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October 9, 2023

China’s model promising to end malaria in East African countries

By Kenyan journalist Allan Olingo. First published in The East African.

Mary Galoroi knows the pain of malaria, having lost her child to the killer disease three years ago. Now she is part of a team of community health workers in Marsabit, Kenya, who travel around trying to educate the local population about the disease.

In March 2021, at the height of the COVID-19 pandemic, Galoroi lost her three-year-old son to malaria.

A laboratory technician collects a blood sample from an infant suspected to have malaria at Ifakara Health Institute in Bagamoyo, Tanzania on October 30, 2009. Photo: Tony Karumba | Nation Media Group.

“The stigma associated with COVID-19 made many people avoid going to hospitals.

I was one of them, hoping that painkillers would help my son's condition. By the time he started convulsing and we took him to the main hospital, it was too late. The doctors diagnosed him with severe malaria and he died a few days later,” she says.

Now Galoroi has become one of the loudest advocates of early detection and hospital intervention within her community.

Malaria remains one of Africa's deadliest diseases, killing nearly half a million children under the age of five every year, with Africa accounting for more than 90 percent of global malaria cases and deaths.

In Kenya, malaria kills more than 12,000 Kenyans every year, despite being preventable and treatable.

The latest Kenya Malaria Indicator Survey released in the year 2020, shows that seven out of 10 Kenyans are at risk of malaria infection. This translates to about 13 million people in malaria-endemic areas and an additional 19 million in the highlands, where seasonal malaria transmission occurs.

Kenya's five-year malaria strategy, due to be completed by the end of this year, has identified low transmission areas in the country for elimination. The country's low-risk malaria areas are mostly in the central region, including Nairobi.

One of the strategies is to have passive and active surveillance systems that will be used to detect malaria cases and to report and investigate cases for appropriate response.

With just a few months left to review the progress of Kenya's 2019-2023 malaria strategy, what lessons can Kenya learn from countries whose strategies have worked for them?

China, for example, used the ‘1-3-7’ strategy, which helped them eliminate malaria in 10 years. It was certified malaria-free by the World Health Organisation in June 2021.

The ‘1-3-7’ strategy means that a country usually has one week to deal with a single case of malaria. To break it down, a case needs to be reported as soon as possible on day one, followed by confirmation and investigation by day three. Seven days after a case is detected, public health measures must be in place to prevent further transmission.

A study published earlier this year in the journal Malaria shows that implementing Kenya's fading malaria strategy would require an increase in the country's health spending.

But more than two decades after the Abuja Declaration, Kenya still falls short of the 15 percent budget allocation recommended for health.

"The sensitivity analysis of financing instruments for expanding health services shows that tax-based financing instruments reduce the welfare of all household categories. In contrast, financing the strategy by increasing foreign transfers to the government slightly benefits all households," the study says.

One of the goals of Kenya's malaria strategy is to ensure everyone in endemic regions is protected from new infections by this year.

Dr Willis Akhwale, advisor to the End Malaria Council, says countries and regions that have committed to surveillance, reporting and diagnosis have seen positive results in reducing malaria cases.

"Countries need to strengthen their health systems and have facilities that are equipped with rapid test kits and are able to do microscopy at the lowest facilities in their countries," he explains.

Across the region, Tanzania has been successful in implementing the Chinese strategy, two years ago it reported this had slowed malaria deaths.

Tanzania case

In April, Tanzania reported a 10 percent reduction in malaria prevalence from 18.1 percent in 2008 to 8.1 percent in 2022. The country said that through its National Malaria Control Programme, it is aiming to further cut malaria prevalence among children under five to less than 3.5 percent by 2025.

Dr Abdallah Lusasi, head of the National Malaria Control Programme, said: "The latest figures show a rapid decline in the infection of the deadly disease for us. Since 2008, they have been able to increase the number of people living in areas free of malaria infection from four percent to 41 percent last year.”

Dr Lusasi also added that the number of confirmed malaria cases has decreased by 55 percent, from 7.7 million in 2015 to 3.5 million in 2022.

According to WHO, Tanzania's success is largely due to its unique implementation programme, in which the Ministry of Health divided the country into small units where different combinations of interventions were used to accelerate malaria elimination.

For example, in very low-risk areas, Dar opted for a case-by-case approach based on the results of malaria surveillance.

In areas at high risk of malaria transmission, such as southern Tanzania, a combination of intensified surveillance, curative, preventive and control interventions was used.

Learning from the Chinese 1-3-7 strategy, the country adopted a package of interventions based on malaria transmission risk.

The data showed that the central regions of Dodoma, Singida, Manyara, Arusha, Kilimanjaro and Songwe will have zero percent prevalence by 2022, while Mwanza, Iringa and Dar es Salaam will have one percent malaria prevalence. However, this has not been the case.

 “We are now shifting our focus and efforts to regions that still have high prevalence to ensure that our prevalence is reduced to 3.5 percent by 2025 and that we eliminate the disease completely by 2030,” he added.

Between 2015 and 2020, Tanzania piloted the 1-3-7 technology, supported by a partnership with China and the UK, in Rufiji. The project, which covered 18 villages in Muhoro and Ikwiriri, was the result of a pilot study conducted jointly by the Ifakara Health Institute (IHI) and the National Institute for Parasitic Disease (China CDC) in Rufiji.

The results showed that malaria could be reduced by more than 80 percent if the Chinese model was rolled out nationwide. According to the researchers, the project then used community-based test, treat and track (T3) as part of a robust surveillance and response mechanism.

"We set out to reduce cases by 30 percent in two years, but through this model we have condensed the challenge by 80 percent, and there are also indications of a significant reduction in malaria cases at health facilities in these areas," said IHI chief executive director Honorati Masanja.

Dr Masanja added: "We are trying to use the Chinese experience to see if the strategy is effective in the Tanzanian environment. The experience so far has been positive and this calls for partnerships between governments, local and private entities at different levels to join forces against malaria".

However, the Chinese model has also faced a number of challenges in East Africa, with resources being a key one.

"The 1-3-7 approach is a resource-intensive and vertical approach," said Dr Amakonde Adiva, a researcher from Tanzania.

"In East Africa, where we have high malaria transmission, the 1-3-7 approach is difficult to eliminate malaria transmission quickly because it is more labour and time consuming and most of the parent ministries lack the resources," he added.

The approach is also better suited to eliminating malaria in areas where the disease is already under control.

"This approach needs to be tailored to the conditions in the region. Most of East Africa's cases are usually reported in remote areas, which affects the timeliness of the Chinese approach to controlling the disease," said Dr Adiva.

According to Dr Akhwale, one of the biggest challenges in Africa is inadequate diagnostic capacity and weak health information systems.

Dr Akhwale explained that eliminating a disease such as malaria means stopping the spread of the disease within a geographical area.

He added that Kenya is still in the control phase, but some African countries have managed to eliminate malaria.

He says the Chinese strategy is great for monitoring cases and assessing what is contributing to new infections.

"Through surveillance, health workers can determine whether cases are imported or due to a new vector, for example, and then use that knowledge to tackle the problem at source," he explained.

As with Kenya's malaria strategy, he says this method can work in low-risk areas.

"But in the endemic areas, for a country like Kenya, we need to reduce the number of cases so that we can move from the control phase to other phases and eventually elimination," he added.

Now, countries in the region have decided to include malaria vaccination as part of their strategy to fight the killer disease.

In the middle of this year, Kenya announced it was expanding its malaria immunisation programmes as it steps up the fight.

"We are committed to expanding malaria vaccination to other parts of the country as more supplies become available. The goal is to make Kenya malaria-free,” said Dr Lucy Mecca, head of the National Vaccines and Immunisation Programme (NVIP), at a recent malaria vaccination launch.

In July, the vaccine alliance Gavi announced that Kenya and Uganda are among 12 countries in Africa that will receive 18 million doses of the first-ever malaria vaccine over the next two years. The first doses of the vaccine are expected to arrive in countries in the last quarter of 2023, with countries starting to introduce the vaccine in early 2024.

Thabani Maphosa, Gavi's managing director for country programme delivery, said the vaccine has the potential to be highly impactful in the fight against malaria, and if widely rolled out alongside other interventions, could prevent tens of thousands of future deaths every year.

"As we work with manufacturers to scale up supply, we need to ensure that the doses we have are used as effectively as possible, which means applying all the lessons learned from our pilot programmes as we scale up to a new total of 12 countries," said Maphosa.

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