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Malaria: progress and challenges toward elimination

  • Page updated onMay 13, 2026
Malaria
Text and photo: Bruno Abarca

Malaria is a disease caused by a parasite (Plasmodium) transmitted through the bite of an infected mosquito (female Anopheles). Through the bloodstream, the parasites reach the liver. There they produce another form of parasite that infects red blood cells. In doing so, they multiply within them, rupture them, and continue infecting others. As a result, an immune response to the infection occurs, with symptoms such as cyclical fever, chills and fatigue. Anaemia also develops as a result of red blood cell destruction, along with kidney damage due to circulating free haemoglobin. Without treatment, other organs become affected, including the central nervous system, which can ultimately lead to death.

In the past, major efforts were made that did not succeed in eradicating the disease but did eliminate it in many countries. However, malaria remains a public health threat for the poorest populations today, particularly in sub-Saharan Africa. The new tools and strategies for its elimination will only achieve their goals if there is a global commitment to pursuing them. This requires action on climate change. The fight against malaria must also be addressed in humanitarian contexts with high parasite transmission, driven by political instability, conflict, mass forced displacement and deteriorated health systems.

Why did malaria eradication fail in the 20th century?

Malaria has accompanied mankind through the centuries.

We have coexisted with malaria since the Neolithic Revolution. That was the moment when populations transitioned from hunting and gathering to farming and animal husbandry. In fact, this disease is believed to have caused the death of Alexander the Great in 323 BC and of Alaric I, the first "barbarian" king to successfully besiege and sack Rome. It was also responsible for Attila abandoning his conquest of Italy in 452 AD and for the death of a third of Christian soldiers during the Third Crusade (1188–1192) (Mertens, 2024)Mertens, J. E. (2024). A history of malaria and conflict. Parasitology Research, 123, 165. https://doi.org/10.1007/s00436-024-08167-4.

Malaria is even attributed to the end of Genghis Khan's military campaign in Eastern Europe in 1241, as well as facilitating the entry of European invaders into the Americas in the 16th century. It was also malaria that defeated more than half of the British and French troops during the Haitian Slave Insurrection of 1791, which ultimately led to Haiti's independence. For example, it is estimated that malaria accounted for 66% of deaths during the American Civil War (1861-1865).

We also know, despite the scarcity of records, that throughout this time, of course, malaria has been and continues to be endemic in Africa.

In the 20th century, mankind thought that malaria could be eradicated in a few years

The mechanism of malaria transmission was discovered in 1897. This led to the development of new techniques in the early 20th century. These included, for example, rapid and massive vector control campaigns, the use of new medications such as chloroquine, and improvements in sanitation and environmental conditions.

Years later, the goal was set to move from isolated interventions to a global programme that would produce sustainable change. This was driven by the desire to minimise the negative impact of malaria on the economy. There was also considerable optimism, stemming from the success achieved by the first residual insecticide, DDT, in interrupting disease transmission. As a result of all this, the WHO launched the Global Malaria Eradication Programme (GMEP) in 1955 (Nájera et al., 2011)Nájera, J. A., González-Silva, M., & Alonso, P. L. (2011). Some lessons for the future from the Global Malaria Eradication Programme (1955–1969). PLoS Medicine, 8(1), e1000412. https://doi.org/10.1371/journal.pmed.1000412.

The "eradication" attempt was based on the rapid and massive application of the residual insecticide DDT

When launching the GMEP, some believed that talking about eradication was unrealistic. After all, despite the existence of DDT, addressing the problem in Africa could be extremely challenging. There were hard-to-reach areas and very weak, or even nonexistent, health systems. Additionally, it was estimated that the cost of this program could be very high. At the same time, however, some advocated for the urgent need to act. The reason was the fear that the potential danger of developing insecticide resistance in mosquitoes could become a reality. Such resistances had been known since 1951.

Finally, it was decided that there was already sufficient technical and scientific knowledge to implement vector elimination actions using residual DDT insecticide. It was expected to eliminate malaria transmission in just over a year and to eradicate the Plasmodium reservoir in another 4-6 years. Eradication and its consolidation were to be achieved in less than 7 years. It was also considered necessary to avoid indefinite-duration epidemiological control approaches and that potential cultural and social barriers were not significant. On the other hand, although resistance of the parasite to chloroquine had already emerged by 1950, it was believed that this would not be a problem. After all, once transmission was interrupted, treatment would be needed only minimally.

There was still no awareness of the risks of failure associated with this approach or the ridiculousness of this overconfidence. Nor was it appreciated how unjust and irresponsible it was to overlook the particularities of different contexts and the needs of the African continent. In fact, this program neglected the region of the planet with the highest malaria burden. In sub-Saharan Africa, the program barely managed to be implemented.

After a failed and exclusive eradication effort, malaria surged back more strongly than before

Numerous efforts were made under the framework of this program, especially in countries with the capacity to mobilize resources for it. However, reality and inequality quickly asserted themselves in the poorest and most vulnerable countries.

Attack actions failed to reach the most remote and hard-to-access areas. Furthermore, during this period, little progress was made in accessing new malaria medications. The only notable efforts in this regard were the attempts by the United States to protect its soldiers in Vietnam. Ultimately, the massive use of DDT against malaria, especially in agriculture, spread resistance of mosquitoes to the insecticide, diminishing its effectiveness. As a result, transmission was only interrupted in many areas for a time. However, after this temporary suppression, malaria resurfaced with tremendous strength. The parasite wreaked havoc on populations that now had reduced immune capacity, while epidemiological surveillance systems were unprepared for it.

In 1969, it was assumed that the eradication strategy should be replaced by a longer-term control strategy, and the program was halted. Just as it was never a real attempt at eradication, but rather elimination, it would be unfair to speak only of failure. A significant number of countries did eliminate the risk of disease for millions of people thanks to this international effort. However, these were countries with higher socioeconomic levels, better health systems, and less intense malaria transmission. Meanwhile, in countries with higher endemic malaria transmission, there were no advances. Furthermore, the opportunity to strategically leverage the tools that existed at the time in the fight against malaria where they were most needed was virtually lost.

Subsequent efforts to control malaria were also unsuccessful

The failure to eradicate malaria served as a stimulus for new strategies and approaches. The study of this failure allowed for learning from mistakes. Thus, there was now more emphasis on community health and strengthening health systems, including the movement for primary health care. However, it took several decades for the world to regain the capacity to vigorously confront the fight against this disease again.

It was not until 1998 that another major global initiative, the Roll Back Malaria Partnership, set the goal of rolling back malaria. However, by 2004, this initiative had failed to secure greater funding for the fight against malaria. Moreover, it had also failed to reverse the upward trend in malaria deaths, which had been rising since 1980. It was clear that the goal of halving malaria deaths was not being met (The Lancet, 2005)The Lancet. (2005). Reversing the failures of Roll Back Malaria. The Lancet, 365(9467), 1439. https://doi.org/10.1016/S0140-6736(05)66391-X. Furthermore, according to some sources, malaria deaths peaked at 1,817,000 in 2004. This was nearly double the figures recorded in 1980, and even triple when considering only children under 5 in Africa (Murray et al., 2012)Murray, C. J. L., Rosenfeld, L. C., Lim, S. S., Andrews, K. G., Foreman, K. J., Haring, D., Fullman, N., Naghavi, M., Lozano, R., & Lopez, A. D. (2012). Global malaria mortality between 1980 and 2010: A systematic analysis. The Lancet, 379(9814), 413–431. https://doi.org/10.1016/S0140-6736(12)60034-8">(Murray et al., 2012)Murray, C. J. L., Rosenfeld, L. C., Lim, S. S., Andrews, K. G., Foreman, K. J., Haring, D., Fullman, N., Naghavi, M., Lozano, R., & Lopez, A. D. (2012). Global malaria mortality between 1980 and 2010: A systematic analysis. The Lancet, 379(9814), 413–431. https://doi.org/10.1016/S0140-6736(12)60034-8.

A change in trend in the 21st century was hindered by the COVID-19 pandemic

It was only between 2005 and 2015 that the trend changed and global malaria case counts and death tolls began to decline. This was partly the result of new global and international initiatives (Murray et al., 2012)Murray, C. J. L., Rosenfeld, L. C., Lim, S. S., Andrews, K. G., Foreman, K. J., Haring, D., Fullman, N., Naghavi, M., Lozano, R., & Lopez, A. D. (2012). Global malaria mortality between 1980 and 2010: A systematic analysis. The Lancet, 379(9814), 413–431. https://doi.org/10.1016/S0140-6736(12)60034-8. These include the creation of the Global Fund to Fight AIDS, tuberculosis and malaria in 2002, and the launch of the United States President's Malaria Initiative in 2005. The Global Malaria Action Plan was also published in 2008, followed by a Global Technical Strategy for Malaria in 2015.

The High Burden to High Impact approach was also launched in 2018 to prioritise the countries with the greatest disease burden (World Health Organization, 2020)World Health Organization. (2020). Malaria eradication: Benefits, future scenarios & feasibility. World Health Organization. https://www.who.int/publications/i/item/9789240003675. However, in 2020 the situation deteriorated once again, coinciding with the COVID-19 pandemic.

Current strategies for malaria elimination

Since 2005, there has been a sustained decline in malaria figures, interrupted only by the COVID-19 pandemic in 2020. Even so, today approximately 250 million cases and 600,000 deaths from malaria occur each year across 85 endemic countries and areas. Many countries have declared malaria elimination within their territories in recent years. However, the world remains far from achieving the targets set for 2030 (WHO, 2023)World Health Organization. (2023). World malaria report 2023. World Health Organization. https://iris.who.int/handle/10665/374472.

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What are the advantages and disadvantages of maintaining vertical malaria control programmes at this stage?

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The current malaria elimination strategy proposes a series of progressive steps

Today, efforts to eliminate malaria are guided by a technical strategy published in 2015 and updated in 2021. This strategy proposes a pathway towards malaria elimination, adapted to each context. To this end, it proposes that three consecutive priorities be addressed as progress is made in reducing disease transmission (WHO, 2021)World Health Organization. (2021). Global technical strategy for malaria 2016–2030, 2021 update. World Health Organization. https://www.who.int/publications/i/item/9789240031357:

The first priority focuses on reducing morbidity and mortality by decreasing transmission. To achieve this, a strategic pillar aligned with universal health coverage is proposed. It involves ensuring access to prevention through vector control and chemoprevention, as well as to diagnosis and treatment.

Once transmission is lower, the focus must shift to pursuing malaria elimination. This requires an emphasis on epidemiological surveillance of clinical cases, with active case-finding (WHO, 2018)World Health Organization. (2018). Malaria surveillance, monitoring and evaluation: A reference manual. World Health Organization. https://iris.who.int/handle/10665/272284. At this stage, it is also essential to understand the determinants of residual transmission. Ending the last remaining pockets of local transmission may require innovative interventions to eliminate reservoirs or to address insecticide resistance where it emerges. Community mobilisation is likewise necessary throughout this process.

Finally, when the goal of elimination is within reach, it is necessary to consolidate achievements. To do this, it is essential to transform and strengthen the surveillance strategy. This involves ensuring the detection, treatment, mandatory reporting, and investigation of any suspected infection cases that still arise. The objective of this phase is to prevent the resurgence of malaria once local transmission has been eliminated.

The first strategic pillar seeks to reduce transmission: to do so, prevention must be expanded

The two main tools for malaria prevention are vector control and chemoprevention (WHO, 2021)World Health Organization. (2021). Global technical strategy for malaria 2016–2030, 2021 update. World Health Organization. https://www.who.int/publications/i/item/9789240031357.

For vector control, the recommended approach is to select the appropriate intervention depending on the context. The two available interventions to choose from are the use of insecticide-treated mosquito nets or indoor residual spraying. Using both simultaneously is not recommended. Alongside this, mosquito resistance to insecticides should be monitored, as should the impact of the selected intervention. In addition to these core interventions, other complementary measures may be considered depending on their effectiveness in the local context and their cost. The use of larvicides is one such example. Other interventions such as insecticide-treated clothing or topical repellents are not recommended at the population level (Messenger et al., 2023)Messenger, L. A., Furnival-Adams, J., Chan, K., Pelloquin, B., Paris, L., & Rowland, M. (2023). Vector control for malaria prevention during humanitarian emergencies: A systematic review and meta-analysis. The Lancet Global Health, 11(4), e534–e545. https://doi.org/10.1016/S2214-109X(23)00044-X.

Chemoprevention consists of administering antimalarial treatment preventively to those at highest risk in areas of moderate and high transmission. It can also be given at specific times of year in areas of high seasonal transmission, regardless of whether these individuals are infected or not. For example, it is recommended for pregnant women, through intermittent preventive treatment with multiple doses, during antenatal appointments. It is also recommended for children in high-risk groups, during the times of year when transmission peaks occur. For individuals without immunity who migrate to an endemic area, and for people from endemic settings who are at high risk of severe malaria, chemoprophylaxis is recommended. This consists of administering doses lower than therapeutic levels, but sufficient to prevent infection.

Since 2023, malaria is also a vaccine-preventable disease

Two vaccines are now recommended against malaria: the RTS,S/AS01 vaccine and the R21/Matrix-M vaccine (WHO, 2024a)World Health Organization. (2024). Malaria vaccine: WHO position paper — May 2024. Weekly Epidemiological Record, 99(19), 225–248. https://www.who.int/publications/i/item/who-wer-9919-225-248. Both can be used in children aged 5 months and older. They require the administration of 3 doses given one month apart, followed by a fourth dose at least one year later. They have been shown to be capable of reducing the number of malaria cases by half with three doses during the first year following vaccination. This is particularly important because it is the period when children are youngest and most vulnerable. The administration of the fourth dose also extends the duration of protection, albeit at a reduced level. When used in high-transmission settings coinciding with the seasonal peak, they can prevent up to 75% of malaria episodes.

The RTS,S/AS01 vaccine implementation programme was rolled out in Ghana, Kenya and Malawi and concluded in 2023. It not only succeeded in reducing transmission. It also managed to reduce mortality from all causes excluding injuries by 13% in the child population eligible for vaccination (Mwapasa et al., 2026)Mwapasa, V., Asante, K., Milligan, P., et al. (2026). Impact of introducing RTS,S/AS01E malaria vaccine on mortality in young children in Ghana, Kenya, and Malawi: An observational evaluation of a cluster-randomised implementation programme. The Lancet, 407, 1796–1808. https://doi.org/10.1016/S0140-6736(26)00248-5. Although the two vaccines have not been directly compared in dedicated studies, both appear to have similar efficacy. The R21/Matrix-M, however, is less costly. They are not expected to replace existing prevention measures, but malaria vaccination is now an additional option to consider (WHO, 2024b)World Health Organization. (2024). Global Malaria Programme operational strategy 2024–2030. World Health Organization. https://www.who.int/publications/i/item/9789240090149.

To reduce malaria transmission, diagnosis and treatment must also be expanded

Correct diagnosis of malaria is essential (WHO, 2024c)World Health Organization. (2024). WHO guidelines for malaria. World Health Organization. https://iris.who.int/handle/10665/379635. All patients in whom malaria is suspected should have diagnostic confirmation. This can be achieved through parasite detection by microscopy or with a rapid diagnostic test. Appropriate diagnosis makes it possible to avoid the overuse of first-line treatments and minimise the risk of resistance. It also helps to improve the management of other possible febrile conditions, with which differential diagnoses are often not performed.

Diagnosis is the gateway to treatment. Likewise, universal access to recommended treatment is what makes it possible to prevent the progression of infection to severe malaria and death. This recommended treatment consists of artemisinin-based combination therapies, with local efficacy exceeding 95%. However, in many countries where malaria is endemic there is widespread circulation of falsified or substandard medicines. This occurs when regulatory authorities lack sufficient capacity to prevent smuggling, counterfeiting, or the circulation of outdated medicines. As a result, patients may use these products or other therapeutic regimens that are no longer recommended, such as artemisinin-based monotherapies. This puts those who use them at risk, but also increases the global threat of resistance to combination therapies. It is therefore necessary to maintain robust surveillance of therapeutic failure (WHO, 2018)World Health Organization. (2018). Malaria surveillance, monitoring and evaluation: A reference manual. World Health Organization. https://iris.who.int/handle/10665/272284.

Both for diagnosis and treatment, community health workers can play a key role. Programmes that deploy them offer rapid diagnostic testing and immediate treatment within the community. In this way they help overcome access barriers and increase the coverage of malaria control efforts (WHO, 2024c)World Health Organization. (2024). WHO guidelines for malaria. World Health Organization. https://iris.who.int/handle/10665/379635.

The second strategic pillar begins once the transmission has already been lowered

Once malaria morbidity, mortality and transmission have been reduced, the focus must shift to accelerating its elimination wherever it persists. This requires adapting the actions from the previous strategic pillar to the new objective, while also initiating new ones (WHO, 2021)World Health Organization. (2021). Global technical strategy for malaria 2016–2030, 2021 update. World Health Organization. https://www.who.int/publications/i/item/9789240031357.

It is a priority to identify and prioritize the most hard-to-reach areas, where the most disadvantaged people live. In these communities, malaria may still persist strongly. Therefore, prevention, diagnosis, and treatment should be intensified in these areas. On the other hand, in regions with few cases, other interventions can be studied. One of these is the use of certain special therapies. These prevent mosquitoes from becoming infected when they bite the infected and undergoing treatment person. Here, it may also be appropriate to adapt strategies to halt the transmission of Plasmodium vivax, not just falciparum. Finally, it is important to provide preventive information and chemoprophylaxis to individuals traveling to areas where malaria is still endemic.

Epidemiological and entomological surveillance (of mosquitoes) must be present at all stages, but adapted to the local transmission risk (WHO, 2018)World Health Organization. (2018). Malaria surveillance, monitoring and evaluation: A reference manual. World Health Organization. https://iris.who.int/handle/10665/272284. In high-transmission settings, aggregate data should be used to track mortality trends. Programme coverage, population behaviours, and operational aspects such as available resources are also monitored. However, as transmission declines, the approach must be adjusted. This is the moment to intensify surveillance among the highest-risk groups. To do so, it is necessary to increase reporting frequency, which allows any potential outbreak to be identified as early as possible. Furthermore, when transmission is already low, individual case data must be analysed rather than relying on aggregate information alone.

The third strategic pillar aims at the complete elimination of the transmission

The third stage prioritises, once elimination is already well advanced, achieving it in full (WHO, 2021)World Health Organization. (2021). Global technical strategy for malaria 2016–2030, 2021 update. World Health Organization. https://www.who.int/publications/i/item/9789240031357. In addition, the aim is to reduce the risk of local malaria transmission re-emerging.

In these final stages, surveillance becomes more complex. There may no longer be any cases, but even so, it is necessary to remain alert to increases in the risk of importation or transmission (WHO, 2018)World Health Organization. (2018). Malaria surveillance, monitoring and evaluation: A reference manual. World Health Organization. https://iris.who.int/handle/10665/272284. Genomic surveillance may be necessary. It can be carried out, for example, by collecting blood samples from pregnant women at their antenatal appointments. This type of surveillance allows monitoring of how parasites mutate and evolve.

For these final steps, it is essential to have well-adapted national strategic plans. However, this is not enough. It is also necessary to work on actions for strengthening the health system and its information system.

Eradicating malaria remains the goal, with a target date set for 2050

The ultimate goal of eradication remains on the horizon. After all, there are no absolute barriers preventing it. Furthermore, today there is a more coherent strategy than that of 1955 for combating malaria. This strategy aims for the elimination of the disease in each country through priorities for action tailored to their levels of transmission and morbidity and mortality.

The world has also changed considerably since the (unsatisfactory) end of the global eradication programmes in 1969. Today there are better tools, greater scientific knowledge and, it seems, a renewed global commitment to this goal. Indeed, some even wish to put a date on it: 2050 (Feachem et al., 2019)Feachem, R., Chen, I., Akbari, O., et al. (2019). Malaria eradication within a generation: Ambitious, achievable, and necessary. The Lancet, 394(10203), 1056–1112. https://doi.org/10.1016/S0140-6736(19)31139-0.

However, eradication will only be possible if the world prepares to address the challenges in the places where malaria will be hardest to eliminate (WHO, 2024d)World Health Organization. (2024). Guiding principles for prioritizing malaria interventions in resource-constrained country contexts to achieve maximum impact. World Health Organization. https://www.who.int/publications/i/item/B09044. These are the countries where transmission levels remain extremely high. They also include countries affected by conflict and humanitarian crises, where the risk of failure of recommended approaches is greatest.

🧠 Let's pause and reflect

To what extent might current efforts to eliminate malaria be repeating the mistakes of optimism and exclusion of the 1955 eradication programme?

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Humanitarian crises: the greatest challenge to malaria elimination

The risk of malaria transmission increases in complex humanitarian emergencies

Malaria has been closely linked to conflicts and humanitarian crises throughout history. That relationship persists today. In 2022, 89% of people in need of humanitarian assistance were living in countries where malaria is endemic (WHO, 2023)World Health Organization. (2023). World malaria report 2023. World Health Organization. https://iris.who.int/handle/10665/374472. Moreover, of the ten African countries with the highest current malaria disease burden, seven had a Humanitarian Response Plan in 2024. These are Nigeria, the Democratic Republic of the Congo, Mozambique, Burkina Faso, Niger, Cameroon and Mali. The remaining three were included in Refugee Response Plans: Uganda (with 1.7 million refugees), Tanzania (with 242,000) and Ghana (with 11,000).

The causes of the high risk of malaria transmission in complex humanitarian crises are well known. They often include displacement of people with low immunity to malaria to endemic areas. This also occurs when people with subclinical infections are displaced to urban environments. Malaria is also associated with poor conditions of water, sanitation, hygiene, and habitability. When housing is precarious, it provides little protection against mosquitoes. Another significant risk factor is the interruption and overload of essential health services. In these cases, there is poor access to diagnosis and treatment. Additionally, malaria increases alongside other concurrent health issues, such as malnutrition.

For all these reasons, it is essential that the fight against malaria brings together many different actors who coordinate rapidly to carry out multisectoral actions (World Health Organization, 2013)World Health Organization. (2013). Malaria control in humanitarian emergencies: An inter-agency field handbook (2nd ed.). World Health Organization. https://iris.who.int/handle/10665/90556.

Reducing malaria transmission in these contexts remains a challenge

Clearly, having a logical and coherent strategy against malaria does not eliminate the challenges of implementing it.

On one hand, there are recommended actions in stable contexts that are less effective in complex humanitarian crises. An example of this is the distribution of insecticide-treated bed nets. Despite being a well-studied effective intervention, there are many barriers to its success in these contexts. These barriers include the difficulty of use in the new living conditions or the need to sell the nets to acquire other goods. It is also known that other actions, such as indoor residual spraying, are not entirely feasible in acute emergencies.

Similarly, essential actions such as epidemiological surveillance can represent a genuine challenge in a complex crisis (WHO, 2018)World Health Organization. (2018). Malaria surveillance, monitoring and evaluation: A reference manual. World Health Organization. https://iris.who.int/handle/10665/272284. In many of these situations, it is not even possible to ensure access to malaria diagnosis and treatment. The problem is compounded when the affected population is on the move. Even in cases where a minimum level of epidemiological surveillance can be maintained, establishing adequate vector surveillance or monitoring of the therapeutic efficacy of antimalarials may be impossible.

References

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How to cite this page

Abarca, B. (May 13, 2026). Malaria: progress and challenges toward elimination. Salud Everywhere. https://saludeverywhere.com/en/health-in-humanitarian-crises/malaria-progress-challenges-elimination/

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