Progress
Major increases in funding and attention given to malaria control
Attention and funding to combat malaria have significantly increased in recent years – thanks in large part to the Global Fund to Fight AIDS, Tuberculosis and Malaria, the World Bank’s Malaria Control Booster Programme, the United States President’s Malaria Initiative (PMI), UNICEF and others. The International Drug Purchase Facility (UNITAID) is also contributing to the increase in international funding for purchasing newer and more effective antimalarial medicines. In addition, other major donors, such as the Canadian International Development Agency, have directed funds more broadly towards improving child survival, which would include funding for malaria control activities.
At the same time, malaria has been included among major international development targets, notably the Millennium Development Goals. For example, one of the eight Millennium Development Goals specifically relates to malaria, AIDS and other infectious diseases, and many of the other Millennium Development Goals, including the goal of reducing child mortality, will be difficult to achieve in malaria-endemic countries without substantially reducing the malaria burden. Since 2007, and building on the recent momentum in the fight against malaria, the United Nations Secretary-General and others have called for a bolder, long-term goal of eliminating malaria as a public health problem. To realize this vision, the Roll Back Malaria Partnership further revised its goals and targets as set out in the RBM Global Malaria Action Plan (2008).
These recent increases in funding and attention given to malaria control have greatly accelerated efforts to reduce the malaria burden, particularly across sub-Saharan Africa. This includes developing new and more effective tools to fight malaria, such as long-lasting insecticidal nets and artemisinin combination therapies, and reducing bottlenecks in the production, procurement and distribution of these interventions. Countries have also been quicker to adopt more effective strategies that would have been out of reach with less funding available, such as changing national drug policies to include more effective – but more expensive – treatment courses, as well as expanding the use of diagnostics. Together, these activities have led to significant increases in coverage with insecticide-treated mosquito nets, and many other key malaria control interventions are also now starting to make their way to the people most in need.
Major progress in scaling up insecticide treated net (ITN) coverage
Much progress has been made across sub-Saharan Africa in quickly scaling up insecticide-treated net (ITN) use among children – rising from 2 per cent in 2000 to 20 per cent in 2006. Despite this progress, though, overall ITN use still falls short of global targets (see figures below).
Rapid progress in scaling up ITN use in all sub-Saharan African countries with trend data
Source: UNICEF global databases 2009.
Household ownership of nets is relatively high, but increases still needed in ITN ownership
Percentage of households owning at least one ITN and one net of any type
Source: UNICEF global databases 2009.
Since 2004 the number of insecticide-treated mosquito nets produced worldwide has more than tripled – from 30 million to 100 million in 2008, with another large increase expected in 2009. The increase in the production of nets and in resources available has led to a rapid rise in the number of nets procured and distributed within countries (see figure below). For example, UNICEF’s net procurement is around 20 times greater today than in 2000.
Manufacturers’ estimates indicate that more than 150 million nets were delivered to African countries during 2004–2008 and are available for use, out of the more than 340 million nets needed to achieve universal coverage in areas with malaria transmission (defined here as one net for every two people). Overall, African countries have received enough nets during this time period to cover more than 40 per cent of their at-risk population (see map below). And financing is available to purchase an estimated 240 million nets in 2009–2010. Based on these estimates, the next round of surveys is expected to show even higher coverage levels.
African countries have received enough nets to cover more than 40 per cent of their at-risk populations
Source: Milliner, J. , ‘Net Mapping Project’, United States Agency for International Development/PMI, Washington, D,C., 2009. The Net Mapping Project is a project of the Alliance for Malaria Prevention, a workstream of the Roll Back Malaria Harmonization Working Group.
Global mosquito net production has been rapidly scaled up
Source: UNICEF Supply Division, 2009, based on estimates from manufacturers of insecticide-treated mosquito nets.
UNICEF ITN procurement is 20 times greater today than in 2000
Source: UNICEF Supply Division, 2009.
Antimalarial coverage moderately high, but increases needed in coverage of more effective medicines
Treatment of malaria among children is moderately high across sub-Saharan Africa, although few countries have expanded treatment coverage since 2000 and many children are still being treated with less effective medicines (see figures below). The lack of any significant progress in the case management of suspected malaria mirrors trends in the treatment of other major childhood illnesses, such as pneumonia, diarrhoeal diseases. This underscores the urgent need to strengthen the integrated community-based treatment of childhood diseases within the overall health system.
Little progress in expanding case management for common childhood illnesses across Africa
Source: UNICEF global databases, 2009.
Note: Trend analysis is based on a subset of African countries covering 75 per cent (pneumonia care-seeking), 50 per cent (ORT with continued feeding) and 57 per cent (antimalarial treatment) of the under-five population in this region.
Despite moderately high treatment rates, many African children are still using less effective medicines
Proportion of children under five with fever receiving antimalarials, 2004–2009
Source: UNICEF global databases 2009.
But the groundwork has been laid to greatly scale up coverage rates with more effective malaria treatment in the coming years. Nearly all sub-Saharan countries have rapidly shifted their national drug policies to promote more effective treatment with artemisinin combination therapies, with financing and procurement significantly increasing since around 2005. These actions, coupled with investments in stronger distribution mechanisms within countries, suggest that many more febrile children will receive prompt and effective malaria treatment in the coming years.
Low artemisinin combination therapy coverage is the result of several factors. First, such therapy is more expensive – about 10 times more – than traditional monotherapy, and countries were slow to roll out new medicines until additional resources were secured. Second, a global shortage in the production and supply of artemisinin combination therapies restricted countries’ ability to quickly implement new national drug policies. Since around 2005, however, both production and funding have been rapidly scaled up (see figure below). The next round of surveys is thus expected to show higher treatment coverage with artemisinin combination therapies.
Recent and rapid scale-up in the global procurement of artemisinin combination therapies
Source: WHO Global Malaria Programme, 2009.
Prevention and control of malaria during pregnancy
Intermittent preventive treatment
Nearly every high-burden sub-Saharan African country has adopted intermittent preventive treatment as part of its national malaria control strategy. Most countries, however, have only recently adopted intermittent preventive treatment as a recommended treatment for pregnant women, and higher coverage is expected in the next round of surveys. Indeed, some countries have already achieved relatively high coverage, including Zambia (60 per cent in 2008) and Senegal (49 per cent in 2006). This higher coverage is due largely to early adoption and implementation of intermittent preventive treatment as a key part of national malaria control activities.
Use of insecticide-treated mosquito nets by pregnant women
Across sub-Saharan Africa the proportion of pregnant women ages 15–49 sleeping under insecticide-treated nets remains too low. Some countries have achieved higher coverage rates, such as Rwanda (60 per cent in 2007–2008), Senegal (52 per cent in 2008–2009) and Zambia (43 per cent in 2008), although higher coverage is expected in the next round of surveys.
Indoor residual spraying
Indoor residual spraying, an effective prevention method where epidemiologically and logistically appropriate, involves applying long-lasting insecticide to the inside of houses and other structures to kill mosquitoes resting on interior walls, ceilings and other surfaces. National programme records may provide the most useful data for monitoring coverage since this intervention is often targeted to subnational areas. In collaboration with National Malaria Control Programmes, the United States President’s Malaria Initiative has supported implementation and scale-up of indoor residual spraying programmes in 14 of their 15 countries. In 2008 alone, more than 6 million houses were sprayed and more than 24 million people were protected by indoor residual spraying as a result of these efforts.