GMAP

[Full Table of Contents]
[Executive Summary]

[Part I: Malaria Today] PDF version

  1. Introduction to the Global Malaria Action Plan
  2. Partnership's Vision and Targets
  3. Global Burden & Coverage Today
  4. Funding for Malaria Today

I. Malaria today

3. Global Burden and Coverage Today

Key messages

  • Malaria is a complex and deadly disease
    • Malaria impacts 109 countries and territories around the world, caused by four species of parasites and transmitted by multiple mosquito vectors
    • In 2000, there were an estimated 350 to 500 million cases of malaria and more than one million deaths, most of them occurring in Africa and Asia-Pacific
  • Following the aborted Global Malaria Eradication campaign in the 1950s – 1970s, malaria received little international attention until recently
  • Over the past decade, there has been substantial progress in raising awareness and increasing the production, adoption and distribution of existing, effective interventions
  • However, there is still much to do to achieve the RBM targets of universal coverage
    • Existing data shows that coverage for all interventions is low in most countries, although there have been substantial gains in LLIN distribution in Africa
    • In particular, case management with diagnostics and treatments need to be significantly strengthened in Africa, the highest burden region

In 2000, malaria caused 350 to 500 million clinical episodes annually[5]Korenromp E. Malaria incidence estimates at country level for the year 2004 – Proposed estimates and draft report. Genève, Roll Back Malaria, 2005. Ces estimations sont conformes à la fourchette calculée par Breman JG et al. Conquering Malaria. In: Jamison DT, Breman JG et al, eds. Disease Control Priorities in Developing Countries Conquering Malaria. Oxford University Press et la Banque mondiale; 2006. p 415 pour 2002.

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and resulted in over one million deaths [6]Year 2000 estimate of 1 million deaths globally extrapolated from 804,000 deaths in Africa estimated in Rowe AK et al. The burden of malaria mortality among African children in the year 2000. International Journal of Epidemiology, 2006, 35:691-704. This is aligned with estimates with Breman JG et al. Conquering Malaria. In: Jamison DT, Breman JG et al, eds. Disease Control Priorities in Developing Countries Conquering Malaria. Oxford University Press and the World Bank; 2006. p 415.

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, most of which affect children under 5 years old in sub-Saharan Africa.[7]The World Health Organization released its most recent World Malaria Report (WMR) 2008 in September 2008. The WMR 2008 contains information on burden, policies, coverage and funding for 109 malaria endemic countries and territories. In the report, WHO uses a revised and updated methodology to estimate the incidence of malaria outside the African Region. This results in fewer malaria cases than previously estimated in the Americas, Eastern Mediterranean, Europe, Southeast Asia and Western Pacific regions. RBM Partners, including WHO, are continuing to improve and align estimates of malaria burden worldwide. Geneva, World Health Organization, 2008.

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Malaria is the fifth cause of death from infectious diseases worldwide (after respiratory infections, HIV/AIDS, diarrhoeal diseases, and tuberculosis) and the second in Africa, after HIV/AIDS.[8]Global Burden of Disease estimates. Geneva, World Health Organization, 2002.

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Recent estimates show that as many as 3.3 billion people live in areas at risk of malaria in 109 countries or territories.[9]World Malaria Report 2008. Geneva, World Health Organization, 2008. In addition to its health toll, malaria puts a heavy economic burden on endemic countries and contributes to the cycle of poverty people face in many countries. For example, it is estimated to have in Africa alone contemporaneous costs of at least US$12 billion per year in direct losses (e.g. illness, treatment, premature death), but many times more than that in lost economic growth.[10]This effect is much larger than direct losses, perhaps even 1 percentage point of GNP per year, which can cumulate to tens or hundreds of billions of dollars of lost GNP over the course of decades. Sachs J, Columbia University, personal communication, 2008. [11]Gallup JL and Sachs J. The economic burden of malaria. American Journal of Tropical Medicine and Hygiene, 2001, 64:85-96.

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Four Plasmodia species infect human beings: P. falciparum, P. vivax, P. malariae and P. ovale.[12]P. knowlesi is a primate malaria species that occasionally infects humans in remote areas of Southeast Asia; however, it will not be dealt with in this report. P. falciparum and P. vivax cause the significant majority of malaria infections. P. falciparum, which causes most of the severe cases and deaths, is generally found in tropical regions, such as sub-Saharan Africa and Southeast Asia, as well as in the Western Pacific and in countries sharing the Amazon rainforest. P. vivax generally is common in most of Asia (especially Southeast Asia) and the Eastern Mediterranean, and in most endemic countries of the Americas. P. malariae and P. ovale contribute to only a small number of malaria infections. P. ovale is found in Africa and sporadically in Southeast Asia and the Western Pacific. P. malariae has a similar geographical distribution to P. falciparum but its incidence is patchy and is probably underestimated.

The lack of acquired immunity makes infants and young children highly vulnerable to malaria. In areas of intense malaria transmission, most cases of severe malarial anemia and deaths occur in infants and young children. Pregnant women are also at high risk of malaria. Each year approximately 50 million women living in malaria endemic countries throughout the world become pregnant.[13]The estimate is based on a model developed by Snow and colleagues using Mapping Malaria Risk in Africa (Snow RW and al. Estimating mortality, morbidity and disability due to malaria among Africa's non-pregnant population, Bulleting of the World Health Organization 1999; 77, 624-640) and its application to UNICEF data on live births (UNICEF, State of the Word’s children, Oxford University Press, 1998) adjusted for the year 2000.

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In stable transmission areas, the major effect is malaria-related anemia in the mother and presence of parasites in the placenta resulting in low-birth weight which contributes substantially to child deaths. In unstable transmission settings, pregnant women have little or no immunity to malaria and their risk of developing severe disease as a result of malaria infection is two to three times higher than that of non-pregnant women living in the same area.[14]Luxemburger C et al. The epidemiology of severe malaria in an area of low transmission in Thailand. Transactions of the Royal Society of Tropical Medicine and Hygiene, 1997, 91 (3): 256–262.

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Consequently, malaria during pregnancy contributes to maternal deaths in both stable and unstable transmission areas. Therefore, pregnant women require special attention and targeted policies.

History of Malaria Control

To understand malaria today, it is important to acknowledge the history of the disease and previous global efforts to control and eradicate it. In the mid-19th century, malaria was endemic in most countries and territories of the world, affecting about 90% of the world’s population and stretching as far north as the Arctic Circle.[15]Wernsdorfer. Historical review of the global malaria eradication program - Concept, achievements, shortcomings. Presentation at WHO Informal Consultation on Global Malaria Control and Elimination, January 2008.

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After successful efforts to reduce malaria with DDT beginning in 1945, in 1955 the 8th World Health Assembly launched the Global Malaria Eradication campaign for all malarious countries except Madagascar and those of sub-Saharan Africa, [16]In these areas, malaria control was to remain the objective until suitable, economically feasible methods became available for elimination of the disease. using IRS, primarily with DDT, as a vector control tool together with case management. In all, 37 of the 143 countries that were endemic in 1950 were freed from malaria by 1978, of which 27 are in Europe or the Americas. [17]Global malaria control and elimination: report of a technical review. Geneva, World Health Organization, 2008.

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The effort had a positive impact on malaria mortality and morbidity in almost all targeted countries. However, some of the countries were unsuccessful in interrupting transmission. By 1973 it was concluded that in some countries a "time-limited eradication program was impracticable"[18]Malaria Control in Countries where Time-limited Eradication is Impracticable at Present: Technical Report Series 537. Geneva, World Health Organization, 1974.

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, and strategies were shifted into long-term integrated control programs. The Global Malaria Eradication campaign was abandoned. Little attention was paid to malaria over the subsequent years. Despite the end of the official WHO campaign, a number of countries have successfully eliminated malaria since that period, including Tunisia (1979), Maldives (1984), and the United Arab Emirates (2007).

Malaria mortality and morbidity began to increase again in the 1980s due to a combination of factors such as the increase in parasite and vector resistance to the current anti-malarial drugs and insecticides, the weakening of traditional malaria control programs, rapid decentralization and integration into deteriorating primary health services, and the development of humanitarian crisis situations in many malaria-endemic areas (Figure I.1). This dramatic increase led to the adoption of the Global Malaria Control Strategy in 1992 [19] In October 1992, the Ministerial Conference held in Amsterdam convened by the WHO endorsed the Global Malaria Control Strategy. and to the creation, in 1998, of the Roll Back Malaria Partnership to coordinate global efforts in combating malaria.

Figure I.1: Evolution of malaria mortality

Source: R. Carter and K. Mendis. Evolutionary and historical aspects of the burden of malaria. Clinical Microbiological Reviews, 2002. 15(4): p. 564 - 594

Progress in Malaria Control

In recent years, malaria has received greater international attention. Malaria has been included among major international development targets and acknowledged as a contributor to global poverty. The United Nations’ Millennium Development Goals call for halting and reversing the incidence of malaria by 2015. In the Abuja Declaration in 2000, African leaders affirmed their commitment to halving malaria mortality by 2010. These initiatives have led to increased attention and funding to fight the disease in the past 10 years. In April 2008, the UN Secretary General has called for universal coverage by the end of 2010 to halt malaria deaths.[20]UN Secretary-General Ban Ki-moon, video message, World Malaria Day April 2008. The Secretary-General reiterated the UN vision for universal interventions coverage in order to end malaria deaths.

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The RBM Partnership has made great strides in increasing awareness of malaria and global coverage with key malaria-control interventions. However, much remains to be done to achieve the ambitious targets of the RBM Partnership: by 2010, universal coverage with appropriate malaria interventions and 50% reduction in fatalities and cases from 2000 levels; and by 2015, near zero preventable deaths and 75% case reduction from 2000 levels.

Today, effective tools exist that make it possible to prevent and treat malaria in most settings, with the potential to substantially reduce the morbidity and mortality from malaria. The primary tools used today for prevention are: long-lasting insecticidal nets (LLINs), indoor residual spraying (IRS) in which insecticides are sprayed on the walls of homes, and intermittent preventive treatment for pregnant women (IPTp) to prevent infection.

Drugs and diagnostics are used for malaria case management. Artemisinin-based combination therapies (ACTs) are the drug of choice against P. falciparum, the most deadly malaria species. Chloroquine (CQ) is still the treatment of choice in many places[21] Amodiaquine is the treatment of choice in chloroquine resistant P. vivax malaria. According to WHO treatment guidelines, "there are relatively few data on treatment responses in chloroquine-resistant vivax malaria. Studies from Indonesia indicate that amodiaquine is efficacious, and there is some evidence that mefloquine and quinine can also be used. The artemisinin derivatives would also be expected to be highly effective, and artemether-lumefantrine could be an alternative treatment. However, there are insufficient clinical data to confirm this."

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against other Plasmodia species (vivax, malariae, ovale).[22]The radical cure for P. vivax and P. ovale requires a 14-day treatment of Primaquine as well, except in certain conditions. See Guidelines for the Treatment of Malaria. Geneva, World Health Organization, 2006.

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Malaria infections can be diagnosed clinically and confirmed by parasitological diagnosis with either microscopy, examining slides with a blood smear to identify the occurrence of parasites, or with rapid diagnostic tests (RDTs). Malaria RDTs assist in the diagnosis of malaria by detecting evidence of malaria parasites in human blood and can be used outside of health facilities.

The following paragraphs present the global progress in production, adoption and distribution of key malaria interventions for which data is available. Data comes from many sources. In addition to the WHO World Malaria Report 2008, data from household surveys, international donors, procurement agencies, product manufacturers and the RBM Commodity database were used. Most of the available data covers years up to and including 2006. Figure I.2 presents estimates of LLINs, IRS, diagnostics and treatments reported in use globally as of end 2006 based on estimates derived from the WHO World Malaria Report 2008 and the RBM Commodity database. This is still far from what is needed to reach universal coverage. (See Figure II.6 in Part II-Chapter 3). In 2007 and 2008, with increased funds from international donor flowing to countries (Figure I.6), many countries have begun broader scale-up of interventions than in previous years. This means that today many countries are likely closer to achieving universal coverage than is reflected in the GMAP.

Although substantial effort will be needed globally to reach universal coverage targets for all populations at risk, the size of the gap that needs to be filled varies widely from region to region and between countries. Many countries in sub-Saharan Africa and parts of Southeast Asia are still far from reaching universal coverage targets and need to gear up control efforts over the next months. In the Americas and in parts of Asia-Pacific, several countries have reached sufficient levels of control and are considering elimination. A regional analysis of progress achieved and gaps can be found in Part III: Regional Strategies. An explanation behind the estimates is provided in Appendix 3: Assumptions behind Current Burden, Coverage and Funding Estimates.

Figure I.2: Number of interventions by region: Evolution of malaria mortality

a) LLINs / ITNs: # of effective ITNs (1 year lifespan) and LLINs (3-year lifespan) in circulation in 2006
b) IRS: # of households sprayed in 2006
c) Diagnostics: # of cases examined by microscopy or RDTs in 2006
d)Treatments: # of treatment courses with any first-line anti-malarial treatment (ACTs only for Africa) in 2006

Source: World Malaria Report 2008. Geneva, World Health Organization, 2008; Roll Back Malaria (RBM) Commodity database

Long-lasting insecticidal nets (LLINs). Long-lasting insecticidal nets are recommended as a key vector control intervention to protect all populations at risk of malaria, and are particularly effective in areas where vectors primarily stay indoors. They provide both personal protection with the net and the insecticide, and community protection by reducing the vector population when implemented at very high coverage.

Progress achieved. Great progress has been achieved in manufacturing, funding and distributing LLINs over the past 5 years. Annual production of insecticide-treated nets (ITNs) almost tripled from 30 million in 2004 to 95 million in 2007[23]Malaria and children: Progress in intervention coverage. New York, UNICEF, 2007.

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and is estimated to reach 110 million in 2008 (Figure I.3).[24]Estimates provided August 2008 from UNICEF supply division. In addition, there has been a strong increase in funding and the subsequent procurement of nets. Funding from the Global Fund led to the procurement and distribution of 1.3 million nets in 2004, 18 million in 2006, and more than 30 million in the first 6 months of 2007.[25]Global Fund Helps Deliver Sharp Increases - Over1 Million on AIDS treatment, 30 Million Malaria Nets Distributed. Geneva, The Global Fund to fight AIDS, Tuberculosis and Malaria, Press release, May 2007.

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The number of nets procured by UNICEF (the largest net procurement agent globally) more than tripled from 2004 to 2006 (from 7 million to 25 million).[26]Malaria and children: Progress in intervention coverage. New York, UNICEF, 2007.

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Figure I.3: Figure I.3: Evolution of global insecticide-treated net production

Source: UNICEF Supply Division data, 2007, based on estimates from insecticide-treated net manufacturers

In 2006, estimates suggest approximately 82 million effective LLINs / ITNs were in circulation around the world.[27]Estimates based on an analysis of WHO World Malaria Report 2008 country program data and the RBM Commodities database for 2006. Numbers of nets in use derived from 3 years of LLINs distribution (2004, 2005, 2006) and one year of ITNs distribution (2006). See Appendix 3. Assumptions behind Current Burden, Coverage and Funding Estimates.

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In 2007 and 2008, significant progress has been achieved in LLIN delivery, especially in sub-Saharan African countries (see Part III – Chapter 2: Africa). Despite the gains in production and distribution, end-user compliance is still a major challenge. A 2004 survey showed that of nets owned, only 56% had been slept under the night prior in Nigeria, 62% in Zambia, and 61% in Ethiopia.[28]Awareness, Ownership and Use of Mosquito Nets in Nigeria, Senegal, Zambia, Ghana and Ethiopia, Cross-country results from 2004 surveys. Washington, D.C., NetMark, 2005.

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Indoor residual spraying (IRS). IRS is an effective method of vector control aimed at killing mosquitoes that enter houses and rest on sprayed surfaces (e.g. walls and ceilings). IRS is widely used in areas of seasonal transmission, including epidemic-prone areas, and increasingly in more malaria-endemic areas. The most common insecticides used are DDT[29]Concerns over the safety of DDT, a persistent organic pollutant, have also been comprehensively addressed in the framework of the Stockholm Convention on Persistent Organic Pollutants (POPs). The Convention bans the use of DDT, except for public health purposes. DDT can be used for IRS where it is indicated, provided that stringent measures are taken to avoid its misuse and leakage outside public health. and pyrethroids. IRS is appropriate in epidemiological settings where vectors mainly stay indoors and in countries where the necessary logistical capabilities can be deployed.

Progress achieved. Efforts are underway (led by the RBM Monitoring and Evaluation Reference Group – MERG) to harmonize indicators and data collection methods to monitor coverage of IRS programs. Depending on local conditions, IRS is being performed either as the main vector-control method or as a complement to LLINs. Twenty-five countries in sub-Saharan Africa are using IRS, although only 17 are using it routinely.[30]Implementation of Indoor Residual Spraying of Insecticides for Malaria Control in the WHO African Region. Brazzaville, Congo, WHO-AFRO, 2007.

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Countries in Southern Africa have implemented successful collaborative programs such as the Lubombo Spatial Development Initiative (LSDI) between Swaziland, Mozambique, and South Africa. LSDI started in 1999 and uses IRS as the main vector control intervention. IRS is commonly used in endemic countries outside Africa, especially in the Southeast Asian region. In total, approximately 24 million households (or ~118 million people) worldwide were sprayed in 2006.[31]Estimates based on an analysis of WHO World Malaria Report 2008 country program data and the RBM Commodities database for 2006. See Appendix 3. Assumptions behind Current Burden, Coverage and Funding Estimates.

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Despite its effectiveness, use of IRS is constrained by implementation and logistical difficulties, limited funding and the 1997 World Health Assembly resolution calling for a reduction in the use of insecticides in disease control.

Intermittent preventive treatment for pregnant women (IPTp). In high transmission settings, all pregnant women should receive at least 2 doses of IPT after fetal motion is first felt (known as the quickening) or in the 2nd and 3rd trimesters. WHO recommends sulphadoxine-pyrimethamine (SP) for IPTp in high transmission settings. This strategy has been adopted in high transmission areas of sub-Saharan African countries while research is ongoing to determine its applicability in other epidemiologic and geographic settings.

Progress achieved. IPTp has been adopted as policy in all 35 sub-Saharan African countries[32]Africa Malaria Report 2006. Geneva, World Health Organization, 2006

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with stable malaria transmission where it is recommended[33]A strategic framework for malaria prevention and control during pregnancy in the African Region. Brazzaville, Congo, WHO-AFRO, Regional Office for Africa, AFR/MAL/04/01, 2004.

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and is part of national malaria control strategies around the region. By the end of 2007, implementation had been initiated in all countries. However, as of 2007, only 20 countries had gone to scale and deployed it at the national level. In sixteen national household surveys conducted between 2006 and 2007, use of IPTp varied from 0.3% of pregnant women who received at least 2 doses of SP in Niger to 61% in Zambia.[34]World Malaria Report 2008. Geneva, World Health Organization, 2008.

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These estimates are in line with reports from WHO-AFRO[35]Presentation from WHO-AFRO, RBM MIP meeting, April 2008.

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that show coverage with the first dose (IPT1) ranging from 23-93%, and the second dose (IPT2) from 5-68%. See Part III – Chapter 2: Africa for a discussion of the challenges faced.

Diagnostics (microscopy or rapid diagnostic tests - RDTs). Parasitological diagnosis is recommended to confirm malaria cases (through quality-assured microscopy or, where unavailable, RDTs) before treatment is started (with the exception of children under 5 years of age in areas of high stable malaria transmission, who should be treated on the basis of a clinical diagnosis as the probability of fever in a child being caused by malaria is high).[36]Guidelines for the Treatment of Malaria. Geneva, World Health Organization, 2006.

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Progress achieved. According to estimates based on the WHO World Malaria Report 2008 data, ~152 million cases of malaria were clinically confirmed, primarily with microscopy, in 2006.[37]Estimates based on an analysis of WHO World Malaria Report 2008 country program data. See Appendix 3. Assumptions behind Current Burden, Coverage and Funding Estimates.

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The use of diagnostics is much stronger in Asia-Pacific, the Americas and the Middle-East and Eurasia than it is Africa, where most fever cases are treated presumptively as malaria. Although most cases were diagnosed by microscopy in 2006, the production of RDTs has increased significantly since 2000, from ~2.9 million RDTs in 2000 to an estimated 80 – 90 million for 2008.[38]Baik F and Bell D. Forecasting global procurement of malaria rapid diagnostic tests: estimates and uncertainties. WHO – Western Pacific Region, 2007. 2008 estimate extrapolated from trend line.

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In 2006, NMCPs reported the distribution of 15.6 million RDTs. [39]World Malaria Report 2008. Geneva, World Health Organization, 2008.

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A comprehensive process to assess the quality of products in the market is being carried out[40]Project led by WHO - Western Pacific Regional Office, Foundation for Innovative New Diagnostics (FIND) and TDR - Initiative for Quality Assurance of Malaria Rapid Diagnostic Tests Outline of product testing and associated protocols.

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and could change the RDT market significantly in the coming years. However, the use of RDTs is still constrained by limited funding and training, as well as concerns about the variability of RDT quality.

Anti-malarial treatment (ACTs, chloroquine, primaquine and others). Appropriate treatment based on parasitological diagnosis should be provided within one day of the onset of illness. By only treating confirmed cases of malaria, the number of anti-malarial treatments needed is substantially reduced.

Progress achieved. Impressive progress has been achieved in product development, manufacturing, procurement and financial accessibility to treatments (especially ACTs), although prompt and widespread coverage with effective treatment is still low in many countries. In product development, a new formulation designed specifically for children has been developed to provide improved and safer access to ACTs. Production and procurement of ACTs have dramatically geared up recently – from 2004 to 2006, annual global procurement of ACTs increased from 4 million to ~100 million doses.[41]RBM Commodity database, 2007.

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The estimated global procurement for 2007 is ~125 million doses.[42]2007 ACT forecast presented by WHO on June 2007 in an Medicines for Malaria Venture / WHO meeting in Bangkok.

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World-wide, approximately 82 million doses of anti-malarial treatments were distributed in 2006, 69 million of these ACTs in Africa.[43]Estimates based on an analysis of WHO World Malaria Report 2008 country program data and the RBM Commodities database for 2006. See Appendix 3. Assumptions behind Current Burden, Coverage and Funding Estimates.

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Outside of Africa, program data from the WHO World Malaria Report 2008 shows that ~13 million anti-malarial treatments were distributed through public health services in 2006.[44]World Malaria Report 2008. Geneva, World Health Organization, 2008.

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While this amount may seem small, it could cover a sizable proportion of malaria cases outside Africa if all suspected malaria cases were first confirmed with parasitological diagnosis.

Coverage with ACTs was low within Africa as of 2006 and 2007. For instance, according to the WHO World Malaria Report 2008, eighteen household surveys conducted in 2006-2007 in the African region showed that an average 38% of children under 5 years with fever took an anti-malarial drug, 19% on the same or the next day. Just 3% of children were given ACTs (at any time). The low coverage in high-burden countries is due to limited access to or availability of ACTs in public health facilities, and the fact that in many endemic countries, most treatments are obtained through the private sector, where ACTs are often too expensive for most patients to buy. Instead patients often purchase less expensive -- and ineffective – treatments. On a more positive note, recent surveys showed use of CQ in Africa declined from 2000-2001 to 2006 in 10 of the 11 countries surveyed.[45]World Malaria Report 2008. Geneva, World Health Organization, 2008.

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Efforts are underway to increase access to ACTs in many places. Investments have been made in scaling up ACT delivery in the public sector through introductions of pre-packaged, low price ACTs targeted to children, and innovative financing mechanisms (such as the Affordable Medicines Facility for malaria, or AMFm) that could potentially decrease the cost of ACTs to patients substantially, making them as affordable as less-effective treatments, even in the private sector.