Have we really failed to roll back malaria?

The World Malaria Report (WMR) 2021 estimates that there were 241 million (95% CI 218–269) malaria cases in the world in 2020, which is the same number as in 2000 (241 [226–260] million).¹ Has the global burden of malaria really not changed over 20 years, after spending more than US$30 billion on malaria control activities, and after distributing more than 2·5 billion insecticide-treated bednets, 3 billion rapid diagnostic tests, and 3·5 billion artemisinin combination treatments?

A major problem with the WMR is that the method of calculation changes every year. For example, WMR 2020 reported an estimated 453 000 deaths from malaria (422 000–496 000) in 2015,² whereas WMR 2021 reports 566 000 deaths (524 000–619 000) in 2015 (appendix).¹ The WMR 2021 method of estimation is considered most robust,¹ but is it accurate? There has been substantial progress in malaria control in Asia and the Americas, so what is really going on in Africa? 20 years ago, the malaria situation in Africa was dire. There was little distribution of insecticide-treated bednets, and the increasingly ineffective chloroquine was still the first-line antimalarial treatment across the continent. Even adjusting for population increases in Africa, and the uncertain effect of COVID-19, returns on investments in the past 20 years seem profoundly disappointing. If these WHO estimates are correct, then deploying insecticide-treated bednets, rapid diagnostic tests, and artemisinin combination treatments across the continent, in addition to deploying seasonal malarial chemoprevention, has had little effect.

The WHO Global Malaria Pro-gramme messaging is confusing and contradictory. WMR 2020 documented an impressive 60% reduction in global malaria mortality since 2000.² In 2021, the reduction became 30% for the same years! In 2015, WMR 2015³ announced a “dramatic decline in the global malaria burden over 15 years” and WHO proudly reported that target 6C of the Millennium Development Goals—namely, a decline in the global incidence of malaria—had unquestionably been achieved. This accomplishment was reiterated as a key message in the 2019 WMR: “on a global scale there was exceptional headway in reducing the burden of malaria in 2000–2015—proof that progress is possible”.⁴ Where are those claims now?

Each year WHO proposes that a substantial increase in international funding is needed. But a clear understanding of what is happening, what is going wrong, and why, are needed to justify this request.

We declare no competing interests.