Jaishree Raman, National Institute for Communicable Diseases
South Africa, Botswana, and Eswatini are among 25 countries identified by the World Health Organisation (WHO) as having the potential to eliminate malaria by 2025.
But now this goal is out of reach. And it’s slipping further away.
The Africa Centres for Disease Control recently raised the alarm over the unexpected and significant increases in malaria cases and deaths in several Southern African Development Community (SADC) countries, including Eswatini and Botswana.
South Africa has not experienced any recent malaria outbreaks, but it has also not managed to stop the local transmission of malaria.
The fragile gains made in the fight against malaria in the SADC region are facing unprecedented threats on multiple fronts. The reasons for the recent upsurges and missed elimination targets are complex. They are multifaceted and include a combination of climatic, biological, human, and financial factors.
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Climate: A Growing Threat
Climate change is a relatively new challenge that malaria programmes are having to deal with. Increased rainfall and associated natural disasters, such as flooding, increase the opportunities for malaria vectors to breed. Warmer temperatures are expanding the range of malaria vectors, potentially widening transmission areas. Increased rainfall and flooding have been linked with increases in cases in Botswana and Mozambique, respectively.
Biological: Rising Resistance
Another challenge faced by malaria programmes is staying one step ahead of the constantly evolving parasites and mosquitoes.
Malaria mosquitoes have become resistant to many of the insecticides used for indoor residual spraying and on insecticide-treated nets. Some mosquitoes have even altered their behaviour by biting earlier in the day and outdoors to limit their exposure to insecticides.
Not to be outdone, the most common malaria parasite in Africa, Plasmodium falciparum, has developed mechanisms to evade detection by malaria rapid diagnostic tests (RDTs). Falciparum parasites, largely limited to countries in the Horn of Africa, have certain mutations that allow them to go undetected by histidine-rich-protein 2 (HRP2)-based RDTs. This causes delays that result in malaria cases being diagnosed at an advanced stage when the disease is complicated to treat.
More concerning is the emergence of falciparum parasites that are resistant to artemisinins in several African countries. Artemisinins are a core component of the most widely used antimalarials in Africa, artemisinin-based combination therapies (ACTs). Recent genomic studies revealed that several SADC countries have large numbers of parasites with mutations possibly associated with artemisinin resistance. While further research is required to confirm the clinical impact of these mutations, the early detection of these mutations highlights the value of genomic surveillance.
Routine genomic surveillance would allow countries to quickly detect an outbreak of treatment-resistant malaria and implement containment measures early. Malaria programmes must embed genomic surveillance into their routine surveillance activities to generate actionable data on the efficacy of diagnostics, antimalarials and insecticides.
Human Factors: Movement and Inequality
The malaria burden varies widely across the region.
Four SADC countries, the Democratic Republic of Congo, Mozambique, Tanzania, and Angola, account for 22% of the global burden. Mauritius, on the other hand, has eliminated malaria and is actively working to prevent malaria transmission occurring within its borders. These vast differences in malaria risk, combined with high levels of human movement – particularly from high burden to lower burden countries – make malaria control, let alone elimination, extremely challenging.
This year, Namibia reported over 95 000 cases, almost six times higher than the numbers reported in 2024. The most affected districts in Namibia share borders with malaria-endemic neighbours. A similar scenario is playing out in Botswana. This highlights the critical value of effective cross-border collaborations in curbing the threat of malaria.
To this end eight southern African countries (Angola, Botswana, Eswatini, Mozambique, Namibia, South Africa, Zambia, and Zimbabwe), collectively referred to as the Elimination 8, implemented malaria border surveillance units in 2017. These units played an integral role by promptly detecting and treating malaria carriers along shared borders.
But many of these units are no longer operational, as the donor funds that supported this and several other critical interventions are no longer available.
Financial
This unfortunate situation shines a spotlight on the over-reliance in the SADC region on donor funding for fundamental malaria control activities. The unprecedented, drastic reduction in donor funding for malaria control, combined with donor fatigue in the face of limited progress towards elimination, paints a concerning picture. Many are predicting dramatic increases in malaria cases and deaths in Africa.
If SADC and Africa are going to win the battle against malaria, the first step must be increasing domestic funding. Local ownership is key to ensuring country priorities are adequately addressed and that programmes are sustainable.
Reaching targets
Getting the SADC region back on track to meet the aspirational goal of a malaria-free Africa by 2030 will be a herculean task.
It will require strong regional collaboration, sustainable domestic funding and strong community participation. All countries will have to work together to optimise limited resources and rapidly share data to inform timely actions.
Through effective collaboration between malaria programmes and affected communities, appropriate use of existing and novel interventions, and domestic funding, malaria elimination in the SADC region can be achieved.
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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.
The views and opinions expressed in this opinion piece are those of the author, who is not employed by Health-e News. Health-e News is committed to presenting diverse perspectives to enrich public discourse on health-related issues.
