EXECUTIVE BOARD 136th session Provisional agenda item 9.1
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Malaria: draft global technical strategy: post 2015 Report by the Secretariat 1. In resolution WHA58.2 on malaria control, the Health Assembly urged Member States to take concrete steps for a global expansion of malaria efforts. It also set targets including that of reducing the disease burden by at least 50% by 2010 and by 75% by 2015. Global malaria efforts and associated challenges were also the focus of resolutions WHA60.18 and WHA64.17. At the Sixty-sixth World Health Assembly, Member States expressed support for the proposal for the Secretariat to draft a global technical strategy for malaria for the post-2015 period. 1 2. In June 2013, the Secretariat began a global consultative process involving Member States and stakeholders, including organizations in the United Nations system, scientific and research groups, nongovernmental organizations and implementing partners. Between March and June 2014, seven regional consultations were held on a draft version of the strategy, at which more than 70 Member States were represented and more than 400 technical experts provided input. To supplement these consultations, the Secretariat hosted an online public consultation between 11 July and 15 August 2014, during which further comments were received. 3. The strategy development process was led by the Secretariat and supported by both the Malaria Policy Advisory Committee and a dedicated Steering Committee, consisting of leading malaria experts, scientists and representatives of Member States. At its meeting in September 2014, the Malaria Policy Advisory Committee reviewed and formally endorsed the revised draft document. The main strategic directions were then submitted to the Regional Committee for Europe at its sixty-fourth session (Copenhagen, 15–18 September 2014) and considered by the Programme Subcommittee of the Regional Committee for Africa (Brazzaville, 1 and 2 September 2014).
CURRENT SITUATION 4. Despite being preventable and treatable, malaria continues to make a devastating impact on people’s health and livelihoods around the world. Some 3400 million people are at risk of malaria infection in 97 countries, territories and areas, and the disease killed an estimated 627 000 people in 2012 (uncertainty range: 473 000–789 000), most of whom were children under 5 years of age in Africa. Around the world, millions of people remain without access to malaria prevention and treatment, and most cases and deaths go unregistered and unreported. Given environmental and demographic trends, including the projected growth in the size of the world population by 2030, even more people will be living in areas where malaria is a risk, putting a further strain on health systems.
See document WHA66/2013/REC/3, summary record of the eleventh meeting of Committee A, section 1 (http://apps.who.int/gb/ebwha/pdf_files/WHA66-REC3/EN/A66_REC3-en-full.pdf).
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5. A critical juncture has been reached in the fight against malaria. There is both an opportunity and an urgent need to accelerate progress towards elimination. Since 2000, a major expansion of WHO-recommended interventions has contributed to a 42% reduction in the global malaria mortality rate, and an estimated 3.3 million deaths have been averted. At present, 52 countries are on track to achieve the Health Assembly’s target of reducing thei r malaria burden by 75% by 2015. The current package of core interventions – namely, vector control, chemoprevention, diagnostic testing and treatment – has proved to be highly cost-effective and needs to be further expanded in order to save more lives. 6. Many challenges threaten continued progress. Emerging parasite resistance to antimalarial medicines and mosquito resistance to insecticides could, if left unaddressed, render some of the current tools ineffective and trigger a rise in global malaria mortality. The global health community needs to pay close attention also to systemic and technical obstacles, such as the inherent weakness of health systems, including poor disease surveillance and limited pharmaceutical regulation; a lack of adequate technical and human resource capacities; the high prevalence of asymptomatic infections, which contribute to disease transmission; the complex biology of the malaria parasites; and the diversity of vectors and their behaviour.
DRAFT GLOBAL TECHNICAL STRATEGY FOR MALARIA 2016–2030 IN BRIEF1 7. The draft malaria strategy 2016–2030 provides a comprehensive framework for countries to develop tailored programmes for accelerating towards malaria elimination. It emphasizes that progression towards malaria-free status does not consist of a set of independent stages but is a continuous process requiring a structuring of programmes in line with subnational stratification by malaria risk. It underlines the need to ensure universal coverage of core malaria interventions, and proposes milestones and goals for 2020, 2025 and 2030. It also identifies areas where innovative solutions will be essential to achieve the goals, and outlines the global financial implications of implementing the strategy. The proposed strategy is built on three pillars with two supporting elements, which are summarized below. 8. Pillar 1: Ensure universal access to malaria prevention, diagnosis and treatment . All core malaria interventions – namely vector control, chemoprevention, diagnostic testing and treatment – should be scaled up to cover all populations at risk. Universal coverage is a key principle of the draft strategy, applying to all core interventions. The draft strategy recommends stratification according to malaria risk, which would enable the tailoring of interventions to local contexts and ensure efficient use of resources. In order to ensure long-term effectiveness of the core interventions, countries are urged to intensify efforts to prevent and manage biological challenges, such as drug and insecticide resistance and diverse vector behaviour; to remove all ineffective antimalarial medicines and substandard vector-control products from markets, and to expand community-based diagnostic testing and treatment. The draft strategy also calls for elimination of falciparum malaria from the Greater Mekong subregion, where multidrug resistance, including artemisinin resistance, has emerged. 2
1 The full draft strategy can be accessed on the WHO website, see http://who.int/malaria/areas/global_technical_strategy/draft_strategy/en/ (accessed 5 November 2014). 2 The draft strategy makes specific reference to this subregion as multidrug resistance (defined here as resistance to both artemisinin and several partner drug components of artemisinin combination therapies) has emerged along the Cambodia-Thailand border.
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9. Pillar 2: Accelerate efforts towards elimination and attainment of malaria-free status. In addition to expanding interventions to all populations at risk, all countries should intensify efforts to eliminate the disease, especially in areas with low transmission. The draft strategy lists priorities for elimination, highlighting among others the importance of renewing political commitment and strengthening cross-border collaboration. At the same time, countries should seek to lower malaria transmission by reducing the pool of infections through implementation of strategies such as transmission-blocking chemotherapy for falciparum malaria and radical cure for vivax malaria. Over the next decade, new tools and approaches are expected to become available that will help to target the infectious parasite reservoir in humans. 10. Pillar 3: Transform malaria surveillance into a core intervention. Strengthening malaria surveillance is fundamental to programme planning and implementation and is a crucial factor for accelerating progress. All countries where malaria is endemic, and those receptive to malaria, should have an effective malaria surveillance system in order to direct resources to the most affected populations, identify gaps in programme coverage, detect outbreaks, and assess the impact of interventions to guide changes in programme planning and implementation. Countries should substantially strengthen malaria surveillance so that it functions as a core intervention. 11. Supporting element 1: Harnessing innovation and expanding research. In support of the three pillars, affected countries and the global malaria community should harness innovation and expand basic, clinical and implementation research. Successful innovation in product development and service delivery will make a major contribution to accelerating progress. Basic research is essential for a better understanding of the parasite and the vectors, and for the development of more effective diagnostics and antimalarial medicines, improved and innovative vector control methods, and other tools such as vaccines. Implementation research will be fundamental to optimizing impact and cost–effectiveness, and to facilitating rapid uptake of new tools. The draft strategy describes research and innovation needs for all three pillars. 12. Supporting element 2: Strengthening the enabling environment. Strong political commitment, sustainable financing and increased multisectoral collaboration hold the key to further progress. An overall strengthening of health systems and improvement in the enabling environment will help to optimize national malaria responses, and enable the adoption and introduction of new tools and strategies in a timely manner. In turn, the expansion of malaria interventions can be used as an entry point for strengthening health systems, including maternal and child health and laboratory services, and to build stronger health information and surveillance systems. Furthermore, the empowerment of communities, a skilled health workforce and strong regulatory frameworks are also cornerstones of success.
ROLE OF THE SECRETARIAT 13. In line with its core roles, the Secretariat will continue to set, communicate and disseminate normative guidance, policy advice and implementation guidance to support country action. It will provide support to Member States in the implementation of the malaria strategy 2016–2030 and provide guidance in reviewing and updating national malaria strategies. It will work with Member States to develop regional implementation plans, where appropriate. 14. The Secretariat will ensure that its policy-setting process responds to the rapidly changing malaria context and that its global technical guidance is regularly updated by incorporating innovative tools and strategies that are proven to be effective. In addition, it will strengthen its own capacities at the global, regional and country levels so that it is better positioned to lead a coordinated global effort
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to reduce the disease burden by at least 90% by 2030, and to support the implementation of all recommendations in the global technical strategy. 15. In order to enable timely procurement of commodities, the Secretariat will continue to assess and issue recommendations for products and compounds for malaria vector control, and assess and prequalify diagnostics and antimalarial medicines. The Secretariat will also continue to support efforts to monitor the efficacy of medicines and vector control interventions, and maintain global databases for efficacy of medicines and insecticide resistance. 16. The Secretariat will promote the generation of research and knowledge that is required to accelerate progress towards a world free of malaria. It will monitor implementation of the strategy and regularly evaluate progress towards the milestones set for 2020 and 2025 and the goals for 2030. It is proposed that the Secretariat report to the Health Assembly every two years for a time-limited period on progress in implementing this strategy after its adoption. The strategy will be updated at regular intervals to ensure linkage with the latest global policy recommendations.
ACTION BY THE EXECUTIVE BOARD 17. The Board is invited to consider the draft WHO global technical strategy for malaria 2016–2030, which is available on the WHO website, 1 and to make a recommendation on its possible endorsement by the Sixty-eighth World Health Assembly.
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See http://who.int/malaria/areas/global_technical_strategy/draft_strategy/en/ (accessed 17 November 2014).
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DRAFT GLOBAL TECHNICAL STRATEGY AT A GLANCE Vision A world free of malaria Milestones 2020 1. Reduce malaria mortality rates globally compared with 2015 2. Reduce malaria case incidence globally compared with 2015 3. Eliminate malaria from countries in which malaria was transmitted in 2015 4. Prevent re-establishment in all countries that are malaria-free >40% >40% At least 10 countries Re-establishment prevented 2025 >75% >75% At least 20 countries Re-establishment prevented Goals 2030 >90% >90% At least 35 countries Re-establishment prevented
PRINCIPLES • All countries can accelerate efforts towards elimination through combinations of interventions tailored to local contexts. • Country ownership and leadership, with involvement and participation of communities, are essential to accelerating progress through a multisectoral approach. • Improved surveillance, monitoring and evaluation, as well as stratification of programmes are required to optimize the implementation of malaria interventions. • Equity in access to services especially for the most vulnerable and hard-to-reach populations is essential. • Innovation in tools and implementation approaches will enable countries to maximize their progression along the path to elimination. Three major pillars maximize impa ct of today’s life-saving tools Pillar 1: Ensure universal access to malaria prevention, diagnosis and treatment Pillar 2: Accelerate efforts towards elimination and attainment of malaria-free status Pillar 3: Transform malaria surveillance into a core intervention Supporting element 1: Harnessing innovation and expanding research • Basic research to foster innovation and the development of new and improved tools • Implementation research to optimize impact and cost–effectiveness of existing tools and strategies • Action to facilitate rapid uptake of new tools, interventions and strategies Supporting element 2: Strengthening the enabling environment • Strong political and financial commitments • Multisectoral approaches, and cross-border and regional collaborations • Stewardship of entire heath system including the private sector, with strong regulatory support • Capacity development for both effective program management and research are a priority
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