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When health crises collide–tackling malaria, COVID-19 and Ebola in Burundi

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“I had never been sick like this,” said Suavis Ndayiziga.

“I spent three days not knowing where I was. If you have malaria symptoms, you need to get treatment as quickly as possible.”

Malaria is a leading cause of death in Burundi. In the first quarter of 2019 malaria cases increased by 59 percent, compared to the same period the previous year. Some 4.7 million cases were recorded in the first six months of the year, representing nearly half of the population. Despite this, the mortality rate was halved thanks to large-scale preparedness and treatment programmes.

In 2020 health teams have spent many months racing to ensure the country is once again prepared. Thanks to the government of Burundi, UNDP, the Global Fund to fight AIDS, Tuberculosis and Malaria (the Global Fund), UNICEF and USAID more than 6.8 million bed nets have been distributed. Mobile clinics are ready to deploy in remote communities and indoor residual spraying has targeted nine of the most affected districts.

And new health crises have been emerging. In August 2019, the Ebola outbreak in the Democratic Republic of Congo, which has claimed 3,456 lives, spread to South Kivu province, bordering Burundi. A national health crisis centre was quickly established within the Burundi Ministry of Health, supported by the World Health Organization (WHO), UNDP and the Global Fund. Despite fears an outbreak could overwhelm Burundi’s fragile health system and derail malaria control, containment appears to be working.

Then, on 31 March, Burundi confirmed its first cases of COVID-19.

Fighting on all fronts

COVID-19 threatens to hamper the malaria response in many ways. Both diseases have similar symptoms, leading to potential misdiagnosis. A massive upsurge in people seeking healthcare will result in shortages of testing, hospital beds and medicines. And lockdowns could prevent community health volunteers carrying out critical malaria control.

“Lessons from Ebola are relevant in this context, specifically the disruptive effect on the delivery of other essential health services, which led to a massive increase in malaria-related deaths in some countries,” said Dr Bouzid, UNDP Global Fund Project Coordinator in Burundi.

“Consequently, WHO is urging countries to ensure continuity of malaria services, to save lives and help reduce the strain on under-resourced health systems. But the safety of health workers is paramount, and so we are working continuously to ensure they have the equipment they need to continue to carry out life-saving malaria control activities.”

Vigilance is key

Containing the potentially rapid spread of COVID-19 is an urgent priority. Scaling up health programmes, helping governments buy the health products and ensuring strong supply chains must be done in a way that builds national capacity and innovates while also using existing systems where possible. UNDP, with funding from the Global Fund, has been supporting the Ministry of Health in Burundi since 2017. This understanding of the country context is imperative as the health landscape is constantly evolving.

Climate change is one aspect of this shifting situation. With a hilly and mountainous landscape, malaria in Burundi is exacerbated by changes to the climate, because mosquitoes are reaching ever higher altitudes.

“Before, I knew nothing about malaria,” said Jacqueline Ngirukwigira, who lives high up in Ngaara Hill, a community previously unaffected by malaria. “But I had a headache, I was shaking, and I had no appetite.”

Countering the effects of climate change has meant distributing bed nets in higher, mountainous communities, and fighting increasing drug resistant forms of malaria which requires the use of different insecticides.

“Now we know you must take the precaution of sleeping under an impregnated mosquito net,” said Pélagie Nzikobanyanka. As a hill farmer with five children, Pélagie was part of the communities targeted during recent bed net distributions.

“You must also clean up where you live and close the windows at night to prevent mosquitoes from entering the house.”

Support to strengthen procurement and supply chains has also made sure medicines and tests are available even in remote communities. Hundreds of community health workers are playing a vital role; carrying out rapid diagnostic tests, providing artemisinin-based combination therapy, and caring for those affected.

“In my community, the impact of my work is very palpable: children are treated very early and it has significantly reduced the number of children dying from malaria,” said Fidel Havyarimana, a farmer in the commune of Kiganda, who has been a community health worker for almost eight years.

The geographical spread of the disease is closely monitored. An increasing number of farmers in the countryside — mainly women — are having to move to the capital for work and then travel home at weekends. This means malaria is spreading throughout the country.

“Times change,” Fidel said. “The rice fields and the marshes of our region mean we have many cases of malaria. Climate change is another factor.”

For Fidel, the devastation wrought by malaria manifests itself in many ways.

“It causes poverty because people have to spend a lot on treatment and they can no longer work. But most of all, the worst thing about malaria is that lots of people die if they are not treated properly.”

Investing in health

The improved health infrastructure developed as part of the malaria and Ebola response and increased investments in medical equipment, means Burundi is better prepared to respond to new disease outbreaks such as COVID-19. This work has been carried out in close coordination with national entities to guarantee sustainability, meaning it can benefit communities now and in the future.

The national health crisis centre, developed during the Ebola outbreak, is now the base for the country COVID-19 response, fully equipped with 200 smartphones and laptops. Pumps purchased for indoor residual spraying of malaria can be repurposed for medical decontamination. UNDP has also been supporting the development of a mobile application, which will now be used to track COVID-19 cases.

The scale of COVID-19 should not be underestimated. Burundi has only one laboratory for biomolecular tests needed for both malaria and COVID-19, with a capacity of 200 tests daily. UNDP and the Global Fund continue to work closely with the government to develop ways to increase testing capacities, utilizing equipment already in place for other diseases.

“Simultaneously responding to some of the biggest health crises the world has ever faced is no small task and requires significant time, coordination and resources. Support to strengthen Burundi’s health systems is well underway, but this important work will need to continue for many years,” Dr Bouzid said.

In line with UNDP’s Strategic Plan 2018–2021 and its HIV, Health and Development Strategy, UNDP partners with the Global Fund, governments and civil society to support and strengthen multi-sectoral national responses to malaria, by providing integrated policy, programme and capacity development support. To date, this has resulted in 79 million cases of malaria being successfully treated and 75 million bed nets distributed.