Eliminating malaria: following Sri Lanka’s lead

In September, the World Health Organization certified that Sri Lanka had eliminated malaria after it sustained zero local transmission for over three years.1 The long history of Sri Lanka’s fight against the disease,2 the country’s natural receptivity to malaria transmission,3 and the context of a 30 year civil conflict4 make this important public health achievement remarkable. Factors that contributed to Sri Lanka’s success include strong leadership, evidence driven policy, strong domestic funding, an ability to adapt to new circumstances, support of international partners, and the maintenance of services in conflict zones.5

Sri Lanka is only the second country in South East Asia to be certified malaria-free. Many more countries in Asia and elsewhere are on the cusp of elimination, however, and WHO estimates that over 20 countries will eliminate malaria by 2020.6

Success in achieving and sustaining malaria elimination requires the collaboration of neighbouring countries. In 2015, Sri Lanka reported 36 cases of malaria imported from other countries.7 To prevent an imported case from sparking a widespread resurgence that could cost Sri Lanka an estimated $169m (£140m; €150m) in the first year alone,8 its malaria programme must be vigilant and responsive. Sri Lanka and countries that are close to elimination, such as Bhutan, China, and Malaysia, benefit from aggressive malaria interventions in neighbouring countries with a higher burden. Elimination efforts can be further strengthened by drawing on regional epidemiological intelligence to target high burden areas that export malaria infections to receptive areas that are low burden or malaria-free.

The logic of crossborder collaboration on elimination is undisputed, given the documented mobility patterns of the disease.9 Regional platforms—including the Asia Pacific Leader’s Malaria Alliance, which ushered in the adoption of a 2030 regional elimination goal,10 and the Asia Pacific Malaria Elimination Network, which provided a model for exchanging knowledge among national programmes—have been instrumental to elimination efforts. Recently, WHO launched a data sharing platform in the Greater Mekong subregion, and similar efforts are under way among the countries collaborating to eliminate malaria in southern Africa, the Elimination 8.

The success of the emerging regional data platforms depends on the willingness and capability of countries to share sensitive data in exchange for collective regional intelligence that could inform decisions and accelerate progress towards their targets. Although timely sharing of surveillance data between countries has remained a technical and political challenge, a tipping point is within reach after recent efforts by WHO and partners to foster data sharing and reposition surveillance as a core intervention, as proposed in the Global Technical Strategy for Malaria 2016–2030.11

The pursuit of crossborder and regional collaboration presents real challenges. There is often a conflict in national priorities among neighbouring countries. Low burden countries want their high burden neighbours to take action along their shared border, to help them reach elimination. However, the priority for high burden countries may be to invest in malaria control in the areas of highest transmission, which may be far from the border. A shared regional approach that reinforces collaboration rather than finger pointing can drive additional financing and pool technical resources to resolve these differences. A crossborder partnership can strengthen accountability among member countries and help to reach marginalised, mobile, and migrant populations, who often do not or cannot access health systems.

The WHO European region provides a good model. In the 2005 Tashkent declaration, malaria affected countries committed to collective action towards regional elimination and called on the WHO regional office and other partners for support.12 This political commitment led to a regional strategy (2006-15) that emphasised robust surveillance to detect every case, integrated vector control, targeted interventions for high risk populations, and crossborder collaboration. The pairing of political will and strong technical support to collaborate across borders was a winning combination: the European region reached its malaria-free goal in 2015 and is the first WHO region to do so.

Similar efforts are under way in South Asia, a key region given the reported cases of artemisinin resistant malaria close to India’s border with Myanmar (also known as Burma).13 In 2015, health ministers in India requested that an expert group on vector-borne diseases, with an initial focus on malaria, be created under the auspices of the South Asian Association for Regional Collaboration, the leading political-economic platform in South Asia. In addition, India has launched a national malaria elimination framework and has proposed a flagship programme in collaboration with the Association of Southeast Asian Nations to promote research on managing malaria. If successful, this programme would show India’s emerging leadership in the fight against malaria and bolster the elimination prospects of neighbouring countries such as Bangladesh, Bhutan, and Nepal.

Given the emerging threats from infectious disease in Asia Pacific, including Zika, greater collaboration on elimination of malaria between countries can provide a platform for regional health security. By promoting regional epidemiological intelligence and data driven decision making, partnership across borders will accelerate efforts to eliminate malaria and protect the progress made by countries like Sri Lanka.