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In the past 150 years, roughly half of the countries in the world eliminated malaria. Nowadays, there are 99 endemic countries-67 are controlling malaria and 32 are pursuing an elimination strategy. This four-part Series presents evidence about the technical, operational, and financial dimensions of malaria elimination. The first paper in this Series reviews definitions of elimination and the state that precedes it: controlled low-endemic malaria. Feasibility assessments are described as a crucial step for a country transitioning from controlled low-endemic malaria to elimination. Characteristics of the 32 malaria-eliminating countries are presented, and contrasted with countries that pursued elimination in the past. Challenges and risks of elimination are presented, including Plasmodium vivax, resistance in the parasite and mosquito populations, and potential resurgence if investment and vigilance decrease. The benefits of elimination are outlined, specifically elimination as a regional and global public good. Priorities for the next decade are described. [ABSTRACT FROM AUTHOR]

The marginal costs and benefits of converting malaria programmes from a control to an elimination goal are central to strategic decisions, but empirical evidence is scarce. We present a conceptual framework to assess the economics of elimination and analyse a central component of that framework-potential short-term to medium-term financial savings. After a review that showed a dearth of existing evidence, the net present value of elimination in five sites was calculated and compared with effective control. The probability that elimination would be cost-saving over 50 years ranged from 0% to 42%, with only one site achieving cost-savings in the base case. These findings show that financial savings should not be a primary rationale for elimination, but that elimination might still be a worthy investment if total benefits are sufficient to outweigh marginal costs. Robust research into these elimination benefits is urgently needed. [ABSTRACT FROM AUTHOR]

In the past several years, as worldwide morbidity and mortality due to malaria have continued to decrease, the global malaria community has grown increasingly supportive of the idea of malaria eradication. In 2015, three noteworthy global documents were released-the WHO's Global Technical Strategy for Malaria 2016-2030, the Roll Back Malaria Partnership's Action and Investment to defeat Malaria 2016-2030, and From Aspiration to Action: What Will It Take to End Malaria?-that collectively advocate for malaria elimination and eradication and outline key operational, technical, and financial strategies to achieve progress toward malaria eradication. In light of this remarkable change in global attitudes toward malaria elimination and eradication, and as the malaria community debates how and when to embark on this ambitious goal, it is important to assess current progress along the path to eradication. Although low-income, high-burden countries are often the focus when discussing the substantial challenges of eradication, the progress toward elimination in middle-income, low-burden countries is a major driver of global progress and deserves better recognition. Additionally, although global support and guidance is essential for success, malaria elimination and eradication efforts will ultimately be driven at the country level and achieved in a collaborative manner, region by region. In this Review, we examine the present status of the 35 malaria-eliminating countries, summarise existing national and regional elimination goals and the regional frameworks that support them, and identify the most crucial enabling factors and potential barriers to achieving eradication by a theoretical end date of 2040., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Prompted by the 20th anniversary of the 1993 World Development Report, a Lancet Commission revisited the case for investment in health and developed a new investment framework to achieve dramatic health gains by 2035. The Commission's report has four key messages, each accompanied by opportunities for action by national governments of low-income and middle-income countries and by the international community. First, there is an enormous economic payoff from investing in health. The impressive returns make a strong case for both increased domestic financing of health and for allocating a higher proportion of official development assistance to development of health. Second, modeling by the Commission found that a "grand convergence" in health is achievable by 2035-that is, a reduction in infectious, maternal, and child mortality down to universally low levels. Convergence would require aggressive scale up of existing and new health tools, and it could mostly be financed from the expected economic growth of low- and middle-income countries. The international community can best support convergence by funding the development and delivery of new health technologies and by curbing antibiotic resistance. Third, fiscal policies -such as taxation of tobacco and alcohol- are a powerful and underused lever that governments can use to curb non-communicable diseases and injuries while also raising revenue for health. International action on NCDs and injuries should focus on providing technical assistance on fiscal policies, regional cooperation on tobacco, and funding policy and implementation research on scaling-up of interventions to tackle these conditions. Fourth, progressive universalism, a pathway to universal health coverage (UHC) that includes the poor from the outset, is an efficient way to achieve health and financial risk protection. For national governments, progressive universalism would yield high health gains per dollar spent and poor people would gain the most in terms of health and financial protection. The international community can best support countries to implement progressive UHC by financing policy and implementation research, such as on the mechanics of designing and implementing evolution of the benefits package as the resource envelope for public finance grows.

Artemisinin-based combinations are currently the most effective anti-malarials and, in addition to vector control, have led to significant declines in malaria morbidity and mortality. However, foci of artemisinin drug resistance have been identified in the Greater Mekong subregion (GMS) of the Asia Pacific, threatening the major gains made in malaria control and potentially creating a parasite pool that is more difficult to treat and eliminate. Efforts are underway to halt the spread of artemisinin resistance, including coordination of activities and funding, and identification of areas of suspected artemisinin resistance, now using a newly identified molecular marker. However, targeting resources to the containment of resistant parasites is likely inefficient and monitoring impact is challenging. A more sustainable solution is the rapid elimination of all Plasmodium falciparum parasites from the GMS. This strategy is more efficient for several reasons. First, a subregional strategy is in line with current commitment to elimination and will build upon the existing national political support for elimination as well as enhancing collaboration among countries. Second, the challenge of human mobility in the GMS is subregional in scope and requires a harmonized elimination strategy. Third, countries will need to improve and intensify malaria operations to reach elimination, and this will be a singular goal across the subregion. Rallying around the goal of P. falciparum elimination will not only utilize existing regional bodies to catalyze political and funding support, but will also leverage the funding already in place to achieve this subregional goal.

Background: Recent progress in malaria control has caused renewed interest in mass drug administration (MDA) as a potential elimination strategy but the evidence base is limited. China has extensive experience with MDA, but it is not well documented., Methods: An ecological study was conducted to describe the use of MDA for the control and elimination of Plasmodium vivax in Jiangsu Province and explore the association between MDA and malaria incidence. Two periods were focused on: 1973 to 1983 when malaria burden was high and MDA administered to highly endemic counties province-wide, and 2000 to 2009, when malaria burden was low and a focal approach was used in two counties. All available data about the strategies implemented, MDA coverage, co-interventions, incidence, and adverse events were collected and described. Joinpoint analysis was used to describe trends in incidence and the relationship between MDA coverage and incidence was explored in negative binomial regression models., Results: From 1973 to 1983, MDA with pyrimethamine and primaquine was used on a large scale, with up to 30 million people in target counties covered in a peak year (50% of the total population). Joinpoint analyses identified declines in annual incidence, -56.7% (95% CI -75.5 to -23.7%) from 1973-1976 and -12.4% (95% CI -24.7 to 2.0%) from 1976-1983. Population average negative binomial models identified a relationship between higher total population MDA coverage and lower monthly incidence from 1973-1976, IRR 0.98 (95% CI 0.97 to 1.00), while co-interventions, rainfall and GDP were not associated. From 2000-2009, incidence in two counties declined (annual change -43.7 to -14.0%) during a time when focal MDA using chloroquine and primaquine was targeted to villages and/or individuals residing near passively detected index cases (median 0.04% of total population). Although safety data were not collected systematically, there were rare reports of serious but non-fatal events., Conclusions: In Jiangsu Province, China, large-scale MDA was implemented and associated with declines in high P. vivax malaria transmission; a more recent focal approach may have contributed to interruption of transmission. MDA should be considered a potential key strategy for malaria control and elimination.

Malaria-eliminating countries achieved remarkable success in reducing their malaria burdens between 2000 and 2010. As a result, the epidemiology of malaria in these settings has become more complex. Malaria is increasingly imported, caused by Plasmodium vivax in settings outside sub-Saharan Africa, and clustered in small geographical areas or clustered demographically into subpopulations, which are often predominantly adult men, with shared social, behavioural, and geographical risk characteristics. The shift in the populations most at risk of malaria raises important questions for malaria-eliminating countries, since traditional control interventions are likely to be less effective. Approaches to elimination need to be aligned with these changes through the development and adoption of novel strategies and methods. Knowledge of the changing epidemiological trends of malaria in the eliminating countries will ensure improved targeting of interventions to continue to shrink the malaria map., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Countries in the Asia Pacific region are making substantial progress toward eliminating malaria, but their success stories are rarely heard by a global audience. "Malaria 2012: Saving Lives in the Asia-Pacific," a conference hosted by the Australian Government in Sydney, Australia from October 31 to November 2, 2012, will provide a unique opportunity to showcase the region's work in driving down malaria transmission. One of the features of Malaria 2012 will be the Asia Pacific Malaria Elimination Network (APMEN), which has focused on harnessing the collective experiences of 13 countries through regional political and technical collaboration since its inception in 2009. Run by country partners, APMEN unites a range of partners - from national malaria programmes and academic institutions to global and regional policymaking bodies - to support each country's malaria elimination goals through knowledge sharing, capacity building, operational research and advocacy.

Background: Policy makers have speculated that one of the economic benefits of malaria elimination includes increases in foreign direct investment, particularly tourism., Methods: This study examines the empirical relationship between the demand for travel and malaria cases in two countries with large tourism industries around the time in which they carried out malaria-elimination campaigns. In Mauritius, this analysis examines historical, yearly tourist arrivals and malaria cases from 1978-1999, accounting for the background secular trend of increasing international travel. In Dominican Republic, a country embarking upon malaria elimination, it employs a time-series analysis of the monthly, international tourist arrivals from 1998-2010 to determine whether the timing of significant deviations in tourist arrivals coincides with malaria outbreaks., Results: While naïve relationships exist in both cases, the results show that the relationships between tourist arrivals and malaria cases are relatively weak and statistically insignificant once secular confounders are accounted for., Conclusions: This suggests that any economic benefits from tourism that may be derived from actively pursuing elimination in countries that have high tourism potential are likely to be small when measured at a national level. Rather, tourism benefits are likely to be experienced with greater impact in more concentrated tourist areas within countries, and future studies should seek to assess these relationships at a regional or local level.

Background: Sri Lanka has a long history of malaria control, and over the past decade has had dramatic declines in cases amid a national conflict. A case study of Sri Lanka's malaria programme was conducted to characterize the programme and explain recent progress., Methods: The case study employed qualitative and quantitative methods. Data were collected from published and grey literature, district-level and national records, and thirty-three key informant interviews. Expenditures in two districts for two years--2004 and 2009--were compiled., Findings: Malaria incidence in Sri Lanka has declined by 99.9% since 1999. During this time, there were increases in the proportion of malaria infections due to Plasmodium vivax, and the proportion of infections occurring in adult males. Indoor residual spraying and distribution of long-lasting insecticide-treated nets have likely contributed to the low transmission. Entomological surveillance was maintained. A strong passive case detection system captures infections and active case detection was introduced. When comparing conflict and non-conflict districts, vector control and surveillance measures were maintained in conflict areas, often with higher coverage reported in conflict districts. One of two districts in the study reported a 48% decline in malaria programme expenditure per person at risk from 2004 to 2009. The other district had stable malaria spending., Conclusions/significance: Malaria is now at low levels in Sri Lanka--124 indigenous cases were found in 2011. The majority of infections occur in adult males and are due to P. vivax. Evidence-driven policy and an ability to adapt to new circumstances contributed to this decline. Malaria interventions were maintained in the conflict districts despite an ongoing war. Sri Lanka has set a goal of eliminating malaria by the end of 2014. Early identification and treatment of infections, especially imported ones, together with effective surveillance and response, will be critical to achieving this goal.

Objective: To compare the costs and performance of the NHS with those of an integrated system for financing and delivery health services (Kaiser Permanente) in California., Methods: The adjusted costs of the two systems and their performance were compared with respect to inputs, use, access to services, responsiveness, and limited quality indicators., Results: The per capita costs of the two systems, adjusted for differences in benefits, special activities, population characteristics, and the cost environment, were similar to within 10%. Some aspects of performance differed. In particular, Kaiser members experience more comprehensive and convenient primary care services and much more rapid access to specialist services and hospital admissions. Age adjusted rates of use of acute hospital services in Kaiser were one third of those in the NHS., Conclusions: The widely held beliefs that the NHS is efficient and that poor performance in certain areas is largely explained by under investment are not supported by this analysis. Kaiser achieved better performance at roughly the same cost as the NHS because of integration throughout the system, efficient management of hospital use, the benefits of competition, and greater investment in information technology.

During the course of the past ten years, the World Bank has become the single largest external financier of health activities in low and middle income countries and an important voice in national and international debates on health policy. This article highlights the Bank's new strategic direction in the health sector aimed at: improving health, nutrition, and population outcomes of the poor; enhancing the performance of health care systems; and securing sustainable health care financing. Millions of preventable deaths and treatable illnesses, together with health systems that are inefficient, inequitable and ineffective, have motivated expanded Bank support for the health sector in many of its client countries. The new policy directions and system-wide reforms observed in these countries are the result of both demand and supply factors. It is part of a general shift in the Bank's approach to development assistance, which sees systemic reform as a way to improve the impact and sustainability of investments in health. On the demand side, the Bank is trying to adapt to ongoing political, technological, economic, demographic, epidemiological and social pressures. On the supply side, the Bank's growing international experience and substantial financial resources are used to complement the development assistance provided by other organizations and the global effort to improve health and health systems in low and middle income countries.

Adults, defined here as people between 15 and 59 years of age, in developing countries have a high risk of premature death and suffer from frequent morbidity and high rates of chronic impairment. Their ill health imposes a major burden on health services and large negative consequences on families, communities, and societies. This paper describes the level and impact of adult mortality and morbidity, and highlights some of its characteristics and causes, which in some cases contradict commonly held beliefs. It concludes that "adult health" is a legitimate public health concern for developing countries that is not being addressed. An agenda for remedial research and action is proposed.

A case-control study of environmental and behavioural risk factors for childhood diarrhoea was conducted in Kurunegala district, Sri Lanka. From five hospitals, 2458 children aged less than 5 years and suffering from diarrhoea were recruited as clinic cases, and a further 4140 reporting with complaints other than diarrhoea were recruited as clinic controls. Community-based cross-sectional surveys were also conducted in three of the five areas served by these hospitals, and from these a further 1659 children were recruited as community controls. Children from households where excreta were reported to be disposed of in a latrine were less likely to have diarrhoea than children whose families improperly disposed of excreta. The results obtained from comparisons of cases with clinic controls (adjusted odds ratio [OR] 1.42, 95% confidence interval [CI] : 1.01-1.98), and of cases with community controls (OR 1.35, 95% CI : 0.85-2.13) were in agreement, suggesting that no important selection bias operated on this association. If the observed proportion (91%) of improper excreta disposal among the population could be reduced to 50%, 12% of childhood diarrhoea episodes would be prevented. Although latrine ownership may be a necessary condition for safe excreta disposal behaviour, diarrhoeal morbidity may only be reduced in Sri Lanka if behavioural changes take place concomitant with the construction of sanitation facilities.

The impact of improved sanitation on the anthropometric status of children under 5 years in Lesotho was investigated using children recruited into a case-control study of diarrhoea morbidity. The children's height-for-age Z-scores were used as an indicator of chronic undernutrition. Classifying children as 'stunted' or 'adequately nourished' revealed some evidence of an association between latrine ownership and attained height. After allowing for confounding variables, the odds of stunting were 18 per cent lower among children in households with latrines (95 per cent confidence interval, 36 per cent lower to 3 per cent higher). More powerful analyses, using height-for-age as a continuous outcome variable, revealed that the mean height-for-age Z-score of children from households with a latrine was 0.27 standard deviations higher than that of children from households without a latrine (95 per cent c.i. = 0.12 to 0.42). These results suggest that the anthropometric status of children may be as responsive to improvements in sanitation facilities as diarrhoea morbidity in some settings.

The impact of a water, sanitation and hygiene education intervention project on diarrhoeal morbidity in children under 5 years old was evaluated in a rural area of Bangladesh. Data were collected throughout 1984-1987, covering both pre- and post-intervention periods, from an intervention and a control area. The 2 areas were similar with respect to most socio-economic characteristics and baseline levels of diarrhoeal morbidity. The project showed a striking impact on the incidence of all cases of diarrhoea, including dysentery and persistent diarrhoea. By the end of the study period, children in the intervention area were experiencing 25% fewer episodes of diarrhoea than those in the control area. This impact was evident throughout the year, but particularly in the monsoon season, and in all age groups except those less than 6 months old. Within the intervention area, children from households living closer to handpumps or where better sanitation habits were practised experienced lower rates of diarrhoea. These results suggest that an integrated approach to environmental interventions can have a significant impact on diarrhoeal morbidity.

Between January 1987 and March 1988 a Health Impact Evaluation (HIE) of the Rural Water Supply and Sanitation Project (RWSSP) was conducted in Kurunegala District. Four related activities were undertaken: 6598 children were recruited into a case-control study of diarrhoea morbidity conducted in five hospitals; an additional 1649 children from the catchment areas of three of the five hospitals were recruited as a community comparison group; environmental microbiology was performed on water samples collected during 3092 visits to the homes of children recruited into the study; diagnostic stool microbiology was performed for 371 children with diarrhoea and 121 controls. In this paper the seasonality of reported diarrhoea and the socio-demographic characteristics and health-related behaviours of each study group are examined. Cases, clinic controls and the community comparison group were all drawn from the essentially rural settlements typical of the southern part of the dry zone of Sri Lanka. The majority of households in these settlements are Sinhalese buddhist, and the main economic activity is subsitence farming. There was some evidence of differences between the three groups, community recruits tending to come from larger and wealthier households than the children recruited at the hospitals. Issues arising in the design and analysis of this Health Impact Evaluation are discussed. In particular, potential sources of bias are examined and the question of validity investigated.

Morbidity due to dracunculiasis (guinea worm disease) and diarrhoea in persons of all ages, and nutritional status of young children, were used as health impact indicators in the evaluation of the Imo State Drinking Water Supply and Sanitation Project in south-eastern Nigeria. Data were collected using repeated cross-sectional surveys and longitudinal follow-up. The study area was found to have a low level of endemicity of dracunculiasis. While no impact could be demonstrated on overall period or point prevalence rates in the cross-sectional surveys, a prospective longitudinal survey showed a significant reduction in the percentage of person-fortnights positive for dracunculiasis in areas served by the project, while the control areas showed no such change. In the cross-sectional surveys it was found that, in the project villages, those persons drinking only borehole water had significantly lower period prevalence rates one year later than others. Moreover, those living further from the nearest borehole had higher rates of dracunculiasis. An impact of the project on diarrhoea morbidity was found only in limited sub-groups of the population. A greater association with water availability rather than quality was suggested for rates in young children. The prevalence of wasting (less than 80% weight-for-height) among children aged less than 3 years decreased significantly over time in all 3 intervention villages; there was no such decline in the control villages.

Between January 1987 and March 1988 a case-control study of the impact of improved water sources on childhood diarrhoea was conducted in Kurunegala District, Sri Lanka. Two thousand four hundred and fifty eight cases of diarrhoea were recruited at five of the hospitals in the district. Another 4140 children presenting at the same hospitals with complaints other than diarrhoea were recruited as controls. Data from the five hospitals suggest that children in households drawing their drinking water from handpumps suffer 46% fewer episodes of diarrhoea than children in families using unprotected traditional sources (95% c. i. 29-59%), while children in families using protected traditional wells suffer 35% fewer episodes than children in families using unprotected traditional sources (95% c. i. 27-41%). There were, however, substantial differences between the different hospitals. Among children recruited at one of the hospitals, the reduction in diarrhoea rates associated with the use of improved sources was estimated to be 93% compared with an average of 18% for the other four hospitals. In common with other case-control studies conducted in Malawi and the Philippines, little evidence of confounding of the association between diarrhoea and water supply was observed. Our results suggest that, in Sri Lanka, the use of improved water supplies, including protected traditional wells, rather than unprotected traditional sources may lead to a substantial reduction in diarrhoea morbidity among children under five years of age.

A health impact evaluation was conducted in conjunction with the Imo State Drinking Water Supply and Sanitation Project in Nigeria. The project consisted of a package of water supply, sanitation, and health and hygiene education given by village-based workers. The evaluation was a quasi-experimental study covering pre-, peri- and post-intervention periods. Data were collected from 3 intervention and 2 control villages. Baseline surveys indicated that the intervention and control areas were similar with respect to most socio-demographic variables. Use of the improved water supply was high, although this was influenced by borehole-to-population ratios and household-to-borehole distances. Water collection time was consequently greatly reduced. Data from a small sample of households showed that borehole water became heavily contaminated during collection and storage, and that there was no significant change in consumption of water per person. Adults in 46% of household units in the intervention area were using ventilated improved pit latrines by the end of the study period. Use by young children (2-5 years old), however, was low. Limitations in the success of the health education component of the project were found. Although changes were found in knowledge, attitudes and practices related to water and sanitation, and in management of childhood diarrhoea, this occurred in both the intervention and control areas.

A health impact evaluation of the Rural Sanitation Pilot Project in Mohale's Hoek district, Lesotho, was conducted from October 1987 to September 1988. A clinic-based case-control design was used to investigate the impact of improved sanitation on diarrhoea morbidity in young children. The results indicate that under-5-year-olds from households with a latrine may experience 24% fewer episodes of diarrhoea than such children from households without a latrine (odds ratio = 0.76; 95% confidence interval, 0.58-1.01). The impact of latrines on diarrhoea was greater in those households that used more water, practised better personal hygiene, and where the mothers had a higher level of education or worked outside the home. In common with studies conducted in Malawi, Philippines, and Sri Lanka, little evidence was found that the relationship between latrine ownership and diarrhoea was confounded by socioeconomic status or environmental variables. For a sample of cases and controls, data on exposure status (presence or absence of a latrine) that were collected by interview at the clinics agreed closely with those obtained by observation during a home visit.