African health experts warn that major advances in tackling malaria have led to widespread complacency and they are calling for a renewed effort to combat the disease.
Although global malaria deaths fell more than 60% between 2000 and 2015, experts participating in a recent survey said they fear progress could stall unless national governments provide more funding, and international organizations target their support more effectively. They point to mounting evidence that mosquitoes are becoming resistant to insecticides, and that malaria parasites are developing resistance to current medicines.
The concerns are highlighted in a new study called Malaria Futures for Africa, which attempts for the first time in many years to gather the views of African opinion-leaders in the countries most affected by the disease.
The study surveyed 68 health ministers, civil servants, malaria program directors, senior researchers and representatives of non-governmental organizations in 14 countries across sub-Saharan Africa.
Many respondents said they believe the World Health Organization (WHO) 2030 targets of eliminating malaria in 35 or more countries and of reducing global death rates by at least 90% compared to 2015 will not be achieved without major changes in the funding and delivery of healthcare services.
“In most countries, national budget allocations are inadequate and national policies are thought to be poorly developed or implemented,” wrote the study’s co-chairs, Dr Richard Kamwi, ambassador of Elimination 8 initiative, and professor Bob Snow of the KEMRI-Wellcome Trust program in Kenya and the University of Oxford. “The need for better, more equal partnerships and for more resources jumps off almost every page.”
Despite the enormous progress made in combating malaria, one child still dies from the disease every two minutes, the vast majority of them in sub-Saharan Africa. The 2017 WHO World Malaria Report warned that progress in fighting malaria has stalled and funding has flatlined. In addition, the estimated cost of malaria to the African economy is more than USD 12 billion a year.
Describing the situation in Namibia, one survey respondent said: “There has been a significant reduction of malaria incidence which, unfortunately, caused a certain level of complacency. That brought a worrisome recurrence of malaria, though deaths remain relatively low.”
A Nigerian expert said that eliminating malaria is feasible given the political will, but is unlikely because of how the program is being handled. “There are great plans, policies and documents… but very little on the path of the government to make things work.”
Many respondents said that because the prevalence of malaria has fallen, basic prevention measures -- including the use of bed nets to deter mosquitos from biting in the first place -- were in danger of being sidelined. The report argued that more education, as well as social and behavioral changes, are needed to get people to use prevention measures properly.
Respondents also support wider access to child formulations of malaria treatments, and to better diagnostic tools. They stressed that until new malaria medicines become available, it is vital to make the best use of existing approaches to prevention and treatment. Many experts called for more emphasis on assessing how malaria prevention, diagnosis and treatment are delivered and could be improved to provide maximum benefit.
This is just one area that survey respondents said they believe is under-resourced, leading many to call for greater spending by their own governments. “Malaria is a disease of the poor that does not affect everyone like HIV/AIDS and so does not receive adequate attention,” said one expert from Malawi. “More people are infected and affected by malaria (24%) than HIV/AIDS (8.9%), but more funding goes to the latter.”
Respondents also said they believe the support of international aid organizations is crucial, providing it aligns with national priorities and is sustained over the long term. However, the study co-chairs warned that this source of funding is under threat: “There is a great danger of malaria slipping down the donor agenda, both because the problem seems less acutely alarming and because donor institutions, which are often accountable to legislatures, witness less progress than they had been promised.”
Threat of resistance
Many respondents expressed concern that mosquitoes are becoming increasingly resistant to insecticides used to control them. And that in 15-20 years malaria parasites could become resistant to artemisinin-based combination therapy (ACT), which is today’s standard of care for people with malaria. Some said they feared that resistance will spread faster because of expanding trade and travel between Africa and Asia, where the first signs of drug resistance are emerging. But others said it was just as likely that resistance will emerge independently in Africa.
The report concluded that better surveillance is needed to track the spread of resistance and more must be invested in developing alternatives to current insecticides and medicines. According to respondents, greater coordination is essential to success. Around one-quarter argued that the lack of global or country plans to address resistance to antimalarial drugs and insecticides could be a major handicap in fighting the disease.
“This study highlights how the public and private sectors must continue to work together to sustain the tremendous gains made so far and to maintain global momentum with the ultimate goal of malaria elimination,” said Harald Nusser, the Head of Novartis Social Business, which commissioned and funded the study. “We have won many battles against malaria, but we have not yet won the war.”