BERLIN – The head of the world’s largest malaria funder has issued a stark warning that the disease now poses a greater threat than HIV or tuberculosis, as a new analysis released Tuesday reveals funding cuts could trigger 990,000 additional deaths by 2030, including 750,000 children under five.

“If I think about the situation we face right now on HIV, TB and Malaria, the one that keeps me awake at night is malaria,” Peter Sands, executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria, told scientists and advocates at the World Health Summit in Berlin last week.

“It’s pretty clear to me that this year more people will die of malaria than last year,” Sands said. “The disruptions in funding have had that impact, and malaria is such an unforgiving disease that it reacts incredibly quickly.”

The report by the African Leaders Malaria Alliance (ALMA) and the NGO Malaria No More UK warns that a malaria resurgence could result in 525 million additional cases and wipe $83 billion from sub-Saharan Africa’s GDP by the end of the decade, killing an additional 165,000 people, most of them children, every year.

“The choice is clear: invest now to end malaria or pay far more when it returns,” said Gareth Jenkins of Malaria No More UK. “Cutting funding risks the deadliest resurgence we’ve ever seen.” 

The findings highlight a critical juncture in the centuries-long battle against a disease that currently claims 597,000 lives annually, with 95% of malaria deaths occurring in Africa and three-quarters of victims being children under five, according to WHO data.

As the Global Fund prepares for its November replenishment summit in South Africa, the analysis models different funding scenarios ahead of the event, where donors will determine contributions for 2027 to 2029. The Fund channels 59% of all international financing for malaria control, such as mosquito nets, treatment drugs, and vaccines, to low-and middle-income countries.

“We are really at a very momentous time in human history,” said Joy Phumaphi, executive secretary of ALMA. “There are tools that are available that can actually facilitate the elimination of malaria. One of our biggest challenges at the moment is financing.”

Yet the current trajectory suggests the opposite of elimination, the Global Fund chief warned.

“At the moment, what we’re doing with malaria is we’re making malaria sustainable,” Sands said. “We’re spending enough to reduce the number of lives that are being lost, but we’re not actually breaking the transmission cycle.”

“If anything,” Sands added, “it’s going the wrong way.”

‘Pandemic preparedness hats’

At a pandemic preparedness meeting during the summit focused on potential future disease threats, Sands said he was struck by how much attention novel pathogens receive compared to malaria, which is killing hundreds of thousands each year.

“In many African countries, the biggest health emergency right now is the upsurge in malaria,” he said. “And you’ve got all these people wearing pandemic preparedness hats who are sort of worrying about Marburg and Ebola and all that stuff – which is fine, those are legitimate threats – none of them, if you take a country like DRC, are going to kill remotely as many people as malaria.”

The data on Malaria’s resurgence bear out his assessment. Cases rose to 263 million in 2023, the latest year for which data is available, an increase of 11 million from the previous year, according to the World Health Organization’s 2024 World Malaria Report. 

“The WHO African region still accounts for over 95% of global malaria cases and deaths,” Maru Aregawi Weldedawit, unit head of WHO’s Global Malaria Programme, told the summit by video link. “Even in the region, 11 countries account for over 70% of the global burden. Progress has stalled and in some settings reversed, with significant setbacks placing the 2030 global technical strategy targets at serious risk.”

“In 2023 alone, Africa recorded 249 million cases and 569,000 deaths, more than the combined deaths from all multiplying diseases such as cholera, measles, yellow fever, meningitis and viral hemorrhagic fevers,” Weldedawit added. “Yet malaria is still managed as a routine illness despite being the leading infectious killer on the continent today.”

Working toolkit, missing money 

The funding crisis runs deep across the global health world, but is particularly severe for malaria. Only $4 billion was mobilized for malaria in 2023 against a needed $8.3 billion, according to WHO data.

Germany’s pledge last week of €1 billion to the Global Fund represents a 23% cut from its previous commitment. The UK, another leading funder of the fight against malaria, is reportedly considering a similar 20% reduction.

“The thing with a disease like malaria is we don’t have to drop by very much in terms of investments in order for cases to spiral out of control,” Phumaphi warned. “If we don’t sustain the same level of coverage, we are going to have a crisis.”

The Trump administration’s gutting of USAID has deepened that threat. Internal USAID memos warned that permanently halting the President’s Malaria Initiative could cause an additional 12.5 to 17.9 million cases and 71,000 to 166,000 deaths annually, a 39.1% increase from current levels.

“We need some of that same sense of urgency around what the risks are with malaria right now, as we have whenever we have an outbreak of one of these other new threats,” Sands said. “The current toolkit works, but you need to get a critical level of funding. Crudely speaking, my view is you need roughly twice as much funding per capita.”

Drug resistance and climate converge

As funding falters, new biological threats are emerging. Professor Isabella Oyier, head of the Biosciences Department at Kenya’s KEMRI-Wellcome Trust Research Program, is tracking the spread of drug-resistant malaria parasites across East Africa through genomic surveillance.

“We’re seeing these variants that are allowing the parasite to escape treatment,” Oyier explained at a side event focused on African scientific leadership. “When an individual comes to a health facility, they will be given an anti-malarial drug, but they will not clear their fever, and they’ll still, two to three days after treatment, have parasites in their bloodstream.”

“The treatment is failing because the parasite has developed mechanisms to escape,” she said.

Partial resistance to artemisinin, the backbone of current malaria treatment, has been confirmed in Rwanda, Uganda, Tanzania, and Eritrea, with signals detected in Ethiopia and Zambia, according to WHO data.

The spread of resistance echoes the chloroquine resistance crisis that emerged decades ago, when the malaria parasite’s ability to evade that once-effective drug forced the development of entirely new treatment approaches, including the artemisinin-based therapies now facing their own resistance challenges.

“That issue of resistance and the need for new tools is something that’s extremely important for us to talk about,” Dr Ngashi Ngongo, Chief of Staff at Africa CDC, told the summit, adding that with current low coverage rates, “if you have an intervention that is 50% effective, you can’t be satisfied with 59% of children sleeping underneath nets.”

“Take 59% of 50%, what does it give you? It’s about 30% of children that are protected,” he said. “No wonder every year we are seeing increasing numbers of cases.”

Oyier’s genomic surveillance work with national malaria control programs has led to the introduction of multiple first-line treatments in East Africa, a strategy designed to outmanoeuvre the parasite by rotating different drug combinations and sequencing the malaria parasite’s genome to identify resistance markers before they become widespread.

“Part of the work I do is using genomic surveillance, working with the National Malaria Control Programme to set up an early warning system so that we can identify these variants,” Oyier explained.

“So that they can then have a response plan and figure out what policy changes they need to make,” she said, noting that generating data locally allows for faster integration with health ministries and more agile national responses.

At the beginning of this month, East African countries began rolling out multiple first-line treatment protocols based on this surveillance data, she said.

“At the beginning of September, they are looking at introducing what we call multiple first-line treatments, which means you want to confuse the parasite. This year I’ll give you drug A. Next year, I’ll give you a different combination, and that messes the parasite up.”

“This is a historical challenge for us,” she said. “We know since chloroquine days, the parasite is going to change. So we need to stay a step ahead and be clever.”

Mosquitos on the move  

Climate change is further exacerbating these challenges by expanding the habitats of mosquitoes. Historical data analysis published in The Lancet Planetary Health shows malaria mosquitoes in Africa have moved away from the equator by 4.7 kilometers per year over the past century and climbed 6.5 meters annually in altitude.

“You have a vector that is really widespread, quite resilient, now complicated with the challenges of global warming and climate change that is actually expanding the habitat of the vector,” Ngongo said.

The Lancet research projects that by 2070, an additional 4.7 billion people could be at risk of malaria or dengue as warming temperatures extend transmission seasons.

“Then you have the partial effectiveness of the interventions themselves,” Ngongo added. “We’ve been pushing ITNs [insecticide-treated nets] for many years, but the effectiveness was just around 50% reduction of cases. Now, when you bring in the issues of resistance, you are further reducing the effectiveness of those interventions.”

MMV: the urgency of developing next-generation treatments

The funding challenges are not just for existing tools.  In view of the growing resistance to existing drugs, the urgency of developing next-generation treatments is even greater, Dr Martin Fitchet, CEO of Medicines for Malaria Venture, emphasised at a plenary WHS session on the issue.

“We were formed 26 years ago because the child mortality rate went up,” he told the summit. “Mortality rate, of which 75% were children under five, doubled to 1.2 million on the world’s watch when it wasn’t really looking, and we’re never going to let that happen again, I hope.”

MMV is now developing next-generation antimalarials designed to overcome resistance and prevent another crisis in which the world is unprepared for new mutations in malaria parasites, including potential single-dose cures and long-acting injectable prevention that could protect children for an entire malaria season.

“The new drugs we discover now are five to eight years from the [arriving to] market,” Fitchet explained. “These drugs have to have a high barrier of resistance, they have to be new mechanisms, brand new ways of working, the next generation after artemisinin.”

“Imagine if you can give a single injection of a medicine supervised to a child or school-age child at the beginning of the season, and they’re completely protected,” Fitchet said. “Complementary to vaccines, complementary to nets. I think we need multiple tools in the toolbox.”

Vaccine breakthrough – but is it enough?

The rollout of malaria vaccines represents a genuine breakthrough. By early 2025, 19 African countries had introduced WHO-recommended vaccines into routine childhood immunisation programs, reaching more than 3 million children, according to WHO data.

The RTS,S vaccine, developed over three decades by GSK and the PATH Malaria Vaccine Initiative, was first recommended by WHO in 2021. Pilot programs in Ghana, Kenya, and Malawi demonstrated a 13% drop in all-cause child mortality among vaccine-eligible children.

The newer R21/Matrix-M vaccine, developed by Oxford University and prequalified by WHO in December 2023, achieved 78% efficacy in initial trials. Both vaccines reduce clinical malaria by more than 50% in the first year after vaccination.

However, Sands expressed frustration that the vaccine breakthrough alone has failed to galvanise donors in the way other recent innovations have. The challenge, he explained, is that simply telling donors “we have the tools but need more money” no longer works as a fundraising message.

“The trouble is, the narrative that says actually we’ve got the tools but we need more money doesn’t really work, because donors don’t want to hear that,” Sands said. “We need to find ways of injecting something new or different or urgent or hopeful, particularly positive, hopeful stuff that changes the narrative.”

He also warned that vaccines will not be sufficient to reverse the surge in malaria cases because they primarily reduce mortality rather than stopping transmission of the disease.

“For some of the donors, they think that the vaccines are the story,” he said. “Personally, I don’t think they’re powerful enough, and not least because they don’t really change the transmission. Yes, they will help us reduce mortality, but they’re not going to really help transmission.”

He drew a contrast with lenacapavir, a long-acting injectable HIV prevention drug that requires just two injections per year and has shown near-perfect efficacy in clinical trials. The breakthrough has reinvigorated donor enthusiasm for HIV prevention in a way malaria vaccines have not.

“If I could change the conversation to talk about lenacapavir in HIV, what we have is a long-acting injectable. It’s the most exciting thing to happen in HIV prevention for at least a decade,” Sands said.

“It’s completely changed the conversation,” he added. “It’s allowed us to talk really differently and excite donors about being part of ending HIV. It has both medical impact and donor mobilisation impact.”

Local solutions

African scientists and policymakers are increasingly demanding ownership of the malaria response. Oyier emphasised the importance of building research capacity across the continent. 

“For me to break that down, you’re all aware that in COVID, everyone knew the COVID language, the Greek alphabet. These are the same across all pathogens,” she said, explaining her genomic surveillance work.

“Part of the work I do is using genomic surveillance, working with the National Malaria Control Programme to set up an early warning system so that we can identify these variants, and so that they can then have a response plan and figure out what policy changes they need to make,” Oyier said.

MMV is establishing five manufacturing hubs across Africa in partnership with Africa CDC. The organization is also making an AI-powered drug discovery tool available as open access to researchers globally.

“We’re working with DeepMind, the Google arm of AI, with our database of 10 million compounds,” Fitchet explained. “We’re building a machine learning tool that is going to accelerate the medicinal chemistry, the design, the invention of new anti-malarials.”

“And here’s the kicker: we’re going to make it available open access for any researcher anywhere in the world, particularly if you’re in malaria-endemic countries,” he said.

Fitchet noted that only one clinical candidate for an anti-malarial drug has come from an African research institution to reach clinical trials in recent years – something he says has to change.

“We’ve only had one clinical candidate for an anti-malarial drug going to the clinic from an African research group in Cape Town, in 2014,” he said, referring to work at the University of Cape Town’s Drug Discovery and Development Centre.

“I think it’s time to have more of those coming out of African research groups and having our first approved and accessible African-invented anti-malarial,” Fitchet said.

While African governments have increased their spending on health in recent years, the continent faces severe fiscal constraints. Low-income countries, on average, depend on foreign aid for one-third of their national health spending, and more than 60 countries worldwide now spend more on debt service than on their health systems, according to World Bank data.

“I think we need to appreciate the enormity of the challenge,” Phumaphi concluded, “and exactly how much is required in funding in order for countries to be able to catch up.”

Image Credits: Yoshi Shimizu, World Health Summit, UNDP, WHO, MMV/Damien Schumann, WHO/Fanjan Combrink, Damien Schumann / MMV.