Angola is among the ten countries with the highest number of malaria cases and deaths (3.4% of the global cases and deaths, 2.6% of global malaria deaths and 15.1% of malaria cases in Central Africa in 2020 ) and malaria continues to be the primary health problem and principal cause of morbidity and mortality in the country. According to the 2013 National Health Development Plan (PNDS: Plano Nacional de Desenvolvimento Sanitário), malaria accounts for 35% of curative care demand, 35% of mortality in children, 40% of prenatal mortality, 25% of maternal morbidity, and causes 60% of hospital admissions in children less than five years of age and 10% in pregnant women. 
Malaria is also a leading cause of low birth weight and anaemia and the primary cause of death (40.3%) followed by tuberculosis (9.3%), HIV/AIDS (7.7%), severe malnutrition (7.5%), respiratory diseases (6.1%), and severe pneumonia (5.7%). 
The entire Angolan population is at risk for malaria, but there is significant geographical heterogeneity in transmission, with hyperendemicity historically observed in the northeast provinces of Cabinda, Cuanza Norte, Lunda Norte, Lunda Sul, Malanje, and Uíge. In the north, the peak malaria transmission season extends from March to May, with a secondary peak in October to November. The central and coastal provinces (Benguela, Bie, Cuanza Sul, Huambo, Luanda, Moxico, and Zaire) are mesoendemic with stable transmission. The four southern provinces bordering Namibia have highly seasonal transmission and are prone to epidemics. 
Between 2017 and 2020, there was a 20.4% increase in malaria cases from 209 to 252 cases per 1000 of the at-risk population. Deaths rose by 4% from 0.47 per 1000 of the population at risk to 0.49 per 1000 of the population at risk.  Before 2020, however, the death rate had been falling – to 0.43 per 1000 of the population at risk in 2019.  The shift in trend began in the first quarter of 2020, prior to most in-country COVID-19 cases. This may be due to a rainfall pattern more conducive to malaria transmission in the 2019–2020 rainy season, in a setting of inadequate vector control coverage, under-investment in artemisinin combination therapies (ACTs) and rapid diagnostic tests (RDTs), and other factors.
The impact of COVID-19 was felt mainly after quarter two, and is thought to have impacted malaria via the response to the epidemic and its repercussions on health systems. Interventions aimed at curbing transmission of COVID-19, such as restrictions to movement, absenteeism, behavioural changes, closure of institutions, and interruption of supply chains, may have resulted in this setback on the malaria mortality trends. 
According to data from the National Malaria Control Programme (NMCP), 8% of all reported yearly malaria cases in 2017 were severe malaria. 
A severe malaria study was performed in January and February 2020 by Medicines for Malaria Venture (MMV)/Clinton Health Access Initiative (CHAI) in order to assess the status of care of severe malaria in Angola and inform improvements in programmatic implementation. The study was carried out in Luanda, Cuando Cubango and Uíge provinces. The main results were presented to NMCP and partners, describing gaps in severe malaria case management training, including healthcare provider knowledge about preparation of injectable artesunate and where and when to administer rectal artesunate; stockouts of necessary commodities; late care seeking behaviours; and omissions in severe malaria surveillance. Only 22% of healthcare providers had training in severe malaria. The data helped to inform the next National Malaria Strategic Plan, with the goal of improving severe case management training and delivery.
A formal program review in August 2020, with support from the World Health Organisation (WHO), also helped to inform the development of the National Malaria Strategic Plan for 2021-2025, 
Severe malaria case management
The National Malaria Control Program recommends that severe malaria is treated with intravenous or intramuscular artesunate in facilities able to administer intravenous medications and when not available, intramuscular artemether. In lower-level facilities, intramuscular artemether is recommended. Although quinine is the third-line option for treatment of severe malaria, it is the most commonly used treatment due to the unavailability of intravenous or intramuscular artesunate or intramuscular artemether as well as push and flooding of the market by local manufacturers of quinine. 
For pre-referral management of severe cases at health posts and health centres, the guidelines recommend intramuscular artesunate. For children under six years of age when intramuscular injection of artesunate is not available, a single dose of rectal artesunate and referral to an appropriate facility for further care is recommended. In the National (Malaria) Strategic Plan (NSP) 2021–2025, use of rectal artesunate as pre-referral management at the community level has been introduced as a new recommendation.
A 2020 rapid assessment  revealed a number of deviating practices such as:
- The widespread use of artemether for severe malaria;
- The interchangeable use of drugs for severe malaria during a course of a treatment (examples of treatment plans changing from artemether to artesunate).
The use of artemether for a prolonged period of time even when the clinical process clearly states the patient is already eating normally (clinical guidelines state these should pass to oral artemisinin-based combination therapy (ACT) as soon as possible. Another reason that may justify the incomplete adherence to artesunate is the required calculations for artesunate dilution. Another potential reason for not having injectable artesunate widely disseminated may be related to healthcare workers’ perceived lack of authorization to administer it.
Integrated Community Case Management (iCCM)
World Vision, a principal recipient under the Global Fund 2016-2018 grant, is implementing the integrated community case management (iCCM) strategy in 18 municipalities within six provinces. The USAID President’s Malaria Initiative (PMI) also commenced the implementation of iCCM in an additional 4 municipalities of 2 provinces at the end of 2017.
An elevated burden of severe malaria has been experienced in the areas along Angola’s borders with the Democratic Republic of Congo and Zambia. To address this issue, two cross-border initiatives were introduced with government funding from Angola and Namibia: the Trans-Kunene Malaria Initiative in 2011 and the Trans-Zambezi Malaria Initiative in 2013.[3,4]
Malaria case distribution in Angola
Severe malaria policy and practice
|Strong||Injectable artesunate (IV or IM)|
*Since artesunate and artemether are often not available, injectable quinine continues to be the most commonly used treatment for severe malaria nationwide.
|Alternative||Artesunate rectal capsules for children less than six years of age|
* A broad spectrum antibiotic should also be associated