Malaria surveillance and control in Central Africa : the challenges of instability and access

Scientific discovery and endeavour has led to significant advances in the development of tools available to fight malaria. Long-Lasting Insecticidal Nets, Rapid Diagnostic Tests and Artemisinin-based Combination Therapy have all been well designed to combat the complex biology of the Plasmodium parasite and its vector. They have significantly contributed to the reduction of malaria associated morbidity and mortality in many different settings worldwide. Despite an estimated 6.8 million malaria deaths averted between 2000 and 2015, malaria remains one of the leading causes of death in sub-Saharan Africa where just 12 countries account for 69% of the global malaria associated mortality (almost 500,000 deaths a year).
When looking at country level estimations over time, it is clear that access to these anti-malarial tools is increasing. However, there are large inequalities in access at sub-national level. As a disease shaped by broad patterns of social and economic development, it is the poorest, most isolated and difficult-to-reach communities that remain disproportionately underserved by malaria control programmes and consequently have the highest burden of disease. These areas often have weak health systems as well as inadequate infrastructure and governance to effectively implement programmes and this can be further exacerbated by political instability and armed conflict. Yet, there is little evidence on how to effectively tailor traditional control programmes to such settings.
This PhD thesis focuses on Central Africa, more specifically the Democratic Republic of Congo (DRC) and the Central African Republic (CAR). Both countries have been classified as “fragile states”, meaning they face particularly difficult political, social and economic conditions. They have extremely limited access to health care in many areas and experience a large amount of social unrest, political instability and conflicts. This thesis aims to contribute quality evidence on how to explore and overcome the challenges presented by isolated or conflict-affected settings and explores how malaria control programmes can be adapted to see malaria effectively controlled and associated morbidity and mortality reduced.
Evidence-based adaptations of control programmes at the sub-national level are essential to develop more flexible strategies, integrated into the national infrastructure. This in turn will be key to accelerate progress among the most vulnerable populations towards Roll Back Malaria’s ambitious global malaria targets to reduce malaria associated mortality and case incidence by 90% by 2030 compared to 2015. Ultimately, malaria control programmes also contribute to achieving universal health coverage.
This thesis begins by examining the history of malaria control in DRC to complete and update the state of knowledge in this vast and diverse country. It is the second largest country in Africa carrying the second highest global malaria burden after Nigeria (estimated 14 million cases per year). It reviews the historic evidence from the colonial period through to early years of independence, until the creation of the national malaria control programme. It explores particularly how programmes could build on successes and learn from failures during a time that was rife with political turmoil. It then explores current malaria control programmes, assessing how to maximise the use of LLINs in remote communities in DRC through different distribution strategies. Additionally, it investigates how a network of community health workers can continue malaria case management services during the on-going conflict in CAR in spite of a highly volatile situation. Finally, this thesis assesses the role surveillance is currently playing, its limitations in accurately estimating malaria burden in the community, and ways this could be improved to better inform policy makers and hence lead to better programming.
Combined, these projects provide a unique perspective on how malaria control programmes can overcome the issue of access to healthcare in isolated or conflict-affected communities. The evidence presented here builds a case for placing a stronger emphasis on decentralising care and surveillance through community health workers and sentinel site systems. In areas where health facility surveillance is weak, these strategies can offer a sustainable solution to capture changes in the epidemiological profile of diseases and better understand the health burden at the local level. The thesis also identifies challenges that need to be overcome for such programmes to be sustainable, including the role of private pharmacies to increase access to treatment and representativeness of surveillance and national financing.