Roll Back Malaria Progress & Impact Series:
Focus on Zambia

Photo: David Lwenje, Zambia National Malaria Control Centre

Source: http://www.rollbackmalaria.org/ProgressImpactSeries/report7.html

Through the National Malaria Control Centre (NMCC), Zambia has built up a strong disease-control programme, with well-defined goals and organizational plans.

Sound policies and good planning have attracted both partners and growing resources. Between 2003 and 2010, nearly US$ 200 million in external funding was allocated to scale up the malaria control programme.

These funds, as well as a growing contribution from the Government of Zambia, were used to roll out appropriate preventive and curative services:

• Over six million insecticide-treated mosquito nets (ITNs) were distributed between 2007 and 2010.
• Over one million households have received indoor residual spraying (IRS) annually between 2008 and 2010, protecting at least five million people per year.
• Health personnel have been trained in proper diagnosis and treatment of malaria, using Rapid diagnostic tests (RDT) and Artemisininbased combination therapies (ACT), in all nine provinces—including an expanding number of community health workers.

Careful roll-out of interventions was quickly followed by good coverage results:

• 73% of households had either one or more ITNs or received IRS in 2010— a 41% increase in household availability of malaria prevention nationally between 2006 and 2010 and a fivefold increase between 2001/20021 and 2008.
• 52% of children under five in rural areas and 46% of pregnant women nationwide (regardless of mosquito-net ownership) used an ITN the night before the survey—a more than twofold increase in the same 2006 to 2010 period.
• Among children with fever in the two weeks preceding the survey, 26% received an ACT in 2010 compared with 13% in 2008—a twofold increase in two years.

These coverage results, in turn, allowed health staff to achieve impact, reduce disease burden and save lives:

• The prevalence of parasitaemia in children under five was reduced from 22% in 2006 to 16% in 2010.
• All-cause child mortality decreased by 29% between 2001/2002 and 2007.
• According to the Lives Saved Tool (LiST a model used to estimate impact based on rates of coverage of the various interventions), the lives of 33 000 children under five have been saved by malaria control interventions since 2001.

These data show that malaria control is working and can generate major health gains. However, reductions in funding from 2008 to 2010 have been associated with decreases in intervention coverage in three provinces. This rapidly led to rebounds in parasitaemia and severe anaemia, highlighting the necessity of maintaining human and financial resources to sustain the gains.

Zambia is now aiming at achieving and sustaining high national coverage rates for malaria control interventions. By anticipating the next steps in sustained control and maintaining a focused and organized approach, accompanied by adequate human and financial resources, final malaria control success could be within reach.

BOX 1: The extent of malaria in Zambia

Malaria in Zambia at a glance

• There are 13 million inhabitants in Zambia.
• Malaria is endemic and transmission is stable with a seasonal peak from November to April.
• There are regional epidemiological variations with a decreasing gradient in malaria transmission intensity from the north-east to the south-west.
• In 2007, there were about 4 million suspected cases and 6000 deaths attributable to malaria.
• Malaria is responsible for about 20% of deaths among children under five.

Zambia has a population of approximately 13 million people (Census Statistics Office, 2010). It is administratively divided into 9 provinces and 73 districts.

The entire country is endemic for malaria with moderate-to-high transmission in all districts. A seasonal pattern of higher transmission is associated with the rains between November and April.

Northern, Luapula and Eastern provinces have the highest annual incidence of malaria, while the lowest is found in Lusaka Province, specifically around the capital city.

The predominant malaria parasite species is Plasmodium falciparum. Plasmodium malariae and ovale account for less than 5% of recorded parasitaemia. Anopheles gambiae and Anopheles funestis are the main vectors.

Measuring malaria's contribution to death and disease is challenging. Without proper parasitological confirmation, the diagnosis of malaria relies on non-specific clinical symptoms, mainly fever. Since 2007, RDTs have been made available widely to assist with parasitological confirmation, although the national healthreporting system did not begin to report confirmed cases until 2009.

Regardless, malaria has always placed an overwhelming burden on the Zambian population:

• The annual reported malaria incidence—including confirmed and unconfirmed cases— was estimated at 358 cases per 1000 population in 2007, a decrease from 412 cases per 1000 population in 2006 (MOH, 2008).
• In 2007, 4.3 million cases of malaria (confirmed and unconfirmed) were reported countrywide, with over 6000 deaths attributable to the disease (MOH, 2008).
• Malaria accounts for 40% of all outpatient attendance, for up to 40% of all infant mortality and for 15–20% of deaths in children under five years of age.

The human and economic impact of the disease is a serious curb to economic development, either directly—through the costs of health care and hospitalization—or indirectly, through work-days lost to personal illness or to caring for a sick child. Malaria accounts for 6.8 million disability-adjusted life years lost in Zambia—more than respiratory infections (5.4 million) or HIV/AIDS (3.2 million)