Global malaria elimination hinges on Africa, experts say

ABIDJAN — As the world celebrates World Malaria Day 2018 under the theme, “Ready to Beat Malaria,” some experts caution that progress could be reversed if more is not done to address the challenges in eliminating the mosquito-borne disease in Africa.

According to the latest research by the World Health Organization, in 2016 nearly half of the world’s population was at risk of malaria. In total that year, 216 million cases of malaria were identified across 91 countries, an increase of 5 million over the year before. While places such as the European region documented no cases at all, some parts of Southeast Asia, Western Pacific, and sub-Saharan Africa saw an increase in numbers.

Globally, the total number of malaria fatalities has declined since 2010, however the Africa region still bears an estimated 90 percent of all malaria cases and deaths, based on the findings of the 2017 WHO Malaria Report.

“Clearly, if we are to get the global malaria response back on track, supporting the most heavily affected countries in the African region must be the primary focus,” WHO Director-General Dr. Tedros Adhanom Ghebreyesus said during the report’s release.

The report illustrates the current status of the global malaria response: Without increased funding and improved coverage of current tools, current efforts have reached the limits of what can be achieved. Many experts argue that response is at a “crossroads.”

Threats to malaria elimination

Some argue that the broadened health agenda of the Sustainable Development Goal 3 — which includes efforts to not only end AIDS, tuberculosis, and malaria by 2030, but also seeks to ensure universal health coverage and access to sexual and reproductive health services, among other embedded goals — overwhelms many fragile African health systems.

“Since 2016, what we have found is that the ministries of health now face a big challenge because during the Millennium Development Goals, they had HIV/TB and Malaria as an MDG, so it was much simpler to address malaria in that the targets were fewer so they were able to put focus on these sets of programs,” Joy Phumaphi, executive secretary of the African Leaders Malaria Alliance explained. In turn, she said, African governments revamped health systems to effectively deliver particular programs to meet 2015 MDG targets on malaria reduction and control while neglecting other areas.

“The challenge now facing ministers of health is how to prioritize, and so because their attention is now being divided and they are not used to managing an integrated health system, we are seeing the collapse because the scope is too broad,” Phumpahi argued.

Dr. Magda Robalo, WHO Africa regional director of the Communicable Diseases Cluster says the broadened framework could light the path for a more holistic approach to mitigating health and other development challenges, simultaneously.

“Yes, the health SDG is broader, which is a good thing because many diseases have the opportunity of being eliminated as a public health problem, so why not. Each country has to make a decision on where to invest and tap into the opportunities that action in other sectors can bring to [the] health [sector],” she told Devex.

Significant achievements against neglected tropical diseases, such as rabies and dengue fever, for example, can be made if countries improve the quality of water, sanitation, and hygiene conditions, Robalo noted.

The World Malaria report indicates continued gaps in basic prevention, diagnostic, and treatment tools on the continent, where less than half of households in sub-Saharan Africa have sufficient access to bed nets — 1 per 2 people. And between 2010 and 2016, the number of people in the region protecting themselves with indoor room spray actually dropped — by 35 million.

Mosquitoes developing insecticide resistance will become a problem if we don’t find tools to counter them, warned Bill & Melinda Gates Foundation deputy director on malaria, Bruno Moonen during the Multilateral Initiative on Malaria conference in Senegal earlier this month. He emphasized how using an active ingredient on bed nets that works even against resistant mosquitoes, for example, would provide additional protection.

“However, no matter what approaches and strategies we use to delay the appearance of resistance, it will eventually happen, and that calls for new active ingredients, new vector control approaches so that when the ones we use end up failing, we have something else to use,” WHO Global Malaria Programme Director Pedro Alonso told Devex. The same applies for antimalarial medicines where parasites could develop resistance to treatments.

“At the same time, I would like to send a clear message that the key tool that we are using right now, insecticide-treated bed nets continue to be effective and there should be no questioning the effectiveness of our core malaria control effort,” he said.

Funding shortage

Stalled progress against malaria could also be accounted to a slowdown in financial support over the past few years against the backdrop of a rising population.

“With population growth, and because funding has plateaued over the past five or six years, that means that per capita investment in the fight against malaria is decreasing in a great number of countries, so it doesn’t seem hard to imagine that with the same level of funding, with the same tools we are seeing the limit to what we can do,” Alonso explained.

WHO estimates that annual funding for malaria would need to increase to $6.5 billion per year by 2020 to reach the first milestone of the “Global Technical Strategy for Malaria,” which is a reduction of at least 40 percent in malaria case incidence and mortality rates globally when compared to 2015 figures.

In 2016, $2.7 billion was invested in malaria control and elimination efforts, mostly channeled through the Global Fund to Fight AIDS, Tuberculosis and Malaria.

To fill the funding gaps, last week’s Malaria Summit London 2018 brought together more than a dozen heads of state, philanthropists, development partners and attracted $4.1 billion in commitments from national governments, pharmaceutical companies, and the summit’s co-host, Bill Gates.

Phumpahi encourages a private sector push to introduce health-incentive taxes on tobacco, alcohol, and even sugar to increase domestic financing for health care.

Robalo agreed, saying dependency on external funding to drive a national agenda has its limits. “As long as you depend on external funding, there will be a time when donor fatigue will come into play and you’ll not be able to do much more with less investment, so this is where domestic funding comes in,” she argued.

Country ownership

Malaria control and elimination efforts require national level governmental support to achieve sustainable progress, experts tell Devex. Leadership and political commitment may continue to be a challenge as some country leaders pull back due to achieved progress, while others that are seeing less success may lose focus and deem malaria elimination a distant goal.

“We need to get the elimination mindset in order to be able to translate our ambition and vision into something concrete,” Robalo urged. For many years, Africa countries have been in control mode, while elimination is a much more drastic attitude that most leaders don’t possess, she asserted. “Those countries that have a long way to go are not yet on the mindset that we are going to beat malaria.”

Lessons from HIV/AIDS eradication efforts indicate that local resources are vital to a country’s success against a health pandemic, Robalo told Devex. “Communities must own the response but we’ve noticed that if countries don’t see it as a big problem, there is much less commitment.”

More than 7 million deaths have been averted globally since 2000 due to improved malaria interventions and national vigilance. However, Phumpahi argues that in order to reverse the stalling trend, health systems must be better integrated to address a number of health concerns in tandem.

“We need a health system that can address the basic health needs of a group in an integrated manner [because] when you have a vertical system, it cannot work forever; in the end the other diseases being neglected will demand change,” she said.