World malaria report 2024

Q&A on this year's report

The following is an interview with Dr Arnaud Le Menach, lead author of this year’s World malaria report. Arnaud is the head of the Strategic Information for Response unit within the WHO Global Malaria Programme.

What would you say are some of the most encouraging news and trends in this year’s report?

There are a couple of things. First, many, many lives have been saved, and malaria cases prevented, over the past 25 years. We estimate in the report that 2.2 billion malaria cases and 12.7 million deaths from malaria have been averted worldwide since 2000. More than 177 million cases and more than one million deaths were averted globally in 2023 alone. So, investments in malaria interventions are working.

Another piece of good news: when we look at malaria deaths and the mortality rate (the number of deaths per 100 000 people at risk), those too continue to be on a downward trend. Globally, the malaria mortality rate has been cut in half since 2000 (from 28.5 to 13.7 deaths per 100 000 people). And deaths from malaria have dropped by 4% since 2020. So we are still making progress.

There are also encouraging trends at the country level. Many countries with a low burden of malaria continue to move steadily towards the goal of elimination. In 2023, 47 of the 83 malaria-endemic countries worldwide reported less than 10 000 cases of the disease. Four countries were certified malaria-free in 2023 – Azerbaijan, Belize, Cabo Verde, and Tajikistan – and Egypt joined them in 2024.

Countries like Liberia and Rwanda have seen huge drops in cases. Cambodia, Lao People's Democratic Republic and Viet Nam reported only a handful of cases of P. falciparum malaria in 2023, despite challenges with drug resistance in that subregion, raising hopes for elimination in those countries. India has moved out of the High Burden High Impact (HBHI) group. Since 2000, the country has cut malaria cases by 17.7 million and achieved a reduction in case incidence of 93%, from 20 to 1.5 cases per 1000 people at risk. So, we are seeing some great progress happening. It’s never as fast as we would like, and there are some worrying plateaus, but the trends are still encouraging.

In terms of interventions, we are seeing improved access to diagnostics, treatments and chemopreventive drugs. New generation insecticide-treated nets, which provide better protection against malaria than the standard pyrethroid-only nets, are being deployed more widely. And more countries are introducing the recently approved malaria vaccines.

Unfortunately, we’re still losing ground on the 2030 anti-malaria targets. How do we get back on track, and can we still meet them?

First, I think it’s important to remember that those are very ambitious targets. We have seen a lot of progress over the past 2 decades, as I just noted, but we’re still not where we want to be. For example, malaria cases are still increasing in many regions. The Eastern Mediterranean Region saw a particularly sharp increase in its malaria caseload after the catastrophic flooding in Pakistan, from about 500 000 cases in 2021 to 4.3 million cases in 2023.

In terms of how to get closer to the 2023 targets, the key goal must be reaching all at-risk areas and people with life-saving interventions, and ensuring those interventions are used correctly. Focusing on the essentials like ensuring people have access to nets and sleep under them and expanding access to diagnostics and treatment – all of that is critical.

Another key reason why progress is lagging is that global funding for anti-malaria efforts is far below what is required. Our report estimates that US$ 4 billion were invested in fighting malaria in 2023 – less than half of the US$ 8.3 billion needed to meet global targets. That funding gap has widened over the past 5 years, from US$ 2.6 billion in 2019 to US$ 4.3 billion in 2023.

As we live in a world where resources are limited, another way to move forward is through the strategic use of data. We need to have a better understanding of where malaria efforts are working, and where more focus is needed. Beyond any one specific intervention, countries should adopt data-driven, cross-cutting strategies that will lower the malaria burden. That might also mean working to improve primary healthcare or building regional partnerships.

One great recent example of this is the Yaoundé Declaration, signed earlier this year by ministers of health of the 11 African countries that suffer from about two thirds of the world’s global malaria burden. The ministers pledged to increase their commitment and funding to malaria control programmes, improve their data systems, bolster health sector infrastructure, and expand multisectoral collaboration. I think it’s an exciting step forward.

This year’s report focuses on the importance of equity, gender equality, and human rights in reducing malaria. Can you explain why these are important for this fight?

I don’t think we can eliminate malaria without taking into consideration the importance of these issues. Health is a human right, and unequal access to malaria prevention and treatment impacts on the realization of this right for everyone, everywhere. Malaria disproportionately impacts people and communities living in poverty and vulnerable situations – a clear example of health inequity. This, in turn, further impoverishes families and households, reducing productivity, discouraging investment and weakening national economies. In Africa, malaria prevalence is highest in low-income households, which also face the greatest financial barriers to accessing care and treatment.

Harmful gender norms play a role, too, increasing the risk of an infection and limiting access to services. In many malaria-endemic countries, married women and adolescent girls require permission to access health services due to harmful social and patriarchal norms. Depending on the context, some activities or occupations can increase exposure to malaria for women and girls, or for men and boys. Indigenous Peoples, migrant populations and persons with disabilities also often face significant obstacles in accessing the health care they need to achieve the highest attainable standard of health and to fulfill their other health-related rights.

To reduce the world’s malaria burden, we need to invest in primary health care as the foundation for strong, equitable health systems. This includes identifying who is most vulnerable to malaria and the barriers they face in accessing interventions and services. Unfortunately, a lot of health data isn’t disaggregated by sex, age, or background. We need better data and knowledge to make more informed decisions on tailoring malaria programmes for most-at-risk communities.

Last year’s report focused on the growing impacts of climate change in the battle against malaria. How did climate and environmental factors impact antimalarial efforts this year?

The problems caused by climate change are many and pose significant health threats. Malaria is transmitted by mosquitoes, so changes to temperature and humidity will have a direct impact on vector biology and, as a result, on malaria incidence.

The impact of extreme weather events, which are expected to become more severe and common, will have serious consequences, particularly for people living in situations of vulnerability. The catastrophic floods in Pakistan in 2022, for example, increased malaria transmission and disrupted health services and livelihoods. This year’s report shows an 8-fold increase in cases in Pakistan between 2021 and 2023, from about 506 000 to 4.3 million.

The long-term effects of climate change on malaria transmission patterns – whether increasing or decreasing – remain uncertain. However, the long-term indirect effects, such as disruptions to food security and access to health care, will likely have an impact on many diseases, including malaria.

There needs to be an urgent response to mitigate climate change. At the same time, more data regarding the impact of climate effects on malaria, and the evidence to support adaptation, are needed to help build resilient, equitable and sustainable health systems.

India moved out of the High Burden High Impact (HBHI) group, and countries like Egypt and Cabo Verde were certified malaria free. What can other countries with a high malaria burden take from these successes?

First, I want to acknowledge and salute the successful efforts by those countries and their public health personnel in either eliminating malaria or significantly reducing its burden. It’s amazing what they have accomplished.

I think, as I mentioned earlier, there are a couple of essential strategies that the countries you named put in place. These include improving case management, strengthening vector control, ensuring a stable supply of essential malaria commodities, having good malaria surveillance systems – all were critical to the progress made. Another common theme in these countries is the importance of having a multisectoral and community approach to fighting malaria. So, combining antimalaria efforts with other public health interventions, encouraging political engagement and local leadership, including involving the communities, and fostering regional and cross-border collaboration.

I would also stress again the essential value of having good data. Understanding where malaria is spreading and how best to support communities with interventions can make all the difference, and combining multiple strategies helps them all to work effectively.

There is some good news about malaria vaccines in this report. How will vaccines continue to have an impact going forward?

Yes, we have 2 malaria vaccines that are now recommended for use, and what we’ve seen over the last few years is very heartening. Around 2 million children in Ghana, Kenya and Malawi received the RTS,S vaccine between 2019 and 2023. Over that time, there was a 13% reduction in overall child mortality and a 22% reduction in hospitalizations for severe malaria among children age-eligible for the vaccine.

As of December 2024, 17 countries had introduced malaria vaccines in their routine childhood immunization programmes. We need to ensure that vaccine supply continues to meet demand, and we need to continue working to strengthen delivery and surveillance systems. These vaccines, if widely deployed, could save tens of thousands of additional lives every year.

Insecticide-treated nets (ITNs) remain the primary vector control tool in most malaria-endemic countries. What impact are they having, and how can countries work to increase their ownership and use?

Yes, ITNs remain a crucial intervention. More than 3 billion ITNs have been distributed globally since 2004 and they have helped dramatically lower the malaria burden since their introduction. In 2023, 73% of households in sub-Saharan Africa owned at least one ITN, and 52% reported sleeping under them.

That said, we’ve seen a rise in vector resistance to the pyrethroid insecticides that are commonly used in standard ITNs. In recent years, there has been a shift to newer types of nets that include 2 active ingredients, i.e., pyrethroid-PBO or dual-active ingredient ITNs. These new nets are now becoming the new standard. About 78% of the 195 million nets delivered to sub-Saharan Africa in 2023 were these more effective nets, up from 59% a year ago. We are hoping to encourage trends that increase the procurement, delivery, and use of these newer, more effective ITNs.

Beside nets and vaccines, are there other antimalarial innovations and interventions that helped move the needle this year?

There are many! Unfortunately, there is no silver bullet to eliminating malaria, especially as compared to other diseases. It will require a combination of strategies and interventions to make substantive progress. But there are a lot of promising interventions that are having an impact.

I’ll just quickly mention three. One, better case management – we’re seeing a positive shift towards more timely and effective care for African children suffering from malaria. Two, seasonal malaria chemoprevention (SMC), or administering monthly doses of antimalarial drugs to children during peak malaria season. An estimated 53 million kids were protected with SMC in 2023, up from only 170 000 in 2012. And three, intermittent preventive treatment of malaria in pregnancy, or IPTp. This intervention has been adopted by 34 African countries and is protecting an estimated 44% of pregnant women and girls at risk.

By combining these and other interventions, improving outreach to populations that are vulnerable to malaria, and using data to understand the impact of these efforts we can ease the burden of malaria. We are not where we want to be yet, but we can get there if we give this fight the priority it deserves, employ these strategies, and work together at the local, national and regional level to end malaria for good.