Malaria: Global progress 2000 – 2015 and future challenges
© The Author(s). 2016
Received: 8 April 2016
Accepted: 20 May 2016
Published: 9 June 2016
2015 was the target year for malaria goals set by the World Health Assembly and other international institutions to reduce malaria incidence and mortality. A review of progress indicates that malaria programme financing and coverage have been transformed since the beginning of the millennium, and have contributed to substantial reductions in the burden of disease.
Investments in malaria programmes increased by more than 2.5 times between 2005 and 2014 from US$ 960 million to US$ 2.5 billion, allowing an expansion in malaria prevention, diagnostic testing and treatment programmes. In 2015 more than half of the population of sub-Saharan Africa slept under insecticide-treated mosquito nets, compared to just 2 % in 2000. Increased availability of rapid diagnostic tests and antimalarial medicines has allowed many more people to access timely and appropriate treatment. Malaria incidence rates have decreased by 37 % globally and mortality rates by 60 % since 2000. It is estimated that 70 % of the reductions in numbers of cases in sub-Saharan Africa can be attributed to malaria interventions.
Reductions in malaria incidence and mortality rates have been made in every WHO region and almost every country. However, decreases in malaria case incidence and mortality rates were slowest in countries that had the largest numbers of malaria cases and deaths in 2000; reductions in incidence need to be greatly accelerated in these countries to achieve future malaria targets. Progress is made challenging because malaria is concentrated in countries and areas with the least resourced health systems and the least ability to pay for system improvements. Malaria interventions are nevertheless highly cost-effective and have not only led to significant reductions in the incidence of the disease but are estimated to have saved about US$ 900 million in malaria case management costs to public providers in sub-Saharan Africa between 2000 and 2014. Investments in malaria programmes can not only reduce malaria morbidity and mortality, thereby contributing to the health targets of the Sustainable Development Goals, but they can also transform the well-being and livelihood of some of the poorest communities across the globe.
Please see Additional file 1 for translations of the abstract into the six official working languages of the United Nations.
2015 marked the end of the era of Millennium Development Goals and the dawn of a new global agenda for human health and prosperity, the Sustainable Development Goals. It was also the target year for malaria goals set by the World Health Assembly to reduce malaria incidence and mortality and the launch of WHO’s Global technical strategy for malaria 2016–2030. These 2015 goals and targets were supported by commitments from endemic countries and the international community to increase the financing of malaria programmes and expand the coverage of malaria control interventions namely, mosquito vector control through use of insecticide-treated bednets and indoor residual spraying; malaria chemoprevention for pregnant women and for children in areas with highly seasonal malaria; and malaria diagnostic testing and treatment for malaria cases. To assess progress in malaria control and elimination worldwide, the World Health Organization reviews available information from malaria endemic countries and implementing partners and publishes them in the World malaria report . The report shows that there have been substantial gains in malaria programme financing and coverage since the beginning of the millennium and that these have had a substantial impact on the incidence of malaria. Nevertheless, significant challenges lie ahead, particularly for the poorest countries in the world and for substantial proportions of the populations living in them.
Progress in malaria control and elimination 2000-2015
Financing of malaria control programmes
The proportion of pregnant women receiving at least three doses of intermittent preventive treatment in pregnancy (IPTp) increased between 2009 and 2014. In 2014, 52 % of eligible pregnant women received at least one dose of IPTp, 40 % received two or more doses, and 17 % received three or more doses. The difference between the proportion of women attending antenatal care clinics and the proportions receiving the first and subsequent doses of IPTp suggests that opportunities to deliver IPTp at these clinics were missed. Adoption and implementation of chemoprevention in children has been more limited. As of 2014, six of the 15 countries for which WHO recommends seasonal malaria chemoprevention (SMC) had adopted the policy. Only one country, Chad, reported adoption of an intermittent preventive treatment for infants (IPTi) policy in 2014.
Diagnostic testing and treatment
Trends in malaria case incidence and mortality rates
The number of malaria deaths fell from an estimated 839 000 globally in 2000 (range 653 000 to 1.1 million), to 438 000 in 2015 (range 236 000–635 000), a decline of 48 %. Most deaths in 2015 remain in the WHO African Region (90 %), followed by the WHO South-East Asia Region (7 %) and the WHO Eastern Mediterranean Region (2 %). The malaria mortality rate, which takes into account population growth, is estimated to have decreased by 60 % globally between 2000 and 2015. Thus, substantial progress has been made towards the World Health Assembly target of reducing the malaria burden by 75 % by 2015, and the Roll Back Malaria (RBM) Partnership target of reducing deaths to near zero.
Malaria in children
The proportion of children infected with malaria parasites is estimated to have halved in endemic areas of Africa since 2000. Infection prevalence among children aged 2–10 years declined from 33 % in 2000 (uncertainty interval: 31–35 %) to 16 % in 2015 (uncertainty interval: 14–19 %), with three quarters of this change occurring after 2005.
Cases and deaths averted
Progress to elimination
Malaria programme financing and coverage have been transformed since the beginning of the millennium, and have contributed to reductions in the burden of disease. However, progress has not been even. Decreases in case incidence and mortality rates were slowest in countries that had the largest numbers of malaria cases and deaths in 2000; reductions in case incidence was 32 % in the 15 countries accounting for 80 % of cases in 2000, while 53 % in the rest. Reductions in incidence need to be greatly accelerated in these countries if global progress is to improve.
Millions of people still do not receive the malaria prevention and treatment services they need. In sub-Saharan Africa in 2014, an estimated 269 million of the 843 million people at risk of malaria lived in households without any ITNs or IRS; 15 million of the 28 million pregnant women at risk did not receive a dose of IPTp; and between 68 and 80 million of the 92 million children with malaria did not receive ACT. Malaria-endemic countries face considerable challenges to fill these gaps as the disease is concentrated in countries and areas with the least resourced health systems as exemplified by lower staff: population ratios and greater use of informal private sector providers. The ability of malaria-endemic countries to strengthen health systems is constrained by low gross national incomes and total domestic government spending per capita. International spending on malaria control is more evenly distributed in relation to malaria burden, but, as indicated previously, a large proportion of this funding is spent on commodities and does not address fundamental weaknesses in health systems. Thus, innovative ways of providing services may be required to rapidly expand access to malaria interventions such as community-based approaches and engaging with private sector providers.
While the lack of strong and adequately financed delivery systems pose a continued challenge to malaria control and elimination, significant biological challenges also need to be faced including the lack of tools to effectively diagnose and treat malaria due to P. vivax and the emergence of parasite resistance to antimalarial medicines and of mosquito resistance to insecticides.
Looking to the future
To address the remaining and emerging challenges, WHO developed the Global technical strategy for malaria 2016–2030 (GTS 2016–2030) , adopted by the World Health Assembly in May 2015. The strategy sets the most ambitious targets for reductions in malaria cases and deaths since the malaria eradication era 60 years ago, notably reductions in malaria incidence and mortality rates of 90 % or greater by 2030, and the elimination of malaria from at least 35 countries. Annual investments in malaria control and elimination will need to increase to US$ 8.7 billion by 2030 in order to achieve these targets. The amount may seem prohibitive given that current levels of investment are less than a third of this total. However, malaria funding increased by more than 2.5 times between 2005 and 2014 and similar rates of increase over a fifteen year period would allow the GTS 2016–2030 funding target to be achieved.
Global progress in reducing malaria is nothing short of remarkable. Malaria case incidence has decreased by 37 % globally between 2000 and 2015 and malaria mortality rates by 60 %. Investments in malaria interventions have played a large part in bringing about these reductions, accounting for approximately 70 % of the decline observed in sub-Saharan Africa between 2000 and 2015. Further reductions in malaria are possible and are called for in the Global technical strategy for malaria 2016–2030. However, annual investments in malaria control and elimination will need to increase to US$ 8.7 billion by 2030 in order to achieve the targets set out in the GTS 2016–2030. While this total greatly exceeds current investments, malaria interventions are highly cost-effective and exhibit one of the highest returns on investment in public health. Investments in malaria programmes will not only strengthen health systems and deepen the reductions in malaria morbidity and mortality, thereby contributing to the health targets of the SDGs, but they can also transform the well-being and livelihood of some of the poorest communities across the globe.
ACTs, artemisinin combination therapies; GTS, Global technical strategy for malaria 2016–2030, IPTi, intermittent preventive treatment for infants; IPTp, intermittent preventive treatment in pregnancy; IQR, interquartile range; IRS, indoor residual spraying; ITNs, insecticide-treated mosquito nets; MDG, Millennium Development Goals; NMCP, National Malaria Control Programme; RDTs, rapid diagnostic tests; SDG, Sustainable Development Goals; SMC, seasonal malaria chemoprevention in children; SP, sulfadoxine-pyrimethamine; WHO, World Health Organization
This commentary draws from the World malaria report 2015 . WHO staff in regional and subregional offices assisted in the design of data collection forms; the collection and validation of data; and the review of epidemiological estimates, country profiles, regional profiles and sections: Birkinesh Amenshewa, Magaran Bagayoko, Steve Banza Kubenga and Issa Sanou (WHO Regional Office for Africa [AFRO]); Spes Ntabangana (AFRO/Inter-country Support Team [IST] Central Africa); Khoti Gausi (AFRO/IST East and Southern Africa); Abderrahmane Kharchi Tfeil (AFRO/IST West Africa); Keith Carter, Eric Ndofor, Rainier Escalada, Maria Paz Ade and Prabhjot Singh (WHO Regional Office for the Americas); Hoda Atta, Caroline Barwa and Ghasem Zamani (WHO Regional Office for the Eastern Mediterranean); Elkhan Gasimov and Karen Taksoe-Vester (WHO Regional Office for Europe); Leonard Icutanim Ortega (WHO Regional Office for South-East Asia); Rabindra Abeyasinghe, Eva-Maria Christophel, Steven Mellor, and Raymond Mendoza (WHO Regional Office for the Western Pacific). Colleagues in the Global Malaria Programme contributed to the review of sections of the report: Andrea Bosman, Jane Cunningham, Pearl Harlley, Abraham Mnzava, Peter Olumese, Charlotte Rasmussen, Aafje Rietveld, Pascal Ringwald, Vasee Sathiyamoorthy, and Emmanuel Temu. Numerous other people contributed to the production of the report and are listed in the acknowledgements section of the World Malaria Report 2015.
Funding for the World malaria report 2015 was received from the United Kingdom Department for International Development, the United States Agency for International Development and the Swiss Agency for Development and Cooperation, through a grant to the Swiss Tropical and Public Health Institute. Collection of malaria programme data was also supported by the “Accelerated Malaria Control towards Pre-elimination in East and Southern Africa by 2015” sponsored by the Government of Monaco.
Availability of data and materials
The world malaria report is available at the following link, including annexes with statistics: http://www.who.int/malaria/publications/world-malaria-report-2015/en/.
REC drafted the manuscript. PA, JA, MA, AB, LB, RC, CAF, TK, ML, EP, SSc, SSt and RW contributed to the conception of the work, analysis and interpretation of data and reviewed the manuscript. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
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