© UNICEF/NIGB2010-0214/Giacomo Pirozzi|
A woman in Niger breastfeeding her baby while lying under a long-lasting impregnated mosquito net in the village of Garin Badjini, in the south east of the country.
Malaria kills a child somewhere in the world every minute. It infects approximately 219 million people each year (a range of 154 – 289 million), with an estimated 660,00 deaths, mostly children in Africa. Ninety per cent of malaria deaths occur in Africa, where malaria accounts for about one in six of all childhood deaths. The disease also contributes greatly to anaemia among children — a major cause of poor growth and development.
Malaria infection during pregnancy is associated with severe anaemia and other illness in the mother and contributes to low birth weight among newborn infants — one of the leading risk factors for infant mortality and sub-optimal growth and development. Malaria has serious economic impacts in Africa, slowing economic growth and development and perpetuating the vicious cycle of poverty . Malaria is truly a disease of poverty — afflicting primarily the poor who tend to live in malaria-prone rural areas in poorly-constructed dwellings that offer few, if any, barriers against mosquitoes.
Malaria is both preventable and treatable, and effective preventive and curative tools have been developed.
Sleeping under insecticide treated nets can reduce overall child mortality by 20 per cent. There is evidence that ITNs, when consistently and correctly used, can save approximately six child lives per year for every one thousand children sleeping under them. Prompt access to effective treatment can further reduce deaths. Intermittent preventive treatment of malaria during pregnancy can significantly reduce the proportion of low birth weight infants and maternal anaemia.
Unfortunately, many children, especially in Africa, continue to die from malaria as they do not sleep under insecticide-treated nets and are unable to access life-saving treatment within 24 hours of onset of symptoms. The proportion of the population sleeping under an ITN – which represents the population directly protected – was estimated to be 36% in 2013.
WHO recommends that oral artemisinin-based monotherapies be progressively withdrawn from the market and replaced with ACTs – a policy that was endorsed by the World Health Assembly in 2007. The number of countries that still allow the marketing of these products decreased from 55 in 2008 to 9 as of November 2013; 6 of those 9 countries are in the African Region. The number of pharmaceutical companies marketing these products dropped from 38 in 2010 to 30 in 2013.
Increasing resistance of the malaria parasite to chloroquine and sulphadoxine-pyrimethamine — previously the most widely used antimalarial treatments — has prompted seventy-nine countries and territories (as of 2011) to change their national treatment protocols to incorporate the highly-effective artemisinin-based combination therapies or ACTs.
There is increasing evidence that where they occur together, malaria and HIV infections interact. Malaria worsens HIV by increasing viral load in adults and pregnant women; possibly accelerating progression to AIDS; and potentially increasing the risk of HIV transmission between adults, and between a mother and her child. In adults with low CD4 cell counts and pregnant women, HIV infection appears to make malaria worse.
However great progress has been made in the past decade. Malaria mortality rates, which take into account population growth, are estimated to have decreased by 45 per cent globally across all age groups between 2000 and 2012, and by 51 per cent in children under 5 years of age. In the African Region, malaria death rates decreased by 49% across all age groups and by 54% in children under 5 years of age (25%).
In accordance with the Millennium Development Goals, the Global Malaria Action Plan (GMAP) from Roll Back Malaria , the goals contained in the outcome document of the UN Special Session on Children: “A World Fit for Children,” A Promise Renewed and the universal coverage goal targets voiced by the UN Secretary General in 2008, UNICEF aims to help ensure that:
- malaria morbidity and mortality are reduced by 75 per cent in comparison with 2005, not only by national aggregate but particularly among the poorest groups across all affected countries;
- malaria-related Millennium Development Goals are achieved, not only by national aggregate but also among the poorest groups, across all affected countries;
- universal and equitable coverage with effective interventions.
How does UNICEF Help?
UNICEF is a founding partner, with the World Health Organization (WHO), the United Nations Development Programme (UNDP), and the World Bank of the Roll Back Malaria (RBM) initiative, a global partnership established in 1998 to catalyze support for malaria control and elimination, and to rally partners around a common plan of action to fight the disease. One of the keys goals of the 2011 revision of the GMAP was to reduce global malaria deaths to near zero by the end of 2015.
In recognition of its role as one of the major killers of children in Africa, malaria prevention and control interventions form an integral component of a minimum package of UNICEF’s high impact maternal and child survival interventions. Integrated programming of this kind utilizes existing systems with relatively high utilization by target groups, including the Expanded Program on Immunization (EPI), Integrated Management of Childhood Illness (IMCI), child health days for children under five and ante-natal care (ANC) for pregnant women. UNICEF is also focused on scaling-up integrated Community Case Management (iCCM) which targets pneumonia and diarrhea, and in some instances also malnutrition. UNICEF also supports countries to implement at scale including through support to rapid signature of Global Fund to fight AIDs, TB and Malaria grants, technical and implementation support especially in the areas of monitoring and evaluation, procurement and supply chain management, behaviour change communication, health systems strengthening and long-lasting insecticide treated nets (LLIN) distribution to ensure effective implementation.
Insecticide-Treated Nets (ITNs)
From 2008 to 2012, UNICEF procured over 120 million nets and provided support to over 30 countries.
Major recent efforts to scale-up the availability of ITNs in Africa are yielding impressive results. By 2011, 78 countries worldwide had adopted the policy to provide nets to all persons at risk of malaria – “ universal coverage”, of which 89 have policy of distributing them free of charge to the end user. According to the latest available data, 53% of all households in sub-Saharan Africa own at least one bed net, and 90% of all people who have access to a net use it. The proportion of the population sleeping under an ITN – which represents the population directly protected – was estimated to be 36% in 2013, with 41% of children under five sleeping under a net in SSA. However variability across Africa is quite high and ranges from as low as less than 30% in some countries to more than 80% in others (based on surveys available in 2012).
Together with its partners, UNICEF distributes ITNs, especially Long Lasting Insecticide Treated Nets (LLINs) using routine health services – particularly at Ante-Natal Care (ANC) and expanded programme on immunization (EPI) contact points - and through mass campaigns – both stand-alone and integrated with other child survival interventions. UNICEF works with Ministries of Health, non-governmental organizations (NGOs) as well as community and village health workers to develop local distribution systems and ensure nets reach their targeted beneficiaries.
UNICEF is also focusing its efforts on scaling-up behavior change communication to ensure that nets are being used effectively each and every night.
Effective malaria case management
Waiting even a few hours for treatment can mean life or death to a child sick with malaria. Through integrated child survival programming, UNICEF supports national governments and partners for treatment of malaria with the new and highly effective ACTs through health facilities, and at community level. UNICEF works with governments and communities to improve and promote prompt and effective malaria case management, and to ensure that children have access to medications within 24 hours of the onset of illness.
In 2010, WHO started recommending use of diagnostic testing to confirm malaria infection in all ages groups and apply appropriate treatment based on the results. According to the new guidelines, treatment based solely on clinical diagnosis should only be considered when a parasitological diagnosis - either a rapid diagnostic test (RDT) or microscopy - is not accessible.
In addition to supporting communities directly through distributions and training of practitioners (both at health facility and community level) in appropriate case management, UNICEF also supports countries to access effective anti-malarial medications and diagnostics of assured quality.
UNICEF is supporting the scale up of integrated community-based management (iCCM) of malaria, pneumonia and diarrhea. This integrated package of interventions provides (in any range of combinations): malaria rapid diagnostic test to determine if children are infected with the malaria parasite, timers to check for rapid breathing to determine if the child has pneumonia, treatment for diarrhea, as well as anti-malarials and therapeutic foods to address any underlying malnourishment. Implementation of this package is being supported in over 20 countries to extend the reach of malaria diagnosis and treatment. UNICEF also provides emergency support especially in humanitarian contexts. In 2012, UNICEF supported humanitarian needs and quick response to potential malaria outbreaks in the Sahel and Horn of Africa regions.
Large scale use of RDTs is improving surveillance and providing new information on changing epidemiology of malaria which contributed to updating and fine-tuning future implementation plans to ensure they are better targeted and more cost-effective. By the end of 2012, UNICEF had procured about 25 million ACT treatments for 28 countries. UNICEF also procured 18 million malaria RDTS in 30 countries in seven regions over the course of the last year. However the proportion of children in SSA who receive an ACT is still variable and in many cases too low (range less than 7% to above 90% in a few countries.
UNICEF is also contributing to the scale-up of Intermittent Preventive Treatment during pregnancy (IPTp) this involves providing pregnant women with at least two doses of an anti-malarial drug, currently sulphadoxine-pyrimethamine (SP), at each scheduled antenatal visit after the first trimester, whether they show symptoms of infection with malaria or not. Such preventive treatment has been shown to substantially reduce the risk of anaemia in the mother and low birth weight in the newborn. UNICEF is supporting the scale-up of IPTp through the procurement of SP and training of providers.
In 2012, there was the introduction of new guidance and recommendations on Seasonal Malaria chemoprophylaxis (SMC) which is recommended for areas of highly seasonal malaria transmission such as in the Sahel. UNICEF contributed to the elaboration of the guidance and has already begun to integrate financing and programming towards scaling-up this highly effective intervention.
Research shows that intermittent preventive treatment for infants (IPTi) may be effective in reducing anaemia and clinical malaria in young children. UNICEF is a member of the IPTi Consortium, which is currently concluding research into the feasibility of introducing this additional intervention in Africa.
Malaria and HIV
UNICEF and partners support improved communication on the increased risks from malaria in people with HIV and the need for intensified prevention and treatment, including provision of ITNs through routine services to people living with HIV, especially pregnant women. Recent evidence suggests that co-trimoxazole prophylaxis for all people with HIV as part of a Basic Care Package and alongside ITNs has the potential to reduce mortality and morbidity and to delay the need for anti-retroviral therapy.
Malaria and Nutrition
Undernutrition contributes to a third of all child deaths in developing countries, and can result in stunted growth which causes irreversible damage to a child’s development. Lessons learned from the field show that, in order to have maximal impact on lives saved, it is essential to integrate the nutritional response with other major causes of mortality in the i.e. Diarrhea (through wash package essentially) and malaria (at a minimum).
Severe malnutrition puts children at greater risk for malaria due to reduced immunity. In addition, being infected with the malaria parasite can rapidly push children into dehydration and malnourishment as the anemia caused by the hemolysis quickly depletes children’s nutritional reserves. Children are therefore far more likely to die if they are already malnourished and come into contact with the malaria parasite, and vice-versa being infected with the malaria parasite can cause children to become malnourished also leading to higher mortality. Reaching out to communities afflicted with severe or chronic malnourishment provides an optimal opportunity to test children to see if they are infected with the parasite and to treat them with effective drugs as quickly as possible. UNICEF is leading the way on scaling-up integrated community case management including in many countries treatment of severe and acute malnourishment. This comprehensive delivery pathway ensures that children have comprehensive access to all the needed medications to avoid mortality.
Monitoring and Evaluation
UNICEF is a recognized leader in monitoring and evaluation of malaria control activities, notably through the collection of key malaria control intervention coverage data through the UNICEF-supported Multiple Indicator Cluster Surveys (MICS), compilation of malaria data in a series of public-access databases that are used for reporting on global goals and commitments (e.g. reporting on MDG and RBM targets) and preparation of high-level reports providing the most up-to-date information on progress in malaria control. UNICEF also supports countries to do post-intervention evaluations such as in supporting Guinea Bissau and DRC to undertake post LLIN campaign surveys. UNICEF is also a leader in implementing and rolling out innovative reporting technologies such as Rapid SMS using cell phones to submit information and data (including malaria) even from hard to reach areas, under names such as SMS for Life in Nigeria, and mTRAC in Uganda.
Health Systems Strengthening
Limited access to utilization of malaria control services still affects millions of children, especially those that live in hard to reach areas with weak or non-existent health systems which is why UNICEF is prioritizing the “equity approach”. By prioritizing support to reach these underserved children, UNICEF is helping to strengthen management of child illnesses including malaria at health facility and community level. One approach being taken by UNICEF malaria programmes is to deploy thousands Community Health Workers (CHWs) who support net distribution, and diagnose and treat malaria cases with RDTs and ACTs and refer severe malaria cases to health centres and hospitals for more sophisticated care. In addition, the MoRES initiative is also focused on ensuring that programmes actually reach and achieve results for the most deprived children by: improving knowledge on the underserved groups and deprivations patterns; improving inter-sectoral programming by distilling and elucidating key bottlenecks experienced by deprived groups; institutionalizing high quality Monitoring and Evaluation with feedback loops, allowing for quick action, particularly for emergency response; encouraging strong government ownership and leadership and sharpening programming with clearly defined accountabilities for all levels.
Global Partnerships for Malaria Prevention and Control
UNICEF plays a key role in global, regional and country malaria partnerships. In 2012, UNICEF spent US$1.57 billion on child survival programming , including funding for malaria control. Key partners funding malaria programming through UNICEF include the Global Fund, the US President’s Malaria Initiative (PMI), the World Bank, the UN Foundation, the Canadian International Development Assistance (CIDA), the UK Department for International Development (DfID), the Government of Japan and also through UNICEF’s national committees.
UNICEF is a founding partner of the Roll Back Malaria partnership and is a key member of the RBM Board. The RBM partnership includes governments of countries affected by the disease, representatives of the private sector, research institutions, non-governmental organisations and others.
UNICEF supports advocacy and partnership efforts by leveraging its own resources and results to ensure that women and children are placed at the centre of national and international development and funding agendas. UNICEF is partners with the Global Fund and WHO to ensure that malaria programmes benefit children and pregnant women, including supporting the procurement of LLINs, antimalarial medicines, specifically ACTs and diagnostics – especially rapid diagnostic tests (mRDTs). UNICEF is also a partner in the US President’s Malaria Initiative (PMI), which was established in June 2005 and pledged to increase funding of malaria prevention and treatment around 2.5 billion from fiscal years 2006 to 2012.
UNICEF also continues to work closely with various partners including the UN special envoy for malaria and the African Leaders Malaria Alliance to accelerate country achievement of universal coverage goals. In addition to leveraging millions of dollars for countries, through supporting the preparation and implementation of proposals to the GFATM, the partnership also helps access World Bank Financing through the International Development Assistance grant mechanism. UNICEF is providing considerable support to GFATM processes through: helping countries elucidate their gaps; strategic and business planning; phase II negotiations and defence; and transitional funding planning.
Throughout sub-Saharan Africa, implementing partners at country level include WHO, WFP and international NGOs such as Population Services International and foundations such as the Clinton Foundation. UNICEF also works closely with civil society and local NGOs in country to ensure efficient and equitable delivery.
It is estimated that US $5.1 billion is required annually to achieve universal coverage and fully scale-up malaria interventions around the world. In addition, 150 million new ITNs are needed to maintain protection for all populations at risk in SSA. Programmatic challenges still remain such as ensuring there is sufficient financing for LLINs to be distributed through all channels but especially routine channels such as ANC and EPI which are often overlooked or their nets plundered in favor of the mass campaigns, financing for Child Health Days and iCCM to ensure integrated delivery, looking at innovative mechanisms such as school-based distributions and sufficient financing to recruit malaria focal points. Many malaria-endemic countries are in the process of developing third generation strategic plans from 2010 to 2015, and beyond. There is therefore high demand for technical assistance to support planning and implementation. In addition with the emphasis on achieving and maintaining universal coverage, many countries are undertaking ambitious LLIN distributions and thus require considerable support with regard to supply management, logistics, and behaviour change communication to ensure efficient, equitable distribution and utilization of the nets. Emergency situations such as humanitarian emergencies and malaria epidemic outbreaks also require a high response from UNICEF which is often the first responder. Procurement and supply management is also often a bottleneck and improving infrastructure and national systems to ensure delivery are also being targeted by UNICEF along with counterparts to ensure that plans are realistic and effective. Demand on all levels of UNICEF to provide technical and managerial assistance is quite high and often last-minute.
UNICEF Country offices in malaria endemic countries are working closely with partners on the ground to “make the money work”. All levels of UNICEF are working together to ensure a complete “continuum of care” from resource mobilization to implementation – ensuring that those most vulnerable to malaria are the beneficiaries of preventive and curative interventions for malaria. In addition, UNICEF will continue to provide support to countries to move towards malaria elimination, wherever possible.
For Additional Information
Malaria on childinfo.org
LLIN Supply Update [PDF]
WHO recommends that oral artemisinin-based monotherapies be progressively withdrawn from the market and replaced with ACTs – a policy that was endorsed by the World Health Assembly in 2007. The number of countries that still allow the marketing of these products decreased from 55 in 2008 to 9 as of November 2013; 6 of those 9 countries are in the African Region. The number of pharmaceutical companies marketing these products dropped from 38 in 2010 to 30 in 2013.UNICEF plays a key role in global, regional and country malaria partnerships. In 2012, UNICEF spent US$1.57 billion on child survival programming , including funding for malaria control.