What might we learn from COVID-19’s impact on the response to malaria? Perspectives from four sub-Saharan African countries.
At the start of the COVID-19 pandemic, many experts worried it would disrupt the recent progress sub-Saharan Africa has made against other infectious diseases.
Having worked with national malaria control programs (NMCP) for several years, we at ICF were particularly interested in the intersection of COVID-19 and malaria. Through discussions with the NMCP staff in four countries—the Democratic Republic of the Congo (DRC), Liberia, Madagascar, and Mali—we learned that while the anticipated and actual impacts of COVID-19 on malaria will continue to vary across sub-Saharan Africa, countries took some important immediate steps using the resources and data they had available.
By better understanding the common challenges and approaches to addressing them, we can help identify each country’s health system's strengths and weaknesses to help foster resilience. This will support the long-term effort to fight COVID-19, malaria, and future pandemics. A summary of the areas worth exploring follows.
Ensuring routine health service delivery despite challenges of COVID-19
As countries first detected COVID-19 cases, there was initial concern that fear of catching COVID-19 may keep populations from seeking health care. Monthly outpatient attendance (OPD) data collected and reported through routine health information systems in each country showed initial drops in care-seeking early on. For example, in Liberia, with the residual memories of the Ebola virus, many were more selective in where they sought care, choosing places with reputations for space, organization, and the power to perform screenings. In Madagascar, the minister of health in July appointed a regional COVID-19 response coordination committee to integrate COVID-19 response into routine health activities and to combine health communication messaging to address both malaria and COVID-19 prevention. Routine data showed that OPD attendance had rebounded to typical annual levels by June and July. Functioning health information systems enabled program and policymakers to monitor the situation and act.
Increased reliance on community health workers
Community health workers (CHWs) are a vital link between the health system and individual communities, especially in assisting with identifying and treating common diseases and childhood illnesses, like malaria, at the community level. In all four countries, CHWs have continued their role of complementing the primary health care system in the advent of COVID-19. CHW presence in communities has been further leveraged in the COVID-19 pandemic to encourage care-seeking, educate community members about malaria and COVID-19 (Madagascar and DRC), and support malaria and COVID-19 surveillance (Madagascar, Mali, and DRC).
Adjusting strategies as part of a response
At the beginning of the pandemic, Ministries of Health (MOH) and NMCPs had to pivot to address COVID-19, adjusting strategies as a response. Madagascar postponed some malaria activities to focus on COVID-19 containment measures. At the beginning of the pandemic Mali adjusted and delayed some components of the national malaria program operational plan. At the beginning of June, Mali resumed key activities, including long-lasting insecticidal net (LLIN) distribution, and the seasonal malaria chemoprevention (SMC) campaign started at the end of July. Countries' immediate pause to review and adapt malaria strategies enabled them to put in place safety measures to mitigate COVID-19 transmission with minimal disruption to critical malaria activities.
Mitigating effects of COVID-19 on supply chains
In some countries, poor procurement forecasting and internal transportation logistics had resulted in key commodity shortages even before the COVID-19 pandemic. Some countries put in place contingency plans should COVID-19 cause disruption to supply chains. These countries prepared to implement large-scale presumptive malaria treatment should rapid diagnostic tests (RDTs) run out, sacrificing the quality of malaria services and data to ensure treatment availability. For example, the Madagascar NMCP was even more concerned about the availability of malaria RTDs and artemisinin combination therapy (ACT). Similarly, Liberia often faces shortages of RDTs and experienced an acute ACT shortage due to COVID-19-related commodity consignment delays. However, none of the countries had to shift to presumptive malaria treatment and continue to manage malaria commodities with minimal effects from COVID-19. There remains a need to continue supporting commodity forecasting with built-in contingencies to address anticipated supply chain disruptions, without compromising the quality of care or surveillance efforts.
The road ahead…
So far, most countries in Africa have fortunately managed the COVID-19 pandemic, and the effects on malaria have largely remained isolated. Functional routine health information systems remain critical in helping decision-makers monitor the situation and make informed adjustments to strategies and activities.
The interplay of COVID-19 and malaria is likely to be a long-term one. With overlapping symptoms between the two diseases and many outstanding epidemiological questions about the nature of COVID-19, surveillance and routine monitoring data will continue to be key for countries to manage both diseases. Despite the many challenges it presents, this pandemic offers sub-Saharan Africa the opportunity to build on progress and lessons learned, strengthening integrated disease surveillance and response systems that differentiate febrile illnesses, including malaria and COVID-19.