Malaria can be eradicated by 2050 if an extra $2 billion is spent annually, say global experts

Currently, malaria spending is around $4.3 billion globally, but additional funds of $2 billion a year will make a big difference


                            Malaria can be eradicated by 2050 if an extra $2 billion is spent annually, say global experts

Malaria, one of the world's oldest and deadliest diseases, can be eradicated as early as 2050, says an ambitious report. A future free of malaria, however, would require an increase in the total spending by about $2 billion annually.

The report by 41 health policy experts, malariologists, biomedical scientists, and economists, highlights three ways to bend the curve to ensure a world free of malaria by 2050: improving management and operations and making better use of existing technologies, rolling out new technologies, and spending more money.

"We synthesize existing evidence and new epidemiological and financial analyses to show that malaria eradication by 2050 is a bold but attainable goal," says the research team.

The Lancet Commission on malaria eradication, a joint endeavor between The Lancet and the University of California San Francisco (UCSF), was launched in October in 2017 to consider the feasibility, affordability, and merit of malaria eradication.

"This report by the Lancet Commission on Malaria Eradication (the Commission) addresses a bold proposition: malaria can and should be eradicated before the middle of the 21st century. Earlier eradication ambitions were put on hold in 1969, and the malaria community shifted its focus to reducing morbidity and mortality through the implementation of prevention and control interventions," says the report.

It adds, "Malaria control programs were often overwhelmed and underfunded, and, especially across Africa, a sense of fatalism existed that substantial progress would never be made. But around the turn of the century, the situation changed dramatically, with reenergized commitment, new and improved tools, and greatly increased funding."

What do the numbers say?

The annual domestic and international spending on malaria increased from approximately $1.5 billion in 2000 to $4.3 billion in 2016. Simultaneously, the number of countries with endemic malaria dropped from 106 to 86, the worldwide annual incidence rate of malaria declined by 36%, and the yearly death rate reduced by 60%.

However, this progress hangs in the balance. Despite global efforts, there are over 200 million cases of malaria reported worldwide each year, claiming the lives of nearly half a million individuals. 

Currently, the disease is still a leading cause of death in children younger than five years in Africa, and in a dozen African countries, it is
responsible for over a fifth of all postneonatal childhood deaths. "Allowing this situation to continue is socially and economically indefensible," reveal researchers. 

"In 2017, 86 countries reported a total of 219 million malaria cases and 435,000 malaria deaths, down from 262 million cases and 839,000 deaths in 2000. However, cases and deaths are not distributed evenly. The good news is that 38 countries had incidences of fewer than 10 cases per 1000 population in 2017, with 25 countries reporting fewer than one case per 1000 population. The same 38 countries reported just 5% of total malaria deaths,” says the study.

Scientists say nearly all of these low-burden countries are actively working towards national and regional elimination goals of 2030 or earlier. However, 29 countries — all in Africa except Papua New Guinea and the Solomon Islands — had high rates of transmission in 2017, reporting over 100 cases per 1000 population, and accounting for 85% of total malaria deaths.

Furthermore, 10 countries account for two-thirds of global cases currently, and the top two alone, Nigeria and the Democratic Republic of the Congo, account for 36%.

"Malaria eradication is a public health and equity imperative of our generation. Despite unprecedented progress, malaria continues to strip communities around the world of promise and economic potential. This is particularly true in Africa, where just five countries account for nearly half of the global burden," says Dr. Winnie Mpanju-Shumbusho, co-chair of The Lancet Commission. 

What do the findings say?

Eradication by 2050 requires both rapid elimination in low-burden countries and accelerated malaria reduction in high-burden countries, says the study. According to the researchers, the driving force behind global eradication is regional elimination.

To reach this historic goal within a generation, malaria eradication must be "embedded" within the communities that will drive change, they add. The researchers recommend developing country-level malaria elimination task forces, with the simultaneous strengthening of regional and subregional organizations.

They say that regional platforms must be supported by global partners to strengthen regional commitment and "motivate unambiguous and energetic commitment" by national and subnational leaders in every endemic country.

While the cost of malaria eradication will be highly dependent on managerial efficiency, the efficacy and cost of new tools, and the degree to which interventions can be targeted, estimates suggest that annual spending of $6 billion or more is required. The current global expenditure is approximately $4·3 billion.

The Commission believes that an additional investment of $2 billion per year is necessary, with a quarter of that coming from increased development assistance from external donors and the rest from government health spending in malaria-endemic countries.

Malaria is still a leading cause of death in children younger than five years in Africa, and in a dozen African countries, it is responsible for over a fifth of all postneonatal childhood deaths (Getty Images)

"To reduce donor dependence, the extra money will come preferably from a modest increase in development assistance for malaria (we propose $0·5 billion) and a substantial increase in government malaria spending, especially in the most affected countries (we propose $1·5 billion)," says the study.

According to researchers, effective management and implementation of malaria programs are the most critical requirements for national and regional elimination and eventual global eradication.

The current slowing of progress, they say, is not primarily the result of biological challenges. It is caused by an inability to deliver key services and interventions where they are needed most.

The researchers say the approach to fighting malaria across low-income and middle-income countries have, so far, been focused on the role of the public sector, resulting in "missed opportunities" to engage with the private sector. Private healthcare providers have important roles in malaria diagnosis and treatment in many countries, they suggest. 

The Commission also stresses the need to improve the "hardware of eradication" by developing and rolling out innovative new tools to overcome the biological challenges to eradication. Innovations and new tools are essential for malaria eradication by 2050.

The findings state that new tools will be particularly crucial if they improve surveillance, counter drug and insecticide resistance, have long durations of efficacy, and do not need difficult or lengthy compliance by individuals or households. 

"Particular emphasis should be given to the identification and development of endgame tools that can reduce malaria burden in the highest transmission areas or prevent re-establishment. Interventions from the malaria toolbox must always be used in combinations that are tailored to local epidemiological and social contexts," says the study.

In a related commentary, Tedros Adhanom Ghebreyesus, director-general of the World Health Organization (WHO), says that the Commission has made a bold call for eradicating malaria by 2050.

"But we will not achieve eradication within this timeframe with the currently available tools and approaches — most of which were developed in the past century or even earlier. So, although the imperfect application of imperfect tools has reduced the burden of malaria and helped eliminate malaria from many countries, it is not enough. The good news is that we, the global malaria community, know what we need to do," he says.

Ghebreyesus emphasizes the need to strengthen delivery systems to ensure that all those in need have access to the optimal mix of strategies, without financial hardship. According to him, the global malaria community, along with research and development partners, must take a "hard look" at the pipeline for transformative new tools.

Some promising products, he says, are emerging, including new diagnostics, medications, insecticides, vector-control approaches, and passive immunization therapies such as monoclonal antibodies. 

"Because of major research and development efforts, the world’s first malaria vaccine, RTS,S/AS01, is now being deployed in a pilot roll-out in three African countries. The world requires a package of tools that can permanently reduce mosquito transmission of malaria to zero and wipe out the reservoir of malaria parasites in humans," says Ghebreyesus in the commentary.

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