A framework for assessing the feasibility of malaria elimination

Abstract

The recent scale-up of malaria interventions, the ensuing reductions in the malaria burden, and reinvigorated discussions about global eradication have led many countries to consider malaria elimination as an alternative to maintaining control measures indefinitely. Evidence-based guidance to help countries weigh their options is thus urgently needed. A quantitative feasibility assessment that balances the epidemiological situation in a region, the strength of the public health system, the resource constraints, and the status of malaria control in neighboring areas can serve as the basis for robust, long-term strategic planning. Such a malaria elimination feasibility assessment was recently prepared for the Minister of Health in Zanzibar. Based on the Zanzibar experience, a framework is proposed along three axes that assess the technical requirements to achieve and maintain elimination, the operational capacity of the malaria programme and the public health system to meet those requirements, and the feasibility of funding the necessary programmes over time. Key quantitative and qualitative metrics related to each component of the assessment are described here along with the process of collecting data and interpreting the results. Although further field testing, validation, and methodological improvements will be required to ensure applicability in different epidemiological settings, the result is a flexible, rational methodology for weighing different strategic options that can be applied in a variety of contexts to establish data-driven strategic plans.

Figure 1

Framework for assessing the feasibility of malaria elimination. Technical feasibility identifies requirements for achieving and maintaining elimination under different scenarios, operational feasibility involves the administrative and programmatic capacity to meet those requirements, and financial feasibility examines the costs involved. Unrealistic operational expectations and/or prohibitively high costs will require considering other technically feasible scenarios that can be achieved given operational or financial limitations.

Figure 2

Relationship between technical, operational, and financial components of the feasibility assessment. Technical feasibility is determined by the importation rate and intrinsic transmission potential, R₀, operational feasibility is determined by the required degree of interventions needed to achieve elimination given these technical metrics, and financial feasibility depends upon the government's ability to secure sufficient funds to maintain the required operational measures.

Figure 3

The effort required to reduce R_C below 1 (in terms of fraction of the population effectively covered by protection measures like IRS or ITNs) increases with greater intrinsic transmission potential.