Carlos C. (Kent) Campbell
"Preventing The Enormous Health And Economic Burden Of Malaria In Africa: We Know What To Do, And Now We Must Do It!"

Malaria is the leading killer of children in Africa, accounting for approximately 20 percent of all-cause mortality in children under the age of five. Africa’s malaria burden is worsening, and many factors, including expanding drug resistance, faltering health services, and the growing impact of HIV/AIDS on health services, contribute to malaria's growing toll on the continent’s health and economic potential.

Malaria strains health systems, particularly in Africa where it accounts for between 30 and 50 percent of hospital admissions and up to 50 percent of outpatient visits in high-transmission areas. Malaria costs Africa more than US$12 billion annually. It has slowed economic growth in African countries by 1.3 percent per year, the compounded effects of which are a gross domestic product level up to 32 percent lower than it would have been if malaria been eliminated in 1960.

However, during the past decade several interventions have proven successful in helping reduce malaria burden. These interventions include: (1) use of insecticide treated nets (ITNs), especially for infants and pregnant women; (2) intermittent preventive treatment in pregnant women (IPTp); and (3) prompt and effective case management (PECM), particularly among children who have fallen ill from the disease. IPT in infancy (IPTi) is an additional preventive approach currently under study. If shown to be safe and effective, IPTi could be introduced into malaria control programs for additional benefits. While not yet demonstrated, evidence suggests that these highly cost-effective interventions can now be implemented in an integrated manner with a focus on national-level prevention. New technologies in ITNs and alternative drugs are anticipated, and may be available to assess in field settings.

Indoor residual spraying (IRS) has been used to control transmission in several southern Africa settings characterized by low intensity seasonal risk. The World Health Organization (WHO) has advocated IRS use only where public health infrastructure is adequately developed and financed. The Malawi national plan does not currently advocate IRS except under very limited epidemic transmission settings, and MACEPA will not support IRS unless the Malawi’s national policy adopted IRS as a broadly applicable control tool.

On April 25, 2000, at the Abuja Summit in Nigeria, the Role Back Malaria (RBM) Partnership and African health ministers set targets of exceeding 60 percent coverage for these interventions by 2005. A key strategy for achieving these goals is delivering malaria interventions through established health systems: antenatal services, well-child services and the Expanded Programme on Immunization (EPI), and community-based programs.

Limited progress has been made since the Abuja Summit. Recent surveys indicate that current national coverage levels in Africa for each of the Abuja targets range from 5 to 40 percent. Key requirements for scaling up coverage Abuja target levels include: 1) A robust national political commitment to malaria control. 2) Effective coordination and application of resources. 3) Adequate supplies and health sector staffing. 4) A sustainable financial base for funding malaria control programs.

In order to maintain continued support for malaria control in Africa, progress of coverage increases must be effectively documented and disseminated. The RBM Partnership has been challenged to develop full-scale national demonstrations of malaria control program coverage of the Abuja targets, to show the magnitude of feasible burden reduction, and to advocate for sustained malaria support globally. In 2001, the External Evaluation of the RBM Partnership concluded that the Partnership should develop "block-buster countries"—countries with demonstrated capacity and commitment supported to rapidly scale up malaria control coverage. Evaluators also suggested that the methods and benefits of national-scale malaria control be appropriately profiled. As demonstrated in Figure 1, such rapid scale up could lead to substantial near-term improvements in child survival and health.

Figure 1: Accelerated Malaria Program Scale-Up This graphic depicts the estimated increased malaria burden reduction (gray area) expected with rapid increased coverage of the core malaria program prevention interventions (ITNs, IPTp, and PECM). This accelerated increase in coverage is compared with gradual incremental increases in coverage that currently characterize most higher readiness countries in Africa. The estimate of enhanced burden reduction that is possible derives from larger population trials of ITNs in varied epidemiologic settings.

A multi-pronged strategy for achieving Abuja coverage targets was proposed in the recently adopted RBM Strategic Orientations. This strategy proposes to demonstrate to the global community that malaria control interventions are robust, and that the infusion of resources to support malaria control remains a sound investment with objective and predictable health and economic impacts. Fundamental questions remain regarding the added value of interventions when they are combined in an integrated national malaria control program and also what the most cost-effective mix of sustained interventions is once prevention coverage exceeds the Abuja targets.