Posted by: APO | 3 October 2007

2001-2010: Decade to Roll Back Malaria in Developing Countries, Particularly in Africa

United Nations A/62/321

General Assembly

Distr.: General

5 September 2007

Original: English

07-49705 (E) 011007

*0749705*

Sixty-second session

Item 49 of the provisional agenda*

2001-2010: Decade to Roll Back Malaria in

Developing Countries, Particularly in Africa

 

2001-2010: Decade to Roll Back Malaria in Developing Countries, Particularly in Africa**

Note by the Secretary-General

 

The Secretary-General hereby transmits the report prepared by the World

Health Organization, in accordance with General Assembly resolution 61/228.

* A/62/150.

** The compilation of inputs required to include the most current information has delayed

submission of the present report.

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Report of the World Health Organization entitled

“2001-2010: Decade to Roll Back Malaria in Developing

Countries, Particularly in Africa”

Summary

The present report highlights the activities undertaken and progress made since

the last report in meeting the 2010 malaria goals, in the context of General Assembly

resolution 61/228 and the Abuja Declaration on Roll Back Malaria in Africa (2000).

The report reviews, inter alia, developments in case management and

prevention, and prospects for the elimination of malaria, including issues related to

research and development and resource mobilization. In addition, the report also

addresses the problems associated with malaria in pregnant women and the special

challenges of malaria and health systems strengthening. The report provides

conclusions and recommendations for the consideration of the General Assembly.

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Contents

Paragraphs Page

I. Introduction and background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1–4 4

II. Access to effective treatment for malaria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5–11 5

III. Malaria in pregnancy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12–14 7

IV. Malaria prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15–20 8

V. Surveillance, monitoring and evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21–22 10

VI. Malaria elimination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23–24 11

VII. Malaria and health systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25–27 12

VIII. Funding and resource mobilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28–31 13

IX. Progress in and challenges to achieving the Millennium Development Goals . . . . 32–33 15

X. Conclusions and recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34–37 16

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I. Introduction and background

1. The seven years since the inception of the Decade to Roll Back Malaria in

Developing Countries, Particularly in Africa have seen the advent of the Global

Fund to Fight AIDS, Tuberculosis and Malaria, the World Bank Booster Programme

and the United States President’s Malaria Initiative, representing significant political

and financial commitments to malaria control. However, the disease continues to

threaten at least 40 per cent of the world population in 107 countries and territories.

Despite global efforts, more than 500 million people suffer from acute malaria each

year, resulting in an annual toll of more than 1 million deaths per year, of which at

least 86 per cent are in sub-Saharan Africa. Every day, an estimated 3,000 children

and infants die of malaria, representing approximately 82 per cent of all malaria

deaths. Approximately 50 million women living in malaria-endemic areas will

become pregnant every year. While malaria in pregnancy is predominantly

asymptomatic, it is a major cause of severe maternal anaemia, and is responsible for

approximately one third of preventable low birth weight babies. It is estimated that

the indirect effects of malaria, which are mostly overlooked in estimates of malariarelated

morbidity and mortality, result in up to 200,000 infant deaths per year in

Africa alone, and contribute to the deaths of an estimated 10,000 pregnant women.

While children and pregnant women are at greatest risk owing to their reduced

immunity, outside of Africa, all age groups are at risk.

2. Recent studies have shown that in some countries nearly two thirds of the

population with illness seeks care outside the health system. This indicates that the

malaria morbidity and mortality recorded through the health system represents only

the “tip of the iceberg”. Almost 60 per cent of all malarial deaths are concentrated in

the poorest 20 per cent of the world population, the highest association of any

disease with poverty, as it is mostly concentrated in poor and marginalized

populations, including refugees and internally displaced persons. Malaria has

lifelong effects on cognitive development, education and productivity levels. In

many countries it is the leading cause of illness and absenteeism in the workforce.

The evidence shows that malaria keeps poor people poor, costing Africa $12 billion

per year in lost gross domestic product (GDP) and consuming up to 34 per cent of

household incomes and 40 per cent of government health spending. Countries with

the highest burden have an estimated 1.3 per cent reduction in economic growth

every year. Malaria lowers economic growth and increases poverty through

numerous channels, including private and non-private medical care costs, reduced

productivity of malaria sufferers and caretakers, by inhibiting the movement of

labour and by discouraging foreign direct investment, trade and tourism.

3. The Roll Back Malaria Partnership, which was launched in 1998 by the World

Health Organization (WHO), the World Bank, the United Nations Children’s Fund

(UNICEF) and the United Nations Development Programme (UNDP), and includes

malaria-endemic countries, their bilateral and multilateral development partners, the

private sector, non-governmental and community-based organizations, foundations

and research and academic institutions, has the main objective of coordinating

support to Member States in order to halve malaria mortality by 2010 and by

75 per cent by 2015, relative to 2000. All of these constituencies are represented on

the Roll Back Malaria Board. During 2006, the Partnership underwent a significant

“change initiative”, which resulted in a restructuring of the Partnership secretariat,

which is hosted by WHO, and made it more responsive to the needs of Member

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States, including the revitalization or restructuring of working groups such as the

Harmonization Working Group, the Monitoring and Evaluation Reference Group,

and the Procurement and Supply Chain Management Working Group, and

subregional networks.

4. The World Health Organization Global Malaria Programme is the key

technical partner in the Partnership providing normative guidance and leadership in

policies and strategies for malaria control. The Programme encompasses a lean staff

at headquarters and at regional and country levels, as well as crucial links with other

WHO departments. The key components forming the basis of WHO strategic

direction are: (a) strong technical leadership and support to countries; (b) a

comprehensive focus on malaria-endemic countries worldwide; (c) supporting

malaria-endemic countries in applying the best available tools, including free or

highly subsidized distribution of long-lasting insecticide-treated nets to all at-risk

groups, indoor residual spraying where indicated and diagnosis of malaria cases and

treatment with artemisinin-based combination therapies (ACTs); (d) working closely

with countries and their in-country partners to ensure that interventions are tailored

to their particular epidemiologic and socio-economic needs; (e) ensuring that

malaria control efforts contribute to overall health systems strengthening and

supporting integrated delivery of essential health services; (f) focusing on the

development and implementation of effective, comprehensive monitoring and

evaluation tools to measure malaria programme performance, effective coverage and

impact; (g) supporting priority research to develop new methods and tools to

address implementation bottlenecks; (h) facilitating well-coordinated partnership at

the country level to ensure that support is harmonized and aligned with national

strategies and plans; and (i) fostering a multisectoral approach, with strong health

leadership, to gather political and financial support for sustainable, predictable

investments in malaria control. At the country level, WHO is successfully working

with partners, such as UNICEF, to scale up distribution of insecticide-treated nets,

and the World Bank, to ensure adoption of appropriate drug policies and increased

access to ACTs worldwide.

II. Access to effective treatment for malaria

5. ACTs are currently considered the best treatment for uncomplicated malaria

due to Plasmodium falciparum. WHO’s call for countries to shift away from

monotherapies, which have lost their effectiveness due to parasite resistance, has

been heeded by many countries. Nevertheless, safeguarding the efficacy of ACTs

continues to be of critical importance. As recommended by WHO, 70 countries —

40 of them in Africa — have adopted artemisinin-based combination therapies as

their first or second-line treatment. The availability of financing for ACTs and the

steadily increasing volume of purchase and strong advocacy have helped to push the

cost of ACTs down. The financing facility UNITAID, established in late 2006 in

partnership with the Global Fund to Fight AIDS, Tuberculosis and Malaria and

UNICEF, has already begun providing antimalarials and is focusing on using market

forces to further reduce the costs of ACTs to make them more broadly accessible. In

2006, a total of 82,774,740 ACT doses were procured, and it is estimated that 120

million treatments will be procured during 2007. Nevertheless, the costs of ACTs

are still often beyond the reach of the most poor, and the majority of patients in

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remote rural areas depend on inappropriate treatments from informal providers close

to their homes.

6. While malaria is an acute illness, it is also a chronic infection; estimates of

frequency of fever among African children suggest one episode every 40 days. The

risk of developing complications and death from severe malaria is greatest during

the first 24 hours. The correct and prompt management of malaria patients is

therefore a fundamental part of malaria control programmes. Early diagnosis and

effective treatment of the disease will shorten its duration and prevent the

development of complications, thereby greatly reducing the majority of deaths from

malaria. In most cases, symptomatic malaria is treated in communities, in peripheral

primary health facilities and informal health structures. Recent studies in Ethiopia,

Ghana and the Niger found that up to two thirds of the population with illness seek

care outside the health system. Effective case management must therefore ensure

that appropriate, effective treatment is available at each level of health care, both

public and private, as, in some affected communities, the private sector may be the

sole provider of antimalarial medications. Increasing community education and

participation is also a vital component of effective malaria case management.

7. The WHO home-based management of malaria approach improves access to

effective treatment by vulnerable populations (especially children under five years

of age) in countries that have low health facility coverage. In Africa, 18 countries

have adopted the strategy, of which a number are scaling it up with good community

participation and are already experiencing a reduction in childhood mortality. In

addition, WHO now recommends the use of rectal artemisinin suppositories as a

pre-referral treatment for severe malaria. This intervention has the potential of

saving child lives by rapidly reducing parasite densities until the child reaches a

health facility where parenteral treatment can be provided.

8. WHO currently recommends parasitological-based confirmation (microscopy

or rapid diagnostic test) before treatment, except for children under five years of age

in areas of high transmission and suspected severe cases if parasitological

confirmation is not immediately available. This will improve the quality of care and

will reduce unnecessary use of antimalarials in general. However, it has led to an

upsurge in the requests for and use of rapid diagnostic tests in countries.

Nevertheless, the gold standard in diagnosis remains high quality microscopy. The

quality of products (medicines and diagnostics) and services is also critical for good

clinical outcomes, and yet poses enormous challenges in countries. In addition, there

are a number of substandard products on the market, and even counterfeit

antimalarial medicines. To ensure that countries procure high quality medicines,

WHO has established a prequalification scheme for both antimalarials and rapid

diagnostic tests with quality assurance laboratories in various regions and is

supporting countries to develop a functional network of diagnostic services; a

quality assurance system for both microscopy and rapid diagnostic tests; and

assessment and training services for microscopists.

9. Monitoring antimalarial drug efficacy is mandatory to allow for proper case

management and for early detection of changing patterns of resistance in order to

revise national malaria treatment policies. Implementation of adequate and effective

drug policy will lead in turn to a reduction of morbidity and mortality. The accepted

malaria standard procedure is therapeutic efficacy testing, which involves repeated

assessment of clinical and parasitological outcomes of treatment during a fixed

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period of follow-up. A standardized protocol for the assessment of antimalarial drug

efficacy has been developed, and WHO helps countries in improving quality control

of the data. Among the 82 countries where falciparum malaria is endemic,

75 countries have implemented a monitoring system using a national sentinel site

network. Based on their surveillance data, more than 60 countries have changed

their antimalarial drug policy from monotherapy to combination therapy.

10. Ensuring effective service delivery will put high demands on the health system

and require it to address multiple issues, including: (a) efficient drug procurement,

supply and distribution systems; (b) quality-controlled laboratory services for

diagnostics; (c) adequate training in disease management of sufficient numbers of

health staff; (d) quality assurance and drug efficacy surveillance; (e) facilities for

referral of severe malaria patients to higher levels of care; and (f) a responsive

health management information system. In many countries’ public sector, these

services, when available, are often of poor quality or facilities lack the necessary

commodities. They are therefore underutilized and bypassed as a source of malaria

treatment even by the most poor. The Global Malaria Programme case management

task force, which bridges all three levels — headquarters, regional and country

offices — has developed an operational manual for case management to support

national malaria control programmes. The manual contains guidance on the

necessary complementary introduction of a community-level surveillance system,

including a revised malaria register, and data-collection and reporting forms to track

key case management indicators for monitoring project performance, outcomes and

impact.

11. Even though ACTs are currently being sold to buyers in the public and nonprofit

sectors at an ex-factory price of approximately $1, they are still prohibitively

expensive for the most poor, and, with retail prices of $8-10 in the private sector,

ACTs are available only to the wealthiest patients. A global initiative to enact a

“global ACT buyer subsidy” is currently under way to save tens of thousands of

lives per year by ensuring that the poor have better access to these essential lifesaving

antimalarial drugs and to preserve the utility of these drugs for as long as

possible. This innovative financing mechanism would result in price reductions for

buyers in all sectors, thereby supporting purchases of drugs across the public,

private and non-profit sectors. By making drugs more readily available to all

sectors, the duration of malaria disease could be reduced, and the current harmful

use of monotherapies, which threaten to rapidly induce drug resistance to

artemisinin, curtailed. Current estimates to fully implement the subsidy stand at

about $275-300 million per year, which includes allocations for monitoring and

evaluation, operational research and supportive interventions. It is expected that the

subsidy of ex-factory prices could increase the volume of ACTs to 250-350 million

treatments. A second-tier subsidy for distribution costs could then raise that volume

of ACTs to 300 to 400 million treatments. Global discussions regarding the subsidy

are ongoing.

III. Malaria in pregnancy

12. Over half of the approximately 50 million women who become pregnant in

malaria-endemic countries each year live in tropical areas of Africa with intense

transmission of Plasmodium falciparum. Even though malaria during pregnancy in

these regions is mostly asymptomatic, it is a major cause of severe maternal

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anaemia, and thereby responsible for approximately one third of preventable low

birth weight babies. In areas of low or seasonal transmission, pregnant women are at

increased risk of dying from the complications of severe malaria, and of

experiencing spontaneous abortion, premature delivery or stillbirth. Co-infection

with HIV, by exacerbating maternal anaemia and low birth weight, increases the

burden of malaria in pregnancy still further.

13. Intermittent preventive treatment in pregnancy (IPTp) with sulfadoxinepyrimethamine

(SP), which has been a policy recommendation since 1998 in

African countries, has been adopted as policy in all 35 African countries — 22 are

deploying countrywide and 13 are at varying stages of implementation. However,

deployment of IPTp is being challenged by widespread and increasing resistance of

the parasite Plasmodium falciparum to SP. Pending further investigations, a meeting

of the technical expert group on IPTp, held in July 2007, recommended the

continued use of IPTp with SP as a strategy, along with scaling up distribution of

insecticide-treated nets and access to effective treatment in sub-Saharan African

countries with stable malaria transmission. IPTp is not recommended for areas of

low, unstable transmission in Africa, Asia and Latin America, where emphasis is

placed on the use of insecticide-treated nets and prompt recognition and treatment of

malaria illness. A system of monitoring the effectiveness of the strategy is being put

in place, and WHO will soon issue guidelines for monitoring SP efficacy in pregnant

women.

14. WHO is working intensively with research partners to ensure that data is

generated on the safety and efficacy of alternatives to SP for both prevention and

treatment without delay. Since the majority of African countries have now changed

to ACT for first or second-line treatment of malaria, there is an urgent need to obtain

safety data on the inadvertent use of ACT in the first trimester of pregnancy. WHO

is supporting the establishment of pregnancy registries to facilitate follow-up of

women who were exposed to ACT during this critical period.

IV. Malaria prevention

15. WHO has made a recent shift in its guidance on the use of insecticide-treated

mosquito nets to protect people from malaria. It is now recommended that

insecticidal nets be long-lasting, and distributed either free or be highly subsidized

and be used by all community members. Analogous to the “herd immunity” benefit

of vaccines, long-lasting insecticidal nets have two kinds of protective effect: one

for the people directly under the nets, and one for the community at large. An

insecticide-treated net provides a physical barrier for the individual sleeping under

it, and in addition, by repelling or killing any mosquitoes that rest on the net,

provides an additional protective effect for the community. Therefore, by covering

entire communities with long-lasting insecticidal nets, everyone sleeping under a

bednet not only reduces their own risk of being infected with malaria, but, through a

“mass effect” of the insecticide being available over long periods in the community,

the number of mosquitoes in the community is also reduced, their lifespan is

shortened and the transmission of malaria is curbed over the long run. Where young

children and pregnant women are the most vulnerable, their protection is the

immediate priority while progressively achieving full coverage. In areas of low

transmission, where all age groups are vulnerable, national programmes should

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establish priorities on the basis of the geographical distribution of the malaria

burden.

16. It is estimated that around 135 million long-lasting insecticidal nets are needed

to achieve universal coverage of only pregnant women and children under five years

of age at risk of malaria in Africa. However, net coverage continues to be below

agreed targets, particularly in most high-burden countries. Throughout the

31 countries that reported in the Africa region in 2005 — the last date for which

complete data is available — 18,166,488 free or highly subsidized insecticidetreated

nets were distributed, and 7,568,439 nets were re-treated. High coverage

rates with a high degree of equity have been achieved in the following situations:

free delivery to entire communities (Eritrea); free or highly subsidized delivery to

pregnant women through the African National Congress (Malawi, Kenya, United

Republic of Tanzania); and free distribution to children under five in combination

with immunization campaigns (Zambia, Ghana, Togo and the Niger). On a more

limited scale, high levels have also been achieved in combination with routine

expanded programmes on immunization and child health days such as the UNICEFsupported

Accelerated Child Survival Development Initiative projects in West and

Central Africa. Unfortunately, in general, community-based projects have never

been able to achieve high coverage levels in poor rural areas. While social

marketing has sometimes been useful for creating demand, its cost-effectiveness has

been questioned and it has not achieved high coverage among poor rural

populations, especially when insecticide kits are needed to re-treat the nets. A policy

targeting only vulnerable groups neglected a crucial point: unprotected individuals

serve as reservoirs for malaria infection, carrying the parasite in their bloodstream,

and therefore not only becoming sick themselves, but also facilitating transmission

back to “protected” groups as nets are not 100 per cent effective. Optimum

community protection is achieved when mass coverage with long-lasting

insecticidal nets is combined with universal access to timely and effective

antimalarial treatment.

17. The bottlenecks to scaling up insecticide-treated nets coverage have been:

(a) the need for regular re-treatment; (b) availability; (c) affordability; and

(d) implementation. Long-lasting insecticidal nets have been developed by industry

to resolve the re-treatment issue and have been found to be significantly cheaper to

use than conventionally treated nets. The cost per death averted and cost per

disability adjusted life years averted with long-lasting insecticidal nets lasting three

years were less than half the comparable costs using conventional insecticide-treated

nets. Long-lasting insecticidal nets should therefore be considered a public good for

populations living in malaria-endemic areas. Countries will continue to need

assistance to scale up the necessary planning, organizational and managerial

capacity to plan large-scale distribution campaigns. This must also include an

information/education component, as some populations are still reticent to sleeping

under an insecticide-treated net or do not use it consistently. The WHO insecticidetreated

nets taskforce has drafted an operational manual to provide practical

guidance for national implementers managing long-lasting insecticidal net

interventions.

18. The other (and older) vector control intervention with wide applicability is

indoor residual spraying: the application of insecticides to the inner surfaces of

dwellings, where anopheline mosquitoes often rest after taking a blood-meal, with

the aim of reducing their life span to such an extent that they cannot transmit

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malaria. Indoor residual spraying has been used systematically and on a large scale

mainly in those countries that were involved in the global malaria eradication

campaign in the 1950s and 1960s.

19. The selection of insecticide for indoor residual spraying in a given area is

based on data on insecticide resistance, costs, safety, type of surface to spray and

local experience. There are currently 12 insecticides recommended by WHO for

indoor residual spraying, belonging to four chemical groups. DDT has the longest

residual efficacy against malaria vectors and plays an important role in the

management of vector resistance. WHO recommends DDT only for indoor residual

spraying, and countries can use DDT for as long as necessary, in the quantity

needed, provided that the guidelines and recommendations of WHO and the

Stockholm Convention on Persistent Organic Pollutants are all met. It is expected

that there will be a continued role for DDT in malaria control until equally costeffective

and efficient alternatives are available. An updated position paper on DDT

has been drafted by WHO, to be issued in late 2007. WHO is preparing a new

comprehensive operational manual and new monitoring systems on indoor residual

spraying, and will in the coming year greatly intensify its work to assist countries to

make the best use of this intervention.

20. Trends in the application of indoor residual spraying vary from region to

region. In Africa, approximately 22 countries use indoor residual spraying for

malaria control or to prevent reintroduction (Angola, Botswana, Burundi, Cape

Verde, Côte d’Ivoire, Eritrea, Ethiopia, Guinea, Kenya, Liberia, Madagascar, Mali,

Mauritius, Mozambique, Namibia, Rwanda, Sao Tome and Principe, South Africa,

Swaziland, Uganda, Zambia and Zimbabwe). In Asia, in four countries — Iraq,

Myanmar, Thailand and Viet Nam (of 22 regular users) — the number of households

covered increased from 2,297,000 to 3,052,000 from 2000 to 2003, and in the

Americas, in 9 (of 21) countries regularly applying indoor residual spraying (Costa

Rica, Nicaragua, Panama, Dominican Republic, Bolivia, Colombia, Ecuador, the

Bolivarian Republic of Venezuela and Argentina), the overall number of households

decreased from 411,000 to 229,000, even though coverage was actually increasing

in some countries. The most people protected by indoor residual spraying in the

world are in India, where 38.5 million people were protected in 2005, mainly with

DDT.

V. Surveillance, monitoring and evaluation

21. Estimates fall short of the real burden as the disease covers a wide spectrum of

presentations: ranging from asymptomatic infection to severe illness and death. The

problem of measuring progress and impact is compounded by inadequate diagnosis

and incomplete reporting. Additionally, countries generally have no baseline against

which to measure. The vastly increased resources and efforts to scale up antimalarial

interventions in populations at risk, particularly the World Bank Booster

Programme, the Global Fund allocations for malaria and the United States

President’s Malaria Initiative, all call for rigorous monitoring and evaluation at the

country level. Current reliance on routine health information systems is not

sufficiently representative, as large sectors of the populace (mostly the lower

quintiles) do not have access to health services, and information is not collected

systematically. This has led to inaccurate programme assessments and failures to

report adequately on the progress made.

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22. Given the complexity of malaria as a disease and multiple malaria control

interventions, many of which are delivered outside the public health system,

monitoring and evaluation solutions need to be flexible to reach the community and

household level, and capture data from hard-to-reach populations. WHO is helping

countries in the development and implementation of a country database with fieldtested

indicators. The information for this database is being collected through the

nationwide strengthening of health information systems, which will also help

countries collect data for other diseases. Intensive data-collection efforts are

ongoing in anticipation of the World Malaria Report 2007 to be released in early

2008, which will contain information on epidemiological, programmatic and

financial indicators. The Global Malaria Programme is also designing a generic

health information management system that will help countries to properly assess

programme performance, leading to improved policies and outcomes.

VI. Malaria elimination

23. The aims of the global fight against malaria are not only to reduce the burden

of malaria in endemic areas, but also to reduce and confine the geographical extent

of malaria-endemic areas in the world. The latter entails the elimination of malaria

from countries and localities where this is feasible. Over the last decade, an

increasing number of countries have been successful in interrupting local mosquitoborne

malaria transmission, seen as vital for public health, business and tourism. At

present, 7 of the 107 malaria-endemic countries and territories worldwide are

reporting zero locally acquired infections. Others have reduced their malaria burden

to levels where elimination is becoming a possibility. The WHO Global Malaria

Programme has decided to put a renewed focus on malaria elimination, including

the development of guidelines for national malaria elimination programmes, the

provision of technical and operational support to countries in the near-elimination

phase, and the setting up mechanisms for official certification. In January 2007, the

United Arab Emirates was the first formerly endemic country since the 1980s to be

certified malaria-free by WHO. Certification procedures for Oman are currently

ongoing. Malaria elimination evolves from a successful countrywide malaria control

effort. The WHO malaria elimination task force has identified four programme

phases in this continuum: control; pre-elimination; elimination; and prevention of

re-introduction. The milestone for the first of these phases has been determined as a

malaria case load of consistently less than 5 per cent of all febrile patients. Full

transition to an elimination programme is usually possible only once malaria cases

are becoming relatively scarce, at less than 1 patient per 1,000 people at risk per

year, or roughly 100 malaria patients per district annually. Progress towards

elimination is in its final phase when locally acquired cases are down to zero. At

present, some 10 countries worldwide are implementing malaria elimination

programmes, including Algeria, Argentina, Armenia, Egypt, El Salvador, Iraq,

Paraguay, Saudi Arabia, Turkmenistan and the Republic of Korea. A further 11 are

implementing pre-elimination programmes,1 and 7 countries are aiming for

“malaria-free zones”.

__________________

1 Azerbaijan, Democratic People’s Republic of Korea, Georgia, Iran (Islamic Republic of),

Kyrgyzstan, Malaysia, Mexico, Sri Lanka, Tajikistan, Turkey and Uzbekistan.

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24. The WHO European and eastern Mediterranean regions have adopted malaria

elimination as (part of) their regional strategy, as a logical extension of the malaria

control successes achieved by their member States. Over the period 1999-2006, the

malaria-endemic countries in the WHO European region reported an almost 15-fold

reduction in the number of locally acquired malaria cases, with a combined total of

only 2,520 such cases recorded in 2006. Nevertheless, even when a country has

eliminated malaria, it still remains at risk for re-introduction through international

travel and migration. Malaria elimination is closely linked to the achievement of

various Millennium Development Goals, as most countries that have successfully

achieved interruption of malaria transmission have also achieved an improvement in

the overall socio-economic situation, health services coverage and living standards

of their populations. Malaria-free status also adds to these developments by

removing barriers to investment and tourism.

VII. Malaria and health systems

25. Recent estimates show that malaria has a significant burden on health systems.

In Africa, malaria, on average, is the cause of 25 per cent to 45 per cent of all

outpatient visits. Malaria also has a high case fatality rate among admitted patients,

as they often present late, or are managed inadequately, or effective drugs are

unavailable. Effective malaria control requires better and improved health

management and information systems and surveillance systems to help health

planners quantify the burden of malaria, and adequately estimate and allocate

resources to health services. Currently, effective delivery of interventions is

hampered by lack of staff, and long-term predictable commitments of funding from

the donor in order to strengthen the health-care infrastructure in malaria-endemic

countries. Poor health infrastructure, coupled with insufficient supplies of essential

drugs and other preventive measures, such as nets and insecticides, and inadequate

supervision of health-care providers, leads to poor service delivery. Malariaendemic

countries need support to: (a) develop managerial capacity to oversee

health-care personnel; (b) develop efficient mechanisms for quality laboratory

services to ensure reliable diagnosis and effective case management; (c) increase

accessibility of health services, especially in geographically remote areas;

(d) improve private-public mechanisms for health service delivery; (e) strengthen

procurement and distribution systems for medicines, reagents, insecticides and other

essential commodities; and (f) put in place measures to retain skilled personnel at

the district and community level.

26. Coordinated sectorwide development will greatly improve efforts to control

malaria. The WHO Global Malaria Programme is focusing on scaling up and

improving its support interventions particularly at the primary care level, in order to

maximize the effectiveness of a given patient encounter with the health system. It is

doing so through cascade-style training, which will address the current deficit in

skilled personnel to deliver effective patient management at the health-facility level

and the lack of training in epidemiology, entomology, and laboratory diagnostics.

Special emphasis is also being placed on maximizing prevention, ensuring that

services are tailored and delivered to the poor, vulnerable groups, and hard-to-reach

populations. This will entail more health-care workers at the community level,

teaching mothers and community-based workers to manage malaria at home.

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27. There is a need for a multisectoral approach and for heightened advocacy with

the ministries of finance to raise awareness of the benefits of investing in health and

to gather political support for long-term investments in the health sector.

Investments in malaria control are high yielding and highly cost effective: for a

typical household of six people, coverage with three long-lasting insecticidal nets

will cost between $0.55 and $0.91 per person per year. For a long-lasting

insecticidal net that lasts five years, costing approximately $5.50, the estimated cost

per child death averted is $145, with costs going down the longer the net lasts. It is

critical to support countries in analysing their implementation gaps and to focus on

understanding which high-impact, cost-effective interventions can be scaled up

quickly in each country’s context. Insecticide-treated nets, indoor residual

household spraying, and intermittent preventive treatment during pregnancy were

identified as neglected low-cost opportunities in sub-Saharan Africa in the 2006

report of the Disease Control Priorities Project. Additionally, the 2004 Copenhagen

Consensus rated controlling and treating malaria as a “very good” use of resources

in developing countries. The limiting factor to achieving high coverage and

overcoming operational barriers is the level of health infrastructure, which in many

malaria-endemic countries, particularly in Africa, is very low and continues to

require substantial assistance from external donors. However, the evidence has

shown that the incremental cost of interventions is lower when implemented

together, as resources can be shared. There is a need for continued research into the

relative cost-effectiveness of different interventions and combinations of

interventions in various settings.

VIII. Funding and resource mobilization

28. The estimated global resources needed to effectively control malaria are about

$3.8 to $4.5 billion per year,2 depending on how fast prevention brings down the

number of cases and therefore the need for treatment. This includes costs for

commodities, distribution, health system strengthening activities, and technical

assistance for national programmes. The average costs for Africa would be $1.7 to

$2.2 billion. In addition, in order to receive adequate attention from donors and in

national budgets, national health priorities must be linked with poverty reduction

strategy papers, achievement of the Millennium Development Goals, and other

development agendas. Issues of harmonization and predictability of external funding

are critical when undertaking long-term investments in the health sector, and call for

heightened coordination of countries and partners. At the country level, reliable

information on burden of disease and financing for malaria services (particularly

national spending) is lacking, rendering difficult informed policymaking and

effective resource allocation. Use of the informal private sector for malaria

treatment, combined with weak health information systems, presents a challenge for

accurate estimation of current malaria spending. Approximately 60 per cent of all

malaria episodes in sub-Saharan Africa are initially treated by private providers,

mainly through the purchase of drugs from shops and drug peddlers. Furthermore, as

donors move towards budget support rather than earmarked funding, there is a

heightened need to develop effective tools to track the flows of development

assistance for health. To address these issues, WHO is supporting the

__________________

2 World Health Organization, “Estimated global resources needed to attain international malaria

control goals”, Bulletin of the World Health Organization, vol. 85, No. 8 (2007).

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implementation of national health accounts in a number of countries, and is

contributing to the development of a malaria sub-analysis framework that could be

used to measure national malaria expenditures. Financing of national malaria

control plans will need to take into account several key issues: (a) in countries that

have adopted ACTs as first-line treatment for malaria, as per WHO guidelines, there

is a need to identify sustainable source(s) of funds to meet current and future needs;

(b) financing the distribution of long-lasting insecticidal nets to achieve wide

coverage and usage, particularly in rural areas; and (c) identifying funding sources

to attract, train and retain key service personnel who form the touchstone of malaria

service provision across all interventions.

29. Governments must intervene to fund malaria control to correct market failures

and inequities in provision of services. Public sector constraints include limited

government revenues and restrictive macroeconomic policies. While there has been

some alleviation in the form of debt write-off, this is still insufficient to encourage

Governments to change their resource allocation patterns. More emphasis and

research into methods of mixing public-private interventions to ensure patients are

receiving the best quality of care is still required. In the 2000 Abuja Declaration, the

Heads of State and Government pledged to allocate 15 per cent of national budgets

to the health sector. Despite modest progress being made by some Member States,

the proportion of national budget devoted to health financing is still low in many

countries (only Djibouti and Botswana have proportioned 15 per cent or more of

their national budgets to health). The last estimates found that about $300 million

per year is provided by domestic sources for malaria.

30. The Global Fund reports that its total international disbursements for malaria

up to August 2007 were approximately $1 billion. The Global Fund to Fight AIDS,

Tuberculosis and Malaria is active in 77 countries, funding a total of 113 malaria

grants for a total approved funding of $1.7 billion. However, the future of the

Global Fund is by no means assured, and yet many countries have completely

overhauled their systems in order to respond to the Global Fund without having

assured long-term commitments beyond the initial two-year grant phase. If countries

“perform well”, they may go onto a further three years or be eligible for the recently

instituted “rolling continuation channel” funding. The Global Fund has also begun

exploring the possibility of funding a countries’ national strategic plan when this is

appropriately costed and is accompanied by a comprehensive workplan.

Nevertheless, the Global Fund has not always been lenient in considering the

implementation constraints particular to malaria, such as supply chain delays,

including the long-lead in artemisinin production for ACTs and availability of longlasting

insecticidal nets, which are only now being resolved. Malaria grants,

generally, have the lowest performance ratings (more grants are rated B2 and C) of

the three diseases and therefore run the risk of grant loss more often.

31. Other major donors have also raised expectations that additional funds will be

available for malaria. The United States President’s Malaria Initiative established in

2005 has a goal of reducing malaria-related mortality by 50 per cent in 15 target

countries in sub-Saharan Africa. This five-year initiative (2005-2010) is an

announced increase in funding of $1.2 billion. However, other United Statessponsored

malaria programmes (such as United States Agency for International

Development umbrella grants for malaria) are being reduced apparently to cover the

President’s Malaria Initiative commitments. Also in 2005, the Global Strategy and

Booster Programme for Malaria Control were launched as the World Bank’s new

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plan for controlling the disease. Over its first phase (2005-2008), 15 countries and

one major cross-border regional project have been approved. The second phase,

2008-2015, is currently being designed. Total commitments for malaria control in

Africa by the World Bank are currently approximately $500 million. In recognition

of the need to ensure that funding is mutually reinforcing and complementary, the

World Bank is emphasizing donor harmonization in malaria control, and is working

to mobilize additional resources from partners. In 2006, the Bill and Melinda Gates

Foundation committed $83.5 million in new malaria grants. This funding will

support some malaria prevention and treatment programmes, as well as research and

development. It is estimated that continual development of new drugs at the rate

dictated by emerging drug resistance would cost at least $30 million a year.

IX. Progress in and challenges to achieving the Millennium

Development Goals

32. One of the key developments in the past two years has been the reinforcement

and redirection of WHO’s malaria department to focus on developing strategies,

guidelines and country-relevant tools on “how” to tackle malaria where the burden

is greatest. The programme is also taking a lead role in defining research priorities

and ensuring that critical gaps in knowledge are being addressed, ensuring that

research outcomes deliver practical policy recommendations. All levels of the

programme are coordinating and streamlining their technical guidance to scale up

the three key interventions, namely, prompt and effective treatment with ACTs,

distribution of long-lasting insecticidal nets to all at risk of malaria, and indoor

residual spraying interventions to reach the poorest populations, and collecting

undisputable evidence of efficacy, efficiency and operational impact.

33. While there are still many challenges to be faced on the African continent,

there is evidence that malaria cases have decreased in seven countries (Botswana,

Burundi, Eritrea, Malawi, South Africa, Swaziland and Zanzibar (Tanzania)). South

Africa, in particular, was able to significantly reduce its morbidity and mortality

through a combination of interventions, including 90 per cent operational coverage

with indoor residual spraying in 2003 and 2004. Swaziland has also been able to

reduce the number of clinical malaria cases by 75 per cent, from more than 45,000

in 2000 to less than 10,000 in 2005, representing one of the few examples of

achievement of the Roll Back Malaria Partnership goal of reducing malaria

morbidity by 2010. As of 2006, the Americas have also brought about a 21 per cent

reduction in malaria cases, and a 69 per cent reduction in mortality, relative to 2000.

Nonetheless, an outbreak of malaria in Jamaica in late 2006 showed that even

countries that have been certified malaria-free or where transmission has been

absent for over 10 years must remain highly vigilant of the threat of reintroduction.

There has also been a decrease in the malaria situation in the nine countries in the

Middle East and North Africa, relative to 2000. The nine malaria-endemic countries

in the WHO’s European region have also shown a decrease in their malaria situation

relative to 2000. Progress in the region has been such that the European regional

strategy for 2005-2015 is focusing on eliminating malaria from the region through

the enhancement of national capacities for decision-making, investing in human

development and capacity-building, improving capacities for disease management,

strengthening capacities for containment and prevention of epidemics, promoting

cost-effective preventive measures, strengthening surveillance and operational

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research capabilities, ensuring community mobilization and enhancing intersectoral

collaboration. In the WHO South-East Asia region, Bhutan, the Democratic People’s

Republic of Korea, Sri Lanka and Thailand have successfully reduced their malaria

burden relative to 2000. However, the region’s countries continue to be hindered by

natural disasters and conflict, which undermines the health care delivery for all

diseases, but in particular for malaria. All of the malaria-endemic countries of the

western Pacific region have mostly shown steadily declining trends in confirmed

malaria cases and annual mortality rates, except for Solomon Islands and Vanuatu.

X. Conclusions and recommendations

34. Malaria control is currently hindered by a number of challenges. First,

while there has been some progress since 2000, there is still a critical shortage

of reliable, accurate and constant malaria data. Information is at times

available at the peripheral level; however, not many countries, particularly in

Africa, have in place either the capacity or management structures to aggregate

and analyse indicators on the epidemiological situation, health delivery

structure, drug and insecticide resistance, and resource flows at the central

level. Without this information, countries cannot monitor programme

performance, coverage or impact. National malaria programmes therefore

cannot effectively guide the allocation of programme resources, take informed

management decisions or enhance public-private collaborations to better reach

target populations and goals. Second, while malaria-specific funding has been

increasing, it is also increasingly focusing on the funding of commodities

without concurrent increases in funding for technical assistance to build

country capacity and the overarching needs of the health systems, which also

hinder implementation of malaria programmes. This lack of funding and lack

of capacity act on each other in a vicious circle: without capacity countries

cannot absorb the available funding, and without funding they cannot develop

capacity. Various initiatives are therefore hindered by implementation

challenges and do not achieve their expected impact, leaving malaria morbidity

and mortality levels unacceptably high.

35. Some interventions have begun to show substantial progress in recent

years. Distribution of long-lasting insecticidal nets, particularly when combined

with strong programmes such as the expanded programme on immunization,

has been particularly effective and has begun to raise coverage rates in some

areas. Increased access to effective case management and coverage with indoor

residual spraying are progressing at a slower pace but are also beginning to

demonstrate considerable improvement. Nevertheless, many countries will need

to undergo extensive and fundamental changes in their malaria control

programmes if they are to reach their malaria controls and targets. Such

changes will require renewed commitment from all levels of the government

and resources (both financial and human) for the implementation of accurate

policies, and sustainable and evidence-proven strategies. New implementation

challenges and knowledge gaps are emerging, and the resources available for

malaria control still fall dramatically short of what is needed to effectively

combat the disease. Compared to many other diseases, the tools to effectively

control malaria are already known. Funding is reaching the country level, but

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malaria-endemic countries still need strategic and technical guidance to

improve their capacities and ensure that funding is being spent effectively.

36. On the basis of the findings of the present report and those of World

Health Assembly resolution 60/18, it is recommended that the General

Assembly call upon malaria-endemic countries to:

(a) Apply WHO-recommended policies, strategies and tools to their

specific contexts, and establish evidence-based national policies, operational

plans and performance-based monitoring and evaluation towards scaling up

effective coverage of major preventive and curative interventions to

populations at risk, and assessing programme performance, intervention

coverage and impact effectively in a timely manner;

(b) With support from WHO, use the country database to systematically

collect and analyse existing information on their malaria situation, including

epidemiology, national policies and programme performance, coverage of

interventions, financing, and drug and insecticide resistance status;

(c) Assess the capacity of their national malaria programmes,

particularly their human resources, and ensure that skilled personnel are in

place in adequate numbers at all levels of the health system to meet technical

and operational needs as increased funding for malaria control programmes

becomes available;

(d) Respond to the need for strengthening their health systems and

ensure integrated delivery of health services at the district level, including

attention to health personnel, supplies of drugs and preventive measures, and

adequate health infrastructure;

(e) Encourage intersectoral collaboration, particularly at the highest

levels of government, i.e. the ministries of finance, education, agriculture,

economic development and the environment, and maintain and strengthen

existing intercountry, multi-institutional, and multisectoral malaria networks;

(f) With support from WHO, strengthen drug resistance surveillance

systems, and WHO to coordinate a global surveillance network for monitoring

and management of drug resistance;

(g) With support from WHO, undertake development of insecticide

resistance surveillance systems, and WHO to coordinate a global network for

monitoring and management of insecticide resistance;

(h) Continue to prohibit the marketing of oral artemisinin

monotherapies, and the cessation of funding for the procurement of oral

artemisinin monotherapies by international agencies;

(i) Waive taxes and tariffs for nets, drugs, and other products needed

for malaria control, both to reduce the price of these commodities to consumers

and to stimulate free trade in these products.

37. On the basis of the findings of the present report and those of the World

Health Assembly resolution 60/18, it is recommended that the General

Assembly call upon:

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(a) Bilateral and multilateral funding partners to become fully

knowledgeable of WHO’s technical policies and strategies, including for indoor

residual spraying, insecticide-treated nets and case management, to ensure that

funding supports only projects that are in accord with these, and consider

submitting technical components of projects under consideration to be

reviewed by WHO prior to approval to ensure adherence to the latest WHO

technical recommendations;

(b) International partners to use monitoring and evaluation systems as

developed by WHO as minimum core indicators, rather than adopting parallel

systems. In addition, WHO, together with countries and other partners, to

develop simple, less costly survey methodologies to effectively assess impact and

coverage of antimalarial interventions in a timely manner;

(c) All donor agencies and food-importing countries to issue a clear

statement outlining their position on the use of DDT for indoor residual

spraying, when it is implemented where indicated and in accordance with

WHO guidelines, and to provide all possible support to malaria-endemic

countries to manage the intervention effectively and prevent the contamination

of agricultural products with DDT and other insecticides used for indoor

residual spraying;

(d) Producers of long-lasting insecticidal nets to accelerate technology

transfer to developing countries, and the World Bank and regional development

funds to consider supporting malaria-endemic countries to establish factories to

scale up production of long-lasting insecticidal nets;

(e) The international community to reach a consensus on appropriate

levels and sources of subsidies for key commodities, namely long-lasting

insecticidal nets and ACTs, to enable expanded access to good quality drugs

and preventive measures to populations at risk of malaria, and to fight the

counterfeit drug trade in developing countries;

(f) The international community, inter alia, to financially enhance the

Global Fund to Fight AIDS, Tuberculosis and Malaria for it to be able to

continue supporting countries, and to provide adequate complementary

resources for technical assistance, particularly for the World Health

Organization and the United Nations Children’s Fund, to ensure that funds can

be absorbed and used effectively in countries.


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