Current status + progress
Every two minutes, a child under 5 dies of malaria
Every two minutes, a child under five dies of malaria. Many of these deaths are preventable and treatable. In 2019, there were 229 million malaria cases globally that led to 409,000 deaths. Of these deaths, 67 per cent (274,000) were children under 5 years of age. This translates into a daily toll of nearly 750 children under age 5.
Malaria is an urgent public health priority. The disease and the costs of its treatment trap families in a cycle of illness, suffering and poverty. Today, nearly half of the world’s population, most of whom live in sub-Saharan Africa, are at risk for developing malaria and facing its economic challenges.
Despite this heavy toll on health and economy, major inroads have been made against the disease as a result of stepped-up funding and programming. Between 2000 and 2019, mortality rates among children under 5 fell from 84 to 67 per cent. Success, however, in the fight against malaria is fragile and closely tied to sustained investment. In recent years, there has been a plateau in the funding of the global malaria response. In 2019, the total of international and domestic funding for malaria control and elimination was $3 billion – less than half of what was needed. In order to achieve the goal of a malaria-free world, annual funding would need to more than double to the USD $6.6 billion target.
Impact of the COVID-19 pandemic and response
There is growing evidence that access to skilled and quality malaria services and care may have been negatively impacted by country responses to the COVID-19 pandemic, including lockdown measures, transportation disruptions, diversion of resources away from essential health services, as well as because of fears of infection. In 2020, for example, there were significant disruptions to bednet distribution campaigns due to COVID-19 mitigation efforts. There are concerns that these disruptions have also affected other malaria prevention and treatment programmes. Many of these disruptions have also coincided with malaria peak season, causing additional concern for the toll that the pandemic could have on malaria mortality and morbidity in children.
Sleeping under insecticide-treated mosquito nets (ITNs) on a regular basis is one of the most effective ways to prevent malaria transmission and reduce malaria related deaths. Since 2000, the production, procurement and delivery of ITNs, particularly long-lasting insecticide treated nets (LLINs), have accelerated, resulting in increased household ownership and use. Over 1 billion ITNs have been distributed in Africa since 2000, and annual distribution continues to increase. In 2019, manufacturers delivered about 253 million ITNs to malaria endemic countries, an increase of 56 million ITNs compared with 2018.
Most countries in sub-Saharan Africa have made considerable progress in household ownership of ITNs/LLINs in recent years, with an average coverage of 69 per cent. However, ownership is uneven across countries, ranging from 31 per cent in Angola to approximately 97 per cent in Guinea-Bissau. In addition, only 35 per cent of households had sufficient ITNs for all household members, which is drastically short of universal access to this preventive measure.
Since 2007, the percentage of children sleeping under ITNs in sub-Saharan Africa increased from less than 40 per cent to over 50 per cent. But despite recent progress in sub-Saharan Africa, the overall use of treated mosquito nets falls short of the global target of universal coverage, and many children are not benefiting from this potentially life-saving intervention. Large country and regional variations exist. For example, during 2014-2020 fewer than 25 per cent of children slept under an ITN in Angola and Zimbabwe, while over 80 per cent of children slept under an ITN in Guinea-Bisseau and Niger.
Most countries in sub-Saharan Africa increased ITN use among children under age 5 in an equitable way. This was largely due to free distribution campaigns that emphasized poor and rural areas. The success of this strategy has been reflected in an increased use of ITNs by vulnerable populations.
Early diagnosis and treatment are essential for more favourable malaria outcomes. As fever is a key manifestation of malaria in children, particularly in malaria endemic regions, care-seeking for febrile children is crucial to reducing child morbidity and mortality. In sub-Saharan Africa, 60 per cent of children with a fever were taken for advice or treatment from a health facility or provider. Data show disparities in care-seeking behaviour for febrile children by residence, with those living in urban areas more likely to be taken for care than those in rural areas. Disparities are also observed by wealth, with a 19 percentage point difference in care-seeking behaviour between children in the richest (71 per cent) and the poorest (52 per cent) households.
Whilst fever is an indicator of malaria in children, it can also be a sign of other acute infections. In 2010, WHO recommended the universal use of diagnostic testing to confirm malaria infection before administering any treatment. Malaria is diagnosed in febrile children by a rapid diagnostic test (RDT), which involves taking a blood sample from the finger or heel to test for malaria Plasmodium (P.) antigens. In sub-Saharan Africa, testing is low, with only one in four (27 per cent) of children with a fever receiving medical advice or a rapid diagnostic test. There was a 13 percentage point gap in testing between the richest and the poorest children (35 per cent vs 22 per cent). Additionally, a greater proportion of children in Eastern and Southern Africa (35 per cent) were tested than in West and Central Africa (21 per cent).
Until recently, the ‘proportion of children under 5 with fever who are treated with appropriate antimalarial drugs’ was the standard indicator for monitoring antimalarial treatment. However, it has become increasingly challenging to track trends following developments in the official recommendations. WHO now recommends universal testing to confirm malaria. In response, many countries have expanded the use of diagnostic testing to focus treatment on those diagnosed with malaria. The current lower levels of antimalarial treatment in febrile children may indicate that anti-malarials are being provided only to confirmed cases. For more information on this issue, see the 2013 edition of the Household Survey Indicators for Malaria Control.
First line treatment
Artemisinin-based combination therapy (ACT) is the most effective antimalarial therapy for P. falciparum, the most lethal malaria parasite and the one most pervasive in sub-Saharan Africa. By the end of 2014, most African countries had adopted ACT as the national policy for first-line treatment. The data continue to support, however, that other less effective antimalarial drugs are still commonly used. Treatment of malaria in children with ACT is low in sub-Saharan Africa with just over half (58 per cent) of children treated with anti-malarial drugs receiving the first-line treatment ACT. In West and Central Africa in particular, ACT treatment is alarmingly low – approximately half that in Eastern and Southern Africa (46 per cent vs 81 per cent). Available survey data indicate that ACT treatment does not differ greatly by residence or wealth within these regions.
Malaria during pregnancy
In sub-Saharan African countries with high malaria transmission, pregnant women are highly vulnerable to malaria infection due to reduced immunity. When infected with malaria during pregnancy, they are more likely to become anaemic and give birth to low-birthweight or stillborn babies. Methods to prevent malaria in pregnancy include:
- Pregnant women sleeping under ITNs – Regular use of ITNs by pregnant women is a vital intervention in the prevention of malaria among pregnant women. Although some progress has been made, the proportion of pregnant women in sub-Saharan Africa who sleep under an ITN remains too low.
- Intermittent preventive treatment during pregnancy (IPTp) – Preventing malaria in pregnant women through IPTp with sulfadoxine-pyrimethamine during antenatal care visits is an effective way of reducing maternal anaemia and low birthweight. Nearly every country in sub-Saharan Africa with a high malaria burden has adopted intermittent preventive treatment for pregnant women as part of its national malaria control strategy. In most countries, coverage of antenatal care services is much higher than current levels of IPTp administration, suggesting that there are missed opportunities to expand access to this life-saving intervention for mothers and newborns.
In 2016, WHO issued a new recommendation that at least three doses of IPTp treatment should be given to pregnant women in malaria endemic regions, starting in their second trimester, with at least one month between each dose. Many countries are still in the process of scaling up this new recommendation.
Between 2015-2020, an average of only 28 per cent of eligible women in sub-Saharan Africa received three or more doses of IPTp. The proportion of women receiving IPTp varies across the region, ranging from 3 per cent at the lowest (Sao Tome and Principe) to 61 per cent at the highest (Ghana).
UNICEF, Progress for Children Beyond Averages: Learning from the MDGs, New York, 2015.
Measure Evaluation, Measure DHS, President’s Malaria Initiative, Roll Back Malaria Partnership, UNICEF and WHO, 2013 Household Survey Indicators for Malaria Control.
Roll Back Malaria Partnership, Annual Report 2018. WHO, Geneva, May 2019.
UNICEF, The State of the World’s Children 2019, UNICEF, New York, 2019.
WHO, Guidelines for the Treatment of Malaria: third edition, WHO, Geneva, 2015.
WHO, World Malaria Report 2020, WHO, Geneva, 2020.
WHO, Recommendations on antenatal care for a positive pregnancy experience, WHO, Geneva, 2016.
Child health coverageDownload spreadsheet
Notes on the data
The following is the Sustainable Development Goal indicators for the monitoring of malaria:
|Sustainable Development Goal||Target||Malaria specific indicator|
|Goal 3: Ensure healthy lives and promote well-being for all at all ages||Target 3.3 By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases||3.3.3 Malaria incidence per 1,000 population|
* This indicator refers to antimalarial treatment among all children with fevers, rather than among confirmed malaria cases, and thus should be interpreted with caution.
For additional information, visit the latest Household Survey Indicators for Malaria Control manual.