Dr Pedro Alonso who directed the World Health Organization’s Global Malaria Program, has had several opportunities in the past two weeks to remind the global community that complacency on malaria control and elimination must not take hold as there are still over 400,000 deaths globally from malaria each year. At the Seventh Multilateral Initiative for Malaria Conference (MIM) in Dakar, Dr Alonso drew attention to the challenges revealed in the most recent World Malaria Report (WMR). While there have been decreases in deaths, there are places where the number of actual cases is increasing.
Around twenty years ago the course of malaria changed with the holding of the first MIM, also in Dakar and the establishment of the Roll Bank Malaria (RBM) Partnership. These were followed in short order by the Abuja Declaration that set targets for 2010 and embodied political in endemic countries, as well as major funding mechanisms such as the Global Fund to fight AIDS, TB and Malaria. This spurred what has been termed a ‘Golden Decade’ of increasing investment and intervention coverage, leading to decreasing malaria morbidity and mortality. The Millennium Development Goals provided additional impetus to reduce the toll of malaria by 2015.
On Facebook Live yesterday Dr Alonso talked about that ‘Golden Decade.’ There was a 60% decrease in mortality and a 40% decreases in malaria cases. But progress slowing down and we may be stalled at a crossroads. He noted that history show unless accelerate efforts, malaria will come back with a vengeance. Not only is renewed political leadership and funding, particularly from affected countries needed, but we also need new tools. Dr Alonso explained that the existing tools allowed 7m deaths be diverted in that golden decade, but these tools are not perfect. We are reaching limits on these tools such that we need R&D for tools to enable quantum leap forward. Even old tools like nets are threatened by insecticide resistance, and research on alternative safe insecticides is crucial.
Dr Alonso at MIM pointed to the worrying fact that investment in malaria overall peaked in 2013. Investment by endemic countries themselves has remained stable throughout and never gone reached $1 billion despite advocacy and leadership groups like the Africa Leaders Malaria Alliance. The 2017 WMR shows that while 16 countries achieved a greater that 20% reduction in malaria cases, 25 saw a greater that 20% increase in cases. The outnumbering of decreasing countries by increasing was 4 to 8 in Africa, the region with the highest burden of the disease. Overall 24 African countries saw increases in cases between 2015 and 2016 versus 5 that saw a decrease. A review of the Demographic and Health and the Malaria Information Surveys in recent years show that most countries continue to have difficulty coming close to the Abuja 2010 targets for Insecticide treated net (ITN) use, prompt and appropriate malaria case management and intermittent preventive treatment of malaria in pregnancy (IPTp).
The coverage gap is real. The WMR shows that while there have been small but steady increase in 3 doses of IPTp, coverage of the first dose has leveled off. Also while ownership of a net by households has increased, less than half of households have at least one net for every two residents.
In contrast a new form of IPT – seasonal malaria chemoprevention (SMC) for children in the Sahel countries has taken off with over 90% of children receiving at least one of the monthly doses during the high transmission season. Community case management is taking off as is increased use of rapid diagnostic testing. Increased access to care may explain how in spite of increased cases, deaths can be reduced. This situation could change rapidly if drug resistance spreads.
While some international partners are stepping up, we are far short of the investment needed. The Gates Foundation is pledging more for research and development to address the need for new tools as mentioned by Dr Alonso. A big challenge is adequate funding to sustain the implementation of both existing tools and the new ones when they come online. Even in the context of a malaria elimination framework, WHO stresses the need to maintain appropriate levels of intervention with case management, ITNs and other measures regardless of the stage of elimination at which a country or sub-strata of a country is focused.
Twenty years after the formation of RBM and 70 years after the foundation of WHO, the children, families and communities of endemic countries are certainly ready to beat malaria. The question is whether the national and global partners are equally ready.