Big Challenges as India Seeks to Eliminate Malaria by 2030

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The Malaria Elimination Group, an independent international advisory group convened by the Global Health Group at the University of California, San Francisco (UCSF), is meeting this week in Chennai, India, to discuss strategies to shrink the global malaria map and take stock of India’s efforts to eliminate the disease. Strong political and programmatic leadership, along with increased financial commitment and strengthened regional collaboration, are crucial to eliminating malaria in India by 2030.

Participants include senior officials from the Government of India, the World Health Organization (WHO), Ministries of Health of malaria-endemic countries in Asia and Africa, technical partners, the private sector, and international health donors, including the Global Fund to Fight AIDS, Tuberculosis and Malaria.

“India’s recent success in eliminating polio shows what can be done when political commitment is strong,” said Sir Richard Feachem, KBE, FREng, DSc(Med), PhD, who directs the Global Health Group at UCSF. “With vigorous action in the low-burden states, and renewed efforts in all states, India can reach the historic goal of malaria-freedom by 2030.”

India has the highest malaria burden in the Asia Pacific region, with more than one billion people at risk of infection. With the support of many partners, India has experienced a remarkable decline in malaria cases, Feachem said. According to the WHO, the country has nearly halved the number of reported malaria cases between 2000 and 2014, from 2 million to 1.1 million.

However, under-reporting of confirmed cases makes it challenging to accurately estimate true burden and populations at risk. Multiple independent reports suggest that actual malaria cases could be between nine and 50 times greater than those reported by India’s National Vector Borne Disease Program (NVBDCP), and malaria-related deaths could be 13 times higher.

Some states and union territories (UTs) are clearly on the path to elimination, but others are not. Fifteen low- and 11 moderate-burden states/UTs are targeting elimination by 2022. Success in these states can be attributed to concerted commitment and dedicated resources, particularly for surveillance.

“We have been successful in reducing the incidence of malaria through the implementation of both national and state interventions,” said A.C. Dhariwal, MD, MSc, who directs the NVBDCP. “We believe the National Framework for Malaria Elimination (NFME) launched by Shri J. P. Nadda earlier this year will serve as a roadmap for advocating and planning malaria elimination in the country.”

India’s goal aligns with the WHO targets for elimination and the 2014 East Asia Summit pledge made by Prime Minister Narendra Modi and 17 other leaders to achieve a malaria-free Asia Pacific by 2030.

Strengthening cross-border measures between India and neighboring Bangladesh, Bhutan, Myanmar, and Nepal will be required to advance malaria elimination in South Asia. According to Sri Lanka’s Ministry of Health, nearly 40 percent of the imported cases to Sri Lanka are from travelers coming or returning from India. Sri Lanka received WHO malaria-free certification in September, 2016, but imported cases could reintroduce the disease. Collaboration across borders is particularly urgent because resistance to artemisinin—a drug used in first-line malaria treatment—was found just 25km from the Indian-Myanmar border.

India’s malaria program is primarily funded by the Government of India and the Global Fund. In 2015, India’s NVBDCP received a three-year grant of US $104.5 million from the Global Fund to boost malaria surveillance, early diagnosis, and treatment. According to Dhariwal, the central government of India allocates approximately US $45 million for malaria per year. The NFME estimates that a total of US $18 billion is needed to achieve India’s 2030 malaria elimination goal. Enhanced domestic financing and cross-border collaboration is critical to achieving the malaria elimination goal and would solidify India’s emerging leadership in regional health security.