Africa’s malaria problems: bottomless pit for funds?

The world’s first successful malaria vaccine is expected to be used across the globe, but before this, preparations have begun this year for young children in Ghana, Malawi and Kenya to be immunised first with the vaccine in selected areas under a pilot Malaria Vaccine Implementation Programme (MVIP) for further evaluation

The World Health Organization (WHO) is coordinating the MVIP in collaboration with the health ministries of the three countries and international partners.

During the programme, several outstanding questions related to the public health use of the RTS, S vaccine is expected to be addressed including the vaccine’s role in reducing childhood deaths and its safety in the context of routine use.

The expectation is that data and information from the MVIP will inform a WHO policy recommendation on the broader use of the vaccine across the globe.

The vaccine would serve as a complementary malaria control tool that could be added to recommended preventive, diagnostic and treatment measures.

The journey of the vaccine from its birth in Europe to Africa has been decades of grit, fortitude and huge financial investments.

Several years ago, Joe Cohen, started serious business on the malaria vaccine at the GSK laboratory in Europe, stretching himself beyond the rigorous and stringent scientific and quality requirements needed to create a potent vaccine, with a huge public health impact on children in Africa, the ultimate beneficiaries of this vaccine, who were then still in the womb of time.

In 1987, the management of the pharmaceutical giant, GSK, which is the manufacturer of the vaccine, had asked Dr. Cohen, co-inventor and the original patent holder of the RTS, S/AS02A malaria vaccine, to take over the leadership of GSK’s malaria vaccine project.

The RTS,S also known as Mosquirix™, was developed through partnerships between countries in the north and south of the globe together with a network of African researchers from Ghana, Kenya, Tanzania, Mozambique, Gabon, Malawi and Burkina Faso.

In 2001, the PATH/MVI entered into partnership with GSK to study the vaccine candidate’s ability to protect young children in sub-Saharan Africa.

The Malaria Clinical Trials Alliance (MCTA) of INDEPTH Network, an international non-governmental organization, which had its headquarters in Ghana, was created in 2006 with a grant of $17 million from the Bill & Melinda Gates Foundation to build the capacity of African scientists to carry out a Phase 3 study on the vaccine at eleven sites across Africa.

The culmination of these research activities has resulted today in the establishment of the MVIP. Financing for the MVIP has been mobilized through an unprecedented collaboration between major global health funding bodies such as Gavi, the Vaccine Alliance and the Global Fund to Fight AIDS, Tuberculosis and Malaria.

According to a WHO statement, the Global Fund to Fight AIDS, Tuberculosis and Malaria has already approved $15 million for the malaria vaccine pilot during the first phase of the programme.

Earlier, commitments of over $36 million, have also been made for the first four years of the vaccine programme.

Previously, there has been more than $200 million in grants from the Bill & Melinda Gates Foundation to advance the clinical development of RTS,S,.

There has also been a GSK investment of more than $350 million, including an additional $260 million expected from GSK, which has been secured for the vaccine project.

Malaria investments in Africa have become not only big business but it is increasingly turning out to be an unending cycle of continuous investments, to solve one of the continent’s biggest public health problems.

Investing into Africa’s age-old disease has not only been about the search for a successful malaria vaccine. The continent has been at the receiving end of investments in research and development, bed nets, anti-malarials and community sensitization programmes, among others.

Over 70 per cent of global malaria investments have been made in the WHO Africa Region.

Total funding for malaria control and elimination reached an estimated $2.7 billion in 2016. Contributions from governments of endemic countries amounted to $800 million, representing 31 per cent of funding.

Two years ago, the United States of America was the largest international source of malaria financing, providing $1 billion (38 per cent), followed by the United Kingdom of Great Britain and Northern Ireland and other international donors, including France, Germany and Japan.

Other investments in malaria appear to be revolving around organizing huge malaria forums, campaign and perhaps what could be described as talk shops.

Usually these malaria meetings are organized in a top-down approach and attended by so called experts and financiers, mapping out plans and projects for beneficiaries, who are way down at the bottom.

These beneficiaries are people at the local community or grass roots level, who are viewed as recipients of the great ideas from experts working in the field of the global malaria control and elimination agenda.

The year 2018 has seen an April London Summit, where $4.1 billion in funding for the fight against malaria was delivered.

As usual, this summit saw high profile people attending: heads of state and government, scientists, business leaders, philanthropists and other global health stakeholders. The aim was to gather at a high-level meeting to galvanize action and announce new and renewed commitments in the fight against the age-old disease.

The meeting, co-hosted by the United Kingdom government and leaders of Rwanda and Swaziland, was held alongside the Commonwealth Heads of State and Government Meeting.

This meeting on malaria was organised without the grassroots, the people who are most affected by the disease. About 90 per cent of Commonwealth citizens live in malaria-affected countries.

Other big conferences that took place around malaria this year, were the Multilateral Initiative on Malaria (MIM) Pan African Conference in Dakar, held in April and the World Malaria Congress, which took place a few months later in Australia.

Several money-spending malaria initiatives have also become very common these days, with Africa, as usual benefitting from the largesse of rich countries and international partners.

Talk of the 10+1 initiative to reduce the toll of malaria-related death and disease in Burkina Faso, Cameroon, Democratic Republic of the Congo, Ghana, Mali, Mozambique, Niger, Nigeria, Uganda and United Republic of Tanzania. The “+1” refers to India, which accounts for more than 60 per cent of all malaria cases outside of Africa.

Approximately 70 per cent of global malaria cases and deaths are concentrated in 10 countries in sub-Saharan Africa, as well as in India.

Another E8 Regional Initiative is aimed at ending transmission in four low-transmission “frontline countries”- Botswana, Namibia, South Africa, and Swaziland – by 2020.

This is to pave the way for elimination in four middle-to high-transmission “second line countries” – Angola, Mozambique, Zambia, and Zimbabwe – by 2030.

Yet another is the Sahel Malaria Elimination Initiative to scale up and sustain universal access to anti-malarial drugs and secure new financing towards malaria programmes in eight countries:  Burkina Faso, Cape Verde, Chad, Mali, Mauritania, Niger, Senegal and The Gambia.

This Initiative is supported by the region’s health ministers and partners including the WHO, the Economic Community of West African States (ECOWAS), the African Leaders Malaria Alliance (ALMA) and the RBM Partnership to End Malaria and Malaria No More, a partner of the RBM.

Why are there so many initiatives targeting the same disease on the continent at the same time? More importantly what are the real reasons for the unending investment in these initiatives and conferences in malaria, with a special focus on Africa?

Is it still a journey in search for new ways to curb the disease? And when is the arrival to secure malaria elimination for Africa, and then perhaps the global eradication agenda?

Tied up to the search for answers are the several expensive research activities on malaria still taking place around the globe.

What has happened to the outcomes of past research activities that have already received huge funding, right on the continent of Africa?

It is time to start counting how many of the outcomes of these research activities have been shared across countries on the continent or translated into policies that are currently being used to control the disease in Africa.

These researches are largely driven by international partners and friendly countries, with no malaria burdens.

Not quite too long ago, a $30 million Bill Gates facility was spent on an INDEPTH Effectiveness and Safety Studies project.  It was the largest phase and perhaps, the first – ever Phase 4 trials in Africa to test and gather data on the safety and effectiveness of anti-malaria drugs that were being used. The research was carried out in Ghana, Mozambique, Burkina Faso and Kenya.

How were the results of this study used in making sure anti-malaria drugs and health systems are strong? Have the results of this study been shared or translated into malaria policies or programme, beyond the countries, where the research took place?

It is concerning that over the last 50 years or so, malaria has been one of the major diseases that have globally dominated public health discussions and investments. Discussions have intensified with the elimination of malaria being moved to the front burner.

Malaria endemic countries in Africa must brace themselves for the numerous investment challenges ahead that are likely to hold back progress towards elimination.

Already, there are hints of serious financial setback in malaria control efforts. WHO has said that the plateau in malaria financing in recent years is a serious concern.

Apart from looking for continuous funding for drugs and other malaria tools, the threat of conflicts, which fuels the spread of malaria, anomalous climate patterns, emergence of parasite resistance to antimalarial medicines, mosquito resistance to insecticides and fake anti-malarials are other issues still contending for attention and investments.

Issues related to human behaviour and the environment are also hampering malaria control efforts.

There are huge investments being made in mass bed nets distribution across communities in Africa. But bed net ownership does not seem to be the big problem, rather its usage, as people are using these bed nets for fishing and other purposes.

African governments should think of how to judiciously use whatever malaria funds are still coming in from philanthropists such as Bill Gates, and benevolent countries including international partner organisations.

Domestic financing must also take centre-stage in the budget lines of individual African countries, if the continent’s leaders are serious about setbacks in progressing to the finishing line of elimination, which others like Paraguay have done.

In June this year, malaria programme managers from E-2020 countries, (countries on the way to elimination) convened in Costa Rica at a WHO global forum to map progress, review elimination strategies and share solutions to common challenges. On the opening day of the forum, WHO certified Paraguay as malaria-free – an event that made news headlines around the world.

The translation of malaria research into policy and sharing of research outcomes across endemic countries must be strengthened and vigorously pursued.

All stakeholders, including grassroots leaders, local chiefs, opinion leaders and other local community members, must be heard at meetings on malaria and brought in, so they can add to the debate on solutions at the national, regional and international levels.

There is the need to get these grassroot people to support research activities and policy outcomes, so they can play a role as both beneficiaries and advocates.

This is one way to ensure that the huge investments being made in malaria research are translated into workable policies acceptable at the community level to ensure that deaths and illnesses connected to the disease are minimised.

It is commendable that researchers from the Kintampo, Dodowa, and Navrongo Health Research Centres of the Ghana Health Service (GHS) are collaborating effectively with other officers of the GHS, the National Malaria Control Programme and local journalists including other partners like the African Media and Malaria Research Network (AMMREN) to carry out a malaria research.

The project is looking at strengthening the quality of malaria care and surveillance and improving malaria care among pregnant women and children under-10 years.

The £800,000 research, funded by Comic Relief, UK and GSK, is being carried out in some local communities in the Brong Ahafo, Upper East and the Greater Accra regions.

It should be possible to share the outcomes of this research across the country and also document them so that others can benefit from lessons learnt on what is working and what is not working.

Perhaps, the time is also ripe to start thinking out of the box by testing innovative ideas and trying new ways of doing things to rein in malaria.

A call was recently made by AMMREN, a Network of African journalists and scientists, acknowledging the need for inclusion of alternative medicine in the malaria control campaign.

In a message to commemorate this year’s World Malaria Day, AMMREN, said there is the need to rediscover the efficacious remedies used by our forebears to repel insects like mosquitoes and in treating diseases including malaria.

According to AMMREN, there are many insect-repellent plants being researched in Cameroon.

“As we seek more pertinent, practical and indigenous ways to beat malaria, we must also seize the amazing job creation opportunities available by tasking and funding young chemistry and biology graduates to work in this area.”

It noted that the global plan to contain the threat of mosquito-resistance to remedies has generated a frantic effort to develop new antimalarials to overcome resistance issues.

AMMREN said it is crucial to expand the mix of efficacious therapies to be able to respond when it is necessary, and it supported the opinion of researchers that contributions can be made to the global plan against malaria by developing Africa’s local herbs and to keep searching until another potent remedy for malaria is found.

“Artemisinin is a Chinese herb on which the whole world is depending to fight malaria. This is an indication that an African herb can also be developed to save our lives.”

“In most African countries, such as Nigeria, Ghana and Tanzania, there are many plants which people use to treat fevers. Surely, the older folks would be glad to reveal truths that have never been told about herbal malaria therapy handed down through generations,” the Network added.

It said the various departments of chemistry, pharmaceutics, and the Centre for Plant Medicine Research in Ghana, for instance, can collaborate and systematically develop an awesome malaria therapy given proper funding.

Prof. Augustine Ocloo, Executive Director of the Centre at Mampong in the Eastern region, has noted that the herbal remedy, Nibima, developed by the Centre to treat malaria, is not only efficacious but also enough research has been conducted on the product to prove its potency in curing malaria.

Funding in herbal products for malaria would surely not be a waste of time and resources. If African grandparents survived malaria with local herbs back then, then surely there is a case for further scientific evaluation of Africa’s herbal products.

But questions still remain if there would ever be an end to Africa’s malaria woes, especially when attention and resources have to be channeled to other emerging conditions such as the Ebola virus disease and the rising incidence of non-communicable conditions such as cardiovascular diseases, cancers, chronic respiratory diseases and diabetes.

By Eunice Menka
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