Malaria: a research agenda for the eradication era

Posted Outubro 31, 2009

The world’s largest meeting on malaria, the 5th Multilateral Initiative on Malaria (MIM) Pan-African Malaria Conference, convenes in Nairobi, Kenya, on Nov 1–6.1 Since the last MIM meeting in 2005, the malaria landscape has transformed dramatically. Scientific progress and support from the highest levels of government galvanised the field, and the global community has begun to coalesce around the most ambitious goal possible—eradication.

Today, malaria-control efforts, particularly in Africa, have extraordinary visibility and unprecedented financial support from governments and philanthropic foundations. In Round 8 of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), approved grants for malaria exceed those for AIDS and tuberculosis combined.2 African governments are playing a larger role in efforts to eliminate malaria deaths, and creative partnerships with political and celebrity champions have accelerated the distribution of millions of insecticide treated bednets. In all, increased control efforts, including uptake of artemisinin-based combination therapies (ACTs), have led to a 50% decline in malaria cases and deaths in 29 countries since 2000, including
in seven countries in Africa.3

Behind these successes, however, lies a worrying reality: the spread of drug and insecticide resistance threatens to unravel the progress. Malaria strains resistant to the cheapest and most commonly used drugs already exist in almost every endemic country. Now, irrational use and continued over-reliance on artemisinin monotherapies are undermining the gold standard for malaria treatment, ACTs. Last year, a study showed significantly longer parasite-clearance times in patients taking ACTs along the Thai–Cambodian border.4 With no new classes of drugs in late-stage development, resistance to ACTs could render ineffective many of the endoperoxide drug candidates being developed as synthetic alternatives to artemisinin.5

Insecticide resistance is also spreading. Long-lasting insecticidal bednets and indoor residual spraying have saved millions of lives, but we are victims of our success. Expanding access to insecticides, combined with agricultural spraying practices, is putting evolutionary pressure on mosquitoes to develop resistance. In east Africa and other areas, two species of mosquito
have already been found to be resistant to commonly used insecticides, including permethrin and DDT.6 Worse, there are no new classes of insecticides in late stage development. The Global Malaria Eradication Programme of the 1950s and 1960s failed in part because of resistance. We must learn from the past, and focus on research that accelerates development of new tools and supports effective use of existing ones.

Evidence-based mechanisms are needed to improve access to effective treatments and displace
monotherapies. Today, only 3% of children under the age of 5 years receive ACTs, partly because 40–60% of patients are treated in the private sector where ACTs remain prohibitively expensive.7 The Aff ordable Medicines Facility for Malaria (AMFm) is an innovative approach to reduce ACT costs. To support the AMFm and other efforts, the ACTwatch project is collecting data on market
penetration for ACTs and building recommendations on how to increase access to and affordability of ACTs.8

At the same time, operational research is crucial to determine which methods and policies can improve availability of existing interventions. Recent studies show that trained community volunteers can deliver antimalarial treatments successfully.9,10 Lessons learned today will speed access to new tools as they become available.

We also need better diagnostics. The lack of accurate diagnostic tools leads to overprescribing of antimalarials by as much as 90% in some resource-poor settings, potentially contributing to resistance.11 An ongoing study of various rapid diagnostic tests is shedding light on their effectiveness in different settings, but more research is needed.12

New or improved tools remain our best hope for eradication. The world may be 5 years away from a partly effective malaria vaccine with the potential to save hundreds of thousands of lives. The most advanced vaccine candidate, RTS,S, is now in phase 3 clinical trials in seven African countries.13 It is time to start discussing financing and delivery even as we invest in next generation vaccine candidates, including transmission blocking and whole-organism vaccines.

At the founding of MIM just over a decade ago, essential malaria research in Africa was minimal. Malaria research initiatives, many of which are led by Africans, are now working with MIM and strengthening Africa’s ability to spearhead the development of new tools and approaches for malaria control. But while African researchers celebrate recent progress, we remain all too aware of the disease’s resilience and continued toll. Substantial political and financial support is needed, along with a critical mass of scientists working on malaria in sub-Saharan Africa, to maintain and implement an effective malaria research agenda.14 How many lives will be saved by what we learn at this Conference? With 2200 malaria deaths in Africa every day, we cannot afford to let up on our crucial mission.

1. Rugemalila J, Ogundahunsi O, Stedman T, Kilama W. Multilateral initiative
on malaria: justifi cation, evolution, achievements, challenges,
opportunities, and future plans. Am J Trop Med Hyg 2007; 77: 296–302.
2 Global Fund to Fight AIDS, Tuberculosis and Malaria. Funding decisions.
November, 2008. http://www.theglobalfund.org/en/fundingdecisions
(accessed Oct 7, 2009).
3 WHO. World malaria report 2008. 2008. http://apps.who.int/malaria/
wmr2008 (accessed Oct 6, 2009).
4 Dondorp AM, Nosten F, Poravuth Y, et al. Artemisinin resistance in
Plasmodium falciparum malaria. N Engl J Med 2009; 361: 455–67.
5 Wells T. A question of quality: interview with Chris Hentschel, President &
CEO of MMV. October, 2008. http://www.mmv.org/IMG/pdf/FINAL_
mmv08_news17_A4pgs.pdf (accessed Oct 7, 2009).
6 Corbel V, N’Guessan R, Brengues C, et al. Multiple insecticide resistance
mechanisms in Anopheles gambiae and Culex quinquefasciatus from Benin,
West Africa. Acta Trop 2007; 101: 207–16.
7 Medicines for Malaria Venture. Understanding the antimalarials market:
Uganda 2007—an overview of the supply side. Nov 6, 2008. http://www.
mmv.org/article.php3?id_article=536 (accessed Oct 7, 2009).
8 ACTwatch. http://www.actwatch.info/home/home.asp (accessed Oct 12,
2009).
9 Sudhakar M, Alem Y, Tegegn A, Woldie M. Acceptability of rapid diagnostic
tests (RDTs) and pre-packed drug (Coartem) through community based
volunteers for uncomplicated malaria in under 5 years’ children, Home
Management of Malaria (HMM) strategy in Jimma town, Ethiopia—
preliminary results. 5th MIM Pan-African Malaria Conference, Nairobi,
Kenya; Nov 2–6, 2009. http://www.mimalaria.org/eng/docs/pdfs/events/
MIM2009Abstracts.pdf (accessed Oct 7, 2009).
10 Ajayi I, Browne E, Garshong B, et al. Feasibility and acceptability of
artemisinin-based combination therapy for the home management of
malaria in four African states. Malar J 2008; 7: 6.
11 Amexo M, Tolhurst R, Barnish G, Bates I. Malaria misdiagnosis: eff ects on
the poor and vulnerable. Lancet 2004; 364: 1896–98.
12 WHO, FIND, CDC, TDR. Malaria rapid diagnostic test performance—
results of WHO product testing of malaria RDTs: round 1 (2008). 2008.
http://apps.who.int/tdr/svc/publications/tdr-research-publications/rdtperformance
(accessed Oct 7, 2009).
13 GSK Biologicals, PATH MVI. Fact sheet: phase 3 trial of RTS,S. http://www.
malariavaccine.org/fact-sheets.php (accessed Oct 8, 2009).
14 Nantulya F, Kengeya-Kayondo J, Ogundahunsi O. Research themes and
advances in malaria research capacity made by the Multilateral Initiative on
Malaria. Am J Trop Med Hyg 2007; 77: 303–313.

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Digitalizing contraceptive counseling to reach rural women and girls in Ethiopia

By: Fana Abay, Marketing and Communications Director, PSI Ethiopia

In rural Ethiopia, women and girls often face significant barriers in accessing healthcare facilities, which can be located hours away. Moreover, there is a prevailing stigma surrounding the use of contraception, with concerns about potential infertility or the perception of promiscuity. To address these challenges, the Smart Start initiative has emerged, linking financial well-being with family planning through clear and relatable messaging that addresses the immediate needs of young couples—planning for the lives and families they envision. Smart Start takes a community-based approach, utilizing a network of dedicated Navigators who engage with women in their localities. These Navigators provide counseling and refer interested clients to Health Extension Workers or healthcare providers within Marie Stopes International-operated clinics for comprehensive contraceptive counseling and services.

In a significant development, PSI Ethiopia has digitized the proven counseling messaging of Smart Start, expanding its reach to more adolescent girls, young women, and couples. This approach aligns with the priorities set by the Ethiopian Ministry of Health (MOH) and is made possible through funding from Global Affairs Canada. The interactive and engaging digital messaging has revolutionized counseling services, enabling clients to make informed and confident decisions regarding both their finances and contraceptive choices.

Clients who received counseling with the digital Smart Start tool reported a higher understanding of their options and were more likely to choose contraception (74 percent) compared to those counseled with the manual version of Smart Start (64 percent). Navigators also found the digital tool more effective in connecting with clients, leading to higher ratings for the quality of their counseling.

By December 2023, PSI Ethiopia, working in close collaboration with the MOH, aims to reach over 50 thousand new clients by leveraging the digital counseling tool offered by Smart Start. This innovative approach allows for greater accessibility and effectiveness in providing sexual and reproductive health services, contributing to improved reproductive health outcomes for women and couples across the country.

Building community health worker capacity to deliver malaria care

By: Christopher Lourenço, Deputy Director, Malaria, PSI Global

Community health workers (CHWs) are critical lifelines in their communities. Ensuring they have the training, support, and equipment they need is essential to keep their communities safe from malaria, especially in the hardest to reach contexts.

For example, in Mali, access to formal health services remains challenging, with four in ten people living several miles from the nearest health center, all without reliable transportation or access. In 2009, the Ministry of Health adopted a community health strategy to reach this population. The U.S. President’s Malaria Initiative (PMI) Impact Malaria project, funded by USAID and led by PSI, supports the Ministry with CHW training and supervision to localize health services.

In 2022, 328 thousand malaria cases were recorded by CHWs); 6.5 thousand severe malaria cases were referred to health centers, according to the national health information system.

During that time, the PMI Impact Malaria project (IM) designed and supported two rounds of supportive supervision of 123 CHWs in their workplaces in the IM-supported regions of Kayes and Koulikoro. This included developing and digitizing a standardized supervision checklist; and developing a methodology for selecting which CHWs to visit. Once a long list of CHW sites had been determined as accessible to supervisors for a day trip (including security reasons), the supervisors telephoned the CHWs to check when they would be available to receive a visit [as being a CHW is not a full-time job, and certain times of the year they are busy with agricultural work (planting, harvesting) or supporting health campaigns like mosquito net distribution].

Supervisors directly observed how CHWs performed malaria rapid diagnostic tests (RDTs) and administered artemisinin-based combination therapy (ACT). They recorded CHW performance using the digitized checklist, interviewed community members, reviewed records, and provided on-the-spot coaching. They also interviewed the CHWs and tried to resolve challenges they expressed, including with resupply of commodities or equipment immediately or soon afterwards.

Beyond the observed interactions with patients, supervisors heard from community members that they were pleased that CHWs were able to provide essential malaria services in the community. And the data shows the impact.

In IM-supported areas of Mali, 36% of CHWs in the first round were competent in performing the RDT, which rose to 53% in the second. 24% of CHWs in the first round compared to 38% in the second were competent in the treatment of fever cases and pre-referral counseling. Between both rounds, availability of ACT increased from 80 percent to 90 percent.

Supportive supervision with interviews and observations at sites improved the basic competencies of CHWs between the first and second rounds, and additional rounds will help to understand the longer-term programmatic benefits.

Taking a market-based approach to scale sanitation in Ethiopia

By: Dr. Dorothy Balaba, Country Representative, PSI Ethiopia

In Ethiopia, PSI leads the implementation of USAID Transform WASH (T/WASH) activity with consortium partners, SNV and IRC WASH. Contrary to traditional models that rely on distribution of free or heavily subsidized sanitation products, T/WASH utilizes a market-based sanitation approach. This approach creates sustainable and affordable solutions, by integrating market forces and supporting businesses to grow, while creating demand at the household level.

During the last six years, T/WASH has worked alongside the private sector and government (Ethiopia’s Ministry of Health, Ministry of Water and Energy, and Ministry of Labor and Skills), among other stakeholders, to increase household access to affordable, quality sanitation products and services. For example, more than 158 thousand households have invested in upgraded sanitation solutions with rapid expansion to come as the initiative scales and market growth accelerates.

T/WASH has successfully trained more than 500 small businesses, including community masons and other construction-related enterprises, with technical know-how in sanitation product installation, operational capacities, and marketing and sales skills needed to run successful, growing businesses. The Ethiopian government is now scaling the approach to all districts through various national, regional, and local institutions with requisite expertise. T/WASH has also worked the One WASH National Program, Ministry of Health, Ministry of Water and Energy, and Ministry of Labor and Skills to examine policies that influence increased household uptake of basic WASH services, such as targeted sanitation subsidies, tax reduction to increase affordability, and increased access to loan capital for business seeking to expand and households needing help to improve their facilities.

To share the journey to market-based sanitation, representatives of the Ethiopian Ministry of Health and the USAID Transform WASH team took to the stage at the UN Water Conference in 2023.

“Rather than relying on traditional aid models that often distribute free or heavily subsidized sanitation products, market-based sanitation creates sustainable and affordable solutions, integrating market forces and supporting businesses to grow.”

— Michael Negash, Deputy Chief Party of T/WASH

Promoting self-managed care like Self-testing and Self-Sampling

By: Dr Karin Hatzold, Associate Director HIV/TB/Hepatitis

Building upon the success and insights gained from our work with HIV self-testing (HIVST), PSI is actively applying this approach to better integrate self-care, more broadly, in the health system beginning with Hepatitis C and COVID-19. Self-testing has emerged as a powerful tool to increase access to integrated, differentiated, and decentralized health services, accelerating prevention, care, and treatment for various diseases, while also increasing health system resilience against COVID-19.

Here’s how we got there.

Seven years ago, the landscape of HIV self-testing lacked global guidelines, and only the U.S., the UK and France had policies in place that allowed for HIV self-testing. High disease burdened countries in low-and-middle-income-countries (LMICs) lacked evidence and guidance for HIVST despite major gaps in HIV diagnosis.

However, through the groundbreaking research from the Unitaid-funded HIV Self-Testing Africa (STAR) initiative led by PSI, we demonstrated that HIVST is not only safe and acceptable but also cost-effective for reaching populations at high risk with limited access to conventional HIV testing. This research played a pivotal role in informing the normative guidelines of the World Health Organization (WHO) and shaping policies at the country level. As a result, more than 108 countries globally now have reported HIVST policies, with an increasing number of countries implementing and scaling up HIVST to complement and partially replace conventional testing services. This became especially significant as nations tried to sustain HIV services amidst the disruptions caused by the COVID-19 pandemic.

By leveraging our expertise, PSI is conducting research to identify specific areas and populations where the adoption of Hepatitis C and COVID-19 self-testing could significantly enhance testing uptake and coverage. This research serves as the foundation for developing targeted strategies and interventions to expand access to self-testing, ensure that individuals have convenient and timely options for testing for these diseases, and are linked to care, treatment and prevention services through differentiated test and treat approaches.

simplifying consumers’ journey to care in Vietnam

By: Hoa Nguyen, Country Director, PSI Vietnam

In late 2022, with funding from the Patrick J. McGovern Foundation, PSI and Babylon partnered to pilot AIOI in Vietnam. By combining Babylon’s AI symptom checker with PSI’s health provider locator tool, this digital health solution analyzes symptoms, recommends the appropriate level of care, and points them to health providers in their local area. The main goal is to support people in low-income communities to make informed decisions about their health and efficiently navigate the healthcare system, while reducing the burden on the healthcare workforce. The free 24/7 service saves people time and subsequent loss of income from taking time off work and from having to pay unnecessary out-of-pocket expenses. Under our global partnership with Meta, PSI launched a digital campaign to put this innovative product in the hands of people in Vietnam. By the end of June 2023 (in the nine months since product launch), 210 thousand people accessed the AIOI platform; 2.4 thousand people created personal accounts on the AIOI website, 4.8 thousand triages to Symptom Checker and linked 2.2 thousand people to health facilities.

Babylon’s AI symptom checker and PSI’s health provider locator tool captures real-time, quality data that supports health systems to plan, monitor and respond to consumer and provider needs. But for this data to be effective and useable, it needs to be available across the health system. Fast Healthcare Interoperability Resources (FHIR) standard provides a common, open standard that enables this data exchange.
PSI’s first consumer-facing implementation of FHIR was launched in September 2022 as part of the Babylon Symptom Checker project in Vietnam, enabling rapid alignment between PSI and Babylon’s FHIR-enabled client records systems. PSI already has several other consumer health FHIR implementations under active development in 2023, including PSI’s collaboration with the Kenya MOH to launch a FHIR-enabled WhatsApp national health line for COVID-19 health information. PSI will also look to adopt and scale health workforce-facing FHIR-enabled tools, such as OpenSRP2, which will be piloted in an SRH-HIV prevention project in eSwatini in partnership with Ona by the end of 2023.

— Martin Dale, Director, Digital Health and Monitoring, PSI

Engaging the private sector for disease surveillance in Myanmar

By: Dr. Zayar Kyaw, Head of Health Security & Innovation, PSI Myanmar

Under a three-year investment from the Indo-Pacific Center for Health Security under Australia’s Department for Foreign Affairs and Trade (DFAT), PSI is enhancing disease outbreak surveillance and public health emergency preparedness and response capacities in Myanmar, Cambodia, Laos, and Vietnam. When PSI conducted a review of existing disease surveillance systems in Myanmar, it identified several gaps: although the Ministry of Health had systems in place for HIV, tuberculosis, malaria and other communicable diseases, they were fragmented, with different reporting formats and reliance on paper-based reporting. In addition, private sector case surveillance data were not routinely captured, yet private clinics and pharmacies are the dominant health service delivery channel in the country. This hindered effective disease prevention and control efforts.

Building on our extensive private sector malaria surveillance work under the BMGF-funded GEMS project in the Greater Mekong Subregion, PSI implemented a case-based disease notification system using social media channels to overcome the limitations of paper-based and custom-built mobile reporting tools. These chatbots, accessible through popular social media platforms like Facebook Messenger and Viber, proved to be user-friendly and required minimal training, maintenance, and troubleshooting. The system was implemented in more than 550 clinics of the Sun Quality Health social franchise network as well as nearly 470 pharmacies. The captured information flows to a DHIS2 database used for real-time monitoring and analysis, enabling rapid detection of potential outbreaks. Local health authorities receive instant automated SMS notifications, enabling them to promptly perform case investigation and outbreak response.

In 2022, private clinics reported 1,440 malaria cases through the social media chatbots, while community mobilizers working with 475 private providers and community-based malaria volunteers reported more than 5,500 cases, leading to the detection of two local malaria outbreaks. Local health authorities were instantly notified, allowing them to take action to contain these surges in malaria transmission. During the same time, pharmacies referred 1,630 presumptive tuberculosis cases for confirmatory testing – a third of which were diagnosed as tuberculosis and enrolled into treatment programs.

Training health workers in Angola

By: Anya Fedorova, Country Representative, PSI Angola

The shortage of skilled health workers is widely acknowledged as a significant barrier to achieving Universal Health Coverage. To address this challenge, PSI supported ministries of health to develop a digital ecosystem that brings together stewardship, learning, and performance management (SLPM). The ecosystem enhances training, data-driven decision-making, and the efficiency of healthcare delivery.

Here’s what it looks like in practice.

In July 2020, PSI Angola, alongside the Angolan digital innovation company Appy People, launched Kassai, an eLearning platform that targets public sector health workers in Angola. Through funding from USAID and the President’s Malaria Initiatve (PMI), Kassai features 16 courses in malaria, family planning, and maternal and child health – with plans to expand learning topic areas through funding from ExxonMobil Foundation and private sector companies. A partnership with UNITEL, the largest telecommunication provider in Angola, provides all public health providers in Angola free internet access to use Kassai.

Kassai’s analytics system to follow learners’ success rate and to adjust the course content to learners’ performance and needs. Kassai analytics are integrated with DHIS2 – the Health Management Information System (HMIS) of Angolan MOH, to be able to link learners’ knowledge and performance with the health outcomes in the health facilities. The analytics track learners’ performance by course and gives visibility by health provider, health facility, municipality, and province. Each course has pre-and post-evaluation tests to track progress of learning, too.

By the end of 2022, there were 6,600 unique users on the Kassai platform and 31,000 course enrollments. PSI Angola’s partnership with UNITEL, the largest telecommunication provider in Angola, allows for free internet access to learn on the Kassai for all public health providers in Angola. Building on its success for malaria training, Kassai now also provides courses in family planning, COVID-19, and maternal and child health. This reduces training silos and provides cross-cutting benefits beyond a single disease.

Implementing the SLPM digital ecosystem brings numerous benefits to health systems. It allows for more strategic and efficient workforce training and performance management, enabling ministries of health to track changes in health workers’ knowledge, quality of care, service utilization, and health outcomes in real time. The ecosystem also supports better stewardship of mixed health systems by facilitating engagement with the private sector, aligning training programs and standards of care, and integrating private sector data into national HMIS. Furthermore, it enables the integration of community health workers into the broader health system, maximizing their impact and contribution to improving health outcomes and strengthening primary healthcare.

Malaria: a research agenda for the eradication era

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Digitalizing contraceptive counseling to reach rural women and girls in Ethiopia

Building community health worker capacity to deliver malaria care

Taking a market-based approach to scale sanitation in Ethiopia

Promoting self-managed care like Self-testing and Self-Sampling

Using peer coaches to counter HIV stigma in South Africa

simplifying consumers’ journey to care in Vietnam

Engaging the private sector for disease surveillance in Myanmar

Training health workers in Angola

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