Kayla Knilans received her Ph.D. from the University of North Carolina and currently studies inflammatory mediators and epithelial repair in inflammatory bowel disease.
Malaria is a mosquito-borne infectious disease caused by parasites of the Plasmodium genus. According to CDC estimates, in 2015 there were around 212 million malaria infections that caused 429,000 deaths. Globally, the number of malaria infections has been in decline, an accomplishment that is largely attributed to the Roll Back Malaria initiative that established a partnership between the World Health Organization (WHO), the World Bank, UNICEF and the United Nations Development Programme in 1998. However, WHO has reported that as of 2015, only 44% of countries endemic for malaria were on track to meet 2020 infection reduction goals. Furthermore, there is concern that increasing global temperatures could cause an increase in the number of malaria infections in several regions due to a longer infection season and an expanding territory for Anopheles mosquitoes, the known vectors for malaria, though the magnitude of the effect is still heavily debated. Sub-Saharan Africa is one geographical region that is expected to be impacted by these changes.
Currently, Sub-Saharan Africa contains 90% of the global malaria infections and 92% percent of malaria-associated deaths. It is therefore a heavy focus for anti-malaria policy efforts, which have been successful in reducing total malaria cases. One study reported that as of 2015, ~660 million clinical cases of malaria have been averted since 2000. The WHO reports that overall, more children and pregnant women in Sub-Saharan have improved access to diagnostic testing and preventive treatment. In 2015, 51% of children seeking care for a fever in 22 African countries received a diagnostic test for malaria, compared to 29% in 2010. However, in some regions health systems are still under-resourced and/or poorly accessible; the WHO reports that 35% of children with a fever were not taken to a health care facility in a survey of 23 African countries.
One anti-malaria measure that has been successfully implemented across regions and populations in Sub-Saharan Africa is the use of insecticide-treated nets. These nets have been shown to be effective even in regions where mosquitoes have demonstrated resistance to pyrethroids, the only class of insecticide currently used in insecticidal nets. One study attributed the used of insecticide-treated nets to be responsible for 68% of malaria case reductions between 2000 and 2015. The study noted that the success of insecticide-treated nets in reducing malaria cases is at least partially due to their cost effectiveness and ease of distribution.
Going forward, there are several reported barriers to continuing successful anti-malaria policy implementation in Sub-Saharan Africa. The major barrier is funding available for anti-malaria efforts. While funding for malaria research and policy implementation rose sharply between 2000 and 2012, and was a critical factor in the global reduction of malaria cases during those years, it has since flatlined. Global funding for malaria as of 2015 was $2.9 billion, well short of the $6.4 billion goal for 2020 that WHO has estimated will be required for further malaria case reduction efforts.
A funding shortage will impact the amount of malaria research, including basic science, clinical, and epidemiological research. It will also slow progress in updating health systems, including training healthcare workers, making diagnostic technologies available, improving health record systems, increasing availability to anti-malarial drugs, and improving accessibility of health clinics to rural and poor populations. Other reported barriers include lack of education about the causes and treatment for malaria, adherence of households to malaria control efforts, cultural norms that conflict with malaria control measures, environmental and health concerns about the use of pesticides, and rising resistance to treatments in both the malaria parasite and the mosquito vectors.
A recent survey of policymakers in Uganda, Tanzania, and Kenya revealed additional complications with making and implementing anti-malaria policy in their respective countries. While funding was identified as a limiting factor in implementing policy, policymakers added that funding cycles often do not line up with seasonal malaria cycles, so funds are not available when they are most needed. Policymakers also expressed a general frustration with politicians, whose priorities and political pressures could undermine policy implementation. Policymakers in Uganda expressed that government leaders have previously enacted policy decisions without fully involving the policymaking community.
Interestingly, the survey participants also noted a discord between researchers and policy makers. Survey participants in Kenya noted that the priorities of research organizations were not always aligned with the national health research needs. They also voiced a need for a venue to bring together researchers and policymakers, and that researchers needed to make their work more accessible to and meaningful to policymakers. This highlights a critical point that is often overlooked in the current debate within the scientific community regarding publication paywalls. Publication paywalls restrict the access of scientific publications to paying customers, usually an academic institution’s library. While these paywalls can slow research progress at resource-limited institutions, paywalls can also have a more direct impact for policymakers on the ability to enact successful policies to improve public health. Without access to all the information, drafting evidence-supported policies that will be effective and supported by local lawmakers becomes more burdensome.
The implementation of successful anti-malaria policy will require significant funding commitments and the cooperation of researchers, policymakers, and politicians in order to meet infection reduction goals. Increasing communication with policymakers should be of interest to the scientific community to help facilitate these efforts. Enhanced communication could lead to funding announcements that are in line with the needs of policymakers and assure that research is accessible to policymakers.