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The Actual Situation of Malaria... yet another debate

December 11, 2011 - 10:00 -- Eric Ndofor

National and Regional statistics on malaria cases and deaths and related issues such as distribution of treated nets does not reflect the actual situation on the ground. For example, with improvement in surveillance systems following institutional strengthening, some countries recently reported a significant "increase" in Malaria cases and deaths after years of reporting decrease.We are talking about the quality of data collection, analysis, synthesis and dissemination.

Data discrepancies (missing, omitted or incomplete data) are frequently observed at all levels- health facilities and systems, national malaria control programs, multinationals, etc. This makes malaria situation and trends analysis challenging and somewhat questionnable. Consequently policies, strategies and plans of action might not adequately target the problem. Now we are talking about waste of scarce resources... its like a peace treaty is being signed but with fighting still on like there was no treaty.

Points to Ponder

- The quality and reliability of clinical data: can we actually depend solely on clinical data for trends and situation analysis? are such data accurate and consistent?

- The collection, recording and reporting of malaria cases: is this practically standardized and consistent? what about feedback and follow-up of discrepancies and other concerns? 

- The strength of malaria surveillance and (health) information systems

These are some basic issues that need to be addressed in order to maximize scarce resources and quickly reduce malaria to an acceptable level where elimination can practically follow.


William Jobin's picture
Submitted by William Jobin on

Yes Eric,

You are right again. Most governments in Africa report malaria through their national health information system, based on clinical reports from the field. These are invariably based on a few common symptoms - high fever, headache and general malaise. Obviously several diseases can cause these symptons.

In Luanda, Angola, a CDC evaluation of these kinds of clinical diagnoses showed a false positivity of 80%, thus the data are useles. In Sudan the false positivity was closer to 90%.

Not only does this cause a tremendous waste of scarce and expensive drugs, but these data are then passed up the line to WHO Geneva and used to make global plans for the fight against malaria. In engineering school we call this GIGO. Garbage in, garbage out.

Until WHO sets up a global monitoring system for malaria that give reliable data, we are operating in the dark. Unfortunately anopheline mosquitoes flourish in the dark.


William Jobin Director of Blue Nile Associates

Submitted by Guest (not verified) on

Malaria story is shocking in many countries. No doubt WHO/GF and other partners have done a commendable job, but in some countries GIGO is well accepted, nationally and internationally. Take the example of India. NVBDCP reports 1.5 million cases. Some studies involving the reputed institutions bring out real stories. Estimated deaths due to malaria 200,000 in a year (Dhingra et al. Lancet 2010,376:1768-1774). In Madhya Pradesh state alone Diamond-Smith et al. (Malaria J. 2009,8,24,8-24) estimated 220, 000 malaria cases in pregnancy with 76,000 abortions, 19,800 still births and 1,000 maternal deaths. GF and WHO can not do much unless the endemic countries are with them with their heart and soul together in fighting malaria. Grant receiving countries must sign MOU to set up a system of fully reliable and internationally acceptable monitoring and evaluation mechanism. As long as "business as usual" attitude prevails, the situation is unlikely to improve. Malaria control must have both political and bureaucratic will to win the war against malaria. Think it over. Bill you may recall our meeting in India about 3 decade ago? Greetings and best wishes,

V.P. Sharma
ICMR Chair in Public Health Research
New Delhi-110016, India

William Jobin's picture
Submitted by William Jobin on

Yes Dr. Sharma,

How could I forget? Thank you for staying in touch, and for your very accurate assessment of the nature of WHO data reported on malaria. You have much more accurate information in India than WHO has for Africa. WHO needs to make significant improvements in dealing with malaria assessment and malaria control in Africa.

I am preparing a response to their Malaria Report for 2011 but already have realized two important points:

The WHO system of reporting malaria cases or malaria deaths from Africa is pointless, as the real diagnoses are cases and deaths from fevers, based on crude clinical symptoms.

PMI and WHO are trying to use Total Deaths from all causes, but the crucial proportion of malaria in those deaths is only a guess. PMI is unfortunately pretending that they can diagnose malaria retro-actively with household questionnaires. That makes the diagnoses even less reliable.

The malaria data reported through national health systems in Africa should not go above the provincial level, because of its many problems. At the provincial level the malaria people can at least see that many of their ph units are not reporting, and that they need to increase the coverage of these units, which often serve only 10-20% of the population.


And they should be aware of the paradoxes in a system with low coverage. As they add ph units to their system and thus get better coverage, it will show an increase in malaria cases in their country.

The second paradox is that of improved diagnoses. As they switch from clinical diagnoses to laboratory confirmed diagnoses in areas with 80% false positives due to clinical diagnoses, they will get a decrease in malaria cases, making it appear that they are controlling transmission, even if they do nothing to control the malaria! In fact they will simply be getting more accurate data.


For global assessments, I think WHO should organize periodic sampling at a national level, perhaps once every 3 years or every 5 years. That way they might get some useful data.

WHO sets goals, asks for funding, and then reports on progress in a more accurate system, if we are to to follow the Management by Objectives which they allude to.

Nice to hear from you again, Sir, It was a real pleasure to learn of all your ecological control methods against malaria during our visit.


William Jobin Director of Blue Nile Associates