The Burden of Malaria in Southern Africa

Malaria infection in Southern Africa The Links between Malaria & Poverty In Southern Africa Malaria is a major public health priority Malaria is the 1st or 2nd leading cause of illness and death Malaria accounts for between 3 (Swaziland) and 50% (Malawi) of outpatient attendances Malaria accounts for between 3% (Swaziland) and 24% (Mozambique) of inpatient deaths Malaria transmission In Southern Africa the intensity of malaria transmission varies considerably and includes malaria-free areas as well as unstable and stable transmission areas. The unstable areas are prone to epidemics which can result in high levels of morbidity and mortality if not prevented or contained.Southern African countries that have unstable transmission and are particularly prone to malaria epidemics are Botswana, Namibia, South Africa, Swaziland and Zimbabwe. Countries with predominantly stable transmission are Angola, Malawi, Mozambique, Tanzania and Zambia. However, within these countries there are also areas with unstable transmission that have a high risk of epidemics. For example, the Northern and Southern Highlands of Tanzania and the Angolan plateau.A number of factors affect malaria transmission in the subregion. The chief determinant is climate which affects both the life of the anopheles mosquito and the development of malaria parasites. The development of the malaria parasite is greatly retarded below 20 Celsius. In addition, relative humidity of over 60% lengthens the life of the mosquito enabling it to transmit the infection.

Bulletins   The Burden of Malaria in Southern Africa Malaria Poverty and Development Population Data and Malaria Control in Southern Africa Malaria Surveillance Bulletins for Southern Africa  More Publications  Reference Documents Roll Back Malaria in Southern Africa - Baseline 2001  Africa Malaria Report 2003  African Summit on Roll Back Malaria

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There are also a number of human factors that affect malaria transmission. Vector control efforts, particularly residual house spraying programmes and source reduction in urban areas have made previously malarious districts malaria-free. Equally the breakdown of vector control has resulted in previously malaria free becoming malarious again such as in the Zambian Copperbelt. Forced and voluntary population movements affect malaria transmission (see below). Man-made changes to the environment also affect malaria transmission. For example, urbanisation leads to source reduction. While dam building – particularly in semi-arid areas can create foci of malaria transmission.  

Population movements and malariaThe movement of non-immunes to malarious areas (e.g. urban migrants visiting families in rural areas, business travellers and tourists) can put individuals at risk of severe malaria. While major population movements from low to high intensity transmission areas triggered by such factors as resettlement schemes, natural disasters or conflict can cause a sharp upturn in malaria incidence and sometimes lead to epidemics. Equally, migration can introduce malaria (or drug resistant strains) into previously malaria-free areas. Other ways migration can affect malaria transmission are by alter environmental conditions which can facilitate or hinder transmission; and return migrants introducing new ideas and malaria control products into rural communities.

Population at risk out of the 139 million people living in Southern Africa, approximately 63% live in malarious areas. In areas of stable transmission, under-five year olds and pregnant women are at greatest risk of severe malaria due to the low levels of acquired immunity. In the predominantly stable transmission countries – Angola, Malawi, Mozambique, Tanzania and Zambia – there are an estimated 13,687,000 under-five year olds and 3,302,600 pregnant women at risk of severe malaria. In the predominantly unstable transmission countries – Botswana, Namibia, South Africa, Swaziland and Zimbabwe – where all age groups have a high risk of malaria due to low levels of acquired immunity, it is estimated 12,382,000 people are at risk of malaria.Estimated population at risk of malaria in Southern Africa, 1998

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Malaria Infection in Southern Africa

The prevalence of malaria cases indicate the intensity of malaria transmission. High levels of malaria prevalence (parasitaemia) in children indicate intense stable transmission. In the map it can be seen that in the stable transmission countries, malaria prevalence among 2-9 years can be as high as 60%. While in the unstable transmission countries, prevalence is considerably lower (<15%). Vector control in some of these countries (e.g. South Africa and Swaziland) has contributed to bringing malaria prevalence down to very low levels (<2%).                          
Malaria morbidityMalaria is a major cause of morbidity in Southern Africa. In recent years, reported malaria cases have been rising in Southern Africa.In part, this rise may be due to the improved coverage of Health Information Systems (HIS) and misdiagnosis due to a general rise in fevers associated with HIV. However, for countries with more robust data (see below) the rise in malaria cases remains strongly suggesting that malaria morbidity is increasing within Southern Africa. Reasons for this are likely to include deteriorating health sectors within the subregion, a breakdown in malaria control efforts, rising drug and insecticide resistance, population movements and environmental changes favouring malaria transmission.

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In areas of stable transmission, the most important risk groups are under-five year olds, pregnant women and travellers who normally reside in unstable or malaria-free areas. The consequences of malaria in pregnancy include anaemia, miscarriages, stillbirths and low birthweight. Cerebral malaria can lead to disabling neurological sequelae. Hence, among young children, an episode of severe malaria may negatively impact on their educational attainment. In stable transmission countries severe anaemia among under-fives is more common than cerebral malaria. In unstable transmission countries, cerebral malaria is the main complication of severe malaria.

Malaria mortalityMalaria is a major cause of mortality in Southern Africa. Obtaining reliable data on malaria mortality is very difficult. Misdiagnosis and unrecorded deaths can mean surveillance data can give a misleading picture. However, by using all cause population-based mortality rates and hospital data on the proportion of deaths attributed to malaria, it is possible to calculate broad malaria mortality estimates. Using this method, it is estimated that between 200,000 and 300,000 malaria deaths occur annually in Southern Africa.  Qualitative reports as well as surveillance data indicate that malaria deaths are rising in some countries (Namibia, South Africa, Zimbabwe). If this is the case, it is likely to be due to a combination of factors including late-treatment seeking behaviour, quality of care, inadequate transport and communication for referral systems to function properly, growing drug resistance and, possibly, HIV.

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It is estimated that in Southern Africa:

	Malaria is responsible for 200,000 deaths per annum
	Between 10,000,000 and 37,000,000 confirmed cases of malaria occur per annum
	The incidence of confirmed malaria is between 73 and 266 per 1000 population per annum
	The incidence of confirmed malaria ranges is between 115 and 420 per 1000 population at risk per annum
	Malaria parasitaemia among children age 2-11 years ranges from 0-5% to 40-60%

The socio-economic consequences of malariaWithin Southern Africa, malaria is a major impediment to socio-economic development and an important cause of poverty. Malaria impacts on the economy at a number of levels including within households and communities, the private sector, government and the macro economy.Within households and communities, the direct economic costs of malaria comprise prevention and treatment costs. Indirect economic costs may include absenteeism from work or school, neglect of domestic jobs, reduced income and poor scholastic performance. Social costs include bereavement, sickness and death.

Such factors are likely to both cause and deepen poverty. Moreover, the burden of malaria is often greatest among the very poor as they are least able to protect themselves and seek treatment. Hence, malaria can exacerbate existing inequalities.Within the Ministry of Health, malaria uses up resources for its prevention and control. In addition, to expenditure on insecticides, drugs, equipment etc., large numbers of malaria patients may lead to health facility staff being stretched beyond capacity and, thereby, reducing the standard of care received by all patients. Malaria also exerts a major burden on other Government ministries, notably education. Malaria causes staff and student absenteeism and death, poor concentration in class and poor scholastic performance.

Malaria affects the productivity of the private sector. Key businesses that are particularly affected by malaria are likely to include agriculture, tourism, mining and construction industries. Employees may be affected by the problem of a sick workforce causing declining productivity and costs of providing sick pay. In the long term this may lead to a reduction in the performance and profits of companies. In addition, for tourism the threat of malaria can negatively affect visitors to the country.Ultimately, the economic burden of malaria damages the economic performance of Southern Africa. Poverty and inequalities are exacerbated, government resources  come under increasing pressure, and the private sector faces reduced investment, growth, profits and inflow of foreign currency. Together, these factors negatively affect the gross domestic product and socio-economic development is hindered.

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The Links Between Malaria and Poverty

Poverty and malaria are inter-linked. Poverty affects malaria. Communities with low incomes, limited education and poor access to health care are least able to engage in malaria control activities. Prevention of malaria may not be affordable nor properly understood. Equally, treatment-seeking behaviour may be influenced by lack of education as well as inability to pay transport, consultation and treatment fees at health facilities.

At the same time, malaria affects poverty. In poor households, a greater proportion of income is likely to be spent on malaria treatment than in richer households. Malaria illness can cause to absenteeism from work and school, poor scholastic performance, lack of labour for cultivation, and a decline in child care; malaria deaths can lead to funeral costs, loss of an income-earner and a rise in orphanhood. Hence, a negative spiral can develop with malaria causing and deepening poverty which, in turn, exacerbates inequalities in society. Within Southern Africa the burden of malaria is greatest within poor communities located in malarious areas. Such communities are resource-poor, have limited access to health and other social services, and low levels of literacy. Malaria-poverty linkages may exist both in poor rural communities as well as peri-urban settlements.

Moreover, in epidemic-prone countries, malaria epidemics are likely to be most severe in the poorest communities.Improvements in access to primary health care and primary school enrolment in Southern Africa are likely to have increased the ability of the poor to prevent and control malaria. However, considerable work remains to be done to break the malaria-poverty negative spiral. Hence, we need to:

	Identify where malaria and poverty coincide in Southern Africa
	Establish the socio-economic burden of malaria on the poor and the poor’s ability to take part in malaria control interventions
	Design malaria control strategies and interventions that target the poor and that can make an impact on poverty as well as malaria
	Bring in other sectors and organisations involved in poverty reduction to take an active role in malaria control within poor communities

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