Malaria control is one of the longest running health programmes at the Ministry of Health (MoH) in malaria endemic countries, including in Indonesia, Thailand and Cambodia in Southeast Asia, and in Tanzania, Mali and Ghana in Africa [3, 4]. In these countries, the programmes run in malaria control are usually carried out by the teams in the National Malaria Control Programme (NMCP) that commonly belong to the MoH of their respective countries [5]. The current main strategies in malaria control programme include enhanced laboratory diagnosis, early treatment of malaria cases with anti-malarial drugs and interventions to reduce human-mosquito contact, such as IRS, larviciding, distribution of ITNs or LLINs, with additional programmes that may differ in several countries [6]. It has been emphasized by the World Health Organization (WHO) that while protecting health workers as well as communities against COVID-19 transmission, maintenance of malaria control programmes in malaria-affected countries should remain vital. In fact, several countries in sub-Saharan Africa, namely Côte d'Ivoire, Comoros, and Ghana, had deferred the ITNs and IRS campaigns during the COVID-19 pandemic when such campaigns have been the mainstay of malaria control efforts in the region for decades [7, 8]. A modelling analysis by the WHO estimated a doubling in the number of malaria mortality rate in 2020 if ITN campaigns were suspended and access to anti-malarial drugs were reduced [8]. As the impact of the COVID-19 pandemic on the established malaria control programme in endemic countries has been acknowledged as substantial, priorities should be made to address the threats COVID-19 poses to the malaria control programme. The estimated greatest threat in malaria control programme during current COVID-19 pandemic is the reduced prevention activities [2]. These include scaling back of control activities, reduced capabilities of the overwhelmed health system, and substandard production of anti-malarial drugs driven by cost cutting. However, resources including funds and personnel are being reallocated from malaria and other programmes to support COVID-19 response efforts [9].
Further delay in infrastructure development in current pandemic era has taken its toll on the interruption of medical supplies distribution in low-income countries both in Africa and Southeast Asia regions, making it more challenging to accommodate test kits and ITNs in remote areas. Presence of COVID-19 has greatly influenced the delay of continuation of the ongoing IRS and larviciding activities in Tanzania and Uganda, resulting to minimal coverage of the targeted houses and mosquito breeding hubs [10]. Inevitable reduction of malaria targeted sites due to budget reduction and reallocation have led to unstable tracking of malaria prevalence post IRS hindrance in these areas [11]. While in some of the countries in Southeast Asia, including Indonesia, almost all malaria activities planned for 2020, such as active case finding through house-to-house visits by community health workers, distribution of LLINs, and migration surveillance have been disrupted due to reprioritization of the state budget and circuit breaker (lockdown) policy in response to COVID-19 pandemic. This has resulted in over 50% decline in active and passive case finding of malaria, where only about 500,000 suspected cases got tested from January through May 2020 alone [12]. Additionally, insufficient personal protective equipment and growing stigmatization over potential source of COVID-19 transmission source further affect these malaria workers [9]. Tailoring malaria intervention strategies in the COVID-19 response has been suggested by the WHO to ensure service deliveries and to prevent fatal consequences of malaria.
In response to previous success stories in COVID-19 clinical case management in various parts of the world, the anti-malarial drugs chloroquine, hydroxychloroquine and artemisinin-based therapy have been widely used to treat the patients diagnosed with COVID-19 in addition to standard supportive care [13, 14]. Reports of bulk procurement from foreign pharmaceutical companies and third-party wholesale distributors by the government or people in panic, have resulted in global shortage of anti-malarial drugs [15]. Consequently, the practice of urgent policies has been implemented in several Southeast Asian countries in order to sustain the access to these drugs. These include local production of drugs similar to those available in the market, substituting the major drug component chloroquine phosphate with quinine sulfate; these drugs certainly need efficacy evaluation. This production of substandard drugs was also driven by cost cutting and supply chain errors [16]. Nevertheless, approximately 95% of the budget that was cut from the Indonesian Department of Research and Development had made it almost impossible to perform trials using this potential drug for COVID-19.
To minimize the impact of COVID-19 disruptions, continuous supply of diagnostic kits and adequate support of ITN, IRS and other preventive actions are utmost important. Maintenance of anti-malarial drug quality is also vital. Particularly in developing countries in Africa and Southeast Asia, these aspects are believed to be better supported by additional funding sources, as tremendous economic and social damage caused by the pandemic could be sustained longer than developed countries. However, additional funding supports from private sectors, international organizations, monetary cooperation and developed countries less-affected by COVID-19 were apparently missing their targets by not directing the aids in these particular regions which is explainable due to the fact that the world’s economy itself has dropped due to the unexpected pandemic. It might also be too much to expect the establishment of a global fund for health during this era [17]. Nevertheless, whilst these countries are currently fighting their respective battles against COVID-19 with differing levels of intensities, exercising options in reprioritization of state budget without creating a crisis for the handling of fatal diseases such as malaria during the pandemic should be encouraged. Lessons learned from the current global COVID-19 pandemic should be able to improve the health system resilience in developing countries in Africa and Southeast Asia, mainly the capacity of health institutions and populations to prepare for and effectively respond to crises [18].
