Malaria Subnational Tailoring

Malaria: Fast facts

• An estimated 263 million cases of malaria and 597,000 malaria-related deaths occurred in 2023.¹
• Malaria is concentrated in 11 countries, with 66% of cases and 68% of deaths in 2023 occurring in Burkina Faso, Cameroon, Democratic Republic of Congo, Ghana, Mali, Mozambique, Niger, Nigeria, Uganda, Sudan, and Tanzania.¹
• From 2015 to 2023, malaria cases declined by 26.6% in the Greater Mekong Subregion (comprising Cambodia, China, Lao People’s Democratic Republic, Myanmar, Thailand, and Vietnam).¹

What is malaria?

Malaria is a life-threatening blood infection caused by parasites of the genus Plasmodium and is most commonly transmitted to humans by infected female Anopheles mosquitoes.² The two most common species of malaria parasites are Plasmodium falciparum and Plasmodium vivax. P. falciparum is the most severe and widespread, causing the majority of malaria-related deaths, particularly in sub-Saharan Africa. P. vivax is less deadly but highly prevalent in Asia and the Americas, with a distinctive ability to remain dormant in the liver and cause relapses.³

The effects of malaria include fever, chills, headache, muscle pain, and, in severe cases, organ failure and death.³

Malaria interventions

Because malaria is primarily spread by mosquitoes, prevention efforts include insecticide-treated nets and indoor residual spraying to kill mosquitoes within households. Other interventions include seasonal malaria chemoprevention in high-risk areas, particularly for children, and intermittent preventive treatment in pregnancy to protect women and their unborn children.² The malaria vaccine RTS,S/AS01 (brand name Mosquirix) was approved by the World Health Organization (WHO) in 2021 for widespread use in areas with moderate to high P. falciparum malaria transmission.⁴ In 2023, WHO also recommended R21, a next-generation vaccine developed by the University of Oxford that is proven to be highly effective in preventing malaria, particularly among children. Disease surveillance systems and community education efforts are also essential for the sustained control—and eventual elimination—of malaria.⁵ When malaria does occur, prompt diagnosis and treatment with antimalarial drugs, including artemisinin-based combination therapies, are critical to prevent severe symptoms and death.

Malaria control today

Global malaria control efforts have achieved notable successes. According to the World Malaria Report 2024, an estimated 2.2 billion cases and 12.7 million deaths have been averted since 2000¹. The malaria mortality rate has been halved, from 28.5 deaths per 100,000 people at risk in 2000 to 13.7 in 2023. Since 2000, 26 countries have eliminated malaria, and 25 countries reported fewer than 10 cases in 2023, compared to just 4 countries in 2000. The WHO Global Technical Strategy for Malaria 2016–2030 calls for reducing both the number of malaria cases and the malaria mortality rate by at least 75% by the end of 2025, and at least 90% by 2030.⁶

Progress has stalled over the past decade, however, due to factors such as climate change, conflicts, and inequitable access to health care. The COVID-19 pandemic further disrupted malaria programs, as evidenced by a 10% increase in malaria deaths in 2020 from the previous year.¹ Emerging resistance to antimalarial drugs and insecticides is creating additional threats to control efforts. In 2023, an estimated 263 million new malaria cases and 597,000 deaths occurred worldwide, marking an increase from previous years.

The figure below illustrates the global trend in malaria cases and deaths from 2000 to 2023:

To reinvigorate progress, new strategies are required that maximize the effectiveness of limited health resources. By strengthening data use at the local level, countries can deploy malaria interventions where they are needed most and address local challenges to malaria control. Improving data use will also enable countries to use mathematical modeling to identify which malaria control strategies offer the greatest impact per dollar spent. Some countries have begun taking this approach, using a strategy called “malaria subnational tailoring.”

What is malaria subnational tailoring?

According to WHO, subnational tailoring (SNT) is the use of local data and contextual information to determine the appropriate mix of interventions and strategies for a given area to achieve optimum impact on transmission and burden of disease at the strategic level or within a specific resource envelope.⁷ Recognizing that transmission varies both between and within countries, SNT uses local data and other contextual information, including resource constraints.⁷

SNT is already being implemented in global efforts to reduce health inequities and optimize resource allocation.⁸ WHO and the Roll Back Malaria Partnership to End Malaria launched the “high burden to high impact” approach in November 2018—led by 11 countries with the highest malaria burden—to get back on track in achieving the milestones established by the WHO’s Global Technical Strategy for Malaria for 2025.⁵ This approach includes supporting high-burden countries’ use of data to tailor malaria interventions at the subnational level to optimize the impact of limited resources.

The malaria SNT process is iterative and engages domestic and international stakeholders across the global health ecosystem. To develop national strategic plans for malaria, countries stratify subnational areas by layering information about malaria epidemiology, entomology, climate, and other factors. This stratification is used to target interventions to specific subnational areas and develop mathematical models that evaluate different scenarios and quantify the impact of subnationally tailored intervention mixes. After recommended scenarios are added to a national strategic plan, interventions are then prioritized based on what will achieve maximum impact with the available resources.

To date, the group of 11 high-burden countries have had two cycles (2019–2021 and 2022–2023) in which SNT has been incorporated into strategic planning and resource mobilization. Malaria SNT is also used in countries approaching malaria elimination, such as countries in the Greater Mekong Subregion.⁹

Why is malaria subnational tailoring important?

Malaria transmission is highly heterogeneous, even in the same country, with different areas experiencing vastly different levels of malaria burden due to geography, climate, socioeconomic conditions, population density, and access to health services.⁷ Subnational tailoring for malaria is therefore crucial because a one-size-fits-all approach to malaria control often fails to address local nuances, leading to inefficient use of resources and limited impact.⁵ For example, the figure below illustrates how malaria burden varies within Mozambique.

By tailoring interventions at the subnational level, malaria programs design intervention mixes that can best address the malaria burden in a local area and deploy resources to where they are needed most. To give another example, high-transmission areas might require intensified mosquito control measures, such as indoor residual spraying and distribution of insecticide-treated nets, whereas areas with lower transmission might focus on case detection and treatment to eliminate residual malaria pockets.⁷ Subnational tailoring also enables programs to address specific challenges that vary by area, such as drug resistance, mosquito behavior, or health system weaknesses.¹⁰

Malaria SNT is also used in countries approaching malaria elimination, such as countries in the Greater Mekong Subregion.⁹ As transmission declines, the disease often becomes localized in specific areas, making national-level strategies less effective. Subnational data and tailored interventions help identify and address remaining hotspots.¹

SNT also addresses inequities by directing resources to underserved communities that might otherwise be overlooked in national strategies. It can also foster better community engagement, as local contexts and needs are better understood and addressed.⁷

By 2023, more than 30 countries have had varying levels of success in implementing SNT. An examination of these efforts dating back to 2019 reveals that some countries stand out as clear exemplars and might offer lessons for other countries.

Exemplars in Malaria Subnational Tailoring study

The goal of the Exemplars in Malaria SNT study is to examine both facilitators and barriers to planning, implementing, and sustaining the SNT of malaria interventions. Five countries were selected for study based on the maturity, quality, and completeness of their SNT processes, as well their progress in reducing malaria burden following the implementation of SNT. The selected countries are Burkina Faso, Mozambique, Nigeria, Tanzania, and Lao PDR.

The Exemplars in Malaria SNT study aims to achieve the following objectives:

• Investigate the processes that each study country undertook to operationalize SNT to inform their malaria control strategy and resource allocation and the barriers and facilitators to implementation.
• Frame which best practices, contextual factors, and core capacities enable each step of SNT to be successfully operationalized across study countries.
• Investigate the key decisions that were made because of the SNT as positive/negative deviance from business as usual, the level of implementation of these decisions, and their impact nationally or subnationally.

Partners

Technical Advisory Group (TAG)

• David Walton: Independent, former President’s Malaria Initiative (TAG Chair)
• Marcia Castro: Harvard T.H. Chan School of Public Health
• Dorothy Achu: World Health Organization, Africa Regional Office
• Scott Gordon: Gavi, the Vaccine Alliance
• Kemi Tesfazghi: Gates Foundation
• Edwine Barasa: KEMRI Wellcome Trust Research Programme
• Busiku Hamainza: Ministry of Health, Zambia
• Melissa Penny: The Kids Institute

Read more

• World Malaria Report 2024
• WHO Malaria Fact Sheet
• Subnational tailoring of malaria interventions for strategic planning and prioritization: experience and perspectives of five malaria programs