by 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. 

Today 94% of the world’s 249 million malaria cases are in Africa. Children under five, pregnant women, migrant populations, and refugees are disproportionately affected by the disease. To address this burden, health ministers from 11 high-burden African countries signed the Yaoundé Declaration earlier this year. These 11 countries committed to accelerating the fight against malaria and reducing malaria-related deaths by increasing domestic malaria financing and ensuring equitable access to high-quality essential malaria services. 

This is a welcome declaration from high-burden African countries. But a similar commitment accompanied by tangible actions is required from all African malaria-endemic countries, irrespective of malaria burden. 

In 2016 the African Union released its catalytic framework to end HIV, tuberculosis, and malaria in Africa by 2030. Despite being signatories of the framework, political commitment by African governments has not translated into increases in domestic investment in malaria control. Between 2021 and 2023 funding for malaria control decreased by $4.8 billion greatly limiting the breadth of control measures that can be effectively implemented. 

South Africa is one of the few malaria-endemic African countries whose malaria control programme has been and continues to be almost entirely domestically funded. This has allowed the country to implement interventions in a sustained manner and support research that allows for evidence-based decision-making, collectively contributing to significant decreases in malaria cases. However, the hope of eliminating malaria is being threatened by an ever-increasing funding gap. High-level political support for malaria elimination has not translated to increased investment in malaria elimination on the ground. Competing health priorities and the perception that malaria elimination requires less funding are partly to blame.

Malaria rebounds quickly 

Malaria rebounds rapidly when control measures are not implemented sustainably with dire consequences. 

Sri Lanka had significantly reduced local transmission during the World Health Organisation (WHO) malaria eradication campaign in 1955. However, when the campaign ended abruptly, the country was unable to effectively implement the required interventions, resulting in an upsurge in cases. It took the country another 50 years to eliminate malaria. 

Addressing the malaria burden in Africa only became a priority in 2000 when it was identified as a significant obstacle to global development and included as a target in the Millennium Development Goals. Between 2000 and 2015 there was increased international funding allowing national malaria programmes to implement effective malaria control measures.   As a result, malaria cases and deaths decreased significantly. Unfortunately, over this period domestic funding for malaria control hardly increased. 

Progress against malaria has stalled since 2016, with some countries reporting increases in malaria burden. There were two million more cases in 2022 compared to 2021. This is partly driven by decreases in international funding to implement essential control measures and surveillance activities. 

Rather counter-intuitively, malaria elimination costs more than malaria control.  In countries like South Africa, which is in the cusp of elimination, investment in malaria must be increased and sustained to prevent the re-establishment of malaria, particularly if they share borders with malaria-endemic countries.

The politics of malaria control

What is needed now is for the political will that’s been shown to be backed by solid financial commitments. Malaria control and politics have a long intertwined history dating back many years. The disease is thought to have evolved in Africa, and spread across the globe through colonisation efforts and the forced migration of labourers from Africa to other parts of the world. 

Victory in wars and advances in the name of colonisation were severely impacted by malaria. The French abandoned the construction of the Panama Canal in central America in the late 1880s due to the debilitating effects of malaria on the workforce. More soldiers died from malaria than from combat during World War I. 

Ironically, we have world wars and colonisation efforts to thank for the development and implementation of large-scale control measures too. 

The construction of the Panama Canal was completed only after an integrated programme to control mosquitoes and infection was implemented. The plan included draining water bodies, treating water bodies that could not be drained with chemicals to kill the mosquito larvae, killing adult mosquitoes with insecticides, screening of living quarters and office buildings and administering quinine to all construction workers on a daily basis. Wide-scale implementation of many of these measures including spraying houses with the insecticide DDT, led to the US eliminating malaria by 1949. – Health-e News