Malaria kills a child somewhere in the world every
minute. It infects approximately 219 million people each year (range
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 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. Due to the
efforts of many partners and a focus on sustaining funding, from 2000 to
2010, the proportion of children sleeping under an ITN in sub-Saharan
Africa grew from 2 per cent to 39 percent.
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, it is estimated that
over the period 2000-2010, increased advocacy and financing allowed
malaria endemic countries to reduce the estimated global malaria
mortality rate by over a quarter (25%).
Goals
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:
By 2015:
- 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 the third biggest killer 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 Neonatal and Childhood Illness (IMNCI), 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, 110 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. AS of 2012, it
is estimated that 33% of the population at risk and 41% of children
under five, were 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 six 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.
Preventive Chemoprophylaxis
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 NutritionUndernutrition
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 StrengtheningLimited 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 ControlUNICEF
plays a key role in global, regional and country malaria partnerships.
UNICEF spends on average $1.8 billion every year 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 by more than $1.2 billion over five years.
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.
Remaining Challenges
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.
Looking ForwardUNICEF
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]
Updated: 23 April 2013
