Scaling up impact for universal coverage against malaria
The benefits of malaria control initiated by the Global Action Plan programme towards reducing the burden of the disease was endorsed by RBM, with the main objective of increasing accessibility, availability and affordability of malaria control interventions to the most vulnerable and needy populations living in remote endemic areas and monitoring groups in forest fringe borders areas [30, 32, 35, 40-42].
This review documented that dedicated leadership momentum, proven effective malaria control interventions, and available resources collectively converged to turn the tide against the malaria public health burden and its related effects. These remarkable global achievements in malaria control have been by the dedicated commitment of an array of stakeholders. Similarly, across Africa and P.R. China functional partnerships between government and other key stakeholders, including the academic and educational sector, non-government and community-based organizations, the private sector, religious and faith-based organizations; and multi-/bilateral development partners have proved to be instrumental in malaria control and information dissemination. Based on proven evidence of the effectiveness of the malaria interventions, key determinants of scaling up impact shaped interventional policies and mechanisms of effective deployment of the full package with measurable results in targeted areas [1, 20, 31, 40, 41, 82, 83].
Our finding revealed that from 1960 to 2000, the malaria situation across African countries suffered from a state of dormancy in malaria political commitment and financial support, resulting in an intolerable toll of malaria morbidity and mortality rates as reported in 1998  with some improvements in the course of 2005 and 2010. The alarming scourge was worsened by 2000 by the emergence and spread of P. falciparum chloroquine and sulfadoxine-pyrimethamine resistance and An. gambiense resistance to insecticides, mainly pyrethroids [55, 73, 75-84], however substantial improvements in scaling up interventions was accentuated from 2005 – 2010[1-40, 83]. In P.R. China the malaria incidence worsened in 1965, 1970 and the early 1980s as a result of severe shortage in health care personnel, the collapse of the cooperative medical system and lack of adequate health policy, were further complicated by major hazards caused by concomitant infectious such as human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS), tuberculosis and schisostomiasis. However, the situation was rapidly addressed with the post 1987 health reforms through expansion and improvement of medical facilities and personnel, decollectivization of agriculture, rural healthcare system, provision of adequate and sustained preventive and curative services, thus resulting in an abrupt decline in malaria burden nationwide [Figure 1a and 1b.
Accordingly, 35 countries in both Africa and South-East Asia are still harboring higher vectorial capacity with high transmission of P. falciparum and P. vivax malaria which are responsible for the majority of the total deaths worldwide. The major contributors (Nigeria, DRC, Uganda, Ethiopia and Tanzania) account for 50% of global deaths and 47% of cases [1-3], Myanmar, Laos, Cambodia and New Papua Guinea in South East Asia . Accordingly, the benefits of scaling up interventions documented in the last decade as result of increased malaria control interventions varied significantly across Africa, including Eritrea, Zanzibar, Zambia, Gambia and South Africa demonstrated high impact point by showing a marked decrease in morbidity and mortality rates compared to other countries within the Africa continent, but still remained less significant compared to the achievements in P.R. China [Supplement1]. Nigeria, Central Africa Republic (CAR) and DRC had the lowest scaling up impact, calling for the attention of both traditional and also non-traditional donors, in government and the private sector in increasing commitment and funding for accessibility and availability of control interventions to larger populations in remotes areas, and addressing the inadequacies in healthcare service and delivery [Figure 1b. However, achieving the most satisfactory results and maximum health benefits requires a sustained scaling up of integrated malaria control interventions, including prompt and effective case management, use of impregnated mosquito nets and/or indoor spraying with insecticides, intermittent presumptive treatment of most vulnerable groups.
The financing provided for malaria control has enabled endemic countries to greatly increase healthcare systems and delivery capabilities to ITNs, LLINs and case management. The percentage of households owning at least one ITN in sub-Saharan Africa is estimated to have risen from 3% in 2000 to 50% in 2011, the number of rapid diagnostic tests (RDTs) and ACTs procured is increasing from 67% globally in 2005 to 76% in 2010. Reductions in reported malaria cases of more than 50% have been recorded between 2000 and 2010 in 43 out of 99 countries with ongoing transmission, while downward trends of 25%–50% were seen in 8 other countries [1-85]. There is documented substantial progress in use of IPTp and/or ITNs in pregnant women in 28 countries. Similarly, there is marked scaling up coverage progress and substantial beneficial impact across a diverse range of African countries, such as South Africa, Swaziland, Zanzibar, Mozambique, Eritrea, Gambia, Senegal, Rwanda, São Tomé and Príncipe [20, 31, 35, 53-85][Figure 1a & 1b. Despite this encouraging progress, our findings showed that there is a high variability and disparity in ITNs/LLINs coverage across African countries over time to endemic population, mainly the vulnerable groups, thus indicating that more efforts are needed before the target of universal access is attained. For example, in Sierra Leone and Togo, the percentage of children under five sleeping under bednets has dropped to < 50% in 2009 after mass distribution campaigns, and was only 25-30% in 2011 [56-65]. The decrease in malaria prevalence is consistent with findings from other countries that high coverage of malaria control interventions (mainly ITNs and ACTs), certainly contributed importantly to the decrease in population infection rate and, consequently, the threat of malaria. The fact in high coverage areas 72% of households with an ITN had at least one person using the net the previous night is encouraging, but also showed that there is still room for improvement. A recent study of 15 standardized national surveys across Africa showed that within ITN owning households, ITN usage by children increases as the number of persons per available net decreases; notably of the 15 countries included in that study [Figure 2. It should be noted in achieving maximum impact due to variations between countries in epidemiology and malaria control programs, the appropriate interventions differ by transmission levels, parasite type and vector behavior and delivery strategies need to be adapted to existing control programs and integrated with other disease and development programs by continuously improving health systems to enable malaria control, scaling up and maintaining universal coverage. Particular attention is required to ensure that control interventions reach the most vulnerable populations, and that gender, socio-economic status or geographic location are not barriers to accessibility, availability and affordability.
Furthermore, the review documented that both African countries and a few endemic counties in P.R. China, for example in Yunnan, Hainan and Guizhou provinces, have recorded different degrees of scaling up impact (35-90%) through the national malaria control interventions thus, reducing the rate of morbidity and mortality in children under five years old and pregnancy related effects. By 1959 there were an estimated 1.58 million cases per year. Despite two major outbreaks in the 1960s and then in the 1970s, the country saw a steady decrease in the number of cases, from millions of cases per year to only 29,039 reported cases in 2000 prior the GFMAT. This very encouraging result recorded highlight the evidence that sustained commitment and efforts on preventive interventions and prompt case management are the major driving forces with the resulting benefits of incremental burden reduction of malaria control towards elimination and in achieving the MDGs globally [3, 20, 32, 40, 41, 58, 79, 82–85]. For example, promising results were obtained after expanded coverage of malaria interventions, principally LLINs reaching over 60% coverage of populations at risk in both countries and ACTs in Ethiopia and Rwanda; malaria cases in Rwanda decreased by 64% and deaths by 66% between 2005 and 2007 among children under 5 years. And in Ethiopia, cases decreased by 60% and deaths by 51% in the same age group in the health facilities selected for the study  [Figure 2.
In P.R. China, the benefits of sustained scaling up interventions on malaria have led to a dramatic reduction of incidence and prevalence rate from 0.19/10,000 in 2000 to 0.035/10,000 in 2011 respectively. The immeasurable benefits include improved health status and life expectancy, increasing productivity, social well being and potential future economic development at national, regional and international levels [28, 67, 81–86], while most countries in SS Africa would need to toe the same path for a better outcome of investment in controlling malaria. Our findings have also documented that inadequate health systems are one of the main obstacles in scaling up interventions and in securing better health outcomes for malaria, often financial, educational and cultural issues are barriers that need to be addressed in surmounting universal uptake of healthcare services in low resources settings. Since the Abuja declaration was followed by the Roll Back Malaria programme, the Global action plan has contributed immensely to the recent health improvement in African countries with substantial evidence of high achievements through malaria control intervention coverage, especially with ITNs, targeted IRS and use of ACTs to reduce child mortality.
The immense health and economic benefits of scaling up coverage interventions in Africa and P.R. China include reducing morbidity and mortality rates, increasing productivity in the households, community and nationwide, lowering disability adjusted life years, increasing life expectancy, improving healthcare service and delivery, increasing accessibility and availability of infrastructure and adequate equipment and antimalarial drugs, provides additional evidence required to increase long-term national and global political commitment and financial funding, with the ultimate goal that malaria control sustainability leads to elimination and global health. Moreover, control and eventual elimination of human parasitic diseases in the P.R. China requires novel approaches, particularly in the areas of diagnostics, mathematical modeling, monitoring, evaluation, surveillance and public health response [87–89] [Figure 3.