Background
WHO uses evidence-informed processes to develop policy guidance to control malaria. The most robust evidence comes from randomized controlled trials (RCTs), although information from a range of study designs may feed into the policy-making process. RCTs generate evidence under tightly controlled conditions, which has led to some malaria policies being overly prescriptive, stipulating that interventions should only be deployed in conditions matching those in the RCTs. The net result is that malaria control efforts may be overly constrained by the way that policy guidance is currently formulated.
From 17–18 September 2019, WHO held an informal consultation to explore the advisability of moving to a new approach that draws on the transferability of study findings to inform policy recommendations. Key outcomes of the consultation included the identification of common themes and recommendations to prioritize for early review; identification of principles to apply when considering the modification or broadening of existing recommendations, or the development of new recommendations that extend beyond available evidence; and the development of a consensus statement.
Statement by the Malaria Policy Advisory Committee (MPAC)
The past 15 years have seen a substantial decline in malaria cases and deaths following the scaling up of essential malaria control interventions, driven by increased investment and reduced commodity costs. This decline has resulted in increased heterogeneity in malaria burden, which demands the effective use of limited resources and a better targeting of interventions.
To achieve their malaria control targets, countries are working to develop detailed national strategic plans with robust stratification and tailored mixes of interventions at the subnational level, adapted to the local context and available resources. While the overall goal remains universal coverage with an appropriate mix of interventions for all populations at risk of malaria, there is broad recognition that, in many cases, available resources are insufficient to fund all elements of these national strategic plans; in these cases, countries are required to make difficult choices. The process of stratification and defining appropriate intervention mixes for each stratum requires additional data and, in turn, increased investment in the collection of routine data and surveillance systems.
MPAC agrees with the consensus statement that emerged from the WHO consultation, with some minor modifications:
- Intervention prioritization should not be driven solely by sequentially optimizing single interventions for maximal coverage.
- Instead, intervention prioritization should be based on local evidence and aligned to the specific needs of different epidemiological strata/settings, as defined in the country’s national strategic plan.
This new data-driven approach moves away from a one-size-fits-all perspective driven by the national strategic plan. It will be critical that countries monitor and document the impact of these stratified approaches through enhanced surveillance, both to learn from the process and to identify and rapidly mitigate potential problems.
MPAC appreciates the concept of “universal coverage” in striving to save lives, reduce disease and ultimately eradicate malaria. The Committee encourages countries to work towards universal coverage of the right mix of interventions, recognizing that coverage of individual interventions will vary by setting.
MPAC calls on the WHO Global Malaria Programme Secretariat to support countries in this prioritization exercise. Country programme funders are encouraged to embrace the flexibilities and additional data required to optimize the allocation of limited resources for maximum impact.
This statement is extracted from the October 2019 Malaria Policy Advisory Committee meeting report.