The aim of this review is to map and synthesise the evidence on the implementation of malaria control programmes during the COVID-19 pandemic in the SADC E8 countries, so as to identify gaps, inform policy and enhance planning for future pandemics and promote attainment of the SADC 2030 Malaria E8 Goal.

The inclusion and exclusion criteria were determined by population, concept and context (PCC) as shown in Table 1.¹²

The evidence for this study was searched in selected online academic databases, which are PubMed, Medline, EBSCOhost, Sabinet, ProQuest One Academic, SCOPUS, Web of Science, Google Scholar and Cumulative Index to Nursing and Allied Health Literature (CINAHL).¹³ Any source of information that was relevant to the study was included in the search.¹³ The search for evidence was done in three steps as follows:

Where evidence was lacking, then searching was conducted in all retrieved documents including those that were not selected initially. As the review question covers eight countries, primary sources and opinion articles were searched at the same time as the main search from the selected databases. The first two reviewers conduced the search independently, discussed differences and resolved them amicably. The third reviewer verified the searches. The timeframe for the search was 3 months. The search included relevant documents published and unpublished in English. Details of the selected sources with full articles are provided. The Ryan software was used to store the results of the search in preparation for selection.

Selection of evidence was done in the Ryann systematic review app with the involvement of two reviewers. Prior to the selection of articles, duplicates were removed. The first-level selection was based on the title and abstract. To pilot the selection process, 25 studies were selected based on the title and abstract. The team discussed differences.¹⁵ There were no disagreements, and hence the third reviewer was not engaged.¹⁶ The reviewers agreed on 75% of the searches, and the main search commenced in the same manner. The second-level selection was based on full text, with any disagreements being solved along the way. The results were reported in the ScR and presented using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for scoping reviews (PRISMA-ScR).

A logical and descriptive summary of the results that align with the review questions is presented in the form of a charting table. The key information of the source, such as author, reference and results or findings relevant to the review objectives, is shown. The elements of the PCC are included in the table chart (see Table 2 and Table 3). The tool was adapted from the one provided in the JBI manual and piloted on three sources by two members of the review team to ensure that all the results that are applicable to the search were charted.¹⁵

The evidence was analysed by counting, identifying and describing concepts, programmes and other criteria of data collected, as these would help meet the objective of the review.¹⁴ The evidence was presented using tables, pie charts and graphs.¹⁵ The number of times that a concept appeared, the population and the place where the study was conducted were also considered.¹⁶

All the articles selected were written in English. Publication dates ranged from 2020 to 2023. More than half of the publications were published in 2021 (n = 4), followed by 2023 (n = 2). The year 2022 had the least publications (n = 1). Nothing was published in 2020 (n = 0). Five (n = 5) articles were selected from journals, while two (n = 2) were selected from grey literature (see Figure 2).

Of the Malaria Elimination 8 countries, publications were available for half of the countries, which are Mozambique, Namibia, South Africa and Zimbabwe. Among these four, the countries with the most publications were Mozambique (n = 2) and Zimbabwe (n = 2). Namibia and South Africa had one publication each (n = 1) (Figure 4). The remaining E8 countries (Angola, Botswana, Eswatini and Zambia) were mentioned in grey literature, but there was no publication specific to the countries (Table 2; see Figure 3).

There was no dominant study design, as each article had a different study design. The designs included a retrospective study (n-1), descriptive epidemiology (n = 1), mixed methods (n = 1) and interrupted time series analysis. There was one commentary (n = 1) and one report (n = 1). In one case (n = 1), there was no mention of the study design. The professional populations involved in the studies included computer scientist (n = 1), epidemiologists, community health workers (CHWs), medical practitioners, public health experts and medical researchers. Community members (children and adults) in malaria-endemic districts and provinces, patients with malaria symptoms, cross-border travellers and key stakeholders were the participants targeted for the studies (see Table 2).

The malaria control programme activities that were implemented in all the E8 countries include the dissemination of information to sensitise the community and other stakeholders and cross-border travellers about malaria, vector control, case management, resource mobilisation and trainings. The activities conducted to disseminate the information on malaria and to advocate for the programmes were holding campaigns to sensitise communities and other stakeholders on malaria disease and distribution of Information, Education and Communication (IEC) materials. Such activities were implemented in Eswatini and Zambia. The vector control activities that were conducted were IRS, larviciding and distribution of LLTINs. Entomological studies were carried out in all the E8 countries. Case management activities include case detection through testing, administering artemisinin-based combination therapy, intermittent preventive treatment (IPT), reactive focal mass drug administration (rfMDA) or treatment without testing and related campaigns treating malaria cases. Testing and treating activities were conducted in all the E8 countries, while rfMDA was only carried out in Zambia. Resource mobilisation and the procurement of commodities required to implement prevention and control activities were carried out only in Zambia. Training on prevention and control activities was conducted only in Mozambique. Zimbabwe is the only country that implemented cross-border activities (see Table 4).

Human and financial resources, vehicles, fuel, equipment, IEC materials, stationary and malaria commodities cut across the board all activities. Resources become activity specific. These were rapid diagnostic and treatment kits for malaria testing; medicines or antimalarial drugs for treatment of cases; insecticides for spraying structures; LLINs for preventing vector–human contact; personal protective equipment (PPEs); stationery for records; electronic devices like cell phones and tablets for data capturing and laptops, projectors and flip charts for training.

While the different countries had common barriers, some were unique for a particular country. Movement restrictions, lack of or inadequate funds, non-supply of commodities, outbreaks where malaria had been eliminated, insecticide and parasite resistance and long walking distances to HFs were the barriers that were reported across the board. Zimbabwe reported the greatest number and kinds of barriers, while Angola, Botswana, Eswatini and South Africa reported fewer barriers besides those that were cross-cutting. Barriers that were reported in Zimbabwe but not in other countries were non-recruitment and training of staff, exposure to the COVID-19 virus through community engagements that would expose staff to contaminated surfaces, household visits and meetings with stakeholders. The reassignment of staff to respond to the COVID-19 pandemic was reported in South Africa. Staff shortage was reported in Mozambique. Insecticide and parasite resistance were not captured in the articles, but they were mentioned in the grey literature. Spray coverages of less than 95% were reported in Botswana, Mozambique and Zimbabwe. Botswana, Eswatini and Namibia reported the withdrawal of the Global Fund (Table 5).

The coping strategies used were in the form of infrastructure (testing sites), commodities (PBO [piperonyl butoxide] mosquito nets) and additional monetary resources. Monetary resources were the most used coping strategy reported, followed by commodities. In Zambia, additional funds (222%) from 2021 to 2023 were availed towards buying items needed to fight malaria. In Eswatini, the End Malaria Fund was used to pay workers, to buy fuel for IRS campaigns and to purchase antimalarial drugs. In addition, unused COVID-19 funds were redirected for use in malaria programmes ($100 000.00). The funds were used to sensitise malaria stakeholders on malaria. Infrastructure was mentioned in one instance. In Mozambique, the coping strategy was in the form of infrastructure and commodities. Coronavirus disease 2019 testing sites were used to test and treat malaria cases, and new ITNs (PBO nets) were used for vector control, resulting in the reduction of cases by 50%. In Zambia and Namibia, support was given to malaria community sensitisation programmes testing, treatment and mass drug administration campaigns. However, the literature was silent on the nature of the support being referred to. South Africa, Eswatini and Mozambique received $4 million to fight malaria. No coping strategies were mentioned for Angola, Botswana and Zimbabwe (Table 6).

This review explores malaria programmes that were implemented in the E8 countries during the COVID-19 pandemic, which is crucial as the information from the study would inform malaria programmes so as to support the attainment of the 2030 Malaria E8 goal. Secondly, the review revealed the gaps in knowledge and research in some of the E8 countries. Thirdly, a total of two reviewers conducted the search and selection of articles, which eliminates any form of bias. Where opinions differed, discussions took place and differences were resolved amicably; therefore, the third reviewer did not have to be engaged to resolve the differences.

Only literature published in English was considered for this review. Both published and grey literature on the topic under review were generally scanty. Published literature for Zimbabwe was published by one publisher, limiting the views of other prospective reviewers. Although there was information on Angola, Botswana, Eswatini and Zambia, the lack of publications on these countries does not give a comprehensive picture of the topic under review, pertaining to these individual countries. Since the review was the first one, no literature was found to compare and contrast the results with.

Funding was one of the major hindrances to the continuation of malaria programmes during the COVID-19 pandemic. The SADC Malaria E8 countries are all member states of the African Union (AU). Harper and colleagues reported that the high malaria disease burden in Africa is caused by poverty, low tax revenues, heavy debts, financial crisis, inadequate local resources and high costs of borrowing funds.²⁷ This necessitates the need for funding. The report recommends that $1.5 billion be made available to enable the implementation of current programmes in the member states during the period 2024–2026 in view of the financial crisis worldwide, increased transportation costs for commodities, insecticide resistance and ‘partial drug resistance’.

The report further advocates for $5 billion each year, so that progress is made towards elimination and the allocation of more local funds (funds to be increased by $300 million among member states). Currently, 70% of malaria resources are funded, indicating that member states rely on donors. According to the same report, Zambia increased domestic funding by 174% and malaria commodities by 222% from 2021 to 2023. If all member states followed suit, the malaria disease burden would be under control such that, even during a pandemic, malaria programmes would not be significantly affected. H.E. President Umarco Sossoco Embalo recommends that funds be availed from many sectors, including high-level national funds to end malaria, prioritising health and funding of malaria programmes, international funding and the use of malaria as a ‘pathfinder’ to reinforce health systems, to be ready for pandemics and climate change and to mitigate and adapt health programmes.²⁸

Malaria elimination should not be solely a state problem. There needs to be a national paradigm shift in which the E8 nations are sensitised to appreciate the fact that malaria elimination is not solely a government issue but the responsibility of every sector and individual. Governments of the E8 countries should have policies that engage all sectors and workers to become malaria stakeholders for elimination of the disease as the health sector budget alone would never manage. Each sector should budget for and set aside, from its budget allocation, a certain percentage towards the national malaria contingency fund. All workers should be mobilised and politicised to appreciate and accept the fact that they have a role to play in the elimination of malaria and the attainment of the 2030 elimination goal. Each worker should pay a malaria tax towards the malaria contingency fund, based on income, but the amount should not exceed $1.00 per month, so that in the event of a pandemic or disaster, malaria control programmes will continue without any interruption. Massive campaigns would have to be conducted on mainstream and social media to educate the nation in the E8 countries.

The barrier of a lack of human resources could be resolved by capacitating communities to be able to deal with malaria cases during a pandemic or disaster. More CHWs should be recruited and trained to serve their immediate communities at the village level, such that in cases of pandemics such as COVID-19, where there are movement restrictions, communities will be able to respond to malaria with the help of CHWs. The AU Report 2021 advocates for the recruitment and training of CHWs for community advocacy and case management, particularly in areas that are not easily reached, and for strengthening response mechanisms for pandemic preparedness and response.^21,22 The use of scorecards where communities record information affecting health service delivery has been used successfully in Zambia. Community needs, experiences and gaps are reported directly to the relevant offices and are addressed in a timely manner. This practice is recommended for the E8 countries, as first-hand information would result in appropriate and effective responses during a pandemic, thereby promoting the continuation of programmes during a pandemic and system resilience, as control would be directed to the high-burden areas.

The non-supply of commodities could be resolved through the local manufacture of malaria commodities, thereby fostering system resilience and economic development, as well as promoting increased access to such commodities. The Kingdom of Eswatini envisages to come up with a factory that packages malaria commodities so as to raise funds for local malaria control programmes.²⁹ The report further recommended the ratification of the African Medicines Treaty for implementation in 2022 and that barriers impeding the local manufacture of malaria commodities be addressed by the African Continental Free Trade Agreement framework, regional economic communities and national regulators.

Parasite resistance results in the clearing of parasites in malaria patients taking longer, and medication will not be effective in such a patient. Parasite resistance can be resolved through entomological studies and surveillance to detect and monitor resistance. Research on resistance in each Malaria E8 country should be conducted to inform malaria control initiatives. The WHO recommends that there be improved resistance detection and prevention of the spread of resistant parasites.²⁷ Insecticide resistance has been resolved through the use of PBO nets, which have been proved effective. In Mozambique, cases decreased by about 50% when PBO nets were used. The use of next-generation ITNs is reported to be twice more effective. In the same vein, the use of next-generation chemicals is recommended for insecticide resistance, which also helps deal with parasite resistance.²⁸

The use of CHWs to attend to malaria programmes at the community level could go a long way towards addressing the problem of patients having to walk long distances to access treatment at HFs.²⁷ Trained CHWs should be capacitated and authorised to attend to malaria patients in the community during a pandemic. Community workers should also be capacitated to detect and report malaria cases to CHWs so that they are attended to in a timely manner at the community level, during a pandemic.

Training in any given health initiative, as well as in other setups, is vital for capacitating implementers. It also enhances effectiveness, efficiency and excellence in service provision. However, the COVID-19 pandemic taught us that recruitment and training may not be possible. It is therefore paramount that malaria programme managers at national and sub-national levels be proactive and ensure that communities are capacitated and equipped to conduct IRS and larviciding in their own neighbourhoods and homes. Communities should be urged to use the mosquito nets from previous years to prevent the spread of the disease through the distribution of ITNs during a pandemic.

The Malaria E8 agenda should be well shared within academia and among stakeholders so that it is supported from all quarters through research, funding, donations and other means. There is a need for SADC to fund or source funds for research on the malaria initiative in each of the E8 countries so that gaps that could hinder the attainment of the 2030 goal are identified and dealt with timeously. Researchers should be directed towards researching on countries that lack information on the malaria agenda, for example, Angola, Eswatini and Zambia. Malaria managers and public health students in higher institutions of learning should be encouraged to research malaria-related issues affecting the attainment of the SADC E8 goal so that there is authentic information as much as possible for effective decision-making, thereby maintaining the trajectory towards attainment of the 2030 elimination goal, even during a pandemic.

Harper et al. define policies as ‘laws, regulations, judicial decrees, agency guidelines and budget priorities’.²⁷ Policies are informed by research, as strong evidence is required before change of policy or formulation of a new one. Furthermore, there is a need for proactivity in research so that, when the need for a new policy or policy change arises, evidence from research is already available to inform the policies accordingly.²⁸ These notions suggest that the absence of policies that promote the continuation of malaria programmes during the COVID-19 pandemic could be the result of a lack of authentic information from research to inform policy, as evidenced by lack of research articles on the topic. In the United States, $30 billion is used on health research every year to promote public health.²⁶

The need for policies that are peculiar to the Malaria Elimination agenda in the E8 countries to be identified and developed for implementation, for the attainment of the 2030 elimination goal, for example, a policy for the continuation of malaria programmes during a pandemic or disaster in the E8 countries. Stakeholder reports, for example, WHO and the African Union, should specifically address malaria control in the E8 countries, given the fact that the countries are responsible for 90% of the global disease burden. The attainment of the 2030 malaria elimination goal in the E8 countries would therefore go a long way towards the regional and global elimination of malaria.

Policies peculiar to a pandemic should be synchronised with existing policies for the elimination of malaria so that they complement each other instead of being retrogressive towards the attainment of the respective elimination targets; hence, one disease will not be contained at the expense of the other, as happened during the COVID-19 pandemic – resources to fight malaria were redirected to respond to the COVID-19 pandemic.