How Data Can Help Create a Fairer Malaria Response

By Jumana Farouky

Equity and inclusivity are the keys to eliminating malaria across the globe. That is the clear message from WHO’s most recent World malaria report, as it presents a detailed snapshot of the progress made so far in controlling and eliminating the mosquito-borne disease.

The findings show that in 2023 there were an estimated 263 million malaria cases worldwide, an increase of 11 million cases from the year before. The WHO African Region still carries the majority of cases at an estimated 94%, and numbers are rising in the WHO Eastern Mediterranean Region, which has experienced a 62% increase in estimated cases since 2021. For many countries, 2023 was a year of conflict, economic instability, and climate-change impacts, all of which create conditions that help spread the disease and make it more difficult to track and treat.

The report also highlights reasons for optimism. Fewer people are dying of the disease, with the mortality rate steadily decreasing from 14.9 deaths per 100,000 people in 2020 to 13.7 per 100,000 in 2023. Last year alone, more than 177 million cases and more than 1 million deaths were averted around the world. So far, the WHO has certified 44 countries and 1 territory as having eliminated malaria – the latest being Egypt, which was declared malaria-free in October this year. Out of the 83 malaria-endemic countries, 25 now report fewer than 10 cases a year.

But despite those hard-fought victories, progress toward malaria control and elimination is still too slow, the report warns. The global malaria incidence rate is nearly three times higher and mortality rate twice as high as needed to meet the targets set by the WHO to reduce incidence and mortality by 90% by 2030.

Dr Le Menach what are the most important or interesting insights that people should take away from the World malaria report?

Le Menach: The first one is how many lives were saved and cases averted with the current level of interventions, not only in low-burden countries, but also in high-burden countries. That’s a good reminder of how critical it is to continue investing in malaria efforts. The impact that extreme weather events are having on the spread of malaria is notable, too. For example, in Pakistan, cases increased at least eight-fold following flooding in 2022. Flooding creates more breeding areas for malaria-carrying mosquitoes and also makes it difficult for healthcare teams to reach many areas where communities are vulnerable to the disease.

Also interesting is the increasing use of new tools. There is a new generation of insecticide-treated nets that are more effective than those treated only with pyrethroids, the main insecticide used in malaria control. This is especially important in places where we know mosquitoes are growing resistant to pyrethroids. And this year, nearly 80% of the nets delivered in sub-Saharan were those more effective nets.

It’s crucial to flag this issue with resistance. In some areas, malaria parasites are developing partial resistance to effective anti-malarial drugs. Such resistance has been confirmed, to date, in four African countries. Mosquitoes are also growing resistant to insecticides – 55 countries have reported resistance to pyrethroid, so far. And we’re seeing a new invasive vector species of mosquito, A. stephensi, reported in eight African countries. These challenges explain, in part, why we are not making the kind of progress we want.

In 2023 and 2024, WHO declared five countries malaria-free – Azerbaijan, Belize, Cabo Verde, Egypt, and Tajikistan. Is there anything these countries have in common that contributed to their victory over the disease?

Le Menach: The foundation of their success is a strong political commitment, at the highest level, to eliminate malaria. And that’s translated to all the levels below, bringing with it the commitment of adequate human and financial resources.

We also see a strong multisectoral and community approach to elimination in all of these countries. That means interventions go beyond the ministries of health to include local leadership and community-level groups, empowering communities to make their own decisions about what is good for them and how best to implement and be accountable for delivering the solution for malaria.

This is also a good way to make sure efforts are focused in the right places. In most low-burden countries, malaria is only found in certain areas or foci. So, with community engagement and a good surveillance system, we can find out where those foci are and adapt responses to the local contexts.

And cross-border collaboration is essential. We’ve seen too many cases where malaria is nearly eliminated in one country and then reintroduced from another. All of the countries that have reached elimination have collaborated with their neighbors, to reduce the import or export of the disease.

With governments driving efforts to control and eliminate malaria, what role does the private sector have in helping tackle the disease?

Le Menach: In many countries, most people’s daily lives take place in the private sector, which includes using private health facilities to get malaria diagnosis and treatment. So, public-private partnership plays a key role in ensuring that these private facilities can deliver high-quality diagnosis and treatment, and that they can reliably collect the information we need to know who is affected by malaria.

There is also the link between the private sector and economic activities. In many places we’ve seen malaria associated with activities such as mining, farming, and logging, which are led by private companies. We’ve seen a lot of initiatives that show how public and private groups can work together to ensure workers are aware of malaria, have access to testing to know if they have it, and, if they do, have access to timely and effective treatment.

And then you have the production and distribution of malaria commodities – everything from nets to diagnostic tools to medication. Private entities are often responsible for that, so how can we ensure good public-private partnerships to promote and support the production and distribution of all the malaria commodities needed?

The report spotlights the $4.3 billion funding gap for malaria programs and research, which is less than half of the target for 2023. What does that shortfall mean for populations dealing with malaria?

Le Menach: For one thing, people are not getting access to the interventions at the coverage that is needed. When you look at the use of nets, for example, in sub-Saharan Africa only about half the population sleeps under a net at night. And the more effective tools, such as the new nets, are more costly. In a world of limited resources, people are faced with a difficult decision: they can use a more effective and more expensive tool, or they can use a tool that is less effective, but they have the budget for it. So, if we had more funding, we could really increase coverage of the latest tools. More research is also needed to develop new, effective interventions.

Another important and often overlooked area that requires more funding is surveillance systems. We need to make sure we allocate resources and interventions to the places and the people that are most in need. And to do that, we need to have strong health surveillance systems and the capacity at the country level that allows for the collection of high-quality data for effective decision-making. That would help us address the gap we currently have in reaching the most vulnerable populations, such as pregnant women and girls, people with disabilities, and Indigenous communities.

If you look at the countries that have eliminated malaria so far, most have adopted a tailored approach. They have moved away from doing everything everywhere to taking a step back to say, okay, where are our last remaining foci of malaria? How do we investigate those cases? What do we do with them?

The development of very strong surveillance systems and the use of high-quality data to make informed decisions are, for me, core ingredients of successful malaria programs and something that every other country dealing with malaria can learn from. Overall, resilient health systems with the required workforce and effective supply chains will be vital for reducing the malaria burden and accelerating us towards elimination.

Dr Arnaud Le Menach is head of the WHO Global Malaria Program’s Strategic Information for Response unit and lead author of the World malaria report 2024.