Towards a malaria-freeAfrica?

1. Malaria in Africa


Malaria is an infectious disease spread by mosquitoes that threatens up to 3.3 billion people in 109 countries - more than half the world's population. Each year, there are more than 225 million cases of malaria of which nearly 1 million are fatal, 90% of them in Sub-Saharan Africa where children and pregnant women are the main victims. Survivors may suffer brain damage. Malaria has a heavy cost in human lives, work hours and economic development. Most people buy  their medicines from local chemists and street kiosks rather than from government clinics and hospitals.


Africa still has the highest burden of malaria cases and deaths in the world. 50 African countries have malarious areas, but 30[1] bear the brunt of 95% of all malaria deaths and 96% of malaria cases world-wide. In sub-Saharan Africa, approximately 365 million cases occurred in 2002 and  963,000 deaths in 2000.  Almost 1 in 5 deaths of children under 5 in Africa is due to malaria. In addition, malaria during pregnancy often contributes to maternal anaemia, premature delivery and low birth weight which lead to increased child mortality. Severe maternal malaria infection contributes significantly to maternal deaths in sub-Saharan Africa, while countries in North Africa have only a few imported malaria cases and no deaths.


The average medicine course can cost between $6 and $10 in many African countries, while 60% of Africans earn less than $2 per day.  Most of these cannot afford the treatment they need and therefore go without.


Several factors have made malaria control difficult and led to substantial increases in cases on the continent during the 1980s and 1990s. Firstly, there was the widespread emergence of resistance of P. falciparum to chloroquine, then the most commonly used anti-malarial drug.  Secondly, the effectiveness of malaria control is limited by weak socioeconomic development, poverty, poor quality of housing and limited access to health care. At national level, inadequate financial resources for malaria control have led to fragmented implementation, limited in both scale and the populations targeted. The societal and health burden of the HIV/AIDS pandemic and numerous humanitarian crises in the past decades have also contributed to the difficulty of controlling malaria. 


2. New opportunities for fighting malaria

In recent years the opportunities for fighting and containing malaria have increased. The Global Fund to fight AIDS, TB and malaria has offered free malaria treatments to many countries in Africa and currently directs part of its help to strengthening national health systems, an important factor in the fight against malaria.


The resistance problem has been solved by changing to artemisinin-based combination therapies (ACT) in most sub-Saharan  African countries.  Artemisin  is a plant which quickly kills the plasmodium parasites that cause malaria. 

Severe malaria is treated with intravenous or intramuscular quinine or, increasingly, with the artemisinin derivative artesunate which is superior to quinine in both children and adults. Lately in South East Asia a new strain of artemisinin resistant malaria has appeared.  Scientists believe that fake and substandard malarial medicines are a major factor in the development of new malaria drug-resistant strains. History has shown that once resistance to anti-malarial treatment emerges it is only a question of time before it spreads.


The development of rapid tests that can diagnose malaria in 15 minutes is helping full recovery.


The recruitment and training of village health workers equipped with rapid diagnostic tests is an important aspect in the fight against malaria.


Access to long-lasting insecticide-treated nets protects children during their sleep when mosquitoes are active.  Insecticides for indoor spraying and insecticide spray pumps are also effective in keeping the insects at bay.


Global Health intervention to fight malaria has had a positive impact in Africa and the number of malaria infections has declined since 2008. In the 2010 World Health Organisation (WHO) report, the annual death toll due to malaria on the continent had decreased from 1 million to 781,000.


Today there are effective tools to treat malaria but only a limited number of patients have access to them. Many pregnant women and, above all, children still do not get the treatment they need. The two main barriers for people suffering from malaria in Africa are: costs of tests and of treatment (cocktail of ACT drugs), and difficulties of reaching health centres.


3. Towards a malaria-free world 

In recent years there has been significant progress in the fight against malaria. The cost of its elimination has been estimated at US $5,300 millions in 2009, $6.2 billion in 2010 and $5.1 billion annually from 2011 to 2020, but even greater is the actual cost in human lives and to the economy. 


To meet the 2015 UN target of ending deaths from malaria and dramatically reverse the disease in Africa, in 1998 the United Nations, in partnership with the WHO, UNICEF, the WB and UNDP, launched the initiative “Roll Back Malaria”, and specifically the 2001 - 2010 decade to Roll Back Malaria in Africa.


A number of medical organizations and NGOs joined the UN’s efforts. They called for a series of crucial measures such as free treatment, expanding use of free quick tests, training villagers to identify and treat simple cases of malaria in home based care centres and distribution of treated bed-nets. These measures save many lives in poor developing countries and regions.


An MSF’study has shown that making tests and treatment for malaria free dramatically increases the number of people who seek treatment. After free tests and drugs were introduced in a region in Chad, the number of malaria patients increased in one year from 10,000 to 100,000. This created other kind of problems as the existing clinics and medical staff could not absorb all the increase. But a positive side effect of free malaria medication is that patients do not rely any more on counterfeit and substandard malarial medications, thus reducing the possibility of resistance.

As the vast majority of drugs and other products used to fight malaria are imported from overseas, the WHO proposed dropping all taxes and tariffs on medicines, bed-nets and other anti-malaria tools as a means to lowering the cost of treatment and life-saving products. Despite the promise from 40 African leaders 10 years ago to do so, only six countries - Guinea, Kenya, Mauritius, Tanzania and Uganda in Africa and Papua New Guinea in Asia - have completely removed tariffs on products used to fight malaria. This is despite the fact that taxes and tariffs on anti-malaria products provide only minimal revenues and these gains are often offset by health costs and lost productivity from preventable malaria illnesses. Taxes and tariffs raise the price thus preventing the poor from access to malaria treatment.


To reach the MDGs on malaria mortality and bring about a real change, greater efforts at national and international level are needed. Political support at country level, and new strategies and funding at international level are two essential requirements. Only through real cooperation between countries and international partners will the MDGs be reached by 2015.


4. Towards free malaria treatment

Many governments in Africa have prioritized malaria and place it high on their health agendas. A few African countries have made commitments towards free malaria treatment and prevention for certain category of patients.


In Cameroon, where malaria accounts for 2/3 of hospital admissions and for 40% of deaths among children aged 0-5 years, a third of the family budget is spent on malaria treatment. From February 2011 there is free treatment for "uncomplicated malaria" for children under five in public and private hospitals. This includes also the medical test kit and treatment. But the qualification of "uncomplicated malaria" raises concerns in the population because eligibility for this category could lead to scams in hospitals and health centres. The government has announced the distribution of 8 million impregnated bed nets.


Ghana will offer free malaria treatment in all public health institutions once the law has been passed.


In Mozambique, malaria is the largest cause of hospital admissions, with 5.9 million reported cases of malaria, 4,209 malaria deaths in 2005 and over three million reported cases in the first three months of 2010 alone. Mozambicans have access to free malaria treatment in all public hospitals and clinics in the country. The distribution of free mosquito nets, house-to-house spraying campaigns, eliminating stagnant water where mosquitoes reproduce and raising general awareness about the disease are other measures they use to fight malaria.


In Mali the prevention and treatment of malaria in children under five years and pregnant women has been free in public hospitals, reference and community Health Centres since November 2010. This includes the drugs for treatment and prevention by sulfadoxine-pyrimethamine tablets as well as mosquito nets treated with insecticide.


Namibia, Botswana, South Africa and Swaziland are building a comprehensive approach that includes using bed-nets, improving diagnosis, and making available safe, effective treatment. But the cornerstone of this highly successful campaign is the spraying of small amounts of insecticide, including DDT, inside houses.


Senegal has made a great effort to combat malaria. The introduction of the ACT and of the rapid diagnostic test, together with the distribution of 3 million bed nets to children, has decreased the number of deaths due to malaria from 1,678 in 2006, to 577 by end 2009. The prevalence rate of malaria has gone down from 30% in 2,000 to 5.7%, currently.  USAID Senegal expects to provide 450,000 doses of treatment against malaria and one million bed nets. Since May 2010 Senegal has been offering free malaria treatment ( ACT only). Some doctors believe that the doses of ACT available will be insufficient for the current needs, especially during the rainy season.


In Chad since January 2011 malaria diagnosis and treatment, as well as bed nets for mothers and children have been free. The fight against malaria will cost between 15 and 20 billion FCFA per year. In 2010, 600 million CFA francs (915,000 euros) were spent on free care for all severe cases of malaria.

Begoña Iñarra, AEFJN Executive Secretary

[1] Nigeria, Democratic Republic of Congo, Uganda, Ethiopia, Tanzania, Sudan, Niger, Kenya, Burkina Faso, Ghana, Mali, Cameroon, Angola, Côte d'Ivoire, Mozambique, Chad, Guinea, Zambia, Malawi, Benin, Senegal, Sierra Leone, Burundi, Togo, Liberia, Rwanda, Congo, CentralAfrican Republic, Somalia, and Guinea-Bissau

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