- Shortages of health care facilities, staff and supplies in Malawi, Kenya and Ghana will make it difficult for the countries to sustain vaccine protocols for the new malaria treatment Mosquirix after their pilot programs end.
- Decreases in U.S. Agency for International Development (USAID) funding could further handicap the health care sectors in sub-Saharan Africa as the region battles endemic disease.
- Despite recent advances in treatment, malaria will remain an endemic in sub-Saharan Africa for years to come.
Sub-Saharan Africa is one of the global centers of malaria, a disease endemic to the world's tropical regions. The illness continues to inflict suffering and sometimes death across the region — infecting more than 200 million people annually, many under the age of 5 — despite extensive efforts to target the mosquitoes that transmit it. The costs of fighting malaria, moreover, have proved burdensome for governments, and the effects of the disease itself can limit worker productivity, hampering economic growth. But after more than 30 years of development and trials, a promising vaccine against the disease is about to be put to the test in pilot programs in three African nations.
In a recent testing phase, the GlaxoSmithKline vaccine RTS,S, known by its brand name, Mosquirix, demonstrated its potential to lessen at least some of the human and economic tolls malaria can cause. The first vaccine of its kind to advance past Phase III trials, Mosquirix is an important step toward combating the mosquito-borne illness. Even so, it is not a panacea. The difficulties of administering the multidose vaccine, the treatment's shortcomings and the institutional constraints imposed by the creaky health care systems throughout the African continent will limit the overall effect of the medicinal solution.
A Lengthy Trial
The new malaria vaccine has traveled a long road to get this far. Scientists first began developing Mosquirix three decades ago; the results of Phase II trials involving a small number of subjects in Mozambique were published in 2004 and 2007. Then between 2009 and 2013, researchers conducted Phase III trials — the largest vaccine trials for malaria to date — on a pool of more than 15,000 infants in Burkina Faso, Gabon, Ghana, Kenya, Malawi, Mozambique and Tanzania. The results showed a 46 percent reduction in malaria cases among children who received four doses of the vaccine, compared with a control group. Most of the trial's participants, however, also used mosquito nets, which may have helped to reduce the incidence of malaria among them. Furthermore, the results showed that the vaccine's effectiveness declined over time.
The next phase of testing, set to begin in 2018, will focus on the feasibility of administering multiple doses of the vaccine on an expanded scale. The World Health Organization has recommended that the pilot programs use all four doses of the vaccine, administered to infants over the course of about a year beginning at the age of 5 months. Researchers chose to launch the pilot programs in Ghana, Kenya and Malawi based on several criteria. All three countries participated in the Phase III trials, and a large percentage of their residents use mosquito nets. Perhaps more important, each possesses a comparatively functional immunization program.
Testing the Limits of African Health Care
Still, the health care systems in these countries struggle with shortages of supplies, equipment and staff. Each country's annual health care expenditure falls well short of the average for sub-Saharan Africa, $98 per person, and pales in comparison with South Africa's $570 per capita annual expense.
Of the pilot program's participants, Malawi spends the least on health care at just $27 per person each year. And its health care system has come under increasing strain over the past year, as unrest in Mozambique sent tens of thousands of refugees flooding across its border. The stream of displaced Mozambicans, combined with the influx of refugees from other nearby nations, has stretched Malawi's medical resources thin. The health care center that serves the Dzaleka refugee camp — which houses three times the number of people it was originally designed to accommodate — also serves the local Malawian population, for example. Foreign aid can provide short-term relief, but it cannot fix the underlying structural issues, such as food insecurity and spotty access to electricity, that continue to plage the country's health care sector.
The situation is less dire in Ghana. The country places minimal tariffs on medical supplies, and its health care system is considered one of the most advanced in West Africa, thanks in part to former President John Dramani Mahama's efforts to promote investment in the industry. Notwithstanding its reputation, however, the country's health care sector still has room for improvement. President Nana Akufo-Addo's administration has said it intends to pursue further reforms on that front.
Kenya, too, has set an official policy goal to better its health care system. Private spending on health care far outweighs public spending in the country, creating a care gap for its poorest people, who are among the most susceptible to diseases such as malaria. In 2013, the Kenyan government shifted more responsibility for building and maintaining health care infrastructure to its counties. Although the counties still receive federal funds for health care, the amount of money they spend on it varies widely; spending in some areas falls far below the national average. The country's unevenly distributed health care resources could skew the pilot program's results.
A Difficult Battle
Beyond these challenges, policy changes in the United States could also make the fight against malaria much more difficult for countries, such as Kenya, that depend on funding from the U.S. Agency for International Development (USAID). USAID provided nearly 4 million mosquito nets to 23 counties in Kenya in 2015. But the U.S. Department of State recently announced that USAID was suspending its funding for all activities conducted by the Kenyan Ministry of Health because of concerns about corruption.
The Mosquirix pilot projects have the greatest chances of success in areas that receive outside financial support and assistance. If the programs prove effective, the next step would be to broaden the scope of the vaccine's use — within the test countries and beyond. The institutional gaps throughout the region, however, will make wider implementation tricky.
Over the past several years, the number of deaths due to malaria has fallen in much of sub-Saharan Africa, and some countries have managed to reduce the total number of infections as well. But even if the new vaccine proves an effective tool for combating the disease, the limits of health care infrastructure and institutions throughout the region means that malaria will likely remain an endemic problem in sub-Saharan Africa for years to come.