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Africa: Malaria Control Up, Majority Not Covered

AfricaFocus Bulletin
Sep 19, 2008 (080919)
(Reposted from sources cited below)

Editor's Note

"Despite big increases in the supply of mosquito nets ...the number available in 2006 was still far below need in almost all countries. The procurement of antimalarial medicines through public health services also increased sharply, but access to treatment, especially of artemisin-based combination therapy (ACT), was inadequate in all countries surveyed in 2006. ... Supplies of insecticide-treated nets (ITN) ... were sufficient to protect an estimated 26% of people in 37 African countries. Surveys in 18 African countries found that 34% of households owned an ITN; ... 38% of children with fever were treated with antimalarial drugs, but only 3% with ACT." - World Malaria Report, 2008

The 2008 World Malaria Report, released this report, documents substantial advances in the war against malaria. As many as 7 African countries reduced malaria deaths by more than 50% between 2000 and 2006. But there were still almost 900,000 estimated deaths from malaria in 2006, 91% of them in Africa and 85% of children under five.

This AfricaFocus Bulletin contains a press release and excerpts from the summary and key points of the report. The full report and additional background material is available on the WHO website at

For previous AfricaFocus Bulletins on health issues, visit

This Bulletin also includes (immediately below) links to two new featured books in the AfricaFocus Bookshop, one about malaria and the other the best-selling The House on Sugar Beach, as well as to an additional selection of books on malaria. Use the links below to browse or order these books and more from Amazon, Amazon UK, Amazon Canada or other sources.

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AfricaFocus Book Notes

The Making of a Tropical Disease: A Short History of Malaria (Johns Hopkins Biographies of Disease) by Randall M. Packard

Randall Packard's far-ranging narrative traces the natural and social forces that help malaria spread and make it deadly. He finds that war, land development, crumbling health systems, and globalization -- coupled with climate change and changes in the distribution and flow of water -- create conditions in which malaria's carrier mosquitoes thrive. The combination of these forces, Packard contends, makes the tropical regions today a perfect home for the disease.

Authoritative, fascinating, and eye-opening, this short history of malaria concludes with policy recommendations for improving control strategies and saving lives.
More on-line:

See more books on malaria at or

The House at Sugar Beach by Helene Cooper

A powerfully written personal narrative of Liberia, with historical insight and journalistic skill. Number 1 Africa best-seller on Amazon.
More on-line:

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Progress made in malaria control, yet burden is enormous

New report finds more funding leading to increased coverage of malaria control interventions

World Health Organization

Press release

18 September 2008 | Geneva -- The global burden of malaria remains enormous, but access to malaria control interventions, especially bednets in Africa, increased sharply between 2004 and 2006, says a new report released today.

"With dramatic increases in funding and intense momentum towards reducing the malaria burden in recent years, we have a greater need for reliable information and analysis," said WHO Director-General Dr Margaret Chan. "This report begins to answer that need. Progress in malaria control has accelerated dramatically since 2006, especially in the wake of the UN Secretary-General's call for universal malaria control coverage by the end of 2010. We expect these expanded efforts to be reflected in future reports."

The World malaria report 2008, which draws upon data collected between 2004 and 2006, paints a complex picture. Some highlights are:

  • New methods estimate that the number of malaria cases in 2006 was 247 million.
  • Small children remain by far the most likely to die of the disease.
  • Malaria deaths have declined in several countries, and a few African nations have managed to reduce deaths in half by following the recommended measures.
  • As of 2006, more funding resulted in accelerated access to malaria interventions, including bednets and effective medicines.
  • In Africa, the artemisinin-based combination therapy (ACT), which is recommended by WHO, reached only 3% of children in need.

Bednet coverage increasing

The report finds that recent increases in malaria funding were beginning to translate into coverage of key malaria interventions, especially bednets, by 2006. The percentage of children protected by insecticide-treated nets increased almost eightfold, from 3% in 2001 to 23% in the 18 African countries where surveys were held in 2006. Procurement of antimalarial medicines also increased sharply between 2001 and 2006. About 100 million people, including 22 million in Africa, were protected by indoor spraying of insecticide.

However, much more work remains to be done. In Africa, only 125 million people were protected by bednets in 2007, while 650 million are at risk.

"Malaria is a primary cause of child mortality," said Ann M. Veneman, Executive Director of the United Nations Children's Fund (UNICEF). "If the availability of bednets and other key interventions can be increased, lives can be saved."

Positive impact

For the first time, three African countries reported dramatic reductions in malaria deaths by 50% or more. Eritrea, Rwanda and Sao Tome and Principe achieved this result between 2000 and 2006/2007 through a mix of bednet distribution, indoor spraying, improved access to treatment and advances in disease surveillance. Furthermore, significant improvements were observed in other African countries such as Madagascar, Zambia and the United Republic of Tanzania.

Six more countries reported a fall in malaria deaths by 2006: Cambodia, the Lao People's Democratic Republic, the Philippines, Suriname, Thailand and Viet Nam.

"We know that malaria control interventions work and that we can make rapid progress towards ending malaria deaths," said Ray Chambers, the United Nations Secretary-General's Special Envoy for Malaria. "Now is the time to expand these results to all of Africa and the rest of the world."

According to data from national malaria control programmes, Africa had a larger increase in funding than any other region between 2004 and 2006. The investments were led by the Global Fund to Fight AIDS, Tuberculosis and Malaria, and supported by bilateral and multilateral organizations and national governments.

In other regions, sources of funding were highly variable, but national governments provided the bulk of monies. While funding for malaria was higher than ever before in 2006, it is not yet possible to judge which countries have adequate resources and there are still significant gaps.

For more information please contact:

Dick Thompson, News Team Leader, WHO, Geneva
Telephone: +41 22 791 1492, Mobile: +41 79 475 5534, E-mail:

Fadela Chaib
Telephone: +41 22 791 3228, Mobile: +41 79 475 5556, E-mail:

World Malaria Report 2008

World Health Organization

[Excerpts only, from summary and key points. Full report and other background material available at]


There were an estimated 247 million malaria cases among 3.3 billion people at risk in 2006, causing nearly a million deaths, mostly of children under 5 years. 109 countries were endemic for malaria in 2008, 45 within the WHO African region.

The combination of tools and methods to combat malaria now includes long-lasting insecticidal nets (LLIN) and artemisinin-based combination therapy (ACT), supported by indoor residual spraying of insecticide (IRS) and intermittent preventive treatment in pregnancy (IPT). Despite big increases in the supply of mosquito nets, especially of LLIN in Africa, the number available in 2006 was still far below need in almost all countries. The procurement of antimalarial medicines through public health services also increased sharply, but access to treatment, especially of ACT, was inadequate in all countries surveyed in 2006.

Household surveys and data from national malaria control programmes (NMCPs) show that the coverage of all interventions in 2006 was far lower in most African countries than the 80% target set by the World Health Assembly. Supplies of insecticide-treated nets (ITN) to NMCPs were sufficient to protect an estimated 26% of people in 37 African countries. Surveys in 18 African countries found that 34% of households owned an ITN; 23% of children and 27% of pregnant women slept under an ITN; 38% of children with fever were treated with antimalarial drugs, but only 3% with ACT; and 18% of women used IPT in pregnancy. Only 5 African countries reported IRS coverage sufficient to protect at least 70% of people at risk of malaria.

In regions other than Africa, intervention coverage is difficult to measure because household surveys are uncommon, preventive methods usually target high-risk populations of unknown size, and NMCPs do not report on diagnosis and treatment in the private sector.

While the link between interventions and their impact is not always clear, at least 7 of 45 African countries/areas with relatively small populations, good surveillance and high intervention coverage reduced malaria cases and deaths by 50% or more between 2000 and 2006 or 2007. In a further 22 countries in other regions of the world, malaria cases fell by 50% or more over the period 2000 2006. However, deeper investigations of impact are needed to confirm that these 29 countries are on course to meet targets for reducing the malaria burden by 2010.

Key points

Background and context

A renewed effort to control malaria worldwide, moving towards elimination in some countries, is founded on the latest generation of effective tools and methods for prevention and cure.

1. The advent of long-lasting insecticidal nets (LLINs) and artemisinin-based combination therapy (ACT), plus a revival of support for indoor residual spraying of insecticide (IRS), presents a new opportunity for large-scale malaria control.

2. To accelerate progress in malaria control, the 2005 World Health Assembly (WHA) set targets of >= 80% coverage for four key interventions: insecticide-treated nets for people at risk; appropriate antimalarial drugs for patients with probable or confirmed malaria; indoor residual spraying of insecticide for households at risk; and intermittent preventive treatment in pregnancy. The WHA further specified that, as a result of these interventions, malaria cases and deaths per capita should be reduced by >= 50% between 2000 and 2010, and by >= 75% between 2005 and 2015.

3. The World malaria report 2008 uses data from routine surveillance (~ 100 endemic countries) and household surveys (~ 25 countries, mainly in Africa) to measure achievements up to 2006 and, for some aspects of malaria control, to 2007 and 2008. In five main chapters, 30 country profiles and seven annexes, the report describes: (a) the estimated burden of disease in each of the 109 countries and territories with malaria in 2006; (b) how WHO-recommended policies and strategies on malaria control have been adopted, by country, region and globally; (c) the progress made in implementing control measures; (d) the sources of funding for malaria control; and (e) recent evidence that interventions can reduce cases and deaths.

Burden of malaria in 2006, by country, region and globally

Half of the world's population is at risk of malaria, and an estimated 250 million cases led to nearly 1 million deaths in 2006.

4. An estimated 3.3 billion people were at risk of malaria in 2006. Of this total, 2.1 billion were at low risk (< 1 reported case per 1000 population), 97% of whom were living in regions other than Africa. The 1.2 billion at high risk (>= 1 case per 1000 population) were living mostly in the WHO African (49%) and SouthEast Asia regions (37%).

5. There were an estimated 247 million episodes of malaria in 2006, with a wide uncertainty interval (5th-95th centiles) from 189 million to 327 million cases. Eighty-six percent, or 212 million (152-287 million) cases, were in the African Region. Eighty percent of the cases in Africa were in 13 countries, and over half were in Nigeria, Democratic Republic of the Congo, Ethiopia, United Republic of Tanzania and Kenya. Among the cases that occurred outside the African Region, 80% were in India, Sudan, Myanmar, Bangladesh, Indonesia, Papua New Guinea and Pakistan.

6. There were an estimated 881,000 (610,000-1,212,000) malaria deaths in 2006, of which 91% (801,000, range 520,000-1,126,000) were in Africa and 85% were of children under 5 years of age.


Policies and strategies for malaria control

National malaria control programmes have adopted many of the WHO-recommended policies on prevention and cure, but with variation among countries and regions.

8. Nearly all of the 45 countries in the African Region had adopted, by the end of 2006, the policy of providing insecticidal nets free of charge to children and pregnant women, but only 16 aimed to cover all age groups at risk. ITNs are also used in a high proportion of countries in the South-East Asia and Western Pacific regions, but in relatively few countries in the other three WHO regions.

9. Indoor residual spraying is generally used in foci of high malaria transmission. IRS is the dominant method of vector control in the European Region. It is used in fewer countries in Africa, the Americas and South-East Asia, and least in the Western Pacific Region.

10. By June 2008, all except four countries and territories worldwide had adopted ACT as the first-line treatment for P. falciparum. Free treatment with ACT was available in 8 of 10 countries in the South-East Asia Region, but a smaller proportion of countries in other regions.

11. The systematic use of intermittent preventive treatment in pregnancy is restricted to the African Region; 33 of the 45 African countries had adopted IPT as national policy by the end of 2006.

Preventing malaria

Despite big increases in the supply of mosquito nets, especially of long-lasting insecticidal nets in Africa, the number available is still far below need in most countries.

12. Between 2004 and 2006, there were modest increases in the supply of conventional ITNs to countries in the African, South-East Asia and Western Pacific regions, the three regions where nets are most frequently used. By contrast, there was a large increase in the supply of LLINs to countries in the African Region, reaching 36 million in 2006.

13. Based on NMCP records of ITN supplies, however, only six countries in the African Region had sufficient nets (ITNs including LLINs) by 2006 to cover at least 50% of people at risk. These were Ethiopia, Kenya, Madagascar, Niger, Sao Tome and Principe, and Zambia. ITN supplies were sufficient to protect 26% of people in 37 African countries that reported in 2006.


16. Indoor residual spraying (IRS) is used focally in all regions of the world. In the African Region, NMCP data indicate that more than 70% of households at any risk of malaria were covered in Botswana, Namibia, Sao Tome and Principe, South Africa and Swaziland. In other regions of the world, relatively high coverage (> 20% of people at risk) was achieved only in Bhutan and Suriname.

Treating malaria

The procurement of antimalarial medicines through public health services increased sharply between 2001 and 2006, but access to treatment, especially of artemisinin-based combination therapy, was inadequate in all countries surveyed in 2006.

17. Between 2001 and 2006, NMCPs reported large increases in the number of courses of antimalarial drugs supplied through public health services. In particular, doses of ACT increased from 6 million in 2005 to 49 million in 2006, of which 45 million were for African countries. These NMCP figures probably underestimate usage, and the exact consumption of ACT is not known.

18. According to NMCP data, only 16 million rapid diagnostic tests (RDT) were delivered in 2006, of which 11 million were for countries in Africa, a small quantity in comparison with the number of malaria episodes.


20. According to national household surveys, however, none of the populations of 18 African countries surveyed in 2006 and 2007 had adequate access to antimalarial drugs. Only in Benin, Cameroon, Central African Republic, Gambia, Ghana, Uganda and Zambia were more than 50% of all children with fever treated with an antimalarial drug. In no country did access to treatment reach the 80% target, and the average across the 18 countries was 38%. The use of ACT was much lower: just 3% of children on average, ranging from 0.1% in Gambia to 13% in Zambia.


Financing malaria control

Funding for malaria control in 2006 was reported to be greater than ever before, but it is not yet possible to judge from NMCP budgets which countries have adequate resources for malaria control.

23. According to NMCP data for 2006, the African Region had more funds for malaria control than any other, and reported a larger increase in funding than any other region between 2004 and 2006. However, the total of US$ 688 million for the African Region in 2006 is certain to be an underestimate because reports were submitted by only 26 of 45 countries. The US$ 4.6 available per (estimated) malaria case in the 26 reporting countries is unlikely to be adequate to meet targets for prevention and cure.

24. The major sources of extra funds for African countries between 2004 and 2006 were reported to be the national governments of the affected countries plus the Global Fund to Fight AIDS, Tuberculosis and Malaria. These two sources dominated funding for malaria control in the African Region and worldwide in 2006.


Impact of malaria control

Some countries that have implemented aggressive programmes of prevention and treatment, in Africa and other regions, have reported significant reductions in the malaria burden.


27. Among 41 African countries that provided case and death reports over the period 1997-2006, the most persuasive evidence for impact comes from four countries, or parts of countries, with relatively small populations, good surveillance, and high intervention coverage. They are Eritrea, Rwanda, Sao Tome and Principe, and Zanzibar (United Republic of Tanzania). All four countries/areas reduced the malaria burden by 50% or more between 2000 and 2006 2007, in line with WHA targets.

28. In other African countries where a high proportion of people have access to antimalarial drugs or insecticidal nets, such as Ethiopia, Gambia, Kenya, Mali, Niger and Togo, routine surveillance data do not yet show, unequivocally, the expected reductions in morbidity and mortality. Either the data are incomplete, or the effects of interventions are small.

29. The reportedly high coverage of indoor residual spraying in Namibia, South Africa and Swaziland is consistent with the observed declines in case numbers in these countries, and evidently builds on earlier successes achieved with IRS.


AfricaFocus Bulletin is an independent electronic publication providing reposted commentary and analysis on African issues, with a particular focus on U.S. and international policies. AfricaFocus Bulletin is edited by William Minter.

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