Hello and welcome to this very special edition of Hot Topics. I’m Thomas Locke and this is Fight Malaria.

Today is World Malaria Day, an international event which started in 2008 to celebrate progress against malaria, but also to remind political leaders that more needs to be done. It’s true that over the last 20 years, we’ve made significant progress against malaria with over 600,000 lives saved each year. Last year’s replenishment of The Global Fund in France, in which nations across the world pledged $14bn over the next three to support efforts against AIDS, Tuberculosis and Malaria, was hard-won in the face of real challenges. Yet more work can and needs to be done to fight this disease. A child dies from malaria – an entirely preventable and treatable disease – every two minutes, and there’s a disparity in funding: an extra $2bn a year is needed to truly make process against the disease. We need to step up the fight against malaria, a point that World Malaria Day tries to make.

But this year’s World Malaria Day is unique. World Malaria Day today is mired in the coronavirus outbreak. It means, on one level, that all of the events scheduled for the day have been moved online – in-person events have been replaced with webinars – but on a more practical, real level, in malaria-endemic regions where health systems are by and large hugely limited, efforts need to be made not only to prevent the transmission of malaria, but also to stop the spread of the coronavirus. Two health issues, both of equal importance, that need to be tackled concurrently. The question is, in the coming months as the coronavirus continues to spread across Africa, how will global health organisations adapt to curb transmission of the coronavirus and maintain vital interventions against malaria? And given the limited nature of the healthcare systems in which they’re working, can the two objectives really be achieved at once? If they can’t, what might that look like for deaths?

New data modelling published this week by the WHO shines some light on this. It states that, if access to insecticide-treated bed nets, for example, was severely disrupted, malaria deaths could double this year. In a stark warning, the data suggests that in a worst-case scenario, in which all bed net distribution campaigns were halted and access to malaria drugs fell by 75%, malaria deaths would reach nearly 800,000 this year, which represents a return to death levels in the year 2000. The race is truly on to accelerate access to malaria control interventions before the coronavirus takes hold and lockdown measures are put in place. So how will global health programmes capitalise on this window of opportunity and how will malaria control programmes adapt?

Joining me to discuss these pertinent issues is Dr Melanie Renshaw, who is the Chief Policy Officer of the RBM Partnership to End Malaria. It was created in 1998 by the WHO, UNICEF, UNDP and the World Bank to accelerate progress against malaria.

Dr Melanie Renshaw, thanks for joining me. How are you doing today?

I’m okay, thank you. And you?

Not too bad, thanks. Not too bad. It’s very hot over here in England. I’m not sure where you’re based, but it’s hot.

Normally I’m based in Kenya, but I’m in the UK for lockdown. Yeah, it’s humid.

This year’s theme of World Malaria Day – Zero Malaria Starts With Me – seems to want to get everyone engaged in the fight against malaria. How do you hope the individuals in malaria-endemic regions will get involved, and similarly, those in non-malaria-endemic regions too?

In malaria-endemic regions, obviously, the populations are at risk of malaria. What we hope that they will do, and it’s particularly important given the COVID pandemic that’s affecting us all at the moment, is that every individual living in a malarious area has a responsibility to make sure that everybody is sleeping under a mosquito net, that if they haven’t got access to a mosquito net, that there is a demand for those mosquito nets. That if a child, especially a child under five, has a fever, that they are taken to a health facility and that they do receive malaria treatment and diagnosis. If there’s indoor residual spraying taking place, that everybody accepts the spray people to come into their houses and spray their houses so that we don’t have refusals. That health workers are engaged and recognised, obviously, that malaria is an important issue in the context of the COVID outbreak and continue to provide treatment. We need the decision-makers across multiple sectors, so Ministers of Health, Ministers of Finance, Ministers of Environment, engaged in the fight against malaria, because it’s a multi-sectoral issue. We also want the heads of state, who actually launch the Zero Malaria Starts With Me campaign a couple of years back, to similarly continue to prioritise malaria at the highest level, ensuring that resources are sufficient, ensuring that malaria services and other essential services are sustained during the COVID outbreak because the approach has to be different in Africa compared to, say, the UK.

If you are from a non-endemic country, it’s important for global solidarity. This is a disease that is killing children under five. It’s an unacceptable number of deaths that we have every year, particularly in Africa, which bears 93% of the cases and deaths. And it’s about ensuring that resources are still available from bilateral governments, that malaria is still going to be prioritised. Obviously, we’re entering into uncertain times and it’s about showing that malaria is something we can prevent and treat. It’s something that we should prevent and treat. And so as global solidarity, it’s something that we should all fight together so that we can eventually eliminate malaria. So, therefore, Zero Malaria Starts With Me is relevant anywhere in the world.

You mentioned global solidarity and last year’s replenishment of The Global Fund was hard-won and a major victory for international development. But there’s still a $2bn disparity between current funding levels and what’s needed. How will you ensure sustained investment, continued political commitment, given that the message of getting ‘back on track’ has been going for a number of years now?

So, throughout this COVID pandemic year, we’re working with the countries at the moment to submit their Global Fund applications for malaria. The window one countries, the first wave, have gone in and they’re going to be reviewed in the next week. The next wave is coming in, which countries are actually struggling a little bit with because they’re obviously all not able to get together to work on their applications. But what we’re really supporting the countries to do is have the best available data that they can possibly have, subnational stratification, for example, and then to design, with the resources available, the absolutely most impactful best package of interventions that they can possibly direct to highest-burden areas, most cost-effective, looking for value for money, looking for savings, so in the event that we don’t fill the full $2bn a year, that we absolutely get the maximum impact from the resources that we have. Obviously, it would be fantastic if we were going to get that extra $2 billion a year, but in the unlikely current environment…One of the beauties of The Global Fund replenishment was it actually means that more than 95%, I think, of the countries in Africa, where the highest burden of malaria is, will be getting significant increases in the resources that they’ve had previously. So that really allows them to direct additional interventions at the highest-burden areas where we have the highest mortality to actually make a very significant difference.

What we’ve had over the last couple of years with The Global Fund – they come in 3-year rounds – is more of a stagnation, a small decrease in the resources. And now this is really the first time in a decade that we’ve been able to actually direct significantly increased resources to malaria-endemic countries in the highest-burden areas, and that includes many of the Western Central African countries that have been falling behind to a degree and many of the highest-burden countries that have also been falling behind to a degree. And so it’s actually, I think, an extremely positive moment in the malaria fight because if we program these extra Global Fund resources effectively, and I believe that’s what’s happening as I’m speaking to you, we will begin to see significant gains. Showing those significant gains, showing the value for money is also a way of sustaining both the attention of donors because this is a global health success. But also of the endemic countries, they start to see the reductions in cases, reduced pressure on the health system, economic gains from removing and reducing malaria from certain areas, and so enhanced domestic resource commitments from both the endemic country governments, but also the private sectors within those endemic countries.

We’ve seen a couple of countries, Zambia is one, that have launched a multi-sectoral malaria fund, which also is an opportunity for subnational resource mobilisation. Or you can give resources nationally and contribute to the overall malaria programming in Zambia. President Kenyatta, the chair of the African Leaders Malaria Alliance (ALMA), is recommending that countries also use similar approaches. So, securing high-level political attention, including resources from government, and then also ensuring that key decision-makers, including the private sector at a national and subnational level, are engaged in the fight against malaria.

You mentioned the coronavirus earlier and how it is not only interrupting global health strategy – people can’t meet anymore – but also poses a serious global health threat. How might malaria control programmes change and adapt?

WHO just released today on an interesting and very alarming model. And, of course, it’s always a perfect storm. It’s never just one thing that hits you. 2020 is the year of all of the big mosquito net campaigns. So something like 29 of the countries are doing their universal coverage campaigns, where basically everyone in the community will get their mosquito net. Obviously, that is going to be more difficult during a lockdown. So we have been working – the RBM Partnership, with WHO and other partners – to give guidance to countries on how to modify and LLIN campaigns in a COVID pandemic. That means switching largely to a door-to-door distribution, so instead of having crowds coming together collecting their mosquito nets, it instead means you go from house to house to house, without physical contact, handing over the mosquito nets, which is much more expensive, and it is more time-consuming. But it means that we can still continue to distribute nets safely during the pandemic. And that’s very much based on experiences from the Ebola outbreak in West Africa. A couple of years back where both Liberia and Sierra Leone successfully carried out their LLIN campaigns during the Ebola outbreak.

So we’re giving advice and guidance to countries. It’s remote because normally we would send additional consultants into countries to really help them to plan something like that, but instead, we’ve got remote teams of consultants providing backstopping support to countries. And we’re working particularly with The Global Fund, but also US government, PMI – the two biggest funders of malaria – to look at how do we secure those additional resources to ensure that, for example, an LLIN campaign can go ahead with this door-to-door, more expensive approach. So that means reprogramming resources. But The Global Fund have also introduced new flexibility and additional resources freed up that we can then use to ensure that we sustain malaria services, HIV and TB services and essential health services during the pandemic. So we’re also supporting countries to make sure that they have sufficient supplies.

We are checking country by country – speaking to every country actually – to see what their supply situation is for their essential commodities. There are delays in some of the supplies coming, partly caused initially by shutdown in China, where a lot of commodities come from. But then as well, it’s now difficulties in shipping commodities. Other shutdowns in other countries, meaning things are not getting either exported or manufactured, so we’re working to identify what countries have gaps and are in danger of stocking out and then looking at how do we get drugs, particularly drugs and artemisinin-based combination therapies (ACTs) and rapid diagnostic tests (RDTs) to them quickly. That means we’re spending extra money, again, to airlift drugs into countries to be sure that they arrive in time and that there aren’t any bottlenecks.

We’re working hard on political advocacy. So President Kenyatta, again, the chair of the African Leaders Malaria Alliance, is writing to each of the heads of state of Africa, making a case for continuing the delivery of essential services, malaria ones particularly, during the COVID pandemic. At the same time today, the RBM Partnership with WHO, the African Leaders Malaria Alliance and The Global Fund are writing to each of the Ministers of Health of Africa outlining the support that we can provide and advocating that it is absolutely essential that case management is sustained in public health facilities and the community level.

The message that you stay at home if you’ve got a fever – which is the message here in the West or in China – does not work if you have malaria and you can die in 24 hours as a child under five. So it’s very important that it is possible through advocacy, making sure the commodities are there, making sure that health healthcare workers and people visiting health facilities are safe and not at risk of increased transmission of COVID-19, but that the malaria services are sustained. So we’re providing both political support, also the guidelines, the guidance is modified, of how to do malaria programming in this pandemic and then, at the same time, through regular calls with countries, we’re speaking to countries on a two-weekly basis, we’ve set up a regular check-in with the partners. If a bottleneck comes up, we can then work to see what we do about that bottleneck.

So it could be, for example, if there is no access – and hope this doesn’t come to this anywhere – no access to health facilities, either because the COVID pandemic is serious or there is a lack of confidence or people are afraid to go to health facilities, we could look out whether something like Mass Drug Administration, whether expanding the age groups for seasonal malaria chemoprevention (SMC), things like that might work. So it will be a learning by doing. But we have at least established a mechanism by which we hope to know when a bottleneck comes and then use everybody, all of the partners, to the best of our ability to try to address that. I think we have enough resources for the short term.

A lot is going to depend on what actually happens, and I guess we’re all watching and waiting and hoping it isn’t as bad in Africa as it is in other places. But we will do our best to make sure that, if a bottleneck comes up, the collective malaria partnership around the world will hopefully be able to help the countries to address the issues. It may be that some countries could – which is something we don’t encourage – could switch to going back to clinical diagnosis because they’re afraid of testing for COVID vs. malaria, but these are some of the things that we then will work through to see how we can sustain safe testing. Similarly, we’re tracking global supply availability to track that there isn’t a major bottleneck coming up in any of the particular commodities. Hopefully, there won’t be, but it will be good that we have a good idea of what’s coming down the pipeline and we also know what it is that countries need. There may be a significant increase in ACT consumption, because people with COVID, if there is a large increase in cases, might take antimalarials in Africa thinking it’s malaria, we want to make sure that there are plentiful supplies and that we can get to countries in good time.

There’s clearly, as you describe, an awful lot of pragmatism between partners, the WHO, The Global Fund and RBM. How disrupted, realistically though, will be obvious these global health programs. The WHO modelling that came out, one of the scenarios is a 75% reduction in access to malarial medicines. Do you think we might edge close to that figure or do you think we have it under control?

It’s impossible to say would be my answer to that, but I’m hoping the types of things that I’ve just been describing will mitigate against that. Certainly, that model also depends on no campaigns taking place at all this year while moving forward. As we speak, Benin is doing its universal coverage campaign for nets. At the end of the month, Guinea-Bissau will be doing theirs. Again, with the modified guidance, with taking care to make sure that mosquito nets are distributed safely from a COVID perspective, but also taking care to ensure that everybody who’s at risk gets their mosquito net. So I’m very confident that the LLINs campaigns, the vast majority of them, will hopefully be going ahead as planned with some slight delay because we’ve had to work on this new methodology. But as well, we certainly are hoping that similarly giving the message you have to still get malaria treatment, setting up community systems, or strengthening the community systems that are already there, to ensure that the most vulnerable have access to ACTs. I think we will be doing everything in our power to ensure that that 75% reduction in case management doesn’t happen.

And looking more generally about the global fight against malaria, one of the key milestones of the Global Technical Strategy for Malaria was at least ten countries would be certifiably malaria-free by 2020. That hasn’t happened, and it looks unlikely that that will happen in the years to come. In light of that, how will progress against malaria be measured going forward? Will those original milestones be adjusted? Will we see some new goals come out? How will pan out?

I checked in with WHO on this one because their targets were not the certification of elimination, it was for elimination. Their overall target is 35 countries by 2030, and they do strongly believe that they will be on track for that. And that needs to get to the thirty-five, at least 10 reaching one year of zero cases by 2020. So that was actually the target that they set themselves. It wasn’t certification as a goal, because certification is a process, a review, an analysis, and what is actually important is having zero indigenous cases. Some of these countries have been certified as having eliminated: Sri Lanka, Azerbaijan, Tajikistan, Algeria, but other countries like China, El Salvador, Malaysia, Timor-Leste, Bhutan, Cabo Verde, Belize and Iran are all considered by WHO to be on track, were considered by WHO to be on track, to have zero cases by 2020. So, I actually think – and this in my opinion, it’s not based on a consultation with anybody – this is probably going to be an easy target to achieve in the Global Technical Strategy. There are a significant number of countries that have significantly reduced their cases.

The bigger challenge will be the high burden to high impact countries, the 10 highest-burden countries in Africa plus India, having them achieve the 90% reduction in cases by 2030 and the 90% reduction in deaths by 2030. I’m hoping that the work that we’re doing at the moment, which is really looking at targeting the stratification, the best-case scenario of if we have these resources, how can we have maximum impact, will lead to a turnaround in acceleration towards 90%. And at the same time, we have new commodities coming through the pipeline. For example, insecticide resistance, of course, is a problem. What we’re seeing, and what we will be able to afford, is moving to PBO nets, which are able to tackle some of the impacts of insecticide resistance. And then we also have some pilot work going on in a few countries with next-generation nets, so not just pyrethroid-only nets, but nets with something else. We believe that they will also help us to have some significant gains in the fight against malaria.

2030 is 10 years away and we hope there will be better commodities moving forward including, and especially perhaps, for insecticide resistance management in Africa, which remains a threat. But generally, I don’t think WHO will change their targets. I think that the GTS targets were based on long and detailed modelling and analysis and consultation. I think what we’re all looking at, the RBM partnership is working on its next five-year strategy now, and we really will look at what will it take to accelerate progress? If this is the target, how do we achieve it? What more can we do? What should we do less of? What lessons can we learn? What are the country’s successes that we can amplify? I think it will be much more about the targets will stay, but how we make sure that we achieve them, how we track whether we’re on track.

Certainly a much stronger emphasis now on data, transparency of data, availability of data, quality of data, so we know in real-time if we are on track or off track and are able to act immediately if and when that happens, so you don’t find out six months after an epidemic or an upsurge that there was an epidemic or an upsurge, you find out almost immediately because you’re seeing the real-time data coming from a certain area and then you’re able to act in the real-time as well.

And where are we with data reporting? How far have we come with that and what kind of delays are we talking in terms of reporting?

I think we’ve come a huge way, and in particular, the last couple of years. One of the reasons for that is that countries’ general health information systems are significantly improving. There’s the DHIS2, which is the tool that the majority of countries are now using and rolling out and decentralising, that’s providing much better access to real-time data. If I, and I wouldn’t have access to a country’s DHIS2 but if they wanted to give me access, I could sit here and see what’s happening in district X, in country Y. What we tended to do in the olden days was rely on surveys. There was kind of a ‘well their routine health information system is so problematic, let’s do a survey to see where we are’. We’re seeing a lot more effort now going into strengthening that routine health information system. It includes enhanced training, mentoring, certainly a better tool. But then you can understand why, if I’d worked for 10 years in a health information system and nobody ever looks at my data and nobody gives me any feedback on my data, that I might not show a huge amount of enthusiasm about cross-checking information.

I think now that there’s so much more emphasis on the use of real-time data for real-time decision making to allow course correction in programming, to have specific modules within the DHIS2 for malaria so that partners can pull the data. WHO has been supporting malaria repositories within the DHIS2 which allows you then to have partner data in there, not just health facility data, increased data transparency agreements between partners. So when you want to know: how much have I spent in country X? It’s available. When are my commodities coming to country Y? It’s now available. I think we’re entering an era of much broader data sharing and, through that process as well, increased investment in data.

I’m hoping that out of this round of Global Fund applications in the resilience and sustainable services for health component that we will see – and I’m sure we will, we’ve seen it already in the first window – requests for significant increased investments in that routine data collection. WHO made surveillance a key pillar, an intervention in fact, in the Global Technical Strategy. I think it’s taken a while for that to bite, but I do think we’re in a moment where that the confidence in data is increasing, the use of data are increasing and I think we’ll be having much higher quality data as a result.

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