The objective of our study was to synthetize policies implemented against malaria (with best results) in these two African countries (Burkina Faso and Senegal) which are at different stages of intervention). To achieve our purpose, we used DHS survey data and information from a literature synthesis.
National representative surveys which include data on diagnostic malaria tests showed that the prevalence of malaria differs greatly from one African country to another, which prevents the implementation of the same kind of health policies against malaria in these countries. Significant differences in the prevalence of malaria are found even between neighbouring countries. In the last 10 last years, national malaria prevalence in Burkina Faso has significantly decreased and malaria prevalence in Senegal has remained very low (around 1%) for several years.
Like almost all African countries, Senegal and Burkina Faso have national malaria programs supported by international and other external funds [32-35]. Most of the funding for the fight against malaria in both countries comes from international partners such as the US National Institute of Health, the UK Department for International Development, the European Commission, the Wellcomtrust and the Bill and Melinda Gates Foundation.
The big question is whether those external funds are adequately distributed according to the needs of the national malaria programs in Burkina Faso and Senegal [33, 35]. Head, who investigated malaria research funds in African countries from 1997 to 2015, found that Burkina Faso is in the group of the highest funded African countries concerning research on malaria (more than $ 30 million) and Senegal is in the second highest funded group of countries ($ 5-30 million) .
It is crucial that the use of funds responds to the real needs of a country. A study by Barrenho demonstrated the importance of effective coordination among different donors of malaria funds if a good level of performance in relevant policies is to be achieved .
Entomological research is an important part of research for implementing regional policies against malaria. In Senegal entomological monitoring is conducted several times a year in each district  and in Burkina Faso it is conducted once a year in some districts. This does not necessarily indicate that one country’s entomological monitoring is more effective than the others. It can be a difference in strategy based on the country context and stage of intervention in the fight against malaria. Burkina Faso may have a few highly relevant sentinel sites, a system which can be as effective as covering each district. As malaria has almost been eliminated in Senegal, a lot of active surveillance and control, including vector surveillance, is necessary. It is important for Senegal to have an entomological surveillance site in each district, but it is not necessary for Burkina Faso if fewer sentinel sites can adequately cover the whole country. Studies have found that several changes occur in mosquito behavior, mosquito abundance, composition, and dominant vectors, sometimes due to policies implemented in the fight against malaria such as the use of ITNs, the use of insecticide, or chemoprevention. Entomological monitoring is an important element in the initial stages of the implementation of a malaria intervention policy and for surveillance .
Both countries have applied a policy of free distribution of ITNs (1.8 ITNs per person every 3 years) throughout the population. Senegal does more with the additional free distribution of ITNs every year in targeted districts and to targeted populations, such as children under five.
Senegal and Burkina Faso have the same proportion (51%) of households in which all children under 5 sleep under an ITN. In Senegal there is a significant difference between the mean number of ITNs used in households in rural and urban areas, but in Burkina Faso, there is no significant difference. A study by Thwing explained that the difference between ITN numbers in urban and rural households in Senegal was due to the fact that Senegal also applied free ITN distribution to children under five. As rural households had more children under five than urban households, it was logical that there were more ITNs in rural areas than in urban areas in Senegal . Several studies have demonstrated that the use of ITNs can greatly reduce malaria risk by reducing the rate of mosquito bites and density of mosquitoes . Wealth level is an important factor in ITN possession in African countries . We found that poor households had the highest mean number of ITN use in both Senegal and Burkina Faso. Studies have demonstrated that the poorest houses are potentially at higher malaria risk than the richest houses .
The possession of ITNs does not necessarily equate to the use of ITNs. The use of ITNs in a population is strongly associated with the education of the population on the prevention of malaria. Senegal and Burkina Faso have implemented communication policies appropriate for the local context and level of education. We found that in Senegal and in Burkina Faso, there is no significant difference in the use of ITNs in relation to the highest education level in the household.
Resistance tests for insecticide are performed in Senegal and Burkina Faso. A policy of indoor residual spraying has not been applied in Burkina Faso, whereas Senegal has implemented indoor residual spraying in districts where the incidence of malaria is higher than 50 per 1,000 persons. Studies have demonstrated the effectiveness of indoor spraying in the fight against malaria. A study by Pluess using randomized comparison found that indoor residual spraying significantly reduces the prevalence of malaria in unstable settings [40-41]. As Senegal is close to malaria elimination, there has been a reduction of immunity in the population. The risk of a rapid resurgence is therefore highly possible if all areas are not under control. A policy of indoor spraying is an effective tool for rapidly decreasing mosquito vector capacity in targeted areas. It must be noted that the use of ITNs in both countries has also contributed to a decrease in vector capacity.
Insecticide resistance research is being conducted in the two countries to determine which insecticide can be used against local malaria vectors. The study of insecticide resistance in the fight against malaria is very important and can influence malaria control in several ways. Resistance to insecticide may produce a gap between the entomological studies and the efficacy of epidemiological studies .
First line treatment is the same in the two countries, but we found a great difference between Senegal and Burkina Faso concerning the diagnosis of cases. As malaria has almost been eliminated in Senegal, more targeted case management in high transmission areas is necessary. Home-based diagnosis is performed and malaria treatment is given to positive cases by health workers with the objective of rapidly decreasing malaria transmission. Senegal introduced home-based management of malaria cases in 2008 with rapid diagnostic tests and artemisinin-based combination therapy as treatment for positive cases .
A study by Landier demonstrated the importance of early diagnosis and treatment in the reduction of malaria transmission. In the case of P. falciparum malaria cases, treatment within 48 hours from the onset of fever is a preventative action against malaria transmission. Without early diagnosis and treatment or with incomplete treatment of victims following bites from infected mosquitoes, gametocyte remains in those individuals for several days after clearance of asexual parasites. They remain infected and can transmit malaria .
Health system organization
Senegal’s national malaria program is decentralized, but the opposite is the case in Burkina Faso. Decentralization allows Senegal to implement a more effective malaria program according to the context of each district, considering, for example, dominant vector species, quantity of rainfall and temperature, and the education level of the population. As a country close to eliminating malaria, Senegal must closely monitor all districts to avoid a resurgence of the disease and maintain very low transmission. A study published in 2016 demonstrated the benefits of local contextualization of policies implemented in the fight against malaria .
Local context is more widely used in communication policies for the national malaria program of Senegal and Burkina Faso. The most appropriate methods of communication for reaching a targeted population must be tailored for different regions. The culture of each region or its socio-economic conditions must be considered if best results are to be achieved from malaria programs . In Senegal, research policies on the feasibility of interventions and their acceptability are integrated into the national malaria program [28-31]. Several studies converge, finding that it is better to work within a local than a national context to eliminate this significant public health problem in Africa.
In Senegal, a demographic and health survey with epidemiological centers for surveillance in each district is organized every year. In Burkina Faso, routine data are collected from all districts and data from surveys (questionnaires) by mobile phone. We can observe that malaria surveillance implemented in Burkina Faso is more passive than active, while in Senegal (a country close to malaria elimination), malaria surveillance is more active than passive. Active surveillance contributes to the reduction of malaria transmission and will facilitate malaria elimination. Testing and treating during active surveillance enable the identification of people who do not go to hospitals and facilitates the early detection of malaria cases, which reduces malaria transmission. A study by Singh found that active surveillance is an effective element in policies implemented for malaria elimination .