Can Malawi eradicate malaria?

Malawi has an exciting and ambitious vision for malaria. In the 2011-2016 National Malaria Strategic Plan, government envisions a malaria-free Malawi. However, with just few months to 2016, the malaria situation on the ground—if taken from the 2014 Malaria Indicator Survey released in February this year—is not so promising.

The survey shows that despite a drop in prevalence from 43 percent in 2010 to 33 percent last year, malaria continues to be a major public health problem in Malawi, with an estimated four million cases occurring annually.

So, when the malaria strategic plan envisions a malaria-free Malawi, is that a realistic goal or just a bark on the moon?

The notion of envisioning nations free from malaria was quite robust and rampant in the 1960s when the Global Programme for Malaria Eradication came into effect.

The programme, however, failed to materialise. By 1969, it had completely become lifeless. Its death, unfortunately, killed every steam of envisioning prospects of malaria eradication. Nations, as a result, turned into malaria control, not eradication.

However, in October 2007 the goal of malaria eradication was resurrected by the Bill and Melinda Gates Foundation, and the aspiration was subsequently endorsed by the World Health Organisation (WHO) and by the Roll Back Malaria Partnership.

This change in direction of malaria control, experts argue, provoked a vigorous debate within the malaria research and control communities as to whether resurrection of the goal of eradication at this point in time is helpful or likely to be counterproductive.

The consensus that has emerged is that eradication of malaria, although theoretically possible, is not likely to be feasible within the medium term using existing control tools.

However, malaria elimination—mostly cessation of local transmission—is a realistic short- to medium-term goal for an increasing number of countries that are already bringing malaria under control.

Though Malawi, currently, is stuck at malaria control with a prevalence rate of 33 percent, some countries in the sub-Saharan Africa have eliminated the pandemic and are moving towards it.

Just two years ago, South Africa, Swaziland, Zambia, Namibia and Mozambique received the 2013 African Leaders Malaria Alliance Award (ALMA) Award during African Union Summit held in Addis-Ababa in January 2013.

They were rewarded for commitment in eliminating malaria—and all these countries, today, have almost eliminated the pandemic.

As part of cementing the successes, Sadc has developed initiatives to bring together Sadc member States for the best control of malaria in the region.

Some of them include the Sadc Malaria Strategic Framework, the Sadc Malaria Elimination Framework, the Sadc Malaria Advocacy and Communication Strategy, Sadc Malaria Minimum Standards for Prevention and Treatment and Management of Malaria.

In addition, Sadc is actually implementing the Elimination 8 (E8) which is an initiative for malaria elimination in eight member States comprising four frontline countries: Botswana, Namibia, South Africa and Swaziland, and four second-line countries: Angola, Mozambique, Zambia and Zimbabwe.

The incidence of malaria in the four first-line countries of elimination is almost less than one case per 1 000 people per year.

The pressure is on Malawi. Interestingly, in Zambia, as in other countries that eliminated the pandemic, government only scaled up its nationwide efforts to improve diagnosis and treatment, expanded use of insecticide-treated nets (ITNs) and indoor residual spraying (IRS).

In a 2011 study Malaria Elimination in Malawi: Research Needs in Highly Endemic, Poverty-stricken Contexts, College of Medicine lecturer Dr Don Mathanga notes that in zones of intense and stable transmission, like Malawi, elimination poses particularly thorny challenges—and these challengers are different from those of traditional control and prevention activities.

Working towards elimination, they add, will require knowledge of how various interventions impact on transmission as it approaches very low levels.

“At present, Malawi is faced with immediate, context-specific problems of scaling up prevention and control activities simply to begin reducing infection and disease to tolerable levels.

“This backdrop of extreme poverty, limited resources, widespread, year-round, and intense transmission, and continued high rates of disease in Malawi, raises challenging issues about the knowledge needs for improving malaria control, let alone pursuing regional elimination,” reads the study.

So, can Malawi eliminate malaria?

Being a tropical country—which is unlike countries like South Africa, Botswana and Swaziland—Malawi, already, has a geographical disadvantage.

However, government is upbeat, says Ministry of Health spokesperson Henry Chimbali.

“Our goal is to eliminate malaria and we know what it takes and how we can do it,” he challenges.

However, Mathanga and others argue that the pathway towards elimination in Malawi must be carefully evaluated given the context of very high transmission, moderate anti-malaria activities and an underfunded health infrastructure.

What is key, even Chimbali agrees, is “adequate resources and extensive investment in malaria through research and programmatic activities”.

Already budgetary support to the health sector in the country is yet to reach the Abuja declaration of committing not less than 15 percent of the total budget to the health sector.

Health Rights and Education Programme (Hrep) executive director Maziko Matemba, who thinks Malawi can eliminate malaria, fears that the financing of malaria, with the withdrawal of The Global Fund, is quite an issue.

However, beyond that Mathanga and others note that Malawi’s engagement with its similarly poor neighbours (Mozambique, Zambia and Tanzania) will be essential in long-range planning and collaborative activities.

“Effective national malaria reduction in settings where regional transmission is intense cannot realistically aim at elimination unless all countries in the region achieve such success.

“Except in the unusual island-nation contexts, cross-border cooperation is essential as part of any elimination plan,” reads the study.

They conclude that the challenges of malaria control in Malawi are formidable, and will certainly be more effectively addressed as increased resources are directed at that problem.