Angola

According to 2021 data from the Department of Epidemiological Surveillance and Hygiene of the Ministry of Health (MOH), malaria was the leading cause of low birth weight and anemia and was the main cause of 42 percent of reported deaths. What is more, in 2021, 33 percent of all patients seeking health care were diagnosed with malaria. 5.6% of all malaria cases were also reported to be severe malaria (people hospitalized for malaria). [2]

The malaria prevalence rate among children less than five years of age has stagnated at about 14 percent from 2011 (Angola 2011 Malaria Indicator Survey [MIS]) to 2015– 2016 (Angola 2015–16 Demographic Health Survey [DHS]).

Malaria is transmitted throughout Angola. 100 percent of the population at risk of the disease. Malaria remains a primary health burden in the country and is the main cause of ill health and death. The central and coastal provinces (Benguela, Bie, Cuanza Sul, Huambo, Luanda, Moxico, and Zaire) are mesoendemic with stable transmission. The four southern provinces bordering Namibia have highly seasonal transmission and are prone to epidemics. [2]

Between 2020 and 2021, malaria case incidence remained stable at between 252 and 254 cases per 1000 of the at-risk population. Deaths rose by 16% from 0.44 per 1000 of the population at risk to 0.52 per 1000 of the population at risk. [1]

According to data from the National Malaria Control Programme (NMCP), 8% of all reported yearly malaria cases in 2017 were severe malaria. [2]

Malaria diagnosis and treatment 

In accordance with WHO guidelines, Angola’s National Malaria Strategic Plan (NMSP) recommends that all suspected cases of malaria be diagnosed using either microscopy or randomized control trials. Only confirmed, uncomplicated, malaria cases should be treated with an artemisinin-based combination therapy (ACT).  

Malaria diagnosis and treatment 

The country has three alternative first-line ACT treatments: artesunate/amodiaquine (AS/AQ), artemether-lumefantrine (AL), and dihydroartemisinin/piperaquine (DP).

Malaria case management is provided at both the health facility and community level. Angola’s national policy calls for the provision of intermittent preventive treatment for pregnant women (IPTp) with sulfadoxine-pyrimethamine (SP) at all health facilities with antenatal care (ANC) services, in addition to distributing insecticide treated nets to pregnant women to help prevent malaria in pregnancy. The goal is that by the end of 2025, at least 50 percent of pregnant women who can access ANC and are targeted for IPTp receive at least four doses of SP from the third month of pregnancy. The first-line treatment for severe malaria in pregnancy is injectable artesunate (IV or IM). 

The current 2021– 2025 NMSP intends to pilot the introduction of rectal artesunate which will be given before transferring children under five years of age with severe malaria at the community level by ADECOS to higher health care facilities to receive IV artesunate in 2022.  

Funding remains the single most important constraint facing the health sector in Angola. Although the government budget allocation to the health sector has increased over the years, the budget growth is not at the same pace as the population growth and does not match the 15 percent commitment made by African Union Heads of State in Abuja. Antimalarials of all kinds — including monotherapies and medicines for severe malaria — are available in private facilities.  

Digital health 

The wide-spread adoption of DHIS2 has significantly improved malaria surveillance reporting. The general objectives of the NMCP are to reduce malaria-related illness and death by 40 and 50 percent respectively by 2025, from 2020 baseline figures. 

Severe malaria case management 

The National Malaria Control Program recommends that severe malaria is treated with intravenous or intramuscular artesunate in facilities able to administer intravenous medications and when not available, intramuscular artemether. In lower-level facilities, intramuscular artemether is recommended. Although quinine is the third-line option for treatment of severe malaria, it is the most commonly used treatment due to the unavailability of intravenous or intramuscular artesunate or intramuscular artemether as well as push and flooding of the market by local manufacturers of quinine. [3] 

For pre-referral management of severe cases at health posts and health centres, the guidelines recommend intramuscular artesunate. For children under six years of age when intramuscular injection of artesunate is not available, a single dose of rectal artesunate and referral to an appropriate facility for further care is recommended. In the National (Malaria) Strategic Plan (NSP) 2021–2025, use of rectal artesunate as pre-referral management at the community level has been introduced as a new recommendation. 

A 2020 rapid assessment [6] revealed a number of deviating practices such as: 

• The widespread use of artemether for severe malaria; 
• The interchangeable use of drugs for severe malaria during a course of a treatment (examples of treatment plans changing from artemether to artesunate). 

The use of artemether for a prolonged period of time even when the clinical process clearly states the patient is already eating normally (clinical guidelines state these should pass to oral artemisinin-based combination therapy (ACT) as soon as possible. Another reason that may justify the incomplete adherence to artesunate is the required calculations for artesunate dilution. Another potential reason for not having injectable artesunate widely disseminated may be related to healthcare workers’ perceived lack of authorization to administer it. 

Integrated Community Case Management (iCCM)

World Vision, a principal recipient under the Global Fund 2016-2018 grant, is implementing the integrated community case management (iCCM) strategy in 18 municipalities within six provinces. The USAID President’s Malaria Initiative (PMI) also commenced the implementation of iCCM in an additional 4 municipalities of 2 provinces at the end of 2017.[2] 

Cross-border initiatives 

An elevated burden of severe malaria has been experienced in the areas along Angola’s borders with the Democratic Republic of Congo and Zambia. To address this issue, two cross-border initiatives were introduced with government funding from Angola and Namibia: the Trans-Kunene Malaria Initiative in 2011 and the Trans-Zambezi Malaria Initiative in 2013.[3,4]