Madagascar

Photo: siblings

Malaria facts 

Malaria remains the fourth leading cause of mortality and the fourth most frequent reason for health facility visits in Madagascar. The entire population is at risk for the disease; however, risk is heterogeneous across the country. [1] 

The country is among the 20 with the highest rates of malaria cases and deaths – in 2020, it accounted for 1.5% of global cases and deaths, and 6.6% of malaria cases in East and Southern Africa. Between 2017 and 2020, the estimated number of cases increased by 76%, from 76 per 1000 of the population at risk to 113, and the estimated number of deaths increased 83%, from 0.19 per 1000 of the population at risk to 0.34. [2]  

The age group most affected by malaria is children aged 6–13 years, representing 33.85 percent of cases. Children under 14 years of age accounted for more than 65 percent of malaria cases in 2019.  

Case management 

Madagascar’s case management guidelines are aligned with WHO recommendations and adapted to the local context. All malaria diagnosis and treatment in public facilities is free.  

Severe malaria cases are treated with injectable artesunate followed by an artemisinin-based combination therapy. Rectal artesunate was introduced in 2020 in select districts at the community level and in health facilities for pre-referral intervention of children less than five years of age with severe disease.[1] 

For case management, the main barrier is the geographical distance between homes and health care facilities, and between primary health care facilities and referral hospitals. In addition, consultation of traditional healers can result in a delay in treatment. Moreover, 80% of the population lives below the poverty line. The socioeconomic status of households and of each individual can thus be a source of inequity in access to care. 

Although diagnosis and treatment of malaria cases is free, the costs of additional treatment and the indirect costs of travel and patient accompaniment can result in a disincentive to attend health care facilities. [3] 

Community-based care 

Madagascar has an extensive programme of community health volunteers (CHVs), with approximately 36,000 CHVs covering the country (two CHVs per fokontany, the smallest administrative level).  

CHVs conduct sensitization activities on the prevention of communicable diseases, including malaria. They also provide integrated community case management (iCCM) services, including malaria testing and treating, to approximately 4.5 million children under five years of age. [1] 

CHVs in targeted areas have been trained on the use of rectal artesunate for pre-referral intervention of children under five years of age with severe disease. Limited supplies of rectal artesunate were distributed in remote high-burden areas in 2020. [1] 

Madagascar plans to extend community-based case management of malaria to all age groups. This approach will be implemented in 41 districts identified as highly endemic, vulnerable and having experienced resurgence in recent years.[3] 

Drug-based prevention 

Madagascar has adopted the WHO multi-pronged approach to drug-based interventions. This includes preventing malaria in pregnancy through the provision of at least three doses of sulfadoxine-pyrimethamine (SP) spaced one month apart starting early in the second trimester (from 13 weeks of pregnancy) until delivery (IPTp3), and prompt and effective diagnosis and treatment of malaria during pregnancy. [1] 

The percentage of women who received two or more doses of IPTp (PPTp2) during their last pregnancy in the last two years increased from 23% to 29% between 2016 and 2018, while those that received IPTp3 increased from 11% to 25% over the same period. 

Because of the frequency of resurgence and the increase in the number of cases in the most vulnerable districts, the National Malaria Control Programme, with the support of its partners, plans to carry out a feasibility study into implementing seasonal malaria chemoprevention (SMC) in districts eligible according to World Health Organization (WHO) criteria.[3] 

Insecticide-treated nets 

Overall, ownership of insecticide-treated nets (ITNs) in Madagascar has been increasing in recent years. In 2013, the percentage of households with at least one ITN had dipped to 69% (from 81% in 2011), likely due to a period of US government restrictions in Madagascar. By 2016 and 2018, however, the percentage of households with at least one ITN was 80% and 78%, respectively. (Note that the 2018 data are from a Multiple Indicator Cluster Survey. This included districts that had not received ITNs in the mass distribution campaign, whereas the Malaria indicator surveys of 2013 and 2016 excluded those areas.) 

The percentage of children under five years of age whose guardians reported they slept under an ITN the previous night increased from 62% in 2013 to 73% in 2016. (In the 2018 Multiple Indicator Cluster Survey, the estimate was 62%.) [1] 

Severe malaria policy and practice 

National treatment guidelines
Recommendation Treatment
Strong Injectable artesunate
Recommendation Pre-referral
Strong Rectal artesunate
Recommendation during pregnancy (prevention)
SP (IPT)