Can Malaria Be Eradicated In Africa?

Malaria no doubt, is one of the greatest threats to realizing the MDG 4 goal of reducing under -5 mortality by two-thirds by year 2015. Available data from UNICEF’s 2008 edition of ‘The State of the World’s Children’ show that malaria causes more than a million deaths each year across the world, and up to 80% of the deaths occur in under-5 children. In sub Saharan Africa (SSA) alone, about 2,000 under-5 children die daily due to malaria and those who survive are exposed to episodes of malaria fever and anemia which can inhibit the child’s mental and physical development if not properly treated. About 90% of malaria deaths occur in Sub-Saharan Africa. Approximately 3,000 people die from malaria each day in this region, most of them children.

Most malaria-related intervention programs designed by public health experts have included the use of insecticide-treated bed nets, and anti-malaria drugs for pregnant women and children. For the past seven years, Global Fund has been championing the fight against malaria and hopes to distribute about 109 million bed nets and 264 artemisinin-combined therapy (ACT) drugs since its inception in 2002. The Global Fund ,which prides itself as the ‘world’s largest financier of the fight against malaria’, in a recent press release announced that it had distributed more than US$3.66 billion in 5 years since its inception in 2002. The Executive Director of Global Fund, Dr. Michel Kazatchkine hinted that through its 146 programs in 78 countries, some 46 million bed nets have been delivered to families at risk, reflecting an increase of over 155% relative to the 2007 result of 18 million bed nets.

Trend analysis of the data from 20 countries of SSA show a rise in the use of ITNs across the continent with about 16 countries tripling their usage since 2000. Ethiopia, Kenya and Rwanda in recent times have recorded high distribution and usage of ITNs in their respective countries. At the recent Roll Back Malaria Partnership meeting which held in Geneva on 22nd of February, to review reports for 2007 ,the presentations revealed sharp decreases in malaria cases and deaths across countries in Africa and Asia due to integrated bed net delivery – the practice of distributing protective bed nets during immunization campaigns such as measles and polio. The reports also showed that the delivery of almost 6.5 million nets during campaigns in 15 malaria-endemic countries helped avert an estimated 350,000 deaths over 3 years. Dr. Awa Marie Coll-Seck, the Executive Director of Roll Back Malaria Partnership feels gratified with the gains made in endemic countries which have resulted in the reduction in malaria deaths.

Encouraged by the results, the Global Fund Board during its meeting in China in November 2007 approved 73 new grant applications for the Round 7 proposals worth more than US$ 1.1billion over the next 2 years. In addition, the Global Fund on March 3rd 2008, opened its 8th Funding Round hinting that the 2008 ‘ Round 8 of proposals is the last chance for malaria-endemic countries in Africa to obtain funding for malaria control activities geared towards reaching the Abuja targets of halving the malaria burden in Africa by 2010. However, in an study of the approved SSA malaria proposals conducted by Aidspan about 95% said they would be distributing ITNs while only about 27% had other interventions like indoor residual spray. This has made some stakeholders have the impression that Global Fund’s major focus is primarily on bed nets and ACT drugs, and it is pertinent at this stage to encourage Global Fund to review its malaria programs and make them more amenable to the health and social realities in the continent.

Despite the successes recorded in the distribution and use of ACTs, it is widely believed that the fight against malaria is far from being won. Faced with the reality, The Bill and Melinda Gate’s Foundation in the last quarter of 2007 convened a malaria conference in Seattle Washington DC, USA during which Bill Gates made a call for the ‘eradication ‘ of malaria. This call has generated a lot of debate among public health experts and stakeholders, the media and the general public. Some feel this is an ‘audacious’ goal considering that the tools to be used in the eradication do not yet exist. However, Dr. Regina Rabinovich, the head of infectious diseases at the Bill and Melinda Gates Foundation believes that with more money, better health systems and probably vaccine, the undertaking can be realized in the long-term.

Dr. Arata Kochi, the WHO malaria Chief, feels it is counter-productive to pursue the eradication of malaria. That effort should focus on pumping more money into nets, medicines and DDT which can help in reducing the case of malaria by 90%. In his opinion, he believes that even countries that have controlled malaria still face the threat of importing fresh malaria cases from neighbouring countries. WHO in 1955 had hoped that malaria would be eradicated with the discovery of DDT, Chloroquine and Quinine. DDT which was used successfully in some countries was eventually banned in 1976 following the anti-DDT campaigns by Environmental Defense, Sierra Club and Endangered Wildlife Trust.

Though the skepticism expressed by WHO is understandable, the global call for the eradication of malaria should not be ignored or thrown away too early without making any efforts considering that the target date for malaria eradication has been fixed for 2050.These same organizations that championed the campaigns have now endorsed the use of DDT based on the available empirical evidence that proved that DDT can safely be used in the malaria fight after a 30-year ban. And as the world celebrates the World Malaria Day (formerly-called ,Africa Malaria Day) on the 25th of April 2008, it is pertinent for governments, donor organizations, aid agencies, NGOs and the public to critically review the threat posed by malaria especially in Sub-Saharan Africa where most countries are lagging behind in the achievement of the MDGs. There is a need to shift away from the undue focus on the distribution of commodities like bed nets and drugs by adopting a more pragmatic approach that is anchored on holistic development of Africa. As long as a large majority of Africans are left to suffer under the yoke of unjustifiable poverty, the goal of achieving sustainable economic and social development in the continent will remain far-fetched and unrealizable. Reducing the high burden of disease in Africa still requires an increase in the resources and the synergy of efforts of both the governments of Africa and those of the developed economies that have been the major funding sources of global health programs.

Recent developments in the global health show that more resources are being allocated to the fight against malaria. For instance, at the 2008 World Economic Forum in Davos, Switzerland, health and business leaders announced on January 25th 2008, an ambitions malaria control effort to save 3.5 million lives over the next five years through the rapid scale-up of malaria prevention and treatment measures in the 30 hardest hit countries in Africa, based on a new report prepared by Malaria No More and McKinsey & Company on behalf of the Roll Back Malaria Partnership (RBM) and presented at the World Economic Forum. Additionally, rapid scale-up, the report suggests would increase annual economic output by as much as $30 billion in Africa, prevent 672 million malaria cases, and free up 427,000 needed hospital beds over five years.

The Bill and Meli

nda Gates Foundation recently awarded 13 new grants totaling about US$200 million to help in the strengthening existing malaria initiatives and to pursue a wide range of research on new strategies to prevent and treat the disease. Furthermore, the US Senate Foreign Relations Committee on March 13 2008 gave approval to “Tom Lantos and Henry J. Hyde Global Leadership on HIV/AIDS, Tuberculosis and Malaria Reauthorization Act of 2008”. Out of the US$50 billion funding to be channeled via bilateral programs and the Global Fund, US$5b is expected to be used for addressing challenges of tackling malaria in high-burden areas, and allow improvements in program monitoring and evaluation.

From the foregoing, it is obvious that the resources available for the fight against malaria are not in short supply. However, there are still obstacles and bottlenecks that need to be taken into consideration while planning such programs. The most critical challenge to be encountered in Africa is the pervasive poverty which has increased by 50% in the last 15years with about 200milion (over one third of the population) living below the poverty line. Another major constrain is the poor state of governance and financial accountability prevalent in most countries of Africa. Annual budgets allocated to the weak and dysfunctional health sector especially in Nigeria and most SSA are below the expected 15% of the Abuja Declaration. Other issues to be given consideration include the impact of global warming and climatic changes on the epidemiology of malaria vectors in Africa. Africans and their communities should be given a voice and more opportunity to make input into malaria intervention programs that are community-owned and driven rather than the subsisting vertically-driven ones supported by some agencies working in Africa.

Global Fund’s grants decision making and approval processes should take some of these developmental realities into consideration. Rather than focus mainly on the distribution of bed nets and anti-malaria drugs, other interventions like Indoor Residual Spraying, health systems strengthening, capacity building and re-orientation of health workers etc, should also be included as major components of the malaria projects they are supporting. Strategic groups like the Friends of the Global Fund Africa (Friends Africa) whose board of directors and advisory board were inaugurated in February 2008 at Kigali in Rwanda should become a strong advisory and advocacy group that will represent the interest of SSA on global health issues rather than the focus on resource mobilization alone.

The CCM in African countries should not only draft and develop proposals but should also be empowered to advise Global Fund on the programs that would best suit the health and development realities in the continent. Often times, most CCMs efforts are channeled at meeting the numerical targets set by Global Fund upon which the funding and absorptive capacities of each CCM are determined. This trend makes most recipients to focus mainly on the distribution of commodities with little or no concern for how these commodities are used or ignored by the population at risk.

Finally, lessons learnt from the success stories recorded in other disease eradication programs like Polio, guinea worm, small pox etc would be useful as the world pushes to control and if possible, eradicate malaria in the world. This calls for concerted and sustained efforts by both the governments and people of SSA, with the support and collaborations from the governments and peoples of other countries within the global family.