By Milliam Murigi
Africa’s fight against malaria is entering a critical phase as early signs of resistance to frontline treatments begin to surface across several countries. While the continent has made significant gains over the past two decades largely due to the widespread use of artemisinin-based combination therapies (ACTs), health experts now caution that those gains could be reversed if urgent action is not taken.
In this interview, Dr. Dorothy Fosah Achu, Team Leader for Tropical and Vector-Borne Diseases, World Health Organization (WHO) Regional Office for Africa (AFRO), breaks down the science behind emerging resistance, the risks it poses to both health systems and economies, and the strategies being deployed to stay ahead of the threat.
Q: What are the current trends in malaria drug resistance across Africa?
A: What we are currently seeing is what we refer to as partial artemisinin resistance. Artemisinin remains the backbone of the most widely used malaria treatments but its effectiveness is beginning to decline in certain areas.
This does not mean the drugs have completely failed, but rather that patients are taking longer to clear the parasites from their system. That delayed response is often the first warning sign that resistance is emerging.
This phenomenon was first detected in Rwanda in 2014, marking a significant moment for the continent. Since then, confirmed resistance has been reported in Tanzania, Eritrea and Uganda. In addition, several other countries are now detecting genetic mutations associated with resistance even if patients are still responding to treatment clinically. The presence of these mutations is particularly concerning because it suggests that resistance could spread more widely over time if it is not contained early.
Q: Why is this development particularly concerning for Africa?
A: Africa carries the highest malaria burden globally, accounting for the vast majority of cases and deaths. In many endemic countries, malaria remains one of the leading causes of hospital admissions and child mortality.
Because ACTs are the primary treatment used across the continent, any reduction in their effectiveness has far-reaching implications. If these drugs begin to fail, we risk seeing a reversal of the progress made over the past two decades.
We could see more patients progressing from mild, uncomplicated malaria to severe malaria. Severe malaria is much harder and more expensive to treat, and it carries a significantly higher risk of death particularly among children under five.
Q: What are the projected public health and economic impacts if resistance is not addressed?
A: The public health consequences could be substantial. If resistance evolves into full treatment failure, the consequences could be severe. We would see a sharp increase in severe malaria cases, greater pressure on hospitals and healthcare workers and a rise in preventable deaths.
Modeling studies, including those conducted by partners such as Imperial College London, estimate that Africa could experience up to 16,000 additional deaths each year if resistance spreads unchecked. This would represent a major setback in global malaria control efforts.
From an economic perspective, the impact is equally serious. Treating severe malaria requires more resources—hospital beds, specialized care, and more expensive medicines. This places additional strain on already stretched health systems.
At the household level, families face higher out-of-pocket costs due to longer illness and lost productivity. At the national level, governments may be forced to allocate significantly larger budgets to malaria control, particularly if they need to switch to newer, more expensive treatments. In essence, failing to act now will cost far more in the future.
Q: What strategies are being put in place to address this growing threat?
A: The World Health Organization has developed a comprehensive strategy to address antimalarial drug resistance in Africa. It is built around four key pillars. First, strengthening surveillance. We cannot manage what we do not measure. Countries need to continuously monitor the effectiveness of treatments through therapeutic efficacy studies, as well as track genetic markers of resistance through molecular surveillance. This helps guide timely policy decisions.
Second, improving regulation and drug use. One of the major drivers of resistance is the inappropriate use of medicines. This includes treating patients without proper diagnosis, using substandard or counterfeit drugs, or not completing treatment courses. Strengthening regulatory systems ensures that only high-quality medicines are used appropriately.
Third, reducing the parasite burden. In areas where resistance is emerging, it is critical to reduce the number of parasites circulating in the community. This means scaling up prevention measures such as insecticide-treated nets, indoor residual spraying, and chemoprevention. It also includes using additional medicines that can block transmission.
Fourth, driving innovation. Innovation is essential both in how we use existing tools and in developing new ones. One key approach is diversifying treatments, using multiple therapies instead of relying on a single drug. At the same time, there is ongoing work to develop new antimalarial medicines and vaccines. Organizations like Medicines for Malaria Venture are playing a crucial role in advancing the next generation of treatments, including drugs that do not rely on artemisinin.
Q: Where do you see the greatest opportunity for progress right now?
A: One of the most immediate opportunities lies in adopting what we call multiple first-line therapies. Instead of relying on a single standard treatment, countries can deploy a combination of different therapies either simultaneously or in rotation. This reduces the selective pressure on parasites and helps slow the development and spread of resistance. However, implementing this approach requires adequate funding. Alternative therapies tend to be more expensive, and countries need support to procure and distribute them effectively.
Q: Could new technologies like gene drive replace current malaria interventions?
A: Gene drive technology is an exciting area of research, particularly for vector control. It involves modifying mosquito populations so that they either cannot reproduce effectively or cannot transmit the malaria parasite. However, this technology is still under study and its long-term impact is not yet fully understood. More importantly, there is no single “silver bullet” for malaria. Even with gene drive, we will still need a combination of interventions that is effective drugs, preventive measures, vaccines and strong health systems. The fight against malaria will always require a multi-layered approach.
