Sustaining malaria elimination requires a whole new approach

This blog was originally published on Global Health Otherwise.

Eliminating malaria is not the same as controlling it. The tools, systems and mindset required are fundamentally different.

Uganda is a country that acknowledges this fact. Uganda’s new Malaria Elimination Strategic Plan (UMESP 2026-2030) starts from a simple but important recognition: The strategies that reduce malaria burden are not sufficient on their own to reach and sustain elimination. The goal is lofty: by 2030, zero malaria deaths and a 75 percent reduction in malaria cases, and at least 19 districts to reach pre-elimination status.

And ambition is needed: Uganda continues to bear a disproportionate share of the global burden, ranking as the third highest contributor to malaria cases and tenth for malaria deaths worldwide. The disease also places a major economic strain on the country, costing an estimated USD 577 million annually in treatment and lost productivity, and accounting for between 30 and 50 percent of outpatient visits.

Uganda has demonstrated that scale works; the challenge now is different. It recognises that the malaria transmission dynamics between the parasite, vector and human host/ human behaviours is situated within health systems, ecological zones and socioeconomic ecosystems. 

The analysis underpinning UMESP told us some hard truths

First, that elimination is fundamentally a last-mile problem. As transmission falls, progress depends less on tools reaching communities, and more on whether people and systems act correctly, consistently and quickly, often for risks that are no longer visible. A missed fever, an unreported case, a delayed response — these are small failures with very large consequences.

Second, performance gaps at this stage are rarely about knowledge or policy. They arise where health workers are overloaded, incentives are misaligned, data exists but arrives too late for action or communities no longer perceive malaria as an immediate threat. These are system and behavioural challenges, not technology gaps.

Third, that sustaining elimination requires shifting from episodic success to institutionalised excellence: in surveillance, response, decision making, financing and accountability. That shift cannot be imported — it must be built from within.

The transition from elimination to preventing reintroduction

Although Uganda has made gains in reducing its malaria burden — between 2009 and 2019, parasite prevalence in children under five fell from 45 percent to just 9 percent — elimination is never enough. 

Elimination status may be compromised by even a single undetected case. Therefore, it is essential to establish comprehensive surveillance systems that support informed decision-making. Effective systems should ensure prompt case identification, efficient data transmission, defined triggers for response and feedback mechanisms that are consistently followed through. 

It requires investing in social behavioural change. As malaria becomes less visible, motivation weakens; health worker behaviour, community norms and trust in systems becomes decisive in elimination settings.

Finally, supporting operations at a sub-national level is crucial; districts, facilities and community service delivery points are where elimination can be won or lost. 

This strongly aligns with the “Big Push Against Malaria” initiative, which recognizes that malaria eradication is not solely a technical goal, but a systems, governance, financing, and behavioural challenge requiring coordinated, country-led action. By emphasizing trusted institutions, responsive surveillance, community ownership, sustainable financing, and long-term political commitment, the statement reinforces the Big Push vision of protecting hard-won gains, strengthening resilient health systems, and advancing anticipatory, locally grounded, and sustainable malaria elimination efforts.

From burden reduction to sustained elimination: a new model for Africa

Uganda matters not only because of its malaria burden, but because of what it represents.

If elimination — sustained elimination — can be achieved in Uganda, it will send a powerful signal across Africa. It will demonstrate that progressive elimination is possible even in complex, high burden settings. It will also generate lessons that matter far beyond national borders. 

Malaria elimination is not a technical finish line. It depends on trust, discipline, learning and collective action.

From Uganda to the world

Uganda represents one of Africa’s most important test cases for malaria elimination. Despite major progress in reducing malaria burden over the past decade, the country continues to face complex transmission dynamics, health systems pressures, and behavioural challenges. Uganda’s new elimination strategy importantly recognizes that sustaining elimination requires far more than scaling interventions — it demands stronger surveillance, community trust, responsive systems, institutional accountability, and a fundamental shift from burden reduction toward long-term resilience and prevention of reintroduction.