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Malaria Control activities are on ground since the formulation of Health Services provision fundamentals outlined in Bohr’s commission in the Sub-continent; and in Pakistan these are functional since 1950s through succession of different approaches. The most ambitious program was the Malaria Education Campaign, spearheaded by USAID since 1961. Then the global approaches was changed due to health priorities and draw backs encountered with wide spread drug and insecticide resistance. Then as a strategy WHO initiated global malaria control program aiming to reducing the malaria burden to manageable levels. Pakistan program was also directed toward control approaches through the decentralization process and other funding difficulties in this era and did not allows successful transformation of the operations.

Malaria personnel cadres were amalgamated and Malaria Control program was made a Provincial transferred subject, leveling an apical set up at the Federal level, for the purpose of policy formulation and maintaining coordination. Further the implementation responsibilities were transferred to respective district government in line with the devolution plans. In 1977 Malaria control activities were integrated with the Communicable Disease Control.

Owing the two major failures in the endemic countries control programs, in 1998, Roll Back Malaria (RBM) initiative was coordinated and started by WHO, UNICEF, UNDP and the World Bank. Pakistan being the signatory to the effect, started RBM implementation in the phased manner by earmarking 273 million from PSDP allocations for 5 years since FY 2001-02, supplemented by the provincial PC-1 allocations while 658 million have been approved for the next 5 years 2007-2012 to support provincial programs.

Under 18th amendment in the constitution Federal Ministry of Health along with its attached departments including Directorate of malaria Control were devolved on 30th June 2011.

Keeping in view the important role played by the Directorate of malaria Control, the honorable Prime Minister of Pakistan approved the revival of this Directorate with effect from 1st July 2011 and placed under the administrative control of Ministry of IPC with following functions and TORs:

To act as Principal Recipient for all Global fund supported Health initiatives.

• Preparation of proposals and liaising with international agencies for securing support of such partner agencies.
  
  
• Providing technical and material resources to the provinces for successful implementation of disease control strategies and disease surveillance.
• In pursuance of Cabinet Division’s decision; The Directorate of Malaria Control transferred from Ministry of Inter Provincial Coordination to Ministry of National Health Services And Regulation Authority

Pakistan has a population of 180 million inhabitants of which 177 million are at risk of malaria. With 3.5 million presumed and confirmed malaria cases annually.

Malaria in Pakistan is typically unstable and major transmission period is post monsoon i.e. from August to November. Major vector species are Anopheles culicifacies and A. stephensi, both still susceptible to the insecticides currently being used. The widely distributed causative organisms are Plasmodium falciparum and Plasmodium vivax. Vivax malaria still dominates the transmission though significant rise in the more lethal form falciparum is observed in Balochistan and Sindh. There is significant drug resistance (chloroquine andÂÂÂ fansidar resistance) prevalent throughout the country where the levels in the western border areas are very significant.The malariogenic potential of Pakistan has a negative impact on its socio-economic growth and productivity, as the main transmission season is spiraled with the harvesting and sowing of the main crops (wheat, rice, sugar cane).

The key underlying risk factors for malaria endemicity and outbreaks in Pakistan include; unpredictable transmission patterns, low immune status of the population in lowest endemicity areas, poor socioeconomic conditions, mass population movements within the country and across international borders with Iran and Afghanistan, natural disasters including floods and heavy rain fall in a few areas, lack of access to quality assured care at the most peripheral health settings, low antenatal coverage and internally displaced population (IDPs) crisis in the agencies and districts along western border. About 700,000 people (National Disaster Management Authority) have recently been displaced from high endemic zone of North Waziristan to neighboring districts of KPK due to conflict situation.

Epidemiologically, Pakistan is classified as a moderate malaria endemic country with a National API averaging at 1.66 (MIS, 2016) and wide diversity within and between the provinces and districts. Plasmodium Vivax and Plasmodium Falciparum are the only prevalent species of parasites detected so far, with P.vivax being the major parasite species responsiblefor >80% reported confirmed cases in the country.

The following Table shows trend of the above mentioned data from (2009-2015).

Source: Malaria Information System

In 2016, 324024 confirmed malaria cases were reported through National malaria disease surveillance system. However, during the same period 3.1 million cases were clinically diagnosed and treated at public sector outpatient facilities and 34 deaths due to malaria were reported in 2016. The total 71136 confirmed malaria cases are less as compared to year 2014.The malaria indictor survey (MIS) was conducted in 2013 in 38 (GF R-10) highly endemic districts of the country showing highest prevalence rates in the region of Federally Administered Tribal Areas (FATA) (13.9%) followed by Balochistan (6.2%), and Khyber Pakhtunkhwa (KP) (3.8%).

According to the data reported from GF targeted districts in 2015 high Annual parasite incidence (8.60/1000 Population) in FATA followed by (5.52/1000 Population) in KPK, (4.47/1000 Population) in Balochistan and (2.11/1000 Population) in Sindh.

Malaria is typically unstable (seasonal) in Pakistan, with a peak starting from August to November. The PV:PF ratio from 43 highly endemic districts supported by GF is 84:16

Outside of GF malaria supported districts the number of microscopic centres for the confirmation of malaria cases is very limited. Two percent of the population and 20% of those visiting health centers will present with a fever (DHIS 2013), and most of the occasions are suspected of malaria particularly in transmission season. As per national guidelines all suspected cases have to be tested either through smear microscopy or appropriate RDT (Malaria, Antigen Pf./PAN Test Kit). The low blood examination rate (BER) of 2.83% reflects the low coverage of confirmatory diagnostic services in the country.

The National strategy for Rolling Back Malaria (RBM) is based on the following key elements:

• Early Diagnosis and prompt treatment at general health facilities and community based approaches towards home treatment.

· Multiple prevention measures including promotion of insecticide treated bed nets & materials, targeted use of residual insecticide spraying, logical and environmental vector management ÂÂ ÂÂ ÂÂ ÂÂ ÂÂ ÂÂ approaches.

• Intensive and comprehensive public education activities with appropriate IEC material to enhance pubic knowledge of malaria, treatments and prevention.
• Improved detection and response to epidemics and malaria emergency situations.
• Developing viable public and private partnerships in the country to combat malaria.

Malaria Strategic Plan, Pakistan – 2015-20

Goal:

By 2020, reduce the malaria burden by 75% in high and moderate endemic districts/agencies and eliminate malaria in low endemic districts of Pakistan, aligned with The Global Technical Strategy (GTS) and Global Malaria Plan of Action (GMAP) 2015-2020.

Objectives:

1) To achieve <5 API in high endemic areas of the province of Balochistan, Sindh, KP and FATA region by 2020.

2) To achieve <1 API within moderate endemic districts of Balochistan, Sindh, KP and Punjab by 2020.

3) To achieve Zero API within low endemic districts of Sindh, KP and Punjab by 2020.

Specific objectives:

1) To ensure and sustain the provision of quality assured early diagnosis and prompt treatment services to >80% at risk population by 2020.

2) To ensure and sustain coverage of multiple prevention interventions (IRS, LLINs & and other innovative vector control tools and technologies) to 100% in the target high risk population as per national guidelines and coverage of foci in moderate and low risk districts by 2020.

3) To increase community awareness up to 80% on the benefits of early diagnosis and prompt treatment and malaria prevention measures using health promotion, advocacy and BCC intervention by 2020.

4) To enhance technical and managerial capacity in planning, implementation, management and MEAL (Monitoring, Evaluation, Accountability and Learning) of malaria prevention and control intervention by 2016.

5) To ensure availability of quality assured strategic information (epidemiological, entomological and operational) for informed decision making and; functional, passive and active case based weekly surveillance system in all low risk districts by 2017.

6) To ensure provision of malaria prevention, treatment and control services in humanitarian crises, emergencies and cross-border situation.

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