africa, EgyptWhile Egypt is officially categorized in the Elimination stage according to the WHO World Malaria Report 2008, its last reported case was recorded in 1998, and the country is awaiting verification of malaria-free status to be classified within the prevention of reintroduction stage.
Click for source and Algeria are currently in elimination. Morocco and Mauritius have interrupted local transmission and are classified by WHO as in the prevention of reintroduction stage. Figure III.3 shows country categorization in the region by both burden and stage.
All countries in the control stage use LLINs and prompt case management as part of their national malaria control strategy. Twenty-five sub-Saharan African countries use IRSAfrica Malaria Report. Geneva, World Health Organization, 2006; The President's Malaria Initiative Progress through Partnerships: saving lives in Africa Second Annual Report. Washington, D.C., PMI, 2008.
Click for source and the 35 high-burden sub-Saharan African countries where IPTp is recommended have adopted it. As of 2006, half of sub-Saharan African countries report using RDTs.Africa Malaria Report 2006. Geneva, World Health Organization, 2006
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The strategies used in the pre-elimination or elimination stage vary widely from one country to another. Successful components of elimination programs can be found in Part II - Chapter 3: Elimination and Eradication.
Figure III.3: Country categorization in Africa
Source: World Malaria Report 2008. Geneva, World Health Organization, 2008
Locally adapted approaches to malaria control and elimination. Selecting the appropriate tools for malaria control requires a deep understanding of local epidemiology, geography and socioeconomic conditions.
High transmission settings of P. falciparum. High transmission settings require universal vector control with either LLINs and/or IRS with full coverage for community protection. IPTp is recommended for all pregnant women. According to WHO recommendations,Guidelines for the Treatment of Malaria. Geneva, World Health Organization, 2006.
Click for source the use of parasitological diagnosis should cover all populations at risk (with the exception of children under 5 who should be diagnosed clinically and promptly treated according to WHO guidelines). ACTs are the first line recommended treatment against P. falciparum.
Low transmission settings of P. falciparum. In areas of unstable or seasonal transmission, IRS might be preferred over LLINs, and IPTp is not recommended. The use of parasitological diagnosis should be universal (even for children under 5). ACTs are still the first line treatment of choice.
Current intervention coverage. Many types of interventions have been used in the region with varying degrees of success. These are described below.
LLINs / ITNs. In the past two years, significant progress has been achieved in the delivery of LLINs through large-scale distribution campaigns as well as routine health system delivery mechanisms such as ANC and child health clinics. Based on country data from the UNICEF 2007 Malaria and Children report, an average of 12% of households in sub-Saharan African countries have at least one insecticide-treated net.Households that have at least one ITN, Malaria and children: Progress in intervention coverage. New York, UNICEF, 2007.
Click for source All sub-Saharan African countries with available trend data have shown a major expansion in net use: 16 out of 20 sub-Saharan African countries with trend data have at least tripled use since 2000.Malaria and children: Progress in intervention coverage. New York, UNICEF, 2007.
Click for source However, national figures often hide important in-country disparities: across sub-Saharan Africa, children living in urban areas are around 1.5 times more likely to be sleeping under an ITN than those living in rural areas, and children in the wealthiest areas are three times more likely to be sleeping under a bednet than the children in the poorest areas.Malaria and children: Progress in intervention coverage. New York, UNICEF, 2007.
Click for source Estimates show that at the end of 2006, ~72 million effective LLINs / ITNs were in circulation in Africa. GMAP estimates based on data from WHO World Malaria Report 2008 and the Roll Back Malaria Commodity database, 2008. See Appendix 3. Assumptions behind Current Burden, Coverage and Funding Estimates.
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IRS. IRS is used either as the main vector control method in certain areas or is used in conjunction with insecticide-treated nets. Twenty-five countries in sub-Saharan Africa are using IRS,Africa Malaria Report 2006. Geneva, World Health Organization, 2006; President's Malaria Initiative Progress through Partnerships: saving lives in Africa Second Annual Report. Washington, D.C., PMI, 2008.
Click for source although only 17 of them use it routinely, not just for the control of epidemics. Two countries are planning pilot implementation programs with a view to scaling up further as they gain experience and skill.Implementation of Indoor Residual Spraying of Insecticides for Malaria Control in the WHO African Region, WHO-AFRO, 2007.
Click for source In 2007 and early 2008, about 18 million people were protected with IRS in 10 countries through President's Malaria Initiative (PMI)-supported projects.The President's Malaria Initiative Progress through Partnerships: saving lives in Africa Second Annual Report. Washington, D.C., PMI, 2008.
Click for source In total in Africa, ~6 million households have been sprayed with IRS in 2006.GMAP estimates based on data from WHO World Malaria Report 2008. See Appendix 3. Assumptions behind Current Burden, Coverage and Funding Estimates.
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Other vector control measures. While LLINs and IRS are the primary vector control measures recommended for Africa, there are examples of countries using environmental management successfully. In Sudan, for example, students are involved with the National Malaria Control Program in filling in vector breeding sites. However, in much of Africa, the breeding habits of the mosquito vector Anopheles gambiae makes environmental management challenging.
IPTp. IPTp has been adopted as policy in all 35 sub-Saharan African countriesAfrica Malaria Report 2006. Geneva, World Health Organization, 2006
Click for source with stable malaria transmission where it is recommended.A strategic framework for malaria prevention and control during pregnancy in the African Region. Brazzaville, Congo, WHO-AFRO, Regional Office for Africa, AFR/MAL/04/01, 2004.
Click for source IPTp is part of national malaria control strategies around the region. By the end of 2007, implementation had been initiated in all countries. However, as of 2007, only 20 countries had gone to scale and deployed it at the national level. In sixteen national household surveys conducted between 2006 and 2007, use of IPTp varied from 0.3% of pregnant women who received at least 2 doses of SP in Niger to 61% in Zambia.World Malaria Report 2008. Geneva, World Health Organization, 2008.
Click for source These estimates are in line with reports from WHO-AFROPresented at the Roll Back Malaria MIP meeting by WHO-AFRO, April 2008.
Click for source that show coverage with the first dose (IPT1) ranging from 23-93%, and the second dose (IPT2) from 5-68%. Important challenges remain to scale-up IPT coverageA number of key challenges / requirements are: 1) Strong collaboration between malaria and reproductive health programs to provide a supportive health systems environment and address constraints for the prevention and control of malaria during pregnancy; 2) need to avoid missed opportunities for reaching the high proportion of pregnant women attending ANC clinics in high malaria transmission areas; 3) need to ensure adequate stocks of the necessary drugs and logistics; 4) strengthening other aspects of the health systems including the availability and capacity building of human resources; and 5) laboratory diagnostic capacities, supportive supervision and monitoring and evaluation capacities. and to engage communities in understanding the need for skilled care during pregnancy and promoting early antenatal care attendance to ensure good pregnancy outcomes and survival of the mother and child.
Diagnostics (Microscopy and RDTs). In 2006, ~12.5 million suspected malaria cases were parasitologically diagnosed by microscopy or RDTs. Although use of microscopy is often not tracked in surveys, ~11 million of these cases were confirmed through microscopy, underscoring the importance of this technology. The remaining 1.4 million diagnoses were conducted using RDTS.GMAP estimates based on data from WHO World Malaria Report 2008. See Appendix 3. Assumptions behind Current Burden, Coverage and Funding Estimates.
Click for source In addition, 24 countries report the use of RDTs in health facilities and 4 countries use them at community level.World Malaria Report 2008. Geneva, World Health Organization, 2008.
Click for source This number is expected to grow substantially if RDT quality issues are resolved, providers are persuaded to follow test results, and if quality assurance systems in countries are improved.
Anti-malarial treatment (i.e. ACTs). There has been a remarkable adoption of ACTs in sub-Saharan African countries: in 2003, only two sub-Saharan African countries had adopted ACTs; as of September 2007, all sub-Saharan African countries except Swaziland and Cape Verde have adopted ACT policy. Approximately 69 million ACTs were distributed in 2006 by sub-Saharan African countries, about one third of the 217 million ACTs needed, provided all ACTs go to malaria cases, not fever cases.GMAP estimates based on data from WHO World Malaria Report 2008 and the RBM Commodities database, 2008. See Appendix 3. Assumptions behind Current Burden, Coverage and Funding Estimates.
Click for source However, as outlined in the WHO World Malaria Report 2008, effective use of ACTs in sub-Saharan Africa is still extremely low. In household surveys carried out in 18 sub-Saharan African countries in 2006 and 2007, only 3% of children under 5 received ACTs at any time.World Malaria Report 2008. Geneva, World Health Organization, 2008.
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Community Health Workers. Community Health Workers (CHW) networks are key to helping countries to reach all populations at risk, even the most remote populations. Estimates of CHW needs for African countries have been estimated by WHO-Global Malaria Program to amount to 500,000 community health agents and 25,000 supervisors. Scaling up CHWs will require additional work in financing, sustaining intervention supplies and quality assurance.
Recommended Regional Approach to Control and Eliminate Malaria
Targets, approaches, and strategic priorities must be tailored to the region as described in this section.
Targets. The target for 2010 in sub-Saharan Africa is to reduce malaria mortality and morbidity by 50%, meaning Africa will reduce its burden to approximately 158 million cases and 480 thousand deaths, based on the 2000 incidence and mortality numbers. By 2015, the objective is to reduce the morbidity to 79 million cases and reach near zero mortality for all preventable deaths.Preventable death is defined as deaths from malaria that can be prevented with rapid treatment with effective medication. Nonpreventable deaths represent an extremely low mortality rate for the most severe malaria cases and occur even with the best available and most rapid treatment. Beyond 2015, the objective is to maintain near zero mortality for all preventable deaths.
While this target is challenging, it is possible and will go a long way to achieving the global targets since Africa bears 71% of global malaria cases. An analysis of 20 high-burden African countriesAnalysis based on the IMPACT model developed by a consortium of organizations led by the Institute of International Programs at Johns Hopkins Bloomberg School of Public Health. This model measures child survival based on work by the Child Health Epidemiology Reference Group (CHERG) and using software developed by the Futures Institute. Countries evaluated represent ~82% of global malaria mortality: Angola, Burkina Faso, Cameroon, Chad, the Democratic Republic of Congo, Cote d’Ivoire, Ethiopia, Ghana, Guinea, Kenya, Madagascar, Mali, Mozambique, Niger, Nigeria, Senegal, Sudan, Tanzania, Uganda, Zambia. The model only looks at the impact on deaths due to P. falciparum. shows that if 2010 coverage goals are met and sustained, over 4.2 million total lives will be saved by 2015. This equates to over 600,000 lives saved per year in these 20 countries alone.
As outlined in Part II: The Global Strategy, this goal will be achieved through universal coverage with appropriate malaria control interventions for all populations at risk in all countries in the control stage and with elimination programs conducted in all countries that are ready.
To reach universal coverage for all populations at risk with appropriate interventions by the end of 2010, significant gaps must be eliminated in sub-Saharan Africa (Figure III.4):
- ~350 million nets need to be in place to reach universal protection with LLINs in sub-Saharan Africa. Assuming that 50-100 million LLINs in circulation today will remain effective over the next two years, 250-300 million new LLINs are needed to reach the 2010 targets, or approximately 125-150 million LLINs per year in 2009 and 2010.
- ~43 million households need to be sprayed with insecticides;
- ~680 million parasitological diagnostics are needed to confirm suspected malaria fever cases; and
- ~217 million ACTs are needed to treat confirmed malaria cases.
Achieving this scale-up will require rapid and concerted action from all RBM partners to accelerate the manufacturing, funding, disbursement and delivery of interventions and support countries in their scale-up efforts. Countries will need a quarterly plan detailing how all commodities will be delivered, by whom and where, based on a full assessment of needs currently being developed with support from the RBM Harmonization Working Group.
Figure III.4: Scale-up in interventionsfrom 2006 to 2010 in Africa
a) Because of 3-year life span, each year approximately 1/3 of the old nets will need to be replaced
b) Actual use is likely not all directed to confirmed malaria cases today
Source: Need based on GMAP costing model; actual based on analysis of World Malaria Report 2008. Geneva, World Health Organization, 2008 and Roll Back Malaria Commodities database
Approaches to main challenges in the region. Several approaches are recommended for the region.
Build human resource and managerial capacity. Capacity building is required at the national, regional and local level. In many countries, malaria control programs lack sufficient human resources to successfully run their programs. This is due to a variety of factors: high attrition rates of skilled staff, difficulty filling positions, competing demands with other programs and the unwillingness of health providers to be stationed in remote areas. Scaling up human resources will require a threefold approach: reducing attrition, expanding the workforce and strengthening skills. As this approach is not malaria specific, NMCPs will need to work closely with the rest of the health sector to develop better national human resources policies. For example, better career management and incentives need to be in place to retain professionals, especially technical experts such as entomologists or M&E specialists.
Given the size of the human resource gap in Africa, countries need to plan for the scale-up of staff into their national plans. Creative approaches to expanding the workforce should be considered, such as using community health workers, volunteer networks or professionals in the private sector. To support the scale up, there is a strong need for better training programs for staff, through pre-service training for new staff and training programs to develop project management expertise.
Improve monitoring and evaluation systems. Few countries in Africa have adequate monitoring and evaluation systems in place, for malaria or any other disease. Well-developed information systems encourage sound planning and help NMCPs monitor progress in the delivery and utilization of interventions, all essential for scale-up. In addition, monitoring and evaluation systems are critical when countries move from scaling up to sustaining control and elimination. As countries move towards sustaining control, surveillance systems for resistance monitoring, pharmacovigilance and quality assurance will also be needed. NMCPs need to ensure that adequate financial and human resources are dedicated to monitoring and evaluation activities.
Expand R&D and operational and implementation research. R&D for new tools and operational and implementation research for new approaches are needed to help African countries to move from sustained control to elimination. Developing new technologies such as vaccines, increasing the quality and field effectiveness of existing interventions and identifying approaches to deliver interventions to vulnerable and hard-to-reach groups is crucial in achieving the goal of eradication. R&D and operational research priorities are described in Part II - Chapter 4: The Malaria Research Agenda.
Optimize procurement and supply chain management (PSM) systems. Effective and timely PSM systems are critical in delivering interventions and providing real-time feedback to NMCPs and district health centers on the flow of interventions. PSM systems need to be optimized to avoid forecasting errors, treatment expiries and intervention stock-outs. Furthermore, effective PSM systems can aid quality assurance and quality control. Currently, the RBM Harmonization Working Group (HWG) is working with many sub-Saharan African countries to assess country needs. These needs assessments will provide a comprehensive forecast of the interventions needed to achieve universal coverage by 2010. Routine forecasting needs to be strengthened and matched with appropriate procurement and delivery strategies, perhaps through links with M&E systems. Using specific PSM systems such as pooled procurement mechanisms or direct payment can play a critical role in shortening the intervention delivery process. See Part IV - Chapter 7: Procurement and Supply Chain Management.
Streamline burdensome financing and reporting processes. Country officials indicate that they spend much of their time responding to financing and reporting requirements of donors and other international partners. The funding and M&E reporting processes of different donors are poorly harmonized and often quite demanding (perhaps appropriately so), leading to heavy workloads for government staff members. Harmonization of donor requirements at the international level is necessary, with common sets of reporting indicators or of funding applications requirements. For countries, developing strong business plans that can be presented to the donor community is a first step in this direction. See Part IV - Chapter 5: In-Country Planning.
Improve emergency response mechanisms. Many countries are in states of humanitarian crises. Up to 30% of malaria deaths in Africa occur in the wake of war, local violence or other emergencies. Malaria deaths often far exceed those caused by the humanitarian crisis itself.
Guiding principles for malaria control in acute and chronic phase emergencies in Africa, Conclusions of WHO / Roll Back Malaria
Consultation, Geneva, World Health Organization, 15 November 2004.
Civil unrest can led to resurgences in malaria, as happened in Burundi.Fatoumata Nafo-Traoré and David Nabarro. Breaking the cycle of malaria and death in emergencies: the way forward. Humanitarian Practice Network, 2008.
Click for source Countries dealing with chronic humanitarian crises over long periods of time, such as Sudan, Somalia, Chad and the Democratic Republic of Congo, require special attention to limit the risk of malaria outbreaks. In these countries, epidemic preparedness systems and rapid response mechanisms are essential. See Part IV - Chapter 10: Humanitarian Crises.
Address Malaria and HIV/AIDS co-morbidities.Malaria and HIV/AIDS interactions and implications: Conclusions of a Technical Consultation Convened by WHO. Geneva, World Health Organization, 23-25 June, 2004.
Click for source Malaria and HIV/AIDS together cause more than 4 million deaths a year in some of the most poverty-stricken areas of the world, particularly sub-Saharan Africa. The resulting co-infection and interaction between the two diseases have major public health implications. HIV/AIDS may increase the risk of malarial illness due to advanced immunosuppression. Those infected with HIV/AIDS who get malaria are more likely to develop severe malaria. Furthermore HIV-infected adults with low CD4 counts may experience a higher rate of malaria treatment failures than non-infected adults. Lastly, acute malaria episodes can temporarily increase viral replication and hence the HIV/AIDS viral load.
Considering the interactions between these diseases and their co-existence in some of the highest burden areas, special consideration needs to be made to address both issues simultaneously. Those infected with HIV/AIDS must be considered highly susceptible to malaria, and more attention should be given when diagnosing febrile patients in areas with high HIV/AIDS infection. Additionally, appropriate antenatal care must be in place to address both diseases in pregnant women and infants. Finally, in a multi-disease scenario, integrated health systems approaches described elsewhere in this plan become even more important.
Strategic priorities. Success in malaria control and elimination is essential in all countries. However, some countries are especially important to achieving the RBM targets, both in the short- and medium- to long-term, because of the distribution of malaria deaths. See Figure III.5.
Figure III.5: Distribution of malaria deathsin Africa
Source: World Malaria Report 2008. Geneva, World Health Organization, 2008
To reach the 2010 targets, countries with the following characteristics are a priority:
- High contribution to global deaths. Of the 35 countries that account globally for ~98% of malaria deaths, 30 are located in sub-Saharan Africa. Therefore, a strong focus on countries in sub-Saharan Africa will have significant impact on the achievement of global targets against malaria. These 30 countries account for 98.5% of the deaths in Africa, with four countries alone accounting for ~50% of deaths on the continent (Nigeria, Democratic Republic of Congo, Uganda and Ethiopia). These countries have very large populations at risk of malaria and share borders with numerous other countries, making control in them an important regional priority as well.
- High burden relative to population size. Some countries such as Gambia, Gabon and Equatorial Guinea account for few deaths because of their small size but experience high mortality rates relative to the total population.
- Countries in states of humanitarian crisis. Countries impacted by chronic humanitarian crisis are of strategic importance in malaria control. The massive population displacement that usually accompanies humanitarian crises is likely to lead to malaria epidemics and increased mortality due to the difficulty in providing affected populations with vector control and case management interventions (difficult access, poor housing conditions, security risks, etc.).
Successful malaria control in these countries is essential to achieve the regional and global targets of burden reduction. Therefore, in addition to the general support provided to all countries in the control stage, the RBM Partnership will coordinate targeted technical assistance to these high priority countries to increase the speed with which they can achieve universal coverage to meet the 2010 targets.
Beyond 2010, countries need to be supported to sustain universal coverage to avoid a resurgence of malaria and an upsurge in malaria mortality and morbidity. Countries in the elimination stage, primarily in Northern Africa, are encouraged to continue their efforts to bring local transmission down to zero and to move to the prevention of reintroduction stage.
International cooperation. The RBM Partnership has set up 4 Sub-Regional Networks – Central African Regional Network (CARN), Eastern African Regional Network (EARN), Southern African Regional Network (SARN) and Western African Regional Network (WARN). Each network is coordinated by a regional node which actively works with local partners across and within countries to share best practices and to create strong ties with international organizations. The RBM Partnership will continue to strengthen these networks so that they can identify and resolve implementation bottlenecks for all Africa, but especially for the high-priority countries.
Targeted assistance to high priority countries. Beyond the support provided by the SRNs to all countries, high priority countries will need targeted technical assistance to build their capacity to meet the 2010 targets. In particular, technical assistance from RBM partners is needed for:
- Planning and developing funding proposals
- Responding to technical review panels (TRPs) and accelerating disbursements from major donors
- Identifying and rapidly resolving procurement and supply chain bottlenecks
- Improving national and district level forecasts of commodities
- Designing and implementing communication and behavior change programs
- Strengthening monitoring and evaluation systems
- Strengthening advocacy efforts
- Building long term capacity across the health system, as it relates to malaria control
- Harmonizing donor requests at the global level
- Initializing global partnerships
To ensure the sustainability of successful control programs, technical assistance should be complemented by increased capacity at the country level and targeted training programs. In particular, in-country experts are required for a number of key activities, such as program and financial management, procurement and supply chain management, in country communication and monitoring and evaluation. Providing these experts to the highest burden countries will increase their chances of success in malaria control over the next years. These technical experts in country would work in a network with coordinators at the sub-regional and global level.
Funding Requirements: US$ 2 billion gap for 2010
In 2003 in Maputo, African leaders affirmed their commitment to increase financial support for the health sector to 15% of total government expenditures. Today, however, 90% of African countries remain below the 15% thresholdMalaria Landscape Report 2007. Geneva, Roll Back Malaria, 2007.
Click for source (averaging 10%).
Click for source Even if countries spent 15% on health, national funding would still be too little to cover the scale-up efforts needed to reach universal coverage by 2010.
Estimates for 2007 from the WHO World Malaria Report 2008 show that resources from endemic country governments in Africa account for only 18% of the US$ 622 million disbursed, the lowest rate among all regions. The remaining disbursements in 2007 came from international donors (The Global Fund 42%, President’s Malaria Initiative 20%, World Bank Booster Program ~8%). (See Figure III.6.)
Figure III.6: Gap in malaria fundingin Africa
Note: See appendices on methodologies to estimate costing needs and current funding
Source: GMAP costing model (WHO, GFATM, World Bank, PMI)
Africa, especially sub-Saharan Africa, has attracted significant support from major international donors. In rounds 1 to 7, the Global Fund committed ~US$ 2 billion for malaria in sub-Saharan African countries (76% of all malaria grants). The World Bank Booster program has committed US$ 470 million in its Phase I and contemplates a lending target of US$ 1.2 billion for Phase II in the coming years, depending on country demand. The President’s Malaria Initiative has pledged US$ 1.2 billion over 5 years.
In Africa, US$ 2.2 billion is needed in 2009 and US$ 2.7 billion in 2010 to scale-up preventive and curative interventions to reach universal coverage (see Table III.2). Preventive costs comprise approximately two thirds of these costs in 2010, case management costs are approximately 20% of the costs, and the remainder is for malaria control program costs. Declining costs through 2015 are due to lower treatment costs needed due to preventive efforts, and the slight increase in 2020 represents increases in populations at risk which need continued preventive coverage.
Table III.2: Summary of annual costs in Africa
|Cost category (US$ millions)||2009||2010||2015||2020||2025|
|Chloroquine and primaquine||1||1||1||0||0|
|Severe case management||23||20||14||9||3|
|Case management cost||489||682||325||217||81|
|Community health workers||42||44||54||54||59|
|M&E and OR||91||103||105||112||121|
|Infrastructure / inst. strengthening||134||260||192||211||233|
|Total control & elimination cost||2,199||2,686||2,196||2,258||2,333|
Note: Diagnostic costs are covered both by RDTs in case management and by microscopy in infrastructure / institutional strengthening
Source(s): GMAP costing model; Johns B. and Kiszewski A. et al