Cameroon

Malaria facts

Malaria is the most widespread endemic disease in Cameroon. Plasmodium falciparum is the predominant malaria parasite species; Anopheles gambiae s.l. is the primary vector responsible for transmission.[1] The Government of Cameroon has made the fight against malaria a priority, with a highlight in the country's Health Sector Strategy (2016-2027).[1]

Overall, Cameroon is among the 15 highest burden malaria countries, with 3% of all global malaria cases and 3% of malaria deaths in 2019 [1]; this represents the 3rd highest number of malaria cases in Central Africa (12.7% of cases).[2]  Suspected malaria cases caused 30 % of all medical consultations, and 21 % of visits to health facilities resulted in a diagnosis of laboratory-confirmed malaria.[1] National statistics from 2015 note that in health facilities, 19 % of deaths were attributed to malaria, and 48 % of all hospital admissions were due to the suspicion of severe malaria.[1]

Between 2016 and 2019, progress was made towards malaria control. Case numbers fell by 3.7%, from 254 to 243 per 1000 of the population at risk.[2] Mortality rates fell by 17% in the same period,  from 0.52 to 0.43 per 1000 of the population at risk.[1] Less than 30% of children who reported having fever were tested for malaria.[2]

Cameroon expects to roll out Phase 1 of its Universal Health Coverage (UHC) initiative in 2021 .[1] The objective is to consolidate various free and subsidized care/treatment packages implemented throughout the country. The specifics of how malaria will be integrated into Phase 1 are still pending, but the National Malaria Control Program (NMCP) is engaged in the UHC development process. Malaria partners anticipate that UHC will increase access and quality of malaria service delivery for the Cameroonian population.[1]

Malaria in young children

In 2017, over 13 % of the malaria-related deaths in children under five years of age. [3]

Case management

Cameroon’s strategy for case management for 2019-2023 includes: [1]

  • An intensification of trainings/refreshers for health personnel on updated national case management guidelines;
  • Sensitization of both public and private sector providers on national guidelines;
  • Extend integrated community case management (iCCM) to all health districts (including 22,000 CHWs in 109 districts not currently covered) to assure good geographic coverage of the population;
  • Implement quality control of commodities

Baseline assessments of case management practices were conducted in 135 health facilities in 13 districts in the North and Far North in September 2019. Conclusions included: [1]

  • 70 percent of facilities performed diagnostic tests (RDTs or microscopy) before providing treatment for malaria.
  • Fifty-three percent of health providers had not received training in case management for malaria.
  • 81 percent of confirmed severe malaria cases were treated with injectable artesunate, IM artemether or injectable quinine. All cases of malaria in pregnant women are treated as severe.
  • Case management of uncomplicated and complicated malaria in children under five was free in only 39 percent of health facilities.

The NMCP conducted a study on the policy of free diagnosis and treatment of uncomplicated and severe malaria in Cameroon from July-August 2018 [1]. Findings included:

  • National treatment guidelines were respected for only 39 percent of severe malaria cases.
  • Significant overuse of severe malaria medications to treat uncomplicated cases was evident.
  • Intravenous quinine was a common treatment given for treatment of severe malaria.

Severe malaria case management in pregnancy

The 2014–2018 National Strategic Malaria Control Plan advises that all cases of malaria in pregnancy be treated as severe malaria, although this is not recommended by the WHO. [1] In the first trimester of pregnancy, intravenous quinine is to be used for the first 24 hours; this is subsequently followed by oral quinine for up to seven days. From the second trimester, the first-line treatment is injectable artesunate; recommended second-line treatments are injectable quinine or intramuscular artemether.  [1] This treatment is not free, but subsidized. This presents a hurdle for many pregnant women needing to access malaria interventions.

In 2018, 54% of pregnant women received at least two doses of intermittent preventative treatment of malaria in pregnancy (IPTp2), similar levels to those in 2014 (53%). The proportion of pregnant women who received at least three doses (IPTp3) increased from 26% in 2014 to 32% in 2018. [1]

The low coverage of IPTp (and the general lack of inclusion of this intervention in antenatal care (ANC) services) was reportedly due to the following:[1]

  • frequent stock outs at the health facility level due to procurement delays and issues with inventory management;
  • noncompliance by health workers;
  • poor management of antenatal care services at health facilities,
  • delayed start of antenatal care services by pregnant women (some as late as seven months),
  • and financial barriers, even though sulfadoxine-pyrimethamine (SP) (the intervention used for IPTp) is supposed to be provided free of charge.
     

Cameroon’s health sector is divided into the following administrative regions:[1]

  • 10 semi-autonomous administrative regions each headed by a governor
  • Each region is further divided into 58 divisions, each headed by a divisional officer,
  • Each division is also split into sub-divisions; each sub-division has a local council and is headed by a mayor.

Seasonal Malaria Chemoprevention

Cameroon introduced SMC in 2016 with sulfadoxine/pyrimethamine and amodiaquine

(SPAQ) to roughly 1.1 million children of eligible age (children 3–59 months old) living in the 45 health districts of the North and Far North regions, with a coverage of 86 percent. [1]

In 2017, four cycles of SPAQ (SP + amodiaquine), the intervention used for SMC, were administered to 1.5 million children aged 3–59 months old (94.5% of children in that age group).[2] About 3.5 million children were administered with SMC in 2018. [1]

Preliminary data from the first two SMC cycles (2017) in the northern region suggested that SMC contributed to preventing malaria in over 95% of children aged 3-59 months.[1]

In view of the SMC programmes in the northern part of the country, the first-line ACT for that part of the country was switched to artemether-lumefantrine (AL) rather than artesunate-amodiaquine (ASAQ) to mitigate against potential drug resistance to amodiaquine. The other eight regions will maintain ASAQ as the first-line treatment.[1]

Vulnerable populations such as displaced persons, nomads, orphans, prisoners, and refugees continue to have limited access to antimalarial services. Additionally, data is of poor quality and there is limited integration of private-sector care providers.[1]

Health financing

The country’s health financing mechanism includes several instruments:[4]

  • Government-subsidized services, the Social Assistance Scheme (Régime d’Assistance Social),
  • Social security,
  • Community Based Health Insurance,
  • Private health insurance,
  • and household out-of-pocket payments

The government laid out plans for universal health coverage in 2018. Malaria treatment is expected to be covered under this system.[1]

Severe malaria policy and practice

National treatment guidelines
Recommendation Treatment
Strong Injectable artesunate
Alternative Injectable quinine
Alternative Injectable artemether
Recommendation Pre-Referral
Strong IV artesunate (first-dose)
Alternative IM artesunate
Alternative IM quinine
Alternative IM artemether
First trimester pregnancy
Recommendation Treatment
Strong IV Quinine