Angola

Malaria facts

Angola is among the ten countries with the highest number of malaria cases and deaths (3% of the global cases and deaths).[1]   Between 2016 and 2019, there was a 14.4% increase in malaria cases from 205 to 235 cases per 1000 of the at-risk population. Deaths however fell by 7.3% from 0.46 per 1000 of the population at risk to 0.43 per 1000 of the population at risk.

According to data from the National Malaria Control Programme (NMCP), 8% of all reported yearly malaria cases in 2017 were severe malaria.[2]

Five provinces especially noted increases in malaria cases and malaria-related deaths between December 2017 and March 2018.[2] Due to the increase in malaria cases, the Ministry of Health initiated rapid assessments in the provinces with the highest burden.[2]

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 careseeking behaviours; and omissions in severe malaria surveillance. Only 22 percent of healthcare providers had training in severe malaria. The data are helping to inform the next National Malaria Strategic Plan and improve severe case management training and delivery.[6]

To inform the development of the National Malaria Strategic Plan for 2021-2025, the NMCP, with support by the World Health Organization (WHO), conducted a formal program review in August 2020. [5]

Angola’s continued reliance on oil revenue, combined with a fall in the price of oil by over half, has continued to make it challenging in recent years for the GRA to follow through on its commitments to procure commodities for all health interventions, including malaria. The effects of the COVID-19 pandemic have exacerbated this ongoing challenge.[5]

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 arthemether. 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 from local manufacturers of quinine. [3]

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 clinical process clearly states the patient is already eating normally (clinical guidelines state these should pass to oral 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 Inj AS widely disseminated may be related to HW’ perceived lack of authorization to administer it.

For pre-referral management of severe cases, the guidelines recommend artesunate rectal capsules (ARC) for children less than six years of age.

Angolan NMCP treatment guidelines state that pre-referral intervention should be done when the time to reach full supportive care is more than 6 hours away. The guidelines and job aids state the following for prereferral intervention: rectal artesunate, artesunate IM, artemether IM and quinine IM. The guidelines do not make any reference to the minimum level of care provision where ARC can be provided.

Rectal artesunate is not provided at community level (community health workers are only allowed to treat uncomplicated malaria cases) and is, supposedly, the first choice to administer in health posts or health centres before referring cases to higher levels. However, the rapid assessment identified that the use of ARC appears to be hampered by lack of training on how to use this product and unavailability of this product in some health facilities.

The Ministry of Health requested US$4.9 million in funding from the Global Fund to purchase injectable artesunate, artemether and quinine (for pregnant women in their first trimester).[2]

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.[2]

Cross-border initiatives

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]

Healthcare system

The healthcare system in Angola consists of three levels:[2]

  • The first level includes health centers and posts, municipal hospitals, nursing stations and doctors' offices;
  • the secondary level consists of general and monovalent hospitals;
  • and the tertiary level consists of central hospitals and specialized hospitals.

As of 2016, there were 2775 public health facilities: 1,675 health posts, 431 health centers, 75 maternal and child health centers, 166 municipal hospitals, 25 provincial hospitals, 1,2 central/national hospitals, 24 specialized health centers, and 28 non-classified health facilities.[3]

As of 2016, government contribution to the healthcare budget was about 60% (about 50 million). This however declined significantly in 2017 to less than 10 million and represented under a third of the total healthcare budget.[4]

Malaria case distribution in Angola

Photo: World Malaria Report 2018

Severe malaria policy and practice

 

National treatment guidelines
Recommendation Treatment
Strong Injectable artesunate (IV or IM)
Alternative Intramuscular artemether
Alternative Injectable quinine

*Since artesunate and artemether are often not available, injectable quinine continues to be the most commonly used treatment for severe malaria nationwide. 

Recommendation Pre-Referral
Alternative Rectal artesunate
Alternative Intramuscular artesunate
Alternative Intramuscular artemether
Alternative Intramuscular quinine

* A broad spectrum antibiotic should also be associated