Regional voices are key to the fight against malaria but not heard enough when decisions are made about policy and resource allocation for malaria.
The 2017 and 2018 World Malaria Reports rang alarm bells, showing that after unprecedented success in global malaria control, progress has stalled and funding has flatlined. Case numbers are increasing in some countries and new challenges such as resistance to insecticides and antimalarials continue to loom. The global health community therefore needs to continue to work together to prevent and reverse the complacency that comes from the expectation that malaria will soon be eliminated.
With this in mind, in 2018, Novartis Social Business commissioned a stakeholder research report, Malaria Futures for Africa, to hear directly from malaria experts on the ground in 15 African countries about their views on progress toward elimination. In 2019, a second report, looking at five key countries in South and Southeast Asia was commissioned to assess progress made toward global malaria goals and examine the unique issues facing the region. Following on from these two reports, research was extended to four Central African countries to examine their specific challenges in 2019.
MalaFA findings: common issues and divergences in Asia and Africa
This research reflects the views of malaria experts in 24 countries across sub-Saharan Africa and South and South East Asia – representing government, the research community and NGOs.
Overall, Asian respondents were more optimistic about reaching 2030 elimination goals for P. falciparum than their African counterparts. Yet, Asian participants were not as optimistic when it came to elimination of P. vivax. Among African respondents, there was a widespread feeling that 2030 targets would not be achieved unless big changes occurred in funding and delivery.
Despite differences, respondents in Asian and African countries also agreed on common areas, including the need for: increased domestic financing; training new cohorts of healthcare workers in malaria care; and continued investment in R&D to effectively fight insecticide and ACT resistance.
Common issues in Asia and Africa
Sustainability of funding
Asia: Asian respondents were concerned about funding from donors falling off in the face of other, more pressing, diseases (TB, NCDs) and increasing GNI gram-negative infections such as pneumonia. However, they largely felt that donors were supportive of their national plans.
Africa: African respondents were concerned about the stability of donor funds and wanted increased domestic funding. In addition, they felt donors were not particularly supportive of national plans.
Insecticide and ACT resistance
Asia: There was more mixed concern about resistance, particularly around ACT resistance. Compared to Africa, fewer respondents felt that resistance to ACTs was a significant threat, perhaps because Asian countries believe they will reach elimination targets before resistance becomes widespread. However, resistance is certainly an issue, with Cambodia, for example, reporting relatively high failure rates for ACTs.
Africa: Nearly all respondents were very concerned about insecticide and ACT resistance and felt that it was essential to pursue R&D for new tools.
Asia: There were big concerns that many malaria outbreaks happen in remote areas and cannot be identified and controlled quickly enough to prevent them from spreading. Indian respondents were particularly concerned about this issue.
Africa: African respondents were concerned that there was insufficient surveillance to identify and control malaria outbreaks, not just in remote areas. This becomes even more of a problem as a country nears elimination.
Divergences in Asia and Africa
Lack of skilled healthcare workers (HCWs)
Asia: Asian respondents were all very concerned about the lack of properly skilled HCWs, particularly in key skills such as microscopy diagnosis. There was a general feeling that there was a loss of skilled capacity as malaria declines.
Africa: While Asian respondents identified a lack of skilled HCWs as the main health system barrier, African respondents focused on the problem of limited availability of health facilities to even host HCWs to serve populations at risk of malaria, particularly in rural areas.
Asia: This was a very frequent concern, with many respondents saying elimination could be at risk.
Africa: Very few respondents expressed concerns about the impact of climate change.
Migrant and hard-to-reach populations
Asia: Migrant and hard-to-reach populations in remote areas are the real crux of the problem in the region. Respondents are very concerned that without finding a solution to this problem, elimination will be very difficult.
Africa: This concern did not come through as strongly from African respondents, probably because malaria is much more common in many African countries.