Pushing aside recent setbacks from the COVID-19 pandemic, which slightly reversed progress, the fight against malaria has been slow but steady. Sizeable investments over the last 20 years have reduced mortality by 60% and averted 1.7 billion new infections, saving 10.6 million lives, especially those of children under five years old. These gains uphold the ambitions of malaria elimination, crystallized through a myriad of international efforts and a vast arsenal of tools covering vector control, preventive measures, and medicines. However, the fight against the disease is far from over and new threats could change the trajectory of the global health community’s efforts to control and finally defeat this complex illness. Current results continue to be off track and misaligned with 2030 global targets, whose objective is to reduce both incidence and mortality by 90% vis-à-vis 2015 levels.

Stepping over the horizon, it is possible to see three major challenges that require thoughtful consideration and action to realistically curb the impact of malaria over the coming years:

First, drug resistance is a global issue affecting endemic regions, although to differing extents. Resistance is defined as the inability of an antimalarial medicine to successfully treat the disease due to the emergence of parasites with reduced sensitivity to a specific therapeutic tool. This is the case, for example, of genetic mutations that render parasites partially or completely resistant to artemisinin and its derivatives. Even though these drugs were discovered in the 1970s, the artemisinin combination therapies (ACTs) that the world's most vulnerable rely on for first-line treatment of malaria were not recommended in international guidelines until 2001. Studies looking into the efficacy of antimalarial therapies discuss the growing evidence of partial resistance linked to certain ACTs in Africa, particularly Eritrea, Rwanda and Uganda. In Southeast Asia, particularly the Greater Mekong subregion, there has also been treatment failure observed in several ACTs, with concerns reported more broadly across the Western Pacific. Latin America, on the other, requires further monitoring. A notable fear among those treating vulnerable patients is how rapidly resistance is arising, and how treatment options for severe malaria can quickly diminish. Similarly, malaria vectors are also becoming resistant to insecticides used in mosquito nets and residual spraying, including pyrethroids, organochlorines, carbamates and organophosphates, meaning that even the most basic of prevention measures are becoming weaker and increasingly ineffective.

Second, there are still lingering issues associated with equitable access to antimalarial medicines, primarily those meant to address drug resistance. While traditional protocols for malaria recommend the use of ACTs, resistance is pushing treatment guidelines towards the deployment and rotation of multiple first-line treatments, so that the effectiveness of single formulations is not exhausted at once. The example of a pilot program in Kenya, launched with the support of the Medicines for Malaria Venture, illustrates this trend. However, difficulties with availability, affordability and quality remain despite the efforts to expand the coverage of malaria-related interventions. In addition to this, new drugs coming to the market could still include significant barriers to access if formulations are not adapted to on-the-ground conditions or do not factor in the perspective and needs of patients. Inability to access antimalarials, whether in remote rural areas, urban settings or amongst displaced populations, may increase the uptake of substandard or falsified medicines, thereby contributing to resistance and posing substantial safety risks.

Third, climate change is affecting malaria transmission patterns in areas grappling with severe variations in temperature, rainfall and humidity, expanding the geographic location of vectors, prolonging their presence, or reintroducing them to areas where they had been previously eradicated. The World Health Organization argues that the relationship between climate change and malaria’s epidemiological behavior is non-linear, emphasizing that such a correlation will depend on national socioeconomic conditions, vector control programs, and other variables. Yet, it recognizes that the consequences of climate change-related natural events in recent years, with the examples of Pakistan and Malawi, are a clear testimony of the linkages that exist between environmental factors and the reemergence or multiplication of malaria vectors. From a logistical standpoint, climate change is not only disrupting supply chains and even altering the timing of seasonal chemoprevention campaigns, but also displacing at-risk populations and breaking the continuum of care in already weakened health systems.

Some angles of these threats are new but, in general, they capture the dominant narrative on malaria’s most pressing challenges. The key question is, what actions are needed to generate more impactful and innovative solutions over time?

This reflection proposes some courses of action:

1. Understanding that the diversified use of ACTs could potentially slow down drug resistance, stimulating the discovery of latest generation antimalarials and immunization tools continues to be critical. Taking into account that Africa is home to 94% of malaria cases and that the continent is the highest consumer of related medicines across low- and middle-income regions, increased investments in clinical research, and local manufacturing could result in more genetically appropriate medicines and vaccines for the continent. This needs to be accompanied by initiatives that promote the responsible use of existing antimalarials, paired with the utilization of rapid diagnostic tests, in light of the significant volume of medicines procured outside points of care. Furthermore, potential for clinical trials in Africa is massive. IQVIA’s experience working in malaria-related projects demonstrates that, together with vector control, the development of new antimalarial drugs and vaccines needs to be part of a multiprong approach in disease-endemic areas. IQVIA is advocating for greater investments in early phase I research since fewer of these studies have been conducted over the last five years.
2. Along with domestically produced supplies, which ideally favors increased availability, shorter distribution times and economies of scale with reduced drug prices, incorporating the views, demands and specific conditions of patients in the medicine value chain can result in more context-appropriate solutions. IQVIA works closely with key players in the life sciences industry to ensure that novel therapies for malaria are designed with end users in mind, examining the needs of the most vulnerable groups (e.g., children and pregnant women), formulation and administration preferences, storage requirements, proposed shelf-life, and the acceptability of products amongst key funding and procurement stakeholders. Concurrently, the training and engagement of community health workers, pharmacists and anyone who supplies antimalarials should accompany the roll-out of new products and interventions, including seasonal chemotherapy regimens beyond the recommended age of five years wherever disease cycles are longer.
3. On the environmental front, technical actions should be geared towards producing information on the climate change and health nexus, building better, more climate-resilient and environmentally sustainable health systems, and providing guidance and tools for climate and health surveillance. In parallel, using climate and disease information for decision-making; establishing robust epidemic detection, preparedness and response systems; and enhancing national capacity to analyze and use climate and malaria data can better identify trends and anticipate transmission patterns. Beyond more effective public-private partnerships and well-coordinated multisectoral engagements, investing in research to better understand the correlation between climatic variations and disease progression could result in helpful insights and more innovative solutions.

Lastly, multilateral organizations, national governments, civil society players and implementers involved in the malaria space, alongside communities advocating for other infectious diseases, are struggling to maintain the interest of policymakers and donors. As international development priorities shift and competing humanitarian crises, geopolitical conflicts and other environmental events emerge, official development assistance is becoming more fragmented and scarcer, jeopardizing allocations for national, regional and global malaria programs. In this midst of this complex and fast-changing milieu, malaria is responsible for over 240 million infections and more than 600,000 deaths each year, disproportionately affecting poor women and children. Such epidemiological dynamics could worsen if much needed resources, corrective measures, clinical innovations, and access considerations are not in place.

As the world focuses its attention of World Malaria Day, it is important to remind the international community about the need to ‘keep the foot on the gas pedal’ to ensure that malaria remains a compelling public health priority. Accelerating progress towards malaria elimination requires political will, sustained commitment, appropriate funding, community engagement, and multi-stakeholder cooperation in a complex global landscape. Above all, it requires solid strategic steering to further integrate malaria into community and primary healthcare settings and veer away from vertical approaches.