One Size Does Not Fit All: Evolving Malaria Guidelines

Shifting gears to agile, data-driven decision-making for national malaria programs

Over the last two decades, a powerful combination of strategies against malaria — including vector control, surveillance, prevention, and treatment — has helped bend the curve, reducing malaria deaths from 2000 to 2020 by one-third. Since 2015, nine countries in Asia, Latin America, and Africa have made rapid progress to reach “malaria-free” status, demonstrating that malaria elimination is achievable across epidemiological, ecological, and economic settings.

Over the last two decades, a powerful combination of strategies against malaria — including vector control, surveillance, prevention, and treatment — has helped bend the curve, reducing malaria deaths from 2000 to 2020 by one-third.

These achievements are owed to several important drivers including advances in malaria research, a boost in funding facilitated by initiatives like The Global Fund and the President’s Malaria Initiative, policies at global and local levels, and implementation activities. One such driver is the World Health Organization guidelines for malaria. For decades, these guidelines developed by the WHO Global Malaria Programme (WHO GMP) have provided a framework for evidence-based decision-making to guide malaria interventions across the world. 

However, these guidelines were imperfect and had three pain points: “perceived lengthy processes; inconsistent recommendations; and the sub-optimal use of WHO’s malaria guidance at the country level,” as described by Pedro Alonso, former Director of the WHO GMP, in his parting letter. The recently published edition of the WHO guidelines for malaria is an attempt to address these inefficiencies and enable faster, more flexible, data-driven decision-making for national malaria programs. Let us take a closer look at some of the highlights of the updated guidelines and what it means for the future of malaria control and elimination efforts.

A one-stop shop for malaria recommendations

If we are to keep up with the rapidly evolving malaria parasite and eventually beat it, our best bet is to invest in mechanisms for rapid and clear dissemination of new evidence. 

The MAGICapp platform, launched by the WHO GMP, is one of the most significant improvements to ensure that malaria guidance is disseminated in an efficient manner. The online platform is designed to accommodate the increasing demands for flexibility and quick dissemination of new policy decisions. With features like powerful filters and a user-friendly display of available information, it is hoped that the “living guidelines” simplify the information-seeking process and create a centralized archive of previous versions. 

Furthermore, each recommendation in this platform is accompanied by corresponding information on the certainty of the evidence, justifications, as well as research gaps that are yet to be filled.

Adapting to local contexts

Echoing the overall trends in global health towards context-based decision-making, the latest version of the WHO guidelines for malaria embraces the idea of flexibility. The eco-epidemiological differences across malaria-endemic regions at country or county levels demand different control and elimination approaches. It is now time to look at granular data, adjust to socio-cultural contexts and recalibrate the malaria toolbox in every new setting. The latest recommendations on malaria chemoprevention reflect this shift towards flexibility, leaving room for national malaria programs to adapt their coverage goals based on disease burdens, available funding, and local health infrastructure.

It is now time to look at granular data, adjust to socio-cultural contexts and recalibrate the malaria toolbox in every new setting.

The translation from general guidelines to country-level implementation policies will need local data across areas of operational research like prevention, chemoprevention, surveillance, and case management. Moreover, efforts need to be directed towards building capacity locally to conduct robust research and generate evidence to inform national and subnational tailoring of interventions. After all, the best results for any health interventions are achieved when driven by actors from the community.

Country ownership for a sustainable fight

The flexibility in the updated guidelines also paves the way for increased country ownership of malaria interventions and makes a strong case for domestic funding.

Let us take the example of the updated recommendations on seasonal malaria chemoprevention (SMC). The updated recommendations no longer limit the intervention to the Sahel sub-region. It can be deployed in other regions in Africa with high seasonal variability in malaria transmission. Moreover, the WHO no longer defines the course of the treatment and neither limits the age of the children who can receive it.

The idea of expanding chemoprevention to new age groups, new geographies, and new frequencies, brings the promise of an additional layer of protection for children in malaria-endemic regions. Indeed, the World Malaria Report 2021 modeling methodology suggested that malaria deaths in young children were underestimated between 2000-2020.

Photo: Luis Sevillano

However, this simple intervention needs a complex logistical infrastructure including delivery methods, global drug supply, and resistance monitoring mechanisms. Most importantly, it often boils down to a question of reallocation of malaria control funds at global and local levels. At present, SMC campaigns are mainly being funded by global actors like The Global Fund and the US President’s Malaria Initiative. Despite the economic growth seen in several of the SMC implementing countries over the last decades, investments in health interventions have not proportionally increased. Domestic funding for SMC accounted for only 6-7% of the total committed funds in 2019 and 2020. This imbalance in funding poses a major risk to the sustainability of the intervention. It is important that countries implementing SMC boost domestic funding and invest in a sustainable plan to fight malaria.

Domestic funding for SMC accounted for only 6-7% of the total committed funds in 2019 and 2020. This imbalance in funding poses a major risk to the sustainability of the intervention.

Aligning operational research priorities with country needs

Now that we have shifted gears towards recommendations that encourage faster, more flexible, data-driven decision-making for national malaria programs, the next step is to fill evidence gaps for implementation.

A broad stakeholder consultation process conducted by the PMI Insights Project has recently defined a set of thirty-three country-driven Operational Research (OR) and Program Evaluation (PE) priorities to address the gaps and align such priorities with country needs. The idea of this project is to create a platform for malaria stakeholders to exchange information on OR and PE topics and paint a comprehensive picture of country research priorities for funders.

The malaria community’s goal is a world where no child has to die from this preventable and treatable disease. Several of ISGlobal’s initiatives and projects are working towards this end by testing new and old drugs for chemoprevention and vector control, conducting operational research on topics like malaria in pregnancy, and sharing knowledge and catalyzing malaria research.