Development and implementation of regionally coordinated, scalable, and sustainable elimination strategies to set the stage for global eradication

Although elimination is likely to be technically feasible throughout much of these regions, existing strategic plans, funding, and operations are tailored more towards burden reduction than achieving elimination. Eliminating malaria in these regions in a sustainable, cost-effective way will require an understanding of how to achieve the greatest possible impact with limited financial resources, while going beyond the paradigm of independent planning and implementation in each country. Reaching the required level of programmatic capacity will require substantial technical, operational, and financial support to strengthen surveillance systems, devise targeted, evidence-based plans, identify sufficient resources to enact them, scale-up parasite-focused and vector control interventions in high risk and hard-to-reach populations, and coordinate activities regionally.

To support all countries to adopt coordinated, evidence-based plans, secure adequate capacity and resources to scale up elimination-tailored strategies, and execute programs that will dramatically accelerate progress towards elimination, CHAI proposes to rapidly scale up direct technical, operational, and financial support to a regional group of national malaria programs within Southern Africa and the GMS. CHAI’s core model is to place staff to work directly with Ministries of Health to improve operational and logistical functioning and ensure that national programs have the capacity and systems in place to achieve their goals. Technically, CHAI will support governments to improve the analysis of surveillance and mobility data, enabling micro planning, spatial and temporal targeting of interventions, and derivation of data-driven strategies for elimination. Operationally, CHAI will support governments to achieve high confirmatory diagnosis rates, improve adherence to test results, strengthen surveillance systems and build national elimination organizations, identify programmatic gaps and define solutions to them, and plan the execution and scale-up of evidence-based strategies to achieve elimination. Financially, CHAI will help cost elimination requirements, reorient existing funding towards optimized, evidence-based strategies, and work to mobilize additional resource requirements for achieving and sustaining elimination. Providing this support to regional groups of countries that share a common malaria catchment, with interwoven epidemiological drivers and closely related populations, is critical given the dependencies of each country’s success upon its neighbours. Achieving successful elimination in lower endemic countries like Swaziland will only be feasible if substantial progress is made in their high endemic neighbours like Mozambique.

The primary outcome of this investment will be to support at least three countries in southern Africa and two countries in the GMS to have eliminated indigenous cases of Plasmodium falciparum and all others within the target regions to make reductions in their parasite reservoirs by catalyzing elimination planning, financing, surveillance, and targeted response activities. This outcome is ambitious and is contingent upon certain externalities that are not entirely within CHAI’s control. Nevertheless, CHAI believes aiming for any outcome short of successful elimination will be insufficient. In the GMS, outcomes less than regional elimination mean accepting that artemisinin-resistant parasites will soon make their way to Africa where they may set back a decade of progress. In southern Africa, they require telling countries that there is no global appetite for ambitious targets beyond scaling up control measures, and that we must do the best we can for as long as we can until resistance, fatigue, and funding gaps eventually overcome programs. Although the primary outcome focuses on the ultimate achievement of elimination in only a few countries, getting there requires simultaneous investment and transformative changes in all countries that share the same malaria problem: again, Swaziland cannot sustainably eliminate until Mozambique achieves substantial reductions in the parasite reservoir in the southern provinces that border it. CHAI thus proposes to embed staff to provide simultaneous support to all countries within the chosen catchment areas to ensure they are working in concert to scale up evidence-based strategies, optimize the use of limited resources, and target interventions to where they will be most impactful. The supporting outputs to achieving elimination in a few places and draining the parasite reservoir everywhere else thus involve substantial technical, operational, and financial gains throughout the entire interconnected region. CHAI believes that this initial investment of a few dedicated support staff will catalyze progress, achieve elimination in some settings, make substantial progress in others, and generate evidence for where increased future investment will achieve it elsewhere. Eliminating malaria will support the Foundation’s strategic goals of accelerating elimination in southern Africa, including achieving it by 2020 in Zambia, Namibia, Botswana, Swaziland, and South Africa, and sub-nationally in southern Mozambique, and in the GMS, with elimination of P. falciparum targeted in Cambodia, Laos, Vietnam, and elimination of P. falciparum from all zone 1 and 2 artemisinin resistance areas targeted for Myanmar and Thailand by 2020.

Progress towards this primary outcome will ultimately be measured according to, first, the number of countries that document zero indigenous cases for at least one year, and second, the number of countries that record meaningful reductions in their annual positivity rates. Supporting outcomes necessary to achieve these goals will include better planning, resource usage, and operational execution in all countries within the target regions. To successfully achieve the project’s goal, CHAI will focus its efforts on achieving three core intermediary outcomes that correspond to technical, financial, and operational improvement in program functioning:

1.1 All countries adopt evidence-based and sustainable strategies and costed operational plans (including the what, where, when, and why)
1.2 All countries have increased and/or more effectively allocated resources for executing malaria elimination programs
1.3 All countries have improved malaria program operations in accordance with their revised elimination strategies and plans

Capacity Strengthening
Financing & Economics
Health Systems
Leadership & Governance
Monitoring & Evaluation
Operational Research
Surveillance

Jul 2015 — Sep 2015

Africa, Southern
Asia, Southeastern