Malaria is the primary cause of morbidity and mortality in Mali. Globally, Mali is among the ten countries with the highest number of malaria cases and deaths (3% of the global cases and deaths, and 6% of cases in West Africa). From 2016 to 2019, cases fell 13%, from 384 to 334 per 1000 of the population at risk, while deaths fell by 21% from 0.76 to 0.59 per 1000 of the population at risk.
The impact of malaria on children under five years of age in Mali is high. Mali has the 2nd highest level of severe anaemia among children under five years of age. Over 40% of children who reported having a fever were not brought for care and less than 30% of the children brought for care were tested for malaria. To reduce the burden of malaria in the country, the High Burden, High Impact approach was introduced in November 2019.
Malaria prevalence varies across regions, from a minimum of 1% in Bamako to a maximum of 30% in Sikasso region. The disease prevalence among children under five years of age was 19% in 2018.
Malaria is endemic to the central and southern regions, where about 90 percent of Mali’s population lives, and it is epidemic in the north due to the limited viability of Anopheles species in the desert climate. The country therefore has three malaria zones:
- Stable malaria zones: In this zone, the disease is transmitted throughout the year, with some seasonal variations. This transmission type impacts the Guinean and Sudanese zones as well as the dams and inner Niger Delta areas.
- Unstable malaria zones: These areas have intermittent transmission of malaria (mainly the Sahelian-Saharan zone) and are impacted by epidemics; local inhabitants are therefore not sufficiently immune to malaria.
- Sporadic malaria zones: This is typical of the Saharan zone and the population has no immunity against malaria with all age groups being exposed to severe and complicated malaria infections.
The country has introduced several policies in support of pregnant women and children.2 These include:
- free health care for children under 5 and pregnant women in 2017
- heavily subsidized care for the rest of the population
Key populations that may not have access to care include the destitute, internally displaced, refugees, repatriated and populations which have limited geographical access to health centers (over 5km), immigrants and nomads.
Mali continues to have high access to (90% in 2018) and high use (79% in 2018) of insecticide-treated mosquito net (ITNs). The proportion of pregnant women (84% in 2018) and children under 5 years of age (79% in 2018) who sleep under nets also remains high. The country intends to reach universal coverage of bed net distribution by 2022.
Malaria case management equally continues to be a key priority of the country’s health agenda.
Persisting political insecurity and the deteriorated state of health care facilities in a number of areas aggravate the situation.
Approximately 50% of the Malian population seeks care in the private sector, where testing rates are very low since many of those facilities do not have access to rapid diagnostic tests.
Providers in private clinics are more likely to treat malaria based on clinical signs and symptoms, without confirming malaria infection. 
New malaria strategy
A new malaria control program was developed for the period 2018–2022 with the chief aim of decreasing malaria mortality and morbidity by 50 % versus 2016 levels. A longer-term goal of the NMCP/Ministry of Health (MOH) is to eliminate malaria by 2030.
The use of artesunate rectal capsules (ARC) prior to the transfer of patients (children) with severe malaria to a higher level healthcare facility has been recommended by the National Malaria Control Programme since 2009, and was incorporated into the National Malaria Control Policy in 2011.
In 2018, 27% of caregivers of children with fever reported seeking healthcare within 24 hours of onset. Of those seeking healthcare, 27% reported seeking care from the public sector (public hospital/clinic or other public sector provider); 12% went to a private sector health provider (pharmacy, private clinic/hospital or to a community health worker), and 21% sought care from other private sector providers (itinerant drug seller, boutique, traditional healer, market).
In Mali, although the majority (80%) of pregnant women attend at least one antenatal care (ANC) visit, only 37% of women living in rural areas attended the recommended four visits, in contrast to 67% of women living in urban areas (Demographic and Health Survey 2018).
Despite this, intermittent preventive treatment for pregnant women (IPTp) has increased over the last few years. The proportion of pregnant women attending antenatal care (ANC) and receiving at least two doses of sulfadoxine–pyrimethamine (SP) – IPTp2 – increased from 38% in 2015 to 55% in 2018. The proportion receiving three or more doses (IPTp3 or IPTp3+) rose from 21% in 2015 to 28% in 2018.
Seasonal malaria chemoprevention
Seasonal malaria chemoprevention (SMC) began in Mali in 2012. By 2018, SMC covered children less than 5 years old nationally and, in 2017–18, it was piloted for children 5–10 years old in the Kita District.
In the programme, all eligible children with fever were tested for malaria before receiving SMC. If the malaria test was positive, then the child is treated with an artemisinin-based combination therapy (ACT).
In 2018–19, Mali was overstocked with injectable artesunate. Stock of other commodities such as SP, rapid diagnostic tests (RDTs), and ACTs was typically minimal at the central level because these commodities are quickly distributed for use at lower levels of the health pyramid.
In the same period, facilities in Mali experienced zero stockouts of all ACT formulations simultaneously, but stockouts of individual ACT formulations did occur. ACT and RDT stockouts were generally most common because commodities are quickly distributed at lower health centre levels.
Severe malaria policy and practice