In Windhoek, capital of Namibia, a small office staffed by three people serves as “the Situation Room”. Once a week, experts from the eight southern African states involved in a joint project participate in a teleconference call. They discuss trends in the data, potential outbreaks of trouble and possible emergency action.
They work for “Elimination8”, the name given to Africa’s first regionally co-ordinated effort to tackle malaria.
In 1998, the African island of Mauritius put an end to a disease that still kills more than 400,000 people every year worldwide, the vast bulk in Africa. But in the two decades since then, no country in sub-Saharan Africa has matched that feat. Now, there is an ambitious effort to make up for lost time by eliminating malaria in not just one country, but in eight.
Elimination — sometimes confused with eradication — means ending local transmission of the disease, though even when that is achieved some infections may still be “imported” by travellers or migrant workers. (Eradication signifies ending all cases of malaria worldwide, a milepost that would mean the battle against the disease had been won.)
Under the Elimination8 plan, the idea is to end malaria by 2020 in four so-called frontline states where transmission levels are already low — below 10 per 1,000. These are Botswana, Namibia, South Africa and Swaziland. Four higher-transmission, “second line” countries — Angola, Mozambique, Zambia and Zimbabwe, where transmission rates can climb as high as 400 per thousand — have until 2030 to get the job done.
The data collection and planning that go on in the Situation Room sound, on the face of it, pretty routine. But, says Kudzai Makomva, a member of the secretariat, the data-sharing is groundbreaking in many ways. “Getting countries to part with sensitive country data for wider sharing for everyone’s benefit is politically very challenging,” she says. “It has been one of the greatest challenges of the partnership, but also one of the best stories of turnaround and success, because this is really coming together now.”
It makes sense to try to combat the disease on a regional basis, says Kevin Marsh, professor of tropical medicine at Oxford university and an expert on malaria.
Neither mosquitoes nor potential human carriers of the disease, such as migrant workers, recognise borders. Best practice — and even diagnostic equipment — in one country can be shared with others, improving both efficacy and providing economies of scale.
“Cross-border surveillance is key,” says Prof Marsh, adding that eradication efforts can be set back if malaria creeps across the border from a country that has not been able to control the disease as effectively.
Working regionally, he says, is also a good way of galvanising political will because it can turn co-operation into competition. “Heads of state have a scorecard,” he says. Leaders hate being outshone by their counterparts in neighbouring countries. “It sounds trivial but it is surprisingly effective.”
Ms Makomva says cross-border co-operation can change priorities. She cites the example of Angola, a high-transmission country with a stretched health system. Understandably, she says, Angolan health authorities concentrate their efforts on the north of the country, where the incidence of malaria is much higher. But that leaves the south, which borders Namibia, relatively unattended.
“We say, ‘Look Angola. We understand the decisions you are taking, but it would be good if Angola could put some resources in the southern part of the country.’ It means focusing on areas that have a regional impact, as opposed to just a national impact.”
Ms Makomva says the project, which only properly got going with the formation of the secretariat in 2015, was set back initially by a number of outbreaks in several of the countries. So instead of making progress, the number of deaths and transmissions actually rose.
“The year 2017 has been a wake-up call for the Elimination8 as the elimination goals of 2020 are at great peril,” says the project’s annual report, published in March 2018. “With only three years to go until 2020, the collective strategy to zero local malaria transmission needs to be revisited to accelerate making progress in ‘bending the curve’ and to remake the lost gains as a result of serious outbreaks.”
But a review by the Global Fund, which is providing a three-year grant worth $6.5m to the project, has found some promising signs. One of the significant achievements has been the establishment of 46 “malaria posts” in underserved border areas between the countries.
The posts, according to the project’s own assessment, have increased the “ability to identify infections and hotspots of transmission . . . minimising the risk of the outbreaks witnessed in 2016/17.”
One problem with elimination drives, says Prof Marsh, is that if they fail, political will can quickly evaporate. That is why only realistic targets should be set. On the other hand, he says, aiming for outright elimination makes sense since anything short of that means the disease will bounce back, requiring a fresh round of funding.
Ms Makomva says of the elimination drive: “It is bold and ambitious. It would be the first elimination by a mainland country in sub-Saharan Africa. We are still very committed to this goal.”