Dr Jaishree Raman is a Principal Medical Scientist and the head of the Laboratory for Antimalarial Resistance Monitoring and Malaria Operational Research at South Africa’s National Institute for Communicable Diseases. 

Malaria exerts a huge public health burden on communities within the Southern African Development Community (SADC). More than three-quarters of the region’s population live in malaria-risk areas. 

The disease is endemic to 14 of the 16 countries that make up the SADC region. These countries are: Angola, Botswana, Comoros, Democratic Republic of Congo, Eswatini, Madagascar, Malawi, Mauritius, Mozambique, Namibia, South Africa, Tanzania, Zambia, and Zimbabwe. 

The malaria risk varies widely within and between the countries.

Four SADC countries (Angola, the Democratic Republic of Congo, Mozambique and Tanzania) account for approximately a quarter of the global malaria burden.

On the other extreme, Mauritius has eliminated malaria and is preventing the reintroduction of malaria. Botswana, Eswatini, and South Africa are identified by the World Health Organisation (WHO) as having the potential to eliminate malaria by 2025. 

This extreme range in malaria transmission intensity across the SADC region poses a major challenge to the Windhoek Declaration, where the SADC Heads of States committed to achieving a malaria-free region by 2030.

Regional response is crucial

The SADC region is characterised by very high levels of population movement through formal and informal border crossings. These highly mobile populations pose a challenge to controlling the spread of infectious diseases. We saw this clearly with the rapid spread of COVID-19 through the movement of people. 

To reduce the chances of the disease spreading through mobile populations, eight SADC countries have implemented malaria border surveillance units. These countries are collectively known as the Elimination Eight (E8).  

These surveillance units test and treat border communities and mobile populations at the community level, and provide malaria health education. The units have contributed to significant reductions in malaria in certain border regions. But their sustainability is under threat.

Challenges 

Most of the national malaria programmes in the SADC region are almost totally dependent on international donors like the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the President’s Malaria Initiative for consumable procurement and intervention implementation. 

During the 7th replenishment of the Global Fund in 2022 over $14 billion was raised. However, this sum fell short of the required $18 billion. As a result of this shortfall, national programmes must now prioritise activities based on their potential impact, cost-effectiveness, and donor priority. 

Another dynamic to the challenge of malaria elimination is related to the disease itself. 

Malaria parasites are becoming resistant to the widely used treatment known as artemisinin-based combination therapies. These parasites are also evading histidine-rich protein 2-based rapid diagnostic tests. And now they are rapidly spreading across east and central Africa. 

In parallel, the mosquito vector is becoming resistant to insecticides used in the mainstays of vector control. These insecticides are used for indoor residual spraying, and insecticide-treated bednets. 

And an urban malaria vector from Asia, Anopheles stephensi, has become entrenched in the Horn of Africa. It’s beginning to spread into other regions of Africa. Should resistant parasites and vectors and/or An. stephensi mosquitoes become established in the SADC region, then the goal of having a malaria-free SADC region would become even more challenging.

What must be done

If malaria elimination is to be achieved across the SADC region, it is imperative that domestic investment in malaria is significantly increased to ensure sustainability and the funding of individual country priorities. 

Together with increasing domestic funding, malaria-endemic countries need to strengthen their malaria surveillance systems. 

In its Global Technical Strategy for Malaria, the WHO highlighted the importance of a strong surveillance system, particularly in countries trying to eliminate malaria. 

Without accurate, current intelligence on the malaria parasites and vectors, malaria hotspots and the drivers of malaria, countries are unable to select and appropriately targeted interventions based on evidence for optimal impact.

The need for strong surveillance systems and the prompt sharing of malaria data across the SADC region has never been more urgent. Regional platforms for the routine sharing of malaria case and resistance data as well as regional containment and response plans must be established as a matter of urgency.

To ensure that these data-sharing platforms report accurate data it is critical that national malaria programmes are staffed with an appropriately qualified cadre of staff at all levels. In addition, it is imperative that there is strong political support for malaria programmes, and that these programmes are led by individuals equipped with critical-thinking skills. They must be capable of rapidly pivoting to novel strategies when faced with unforeseen challenges like climate change or novel pandemics.

Vaccines and new treatments 

Despite these challenges, with strong collaboration and investments, the SADC region can achieve its goal of having a malaria-free region. 

The rollout of the first WHO-approved malaria vaccine has resulted in dramatic decreases in childhood mortality. These positive outcomes will be greatly enhanced once the second WHO-approved malaria vaccine is deployed more widely. 

New formulations of effective insecticides are now available and novel technologies like gene drive and sugar-baited traps are demonstrating high levels of efficacy in preliminary trials. – Health-e News 

SADC Malaria Day is marked every year on the 6^th of November.