Q&A on the World Malaria Report 2016

13 December 2016

1. Why have some of the key metrics in this year’s report changed from the previous year?

Last year’s report provided projections for 2015 based on trends up to 2013 and 2014; this year’s report includes the latest data we received from the national malaria programmes and nationally representative household surveys from 2015.

Overall, there is a reasonably good match between last year’s projections and this year’s estimates. South-East Asia is the one region where the number of reported cases came in much lower than predictions, which required us to update other global statistics in the report.

2. The report shows that total funding for malaria has flat-lined since 2010. How likely are we to meet the funding levels needed to achieve the 2020 targets of the Global Technical Strategy for Malaria (GTS)?

The goals set by the GTS are ambitious, and robust funding is necessary to achieve them. Because economic growth has slowed in many of our big donor countries, we will need to diversify our funding sources in order to achieve GTS targets. The development of new domestic financing mechanisms would help provide a much-needed increase in contributions from malaria-endemic countries.

In addition, we must use the funds we do have more strategically. We must select the most appropriate interventions for individual settings, and we need to target populations that will benefit the most.

3. We’ve spent a lot of money fighting malaria, but progress towards some GTS targets is off-track. Please explain.

First, it is important to understand that progress is not always linear; it is normal to see some fluctuations in trends as countries make progress towards elimination. Seeing some increases in malaria case incidence in a given year is part of the overall pattern of decline. It is when we see countries having multiple years in a row with increases that we start to be concerned.

Progress also varies by country. A good number of malaria-endemic countries are on track to achieve the GTS 2020 milestones. However, many also are not. Progress is slowest in low-income countries with a high malaria burden, weak health systems and poor access to interventions. Increased funding and strengthened programmatic efforts are urgently needed to accelerate progress in these countries.

4. The report shows that the fewer malaria cases a country has, the higher the per capita spending on control and elimination programmes. Shouldn’t it be the other way around?

In low burden settings, programmatic efforts rely less on the delivery of commodities (which tend to be very cost-effective) and instead focus on activities that require more human resources and more of people’s time. This is particularly true for malaria surveillance and case investigation, which requires teams of malaria personnel to investigate individual cases. However, while elimination is expensive in the short-term, the longer-term financial and human benefits of achieving elimination in a country outweigh the costs.

5. The majority of malaria cases and deaths are concentrated in a number of countries in sub-Saharan Africa, where progress has been slow. What new approaches will be taken to help these countries accelerate progress?

The countries with the highest malaria burden are the countries where progress is most challenging. These countries tend to be very poor and have weak, inaccessible health systems – and, as a consequence, the lowest coverage rates for interventions. We have cost effective tools to prevent and treat malaria; a greater effort is needed to ensure that these tools are made available to those who currently do not have access to them.

6. Is malaria elimination a realistic goal for high-burden countries?

Elimination is ultimately the long-term goal for all malaria-endemic countries. But without large increases in funding, innovative new tools, and major improvements in national health systems, it is unlikely that the 13 countries with the highest number of malaria cases – Burkina Faso, Cameroon, Cote d’Ivoire, Democratic Republic of the Congo, Ghana, India, Kenya, Mali, Mozambique, Niger, Nigeria, Uganda and United Republic of Tanzania – will achieve elimination during the timeframe established by the GTS. However, we can still make a lot of progress in these countries with the tools we have now. Many people will benefit from these efforts, even if elimination is not reached in the near-term.

7. Why are we seeing a decline in 2015 in the procurement of ACT treatments, a decrease in coverage with IRS, and an expected decline in ITN procurement next year?

Decreases in artemisnin-based combination therapy (ACT) procurements are twofold. First, there are fewer cases of malaria than in previous years, so fewer treatments are needed. Second, increased testing for malaria means that only patients with a positive test result are receiving treatment.

Decreases in coverage with indoor residual spraying (IRS) of insecticides are occurring as countries change or rotate the insecticides they are using to try to prevent the spread of mosquitoes resistant to pyrethroids – a class of chemicals also used in insecticide-treated bednets. As alternative insecticides are more expensive than pyrethroids, increased funding for IRS is needed to maintain high coverage levels.

Insecticide-treated bednets (ITNs) can last for three years and are distributed in three year cycles, so we expect to see some fluctuation in numbers year-by-year. The number of ITNs procured this year was slightly lower than in the two preceding years, which were the highest on record. However, if we don’t see a subsequent increase in ITN coverage in 2017, then there will be cause for concern.

8. What are the reasons behind the five-fold increase in the number of women receiving three doses of IPTp?

It is the result of countries responding effectively to new policy guidance on intermittent preventive treatment in pregnancy (IPTp) issued by WHO. WHO updated the recommended dosing – from two to three doses – based on recommendations from an evidence review group in 2012.