GMAP

[Full Table of Contents]
[Executive Summary]

[Part III: Regional Strategies] PDF version

  1. Introduction to Regional Strategies
  2. Africa
  3. The Americas
  4. Asia
  5. Middle East and Eurasia

Part III: Regional Strategies

5. Middle East and Eurasia

Introduction to Malaria in the Region

There are 17 countries or territories with malarious areas in the region, located in Central Asia, Transcaucasia, in the Middle East and on the European-Asian border.

Central Asia (7): Afghanistan, Iran, Kyrgyzstan, Pakistan, Tajikistan, Turkmenistan and Uzbekistan

Transcaucasia (3): Armenia, Azerbaijan and Georgia

Middle-East (5): Iraq, Oman, Saudi Arabia, Syrian Arab Republic and Yemen

Others (2): Russian Federation and Turkey

Population at risk. ~270 million people are at risk of malaria, which represents 8% of the world population at risk. Only ~21% of the population at risk is located in areas of high transmission,[76]Where reported malaria case incidence is above 1 per 1000 population per year. the remaining 79% in areas of low transmission.

Malaria transmission. Since the early 1990s, malaria transmission in the region has increased due to political and socioeconomic problems, mass population migration, extensive development projects, and weakened malaria prevention and control programs. Overall, the countries in the region can be classified in the following groups:

P. vivax is the most prevalent species of malaria and occurs in all malarious countries. The prevalence of P. falciparum varies greatly among countries: it is dominant in Yemen (98% of cases) and Saudi Arabia (77%), common in Pakistan (30-40%) and still occurs in a low and decreasing share of cases in Iran, Afghanistan and the southern part of Tajikistan.

Malaria burden. The Middle East and Eurasia had approximately 13 million cases in 2002 and ~56,000 deaths in 2000, comprising less than 3% of worldwide cases and approximately 5% of worldwide deaths.[77]Breman JG et al. Conquering Malaria. In: Jamison DT, Breman JG et al, eds. Disease Control Priorities in Developing Countries Conquering Malaria. Oxford University Press and the World Bank; 2006. p 415.

Click for source Among the 17 countries, 3 of them (Pakistan, Afghanistan and Yemen) account for more than 99% of regional deaths (Figure III.17).

Figure III.17: Malaria cases and deaths in the Middle East and Eurasia

Note: Countries with negligible burden are not shown (Armenia, Azerbaijan, Kyrgyzstan, Uzbekistan, Georgia, Iraq, Turkmenistan, Russian Federation, Oman, Syrian Arab Republic, Tajikistan, Saudi Arabia, Turkey)
Source: World Malaria Report 2008. Geneva, World Health Organization, 2008

Adapted Approaches and Current Levels of Coverage

Afghanistan, Pakistan and Yemen are classified by WHO in the control stage. All three use LLINs as the main vector control intervention complemented with targeted IRS. IPTp is not recommended in these countries due to the low level of transmission.

Fourteen countries are in various stages of elimination: pre-elimination, elimination or the prevention of reintroduction. Seven are in pre-elimination (Azerbaijan, Iran, Tajikistan, Turkey, Uzbekistan, Georgia and Kyrgyzstan), and four are in elimination (Iraq, Saudi Arabia, Armenia and Turkmenistan). Oman, the Syrian Arab Republic and the Russian Federation are classified by WHO as in the prevention of reintroduction stage. In Oman and the Syrian Arab Republic, targeted IRS with pyrethroids is used as the main vector control intervention. LLINs are part of the national strategy in 8 countries.[78]Armenia, Azerbaijan, Kyrgyzstan, Iran, Iraq, Saudi Arabia, Tajikistan and Uzbekistan. The use of larvivorous fish – mostly in rice fields – is being promoted along with impregnated mosquito nets against outdoor-resting Anopheles species in most countries. All suspected cases are confirmed by microscopy, almost exclusively through public sector facilities. Treatment policies are in line with WHO recommendations. Figure III.18 presents the country categorization in the region.

Figure III.18: Country categorization in the Middle East and Eurasia

Source: World Malaria Report 2008. Geneva, World Health Organization, 2008

Locally adapted approaches to malaria control. Choosing the appropriate tools for implementation requires a deep understanding of local epidemiology, geography and socioeconomic conditions. This section provides a summary of the appropriate malaria interventions for the three countries in control.

Control with P. falciparum transmission only. Malaria in Yemen is caused primarily by P. falciparum transmission. Populations at risk need to be covered by either IRS or LLINs where appropriate. IPTp is currently not recommended. Case management includes timely diagnosis and timely and efficient treatment with ACTs.

Control with mixed transmission. Afghanistan and Pakistan have both P. vivax and P. falciparum transmission. LLINs or IRS should cover populations at risk where appropriate. The use of parasitological diagnosis to confirm parasite species is required by microscopy and where not possible, by RDTs. First-line treatment against P. falciparum is ACTs and against P. vivax is chloroquine and 14-days of primaquine. For mixed cases, ACTs and primaquine is recommended.

Current intervention coverage. The section below provides a summary of coverage with malaria interventions in the region.

LLINs / ITNs. LLINs are distributed free of charge in Pakistan and Yemen. In Yemen, all populations at risk are targeted while in Pakistan and Afghanistan, children under five and pregnant women are targeted. In these 3 countries, ~762 thousand LLINs / ITNs were in circulation in 2006. This represents a significant increase from previous years. In total, 1.2 million effective LLINs / ITNs were in circulation in the region in 2006.[79]GMAP estimates based on data from WHO World Malaria Report 2008 and the Roll Back Malaria Commodity database, 2008. See Appendix 3. Assumptions behind Current Burden, Coverage and Funding Estimates.

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IRS. Countries in the region are using IRS with pyrethroids as a complementary strategy to LLINs, but the scale of operations is very limited and quality of spraying is low. Pakistan is using IRS only for the containment of epidemics. An estimated ~2.9 million people in the three countries are covered by IRS, which represents ~29% of population at risk.[80]Dr. Hoda Atta, WHO-EMRO, personal communication, September 2008. In all countries in the Middle East and Eurasia, 1.1 million households (or 5.6 million people) are covered by IRS in 2006.[81]GMAP estimates based on data from WHO World Malaria Report 2008. See Appendix 3. Assumptions behind Current Burden, Coverage and Funding Estimates.

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Diagnostics (Microscopy and RDTs). Even though parasitological diagnosis is essential in Afghanistan and Pakistan due to presence of both P. falciparum and P. vivax, the use of microscopy is weak and RDTs are not widely available. In Pakistan, Afghanistan and Yemen, ~5.8 million cases were examined by microscopy. Reported data suggests no use of RDTs. In the entire region, ~11 million cases were examined by microscopy.[82]GMAP estimates based on data from WHO World Malaria Report 2008. See Appendix 3. Assumptions behind Current Burden, Coverage and Funding Estimates.

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Anti-malarial treatment. Treatment policies against P. vivax infections are chloroquine and primaquine in all countries except Afghanistan (where chloroquine only is being used). ACTs are first-line treatment against P. falciparum (in Afghanistan, only for confirmed cases due to the low proportion of P. falciparum cases). The presence of resistance to chloroquine and sulphadoxin-pyrimethamine from P. falciparum has led all countries with P. falciparum transmission to change their first-line treatment policies to ACTs. In Pakistan, Afghanistan and Yemen, approximately 512 thousand treatment courses were delivered in 2006. For the region, 1.7 million treatments were delivered in the same year.[83]GMAP estimates based on data from WHO World Malaria Report 2008 and the Roll Back Malaria Commodity database, 2008. See Appendix 3. Assumptions behind Current Burden, Coverage and Funding Estimates.

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Recommended Regional Approach to Control and Eliminate Malaria

Targets, approaches and priorities must be tailored to the region.

Targets. The target for 2010 is to reduce malaria mortality and morbidity by 50%, which means that the Middle East and Eurasia will have less than 6 million cases and 25,000 deaths. By 2015, the objective is to have less than 3 million cases and to reach near zero mortality for all preventable deaths.[84]Preventable death is defined as deaths from malaria that can be prevented with rapid treatment with effective medication. Non-preventable deaths represent an extremely low mortality rate for the most severe malaria cases and occur even with the best available and most rapid treatment. Beyond 2015, the objective is to maintain near zero mortality for all preventable deaths.

As outlined in Part II: The Global Strategy, this will be achieved through universal coverage with appropriate malaria control interventions for all populations at risk in all countries in the control stage (Afghanistan, Pakistan and Yemen) and with elimination programs being conducted in all countries that are ready (all other 14 countries).

To reach universal coverage with appropriate interventions by 2010 in the region (see Figure III.19):

Figure III.19: Scale-up in interventions from 2006 to 2010 in the Middle East and Eurasia

a) Because of 3-year life span, each year approximately 1/3 of the old nets will need to be replaced
b) Actual use is likely not all directed to confirmed malaria cases today
Source: Need based on GMAP costing model; actual based on analysis of World Malaria Report 2008. Geneva, World Health Organization, 2008 and Roll Back Malaria Commodities database

Approaches to main challenges faced by countries in control stage. Challenges faced by Pakistan, Afghanistan and Yemen differ from those of elimination countries in the Middle-East and Eurasia. The main challenges are outlined below.

Improve quality of laboratory services for diagnosis. In Afghanistan and Pakistan parasitological diagnosis is essential to distinguish between cases of P. vivax and P. falciparum. However, coverage and quality of microscopy services need to be improved. Afghanistan launched a pilot project to increase the use of RDTs and plans to expand coverage with microscopy facilities as part of its health system strengthening program in its Global Fund Round 8 proposal.

Strengthen monitoring and evaluation systems. In Afghanistan, routine monitoring systems are weak. In Pakistan and Yemen, the quality of M&E systems needs to be improved. There is little standardization and often duplication in the information collected. Robust systems are needed to provide reliable data to the national control program. The number of M&E specialists needs to be increased. M&E specialists need better pay, more training and special career paths and incentives to keep them in the job.

Strengthen leadership and management skills at all levels. Several countries have decentralized national malaria control programs to regional or local levels. However, at the sub-national level, there is little capacity to manage the human and financial resources. Increased training for planning and for program management at the regional and local levels is needed.

Increase compliance in the private sector. In several countries, most anti-malarial drugs are provided through the private sector (e.g. 80% in Pakistan).[85]Dr. Hoda Atta, WHO-EMRO, personal communication, September 2008. Private sector providers often do not comply with the national policies. Quality monitoring systems of anti-malaria interventions (especially drugs) need to be in place.

Continue control during political turmoil. Wars and political turmoil especially in Afghanistan are impacting anti-malarial programs negatively. Indoor-residual spraying activities have been interrupted in Afghanistan as a result of the ongoing conflict. Innovative approaches need to be in place to maintain the activities of the malaria control program where security is a concern, as was done in Iraq with the stock-piling of key malaria interventions ahead of time.

Approaches to main challenges faced by countries in elimination. Countries in elimination in the Middle East and Eurasia face a unique set of challenges.

Preventing large scale epidemics. Recently, large-scale outbreaks of P. vivax malaria have occurred in transcaucasian and Central Asian countries. These countries are situated in epidemic-prone areas where malaria transmission could resume, following a weakening or discontinuation of malaria control measures. Processes to detect epidemics and rapid response mechanisms need to be strengthened.

Migrant populations and cross-border coordination. The number of imported malaria cases is on the rise, due to an increase in labor mobility in neighboring countries and displaced populations. Countries such as Turkmenistan, Kyrgyzstan and Uzbekistan are especially at risk from immigration and vector migration from neighboring Tajikistan and Afghanistan. Surveillance at border areas and cross-country collaboration efforts are essential to prevent resurgence in malaria transmission.

Adapting to changing agricultural behaviors. The often uncontrolled extension of agriculturally-used land (e.g. rice fields) towards population centers brings populations closer to potential malaria breeding sites and can lead to increased malaria transmission. Surveillance and increased use of interventions (such as targeted vector control measures) is key to success.

Sustain political and financial commitment. In countries with very low levels of burden, political commitment and national financial support can decline if malaria is not perceived as a public health priority. It is essential that high level support from political leaders is maintained through continuous advocacy efforts that clearly outline the risks of reemergence.

Strategic priorities. Success in malaria control and elimination is essential in all countries. However, some countries are especially important to achieving the RBM targets. (See Figure III.20.)

Figure III.20: Distribution of malaria deaths in the Middle East and Eurasia

Source: World Malaria Report 2008. Geneva, World Health Organization, 2008

Priorities to reach the 2010 targets. None of the 35 countries that account for 98% of estimated malaria deaths worldwide are located in the Middle East and Eurasia. However, within the region, the burden is highly concentrated: almost 100% of deaths and 97% of cases are concentrated three countries – Pakistan, Yemen and Afghanistan (See Figure III.20). Therefore, to successfully meet the targets within the region, these countries should receive focused attention and tailored assistance from partners.

Priorities beyond 2010. When the countries in the control stage have reached universal coverage, they need to be encouraged in sustaining universal coverage to avoid a resurgence of malaria and an upsurge in malaria mortality and morbidity until the move to elimination is possible. Countries in the elimination stage are encouraged to continue their efforts to bring local transmission down to zero and when this is achieved, to move to the prevention of reintroduction stage.

International support required. International support for the control countries is important both to reduce the burden in these countries, but also to ensure that malaria is not reintroduced into the 14 countries currently on the path to elimination or preventing reintroduction. The RBM Partnership does not currently have a Sub-Regional Network (SRN) in this region. Given the lower overall burden in the region, a small SRN focused on coordinating partners and countries could be valuable to ensure regional cooperation. Technical assistance and country capacity building are probably better provided directly by countries or partners in the region than by the RBM Partnership.

Funding Requirements: US$ 134 million gap for 2010

Estimates show that a large proportion of disbursements against malaria in the region come from national spending. Among the US$ 92 million disbursed in 2007, 89% came from national health budgets, the rest from international donors. (See Figure III.21) Resource-rich countries such as Iraq or Saudi Arabia fund their national anti-malarial programs to a large extent. So far, grants from the Global Fund have been awarded to 9 countries in Rounds 2 to 7, for a total amount of US$ 76 million, the three largest recipients being Yemen (US$20 million), Pakistan (US$ 18 million) and Afghanistan (US$ 15 million).[86]These are malaria-only grants from the Global Fund against AIDS, Tuberculosis and Malaria. An additional "integrated" grant of ~US $3 million was awarded to Afghanistan to build the country capacity against all three diseases (AIDS, Tuberculosis, and Malaria). Other major donors include USAID, which funded a project from 2003 to 2006 in Tajikistan, Kyrgyzstan and Uzbekistan.

Figure III.21: Gap in malaria funding in the Middle East and Eurasia

Note: See appendices on methodologies to estimate costing needs and current funding
Source: GMAP costing model (WHO, GFATM, World Bank, PMI)

The Middle East and Eurasia lack US$ 134 million based on 2007 spend to fully implement its control and elimination programs in 2010. Most of these costs are for the control countries: Pakistan, Yemen and Afghanistan. (See Table III.5) Unlike other regions, the Middle East and Eurasia will experience a significant drop in resources needed as many countries in the region eliminate malaria and limit their malaria spending to prevention of reintroduction activities.

Table III.5: Summary of annual costs in the Middle East and Eurasia

Cost category (US$ millions) 2009 2010 2015 2020 2025
LLINs/ITNs 50 50 36 29 0
IRS 25 35 48 25 65
IPTp 0 0 0 0 0
Prevention cost 75 85 84 54 65
RDTs 54 68 18 0 0
ACTs 1 1 0 0 0
Chloroquine and primaquine 0 0 0 0 0
Severe case management 0 0 0 0 0
Case management cost 55 70 18 0 0
Community health workers 5 5 5 4 1
Training 8 6 4 3 1
M&E and OR 21 22 23 21 13
Infrastructure / inst. strengthening 23 38 24 18 6
Program cost 58 71 55 46 21
Total control & elimination cost 188 226 157 101 86

Note: Diagnostic costs are covered both by RDTs in case management and by microscopy in infrastructure / institutional strengthening
Source(s): GMAP costing model; Johns B. and Kiszewski A. et al