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ALMA Chair Authors Intro to the Lancet Commission on Malaria Eradication

Despite international efforts to control and eliminate malaria for the past century, the disease continues to be a public health threat, particularly in sub-Saharan Africa. In 2017, there were an estimated 200 million malaria cases and 403 000 deaths across the region, of which 61% were children younger than 5 years. The WHO Director-General's 1954 annual report considered at the Eighth World Health Assembly, adopted malaria eradication for all endemic countries except mainland sub-Saharan Africa and Madagascar (resolution WHA8.30 [1955] and statement of Dr Williams). The Global Malaria Eradication Programme ran until 1969 (resolution WHA22.39 [1969]). 37 of the 143 countries that were endemic in 1950 were freed from malaria by 1978.4 In many other countries, major gains were made in decreasing the malaria burden. The global eradication declaration led to increased commitment to fight against the disease, including increased funding, and resulted in the successful elimination of malaria in many countries. However, the campaign was based primarily on the use of one method: vector control through spraying.

Malaria slowly crept back, with increases in cases over the following decades until the beginning of the new millennium. The launches of the RBM Partnership to End Malaria (RBM Partnership), the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the US President's Malaria Initiative have together led to substantially increased funding, enhanced political will, and renewed commitment to malaria control, and this has helped endemic countries to reduce deaths by more than 60%. The gains achieved have generated optimism for eradication. However, over the past 3 years, the reduction in the number of cases has somewhat stagnated, especially in the highest-burden countries.

The Lancet Commission on Malaria Eradication's new report contends that malaria eradication within a generation is ambitious, achievable, and necessary. This recommendation aligns with the African Union's Agenda 2063: The Africa We Want, which visualises an Africa free of malaria, with a high standard of living, a high quality of life, sound health and wellbeing, and expansion of the provision of basic services including health. To achieve this vision, the African Union codified its commitment to eliminate malaria in the Catalytic Framework to End AIDS, TB and Eliminate Malaria in Africa By 20308 and Africa Health Strategy 2016–2030.9 These crucial documents aim to increase political and individual accountability for malaria elimination by setting aggressive targets; promoting multisectoral ownership of health at the regional levels, Regional Economic Communities, and national levels; strengthening health systems and disease surveillance; supporting advocacy and communication; and addressing social determinants of health, including equitable access to vital health services and commodities.

Malaria eradication is possible within a generation, but it is essential that we accelerate progress. This will require major action from the countries of Africa and from the global malaria community to address the constraints impeding the efficient delivery of existing effective key malaria control strategies and forthcoming new innovations and tools.

To reach this historic goal within a generation, malaria eradication needs to be embedded within the communities that will drive change. As Africa Health Strategy 2016–20309 highlights, communities should be fully engaged in the fight against malaria, demanding their right to health. This community engagement requires urgent, effective decentralisation and community-level integration of health services to build sustainability. The Zero Malaria Starts with Me campaign launched by the African Union and the RBM Partnership is a crucial advocacy and accountability strategy to drive action and ownership of the malaria fight at all levels and across all sectors.

In addition, as outlined by the Lancet Commission's report, we must enhance political will and accountability. This requires strong leadership from the heads of state and government, with increased public and private sector domestic resource commitments. In my own country, eSwatini, we recognise the importance of sustaining financing for malaria despite nearing elimination. We have also enhanced multisectoral engagement and financing through the national End Malaria Fund, introduced in May, 2019, which mobilised more than US$600 000 in pledges during the launch event.

Additionally, I strongly advocate for the use of national malaria scorecard accountability tools, which track progress, identify bottlenecks, and stimulate action. In Zambia, the national malaria scorecard is presented to the End Malaria Council, which convenes high-level multisectoral stakeholders to provide insights into challenges that need to be addressed. Malaria scorecards can also be decentralised and deployed at the community level—for example, governors and other subnational leaders routinely review malaria scorecards in Mozambique.

Our non-malaria-affected donor countries should join us in working together to achieve this global good of malaria eradication. Increasing funding from all sides will ensure that this disease is eradicated for eternity. We, in turn, will ensure that resources are effectively spent and that capacity is built at all levels to support effective and efficient management. Out-of-pocket expenses in health must be avoided in this age of universal health coverage. A demand-driven approach to distribution of long-lasting insecticide-treated nets with tiered pricing will only lead to poor access and increased poverty.

The struggle has been constant to keep up with the malaria mosquito and the parasite, both of which are evolving to evade the effect of malaria interventions. For this reason, we (the malaria community) must make sure that innovation is prioritised. Measures should include investing in research and development to ensure that more effective interventions and commodities are available. Also, we must enhance our policy-making process so that these tools can be rapidly deployed, and make certain that our regulatory systems are robust and responsive. We must also innovate so that we have new methods of delivery, enhanced ways of tracking progress, and the availability of real-time data to enable us to better target interventions.

In conclusion, I welcome the challenge and excitement of this renewed call for malaria eradication. In my own country, we expect to eliminate malaria within the next 5 years. We are looking forward to the day when all the countries in Africa join us. Until that day, we must all band together to ensure malaria is eliminated community by community, district by district, country by country, region by region, and continent by continent.

I am Chair of the African Leaders Malaria Alliance (ALMA). I declare no other competing interests.

His Majesty Ingwenyama King Mswati III