The impact of COVID-19 on developing countries
Humanitarian crises monitoring: response on the current situation and the immediate risks and threats
Medicines for Malaria Venture, April 2020
Medicines for Malaria Venture (MMV) is a leading product development partnership (PDP) in antimalarial drug research. Its mission is to reduce the burden of malaria in disease-endemic countries by discovering, developing and facilitating delivery of new, effective and affordable antimalarial drugs.
Over recent years, MMV has developed end-to-end capabilities spanning drug discovery, development and delivery, that have brought new malaria medicines to millions in need. PDPs like MMV are contributing in important ways to the global effort against COVID-19.
COVID-19 is having a significant global impact on health, economy and society at large, which is expected to also extend to the long-term. The negative impact of this crisis will be even greater for the most vulnerable populations in resource-limited settings and humanitarian crises, due to the limitations and fragility of healthcare systems.
Already now there are signs that control efforts on epidemics like malaria are being compromised by COVID-19, similar to the situation experienced with recent outbreaks of the Ebola virus. There are disruptions in supply chains and shortages are being experienced for key medical products due to both the blocking and suspension of imports and exports of goods. Additionally, in response to COVID-19 medicines have been redeployed, including some antimalarials.
Access to life-saving medicines, including antimalarials, and to emergency care is being compromised – this is a particular challenge for the elderly and people affected by chronic diseases, but also includes millions of children under five years of age and pregnant women, who are at greatest risk of malaria morbidity and mortality.
It is against this background that MMV is submitting comments in response to the International Development Committee’s request for feedback on the impact of COVID-19 on developing countries around the world, and the UK’s response to this.
The similarities in symptoms between COVID-19 and malaria (as well as other illnesses such as typhoid) mean that accurate diagnosis is paramount – yet healthcare workers often lack the diagnostics to distinguish between diseases and thus prescribe appropriate treatment.
The message that people with fever should remain at home as they could potentially be infected with COVID-19 could be life-threatening for people who have fever due to malaria, as severe malaria can kill within 24 hours.
Fear of contracting COVID-19 at health centres may reduce the instances of seeking care, whether on an ad hoc basis or for routine care and cover, e.g. for Intermittent Preventive Treatment in pregnancy (IPTp) which is administered during antenatal check-ups.
Seasonal Malaria Chemoprevention (SMC) for children as well as bed net distribution are no longer possible at central facilities due to the need to avoid gatherings and personal contact. Door-to-door visits may be possible, but are slower, more expensive and require additional protective equipment (e.g. masks, gloves) which may not be available.
The closure of schools disrupts malaria campaigns and other health and nutrition programmes, which could increase the vulnerability of children to preventable illnesses and increase malnutrition.
The announcement of lockdowns in urban areas in some countries has resulted in an exodus of migrant and lower-income workers into rural areas, leading to challenges in reaching these populations for health campaigns such as malaria testing, IPTp and SMC.
Phone calls and video conferencing to discuss alternative ways to deliver healthcare in the community may not be accessible to all or feasible due to limited telecommunications and internet infrastructure, forcing healthcare workers to meet face to face and therefore placing them at further risk.
Among internally displaced persons, asylum seekers, refugees, returnees and migrants, as well as in humanitarian crises and in other fragile settings, all these constraints are dramatically compounded by the disadvantaged living standards and obstacles experienced by these populations in accessing health services.
The already limited resources of Ministries of Health in developing countries are likely to be absorbed by COVID-19, both in terms of financial and of human resources. Due to the increasing number of COVID-19 cases, and in the face of limited health care infrastructure, manpower, supply and storage facilities, malaria-endemic countries could be obliged to significantly shift their health resources to COVID-19 emergency care. This could lead to an increase in the number of cases and deaths for malaria and other major diseases among the most vulnerable populations.
The indirect impacts of the outbreak on developing countries, and specific risks and threats:
Access to antimalarial medicines and the production of these medicines are being disrupted globally due to lockdowns, import-export suspensions and the redeployment of some antimalarials in response to COVID-19. An example is the current supply situation for chloroquine, an antimalarial used to prevent and treat malaria in areas where the parasite remains sensitive to its effects, and hydroxychloroquine, used for malaria and as a treatment for rheumatoid arthritis and lupus. Since chloroquine and hydroxychloroquine started being considered as potential prophylaxis and treatment options for COVID-19, some countries have started banning exports and sales in pharmacies and restricted use to hospitals. Also, the lockdown of countries hosting major manufacturers of these medicines, key starting materials and active pharmaceutical ingredients has resulted in increased demand for these products, which now outweighs the supply. As an additional consequence and risk, the circulation of counterfeit drugs is also mounting.
In many developing countries, small- and mid-sized businesses employ the bulk of the workforce. Extended lockdowns could result in significant income losses and large-scale unemployment, including among migrant workers, thus leaving households with little or no resources for food and basic medical supplies such as antimalarial medicines.
Lessons identified and learned/applied from previous experience with infectious diseases (for example, Ebola):
The 2014 – 2016 Ebola outbreak in Guinea, Liberia and Sierra Leone significantly disrupted malaria control efforts and led to a wide increase in malaria infections and mortality. Estimates indicate that ‘excess’ deaths from malaria during the outbreak exceeded deaths from Ebola.
Learning from this experience, WHO has published a Q&A on Malaria and the COVID-19 Pandemic and has included malaria in its operational guidance for maintaining essential health services during an outbreak in the COVID-19 response. This guidance, inter alia, encourages the continuation of healthcare-seeking behaviour for fever and suspected malaria, appropriate malaria case management, including testing and treatment in health facilities and at the community level. Furthermore, it also encourages delivery, insofar as is possible, of vector control measures such as bed nets, household spraying and preventive treatment, and timely orders for malaria commodities in consideration of likely delays in deliveries.
This experience also shows that existing and new epidemics always need to be addressed with a robust, concurrent response, and that key elements need to be in place to support health systems. This comprises adequate safeguarding of the essential supply of treatments for major poverty-related diseases, such as malaria. Additionally, attention needs to be given to populations at heightened risk of being marginalized in health systems, such as internally displaced persons, asylum seekers, refugees, returnees and migrants. Of further importance is scaling up the production of key starting materials and active pharmaceutical ingredients to respond in a timely manner to the increasing needs for health products for existing and new threats. It is also critical to ensure support to global health research and development to ensure new health tools for existing and new threats.
The impact of the outbreak, and consequential mitigation measures, on fundraising:
As many donor governments supporting global health are now investing in a strong response to the COVID-19 crisis, earlier commitments to other global health priorities and key poverty-related diseases might be put at risk owing to this re-allocation of funds.
This could potentially result in the de-prioritisation of funding for access programmes for major poverty-related diseases as well as for research and development, which could in turn compromise scientific capacity to address these key global health challenges.
The implications for DFID’s policy on a global heath strategy:
The UK Government is a key actor in the fight against major poverty-related diseases such as malaria. Funding from the UK has helped prevent hundreds of thousands of deaths, including of pregnant women and children who are often the most vulnerable. Continued investment is critical to scaling up development and for access to innovative interventions in the fight against deadly diseases, as well as to ensure the strengthening of health systems globally – our first lines of defense against existing and emerging health threats.