Resistance to a key drug used to treat malaria in Africa is spreading. Experts warn action is now urgent and any delay will cost lives and create economic misery. 

Artemisinin-based combination therapy (ACT) is the main first-line malaria treatment used in Africa and the best available option, according to the World Health Organization (WHO). 

ACT has saved millions of lives, but the parasites that give you malaria are becoming resistant to one of the two drugs in the treatment, artemisinin. 

The WHO reports that this has happened in Rwanda, Uganda, Eritrea and Tanzania. Resistance, Resistance is suspected in at least four other countries, and tests are being carried out in these and further countries as it is likely that the problem is spreading.

This is known as partial resistance to ACT because the parasites can still be killed and have not developed resistance to the other drug used with artemisinin, most often Lumefantrine.

“Too often, the response stops at detection. Countries are left with data, but without the financing, coordination, or readiness to act on it.” 

Professor Deus Ishengoma, a malaria specialist from Ifakara Health Institute in Tanzania and professor at Kampala International University, says action is not being taken quickly enough: “We should have acted yesterday, but we haven’t. So we should act today.”

He explains that no one knows when the situation will turn from “orange to red.” Red means full treatment failure and a jump in the number of deaths.

“When you start to see the first signs, which we already saw in a good number of African countries, you start seeing some patients who do not get cured as expected. And as we move into the second stage, the third stage, the number starts building up. In the fourth stage, that’s when the drug fails completely and you get into panic mode… and more deaths,” Ishengoma told Health Policy Watch.

“In countries like West Africa, where things haven’t got worse, they should act now and prevent it. In eastern Africa, where we are now in the third stage, we should not allow it to go into the fourth stage, where the drugs will completely fail.”

AMDR Action says that Africa is at a “critical inflection point”. The group of experts say “the risk is no longer theoretical”, yet “without intervention, the region faces rising treatment failure rates and associated economic costs, increased malaria cases and mortality, escalating healthcare expenditures, and communities losing trust in curative health services.”

Some experts argue that several countries are responding well. Professor Maciej Boni, an epidemiologist at Temple University in Pennsylvania specialising in malaria, told Health Policy Watch that changing policy and drugs takes time.  

“For the seven or eight countries that have identified artemisinin-resistant parasites inside their borders, the time to act is now. For the rest of East Africa, I think they would need to act in the next year or two,” said Boni.

He praised Burkina Faso for procuring alternative drugs before resistance to ACT had been detected. 

More deaths if countries wait for the drugs to fail

Worldwide, deaths from malaria have come down over the past 25 years, and 47 countries are now malaria-free, the latest being Georgia, Suriname and Timor-Leste, in 2025. 

Yet in Africa, experts warn decades of progress are at risk. The latest figures available from the WHO (2024) show a slight rise in people dying from malaria to 610,000. 95% of those deaths were in Africa. 

Boni says in countries with high numbers of deaths from malaria, “these death counts could increase 20% over a five-year period.”

Oliver Watson, an infectious disease mathematical modeller at Imperial College London, explains that delaying action ultimately costs countries much more than if new interventions, like introducing different drugs, are funded quickly. 

Watson has modelled the impact of delayed action based on current resistant patterns in Africa. 

“The health estimates are huge, with up to half a billion additional patients where the drugs no longer clear the infection,” Watson told Health Policy Watch.

This leads to “catastrophic economic losses” for affected countries as patients living with malaria struggle to work and feed their families. 

The cost to health budgets of delaying action is also much higher than early intervention. “Taken together, the modelling suggests that the additional pressure on health systems and households could plausibly amount to well over a billion dollars over the next 15 years,” said Watson.

Diversifying drugs

To deal with drug resistance, “you try to diversify the drug supply”, Boni explains. By getting multiple drugs in use, “you make it challenging for the parasite, as it jumps from person to person, to acquire resistance to all the drugs”.

There are four artemisinin combination therapies (ACTs) “realistically” available for use in Africa, according to Boni, but he adds that some are expensive and not all are available at scale. 

Two promising new drugs are in the pipeline but not available yet, including one which doesn’t use artemisinin. 

But AMDR Action told Health Policy Watch the new medicines may not be available quickly enough for those countries already affected by resistance. There, they believe drug alternatives need to be in place within six to 12 months. 

Other measures being used include vaccines, chemoprevention for those who are more vulnerable (giving a course of antimalarial drugs to prevent infection), and insecticide-treated nets to avoid being bitten in the first place. 

However, some mosquitoes (rather than the parasites they carry) are also becoming resistant to insecticide on treated nets, which is reducing their effectiveness. 

Strategies like testing before treating to ensure drugs aren’t being used when it’s not malaria, driving up resistance, are also part of the solution. 

Boni says that it “takes years” to change malaria policy, and you don’t do it quickly if you don’t have the money.”  

But funding has gone down as the costs, driven by emerging resistance, have gone up. 

For Boni, “the disappearance of funding from USAID and the US government in general has made all this more challenging.”

Ishengoma in Tanzania says countries facing resistance need help from international funders, but ultimately wants his country and others in Africa, to take the lead in their own solutions.  

‘The battle is not all lost’

Ahead of World Malaria Day (25 April), the WHO says: “With the tools and resources available today, no one should die from malaria.” 

Resistance to antimalarials like ACT was anticipated, but AMDR Action says “waiting for clear treatment failure will mean acting too late. The tools, data, and platforms to act already exist… And the warning signs are already clear. The question is whether we respond to them.”

Ishengoma, who lost two siblings to malaria, is pushing for action to prevent a return to anywhere near the scale of deaths he witnessed in the 1970s and 80s in Tanzania, “when we were growing up… and children were dying.”

“The battle is not all lost. We still can go in today and save our people.”

With support from The London School of Hygiene and Tropical Medicine

Image Credits: WHO, Global Fund, Paul Adepoju .