Cross case study analysis on malaria elimination : synthesizing lessons from country experience

Malaria is transmitted by female Anopheles mosquitoes and is caused by parasites of the Plasmodium family. On a global level malaria morbidity and mortality has declined; from 2000 to 2015 the incidence rate of malaria is estimated to have decreased by 41%. With these reductions have come the call for malaria elimination in low transmission countries, which is defined as the reduction to zero of the incidence of infection caused by a specified agent in a defined geographical area as a result of deliberate efforts. Global eradication is also now on the agenda of the global malaria community. Eradication is defined as the permanent reduction to zero of the worldwide incidence of infections caused by the malaria parasite as a result of deliberate efforts.
The first attempt to eradicate malaria, the Global Malaria Eradication Programme (GMEP) (1955-1970), was discontinued after 1969 when eradication was no longer considered attainable with the funding, capacity and tools available. For most countries, elimination was no longer considered feasible and most programmes reverted to strategies for malaria control. Beginning in the early 1990s, however, action was taken to update control strategies and secure more funding for malaria control. Major gains in malaria control followed as initiatives and new tools brought new life to malaria control. By 2007, many countries were making steady progress in controlling malaria and this message of progress was elevated in October 2007 when the Bill & Melinda Gates Foundation announced the foundation’s goal to eradicate malaria. Malaria partners, including the World Health Organization, began to support efforts and strategies for elimination and eradication. Then, in 2015, a strategy to support global eradication was developed by the WHO Global Malaria Programme: the Global Technical Strategy for Malaria 2016-2030 (GTS) was published.
While there is a tremendous amount of literature on malaria control and, more recently, malaria elimination, what was lacking is information on how malaria programmes have made progress or achieved elimination while others have not. Further, most research does not cover comprehensively the broad spectrum of strategies and activities employed by a national malaria programme, nor the technical, operational and financial aspects or enabling or challenging factors for malaria programmes.
In order to fill this gap, this thesis seeks to accomplish two aims. The first aim is to capture and review the experiences of national malaria programmes that have a goal of malaria elimination or have achieved elimination and identify successes and challenges. The second aim is to compare and synthesize experiences from multiple malaria elimination programmes across systems and cultures in order to distill key determinants, success factors and remaining challenges.
For the first aim, methods were developed to collect and review information from the Bhutan and Sri Lanka malaria programmes, which were seeking to eliminate malaria at the time of analysis. The case study methodology was chosen as the best way to comprehensively capture the experience of malaria programmes. It uses a mixed method approach, which included a desk review, in-country document review, quantitative data extraction, key informant interviews, and analysis.
Sri Lanka has successfully eliminated malaria, as of September 2016 when the WHO certified the country as malaria-free. Sri Lanka reported zero indigenous cases since October 2012. A major challenging factor in the country was the nearly 30 years of civil conflict, which affected the most malarious areas of the country, the north and east. A second major challenging factor is the proportion of P. vivax infections, which rose as cases decreased. A previous attempt to eliminate malaria in the country occurred in the 1960s, after implementing IRS with DDT.
Bhutan has made major progress towards malaria elimination since 2000. Malaria transmission in Bhutan has mainly occurred in the southern, low-lying region bordering the Indian states of Assam and West Bengal. Transmission occurs throughout the year in this region. Malaria importation in the southern part of the country is a major challenge for elimination in Bhutan.
For the second objective, a cross case-study methodology was employed. This method compared the experiences of malaria programmes documented in the existing case-study reports (long report form) under two important themes, vector control and programme management. Methods for the cross-case analysis included development of a conceptual framework, qualitative data extraction, conduct of a workshop to review data extraction and key learnings, and analysis. These analyses included nine countries in the UCSF-WHO GMP Eliminating Malaria Case-Study Series (Bhutan, Cape Verde, Malaysia, Mauritius, Namibia, Philippines, Sri Lanka, Turkey, Turkmenistan).
The results of this body of work align closely with the overarching global framework of the WHO Global Technical Strategy (2016-2030). Strong malaria elimination programmes focused on their surveillance and response interventions, ensuring case-based surveillance was in place with identification, classification, follow up and response on an individual case basis. Entomological surveillance was an important part of this surveillance system – the vector control programme must have sufficient capacity and technical skills. Case management is also an important component of surveillance systems, in that programmes must ensure timely access to quality diagnosis and treatment services, and reporting must be timely and accurate. Human resources must be sufficient, which is often a challenge in the periphery. The strongest malaria programmes crafted evidence-based strategies when they were able to access and use quality data, so use of data plays a strong role in decision-making on strategies and intervention choice. However, across the case-studies it was found that programmes did not sufficiently link parasitological and entomological surveillance data, nor was it documented clearly how prevention interventions were monitored to ensure they were targeting the most at risk, and evaluated on effectiveness in the field. This research did show though that highly flexible programmes have the ability to adapt to changing conditions, using data to develop strategies and target interventions in response to the current conditions. This flexibility in turn requires human resource capacity and technical skills.
The results of this work also indicate the requirement of robust leadership of malaria programmes, and an element of verticality that ensures accountability and action to reach elimination goals. Motivation and incentivization are key to ensuring programme operations, and there is a crucial need to identify the best methods to maintain a high level of motivation and work quality. Not surprisingly political and financial commitment to the elimination goal are major enabling factors for malaria programme success. As malaria incidence decreases, access to financial and human resources will likely decrease as attention shifts to other higher priority vector-borne diseases. Considering the risk of declining resources and commitment, and the existing needs in surveillance, programmatic tools and quality of interventions, the gains made since 2000 to current day are fragile. Vigilance as well as commitment and financial support must be maintained for malaria programmes in order to reach elimination and eventual global eradication.