About this report

The path to malaria elimination in sub-Saharan Africa is an Economist Intelligence Unit report, sponsored by Abbott. The report looks at the strategies countries in sub-Saharan Africa are using to combat the disease and the challenges that countries are facing on the path to malaria elimination. 

The report is informed by both desk research and expert insight with health officials and policymakers. We would like to thank the following individuals (listed alphabetically) who have generously contributed their views and insights for this report:

• Mr Moonga Hawela, Chief Parasitologist for the Minister of Health, National Malaria Administration, Zambia
• Dr Daniel Kyabayinze, Epidemiologist / Study Coordinator at FIND (Foundation for Innovative New Diagnostics), Kampala, Uganda
• Prof Olugbenga Mokuolu, Malaria Technical Director at Nigeria’s National Malaria Elimination Program and Associate Professor of Paediatrics, University of Ilorin  
• Dr Davis Nwakanma, Head of Laboratory Management of Medical Research Council Unit, The Gambia Unit
• Dr Felicia Owusu-Antwi, National Professional Officer for Malaria, World Health Organisation (WHO), Ghana
• Prof Robert W. Snow, Professor of Malaria Epidemiology, University of Oxford and Principal Investigator, KEMRI-Wellcome Trust Programme, Kenya

The report was written by Andrea Chipman and edited by Gerard Dunleavy.

Executive summary

Since 2000, 1.5 billion malaria cases and 7.6 million malaria deaths have been averted. Despite this remarkable achievement, progress has strikingly slowed in the past five years, with global case incidence declining by less than 1% since 2015, compared with a drop of 28% between 2000 and 2015. More worryingly, the number of malaria cases has even increased in some high-burden countries.

Five countries account for more than half of the world’s 229 million malaria cases in 2019. All of them are in sub-Saharan Africa: Nigeria (27%), the Democratic Republic of the Congo (12%), Uganda (5%), Mozambique (4%) and Niger (3%). In addition, 94% of the 409,000 malaria deaths worldwide were in Africa.

The WHO Global Technical Strategy for Malaria 2016-2030, which the World Health Assembly adopted in May 2015, sets out a number of goals for 2030, including: reducing malaria cases by at least 90%; and reducing malaria mortality rates by at least 90%; eliminating malaria in at least 35 countries. However, due to a variety of reasons, including weak health systems, insufficient funding, and inadequate surveillance systems, most countries in sub-Saharan Africa are not on track to meet these ambitious targets.

After five years of stalled progress, efforts to reignite the previous headway made against malaria are further challenged by the Covid-19 pandemic. Lockdowns have disrupted supply chains, made it more logistically difficult to run preventive programs and treat populations affected by malaria, especially in remote areas. This could further undermine efforts to meet the 2030 goals. The latest WHO malaria report suggests that even a 25% disruption in access to effective anti-malarial treatment could lead to an additional 46,000 deaths in the sub-Saharan Africa region.

Experts interviewed for this report emphasize that it is impractical to come up with a onesize-fits-all strategy for eliminating malaria. Rather, they say, it is important to stratify countries and regions within countries in order to identify those in which elimination is a realistic goal and those in which the interim goal should be reducing deaths and improving case management in order to move toward pre-elimination. 

Key findings:

• Countries in sub-Saharan Africa are on very different trajectories with regard to malaria. While elimination by 2030 is a genuine prospect for some countries, especially in southern Africa, many countries in Central and East Africa are struggling to reduce deaths and cut caseloads. In many cases, there are significant differences within countries as well. Until recently, there was a tendency to treat countries—and regions within countries—as if they are on the same trajectory for eliminating malaria, resulting in inefficient use of finite resources. In recent years, more stratified approaches have been taken to combat malaria across the region.
• Covid-19 disruptions could lead to setbacks: Disruptions to malaria prevention, diagnosis and treatment services due to Covid-19 could increase deaths from malaria by up to 36% over 5 years. The impact of Covid-19 on the functioning of health services has led to a drop in testing for malaria, and, in some cases, a reduction in the number of children presenting at hospital with malaria. There is also evidence of disruption in imports of commodities, which has affected both treatment and diagnostics. 
• Greater investment is needed to get back on track to meet 2030 goals. Annual global expenditure for malaria is estimated to be $4.3 billion, $2 billion short of what is needed to meet the goals of the WHO’s Global Technical Strategy for Malaria 2016-2030 (GTS). While the current annual costs are high, and will even increase as countries move towards elimination, the returns will be even greater. Achieving the goals of WHO’s GTS is projected to generate US$4 trillion in economic output. With an estimated return on investment of 60 to 1 for sub-Saharan Africa, malaria interventions represent one of the highest returns on investment in public health.
• Surveillance remains a serious challenge, given the sparseness of high-quality data that is up to date. The swift uptake of District Health Information Systems 2 to manage health information across sub-Saharan Africa is a positive step. However, the majority of countries in sub-Saharan Africa use models that rely on intermittent community parasite prevalence data to estimate their malaria burden. Such an approach underestimates the true burden and is especially less reliable at capturing recent trends, depriving policymakers of the essential data needed to make the most appropriate and informed decisions. Digital technologies and mobile devices hold great promise, offering the opportunity to map, track, prevent and treat malaria outbreaks in real-time.
• Multi-pronged approaches are essential to reinvigorate progress: Acknowledging the heterogeneity of malaria within national borders, policymakers are increasingly aware of the need to tailor, multi-pronged approaches to combat malaria. Experts interviewed highlighted that a whole package approach is needed to reinvigorate progress in malaria control and elimination.