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In Tanzania malaria is a major public health problem. Malaria is endemic in almost all parts of the country (Figure 5). It accounts for over 30% of the disease burden and is a threat to every one of the estimated 32 million people (94% of the population) living in areas where transmission is possible The disease is estimated to cause between 100,000 and 125,000 deaths a year and is the leading cause of outpatient attendance for children under the age of five (38%) and for all other patients (32%) [18]. An estimated D 65 million is spent on the prevention and treatment of malaria in Tanzania each year, which amounts to 39% of all health expenditures and just under 1.1% of GDP [19].

Malarial control strategy

The current malarial control strategy is outlined in the National Malaria Control Programme’s (NMCP) Medium Term Strategic Plan (MTSP) (2002-2007) and is based on strategies and targets from the 2000-2001 Roll Back Malaria Action Plan [18]. The strategy mainly promotes the use of ITNs coverage of prompt and effective treatment for malaria and the use of IPT of malaria among pregnant women. However it also includes other vector control measures such as IRS and epidemic prevention and control.

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Figure 5. The spatial distribution of malaria endemicity in Tanzania (source: MAP [20])

Vector control with ITNs- Tanzania’s current vector control strategy has mainly relied on intensive promotion of ITN use through a public private partnership approach. The National Insecticide Treated Nets programme (NATNETS) has four key components: 1) the ITN Cell in the NMCP coordinates and facilitates all ITN activities in the mainland of Tanzania; 2) the SMARTNET social marketing project creates demand, promotes behaviour change, supplies free-of-charge insecticide kits to the Tanzanian net manufacturers for bundling with all nets distributed on the Mainland and distributes subsidized insecticide re-treatment kits to the commercial sector; 3) the Tanzania National Voucher Scheme (TNVS) distributes discount vouchers to pregnant women and infants through clinics and dispensaries, allowing them to purchase ITNs from private retailers at approximately 75% discount [21-22] and 4) a mass “catch-up” distribution campaign to provide free LLINs to all children under five years since coverage of risk groups increased too slowly under the voucher scheme [23]. A national net re-treatment campaign is being carried out at the same time as the catch-up campaign.

Malaria case management - Until 2001 chloroquine was the main antimalarial used, but due to high levels of chloroquine resistance it was officially withdrawn and replaced by

sulphadoxine-pyrimethamine (SP). Amodiaquine was the second line treatment and quinine third line and first choice in severe malaria. In 2006, SP was in turn abandoned in favour of Artemether-Lumefantrine (ALu, trade name Coartem®, Novartis AG). Quinine remained the

drug of choice for severe malaria. Through funding from the GFTAM the drug is provided free to all government health care facilities in Tanzania where it should be made available free to children under the age of five in accordance with the exemption policy and at asubsidised price of TSH 300 (USD 0.25) to all other patients. Subsidised ALu is also available in the private retail sector in Accredited Drug Dispensing Outlets (ADDOs). In all other private drug retail outlets it is currently unaffordable for most of the population at its current maker price of USD 8-10 for an adult dose.

Intermittent Preventive Treatment (IPT) - IPT with SP is recommended for pregnant women during antenatal visits as a prophylactic measure during pregnancy. The two doses should be given as directly observed therapy at 20-24 weeks and 28-32 weeks gestational age.

IRS - Although Tanzania was one of the pioneers in launching indoor residual spraying in the 1960s and 1970s, it has never been used systematically enough to have a significant impact. At present, the country plans to re-introduce IRS as a complement to the ITN programme to prevent and control malaria epidemics in 25 epidemic prone districts [24].

Epidemic prevention and control - The Malaria Epidemic Early Detection System (MEEDS) is based on plotting weekly and monthly malaria cases into a monitoring chart designed with a threshold representing alert and action lines derived from retrospective data for each health facility. Through this system, epidemic prone districts are required to note and report any substantial increase in the number of malaria cases and deaths.

Coverage achieved to date

A nationally representative survey has been conducted to provide information on the status and progress of the MSTP in 2007-08 [25] and results can be compared with a similar survey conducted in 2004-05 [26]. Results show improvements, but targets set for 2007 have not been reached. More than half of the children reported to have fever were given an

antimalarial drug to treat the fever but only 34% were treated on the same day or the next, which is far below the 60% target for 2007. Household ownership of nets (both treated and untreated) increased in the country after the implementation of the ITN programme from 46% in 2004-05 to 56% in 2007-08 but ownership of ITNs is much lower (23% in 2004-05 and 39% in 2007-08). This resulted in 34-36% of children and pregnant women sleeping under a mosquito net and 26-27% under an ITN the night prior to the survey. This means that the 60% target set for 2007 was not reached. In 2007-08 57% of women with a live birth in the two years prior to the survey reported taking IPTp but only 30% took the two recommended doses. The 60% target set for 2007 was therefore not reached for IPTp either.

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Coverage with IRS and MEEDS has not been implemented on a national scale. Since 2007, IRS operations in Mainland Tanzania have been limited to two districts (Muleba and

Karagwe) in Kagera Region, where repeated spraying has been carried out in more than 10% of households. Plans are underway to scale up IRS coverage to about half the districts in Mainland Tanzania by the end of 2013. MEEDS mechanisms have been established in 19 districts of the county (less than 15%) [27].