Following the failure to eradicate malaria worldwide in the 1960s and 1970s, WHO and its partners adopted a new set of control interventions, which were updated on a regular basis. The aim of these interventions was to redesign the various control interventions to make them more effective and efficient. These new control interventions focused mainly on controlling morbidity and reducing or even stopping mortality, especially in malaria-endemic areas. To make the interventions more precise, the WHO recommended that they be adapted to the socio-economic and epidemiological factors of different regions of the world. These control interventions were mainly: access to diagnosis and prompt treatment of malaria cases, the use of bed nets and vector control, and preventive measures in high-risk groups [1].
This global control program has had a significant impact on the incidence and prevalence of malaria in the world over the past 20 years. These good results have been the result of good coordination and sustained efforts by WHO and its partners through various targets and actions, including the Roll Back Malaria program launched in 1999, the targets for reducing malaria morbidity and mortality by 2030 [2] and the strengthening and development of new control interventions. These actions, reinforced by initiatives such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, the commitment of African leaders through the Abuja Declaration [3] and the US President's Initiative to Fight Malaria [4], have made it possible to reduce malaria mortality by 60% in the world and by 44% in Africa. Even more impressive, according to the WHO 2020 report, 21 countries in the world have successfully eliminated malaria [5].
Despite these good results, elimination has not always been achieved, and malaria-related morbidity and disease remain high in endemic areas. Indeed, malaria remains a public health problem and a serious socioeconomic threat in most parts of the world. Despite the efforts of WHO and its partners, the WHO African Region appears to be resistant to the impact of control interventions. For example, the number of malaria cases has continued to increase since 2015, with 90% of malaria cases in 2016, 92% in 2017, 93% in 2018, 94% in 2019 and 95% in 2020 [5–9]. And in 2020, 94% of deaths recorded worldwide will occur in the African region. Children under 5 years of age are more affected, with a mortality rate of 77% [5,9]. In the same year, Mali recorded 843,961 severe cases with 1708 deaths [10]. Furthermore, the funding needed to control and eliminate the disease worldwide has increased significantly over the years, reaching US$1.3 billion in 2017, US$2.3 billion in 2018 and US$3 billion in 2019 [5]. In Mali, the main funding for malaria control comes from the Global Fund and the US President's Malaria Initiative, representing 36% and 43% of malaria control investment respectively [11].
In general, according to the 2007–2011 Strategic Plan for Malaria Control, malaria control interventions in Mali are essentially based on prevention and management of the disease. Prevention tools include the use of long-lasting insecticide-treated nets (LLINs) distributed to the general population, intermittent preventive treatment (IPT) for pregnant women, seasonal malaria chemoprevention (SMC) for children under five years of age, and indoor residual spraying (IRS). The management of malaria-related disease focuses on the systematic confirmation of all suspected cases of malaria by rapid diagnostic tests (RDTs) and early treatment of confirmed cases with artemisinin-based combination therapy (ACT), the control of epidemics and malaria-related emergencies, and the monitoring and evaluation of cases. In addition to these main axes, communication, social mobilization and operational research on new control interventions, drug and vaccine trials are also included [12].
These interventions continue to produce encouraging results, thanks to the commitment of national and international health and political authorities. In most cases, these results vary from year to year and from malaria-endemic area to malaria-endemic area around the world.
In Africa, the number of households using insecticide-treated nets (ITNs) increased significantly between 2000 to 2021. In 2020, 65% of households in sub-Saharan Africa had at least one ITN [9]. In Mali, this rate is 75% in 2018 and 91% in 2021, according to the 2018 Demographic and Health Survey Report [13] and the Malaria Indicators Survey in Mali [14]. Chemoprevention, which aims to prevent and reduce malaria disease and its consequences in the most vulnerable groups by using a combination of antimalarial drugs. In 2019, 49% of pregnant women in Africa received at least two doses of IPT during their pregnancy and 34% received at least three doses. This 3 dose rate increased slightly from the 2018 rate of 31% [5]; but decreased slightly to 32% in 2020. A similar trend was observed in Mali, where the proportion of pregnant women receiving the three doses of IPT increased between 2017 and 2018, i.e. 40% and 45% respectively and it decreased, from 45% in 2018 and 35% in 2021 [13,14]. Seasonal malaria chemoprevention is clearly making progress in the Sahelian region of Africa and has a significant impact on the incidence of malaria in children, and especially on the lethality rate. Several studies conducted in this region have demonstrated its efficacy [15–18]. On the other hand, poor compliance related to adverse drug reactions, particularly vomiting, abdominal pain, diarrhea, headache, fever and itching [19], may have a negative impact on the effectiveness of this control intervention [20]. In 2019, 22 million African children have treated with the SMC and 34 million in 2020 [5,9]. In Mali, 4 million children were targeted to receive SMC in 2018, and 4.2 million children were treated, representing a coverage rate of 106% [13].
Access to care is a very important factor in the management and prevention of malaria. Not only does it allow diagnosis and early treatment, but it also provides feedback on epidemiological information. However, access to healthcare remains poor in many parts of Africa, particularly in rural areas. This lack of access is mainly due to the absence of local health structures, poor access to health structures due to poor road networks (especially during the rainy season, a period of high malaria transmission, when heavy rains worsen the situation), and the cost of diagnosis and treatment. In 2019, 81% of children under 5 with fever in Africa had sought care, and of these, only 42% had received artemisinin-based combination therapy (ACT). By 2020, however, these percentages are projected to decline, with 76% of febrile children seeking care and only 29% receiving ACT [5]. In Mali, according to the Malaria Indicators Survey Report, 60% of febrile children under 5 had sought care and only 19% of these had received ACTs as antimalarial treatment [14].
The High Burden High Impact (HBHI) principle is to focus on local data and information collected in the field [5]. Mali is one of the 10 sub-Saharan African countries that meet the HBHI criteria. It is in this context that we have initiated this work at the level of community health areas, with the aim of assessing the impact of the control measures implemented on the population.