Funded investments contributed to the reduction of malaria morbidity and mortality in children under five: fifteen years retrospective study from 2009 to 2023 in Burkina Faso

Abstract

Background

Many countries worldwide, particularly those in sub-Saharan Africa, suffer from malaria burden, both mortality and morbidity. Multiple funding agencies are investing to improve the health of populations. The aim of this study was to assess the impact of malaria funding on mortality and morbidity in children under 5 years of age over a 15-year period.

Methods

A retrospective study was conducted from 2009 to 2023 across the country. Analysis was based on a secondary analysis of routine data from health facilities via DHIS2. Financial data was assembled from the malaria programme and health accounts.

Results

Between 2009 and 2023, Burkina Faso’s population grew by 50.7%, from 15.2 to 22.9 million. Children under 5 represented 19.1% of the population in 2009 and 17.9% in 2023 and increased in number by 41.4%. In fifteen years, Burkina Faso invested USD13,545 million in the health sector, including 15.3% against malaria. These efforts yielded several benefits in health services including: the reduction of distance travelled by the population to health facilities from 7.2 to 6.0 km; the number of new contacts per capita for children under 5 per year increased from 0.8 to 2.1; the malaria case fatality rate decreased from 3.4% to 1.3% in children under 5. Stratified analysis identified three regions out of thirteen [Sahel (IRR = 4.1), Boucle du Mouhoun (IRR = 3.5) and Nord (IRR = 3.4), where the risk of malaria mortality was three times higher than in the Centre.

Conclusion

The study demonstrated the impact of funding on malaria morbidity and mortality, and diverse local risk of death from malaria in children under 5.

Background

Over the past 20 years, malaria illness and death has been reduced globally through the impact of the widespread use of insecticide-treated nets, indoor residual spraying, and prompt treatment of clinical malaria cases with artemisinin-based combination therapy (ACT) [1]. To achieve this progress, international financing for malaria control was increased at least 20-fold [2]. Unfortunately, these efforts have been stalled by the onset of the COVID-19 pandemic, mainly in the World Health Organization (WHO) African region [3]. The latest World Malaria Report 2024 noted an increase in cases from 249 to 263 million cases from 2022 to 2023, and an incidence of 60.4 cases per 1000 population; sub-Saharan Africa (SSA) accounted for 94% of the cases [4, 5]. Children under five accounted for more than two-thirds of all malaria deaths in SSA [5]. The malaria mortality rate stabilized in recent years with 57 deaths per 100,000 people in 2019 [6] to 61 in 2020 and 56 in 2022 [3]. Thirty-one countries of the approximately 85 malaria-endemic countries have succeeded in reducing malaria mortality rates, but by less than the target of 55% set for 2022 [7]. In this context, the global financial investment in malaria control to achieve the Global Technical Strategy (GTS) for malaria targets in 2025 and 2030 will be under considerable pressure to maintain and expand intervention coverage levels. This will require continued investment, better identification of optimal combinations of interventions to address local context, and assurance of quality data to track progress.

In 2023, the 11 High Burden High Impact “HBHI” countries [8] (including Burkina Faso) were responsible for 66% of global malaria cases and 68% of deaths [4]. This situation remains unacceptable in these countries, although recent investment efforts offer hope [9]. Numerous financial investments have been made by the government and its technical and financial partners over the last few decades to reduce the lethality of malaria. Despite this, lethality among children under 5 in Burkina Faso stands at 1.3% in 2023 and has not reached the target of less than 1% [9–13].

While national malaria control programmes and their funding partners are constantly seeking a link between their funding and health outcomes to justify resource mobilization efforts, the association between investment funding and malaria morbidity and mortality is not often assessed. The aim of this study was to analyse the effects of financial resource mobilization and their use in the fight against malaria in Burkina Faso over the last fifteen years (2009 to 2023) in children under 5 years of age. The results of this study could help identify key areas of investment that should be improved for better malaria control in Burkina Faso and other endemic countries to achieve the 2030 GTG targets.

Methods

A retrospective study was conducted over 2009 to 2023 in all 13 Regions of Burkina Faso to review the effects of malaria control investments on malaria morbidity and case fatality in the target population of children under five. Burkina Faso is a country located in the heart of West Africa with no coastal assess. The total population was 22.9 million in 2023, including 17.9% of children under five [14]. The health system is organized in three levels: central level (for strategic orientations) includes national hospitals; intermediate level which coordinates operational actions consisting of the primary health centres grouped in districts; and the peripheral level includes primary health care [15]. Twelve indicators sourced from the National Health Development Plan 2011–2020 and 2021–2030 performance frameworks, were used in the study [15, 16] (Fig. 1). Morbidity and mortality data were extracted from secondary routine data collected in the primary health facilities and registered in District Health Information System (DHIS2) Version 37 from 2009 to 2023. For quality control, the routinely collected data was first checked by health information system managers at the district and regional level and validated at the central level during a workshop gathering all stakeholders.

Fig. 1.

Outcome measurement indicatorsDistance to travel by populations to health facilities (km) vs per capita expenditure and new contacts per capita per year in children < 5 years

Audits on the quality of these data were conducted each year to assess their concordance index, which was 80.5% in 2018 [17]. These data are then published in Burkina Faso Ministry of Health statistical yearbook. The financial data came from the national malaria control programme and the health accounts of Burkina Faso (2009 to 2023) developed according to the international methodology of the “System of Health Accounts (SHA 2011)” and the “Health Accounts Analysis Tool (HAAT/3.4)” all recorded according to WHO requirements in the Global Health Expenditure Database (GHED) [2]. The monetary unit of the national budget in Burkina Faso was the West African XOF (FCFA). For reasons of comparability, financial data were converted into US dollars at a rate of 1$ for 580 XOF. The variables studied are the outcomes from funding used to improve the accessibility of health services offered to populations. These are indicators that measure the results of funding. They include: the use of human resources, the build and equipment of infrastructure and the provision of medicines and other healthcare services (training and management control systems for all these resources). These investments have reduced the distance travelled by populations to access these services. Other descriptive variables added to the data are: the proportion of children under five, the incidence of malaria in children under five, the number of new contacts among children under five, the proportion of severe malaria cases in children under five, the number of deaths related to severe malaria among children under five, health districts (n = 63), health regions in Burkina Faso (n = 13), the threshold for basic health personnel per health facility (n = 3 recommended staff members) and the year of data collection (2009 to 2023). During the first seventh years of the study period, Burkina Faso had sixty-three health districts; following the administrative reorganization in 2015, this increased to 70 health districts. The new districts were implemented gradually over time. To enable consistent statistical analysis, the health areas of the 63 initial health districts that existed at the start of the study were considered as fully operational throughout the study period. Surveys were carried out in these 63 health districts over the 15-year period (945 observations). The data from the health entities grouped together to create the new districts were transferred to the original districts. At health district level, the independent variables chosen were: the distance travelled by population to reach health facilities; the proportion of health facilities meeting basic health staffing standards; the proportion of essential generic drug stores with no pharmacy stock-out in the supply of tracer medicines; the number of new contacts per year per child under 5; and the incidence of malaria in children under 5. The dependent variable was the number of deaths attributable to severe malaria in children under 5.

The health districts were categorized into districts that had reached or exceeded the reference threshold value or not for each of the independent variables considered. The reference threshold for the dependent variable used was the median for the number of deaths attributable to severe malaria per district per year, and this value was 30 deaths for this study. For the computation of the Incidence of Rate Risk (IRR), the group of districts that reached or exceeded the reference threshold value for each independent variable and that exceeded the threshold of 30 severe malaria deaths/year/district was considered as the reference group and was assigned an IRR = 1. At health region level, the independent variables and the dependent variable considered were identical to those used in the calculation of the IRR of high number of deaths due to severe malaria in children under five at district level. The central region (including Ouagadougou, the capital city of Burkina Faso), which had the fewest districts with more than 30 severe malaria deaths, was taken as the reference; it was assigned an IRR = 1.

Descriptive statistical analysis and Poisson regression [18] measures were performed using R version 3.6.2 software. The model was run with Poisson regression analysis, initially univariate and followed by multivariate modelling, to examine the factors of investments and interventions and their association with the evolution of severe malaria case fatality. Only factors associated with a p-value < 0.05 in the univariate regression analysis were considered in the multivariate regression. The adjusted IRR was reported with their 95% confidence intervals. The level of statistical significance was set at 0.05.

Results

Description of indicators evolution

Between 2009 and 2023, the Burkina Faso population increased by 50.7%, from 15.2 to 22.9 million. Children under 5 represented 19.1% of the total population in 2009 and 17.9% in 2023, with an overall increase in the number of children of 41.4% (Table 1). Between 2009 and 2023, Burkina Faso MoH invested a total of USD13545 million for healthcare expenditure, including 15.3% for malaria control programmes and 4.8% to fund free healthcare. The ratio of current health expenditure to the Gross Domestic Product (GDP) fluctuated between 7.5% and 8.5%, reaching an annual average of 6.8%. Per capita health expenditure rose from USD 24.2 to USD 75.5 with an increase of 212% (Table 1). The distance travelled by population to reach health facilities had fallen from 7.4 to 6.0 km from 2009 to 2023. The proportion of health facilities meeting the basic staffing standard of 3 health workers varied between 83.2% and 72.5% and the number of essential health workers rose from 7,726 to 17,683, with an increase of 128.9%. The proportion of essential and generic drug stores with no stock-outs of tracer medicine in pharmacy progressed in a downward direction over time from 92.0% in 2009 to 11.3% in 2023. From 2009 to 2023, the number of new contacts per capita per year among children under 5 increased from 0.8 to 2.1. The incidence of malaria in children under 5 fluctuated from 898 ‰ to 867.3‰. Since the nationwide roll-out of seasonal malaria chemoprevention (SMC) in 2015, the annual number of children receiving SMC increased from 2.7 million in 2015 to 4.0 million in 2023. The proportion of severe malaria cases decreased from 8.2% to 4.5%. The number of deaths attributable to severe malaria fell from 5949 to 1108 and the case fatality decreased from 3.4% to 1.3% (Figs. 2 & 3).

Table 1.

Performance indicators over the period 2009 to 2023

Years	2009	2010	2011	2012	2013	2014	2015	2016	2017	2018	2019	2020	2021	2022	2023
Total population (Million)	15,2	15,7	16,2	16,8	17,3	17,9	18,5	19,0	19,6	20,2	20,5	21,5	22,0	22,2	22,9
Children under 5 (Millions)	2,91	3,00	3,09	3,17	3,24	3,31	3,38	3,45	3,52	3,59	3,60	3,70	3,90	4,00	4,10
Total health care expenses ($106)	512	549	524	542	642	631	650	811	909	818	906	1199	1390	1662	1801
Current health care expenses ($106)	475	411	453	520	620	580	614	775	849	756	863	1142	1337	1558	1727
Expenses for malaria ($106)	51	129	101	84	124	78	73	141	115	96	132	189	208	293	260
Per capita expenditure per year ($106)	24,2	34,4	32,7	34,7	38,2	36,5	36,2	43,8	47,7	41,5	43,4	55,8	62,2	70,3	75,5
Health expenditure as % of GDP	7,5	6,9	4,8	5,2	5,6	5,3	6,2	7,1	8,1	6,1	6,1	8,0	8,3	8,3	8,5
Number of basic health care facilities	1602	1665	1727	1791	1833	1880	1932	2015	2099	2158	2220	2293	2268	2361	2395
Distance to travel by populations to health facilities (km)	7,4	7,3	7,2	7,1	7,0	6,9	6,8	6,7	6,6	6,4	6,3	6,2	6,1	6,1	6,0
Health facilities meeting minimum staffing standards proportion	83,2	83,1	88,8	85,3	86,1	89,8	94,3	77,3	91,0	84,8	87,1	85,4	89,2	89,6	72,5
Essential health care staff	7726	7975	8301	8319	8799	9176	10,742	11,166	12,462	13,970	15,156	15,912	16,667	17,052	17,683
Proportion of essential and generic drug stores with no stock-outs of tracer medicine in pharmacy (%)	92,0	91,7	91,8	80,4	75,9	81,3	77,0	28,0	18,6	13,0	18,2	14,5	13,4	7,4	11,3
Proportion of malaria consultations	45,0	48,1	44,5	45,9	46,5	51,9	45,7	45,0	30,3	41,3	39,1	39,8	37,3	37,8	35,1
New contacts per capita per year in children < 5	0,8	1,4	1,5	1,7	1,7	1,8	1,7	2,5	3,1	3,1	3,3	2,5	2,6	2,3	2,1
Number of children receiving SMC treatment for seasonal malaria (000)	ND	ND	ND	ND	ND	ND	2721	4163	3031	3393	3865	4308	4594	4700	4035
Malaria incidence in children < 5 per 1000	898,0	913,0	897,0	1125,0	1092,0	1175,0	1090,0	1149,0	1725,0	1631,0	1535,0	1304,0	1229,0	1065,0	867,3
Proportion of severe malaria in children < 5 (%)	8,2	7,1	7,6	7,6	5,9	5,7	5,9	3,9	3,9	3,8	3,8	4,4	4,8	4,6	4,5
Proportion of cases confirmed by thick film or TDR	ND	ND	14,34	68,45	84,75	85,07	82,87	82,80	80,62	77,76	66,90	43,68	68,63	68,63	63,7
Proportion of confirmed uncomplicated malaria cases treated with ACT	ND	ND	ND	ND	90,0	95,9	99,8	97,4	88,0	90,5	93,1	90,7	91,7	97,4	98,0
Number of malaria cases treated at community level by community-based health workers	ND	ND	ND	ND	ND	ND	ND	ND	16 275	41 672	67 069	134 153	212 362	212 878	215 253
Number of severe malaria cases	173 338	194 028	176 636	255 105	197 715	211 093	204 416	186 538	229 417	214 661	236 909	187 752	199 464	178 439	151 624
Number of deaths due to severe malaria in children < 5	5 946	6 301	4 093	4 306	3 031	2 707	2 736	1 720	1 713	1 722	3 204	1 525	1 560	1 680	1 108
Severe malaria case-fatality rate in children < 5 (%)	3,4	3,2	3,1	3,1	2,4	2,0	2,0	1,5	1,4	1,5	1,4	1,4	1,3	1,4	1,3

Fig. 2.

Distance to travel by populations to health facilities (km) vs per capita expenditure and new contacts per capita per year in children < 5 years

Fig. 3.

Theorical distance of populations to health facilities (km) vs Malaria incidence in children < 5 and number of deaths due to severe malaria in children < 5

Relative risk of high mortality from severe malaria in children under 5

In the univariate analysis (Table 2), all the variables evaluated in the model were significantly associated with the risk of malaria-related mortality. In the multivariate analysis (Table 2), malaria mortality risk was increased when the distance travelled by population to health facilities was above 6 km [IRR = 1.17, p < 0.001], the health facilities basic standard staff number was lower [IRR = 1.09, p < 0.001], the number of new contacts lower to 2 [IRR = 1.27, p < 0.001]; However, when the drug availability was lower than 70%, the risk for child malaria death was reduced [IRR = 0.96, p = 0.018]. Child malaria mortality risk varied by Region and when compared to the Central Region, three Regions had a greater than threefold risk of mortality: Sahel: IRR = 4.14, p < 0.001; Boucle du Mouhoun: IRR = 3.45, p < 0.001; and Central-North: IRR = 3.24, p < 0.001 (Fig. 4).

Table 2.

Incidence and relative risk factors for malaria deaths in children under five in Burkina Faso from 2009 to 2023, at district and health region levels

Variables	Threshold reference	Number N = 945	Number of health district recording > 30 deaths	Univariate analysis		Multivariate analysis
				IRR (95% CI)	P	IRR (95% CI)	P
Distance to travel by populations to health facilities	≤ 6 km	433	191	1		1
	> 6 km	512	321	1.58 (1.55–1.61)	< 0.001	1.17 (1.13–1.20)	< 0.001
Health facilities meeting minimum staffing standards proportion	≥ 3 agents	452	201	1		1
	< 3 agents	493	292	1.09 (1.07–1.11)	< 0.001	1.09 (1.06 −1.11)	< 0.001
Proportion of essentials generic drug stores with no stock-out	> 70%	414	312	1		1
	< 70%)	531	219	1.01 (0.99–1.04)	< 0.001	0.96 (0.93–0.99)	0.018
New contacts per capita per year in children < 5	≥ 2	483	163	1		1
	< 2	462	220	1.68 (1.63–1.74)	< 0.001	1.27 (1.22–1.31)	< 0.001
Malaria incidence in children < 5 per 1000	≤ 1162	476	169	1		1
	> 1162	469	214	0.94 (0.91–0.96)	< 0.001	1.02 (0.97–1.04)	0.081
Regions	Centre	75	–	1		1
	Boucle du Mouhoun	90	–	4.41 (4.19–4.64)	< 0.001	3.45 (3.25–3.66)	< 0.001
	Cascades	45	–	2.34 (2.18–2.51)	< 0.001	2.00(1.85–2.15)	< 0.001
	Centre-Est	105	–	2.78 (2.63–2.94)	< 0.001	2.44 (2.30–2.58)	< 0.001
	Centre-Nord	60	–	4.05 (3.83–4.29)	< 0.001	3.24 (3.04–3.44)	< 0.001
	Centre-Ouest	75	–	2.48 (2.34–2.64)	< 0.001	2.00 (1.88–2.13)	< 0.001
	Centre Sud	60	–	2.89 (2.70–3.08)	< 0.001	2.44 (2.28–2.62)	< 0.001
	Est	90	–	2.94 (2.78–3.10)	< 0.001	2.29 (2.15–2.44)	< 0.001
	Hauts Bassins	105	–	3.25 (3.07–3.43)	< 0.001	2.70 (2.54–2.86)	< 0.001
	Nord	75	–	2.82 (2.66–2.99)	< 0.001	2.46 (2.31–2.61)	< 0.001
	Plateau Central	45	–	2.94 (2.76–3.13)	< 0.001	2.60 (2.44–2.78)	< 0.001
	Sahel	60	–	5.22 (4.94–5.52)	< 0.001	4.14 (3.89–4.41)	< 0.001
	Sud-Ouest	60	–	2.91 (2.74–3.09)	< 0.001	2.40 (2.25–2.56)	< 0.001

Fig. 4.

Comparative degree of risks of severe malaria mortality in the 13 Regions in Burkina Faso, 2009–2023

Discussion

Despite the fact that national malaria control programmes and their funding partners are constantly seeking a link between their funding and health outcomes to justify resource mobilization efforts [1, 19], the association between investment funding and malaria morbidity and mortality is not often assessed. For the first time in Burkina Faso, this study analysed the effects of health financing in general and malaria control in particular on malaria morbidity and mortality through key investments (building and equipping of health facilities; recruitment and assignment of health staffs to health facilities; acquisition of essential drugs for health facilities pharmacies; strengthening health personnel skills in malaria management).

In the 15 years from 2009 to 2023, funding for health and malaria in Burkina Faso increased by 129.04% and 86.53% respectively. The ratio of current health expenditure to GDP fluctuated between 4.8% and 7.5%, with an annual average of 6.3%. These efforts remain insufficient, as the WHO recommends an increase of at least 1% of GDP each year to impact the healthcare system [20]. Above all, despite wide agreement according to the Abuja Declaration in 2001, Burkina Faso has not yet achieved the 15% of expenditures devoted to health [17]. Malaria control strategies in Burkina Faso have been documented for their effects and their limitations [21–23]. Financial and health investments have reduced the distance travelled by the population to reach health facilities from 7.0 to 6.0 km, but not yet reached the expected target of 5 km in the National Health Development Plans (PNDS) 2011–2020 [15] and 2021–2025 [16]. This reduction in travel distance has likely contributed to an increase in new contacts per inhabitant per year for children under 5. The number of health care staff has increased substantially, however, their inadequate distribution meant that standards were not equitable across all Regions [15, 16]. The conjunction of all these investment efforts likely contributed to better notification of malaria cases in health facilities and communities, which explains the seemingly paradoxical high incidence of cases. This associated effect also led to better clinical management, resulting in a significant reduction in disease progression to severe malaria cases and mortality [24, 25]. These results have also been reported in other studies, which indicate that the shorter the distance to the health facility, the lower the risk of malaria, and non-accessibility to health facilities is a major barrier to seeking health care [24, 26].

The results of this study indicate that distance from health facilities is significantly associated with malaria mortality. Indeed, children living over 6.0 km from a health facility saw their mortality risk increased by 1.17 times, compared with those who were close by. Healthcare facilities were often faced with drug shortages during this study. This situation was surprisingly associated with a significant reduction in the risk of malaria mortality in children under 5 (IRR 0.96, p = 0.018). This could be explained by the fact that the parents of these children had alternative access to purchase drugs from public or private pharmacies in neighbouring villages. The time to acquire emergency drugs for severe malaria may be relatively longer, however, parents were making the effort to obtain them more quickly. Data in Table 1 suggests that very high percent of children with confirmed malaria have received an ACT (> 90 + % from 2013 to 2023)—so stockouts going from very low to very high rates does not appear to be changing ACT treatment rates. An alternative issue on access to quality drugs has been increasing because community health workers have quality stocks of certain priority medicines including for malaria. This could explain some of the changes between 2017 and 2023 (you have data for that interval). Therefore, when shortages occurred, the population had access to medicines in private pharmacies, which experienced fewer shortages and had better storage systems. Between 2009 and 2016, public facilities experienced fewer shortages. However, reporting on the use of ACTs only began in 2013. Other studies have reported similar findings [27–29].

During this study, a significant reduction was observed in the risk of malaria mortality. Three regions of the country were found to be more at risk of malaria mortality than others: the Sahel, Boucle du Mouhoun and Central-North regions. Indeed, the risk of malaria-related mortality was at least 3 times higher for children living in these regions than in the Centre region. These regions are among the largest and most affected by the security crisis since 2016, with internal population displacements and the closing of several health facilities. Their populations live in scattered farming hamlets, with difficult and potentially delayed access to health services. Two other regions (Cascades and Central-West) were at lower risk of malaria-related mortality for the study. They are headquarters of the main research centers conducting epidemiological studies and clinical trials of drugs and vaccines to control malaria. These intervention trials likely began to reduce transmission, and hence reduced malaria mortality. In the remaining regions, the risk of malaria mortality was 2 to 3 times higher than central region. These geomapping levels of mortality risk were also reported by Mady et al. in 2020 in Burkina Faso [19]. However, they reported that health districts with high malaria mortality were identified in the north, north-west and south-west of the country, which does not correspond to the results of this study. this study is a cumulative report over 15 consecutive years, but the results are still in line with those of the Institut National de Santé Publique du Burkina Faso on the health status of the population of Burkina Faso in 2019 and 2021 [30, 31].

This study generated useful data on malaria risk and death in Burkina Faso with a geolocation of these risks. However, the results may conceal limitations. The data including financial inputs, programme actions that may alter disease outcomes, and the outcome measures were derived from aggregated information reported in public government documents over time and across the nation; this may lead to a loss of information or conceal differences between and among important categories of subgroups [32]. An additional limitation is that over the time interval of the study a number of changes occurred including: important political and social changes in national governance between 2011–2012; coinciding with revision of the National Health Development Plans (PNDS) 2011–2020 [15] and the transition from the Razi database to the ENDOS (DHIS) at Ministry of Health [33]; and the SARS-CoV2 pandemic in 2020–2023[34]. While these factors may have affected the consistency of the national data for financing, health system changes, and outcomes across certain intervals, one can expect that over the 15 years time interval of this study, there will always be modifications and this will be true for Burkina Faso and all other malaria endemic countries in sub-Saharan Africa. Despite these possible limitations, the data show consistency over time and the findings of associations among the inputs, outputs, outcomes and impact demonstrate strong plausibility and provide important evidence that investment against malaria can save lives.

This analysis suggests that enhanced resources for health systems and for malaria control in Burkina Faso have led to a number of outcomes that have ultimately saved lives. Reducing distances to health facilities has improved access to health services, thereby increasing the number of new contacts and promoting early and appropriate care for sick children to save lives. This has revealed nested malaria cases that have escaped the reporting system of health facilities. Since 2016, the contribution of community health workers to the diagnosis and management of malaria cases in the community has led to a slight upsurge in malaria cases across different regions, reminding us that what was reported was just the tip of the iceberg, with cases arriving at health facilities. If 2024 is already reporting a drop in malaria cases, it’s appeared that the system is probably reaching saturation point with cases identified and added up by the community. The country will, therefore, be in a position to observe the real impact of health interventions if investment efforts are maintained and reinforced.

Conclusion

Although global and malaria-specific funding efforts by the government and its partners have enabled significant investments that have contributed to a substantial reduction in malaria-related mortality over the past 15 years, malaria remains a public health problem in Burkina Faso. This study shows how the use of funding impacts the provision of and access to healthcare. Establishing this link was important to encourage governments and their partners to redouble their efforts in financing health in general and malaria in particular, with a view to strengthening the implementation of transformative investments in health. This contributes and guides toward the elimination of malaria and other similar diseases through the policies recommended by the WHO. It has also made it possible to map the three regions at risk of malaria mortality among children under 5 in three regions of the country (Sahel, Boucle du Mouhoun, and Centre-Nord) where investments were considered sufficient.

Author contributions

EAA, JBY, BK, FB, LB, SBS: designed the study. EAA, JBY, BK, FB, SN, LB, SBS: managed and analyzed data. EAA, JBY, BK, FB, LB, SBS: have written the paper. All authors contributed to final revision of the manuscript.

Funding

This study was not funded.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Competing interests

The authors declare no competing interests.