Global health experts define malaria work packages

28 February 2017

Members of the WHO Strategic Advisory Group (SAG) on malaria eradication recently convened in Geneva to review and define a set of work streams for the next 2-year period. The proposed scope of work is cross-cutting and spans a breadth of domains: biological, technical, financial, socio-economic, political and environmental.

Over the course of the 2-day meeting, members of the advisory group reviewed work packages focused on the “Economics of malaria eradication” and “Health systems requirements for eradication”. They addressed, among other topics, community mobilization approaches, eradication strategies in high transmission settings, and risks that could derail a malaria end-game such as climate change and civil unrest. The malaria research agenda and the development pathway for new tools was another key area of discussion.

WHO position statement

At the inaugural meeting of the SAG in August 2016, members agreed to develop a position statement for WHO that clarifies the current terminology around malaria “elimination” and “eradication” and confirms the Organization's long-term commitment to malaria eradication. The statement was developed last fall and will be reviewed by WHO’s Executive Board in May 2017 after the World Health Assembly.

Speaking at the recent SAG meeting on 16–17 February, Dr Ren Minghui, WHO Assistant Director General for HIV/AIDS, Tuberculosis, Malaria and Neglected Tropical Diseases, thanked members of the advisory group for this important piece of work.

"The position paper does an excellent job of clarifying WHO’s unequivocal support for the goal of eradication while giving this group the time and space to make a well-considered recommendation on the elements necessary to achieve that goal,” he said.

Progress in the malaria fight

Dr Pedro Alonso, Director of the WHO Global Malaria Programme, shared with SAG members the latest global estimates and trends from the World Malaria Report 2016, including a 41% reduction in malaria case incidence and a 62% decline in mortality rates since 2000. Seventeen countries have attained zero indigenous cases since 2000. According to a recent report from WHO, 21 countries are well placed to eliminate malaria by 2020.

This public health success story, he noted, was the result of a massive scale-up of core vector control tools in endemic countries – primarily long-lasting insecticidal nets and, to a lesser extent, indoor residual spraying – coupled with the introduction and wide-scale deployment of rapid diagnostic testing and artemisinin-based combination therapies.

The roll-out of preventive treatment strategies, such as IPTp and seasonal malaria chemoprevention, are making a measurable difference in reducing the malaria burden among high-risk groups, he added.

The unfinished agenda

Despite significant gains in the malaria fight, major gaps in programme coverage remain, and progress towards key global targets must be accelerated. “In the face of massive progress, we have a massive unfinished agenda,” said Dr Alonso. In 2015 alone, there were 429 000 malaria deaths and 212 million new cases of the disease.

The Global Technical Strategy for Malaria (GTS) calls for a 40% reduction in malaria case incidence and mortality by 2020. Less than half of the 91 countries with malaria transmission are on track to achieve these critical milestones.

Achieving the 2020 targets of the GTS will require robust funding, particularly from domestic sources. In 2015, malaria financing totalled US$ 2.9 billion, representing only 45% of the GTS funding milestone for 2020, said Dr Alonso.

He recalled a lesson learned from the 1970s when steep cuts in international malaria funding had dire consequences. “What happens when you take your foot off the accelerator? History has shown that malaria comes roaring back with a vengeance”, he warned.

Next steps

After 2 days of deliberations, SAG members agreed that some of the proposed work packages (below) would need to be consolidated and further refined. Members of the advisory body will take forward the various streams of work this year and reconvene in the fall to report back on their progress.

Proposed work packages

1. Economics of malaria eradication

Evaluate the potential for malaria eradication to contribute to poverty alleviation, reduce economic inequality, increase economic output, provide collateral benefits to agriculture and society, and improve health.

2. Health systems strengthening to support malaria eradication, and use of malaria eradication strategies to improve health systems

Integration of other health programmes into a malaria eradication strategy; strengthening surveillance for other diseases through an eradication platform; engaging the private sector in eradication.

3. The strategy for achieving eradication in high-transmission areas

Current high transmission areas, particularly those in resource-limited or conflict areas, will be the most difficult areas from which to eradicate malaria. Identify these areas and develop strategy for accelerating to zero.

4. Potential risks that could threaten or delay eradication

Modelling and risk analysis of likely or potential threats that could change the basic assumptions on which the case for eradication was made, including climate or environmental change, biological threats, complex emergencies, operational risks, etc.

5. Populations that may be at risk of malaria in the future

Combining forecasting of trends in population growth, migration, development, urbanization and climate change, can we determine whether there are new populations that will be at risk of malaria in the future that are not accounted for currently, or conversely, whether there are populations whose risk is likely to decline?

6. Mobilizing communities to take ownership of eradication and communicating the potential benefits of eradication to the community

Communication strategies at community, national and global levels; models from other diseases to integrate leadership, advocacy and partnerships; community mobilization strategies.

7. Financing models for eradication

Proposed financing models, including potential involvement of the private sector.

8. Lessons from previous eradication efforts

Review the Malaria Eradication Research Agenda (malERA) paper and commission analysis looking at small pox, guinea worm, onchocerciasis, polio and previous malaria effort.