AFRICAN UNION UNION AFRICAINE
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TH4 SESSION OF THE AU CONFERENCE
OF MINISTERS OF HEALTH
4-8 MAY 2009
ADDIS ABABA, ETHIOPIA
Theme: “Universal Access to Quality Health Services: Improve Maternal, Neonatal
and Child Health”
MEETING OF EXPERTS
4-6 MAY 2009
UNIVERSAL ACCESS TO HIV/AIDS, TB AND MALARIA SERVICES BY 2010:
UPDATE ON MALARIA
LIST OF ABBREVIATIONS AND ACRONYMS
ACTs: Artemisin Combination therapy
AFRO: African Regional Office
AMFM: Affordable Medicines Facility for Malaria ANC: Antenatal Clinic
CARN: Central Africa Regional Network EARN : Eastern African region Network GFATM: Global Fund to fight AIDS, TB and Malaria HIV: Human Immuno-deficiency Virus
HMM: Home Management of Malaria
IPT: Intermittent Prophylactic Treatment
ITNs: Insecticide treated nets
ITPP: Intermittent Preventive Treatment
IRS: Indoor Residua Spray
LLINs: Long Lasting insecticides Nets
MSPs: Malaria Strategic Plans
M & E: Monitoring and Evaluation
MDGs: Millennium Development Goals MIM: Multilateral Initiative on Malaria
MMV: Malaria Medicines Venture
MVI: Malaria Vaccine Initiative
ORID: Other related infectious diseases
PMI: President’s Malaria Initiative
RBM: Roll Back Malaria
SARN: Southern Africa Region Network
SRNs: Sub-Regional Networks
SUFI: Scaling up for Impact
TDR: Tropical disease Research
UNAIDS: Joint UN Programme on AIDS UNITAD: International Drug Purchasing facility WARN: Western Africa Region Network
WBB: World Bank Booster Programme
WHO: World health Organisation
The AU Heads of State and Government adopted the Abuja Declarations and Plans of Action in 2000 and 2001, committing themselves to intensifying the fight
against HIV/AIDS, TB, Malaria and other infectious diseases (ORID). At their Abuja
Special Summit of May 2006, they reaffirmed these pledges and committed themselves
to scaling up action towards universal access to HIV/AIDS, TB and Malaria services BY
2010. As was requested, the AU Commission, in collaboration with WHO and UNAIDS,
prepared the 2-year Progress Report on the status of implementation in 2008. This
Report draws for the 2008 Report, which had been compiled from several published and
unpublished reports on the malaria situation in Africa as at end of 2007, unless
otherwise stated. It incorporates a few updates. It describes the progress made in the
implementation of these targets with special focus on the implementation of the 11
priority areas outlined in the Abuja Call for Accelerated Action towards Universal
Access to health Services.
All countries in Africa have established RBM coordinating bodies and, developed Malaria Strategic Plans (MSPs). Only limited countries have achieved the goal of
devoting 15% government expenditure to health with a regional average of 8.8 %.
Several initiatives to increase funding for malaria control have emerged and include the
Global Fund (GFATM), World Bank Booster Programme (WBB), the Presidents’ Malaria
Initiative (PMI) and The Islamic Development Bank. At the time of the original Report,
the GFATM had committed 1.7 billion US $ to malaria control in Africa and about US
$ 645 million form various sources was spent on malaria control in Africa (to be
To increase access to malaria control interventions, 74% of countries had waived taxes on anti-malarials, 64% had removed taxes or introduced waivers on ITNs while
about half had waived taxes and tariffs on nets, netting materials and insecticides. In
2006-2007, over 33 million ITNs were distributed through campaigns in 22 countries.
About 25% of households own at least one mosquito net of any type, while 12 % own at
least one ITN. By 2007, 7 countries had achieved more than 40% household owning at
least 1 ITN. On average, 8% of children under-five sleep under an ITN. However, ITN
use by children under five has exceeded 40% in Rwanda, the Gambia, Guinea Bissau,
Sao Tome and Principe and Guinea Bissau. Use of ITNs by pregnant women is even
lower at 5%. The 2008 updates have not incorporated.
All the 35 countries where intermittent prophylactic treatment (IPT) is recommended had adopted the policy but only 20 countries are implementing country-
wide. Coverage with IPT is less than 10%. However, some few achieved higher IPT
All countries except 2 had adopted Artemesin Combination Therapy (ACT) as 1
line treatment for malaria, with 25 already implementing the policy. Across the region,
34% of children with fever received an antimalarial treatment. However, in some
countries, antimalarial treatment within 24 hours mostly is chloroquine which is no
longer effective. The use of ACT is very low; in some 14 countries with 2005-7 data, the
median proportion of children under five years with fever receiving an ACT was only 2%.
By end of 2007, 25 out of the 42 malaria endemic countries in the region had included IRS in their national strategy. Of these, 17 routinely implement IRS as a major
malaria control intervention while six are piloting IRS in a few districts In the 2006-2007
malaria season a total of about 5 million units/structures were sprayed with an
operational coverage in target areas of about was 83% protecting about 21 million
Several initiatives to increase access to malaria control commodities have emerged. The Affordable Medicines facility for Malaria (AMFm) was established to
bring down the cost of ACTs and help phase out the monotherapies to avoid the
development of resistance. The Global RBM partnership was established in 1998.
Consequently, all countries in the African region have established partnerships at the
country level. Also, sub-regional RBM partnerships networks (SRNs) have been
established that bring together all key partners in the sub-region to consolidate support
for malaria control in the respective countries.
Since 2000, 25 April had been commemorated as Africa Malaria Day. Regional events have been held across the sub-region and nationally. The commemoration of
Africa Malaria day has firmly place malaria on top of the agenda in many countries. In
2007, 25 April was also declared World Malaria Day, and is now commemorated
worldwide. In 2007, the AU Launched the Malaria Elimination Campaign.
Data from over 25 household surveys conducted in 2005-2007 has been used to compile this report. All the countries in the sub-region have functional HMIS although
interpretation of the trends in malaria cases and deaths is difficult due to incomplete
reports, non-standardized reporting and reliance mostly on clinical diagnosis. However,
in selected countries that have scaled up interventions but also have more consistent
and complete data, there have been reductions in malaria cases and deaths at health
facility level. Most countries in the region are moving towards universal access to
malaria prevention and control among all at risk of malaria. Malaria Elimination by 2010
can only be achieved if all affected countries double efforts and move forward
Member states have made moderate progress towards achieving targets set at the Abuja 2000, 2001, RBM and MDGs. Great political commitment, adoption of better
policies as well as increased funding for malaria control from governments,
development agencies and funding initiatives have contributed enormously to these
gains. However none of the countries had achieved all the targets. Furthermore,
resistance to Artemesin therapy was recently reported in Thailand.
In September 2008, the UN Secretary General’s Special Envoy on Malaria convened an MDG malaria Summit under the theme “World Leaders Unite”. It was
attended by 089 African heads of State and Government, the AU Commission
Chairperson and a number of Health Ministers. Participants “announced more than $3 billion in new funding for the fight against Malaria, and committed their stewardship to
spur the world toward the ultimate goal: near zero deaths by 2015”.
1. Malaria Control Targets were set by African heads of State and Government at
the 2000 Special Simmit on Roll Back Malaria; and the 2006 Special Summit on
HIV/AIDS, Tuberculosis and Malaria which adopted the “Abuja Call for Accelerated
Action towards Universal Access to HIV/AIDS, Tuberculosis and Malaria services”. In
the Call, th Leaders collectively rededicated themselves to a comprehensive remedial
effort based on an implementation mechanism that addresses the following priority:
i: Leadership at National, Regional and Continental Levels
ii: Resource mobilisation
iii: Protection of Human Rights
iv: Poverty Reduction, Health and Development
v: Strengthening Health Systems
vi: Prevention, Treatment , Care and Support
vii: Access to Affordable Medicines and Technologies
viii: Research and Development
ix: Implementation at national level
xi: Monitoring , Evaluation and Reporting
Africa’s move from Malaria Control to Elimination
2. The Africa Malaria Elimination Campaign also takes into account the variation in
the burden and epidemiology of malaria in the different regions of the continent. It
defines the focus of malaria control and elimination through incremental programming
for elimination by region within the member states. Countries with high burden of
malaria will aim at disease control thus reducing malaria as a public health problem
through the Scaling Up for Impact (SUFI), with a long-term goal of eliminating malaria,
while the immediate direction in countries with low burden of malaria will be elimination of malaria. Countries that succeeded malaria elimination as well as those countries
currently are free of malaria would aim to maintain the malaria-free status.
The Africa Malaria Elimination Campaign
3. The main goal of the Africa Malaria Strategy is to reduce the burden of malaria
with the ultimate aim of elimination through ensuring universal free or highly subsidized access to prevention and treatment interventions, and to contribute to the socio-
economic development of the people of Africa in support of making progress towards
the Millennium Development Goals by 2015 and the WHO Malaria Strategies. Through
incremental steps, African countries will subsequently aim to eliminate malaria and
interrupt local transmission. The planning needs to be country specific in order to deal with the timelines required to reach the preparatory stages of elimination. The general
direction to move from malaria control to elimination through incremental programming;
High Transmission Areas
4. In most of the African countries, malaria transmission is intense with high levels
of malaria morbidity and mortality. Although the Progress Report on the Abuja
Declaration found that considerable progress had been made, the current status of
coverage with anti-malarial interventions is unlikely to produce impact by 2010, unless
drastic steps are taken. Sustainable financing for the implementation of malaria
interventions and strong advocacy for social and community mobilisation for sustained
delivery and use are critical for achieving impact. In addition, strong surveillance and
health information systems as appropriate and strong inter-country and cross border
collaboration are critical in order to achieve reduction in the burden. Once this stage is
completed, the duration of which depends on the efforts and achievements of individual
countries, this group of countries would subsequently aim to move on to the stage of
Low Transmission Areas
5. The intensity of transmission and incidence of malaria in these is relatively low and involves parts of the countries. There have been improvements in access to anti-
malarial measures, as well as promising impacts on malaria prevention and control
efforts. For these countries, the immediate direction of the Africa Malaria Strategy is to
move from malaria control to elimination, as a logical extension of the successes in
malaria control achieved by these countries. The approach in these countries should be
the implementation of anti-malaria program deliberately aimed at elimination. Through
the incremental stage, these countries will subsequently aim to maintain a malaria-free
Transmission has been interrupted
6. Five Countries in which interruption of malaria transmission was declared recently, the policy of the Malaria Strategy will be prevention of malaria re-introduction
and, subsequent certification of malaria elimination.
STATUS OF IMPLEMENTATION (as per 2008 Report to the Special Session of the
AU Conference of Ministers of Health)
? (To be updated as the 2010 reporting on universal access is undertaken)
7. In the Abuja summit 2006, the Heads of State and Government specifically requested for periodic reports on the status of implementation according to the
programme areas that are relevant to malaria in section 1.2 above, targets set in the
Abuja Declarations, the RBM Strategic plan and the MDGs. The report was been
compiled from published and unpublished reports that have been reviewed,
summarized and synthesized to gives an overall view of the situation in the region.
Where possible, data was presented in the form of tables, graphs and charts (not
included this time), to allow comparison across the continent. Given that some of the
data are survey-based, it was not possible to have recent data on all the countries as
the attention has been paid to 2005-2007 data except for trend analysis in countries
with two data points after the year 2000. A summary follows here-below:
Leadership at National, regional and continental Levels
8. Since 2000, all countries in the region established RBM coordinating bodies and also developed Malaria Strategic Plans (MSPs) in line with recommended WHO strategies. Currently, 18 countries have developed second generation MSPs or are in the process of finalizing them. These MSPs have been useful for guiding and coordinating partner involvement in malaria control as well as in mobilizing resources from the GFATM.
9. Countries committed themselves to increase government expenditure on health. The progress towards this goal in slow but progressive, as more and more countries increase their budget allocation to the health sector. Since 2001, several initiatives to increase funding for malaria control had emerged to complement government expenditure on health as well as other bilateral and multilateral arrangements in individual countries. The major initiatives funding traditional malaria control include the Global Fund (GFATM), World Bank Booster Programme (WBB), the Presidents’ Malaria Initiative (PMI) and The Islamic Development Bank. The Bill and Melinda Gates Foundation is a major funder of malaria research aimed at developing or improving malaria control tools. Furthermore, Countries receive technical support from WHO and other RBM partners in proposal development, which is a pre-requisite for accessing the funds as well as grant negotiation and implementation support. As mentioned above, more funding was announced in 2008 at the MDG Malaria Summit.
Prevention, Treatment, Care and Support
10. Following the Abuja Declaration of 2000, several countries have scaled up use of malaria prevention and control measur.
Insecticide Treated Nets (ITNs)
11. To increase the access to malaria control interventions, 74% of countries have waived taxes on antimalarials, 64% have removed taxes or introduced waivers on ITNs while about half have waived taxes and tariffs on nets, netting materials and insecticides. Since 2002, several countries have prioritized the rapid scale up of ITN use by targeting mainly young children and pregnant women with free or highly subsidized ITNs.
12. In 2006-2007, over 33 million ITNs were distributed in 22 countries, mainly through integration with immunization campaigns and maternal and child health services. This has resulted in a dramatic increase in ITN coverage to about 50% in those countries. However, the ITN use at household level is consistently lower than ITN possession due to inadequate communication about consistent use of ITNs. Also, distribution of free ITNs through routine EPI and ANC services is still very low. Across the region, 25% of households own at least one mosquito net of any type. However, some countries such have much higher coverage with any net. With regard to insecticide-treated nets (ITNs), about 12 % of households have at least one ITN. By end
of 2006, some countries had achieved high coverage rates with ITNs. On the average,
8% of children under-five sleep under an ITN. In all countries where this is relevant, the
trend in the data available showed that ITN use among children aged less than 5 years
has increased at least thrice in 19 countries since 2000. ITN use by children under-five
years in 2006-2007 had exceeded 40% in 06. In spite of these gains, ITN use still falls
far short of the regional and global targets.
13. Use of ITNs by pregnant women is a key intervention for prevention of malaria.
Across the region, it is estimated that only 5% of pregnant women sleep under an ITN.
Some countries with recent data (2003-2007) have achieved higher coverage levels.
Intermittent Preventative Treatment of Malaria in pregnancy (ITPp)
14. Intermittent Preventive treatment of malaria in pregnancy using at least 2 doses
of SP is a safe and effective way for protecting both the mother and her unborn child
from malaria. By the end of 2007, all the 35 countries where IPTp is recommended had
adopted the policy but only 20 countries were implementing it country-wide and the rest
on a limited scale. Coverage with IPT has remained low with most countries with recent
data having coverage less than 10%. However, some countries like Zambia 61%,
Malawi 45% and, the Gambia 33% have higher IPT coverage principally because they
adopted the policy much earlier.
15. The potential for scaling up IPT in malaria-endemic countries is linked closely to
the coverage and quality of Antenatal Consultation (ANC) programmes since the 2
doses are usually administered at ANC in the second and third trimester of pregnancy.
Across the region, more than tow-thirds of pregnant women were attended to at least
once by skilled health personnel during their pregnancy. However, very few attend ANC
up to 4 times as recommended by WHO while others report too late to receive the two
16. Since 1998, most countries in the sub-region have established sentinel sites for
stdrug efficacy monitoring. Based on the results, all countries except two have reviewed line treatment for malaria.
their anti-malarial treatment policies and adopted ACTs as 1By the end of 2007, 25 countries are implementing an ACT treatment policy with 20 of 1them implementing countrywide. Availability of funds from the GFATM and other
funding initiatives has enabled countries to implement the new treatment policies. The
policy change from chloroquine to ACT for malaria treatment has slowed down the
implementation of home management of malaria (HMM). By the end of 2007, none of
the countries has implemented ACT use in home management of malaria except in a
few pilot projects.
17. Across the region, 34% of children with fever receive any antimalarial treatments.
In countries with data for 2005-2006, access to any antimalarial medicine ranged from
5% to 62. Although some countries may have achieved the Abuja target, most of these treatments were with chloroquine and other less-effective medicines. In the 14 countries with recent data that have adopted the ACT policy, the median proportion of children under five years with fever receiving an ACT was only 2% (range < 1 to 13).
The major constraints to scaling up ACTs in these countries are funding since the medicines are more expensive and inadequate supply chain management infrastructure.
Indoor Residual Spraying (IRS)
18. Since 2005 there is a renewed interest in large-scale IRS programs as a major component of malaria control effort. Several countries have included IRS in their malaria control strategy, while others have expanded existing programs. By end of 2007, 25 out of the 42 malaria endemic countries in the WHO African region had included IRS in their national strategy for malaria control. Of these, 17 routinely implement IRS as a major malaria control intervention; six are piloting IRS in a few districts, while 2 are planning pilot implementation with a view to scaling up In the 2006-2007 malaria season a total of about 5 million units/structures were sprayed using different groups of insecticides. Average operational coverage in target areas was 83%.
19. Reduction in malaria cases and deaths in countries deploying IRS has been documented in some countries where the IRS programs are generally adequately resourced technically and financially. Although there is a renewed interest in scaling up IRS. even in highly endemic areas in Africa, there are several challenges to overcome before full scale up. In most of the countries that have just adopted IRS, there is limited technical capacity for effective and efficient management of IRS programmes. Clearly if the African region is to go to scale with IRS considerable and sustained investments will be needed.
Access to affordable medicines and technologies
20. Globally, ACTs are the recommended 1
st line treatment for uncomplicated
malaria. As a result, all but 2 countries in AFRO have adopted this policy. As discussed earlier, there is always a lag between adoption of the policy and implementation due to cost of medication, weak procurement and supply systems, etc. Since 2003, there has been an increase in the production and procurement of ACTs. In addition, funding
initiatives such as the Global Fund, PMI, World Bank Booster Programme and UNITAID have provided funding to countries to implement the ACT policies. As a result, there is a marked increase in the procurement of ACTs globally. Whereas only 3,000,000 ACT
doses were procured in 2003, in 2006 over 100,000,000 doses were procured globally. The Affordable Medicines facility for Malaria (AMFm) was established to bring down the cost of ACTs. The facility will also ensure that the Artemesinin monotherapies are also phased out to reduce the risk of rapid development of resistance to the therapy. About 4 ACTs are in the pipeline to be launched soon. To ensure sustained ACT supply,
production of Artemisia the raw ingredient for production of ACTs has increased with several African countries involved in cultivation of Artemisia annua.