Malaria Elimination: What Can Africa Learn from China?

2.1. P=Provision of Packages of Free Basic Public Health Services

In its bid to eliminate malaria, the Chinese government provided basic public health care services to its population free of charge. There was no age restriction as both adults and children benefited from this free treatment of malaria regardless of their legal or financial status. This is not the case in most African countries, such as Cameroon, where malaria treatment is free only for children below 5 years old.4

2.2. C=Creation of a Multi-Sector Collaboration

The fight to eliminate malaria was not just the fight of the Ministry of Health. China adopted a model which involved multi-sectorial collaboration involving at least 13 ministries such as the Ministry of Finance, Ministry of Research, Ministry of Education Development, Ministry of Public Security, the Army, Police, Ministry of Commerce, Ministry of Industry and Information Technology, Customs, Media and Tourism jointly fought to end malaria nationwide.4 China understood that it was important to get all relevant departments and the whole society involved and to cooperate in order to achieve its malaria elimination goal. In most African countries, health issues are solely considered as the affair of the Ministry of Health and not treated as a common problem. Households, through cost recovery, finance part of “the construction of the health infrastructure, operating costs, the repurchase of pharmaceutical products, staff motivation, maintenance costs, and tool management.”

2.3. A=Application of New Genetics-Based Approaches

In its search for alternative solutions to malaria elimination, China developed innovative genetic-based approaches which helped to characterize malaria parasite populations. Malaria, which is caused by obligate intracellular parasites, faces an important decision of whether to continue proliferation or invest in sexual transmission, which is a developmental dead-end if not ingested by a susceptible Anopheles mosquito. This stage makes for a promising point of transmission intervention, as very few parasites differentiate into gametocytes, and even fewer are permitted to develop in the vector. Targeting gametocytes will not only prevent the spread of malaria through the local community in Africa but also reduce the overall population disease burden in 33 moderate and high transmission countries in the WHO African Region, where there were an estimated 33.8 million pregnancies, of which 34% (11.6 million) were exposed to malaria infection.3 Historically, public health interventions that seek to disrupt mosquito transmission through environmental elimination or aim to limit human exposure to mosquito vectors have been very effective in reducing malaria prevalence in many but not all endemic regions if sustained.

In addition, China embarked on active surveillance of biomarkers that were related to drug resistance and categorizing parasitic cases into indigenous or imported, as well as identifying the sources of infections. With the ongoing rates of transmission in Africa, adapting and applying this strategy may change the rates of transmission in Africa.5 A therapeutic efficacy study would need to be carried out in several African countries. WHO recommends that therapeutic efficacy studies (TES) for 1^st and 2^nd line antimalarial medicines should be routinely carried out and data made available for decision-making due to the threat of emergence and spread of artemisinin resistance in malaria-endemic countries, especially in Africa.6

With support from the Harvard Global Institute, China formed an academic partnership to advance data-driven decision-making methods among researchers. The partnership drew researchers from the Chinese National Institute of Parasitic Diseases, the Chinese Center for Disease Control and Prevention, faculty from Harvard University and the Harvard T. H. Chan School of Public Health, and scientists from the Broad Institute of Massachusetts Institute of Technology and Harvard. By employing DNA sequencing and advanced genomic-based tools to understand and predict parasite movement and to differentiate imported from indigenous parasites, this scientific partnership offered a road map for other countries seeking to control the disease across different elimination settings in Africa. China’s efforts to partner with malaria-endemic countries like Lao People’s Democratic Republic, Myanmar, and Vietnam to combat the disease have enabled meaningful connections in terms of providing guidance and support to control and eliminate malaria in Africa and other parts of the world.7

2.4. A=Adherence to the 1-3-7 Timeline

The 1-3-7 strategy that was initially developed and implemented in China in 2012 showed significant success on the road to malaria elimination. There is a need for this strategy to be adapted to the local contexts in several African country settings and strictly respect the timeline of the strategy over many years as China did. According to this strategy, “1” signifies the one-day deadline for health facilities to report a malaria diagnosis; “3” signifies that by the end of the 3^rd day, health authorities are required to confirm a case and determine the risk of spread; and, the “7” signifies that within 7 days, appropriate measures must be taken to prevent further spread of the disease.4 In summary, the 1-3-7 surveillance and response model involves the investigation of malaria cases confirmed through rapid diagnostic testing (RDT) within three days and the application of targeted control measures to prevent further transmission within seven days. Furthermore, the reduction in annual parasite incidence (API) is attributable to the malaria control program efforts with support from the President’s Malaria Initiative (PMI), the United States Agency for International Development (USAID), Global Fund and other non-programmatic factors.

2.5. E=Elimination of Mosquito Breeding Grounds

China made a major effort to reduce mosquito breeding grounds and stepped up the use of insecticide spraying in homes in some areas.8 China’s government brought malaria cases down by using anti-malarial drugs, distributing insecticide-treated nets, and most importantly, spraying mosquito breeding grounds. Over the years, household spray applications had been made, and arial larviciding was done. It also included drainage, removal of mosquito breeding sites, and spraying (occasionally from aircraft) of insecticides. Total elimination of transmission was slowly achieved in China.9 Africa needs to implement insecticide spraying (occasionally from aircraft) to disrupt open and hidden mosquito breeding grounds.

2.6. K=Keeping Malaria at Bay

The risk of imported cases of malaria was a major concern, particularly in southern Yunnan Province of China, which borders three malaria-endemic countries of Lao People’s Democratic Republic, Myanmar, and Vietnam. China also faced the challenge of imported cases among Chinese nationals returning from sub-Saharan Africa and other malaria-endemic regions. In the WHO African Region, where there were an estimated 33.8 million pregnancies, of which 34% (11.6 million) were exposed to malaria infection, WHO and the RBM partnership to end malaria launched the high burden to high impact approach (HBHI) country-led approach as a mechanism to support the 11 highest-burden countries to get back on track to achieve the GTS 2025 milestones.2 These 11 countries (Burkina Faso, Cameroon, the Democratic Republic of the Congo, Ghana, India, Mali, Mozambique, the Niger, Nigeria, Uganda, and the United Republic of Tanzania) accounted for 70% of the global estimated case burden and 71% of global estimated deaths.2 To prevent the re-establishment of the disease, the country stepped up its malaria surveillance in endemic zones and has engaged actively in regional malaria control initiatives. Throughout the COVID-19 pandemic, China has maintained training for health care providers through an online platform and held virtual meetings for the exchange of information on malaria case investigations, among other topics.10