Collaborating towards a malaria-free East Africa: A look at the milestones and achievements

Africa continues to bear the highest malaria burden. According to WHO’s World Malaria Report 2022, 96 percent of all malaria cases (238 million cases) and 98 percent of all malaria deaths (603,877 deaths) occurred in Africa in 2021. Nearly 77 percent of malaria deaths were among children under the age of five. While eight percent of deaths in children under the age of five globally are due to malaria, in Sub-Saharan Africa, this percentage is higher, at 17 percent.

This burden undermines the continent’s collective social and economic development, and is a barrier to achieving the objectives of Africa’s development blueprint – Agenda 2063, captured in the catchphrase, “The Africa We Want”.  The elimination of malaria on the continent is part of the agenda.

Currently, Africa is on track to achieve malaria elimination by 2030. However, significant progress is achievable when there is strong political will, country ownership, solid partnership, adequate resources, and a shared sense of urgency.

East Africa accounts for a quarter of the global malaria cases, making it a significant area of focus in the global fight against malaria. Countries in the region have made notable progress in reducing malaria cases and deaths over the past decade by implementing insecticide-treated nets, improved diagnostic testing, and effective treatment with antimalarial medications. However, malaria still poses a major health challenge in the region, especially in rural and remote areas with limited access to healthcare services.

This year’s World Malaria Day theme, “Time to Deliver Zero Malaria: Invest, Innovate, Implement,” underscores the urgent need for action and further investment to achieve zero malaria. The theme highlights maximising the impact of current investments by expanding existing interventions, and calls for celebrating research community efforts and encouraging more investment in transformative tools.

Biological risks are threatening progress against malaria

Malaria elimination faces numerous challenges, including the emergence of resistance to antimalarials by the malaria parasite, and increasing resistance to insecticides by the mosquitoes that transmit it. Furthermore, the migration of the An. stephensi mosquito (which transmits malaria in urban areas) from South Asia and the Middle East to Africa, exacerbates these challenges, reducing the effectiveness of current tools and increasing costs, with the potential for malaria resurgence.

Partial resistance to existing anti-malaria medicines has been reported in Burkina Faso, Angola, Rwanda, and Uganda, highlighting the need for continuous monitoring of antimalarial efficacy and updating national treatment policies and guidelines, including introducing new antimalarial medicines.

Malaria parasite mutations pose another challenge by hindering the detection of the disease through rapid diagnostic tests (mRDTs), as they no longer produce the protein essential for detection. This results in inaccurate and inappropriate diagnosis and treatment of malaria cases.

The good news is that next-generation commodities such as new mosquito nets and insecticides for indoor residual spraying are available, and new malaria medicines exist. However, these are more expensive than the traditionally used commodities. Partners must support market shaping for next-generation commodities to reduce costs.

Significant investments are still required

Significant investments are still required to increase coverage of key interventions and achieve the ambitious goal of eliminating malaria by 2030. For example, Kenya, Tanzania, and Uganda have insufficient resources to fully implement their respective Malaria Strategic Plans, with a shortfall of at least 50 percent. 

Accelerating progress against malaria requires countries to have sufficient resources to deploy tailored, locally appropriate, life-saving interventions at scale, based on malaria transmission settings. Existing and pledged resources are insufficient to fully support malaria programmes, especially in the face of global inflation, supply chain disruptions, and other economic shocks such as the crisis in Ukraine and the impact of the Covid-19 pandemic.

While the global community’s pledge of $15.7 billion to replenish The Global Fund is highly welcome, it remains of concern that this fell short of the replenishment’s $18 billion target. Mobilising additional resources, including from the domestic public and private sectors, must be a priority for getting back on track to ending malaria.

Upon assuming the ALMA chairmanship in August 2022, His Excellency President Umaro Sissoco Embaló, President of the Republic of Guinea Bissau, prioritised a four-point agenda that emphasises multi-sectoral advocacy, action, and resource mobilisation to close funding gaps; harnessing of data for accountability and action; engaging a robust continental youth corps; and enhancing regional and cross-border coordination in the fight against malaria.

Multi-sectoral advocacy and resource mobilisation

Mobilising additional resources, including from the domestic private sector, remains crucial for increasing access to insecticide-treated nets, indoor residual spraying, rapid diagnostic tests and malaria medicines, as well as supporting the development and rollout of new tools.

To date, 12 countries have launched or announced End Malaria Councils and End Malaria Funds (EMCs and EMFs), with another 13 in progress. Several have integrated EMCs into national strategies as the primary mechanism for mobilising multi-sectoral advocacy, action, and resources. Over $32 million has been raised by the councils and funds to date, and malaria has been kept high on the agenda in these countries. These high-level, multi-sectoral councils work to maintain malaria high on the development and financing agenda.

In Kenya, the End Malaria Council has launched a national taskforce to develop a plan for locally manufacturing malaria commodities, such as malaria Rapid Diagnostic Tests, with catalytic funding to support manufacturers seeking pre-qualification. This initiative is aimed at boosting the country’s overall efforts to combat malaria.

Additionally, the council has partnered with SC Johnson in a five-year commitment, with an initial investment of $400,000 and an additional $1 million for Social and Behaviour Change Communication (SBCC) and vector control. This partnership supports vector control, including an initial pilot of drone-based larval source management, communications, and local manufacturing of health commodities.

The council has also supported the launch of the Kenya Youth Army and the Great Lakes Malaria Initiative, further strengthening its efforts to eliminate malaria in the region.

In Uganda, Malaria Free Uganda (MFU) has made significant strides in the fight against malaria. Through a partnership with the private sector, MFU trained over 6,000 health workers on malaria testing and treatment, and worked with the Uganda Parliamentary Forum on Malaria to support advocacy efforts.

The council organised a national communications campaign to raise awareness of malaria and educate people on how to prevent and treat the disease. Additionally, the council supported training of private sector pharmacy and health workers on malaria best practices in more than 25 districts, including regions experiencing malaria upsurges.

To combat malaria in urban areas, the council mobilised resources to support vector control activities. Furthermore, the council coordinates with the Zero Malaria Business Leaders Initiative (ZMBLI) to mobilise financial contributions from the private sector, further strengthening Uganda’s efforts in the fight against malaria.

In addition to the EMCs in Kenya and Uganda, Tanzania, and Rwanda are also working to establish their own EMCs. Tanzania announced its EMC in 2023, while Rwanda made a similar announcement during the Kigali Summit on Malaria & Neglected Tropical Diseases (NTDs) in June 2022. Burundi is also planning their launch in 2023.

These initiatives by the EMCs in the region are contributing towards ending malaria in their respective countries. In some cases, the councils also address neglected tropical diseases (NTDs) and broader health issues.

Malaria is a clear pathfinder for pandemic preparedness and response

Investing in ending malaria has a high return on investment. Research has shown that for every $1 invested in ending malaria, the economic return on that investment is estimated to be $26.

Reducing malaria transmission results in improved health outcomes, increased productivity, and reduced healthcare costs, which in turn contributes to economic growth. Therefore, investing in ending malaria not only saves lives, but also has a significant positive impact on the economy.

Furthermore, investments such as for community health workers and enhanced disease surveillance, will strengthen Africa’s health systems’ capacity and resilience to respond to future epidemics and pandemics. Strengthening the capacity of countries to defeat malaria will enhance broader pandemic preparedness and response. 

The Covid-19 pandemic and other disease outbreaks (for example, Ebola) have contributed to increased awareness and political will for addressing health crises. In response, the global community is working to strengthen health systems to be better prepared for the next disease outbreak and address existing health threats (e.g., malaria, HIV/AIDS, TB, and NTDs).

Malaria is a pathfinder for pandemic preparedness and response. Through investments in malaria prevention, diagnostic testing, and treatment, countries and development partners have an opportunity to strengthen health systems, including expanding community health worker programmes, enhancing digital tools for disease surveillance and detection, sharing real-time data, increasing the capacity of national laboratories, and strengthening supply chains.

Community Health Workers (CHWs) are uniquely positioned to strengthen the fight against malaria and the pandemic preparedness and response. Having a robust and well-trained network of CHWs within the primary health care system can provide quality data and early warning for disease outbreaks by expanding the reach of disease surveillance into communities, including those that are hard to reach. CHWs also reduce the burden on health facilities and remove barriers to accessing health care services by testing, treating, and triaging cases and educating at-risk populations on health issues within their communities.

Use of data for accountability and action

Access to quality, real-time data is important for driving decision-making and action. Improving data quality and availability, including by pooling data into malaria repositories, and using data to drive action and accountability through scorecard management tools, enables policymakers, health administrators, and partners to systematically identify and respond to upsurges and operational bottlenecks. Use of subnational data has enabled countries to undertake subnational stratification and target malaria interventions to maximise impact.

The ALMA Scorecard for Accountability and Action, regional scorecards, national scorecards, and community scorecards, continue to drive action, including enhanced resource commitments, addressing emergencies and upsurges, facilitating commodity procurement and intervention deployment, and enhancing the availability and quality of data.

East African countries, including Kenya, Uganda, Rwanda, Burundi, and Tanzania, have adopted national malaria control and elimination scorecards, and are enhancing their response to national accountability mechanisms.

Kenya has linked their malaria scorecard to DHIS2 and decentralised it to country level. In Tanzania, 90 members of parliament were trained in the use of the malaria scorecard. The countries are demonstrating their commitment to fighting malaria by sharing their scorecards on the ALMA scorecard hub and with partners, and by documenting best practices at the local level.

Several countries have also been recognised for their successes in related areas. Kenya won an award for the best reproductive, maternal, new-born, child and adolescent health (RMNCAH) scorecard tool; the Republic of the Congo for the best neglected tropical disease scorecard tool; Ethiopia for the best community scorecard tool; Rwanda for the best institutionalisation of scorecard tools across malaria and RMNCAH; and the United Republic of Tanzania for the best innovative use of scorecard tools. These awards reflect the countries’ broader commitment to improving health outcomes, not just for malaria, but also for NTDs, RMNCAH, and overall health.”

Member states are recruiting youth to champion the fight against malaria

Youth are an important constituency under the African Union’s development agenda. African youth account for 60 percent of the population, representing the largest segment of the population. Their passion, innovation, and creativity have vast potential to contribute significantly to the fight against malaria.

At the urging of the ALMA Chair, member states are establishing national campaigns to coordinate youth as the next generation of malaria leaders. Kenya, Eswatini, Zambia, Mozambique, Uganda, and Tanzania, have established their national ‘malaria youth corps’, whilst efforts are underway to establish similar initiatives in other countries.

Kenya was the first country in the region to launch its national malaria youth corps. The Kenya Malaria Youth Corps celebrated its first anniversary with community engagement activities in Busia County, the most malaria-endemic county in the country.

The activities included door-to-door sensitisation, a malaria walk, and school visits.

The corps drives conversations on malaria through social media, generating an average of 49,000 impressions monthly. Additionally, the corps coordinates logistics and planning for World Malaria Day, holds roadshows in three malaria-endemic counties, and presents malaria edutainment to the community.

The corps also drives extensive malaria awareness in communities through TV and radio, and supports the dissemination of the Kenya Malaria Social and Behaviour Change (SBC) strategy at the county level.

In addition, the corps is part of the Country Coordinating Mechanism for the Global Fund, where it contributes ideas and strategies, and has pitched concepts for funding for community-led advocacy and research to different potential funders. In February 2023 at the KEMRI Annual Scientific and Health (KASH) Conference, the corps presented its innovative approach to effective malaria surveillance in Kenya.

Tanzania also launched its youth corps in 2022. As part of their efforts to combat malaria, youth champions in Tanzania participated in a community biolarvicide spraying in Dodoma on World Malaria Day, further strengthening their commitment to eliminating malaria in the country.

The Zero Malaria Starts with Me campaign is a framework for multi-sectoral advocacy and action

Since 2018, countries across Africa have been implementing the Zero Malaria Starts with Me campaign. This campaign promotes multi-sectoral advocacy, action and resource mobilisation as key success factors for malaria control and elimination.

In 2022, Burundi, Cabo Verde, Cameroon, and South Sudan launched the campaign, bringing the total number of countries that have launched it to 27.

Kenya launched its ‘Zero Malaria Starts with Me’ campaign in 2021, while Uganda initiated the “Zero Malaria Business Leadership Initiative” in partnership with the Ecobank Foundation, to mobilise private sector advocacy and resources.

Regional and cross-border coordination

Malaria and the mosquitoes that transmit it do not recognise national borders. Furthermore, the region is increasingly interconnected with significant cross-border movement across the continent. Thus, an effective malaria response often requires cross-border collaboration and coordination.

The Great Lakes Malaria Initiative (GLMI) is a cross-border programme working towards the elimination of malaria in six East African countries: Burundi, Kenya, Rwanda, Tanzania, Uganda, and the Democratic Republic of Congo. It aims to reduce the malaria burden in the region through harmonised malaria control and elimination strategies, increased domestic financing, and cross-border collaboration.

The initiative serves as a model for other cross-border programmes and highlights the power of regional collaboration in the fight against malaria. The GLMI also supports joint coordination efforts in the East African Community (EAC), including technical working groups, joint monitoring, and reporting to EAC ministers of health.

To facilitate cross-border collaboration, the initiative promotes joint planning and implementation of interventions along the Rwanda-Tanzania and Uganda-Kenya borders. Work is also underway to develop a draft regional framework for communication, advocacy, and community engagement, strengthening the GLMI’s efforts to eliminate malaria in the region and contributing to the global goal of eliminating malaria by 2030.

Local manufacturing can enhance regional resilience and growth

Investment in local manufacturing can enhance regional resilience and growth in Africa. Efforts are being made to promote local production of health commodities to ensure their affordability, accessibility, and long-term sustainability, as well as to support regional economic development. However, challenges to manufacturing life-saving local commodities in Africa remain.

Access to life-saving commodities is essential to sustain malaria services and accelerate progress. African countries require access to critical malaria commodities such as insecticide-treated nets, rapid diagnostic tests, artemisinin-based combination therapies (ACTs), and new insecticides.

Ongoing efforts to promote local manufacturing include strengthening infrastructure, technology transfer to produce next-generation nets in Tanzania, and WHO prequalification for malaria rapid diagnostic tests and market access in Kenya. The use of Piperonyl butoxide (PBO) nets or dual insecticide nets has led to significant decreases in malaria cases by more than 40 percent in Tanzania and Malawi. Countries are also using new insecticides for indoor residual spraying. 

Conclusion

As the fight against malaria continues in East Africa, governments, organisations, and communities are working tirelessly to combat this deadly disease. The End Malaria Councils in Kenya and Uganda are making significant strides towards multi-sectoral advocacy and resource mobilisation, while the Great Lakes Malaria Initiative (GLMI) is a testament to the power of cross-border collaboration in the fight against malaria.

Additionally, the adoption of national malaria control and elimination scorecards in East African countries is helping to increase accountability and progress towards malaria elimination goals.

Efforts to promote local manufacturing of malaria commodities in Africa are also underway, with the aim of ensuring affordability, accessibility, and long-term sustainability of life-saving commodities.

The involvement of youth in initiatives highlights the importance of engaging the next generation in the fight against malaria. While challenges remain, the time to deliver zero malaria in Africa is now, and it will require continued investment, innovation, and implementation efforts.

The progress made in the region gives hope that the global goal of eliminating malaria by 2030 can be achieved with continued collaboration, innovation, and investment.