Health equity and inclusion remain fundamental to #endMalaria

Shobha Shukla *

Governments have promised to end malaria by 2030. With around five and a half years left to eliminate the vector-borne disease worldwide, it is alarming that progress is off the mark. More worrying is that whatever progress has happened towards ending malaria, can be reversed. Without adequate science-backed and strategic investments and actions, how will countries that have ended malaria, keep the burden below the elimination levels? Climate change worsens the crisis as disease patterns shift.

Equitable access to life-saving malaria tools is key to reversing trends

We cannot divorce equity and inclusion from malaria response. And we cannot dislocate #endMalaria goals from other SDGs for sustainable elimination of the disease worldwide “where no one is left behind.”

“Even if it is hard and difficult, and even if it is not ‘popular’, we need to keep remaining inclusive and equitable in our approaches towards ending malaria. We need to uphold gender equity, social inclusiveness, disability rights and inclusion, because if we focus on health equity and inclusion, it is doing justice to #HealthForAll where no one is truly left behind,” said Professor (Dr) Maxine Whittaker, Dean at James Cook University, Australia and Advisor to CSO Platform (www.MalariaFreeMekong.org). She was speaking with CNS Managing Editor Shobha Shukla at the End Malaria Dialogues at World Health Summit Regional Meeting.

Reinvigorated global efforts warranted to curb rising malaria threat

According to World Health Organization (WHO) Global Malaria Report 2024, there were over 263 million people who suffered because of malaria and over 597,000 who died of it worldwide in 2023. These figures are so disturbing, appalling and unacceptable for a disease which is both preventable and curable.

Not just this: the number of people with malaria disease in 2023 was more than those who had malaria in 2022 (11 million more got malaria in 2023 than those who got in 2022).

Around 95% of malaria deaths occurred in Africa, where many at risk of malaria still lack access to the services they need to prevent, detect and treat the disease.

In Asia and the Pacific region, in terms of number of people with malaria, India has the maximum cases but as a percentage of those with malaria in a population, Papua New Guinea has the highest prevalence.

Malaria-free places must remain malaria-free

As of November last year (2024), 44 countries and 1 territory had been certified malaria-free by WHO, and many more are steadily progressing towards the goal. Of the 83 malaria-endemic countries, 25 countries now report fewer than 10 cases of malaria a year, an increase from 4 countries in 2000.

Since 2015, Africa has also achieved a 16% reduction in its malaria mortality rate. However, the 2023 mortality rate of 52.4 deaths per 100,000 population at risk is still more than double the target level of 23 deaths per 100,000 population set by the Global Technical Strategy for Malaria Elimination 2016-2030, and progress must be accelerated.

Do not take the foot off the #endMalaria accelerator

Places that have eliminated malaria, need to ensure there is no resurgence of malaria. Disease surveillance or prevention for example must go on in a robust and science-backed manner and should be fully funded.

“Once you take the foot off the accelerator, malaria resurgence occurs – that has been well documented. This is what we are very concerned about because all the gains we have made, not just in malaria but in maternal and child health and infant mortality, can wither away. Malaria was one of the major causes of that in some countries that are close to elimination,” says Whittaker.

In December 2024, WHO Global Malaria Report 2024 communique said that “WHO is also calling for investments in robust data systems that are capable of monitoring health inequalities, including through the collection and analysis of data disaggregated by sex, age and other social stratifiers. Equity, gender equality and human rights should be the cornerstones of antimalarial innovation, with people most impacted by the disease engaged in the design and evaluation of new tools and approaches.”

#EndMalaria funding is less than HALF of what is required

Whittaker underlines the importance of fully funding the fight against malaria.

Funding for malaria control globally remains inadequate to reverse current trends, especially in malaria high-burden African countries. In 2023, total funding reached US$ 4 billion, falling far short of the year’s funding target of US$ 8.3 billion set by the Global Technical Strategy. Insufficient funding has led to major gaps in coverage of insecticide-treated nets, medicines, and other life-saving tools, particularly for those most vulnerable to the disease.

Prof Whittaker looks up to domestic philanthropies and corporate social responsibility of the private sector to bridge the funding gap. The funding cuts to WHO have only added to the problem.

Beyond funding, malaria-endemic countries continue to grapple with fragile health systems, weak surveillance, and rising biological threats, such as drug and insecticide resistance. In many areas conflict, violence, natural disasters, climate change and population displacement are exacerbating already pervasive health inequities faced by people at higher risk of malaria, including pregnant women and girls, children aged under 5 years, Indigenous Peoples, migrants, persons with disabilities, and people in remote areas with limited healthcare access.

The proverbial last kilometre

Prof Maxine Whittaker has contributed significantly over the years in helping shape a community-centric response towards ending malaria in Greater Mekong Sub-Region. Along with Thailand, three other countries are close to #endMalaria goal, but the last kilometre can be longer or tougher than one can imagine.

One concern she shares is what she heard from many others at World Health Summit regional meet. Community engagement is either not there or not enough in malaria response with dignity, rights, equity and justice. Some should NOT be more equal than others.

Whittaker believes that “Engaging people and communities helps us find best of ways to meet their needs.” She is hopeful and shares that there are plans to ensure that there is no reestablishment of malaria in Greater Mekong Sub-Region.

Malaria response along the Thailand and Myanmar border is marred by the conflict brewing in Myanmar. Thailand was very close to being able to eliminate malaria, but malaria again got reestablished in some parts, shared Dr Whittaker.

“We need proper decentralisation, along with financial and resource devolution, to ensure that local problems get best of local solutions to end malaria. This requires an educated decentralised management and health workforce. If we look at experiences, we will see that some may think after getting close or achieving malaria elimination that ‘there is no need to worry about’ or ‘there is no malaria problem anymore in backyard’ and slacken not just programmes but also investment. We need to keep investing in #endMalaria programmes as well as be a lot smarter now!” says Whittaker.

Climate change and malaria

WHO reported that the 2022 floods in Pakistan were a massive setback for fight against malaria and a warning for the world of how climate change will impact disease response efforts. Pakistan experienced the worst flooding in its history in 2022. At its height, more than a third of the country was underwater and 33 million people were affected.

“Even before the waters receded, the mosquitoes came en masse, driving the worst malaria outbreak in the country since 1973,” said the WHO report. It had the biggest impacts on the poorest people. When the rains started to subside, there were huge collections of stagnant water everywhere which was a perfect breeding ground for malaria.

As per the WHO, before the floods, there was gradual progress in malaria control in Pakistan. But after the floods this country saw at least a four-fold increase in the reported number of malaria cases.

Professor Maxine said: “With climate change, as places get warmer, parasites may not like that. Which means they may move to higher altitudes or cooler climates. This could be a problem then when they cause diseases and untimely deaths.”

Malaria vaccine: is it helping?

As of December 2024, 17 countries in Africa had introduced malaria vaccines through routine childhood immunisation. The continued scale-up of the vaccines in Africa is expected to save tens of thousands of young lives every year.

Newly developed malaria vaccine may not suit near-elimination settings, says Whittaker. "Malaria vaccine is doing reasonably well as a package of public health interventions to actually reduce morbidity and mortality and also help reduce some of the infant and child malaria cases. It was designed for a particular purpose, whether it is going to be of use in southern or southeast Asian region, or the Pacific, is not certain."

Professor Whittaker calls for a whole-of-society and whole-of-government approach to end malaria - with equity, inclusion and justice as key cog in the wheel.