Two decades of Malaria in Burkina Faso (2004–2024): national and regional trends and coverage of preventive interventions in children under five and pregnant women

In sub-Saharan Africa, malaria remains a heavy public-health burden, and Burkina Faso ranks among the hardest-hit countries. We set out to trace how the disease evolved nationally and across the country's regions between 2004 and 2024, together with the reach of preventive interventions aimed at under-fives and pregnant women. We retrospectively analyzed routine malaria surveillance data from the national health information system at both the national level and across the 13 administrative regions of Burkina Faso. The association between fourth-round seasonal malaria chemoprevention (SMC) coverage and the number of malaria cases among children under five years of age was assessed using a fixed-effects negative binomial regression model incorporating a linear temporal trend and standard errors estimated using the wild cluster bootstrap. The robustness of the findings was assessed through five sensitivity analyses. The proportion of severe malaria cases among children under 5 years of age increased in all 12 regions studied between 2016–2018 and 2022–2024, despite a concurrent decline in incidence and mortality in this population. National malaria incidence increased from 140.9 cases per 1000 population in 2004 to a peak of 607.0 cases per 1000 population in 2017, before declining to 458.0 cases per 1000 population in 2024. This trend was primarily driven by uncomplicated malaria cases. The case fatality rate (deaths per 100 severe cases) increased from 1.07% (95% CI 1.03–1.11%) in 2004 to a peak of 2.32% (95% CI 2.27–2.37%) in 2009–2010, before declining to 0.63% (95% CI 0.60–0.65%) in 2024. Marked regional disparities persisted; the Sud-Ouest region had the highest mean incidence, whereas the Sahel region recorded the highest case fatality rate, the highest mortality among children under 5 years of age, and the lowest coverage of intermittent preventive treatment. The widespread increase in the proportion of severe cases among children under five years of age, despite declining incidence and mortality in this group, warrants further investigation and represents a novel finding for Burkina Faso. The malaria burden has otherwise declined since 2017, alongside an improvement in case fatality. Substantial regional disparities further highlight the need for strategies tailored to local contexts.