25 April 2017, Rwanda joined the world to commemorate World Malaria Day. It is now time to highlight the need to sustain country efforts and commitment to control and eliminate this life- threatening disease. This year the world malaria day theme is:” Closing the preventive gap for Malaria.” It is thus very imperative to reflect on the achievements made so far, the challenges encountered and the way forward to end Malaria by 2030 in African Region and Rwanda in particular as recommended by the Sustainable Development Goals (SDGs).

Malaria is a serious, sometimes fatal, disease spread by mosquitoes and caused by a parasite.

In Rwanda, there are three species of anopheles mosquitoes:   “Anopheles arabiensis, Anopheles gambiae and Anopheles funestus” which are the malaria vectors. Three parasites species namely “Plasmodium falciparum, Plasmodium ovale and Plasmodium malariae” have been detected in Rwanda to date. Plasmodium falciparum is the most common parasite contributing at 97 to99% of the parasite population.

WHO has estimated that 212 million new cases of malaria and 429,000 deaths occurred in 2015. Approximately 90% of malaria cases and 92% of deaths occurred in the WHO African Region. While malaria can be eliminated, the fight against malaria remains a tough battle on the global arena especially in Sub Saharan Africa. In fact, Africa still has critical gaps in access to proven, life-saving malaria prevention and control tools.  70% of all malaria deaths occurred among children under the age of five. Although we know that Long -Lasting Insecticidal Nets (LLIN) are the pillar of malaria prevention tool, the use of mosquito nets has increased substantially but the coverage gap remains huge in Africa.  In 2015, an estimated 47% of the population at risk of malaria did not sleep under a treated net. Indoor Residual Spraying (IRS) is another powerful tool   to protect population against mosquito’s transmission but it is very expensive and very difficult to cover the entire country with this intervention. In addition,   progress in the malaria fight is threated by the emergence and spread of mosquito resistance to insecticides.

Since 2000, the world has made progress in the fight against malaria and increase of prevention and control measures have led respectively to a 29% reduction in malaria mortality rates and 21% malaria incidence globally since 2010. Rapid diagnostic tests and effective treatment for malaria are available.  In addition, The Global Technical Strategy for Malaria 2016–2030 was adopted by the World Health Assembly in May 2015 to guide countries to accelerate progress towards of reducing global malaria incidence and mortality rates by at least 90% by 2030.

Rwanda has achieved significant progress in reduction of the burden of malaria over the past decade. In 2005, malaria was the leading cause of death among children under age five. In 2012, malaria ranking has dropped to number four. However, the malaria incidence rate increased every year from 112 per 1,000 in 2013-2014 to 308 per 1,000 in 2015-2016.The increase in malaria cases was observed in all provinces with the largest records in the Eastern and Southern provinces. All 30 districts in Rwanda are at risk of malaria.

Health data from 2015 show that malaria became the second cause of morbidity in Rwanda representing 7.4% of outpatient consultations and the sixth cause of mortality representing 4.3% malaria proportional mortality. This shows that Malaria gains in Rwanda are fragile and efficient interventions need to be scaled and gains be consolidated.

The factors that are contributing to malaria increase in Rwanda include: Non-universal coverage of effective interventions (LLINs, IRS), the resistance to pyrethroid insecticide, the climate change with increase of the temperature and environmental modification and increase of water bodies and internal and  external movement of population.

In January 2016, the Government of Rwanda and partners have developed a Malaria Contingency Plan in response to the increase in malaria cases. The following interventions were implemented to address malaria rise in Rwanda: 

A Home Based Management of fever for adults at community level was set up countywide to reduce the malaria burden and prevent severe malaria and death. 

In 2016-2017, the country distributed more than 6 million nets in 30 districts ensuring universal coverage of the entire population.

The country has increased access to health services for all through Community Based Health Insurance (CBHI).  The Government of Rwanda (GOR) provides free treatment of malaria to the most vulnerable population (Ubudehe 1&2 categories) to ensure that all financial barriers are no more to hinder the health service delivery for the community.

Extension of Indoor residual spraying (IRS) in Districts with high malaria burden where 5 out of 8 were sprayed (Nyagatare, Kirehe, Bugesera, Gisagara and Gatsibo);

The Ministry of Health through Rwanda Biomedical Center is reinforcing  communication strategies and more emphasis is put on environmental hygiene and sanitation, appropriate use of treated bed nets and seeking early treatment.

As a global consensus to reduce malaria incidence and mortality rates by at least 90% by 2030 and attaining the SDGs targets, the country will need to:

1) Conduct further investigation on causes of the increase of malaria in the country to understand the recent pattern of malaria in Rwanda in order to address them accordingly.

2) Conduct strong advocacy to mobilize increase in domestic and external funding for malaria control to ensure that all malaria interventions are covered.

3) Advocacy for cross-border malaria collaboration initiatives with neighbouring countries to reduce the transmission of malaria and control.

4) Develop a long-term LLIN procurement, distribution and monitoring plan to ensure continuous supply and replacement of LLINs.

5) Strengthen the Home Based Malaria for adults and motivate the Community Health Workers in controlling malaria at Umudugudu level.

6) Develop a comprehensive research agenda to ensure better planning and decision -making   at all levels.

7) Strengthen the use of malaria data for timely decision-making and use .

Malaria is preventable and treatable. Rwanda-free of Malaria is possible.  WHO is committed to support the country to implement cost – effective and evidence-based strategies and put an efficient system to track the progress to eliminate malaria.  Definitely, let us unite, work together, mobilize adequate resources to end the disease and have Malaria –free Africa.

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For more information, please contact:

Dr Michel GASANA, NPO/MAL  e-mail: gasanam [at] who.int (gasanam[at]who[dot]int)   

Mr. Jean Bosco GASHEREBUKA, HPR, e-mail: gasherebukab [at] who.int (gasherebukab[at]who[dot]int)
Below:

01. Awareness  song on malaria prevention

02. Interview with Head of Malaria and  other parasitic diseases Division, Rwanda Biomedical Center