Tanzania

The entire population of Mainland Tanzania is considered at risk for malaria, although transmission varies significantly among and within regions. 93% of the population in Mainland Tanzania live in malaria transmission areas.

The country has three malaria transmission seasons [1]:

• Stable perennial transmission: 60% of the country
• Stable malaria transmission (with seasonal variation): 20% of the country;
• Unstable seasonal malaria transmission: 20% of the country.

Tanzania is among the ten countries with the highest malaria cases and deaths, accounting for 3.1% of the global cases and deaths, and 4.1% of global deaths in 2021. It also accounted for 12.8% of malaria cases in East and Southern Africa in 2020). [2] Between 2020 and 2021, case incidence increased by 2.1%, from 123 to 126 per 1000 of the population at risk; however, deaths decreased by 1.7 (from 0.41 to 0.40 per 1000 of the population at risk) during the same period. [2]

Plasmodium falciparum is responsible for 96% of malaria infection in Tanzania, while P. malariae and P. ovale account for the remaining 4%. The principal vectors of malaria in Tanzania are mosquitoes of the Anopheles gambiae complex (An. gambiae s.s. and An. arabiensis), and An. funestus. [1]

In 2017, under-5 mortality was at 5% while neonatal mortality (under 12 months) was at 9%. Incidence of under-5 cases was at 37%.[3] In the same year, prevalence on the mainland varied by region from <1% in the highlands of Arusha to as high as 15% in the Southern Zone and 24% along the Lake and Western zones. [1]

The Global Fund and PMI provide more than 90% of malaria funding to mainland Tanzania. This does not include staff salaries, which are paid by the government.[4] Other donors to the country’s healthcare system include African Development Bank, Danish International Development Agency (DANIDA), Japan International Cooperation Agency, UNICEF, United Kingdom’s Foreign, Commonwealth & Development Office (FCDO), the World Health Organization (WHO) and research institutions. [3]

Strategy and universal health coverage 

The country has a Malaria National Strategic Plan (MNSP) for the period 2020 – 2025. [1] The focus of the MNSP is to achieve and maintain high coverage of timely parasitological diagnosis of malaria by ensuring that in both public and private points of care are available; skilled providers are in place; and high-quality testing services are available. [1] The Plan also calls for access to case management services for people with limited access and in hard-to-reach areas. [1] 

These will be complemented by behaviour change communication actions to encourage patients to seek a confirmatory diagnostic test before treatment, and healthcare providers to adhere to the test results. [1] Tanzania is also undertaking a reorganisation of the health services to achieve Universal Health Coverage (UHC). This initiative entails reimbursement through a single national health insurance scheme whereby it will be the most prominent mechanism in financing health facilities. [1] 

Case management 

The National Guidelines for Malaria Diagnosis, Treatment, and Preventive Therapies 2020 calls for parasitological confirmation by microscopy or malaria Rapid Diganostic Test (mRDT) for all patients with suspected malaria before initiation of treatment. 

In 2013, the National Malaria Control Programme (NMCP) revised the National Diagnostic and Treatment guidelines to include injectable artesunate for the treatment of severe malaria. The current guidelines call for referral of patients with severe malaria from lower-level facilities to the nearest health centre with the capability of administering intravenous artesunate after first giving the patient an intramuscular injection of artesunate. Intramuscular artemether can be used as second-line drugs if artesunate is not available.[1]  

Use of pre-referral rectal artesunate at lower-level facilities is also permitted if injection is not available, yet in practice this does not occur because rectal artesunate is not procured by either the Government of Tanzania or its partners.[1] The NMCP has revised the malaria diagnosis and treatment guidelines to include injectable artesunate as the treatment of choice for severe malaria in the first trimester as recommended per WHO guidelines.[1]  

Drug-based prevention 

The NMCP implements intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) for all pregnant women except those in very low-transmission councils.[1]  Between 2015/2016 and 2017, the proportion of women receiving at least one dose of IPTp increased from 69% to 84%, those receiving 2 or more doses (IPTp2) from 35% to 57%, and those receiving at least 3 doses (IPTp3) from 8% to 26%.[1] 

The strategic focus is to increase the number of women accessing IPTp2 to 95% through improved supply chain management of SP, IPTp administration at each scheduled ANC visit, improved capacity of healthcare providers through training and supervision, and improved frequency of ANC attendance.  In addition, new intervention packages in the NMSP include seasonal malaria chemoprevention (SMC) and intermittent preventive treatment in school children (IPTsc) and in infants (IPTi). These interventions are currently being explored for their efficacy, effectiveness, and feasibility under implementation research and have not yet been adopted by the programme. 

Insecticide-treated nets 

Large insecticide-treated mosquito net (ITN) distribution schemes targeting the biological vulnerable groups through social marketing and discount voucher schemes started in 2004, and evolved over time to mass campaigns. The current strategic approach to net distribution in the NMSP 2020–2025 is a mix of catch up (mass replacement campaigns) and keep up (through targeted distribution, schools and Reproductive and Child Health clinics) net delivery systems as well as through the commercial sector.[3] 

Ownership of ITNs has steadily increased in Tanzania, reaching a peak of 92% of households with at least one ITN in 2011–2012. Ownership then dipped to 65% in 2015–16 – although this survey was carried out before a mass distribution campaign and increased to 78% in 2017. [1] In 2017, 54% of children and 51% of pregnant women slept under bed nets, both showing decreases since 2011–12 (from 73% and 76%, respectively).[1] 

Treatment for malaria²

The target of Tanzania’s national malaria strategy is to reduce case fatality rate in patients admitted due to malaria from 3% in 2012 to less than 1% in 2020. [2] In 2013, the National Malaria Control Programme revised the National Diagnostic and Treatment guidelines to include injectable artesunate for the treatment of severe malaria. [2]

The guidelines also call for the referral of patients with severe malaria from lower-level facilities to the nearest health center. Intramuscular injection of artesunate should be administered prior to the transfer of the patient.[2] Intramuscular artemether or quinine can be used as second-line drugs when artesunate is not available. [2] Use of pre-referral artesunate rectal capsules (ARC) at peripheral health facilities is also permitted when injectable artesunate is unavailable. [2] This presently does not occur as the government of Tanzania and its partners have not yet begun procuring rectal artesunate. [2]

Commodity needs:

For 2021, there is an estimated need of: 1.7 million injectable artesunate vials. [1] A surplus of 1.9 million vials was available from 2020, and it is estimated that a surplus of 1.2 million vials will be available at the end of 2021. [1]

It is estimated that 8 million sulfadoxine–pyrimethamine (SP) treatments will be required in 2021. [1] The Government of Tanzania has committed to procuring SP as part of its investments in maternal and child health.