Introduction

The world has made tremendous progress in the fight against malaria in the past 15 years. According to the World Malaria Report, malaria case incidence was reduced by 41 percent and malaria mortality rates were reduced by 62 percent between 2000 and 2015 (WHO 2016c). At the beginning of 2016, malaria was considered to be endemic in 91 countries and territories, down from 108 in 2000.

Despite this progress, malaria continues to place a heavy toll on the world. In 2015, 212 million cases occurred globally, leading to 429,000 deaths, most of which occurred in children under age five years in Africa. These estimates are likely to be conservative, as adult deaths from malaria might well be underestimated in Africa and India (Adjuik and others 2006; Bawah and Binka 2007; Dhingra and others 2010; Gupta and Chowdhury 2014).

More than 100 countries have eliminated malaria in the past century. Of the 106 countries with ongoing transmission in 2000, 57 reduced malaria incidence more than 75 percent by 2015, in line with the World Health Assembly target for 2015 of reducing the malaria burden by 75 percent. An additional 18 countries reduced incidence by more than 50 percent (WHO 2015e), also achieving target 6C of the Millennium Development Goals, which called for halting and beginning to reverse the global incidence of malaria by 2015.

An increasing number of countries are moving toward the elimination of malaria. Since 2000, 12 countries have eliminated malaria; 4 were certified as malaria free by the World Health Organization (WHO) between 2007 and 2013 (Armenia, Morocco, Turkmenistan, and the United Arab Emirates); an additional 8 moved into the WHO’s prevention-of-reintroduction phase after sustaining at least three years of zero local malaria transmission (Argentina, the Arab Republic of Egypt, Iraq, Georgia, the Kyrgyz Republic, Oman, the Syrian Arab Republic, and Uzbekistan); and 5 interrupted local transmission (Azerbaijan, Costa Rica, Paraguay, Sri Lanka,¹ and Turkey). The WHO European Region reported zero indigenous cases for the first time in 2015, in line with the goal of the Tashkent Declaration to eliminate malaria from the region by 2015.

According to the WHO (2016a), an additional 21 countries are in a position to achieve at least one year of zero indigenous cases of malaria by 2020.² These dramatic declines can be attributed to the scale-up of effective malaria control tools and technologies coupled with renewed political leadership and financial commitment.

Bolstered by these successes, most national malaria programs now consider elimination to be an attainable goal, and the idea of eradication is once again on the global health agenda. Many countries have developed national elimination goals, and regional networks have been formed to facilitate collaboration (Newby and others 2016). Leaders from the Asia Pacific Leaders Malaria Alliance and the African Leaders Malaria Alliance endorsed regional goals for malaria elimination by 2030 in November 2014 and January 2015, respectively, galvanizing support for elimination and eradication (APLMA 2015; United Nations 2015).

In this context, two new global malaria policy and advocacy documents supporting elimination and eradication were released in 2015: the Roll Back Malaria (RBM) Partnership’s Action and Investment to Defeat Malaria 2016–2030 and the WHO’s Global Technical Strategy for Malaria 2016–2030. The Global Technical Strategy (GTS), which the WHO ratified in May 2015, calls for at least another 40 percent reduction in malaria-related mortality and morbidity between 2015 and 2020. Other goals and targets are illustrated in table 12.1. A third document, launched in September 2015, From Aspiration to Action: What Will It Take to End Malaria?, outlines the resources and strategies needed for global eradication by 2040, calling by 2020 commit to eradication in the next five years (Gates and Chambers 2015).

Table 12.1

Global Milestones and Targets for Elimination.

Despite these advances, malaria elimination and eradication face significant technical, operational, and financial challenges. About 3.2 billion people remain at risk of malaria; in 2015 alone, there were an estimated 214 million new cases of malaria and more than 400,000 malaria-related deaths. Global progress in malaria control and elimination is marked by vast disparities between and within countries, with vulnerable groups that have poor access to health services continuing to be marginalized. The Sub-Saharan Africa region shoulders the heaviest burden, with two countries—the Democratic Republic of Congo and Nigeria—accounting for more than 35 percent of global malaria deaths. In these areas, malaria control programs aim to maximize the reduction of malaria cases and deaths; elimination will likely require more potent tools and stronger health systems.

A few countries that have successfully reduced malaria transmission are struggling to maintain their gains. An increased number of cases has recently been reported from a number of countries, including Cambodia, Djibouti, Madagascar, Uganda, and República Bolivariana de Venezuela (WHO 2015e). Furthermore, as the global malaria burden declines, emerging biological threats have the potential to critically weaken malaria responses in several parts of the world. In 2014, 60 countries reported resistance of mosquitoes to at least one insecticide used in vector control strategies; resistance of parasites to artemisinin, the cornerstone of malaria chemotherapy, has been detected in five countries in the Greater Mekong subregion, posing a serious threat to global health security.

This chapter summarizes the literature on malaria elimination; describes the progress made; and discusses malaria epidemiology, interventions, and challenges. In addition, it presents empirical information on financing and economics, including cost information from various settings. It concludes with a discussion of the economic basis for eradication and recommendations for research.

What Are Elimination and Eradication?

In areas of moderate to high transmission that are implementing malaria control, interventions are deployed on a large scale to reduce the public health burden of the disease. In elimination settings, targeted interventions aim to interrupt local transmission in the specific places where it becomes increasingly concentrated, that is, small geographic areas or special subpopulations that may be harder and costlier to reach. The key decisions facing policy makers in low- and moderate-transmission settings are when to embark on malaria elimination (Sabot and others 2010); which interventions to implement and where and when; and at what levels of intensity and reach. Critical to this debate are the political and financial commitments that are needed long after the disease stops being a public health burden.

Malaria elimination involves stopping indigenous transmission through active control measures (Cohen and others 2010; Smith and others 2009). The complete absence of local incidence is very unlikely to be achieved in places with high intrinsic potential for transmission and elevated importation of cases (Cohen and others 2010). For example, even the United States, a relatively low transmission risk area, identified 156 locally acquired cases between 1957 and 2003 (Filler and others 2006). Even countries that do not contiguously border endemic neighbors experience considerable importation annually: Sri Lanka reported 49 confirmed imported malaria cases in 2014, and in Tanzania, Zanzibar’s estimated importation of 1.6 cases per 1,000 residents could potentially produce 1,300 incident cases (Le Menach and others 2011). Transmission from imported cases may lead to first degree introduced cases; a second degree of transmission from an introduced case produces an indigenous case: both are products of local transmission. Elimination accordingly requires preventing all indigenous cases, but introduced cases may continue to occur sporadically.

As more countries and regions eliminate malaria and implement measures to prevent reintroduction, fewer imported infections will occur, and eradication will become increasingly feasible. See box 12.1 for the WHO definitions of control, elimination, and eradication.

Box 12.1

Definitions of Control, Elimination, and Eradication.

Progress Toward Malaria Elimination

Elimination in the Twentieth Century

Until the mid-nineteenth century, malaria was endemic in most countries across the globe. Countries that did not have malaria included the Pacific islands east of the longitude of Vanuatu (the Buxton line) (Mendis and others 2009), which have no Anopheles mosquitoes; or countries that were too high in elevation or too cold in temperature (map 12.1).

Map 12.1

Malaria Transmission Worldwide, 1900, 1990, and 2015.

Between 1900 and 1945, only nine countries in Europe eliminated malaria (Feachem, Phillips, and Targett 2009). Sparked by the availability of chloroquine for treatment and dichloro-diphenyl-trichloroethane (DDT) for vector control, the WHO launched the Global Malaria Eradication Program (GMEP) in 1955 to interrupt transmission in all endemic areas outside of Africa (Najera 1999). The program relied on vector control—mainly indoor residual spraying—and systematic detection and treatment of cases. The campaign succeeded in eliminating malaria in 37 of the 143 countries or economies where it was endemic in 1950 (Wernsdorfer and Kouznetzov 1980), including some lower-income areas with tropical climates such as Maldives; Mauritius; Réunion; Taiwan, China; much of the Caribbean; Brunei Darussalam; most of China; Hong Kong SAR, China; Singapore (Feachem and others 2010).³ In many other countries, the burden of disease and deaths from malaria was greatly reduced. For example, in India, the number of malaria cases declined from an estimated 110 million in 1955 to fewer than 1 million in 1968, and in Sri Lanka, the incidence of malaria declined from an estimated 2.8 million cases in 1946 to just 18 cases in 1966 (Mendis and others 2009).

However, failure to sustain strong funding for the program, particularly in the face of increasing costs due to mounting drug and insecticide resistance, led to the effective end of the GMEP in 1969 (WHO 1969) when the World Health Assembly recommended that countries not yet ready for “eradication” focus on controlling malaria as a first step toward the ultimate goal of getting rid of malaria altogether. Multilateral agencies withdrew their support for malaria programs in favor of general health programs. In the ensuing years, although most countries that had eliminated malaria continued to remain malaria free, the scaling back of control efforts in malarious countries led to a global resurgence of the disease during the 1970s and 1980s and a complete reversal of progress in some countries, such as Sri Lanka and Pakistan (Abeyasinghe and others 2012; Cohen and others 2012).

The experience of the GMEP provides critical lessons for contemporary elimination programs about the need to maintain vigilance and sustain investments during the latter stages of elimination efforts.

Elimination in the Twenty-First Century

The adoption of the Global Malaria Control Strategy in 1992 (WHO 1993) and the launch of the Roll Back Malaria initiative in 1998 (Nabarro and Taylor 1998) stimulated increased interest and financial investment in malaria control. Increased investment in research and development resulted in highly effective malaria control tools—notably, long-lasting insecticide-treated nets (LLINs), rapid diagnostic tests, and artemisinin-based combination therapies (ACTs). The creation of the Global Fund to Fight AIDS, Tuberculosis, and Malaria; the President’s Malaria Initiative; and other financing mechanisms allowed for the wide-scale deployment of these new tools. The first Global Malaria Action Plan for a malaria-free world 2008–2015 served as a valuable guide for countries and partners to mobilize resources. Between 2005 and 2014, global investment for malaria control increased from US$960 million to US$2.5 billion annually, leading to dramatic declines in the global malaria burden and rapid shrinking of the malaria map. With the end of the Millennium Development Goals in 2015 and the transition to the era of the Sustainable Development Goals, the malaria community has once again committed to the vision of a malaria-free world.

Table 12.2 summarizes the countries and territories that eliminated malaria between 1900 and 2015.

Table 12.2

Number of Countries and Territories That Eliminated Malaria, by Region, 1900–2015.

Currently 35 countries are moving from low-endemic malaria to elimination (Newby and others 2016). These countries fit into one of two categories: (1) countries that have assessed the feasibility of elimination, declared a national evidence-based goal, and launched a malaria elimination strategy; or (2) those that are strongly considering an evidence-based national elimination goal as determined by expert opinion, have made substantial progress in spatially progressive elimination (by eliminating malaria from specific islands or geographic areas), and are greatly reducing malaria nationwide. These 35 countries have elimination goals ranging from 2013 to 2035, with the majority aiming for, and likely to achieve, elimination by 2020 (annex 12A).

Five countries—Argentina, the Kyrgyz Republic, Paraguay, Sri Lanka, and Uzbekistan—recently achieved three consecutive years of zero local transmission. All but Uzbekistan have initiated the WHO process for malaria-free certification. Three other countries have achieved zero local transmission but have not yet sustained it for three consecutive years: Azerbaijan, Costa Rica, and Turkey.

Lessons Learned and Planning for Success

Lessons learned from the GMEP highlight the fact that a single strategy is unlikely to be successful everywhere given the complexities of malaria transmission systems, and given that a long-term commitment with a flexible strategy that includes community involvement, integration with health systems, and the development of agile surveillance systems with supporting infrastructure is needed (Najera, Gonzalez-Silva, and Alonso 2011). A review conducted at the GMEP’s conclusion cited the lack of robust assessments to determine the feasibility of malaria eradication programs (WHO 1968; see box 12.2), including an assessment of the technical and operational evidence and government commitment to sustain funding. Attempting to eliminate malaria before it is feasible to do so can raise expectations, damage the credibility of the public health sector (Moonen and others 2009), and require prolonged expenditure (Sabot and others 2010). Reducing transmission without sufficiently sustainable interventions to maintain those reductions may also lead to epidemics and resurgence. Out of 49 discontinued programs during GMEP, resurgence was reported in 36 programs following cessation, usually because of an inability to maintain sufficient financial resources (Cohen and others 2012). Countries should assess the technical, operational, and financial feasibility of achieving their goals (discussed further in the section titled Prospects for Malaria Eradication) before embarking on a costly restructuring of their programs (Moonen, Cohen, Tatem, and others 2010; WHO 2014a).

Box 12.2

Challenges to Elimination: Select Examples.

Challenges and Threats to Success

In contrast to previous attempts at eradication, current efforts explicitly acknowledge that malaria eradication requires a long-term effort incorporating multiple activities and embracing multiple interventions, disciplines, approaches, and organizations. Success will be built largely on a series of effective national and subregional elimination programs, driving global eradication from the bottom up, with countries integrating malaria surveillance, transmission interruption, and treatment programs into their national health systems. Nevertheless, challenges exist.

Addressing Artemisinin Resistance

Resistance of parasites to artemisinin derivatives, the mainstay of malaria treatment, is a mounting problem. Delayed parasite clearance times following artemisinin monotherapy or ACT were first detected in Western Cambodia in 2007 and soon after along the Thai-Burmese, the Thai-Cambodian, and the Cambodian-Vietnamese borders (Carrara and others 2013; Dondorp and others 2009; Hien and others 2012; Phyo and others 2012). Plasmodium falciparum artemisinin resistance is evident in five countries in the Greater Mekong subregion (WHO 2015b), most recently in Myanmar, just 25 kilometers from the Indian border (map 12.2). Delayed parasite clearance times are correlated with some specific mutations (580C→Y, 539R→T, 543I→T, 493Y→H, and 446F→I) in the propeller domain of a Kelch protein gene located on chromosome 13 (PF3D7_1343700) (Ariey and others 2014; Straimer and others 2015). K13 mutant parasites associated with artemisinin resistance are currently prevalent throughout mainland South-East Asia from southern Vietnam to central Myanmar (Ashley and others 2014; Ménard and others 2016; Takala-Harrison and others 2015).

Map 12.2

Frequency Distribution of the Wild-Type K13 Allele in Asia and Worldwide.

This development has major implications for malaria elimination: First, parasites susceptible to artemisinin will be eliminated earliest, and the remaining parasites in low-transmission areas will be resistant and the hardest to kill (Maude and others 2009). Second, artemisinin-resistant parasites are selected for concomitant resistance to ACT partner drugs, resulting in high late-treatment failure rates, as observed in Cambodia with dihydroartemisinin-piperaquine (Amaratunga and others 2016; Duru and others 2015; Leang and others 2013; Leang and others 2015; Lon and others 2014; Saunders and Lon 2016; Spring and others 2015) and along the Thai-Myanmar border with artesunate-mefloquine (Carrara and others 2013). Although innovative compounds with different modes of action are in development, they will not be ready for deployment before 2020 (Wells and Hooft van Huijsduijnen 2015; Wells, Hooft van Huijsduijnen, and Van Voorhis 2015). Therefore, novel strategies and regimens using available antimalarial drugs need to be further evaluated. These strategies may include drug rotation between different ACTs, extension of the three-day ACT course to five or seven days, and the triple combination of artemisinin derivatives with two partner drugs in a three-day therapy.

The WHO (2012a, 2015d) has labeled multidrug-resistant malaria in the Greater Mekong subregion as a regional public health disaster with the potential for severe global consequences. In March 2015, the WHO concluded that eliminating malaria in this subregion is the only way to extend the lifespan of artemisinin derivatives as an effective treatment and outlined a strategy for elimination by 2030 (WHO 2015d).

The potential spread of artemisinin resistance poses a substantial risk to global health security and economic development. Widespread resistance could increase global malaria mortality by an estimated 25 percent, with an annual economic impact of more than US$0.5 billion (Lubell and others 2014). These increases in mortality and in costs could undermine years of investments, making the case for preventing the spread of resistance even more compelling. Geospatial and temporal mapping of the emergence and spread of parasite resistance allows policy makers to mobilize resources efficiently and to adopt more efficacious treatment regimens (Ashley and others 2014; Ménard and others 2016; Takala-Harrison and others 2015).

Malaria Elimination Interventions and Strategies

Elimination and control rely on similar interventions: high-quality case management, vector control, and surveillance. However, while high coverage rates are desirable in control programs, interventions in elimination programs must be highly targeted and tailored, and the right tool needs to be selected according to vector and human behavior (table 12.3). Redistributing resources toward elimination-specific interventions, such as strengthening surveillance systems to identify and investigate transmission foci, may produce economic efficiencies. However, continued investments in enhanced program and managerial capacity are needed.

Table 12.3

Key Differences between Interventions for Malaria Control and Elimination.

Program Management

Reorienting a program from control toward elimination involves retraining staff, developing strong surveillance capacity, building a data architecture that can monitor and direct activities, instituting managerial practices that ensure a capable and ready workforce, and changing program tasks from curative services to preventive community action. These activities involve securing political and financial commitment for at least 6–10 years after elimination has been achieved, as demonstrated by the experiences of Turkmenistan and Sri Lanka, described in boxes 12.3 and 12.4 (Feachem and others 2010).

Box 12.3

Eliminating Malaria in Turkmenistan: Going the Last Mile.

Box 12.4

Eliminating Malaria in Sri Lanka: Flexibility under Fire.

Despite the need for intensified surveillance and response capabilities during the elimination phase, governments and external donors typically reduce funding as incidence declines (Cohen and others 2012). Program activities are often integrated into the local health system to increase efficiency (Liu and others 2013; Tatarsky and others 2011). A review of managerial experiences with disease elimination suggests that dedicated staff should run and oversee some tasks (vector control and rapid case investigation), while local health teams could oversee others (case management, surveillance, and reporting) (Gosling and others 2014).

Regional collaboration can further reinforce collective goals and foster positive cross-border externalities and financing (Barclay, Smith, and Findeis 2012; Gosling and others 2015; Moonen, Cohen, Snow, and others 2010). For a description of regional initiatives, see annex 12B.

Economics and Financing of Malaria Elimination

One of the strongest arguments against eliminating or eradicating any disease involves the costs associated with finding and treating a decreasing number of cases (Lines, Whitty, and Hanson 2007). These final few cases will likely require an outlay of resources that appear to be disproportional to the marginal return. Maintaining a high level of financial support when transmission has been reduced to low levels remains a challenge. Policy makers have to decide whether to maintain control activities indefinitely or whether to actively pursue elimination.

Articulating the costs of elimination and the relative benefits of investment in elimination versus control will help inform these decisions. Three methods can be used to assess the incremental costs and associated benefits of malaria elimination:

• Analyzing the costs and benefits of an elimination program, summarized using a benefit-cost ratio
• Determining the financial cost savings of an elimination campaign relative to alternative scenarios (for example, control or resurgence costs)
• Evaluating the macroeconomic impact of malaria control and elimination against the economic burden that malaria places on society

Costs and Benefits

Since the conclusion of the GMEP in the 1960s, several studies have reported the costs and consequences of malaria elimination and control, but few benefit-cost analyses have been conducted (table 12.4). Beyond the direct benefits on health, the main economic benefit considered in the studies is increased labor productivity resulting from reductions in absenteeism. Other benefits include gains from the migration of labor into previously malarial areas and lower treatment costs. Most studies assume a 10-year elimination campaign, and only two (Ortiz 1968; Ramaiah 1980) used empirical data.

Table 12.4

Benefit-Cost Ratios Associated with Malaria Elimination Programs.

All studies showed positive benefit-cost ratios, indicating sizable benefits relative to costs. Benefit-cost ratios ranged from 2.4 in the Philippines (Mills, Lubell, and Hanson 2008), 4.14 and 9.22 for control in India (Prakash and others 2003; Ramaiah 1980), 17.09 for elimination in Greece (Livadas and Athanassatos 1963), to 146.3 and 14.3 for control and prevention of reintroduction, respectively, in Sri Lanka (Barlow and Grobar 1986). Of these countries, Greece continues to report outbreaks as a result of imported cases, despite having eliminated malaria, and Sri Lanka is in the process of seeking WHO malaria-free certification (Samaraweera 2015).

Benefits

Many of the economic benefits associated with malaria interventions extend beyond health to include larger macroeconomic and demographic effects. Investments reduce private out-of-pocket expenditures on prevention and treatment (Chuma, Thiede, and Molyneux 2006; Guiguemdé and Guy 2012), increase productivity, and increase agricultural output via reclaimed land (Gallup and Sachs 2001; Mills, Lubell, and Hanson 2008; Utzinger and others 2002). Lower child mortality may reduce fertility (Aksan and Chakraborty 2013), increase literacy and human capital (Lucas 2010), and eventually increase labor productivity. Domestic and foreign investment may be channeled to formerly malarious areas, contributing to fiscal growth.

Comparing the marginal benefits of control to those of elimination is difficult. Elimination can improve health equity because the last remaining foci of infection are often concentrated within poor or marginalized populations (Feachem, Phillips, and Targett 2009). Prevention of reintroduction also protects against resurgences. Furthermore, eliminating malaria within a single country may confer substantial regional externalities and global public good, fostering collaboration. Elimination may also confer threshold benefits by permanently reducing the receptivity of an area to the reestablishment of local transmission (Chiyaka and others 2013; Sabot and others 2010; Smith Gueye and others 2013), but methods to measure the value of the diminished resurgence risk have yet to be established. Some studies have examined the relationship between elimination and tourism demand in the Dominican Republic, Mauritius, and South Africa, but with little success because of confounding factors such as the overall increase in global travel (Maartens and others 2007; Modrek and others 2012). As benefits become less tangible, they are more difficult to measure. Gaining an understanding of the larger set of economic benefits will require better macroeconomic models that quantify the links between elimination and other outcomes (Mills, Lubell, and Hanson 2008).

Costs and Cost Comparisons

Much of the debate regarding elimination concerns the government’s costs of delivering services. However, programmatic costs are only part of the picture—individuals, households, and employers also incur costs for treatment and prevention. From a programmatic perspective, costs increase as control interventions are scaled up, because interventions are often provided for free to increase coverage and to shift costs from individuals to programs.

Analyses of program expenditures are limited to a few studies primarily in Africa and Asia. A systematic literature review identified 21 studies on the costs of malaria elimination with known data sources (Shretta and others 2016). Program expenditures were divided by the cost per capita to account for differences in intended coverage and benchmarked to the first year of data for each country. The reported costs ranged from US$0.18 in Mexico in 1971 (Suarez Torres 1970a) to US$27 in Vanuatu (Kahn and others 2009) (all in 2013 U.S. dollars). Barring a few exceptions, reported costs per capita were generally lowest in East Asia and Pacific and Mexico (Suarez Torres 1970b) and highest in African countries, such as Mauritius (Tatarsky and others 2011), São Tomé and Príncipe (Kahn and others 2009), Swaziland (Kahn and others 2009; Sabot and others 2010), and Zanzibar (Sabot and others 2010). Only Mauritius seeks to prevent reintroduction by screening passengers at ports of entry and using targeted vector control, which may account for the high costs.

Costs for elimination have varied but have generally been low. In the 1960s they were less than US$1 per person-year. Estimates from Nepal and Thailand ranged from US$0.64 to US$1.33 per person-year in the 1980s (in 2006 U.S. dollars) (Mills, Lubell, and Hanson 2008). A retrospective study reports elimination expenditures (including from nongovernmental funders) in Jordan, Lebanon, and Syria of US$0.96, US$0.73, and US$1.69 per person-year, respectively (de Zulueta and Muir 1972). These estimates are lower than those from more recent studies, and it is unclear how directly comparable they are because of variable inputs and the availability of new and more costly tools as well as the rise of new challenges, such as insecticide and artemisinin resistance and human migration (figure 12.1).

Figure 12.1

Costs of Malaria Elimination, by Country, Various Years.

Financial Cost Savings of Elimination Relative to Alternative Scenarios

To generate results most relevant to policy, malaria elimination requires a comparison of cost with a counterfactual scenario of malaria control, the costs of which vary substantially with the level of control. Scenarios may encompass a range of alternatives, from a null state of disease without intervention to a state of controlled low-endemic malaria (Sabot and others 2010), to scenarios illustrating the costs of doing “business as usual” with a relatively stable control state punctuated by spikes of epidemics or resurgence when efforts are slowed.

In practice, while an abundance of literature examines the costs of comprehensive control, studies comparing the costs of elimination to the costs of control to determine the financial cost savings of an elimination program relative to control or resurgence are scarce. Nevertheless, once malaria is reduced to a level at which it is no longer a public health threat, reorienting the program from control to elimination is likely to require a significant one-time investment (Sabot and others 2010). One study that projected costs to a 20- to 50-year timeline for Hainan and Jiangsu provinces in China and in Mauritius, Swaziland, and Zanzibar found that elimination is likely to be more costly than control in the short term and is likely to remain more expensive than control at substantially longer timeframes (depending on the inputs of the post-elimination program).

Programs can also be integrated, making disease programs more efficient as well as creating a platform for mobilizing resources, even if malaria is no longer considered a priority. For example, in Singapore, integrating dengue and malaria surveillance facilitated interagency collaboration and reduced transmission of both diseases (Luckhart and others 2010). When transmission decreases and eventually ceases, costs are likely to decline and eventually stabilize as efforts turn to preventing reintroduction primarily through surveillance, vector control, and emergency response. Private out-of-pocket expenditures are also likely to become negligible as the number of cases declines. Two studies (figure 12.2) with empirical data on expenditures over multiple programmatic phases found that expenditures declined when moving from elimination to prevention-of-reintroduction (Abeyasinghe and others 2012; Smith Gueye and others 2014). A study in Sri Lanka estimated the financial cost of prevention of reintroduction activities to cost US$0.37 in 2014 (Shretta and others 2016), less than a quarter of the expenditures in previous years (Abeyasinghe and others 2012).

Figure 12.2

Malaria Program Expenditures in Select Countries, by Phase.

Elimination should therefore not be justified on the basis of short-term cost savings alone. A focus only on relative cost savings ignores many other factors (for example, population growth, economic development, reductions in malaria in neighboring countries) that could permanently alter the epidemiology of the area, reduce transmission, accelerate the elimination timeline, and decrease costs (Smith and others 2013).

Financing and Efficiency

Development assistance for malaria quadrupled between 2007 and 2013. However, the proportion of development assistance directed toward malaria-eliminating countries declined more than 80 percent and continues to decline (figure 12.3). Securing funding for a disease that occurs infrequently is challenging. Malaria-eliminating countries typically have lower disease burdens and are often middle-income countries; therefore, they are a lower priority for donors. The Global Fund to Fight AIDS, Tuberculosis, and Malaria has historically allocated about 7 percent of its portfolio to malaria-eliminating countries but, under its new funding model, now allocates about 5 percent, representing a projected decrease of 31 percent in national funding allocation—a serious shortfall at a time when maintaining national gains and advancing the elimination agenda are essential (GHG 2014; Zelman and others 2016).

Figure 12.3

Overseas Development Assistance Commitments for Malaria, 2007–13.

Eliminating countries finance about 80 percent of their malaria programs (CEPA 2013), and this spending has been increasing steadily since 2000. However, spending still falls short of the US$8 billion per year needed to reach the 2030 targets (WHO 2015a).

Greater emphasis is being placed on building the capacity of countries to fund their own programs through increased government spending as well as innovative financing mechanisms. Box 12.5 and annex 12C describe some mechanisms that are being implemented or considered and their applicability to malaria programs.

Box 12.5

New Financing Mechanisms to Support Malaria Elimination.

Efficiency in the portfolio and delivery of interventions will ultimately increase cost-effectiveness. More efficient deployment of resources, however, requires a robust surveillance platform in which high-quality data can be collected and analyzed so that measures of response can be adjusted in a timely manner (box 12.6).

Box 12.6

Tools for Identifying Efficiency Gains.

Prospects for Malaria Eradication

The benefits of achieving and maintaining elimination include a strong public good component—an incremental contribution to global malaria eradication. While many argue that eradication is unlikely given existing tools (Greenwood 2008; Tanner and de Savigny 2008), particularly for high-burden countries in Africa, the global pipeline for new products has never been stronger, supporting the mounting optimism that global eradication is plausible. The technical and operational feasibility of eradication, the operational complexity, and the political appetite need to be considered when assessing the prospects for eradication.

Political and Financial Commitment

In 1939, Boyd summarized the prevailing public health point of view and emphasized that “malaria control should not be a campaign—it should be a policy, a long-term program. It cannot be accomplished or maintained by spasmodic effort. It requires the adoption of a practicable program, the reasonable continuity of which will be sustained for a long term of years” (Boyd 1939, 5).

The success of malaria eradication will depend on the ability to mobilize collective action. At a minimum, universal political commitment to achieving an agreed-on target is required, as are financial resources to sustain that commitment. Although countries may be willing to eliminate the disease within their borders, the last country to eliminate it has little incentive to do so on its own, given the larger interests of all other countries (Barrett 2004). The smallpox eradication program nearly failed because of lack of political commitment (Barrett 2007), and the GMEP was cut short for the same reason. Although global attitudes have shifted toward malaria elimination and eradication, political and financial support is needed to bolster the goal of global eradication, should that goal be adopted for malaria.

There are concerns that concentrating resources in areas with lower burdens of disease may divert resources from lower-income countries with higher burdens of disease (Shah 2010); however, progress in low-burden countries is likely to drive global progress toward eradication (Newby and others 2016). In addition, because malaria-free countries stand to benefit from eradication, they have an incentive to offer financial assistance if they are assured that the last countries will work toward elimination (Barrett 2007; Taylor, Cutts, and Taylor 1997).

See box 12.7 for future research priorities.

Box 12.7

Priorities for Research.

Conclusions

Despite the absence of a highly efficacious vaccine, many countries around the globe have successfully eliminated malaria and prevented its reintroduction. As malaria elimination progresses in more areas, the case for global eradication is likely to become more compelling. Promising new tools are already in the product development pipeline, including radical treatments, sensitive rapid diagnostic tests, and next-generation vector control methods. Piloting the effective use of these innovations will ensure that they can be scaled up safely and effectively. The introduction of game-changing innovations—including anti-infection or transmission-blocking vaccines and novel mosquito control strategies—could substantially accelerate this next phase. As new technologies and advances occur, the cost of elimination may decline as efficiencies are realized and targeting becomes increasingly focused. Elimination may become progressively easier with new drug therapies, simplified treatment regimens, and more effective vaccines. With smallpox, the targeted nature of surveillance and containment and improved needle technology for vaccinations contributed significantly to the success of the eradicaton campaign.

Malaria eradication calls for a long-term investment that will yield dividends over time. If successful, countries would no longer need to implement prevention measures, thereby reaping an “eradication dividend” and accruing substantial economic benefits for all countries. However, eliminating malaria transmission worldwide will require renewed focus in several areas. Strengthening the human resource capacity of programs is essential. Combating the threat of importation will require collaborative regional surveillance efforts that reach communities and the private sector. In addition, as new tools become available, support will be required for their adoption and rapid uptake to combat the effects of drug and insecticide resistance. These actions all require sustained political and financial commitment to ensure success. While increasing numbers of countries are moving toward financing their own programs, external assistance to the last affected countries will be essential—possibly through a dedicated “last-mile fund”—to ensure that the resources required to complete eradication are available in the final phase.

Annexes

The following annexes to this chapter are as follows. They are available at http://www.dcp-3.org/infectiousdiseases.

• Annex 12A. Status and Goals of Elimination Countries, by Region
• Annex 12B. Regional Initiatives to Eliminate Malaria
• Annex 12C. Potential Financing Mechanisms for Malaria Elimination

Notes

World Bank Income Classifications as of July 2014 are as follows, based on estimates of gross national income (GNI) per capita for 2013:

• Low-income countries (LICs) = US$1,045 or less
• Middle-income countries (MICs) are subdivided:

  alpha a.	lower-middle-income = US$1,046 to US$4,125
  alpha b.	upper-middle-income (UMICs) = US$4,126 to US$12,745

• High-income countries (HICs) = US$12,746 or more.

1

Sri Lanka obtained WHO certification as a malaria-free country in September 2016.

2

Algeria, Belize, Bhutan, Botswana, Cabo Verde, China, Comoros, Costa Rica, Ecuador, El Salvador, the Islamic Republic of Iran, Republic of Korea, Malaysia, Mexico, Nepal, Paraguay, Saudi Arabia, South Africa, Suriname, Swaziland, Timor-Leste.

3

Despite a highly receptive environment in Taiwan, China, intensive spraying combined with improved housing and socioeconomic conditions, better environmental management, and strong case management reduced morbidity to very low levels, and the WHO certified Taiwan, China, as being malaria free in 1965 (Yip 2000).

4

Polymerase chain reaction testing in African and Asian settings shows a higher proportion of both P. malariae and P. ovale infections than was previously thought (Baltzell and others 2013; Barrett 2007; Oguike and others 2011).

5

In the case of smallpox, there were no long-term carriers, survivors gained lifetime immunity, infections were easily detected, only symptomatic persons could transmit the disease, and vaccination of only 80 percent of the population was necessary to eliminate transmission (Barrett 2007).

Corresponding author: Rima Shretta, University of California, San Francisco, Global Health Sciences, San Francisco, California, United States; ude.fscu@atterhS.amiR.

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