“In 2000, malaria was identified as one of the biggest impediments to global development and selected as a critical global target of the Millennium Development Goals (MDGs). Target 6c aimed to halt and begin to reverse the incidence of malaria by 2015.” According to a joint WHO-UNICEF report released over a week ago, target 6c has been met – malaria death rates are down by 60 percent in the last 15 years, translating into 6.2 million lives saved, the vast majority of them African children.
“Global malaria control is one of the great public health success stories of the past 15 years,” said WHO Director-General, Margaret Chan in an interview. She added that the achievement is a sign that strategies to beat the killer disease were on target, and proof that it can be eradicated. More countries are on the verge of eliminating malaria; last year, 13 countries with malaria in 2000, reported zero cases of the disease and six countries reported fewer than 10 cases. The fastest decreases were seen in Central and Eastern Asia, and Caucasus, these regions reported zero cases in 2014.
However, Africa still accounts for 80 percent of cases and 78 percent of deaths, even though the number of infections fell by 50 percent across the continent mostly with the use of insecticide-treated bed nets (ITNs) – 68 percent of malaria cases were averted by ITN’s. While anti-malarial drugs called Artemisinin-based combination therapies (ACT’s) and indoor spraying accounted for 22 percent and 10 percent of cases prevented. The increased use of rapid diagnostic tests (RDT’s) has also made it easier to distinguish between malarial and non-malarial fevers, enabling timely and appropriate treatment.
Based on these reports, I had an interview with Melanie Renshaw, Chief Technical Advisor for African Leaders Malaria Alliance (ALMA) and Co-Chair, Roll Back Malaria Harmonization Working Group (HWG). She explained the effectiveness of core interventions in Africa, Nigeria’s commitment to the fight against malaria, and getting Africa to better understand the effect of malaria control.
Ventures Africa (VA): The fastest decreases in combating malaria are seen in central and eastern Asia, what are they doing differently from Africa?
Melanie Renshaw (MR): It’s largely down to malaria itself. Africa has the very highest burden, the best mosquitoes, the champion mosquitoes actually for transmitting malaria, so it’s less about the success, than trying harder or investing more or doing better, it’s much more the underlying nature of the malaria transmission burden in Africa being significantly worse, much more harder to control, and much harder to have impact, than in Asia where the mosquitoes are much weaker in transmitting malaria. It’s very much down to the nature of the malaria itself rather than “Wow! They are doing a fantastic job in Asia!” I’m not saying they aren’t. They’ve always had, relatively speaking, a lower burden than the vast majority of Africa, and so once you’re in a country where malaria is a less high burden, and it’s easier to control, it’s easier to make them go down.
VA: So what can be done for Africa? Aside from the ITN’s, what other intervention is strong enough to fight malaria in Africa?
MR: We’ve always said we should use combination of tools, so that includes the tools we have at the moment, which includes the long-lasting insecticidal net which countries in Africa are continuing to either scale up, or sustain the scale. In some countries it depends on, first of all the situation of your insecticide resistance, if you have insecticide resistance to pyrethroids it’s also a good idea to do indoor residual spraying. Many of the southern African countries in particular but also others including Ghana, Ethiopia, they are also doing the indoor residual spraying and that’s equally effective in terms of reducing malaria.
What we are really hoping is that countries will continue to sustain the coverage of mosquito nets and also indoor residual spraying, and in the few countries that have really scaled up, that that scale up will be complete in the next year or two and then at the same time to strengthen case management and diagnosis, particularly the rapid diagnostic care and then also treatment with ACTs [Artemisinin Combined Treatments] One of the key things with the increase in treatment and diagnosis is rolling that out first at the community level to integrate and educate the management and which allows treatment of [children under the age of five] where they live and also in several countries enhance quality anti-malarial through the private sector, and Nigeria is a perfect example of that. There was a programme called the affordable medicines facility for malaria and that really worked to get high levels of quality anti malaria drugs into the private sector and that’s continuing now. I think our main and core interventions are remarkably effective and then we are also waiting for new tools, better tool under development. For example, we have combination mosquito net with the combinations of insecticides now. So, the same way there are ACTs, artemisinin based combination therapies for malaria treatments – there are two different drugs working differently and therefore being more effective at combatting resistance, we’re hoping we’ll have similar tools for mosquito nets and there are a number of better anti-malarias coming through, treatments. For example single-dose treatments instead of a three-day treatment, so that major compliance is obviously much better. So we have a lot of good tools. We can, even with the tools that we have today, according to the WHO, we’ll see a 90 percent reduction in malaria in the next 15 years based on the level of malaria we have today. So even with the the tools we have, we should still make a very significant decrease in malaria but if we get some extra tools that maybe just what we need to combat it and finish it off once and for all
The other key thing I think that’s been very good is ownership. I’m obviously working for the African Leaders for Malaria Alliance, which is an alliance of the heads of state governments of Africa. They form the alliance and they formed the alliance to have better tracking and accountability and action around malaria probably using malaria as a pathfinder to show how high level leadership, action and ownership can actually lead to significant change and malaria has been probably one of the biggest successes in health in recent years. The report that was published Thursday, it shows that 25 percent of the under five deaths that have been averted in Africa are actually due to malaria deaths averted. So it shows how, with the right tools, with the right resources, with clear targets and with political ownership and commitment, we can actually see very significant results – something like 5.9 billion lives saved in children since 2000. It’s pretty impressive.
VA: Why are the ITNs the most effective core intervention in Africa?
MR: Indoor residual spraying works as well as the net, but if you’re trying to reach every house and spray it, that could be something of a logistic nightmare across the whole of Africa. So lots of the spraying that takes place is indoor residual spraying is where houses are put together, where you can have good infrastructure, the roads are good if you need to access every house and in the more rural areas, mosquito nets tends to be easier because basically they can be distributed. But with spraying you have to do every year. What we plan to do is have mosquito nets distributed on a three year basis through a campaign. Everybody living in a household, one for every two people and so everyone gets the net and that means for three years they have a net and you don’t have to replace it. So it tends to be easier to have universal coverage with mosquito nets than it is logistically, and sometimes, financially to do it with indoor residual spraying. The reasons mosquito nets/spraying are so effective – they kill so many mosquitoes as long as the insecticide is still working. And as well for mosquito nets, they also offer a barrier. The insecticide which kills the mosquito and then the nets stops them from biting you in the first place as well. They are just pretty effective tools.
Now if you’re sick with malaria, then you’d obviously be getting ACTs treatments. Now the treatments are very effective. I’ve actually never taken one. I’ve never had malaria since ACTs have been around. But in the old days when you take an anti-malaria, you still feel sick for several days. These days, ACTs, they clear the parasites out of your blood almost immediately, you could almost feel better within twenty four hours. They are very effective and at the moment, there’s no resistance to artemesin, the main drug in the combination. That means you don’t have failing cases after treatment because it is effective. And if you get your treatments quickly as soon as symptoms have developed there should be no malaria. One of the problems is mosquito nets and sprays bring down the number of malaria deaths, but they don’t prevent every malaria case, you could still get sick. They’ll reduce malaria by about 50 percent and then it’s important that you get that other 50 percent treated and get them treated quickly. If everyone got treated as soon as they first develop symptoms, nobody will die at all. But then is about “do people recognise these symptoms? Do they access treatments effectively enough? I say that’s one of the reasons why private sector availability and quality of are important; public sector having all the availabilities and health facilities and also the community level where kids are still dying from malaria in the vast majority of Africa, so getting treatment close to where the children are in these communities is also another way. If everyone got their ACT’s within half an hour of being bitten, there won’t be anyone dying from Malaria.
VA: The ITNs and the sprays are cheaper I believe?
MR: Nets are cheaper per person protected yeah.
VA: What about the ACTs? How cost-effective are they? Are they readily accessible?
MR: It’s relatively accessible. Basically the vast majority of ACTs are financed either through the Global Fund for AIDS TB and Malaria and that’s particularly true for the public sector. The vast majority of ACTs used in treating patients in most of Africa have come from the Global Fund, or from countries which are supported by the US President’s Malaria Initiative. The majority of countries also give out malaria treatments free particularly to [children under five] and pregnant women in hospitals and health facilities. So that also makes them more accessible. In community case management where that’s rolled out, those are always free. I don’t know of any case where they’ve ever actually charged for those. The other way that people get their ACTs is through the private sector and that’s why the affordable medicine facilities for malaria were set up to see see how you can reduce the price of ACTs – quality ACTs in the private sector, and that’s also been quite effective as well. I think the average cost if you were buying an ACT, real cost from the manufacturer, is around a dollar, but because of the Global Funds, OMI and others, the price is usually free to the end users of the public health facilities or sometimes it’s the service charged within a country for health, then it’s just part of the routine service charge, so then it’s heavily subsidised. Private sectors efforts are on-going to get affordable ACTs into the private sector. And the AMFF countries which includes Nigeria, Uganda, Tanzania, and many of the high burdened countries are still continuing to subsidise ACTs to the private sector, which started a few years ago.
VA: How can we get Africans, especially sub-Saharan Africa to better understand the effect of malaria control?
MR: I think it’s better than it was. I think it’s less these days about community behaviour and knowledge. I think that has improved very significantly and I think it’s about making sure everybody still has or gets increased access to malaria prevention and controls. The other thing we probably need to do is have better data so that we know how well we are doing. Sometimes it’s actually hard from health information system or surveillance to actually see how well we’re doing on a country by country basis. I think one of the things WHO in particular is going to focus on in the next years is improving surveillance and data availability, so you can then make real time programming decisions and know exactly where you are in terms of moving towards malaria elimination. But I think increasing access to ACTs through the community approach, through health systems strengthening, and through the private sectors. Mosquito nets continue to be distributed free of charge to the end users which also significantly increases the uptake. I think mosquito nets distribution is one of the most equitable mechanisms of delivering health because they very much do target poorer families living in poorer, more difficult to access rural areas. We certainly need to increase domestic revenue for malaria control, so that instead of having malaria controls financed from outside of Africa, to have it actually financed by country governments with malaria control prioritised in health budget for example.
I think what would be fabulous as well, moving forward, will be to see many of these commodities, the vast majority of which are now manufactured outside of Africa, manufactured locally and it will be even more fantastic to see some of these new innovations that are coming along, particularly those new innovations coming out of Africa so that it’s low cost solutions developed in Africa, which if they were the final solution that could really help us move towards malaria eradication, that would be fantastic as well.
VA: So how is Nigeria doing in terms of our commitment to the fight against malaria?
MR: In my opinion, I think as part of the Global Funds concept notes that I was just talking about, the government committed about $400 million to the fight against malaria which includes money for drugs, ACTs and for RDTs, and also for larval control and surveillance and training. So that’s definitely a positive move, and that means that Nigeria met all of the requirements, which is to pay at least 40 percent of the amount, compared to what the Global Fund was committing. I think it’s actually a good contribution but also I understand that also in development under discussion, the possibility of a malaria bond. That will be increasing the government commitment to malaria but that’s still at the development stage I think. But at least we have that example of the $400 million commitment from government.
VA: How co-operative are the governments in AFRICA?
MR: It depends very much from country to country. One of the interesting things that have come out is this latest Global Fund concept note that nearly every country in Africa, certainly all the ones with big malaria problems have submitted concept notes to the Global Fund. In those concept notes, you have to say how much of your domestic resources are contributed to malaria and what we’ve seen is more than a hundred percent increase in domestic resource commitment for malaria, TB and HIV in the next three years compared to the the last three years. There are some countries where there’s been extremely significant increases. Zambia is one where the government are financing probably the most significant portion of their treatment and also of malaria prevention. We are seeing increasing number of examples of domestic resource commitment from countries in Africa contributing to the fight against malaria. Now if we are to achieve the target set out by WHO by 2030, it will require even more increases in domestic resource contributions from endemic countries. Whilst we are beginning now, I think that the positive examples in a number of countries probably in increasing the vast majority of countries, in terms of their commitment to malaria spending, I think that needs to be significantly reinforced even more moving forward. I think it’s a vision that the vast majority of resources by 2030 should come from Africa’s domestic resources commitment rather than from donors in the vast majority of countries, especially given the scope of scale of economic development in Africa. So it’s definitely improving, but there’s still more work to be done, but at least the signs are there that there has been a 100 percent increase in just the last three years in terms of commitments. We’ll be tracking that to see if those commitments come to fruition. I think that a vast majority of them will.