The disease is easy enough to treat, but access to the most effective treatments remains inadequate. Africa bears the greatest burden: 95 percent of malaria deaths occur on the continent, and 78 percent of these deaths are children under five years old. This suffering and loss of life is all the more tragic because malaria is preventable and treatable. Doctors Without Borders (MSF) treated more than 3.7 million cases of malaria in 2023, in some of the most at-risk, hard-to-reach parts of the world. Democratic Republic of Congo (DRC), Nigeria, Niger, Burkina Faso, and Central African Republic (CAR) saw the highest number of malaria cases.
Together with the regional health authorities, MSF has been working since 2019 on a strategy to reduce and control malaria based on three pillars: early diagnosis and treatment, health promotion and vector control. The vector control team studies the behaviour of malaria-transmitting mosquitoes to develop the best strategies to prevent transmission of the disease.
Malaria is a parasitic infection spread by the bite of infected female Anopheles mosquitoes. Once the parasite is inside the human body, it makes its way to the red blood cells, where parasites multiply rapidly until they burst out of the red blood cells and into the bloodstream.
Infants and children under five years old are especially vulnerable to infection and serious consequences of malaria since they haven't yet developed immunity. People displaced by conflict or natural disaster are also at an increased risk of malaria, often due to living conditions that fuel transmission: inadequate shelter in overcrowded camps near standing water and livestock. Displaced people coming from places where malaria is not common to areas where malaria is common are particularly vulnerable because they lack the partial immunity developed by continuous exposure since childhood; when infected, they tend to get very sick.
Pregnant women with malaria are at increased risk of anaemia, severe sickness, and death; there is also a higher chance that the pregnancy will develop complications or end in miscarriage, or cause foetal growth restriction.
Malaria often begins as a flu-like illness. Fever typically appears 9-14 days after infection (typical cycles of fever, shaking chills, and drenching sweats may develop) and may be accompanied by multiple non-specific symptoms, which makes clinical diagnosis difficult. The disease also causes the destruction of red blood cells, leading to anaemia.
If simple malaria is not treated, it can become severe, increasing the risk of death. That’s why early diagnosis and quick treatment are vital. Severe malaria parasites that attack the brain can cause seizures and coma, and other severe cases can lead to breathing problems, kidney failure, and/or severe anaemia. Each year about eight million malaria patients develop life-threatening complications.
Malaria-carrying mosquitoes usually bite from dusk to dawn. Since mosquitoes breed in water, they are especially plentiful during the rainy season, causing malaria infections to increase.
The most basic prevention measure is to avoid bites. This can be done through indoor spraying of homes with safe, long-lasting insecticides and/or by sleeping under mosquito nets treated with long-lasting insecticide. More recently, antimalarial drugs have been used to prevent infection among the most at-risk populations for limited periods of time.
Seasonal malaria chemoprevention (SMC) is now recommended for children during the highest-transmission months in some regions. Preventive drug treatment is also recommended for pregnant women at routine prenatal care visits after the first trimester of pregnancy, for infants during routine vaccination visits, and at the time of discharge for some hospitalised children.
Diagnosing malaria is usually done with rapid diagnostic tests using blood from a finger prick. The tests are easy to perform, and community health workers can be trained to do them. A more accurate test is done by using a microscope to look directly for malaria parasites in a drop of blood. But most primary health facilities don't have microscopes or trained lab technicians, and microscopy is much more labour-intensive, so this diagnostic test is often not feasible.
In some settings, no testing is available at all, so community health workers must diagnose sick children based on symptoms alone. This often leads to the overdiagnosis of malaria while the real cause of patients’ symptoms goes untreated.
The most effective treatment for malaria is a combination of two drugs known as artemisinin-based combination therapy (ACT), which cures most infections in three days.
Our programmes incorporate various prevention approaches, depending on context—from distribution of mosquito nets to spraying larvicide to prevent the breeding of mosquitoes. In some affected regions malaria is highly seasonal, with the number of infections increasing exponentially during the few months of the rainy season.
In Africa’s Sahel region, malaria is highly seasonal and most cases happen during a 4-5 month period. In 2012, MSF piloted a seasonal malaria chemoprevention (SMC) in Mali, Niger and Chad, now used in several countries. SMC involves providing antimalarial drugs to prevent infection among those most at-risk – children under five. Malaria can also be prevented by avoiding being bitten by the mosquitoes that carry the parasite, through the use of insecticide-treated mosquito nets, unavailable for many.
Malaria spikes are too often treated as an unpredicted emergency despite the fact that we now have tools – from weather monitoring to close surveillance of new cases – to anticipate the onset of malaria peaks. Countries need to use these tools better to prepare for seasonal outbreaks by pre-positioning preventive antimalarials and mosquito nets that can be distributed once the rainy season begins and by investing more in community-based care.
One of the biggest challenges MSF faces is getting malaria care to those who need it the most: people living in remote, insecure areas with little or no health care access. Whether because of seasonal rains that flood roads or active armed conflict that forces people to leave their homes, finding better ways to effectively reach and treat our patients where they are is a challenge MSF is always trying to overcome.
One strategy is to use mobile clinics that travel to remote villages without health clinics nearby. For example, in the Central African Republic, many regions are isolated because of armed conflict, which has disrupted the already weak government health services. There is no public transportation for people to travel to larger towns. MSF mobile clinics drive two to three hours to visit remote villages to test for and treat malaria, transferring those already severely sick to hospitals.
Another strategy is to train and equip community health workers with supplies for providing care in areas MSF teams can’t reach consistently. In South Sudan, MSF has de-centralised simple malaria care by training community health workers who can test for and treat malaria in clinic teams. When people are forced to leave their homes because of fighting nearby, these health worker teams move with them since they are part of the community, and continue providing health care. The teams run clinics wherever they are six days a week, caring for thousands of people displaced by the conflict while on the move. MSF re-supplies them with tests and drugs when security allows.
Community health workers in all projects also pass on vital educational messages about the importance of using mosquito nets wherever possible and seeking treatment for children when they have fever.
The WHO recommendation of ACT, which contains the drug artemisinin, in 2001 was a major breakthrough, replacing old, ineffective treatments such as chloroquine, or quinine. But the malaria parasite has developed resistance to artemisinin in parts of Southeast Asia, meaning that ACT may no longer be effective. If the spread of resistance cannot be stopped, it represents a major risk to public health, and would most likely lead to a resurgence of malaria, since there aren’t currently any new drugs available.
Our projects are actively researching the emergence of artemisinin-resistant malaria and piloting strategies to combat it. We’re also working to find and treat patients with artemisinin-resistant (ACT) strains of malaria, and along the way adapting strategies and tools to better meet the challenges of resistance and malaria elimination.
Our financial independence enables us to freely evaluate medical needs, reach communities in need without restriction, and directly provide high-quality medical care.
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