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Rethinking district-level governance of malaria in Ghana: A narrative review

* E-mail: [email protected]

Affiliation Consultant, Accra, Ghana

• Nii Ayite Coleman

Published: July 13, 2022

• https://doi.org/10.1371/journal.pgph.0000764
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The goal of global malaria programming is to eliminate and eventually eradicate the disease. Achieving this global goal requires eliminating malaria in individual endemic countries. This paper, based on the observations of current and former implementers of malaria programs at district level, examines Ghana’s malaria strategy to determine its adequacy for the elimination of malaria in the country, with a focus on the governance of district health systems. The paper argues that Ghana’s malaria strategy is medically oriented, focusing predominantly on diagnosis and treatment of the disease. The strategy ignores determinants of malaria that are related to lifestyle and environment. Furthermore, there is limited engagement with other district-level stakeholders, and what engagement does occur is neither systematic nor sustained. Ghana’s malaria strategy therefore requires a systematic rethinking to mobilize the participation of communities in district governance for malaria. The paper proposes several possible actions to restructure district governance of malaria. In Ghana, the malaria program should engage with key stakeholders in districts, using a systematic and sustained approach, to strengthen multisectoral action and community participation. This will require new accountability relationships for malaria progress within communities and among District Assemblies, district health authorities, and communities. Malaria programs in other African countries may also need to be similarly redirected towards community health governance for malaria progress. Simultaneously, global health and malaria agencies should redefine malaria as a social problem and collectively adopt a social determinants approach to strengthening national malaria programs. Pursuing the goals of elimination and eventual eradication of malaria without incorporating effective control of mosquito breeding and public health regulation is a fundamentally flawed approach. Progress on malaria requires a paradigm shift, from a medical perspective to a social determinant-informed approach with sustained and systematic engagement of all stakeholders in local communities.

Citation: Coleman NA (2022) Rethinking district-level governance of malaria in Ghana: A narrative review. PLOS Glob Public Health 2(7): e0000764. https://doi.org/10.1371/journal.pgph.0000764

Editor: Dmitri Nepogodiev, University of Birmingham, UNITED KINGDOM

Copyright: © 2022 Nii Ayite Coleman. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: Support for this global engagement was provided by Harvard University’s Defeating Malaria: From the Genes to the Globe Initiative and the Takemi Program in International Health at the Harvard T.H. Chan School of Public Health. Additional grant support was received from the Bill & Melinda Gates Foundation (INV-032429) and the JC Flowers Foundation. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The author have declared that no competing interests exist.

Introduction

Primary health care (PHC) is the cornerstone of health development in Ghana and the key mechanism for attaining universal health care coverage in the country. Among its many components, PHC includes essential health services, health education, immunizations, prevention and control of locally endemic diseases, and the provision of essential drugs. Furthermore, it is supposed to be “made universally accessible with the full participation of the community” [ 1 ]. The WHO has emphasized this point:

Measures have to be taken to ensure free and enlightened community participation, so that notwithstanding the overall responsibility of governments for the health of their people, individuals, families, and communities assume greater responsibility for their own health and welfare, including self-care…. Governments, institutions, members of health professions as well as all agencies involved in health and development, will therefore have to take measures to enlighten the public in health matters so as to ensure that people can participate individually and collectively, as part of their right and duty, in the planning, implementation and control of activities for their health and related social development [ 2 ].

The concept of participation has been further elaborated into a focus on community health governance. As national health systems and global health programs strive to improve the performance of their interventions, health systems governance is receiving increasing attention. The proliferation of work on health systems governance over the past decade is based on the expectation that good governance ultimately leads to better health outcomes [ 3 ]. Building on the PHC “village health committee” model, community health governance is understood to include all stakeholder groups in the community and encompasses accountability. Community health governance nurtures accountability relationships between the entire spectrum of stakeholders in the community and thereby engenders better district health systems governance.

The concept of governance is universal in communal contexts such as families, clans, villages, associations, companies and nation-states. In each communal context, representatives are chosen to act on behalf of the collective [ 4 ]. The domain of governance can be considered the relationships between the representatives and the represented aimed at ascertaining responsive and effective action in the interests of the collective. There are multiple detailed definitions of governance. Lehman and Gilson’s definition emphasizes the multidimensional nature of governance, stating that governance entails: “ensuring that strategic policy frameworks exist and are combined with effective oversight, coalition building, regulation, attention to system-design and accountability” [ 4 ]. In practice, governance of a country is dependent on the political arrangements at national level, often enshrined in a national constitution, that define the relationship between the government and the governed. In Ghana, constitutional arrangements for national governance form the basis for governance in all sectors of the economy, including health [ 5 ]. It also defines arrangements for sub-national levels, including the district level [ 6 ]. Governance is also recognized as a key element that facilitates the functioning of the health care sector. In health, as in many other sectors, governance is not just a top-down function but needs to be operationalized by individuals at all levels in the health system. In this case, the importance of governance in district (or similar level) health systems is increasingly being recognized as crucial to the achievement of universal health care coverage as well as sustained improvements in the performance of health interventions and outcomes, including malaria [ 7 ].

This paper explores the challenges and opportunities inherent in the district-level governance of malaria interventions in Ghana. First, it presents an overview of Ghana’s malaria strategy and assesses the nature and scope of the malaria program’s engagement with district- and lower-level communities, authorities, and other stakeholders. Second, it considers the relationships between and within stakeholder groups in the district. Then it discusses the challenges of district health system governance to the implementation of the malaria program. The paper concludes by making suggestions to facilitate improvement in the governance of the district health system in Ghana and comments on the implications of this situation for other malaria-endemic countries.

The paper was prepared for the governance working group of the “Rethinking Malaria in the Context of COVID-19” process convened by Harvard University (see: https://www.defeatingmalaria.harvard.edu/rethinking-malaria/ ). I was tasked by the working group to draw on my 34-year career serving in the Ministry of Health in Ghana at district, regional, and national levels to provide observations on district-level governance of malaria programming. I have worked as a medical provider at district hospitals, a District Medical Officer of Health, a Regional Director of Health Services, and as Director of Policy, Planning, Monitoring and Evaluation of the Ministry of Health. I also served as the Director of the Accra Metropolitan Public Health Department. In preparing the paper, I solicited the viewpoints of malaria program implementers by interviewing four individuals who all worked in one district. The interviewees were: a regional coordinator for the malaria program, a District Assembly malaria focal point person, a District Assembly public health official, and the medical superintendent of a hospital in the district. The interviewees included two men and two women; of these, one was early career, two were mid-career and one was retired. During the semi-structured interviews, I asked each participant to reflect on the malaria situation in the district, the roles of their institutions and other stakeholders in combating malaria, the key challenges faced, and their ideas for addressing the identified challenges. I reflected on these comments and integrated their views with my observations. (The interviews are cited as “personal communication” in the paper to maintain the interviewees’ anonymity.) A literature search was conducted in two databases (PubMed and Web of Science) using the search terms “Ghana”, “district”, “governance” and “malaria”. However, no directly relevant papers were found. All published documents used as sources in preparing this paper are cited. The findings and commentaries presented herein are based on triangulating policy documents and the observations and experiences of malaria program implementers.

Ghana’s malaria strategy

Ghana is classified as being in the malaria “control” phase. Malaria-specific mortality among children less than 5 years old has declined from 14.4% in 2000 to 0.6% in 2012. The same level of success, however, has not been achieved with malaria morbidity [ 8 ].

A review of Ghana’s national malaria strategy was conducted in 2013. Based on recommendations from the review report [ 9 ], as well as various new interventions emerging at the global level, Ghana’s National Malaria Control Program developed the National Malaria Control Strategic Plan for 2015–2020, which was published in August 2014. [ 9 ] The plan’s overall aim was to reduce the country’s malaria morbidity and mortality burdens by 75% by the year 2020 (using 2012 as baseline). Specific objectives included [ 10 ]:

• To protect at least 80% of the population at risk with effective malaria prevention interventions by 2020.
• To provide correct diagnosis to all suspected malaria cases and prompt and effective treatment to 100% of confirmed malaria cases in accordance with treatment guidelines by 2020.
• To strengthen and maintain the capacity for program management, partnership, and coordination to achieve malaria programmatic objectives at all levels of the health care system by 2020.
• To strengthen the systems for surveillance and monitoring and evaluation in order to ensure timely availability of quality, consistent and relevant malaria data at all levels by 2020.
• To increase awareness and knowledge of the entire population on malaria prevention and control so as to improve uptake and correct use of all interventions by 2020.

In general, the strategic plan sought to consolidate gains, accelerate malaria control in high transmission areas, and move towards establishing lower-transmission areas in Ghana by the end of 2020 [ 11 ]. The strategy and the program overall are both dominated by a medical approach–that is, malaria is viewed as a disease requiring treatment in a health care facility.

Using a medically-oriented approach to malaria is, in my opinion, a serious mistake that will result in keeping Ghana in the malaria control phase. It is an inadequate strategy if the goal is to achieve elimination and eradication of malaria. Malaria is more than a medical problem; it is also a social problem directly influenced by social determinants including lifestyle and environmental factors [ 12 ]. Indeed, malaria is as much an outcome of environmental and lifestyle factors that result in poor sanitation and lack of infrastructure as it is of insufficient knowledge or lack of access to health care. One result of focusing only on malaria as a health care problem is uncontrolled mosquito breeding that leads to extensive human exposure to the vector in communities. Malaria therefore cannot be eliminated without eliminating major mosquito breeding sites. To pursue malaria elimination in Ghana necessitates addressing mosquito breeding in every community. Setting a goal of elimination, and eventually of eradication, of malaria without including effective control of mosquito breeding and public health regulation as a key component of the strategy is fundamentally flawed. Elimination of malaria requires a paradigm shift from a medical perspective to a social determinant approach. A social determinant approach to malaria would engender sustained and systematic engagement with the full spectrum of stakeholders in every community.

Although Ghana’s national malaria strategy states an intention to increase the population’s awareness and knowledge about malaria prevention and control [ 9 ], in practice the malaria program’s engagement with stakeholders has been constrained by its overall orientation towards medical interventions. For example, the Social and Behavior Change Communication (SBCC) Strategy for the National Malaria Control Programme has a limited scope of activities focused mostly on national and regional mass media campaigns [ 13 ]. Interpersonal communication activities conducted at facilities and in communities focus on adherence to national case management guidelines and prompt health care-seeking. School-based interpersonal communication activities, conducted in tandem with distribution of Insecticide-Treated Nets (ITNs), focus mostly on correct and consistent use of ITNs and ITN care practices. The communication strategy included focusing on “advocating to political leaders, policy makers, opinion leaders and corporate bodies for support for malaria control” and “sustaining communication, education, and community mobilization to increase knowledge among the general population to enhance uptake of malaria prevention interventions” [ 13 ]. However, these activities rarely, if ever, address community-based social and environmental strategies for malaria elimination. Ghana should be supporting districts to design and implement these strategies at the district level.

District-level engagement in malaria interventions

Ghana, a parliamentary democracy, has 16 administrative regions that are further sub-divided into 216 districts. Each of these is governed by a District Assembly. Community mobilization on health is predominantly implemented through the District Health Service, and engagement with stakeholders (such as health care providers, community organizations, local leaders, the private sector and others) should be carried out by the District Health Management Team (DHMT). The Ghana Health Service and Teaching Hospitals Act (Act 525) of 1996 also made provision for a certain degree of engagement with some stakeholder groups through the creation of a District Health Committee [ 6 ]. Section 23 of the Act establishes a District Health Committee with representation from the District Health Service, the District Assembly, local religious and traditional leadership, and health care workers from the public and private sector. It also specifies that at least one of the minimum two community representatives is a woman. The core function of this District Health Committee is essentially advisory. Section 24 (1) of the Act says: “A District Health Committee shall advise the District Director of Health Service in the performance of his functions in the district and shall perform such functions of the [Ghana Health Service] Council in the district as the Council may assign to it.” [ 6 ] According to interviewees and my experience, however, District Health Committees are not in place in all districts. As a result, district-level engagement with potential stakeholders is widely variable and often ad hoc.

Concerns about district-level engagement in health overall are amplified in the case of malaria. The national malaria program appears to have limited engagement with district health systems; furthermore, it has limited stakeholder participation in its programming. This results in the malaria program appearing to district-level stakeholders to be prescriptive and lacking accountability to its intended beneficiaries. A few examples: First, the malaria program is not perceived to be truly rooted in the communities. It is associated only with the implementation of certain specific activities, such as distribution of ITNs or larviciding. One person working as a “District Malaria Focal Person” recently acknowledged this, stating that they only engage stakeholders for specific activities. Instead of regular and sustained interactions with facilities, for example, the focus person noted that they only “deal with the hospital when there are any problems with data.” (Personal communication, 2021) Second, in some districts, focal point persons arrange for larviciding to be carried out by private companies without the full knowledge and participation of the Public Health Department of the District Assembly. (Personal communication, 2021)

This lack of effective engagement of stakeholders in the malaria program is partly related to the national strategy’s emphasis on medical solutions to malaria morbidity and mortality. It is also partly due to the rigidity of the program’s protocols. However, the context in each district is also important. In particular, the continued absence of District Health Committees (despite having been mandated in 1996) demonstrates a lack of institutional capacity that prevents the Ghana Health Service in general, and the national malaria program in particular, from truly engaging with a broad spectrum of stakeholders over the long term.

Concerns about national capacity and overly medicalized approaches to health problems are not new problems. In September 1976, Professor Comlan Quenum, addressing the WHO Regional Committee for Africa, said:

We can no longer consider health programs without reference to other sectors of socioeconomic development…. The myths of the past imposed a dichotomy between politics and health, a dichotomy between socioeconomic development plan and the health program, as if health, which is essentially a social sector, could be dissociated from the national will expressed through a particular political choice.…We must also devise new procedures for strengthening health services. This requires a special effort to make the most of local resources, particular manpower. It is fair to say that there can be no development without using all human resources to full advantage, i.e. without material and cultural development of the people as a whole. Regrettably, the existing health delivery systems exclude the communities concerned; their health and their environment can be improved only if they play an active part in the systems organized for that purpose. That is why all our future efforts must be aimed at enlisting authentic community participation so as to help its members become aware of their needs and to encourage them to cooperate in finding solutions and managing services. [ 1 ]

These words still ring true over 40 years later with respect to malaria. The elimination and eventual eradication of the disease require a more nuanced appreciation of malaria as a social problem and a call for a coherent community response. Although Ghana has yet to fully realize this, it does have many of the necessary structures in place. Now we need to recognize and organize them to make full use of all available resources in reducing the toll of malaria.

Relationships between and within stakeholder groups in the district

Various malaria stakeholder groups exist at the community and district levels in Ghana. Several types of stakeholder groups are already active in the communities, including households, youth organizations, women’s groups, religious organizations, elected local officials, and traditional leaders. Other key stakeholders are health care service providers, district health authorities, and the district assembly. This section describes how each of these stakeholder groups can and should be engaged in anti-malaria efforts.

Households and community-based organizations

Malaria is endemic in Ghana and every person living in the country is at risk of contracting it. Thus everyone in Ghana has an interest in the control, elimination, and eventual eradication of malaria. It is the number one killer of children and the leading cause of reported morbidity in the country. Households and local associations, such as women’s groups, youth organizations, and religious bodies, are frontline stakeholders in malaria in cities, towns and villages across the country.

Individuals and groups also often have other stakes in malaria besides self-interest. Civil society organizations, both indigenous and international, are growing in numbers and have emerged as an important stakeholder group representing the people whose voices are not being heard. For example, there is a National Coalition of NGOs in Health and a specific coalition of NGOs in malaria. Increasingly, civil society organizations are becoming active in the implementation of social programs, including to address malaria, in districts across the country. These efforts require support from the national program as well as from donors.

Health care service providers

Health care services in the district are provided at facilities with varying capabilities and owned by various groups including government, private and religious organizations. Public health care services are provided by the District Health Service (DHS), usually through a network of health centers, clinics, Community-based Health Planning and Services (CHPS) compounds and outreach centers, with a district hospital serving as a referral facility. This public network provides allopathic medical care and preventive medicine including maternal and child health services and immunization.

Allopathic medicine does not have a monopoly over the diagnosis and treatment of malaria. Indeed, a few district hospitals around the country are now also practicing herbal medicine. National legislation on traditional and alternative medicine has supported pluralism in health care delivery. As a result, although allopathic medicine is dominant, other forms of alternative medicine and health care practices are also increasingly available [ 14 ]. The production and use of traditional herbal preparations are growing, and traditional medical practitioners (such as Traditional Birth Attendants, herbalists, bone-setters, and spiritualists) are well patronized. All health practitioners, whether in allopathic or other traditions, should be fully supported to help their patients and communities to understand, prevent and treat malaria effectively.

District health authorities

The district health system is characterized by multiple care systems, varied ownership, and fragmented leadership. There is no single district health authority. Instead, the current legislation regime for districts mandates both a District Health Service (of the Ghana Health Service) and a Public Health Department (of the District Assembly). The health service’s District Health Management Team (DHMT) oversees health centers, clinics, CHPS compounds and outreach services, and the district hospital. The district hospital, under a medical superintendent, provide a range of basic health care services, including emergency surgery, blood transfusion and laboratory services. The Public Health Department (PHD) of the District Assembly, made up of health inspectors, is responsible for public health services, oversees sanitation and waste management, and enforces public health regulations [ 6 ]. In practice, district-level health leadership and governance is fractured into three core services: basic medical care and preventive medicine (under the DHMT), district hospital care under medical superintendent, and public health services under the PHD. Each has a different source of funding and interactions among them may be ad hoc. Yet malaria requires interventions by all three areas of health service, plus others in other sectors.

Traditional council

Traditional leaders—chiefs and their councilors—based in villages and communities are the frontline authorities. For the majority of Ghanaians, traditional leaders are regarded as representatives of the people in their respective towns and villages. Ghana’s traditional system of government predates colonialism [ 15 ]. For example, the Asante ethnic group has long had a highly organized system of government in place:

The Asantes were politically united under the Asantehene before colonial rule…At the side of the Asantehene stands the Asanteman Council, composed of paramount chiefs of the member states of the Asante confederacy. The paramount chiefs assist the Asantehene in his direction of the affairs of the Asante nation. The paramount chiefs also hold positions in their own states. As paramount chiefs of their states, they govern their people with a council comprised of elected representatives of the state. Similarly, sub-chiefs and village chiefs serve their smaller communities with the help of elected representatives from the local communities. Within these communities the town chief or village head serves the people as the leader of the community. But he consults with a council which is made up of the heads of the respective lineages who are resident in the village or the community. In other words the political structure of the Asante social system radiates the authority of the Asantehene through to the level of the extended family network. [ 16 ].

A version of this political system “remains in evidence today” in that the central government relies on chiefs to deal “with traditional matters” [ 16 ]. Traditional political authority is enshrined in Ghana’s constitution (Article 270 of the 1992 Ghana constitution) [ 5 ] and has been institutionalized in the Ministry of Chieftaincy Affairs. The Traditional Councils have strong stakes in the well-being and development of their people. The endorsement of chiefs, though informal, is important for the successful implementation of any public sector project or program in local communities. Strong support from traditional leadership is therefore critical to any effort to address malaria.

District assembly

Ghana’s current efforts at decentralization began in 1988 with the promulgation of PNDC Law 207. In 1992, Article 240 of the Ghana constitution further stipulated “a system of local government and administration which shall, as far as practicable, be decentralized” [ 5 ]. The Local Government Act of 1993 (Act 462) then sanctioned a body called the District Assembly (DA) to be responsible for overall development in the districts through the exercise of deliberative, legislative and executive powers [ 17 ]. The DA membership comprises two-thirds elected and one-third appointed members, and is headed by a District Chief Executive (DCE) appointed by the national President [ 5 ]. As one scholar noted, “The District Assemblies were to be the foundation on which Ghana’s new democracy was to be erected” [ 18 ].

The DA has two committees, the Audit and the Executive Committees. The Executive Committee (EC), which is headed by the DCE, serves as the cabinet. The EC has five statutory sub-committees: Finance and Administration, Development Planning, Social Service, Justice and Security, and Works. The role of the DA is to coordinate and oversee implementation of public programs by decentralized departments of the Public Service. The departments provide technical guidance and carry out the actual implementation of policies, projects and programs as mandated by the DA and the national Government. The DA also has locally-elected sub-district councils.

Coordination and oversight of social services is carried out by the Social Services Sub-Committee (SSSC) of the District Assembly. It comprises heads of district departments and agencies, including health, youth and sports, education, water, community development, physical planning, agriculture, disaster prevention and management, and social welfare. Beyond coordination, the SSSC also has a strategic function. It is expected to examine and collect data about the full range of social welfare concerns in the district, and to propose short-, medium- and long-term social development plans for the district for consideration by the DA. Clearly, malaria concerns should be a major focus for the SSSC.

The DA system overall has faced numerous challenges, of which “fiscal decentralization remains one of the most intractable problems” [ 18 ]. In essence, the absence of fiscal decentralization is a major roadblock in the evolution of decentralized governance in Ghana. The DA is funded through an irregular and unreliable District Assembly Common Fund and the meager local taxes it is able to collect. The DAs have severe budgetary constraints and thus lack effective control over departments and programs in their districts. Without meaningful fiscal decentralization, the decentralized departments of the DA are funded through their respective sector Ministries. As a result, district heads of departments and agencies have stronger “vertical” alliances—that is, to higher levels of their sectoral ministries—than they do to the District Assembly.

In practice, the absence of fiscal decentralization has paralyzed the DA, rendered the SSSC weak and ineffective, and made the DA and its sub-district structures (called zonal councils and unit committees) almost redundant in their communities. One particular result of the ineffectiveness of the SSSC is that locally-coordinated multisectoral action is incoherent. There is an absence of accountability relationships between and within the District Assembly, the district health authorities, and the communities.

The DA’s inability to effectively coordinate among decentralized departments poses a significant challenge to the malaria program (and other programs dependent on multisectoral collaboration). The fractured district health leadership and the complicated financing architecture of the district turn departmental programs into vertical programs, hampering the development of alliances and coalitions, and forestalling multi-sectoral collaboration.

Challenges of district health systems governance

Ghana’s administrative decentralization process has a long history. It began with efforts by the colonial administration to establish a local governance system. After an initial period of “Indirect Rule” through the Traditional Councils, disagreements over taxation and other issues between the colonial administration and the Traditional Councils led to the establishment of an alternative and parallel modern local government system; the 1944 Native Authority Ordinance neglected the traditional authorities and put the colonial administration in direct control of the localities [ 15 ].

Since Ghana achieved independence in 1957, its subsequent governments have focused on developing a local government system that is an appendage of the central government. Traditional political authority, though legitimate, has been marginalized in the national development agenda. As a result, traditional political authority and modern local government offer disparate political leadership at the community level—this impedes systematic local development. The existence of parallel traditional and modern political authorities presents formidable challenges that are evident in the complex relationships among three key sets of stakeholders: the DA, district health authorities, and communities.

Three key challenges emerge during interactions among the stakeholders.

• Fractured political leadership and unaccountable frontline workers The challenges of governing district health systems are inseparable from the burdensome challenges of local government reforms and decentralization in Ghana and the perennial journey “towards democratic local government structures, and accountable systems of public administration that are able to deliver on the developmental demands of the people” [ 18 ]. Traditional and modern political leadership both have constitutional legitimacy—and both have often failed to provide meaningful collective community leadership. The decentralization policy has left a gap in local governance by failing to create a working interface between traditional and modern political authorities at the community level. This, in turn, leaves frontline workers without clear areas of authority and lines of accountability. Malaria programs may not be able to function effectively without clear leadership and access to resources.
• Weak DAs and ineffective SSSCs hamper intersectoral collaboration, coordination and efficiency The DAs do not have strategic policy frameworks that foster multi-sectoral collaboration and coordination of the implementation of departmental programs. In lieu of an overall district development agenda, disparate projects and programs of the central government are implemented in isolation by various ministries, departments and agencies. The notion of a composite district budget, controlled by the DA and designed to meet the specific priorities and context of a given district, remains an idea that would require fiscal decentralization to become reality. In the absence of a district agenda in every district, there cannot be either coherent district health agendas or multisectoral district malaria agendas.
• Legal regime fractures district health leadership As noted, three components of the health system—medical care, preventive medicine and public health services—operate independently in districts without effective arrangements to foster sustained collaboration and coordination of health programs in the district. There is no joint planning for health in the district, and there is no district health strategy. As a result, the district health system does not “own” the malaria program, nor does it have the capacity to engage the full range of multisectoral stakeholders.

The way forward—For Ghana and in other endemic regions

Exploring the challenges of district health systems governance for malaria raises many bigger questions—about the relationship between central and district governance, about the political economy of global health, about local development and the delivery of social services, about health as a catalyst for community development, about the relationship between traditional political authority and modern political authority, and about the governing of community health. Such questions may seem intractable. However, devising strategies for effective community responses to malaria helps focus in on key issues.

In Ghana, it is clear that an effective approach to malaria control, and eventually to malaria elimination, requires establishing improved relationships between traditional and modern political authorities at the district level in Ghana. The constraints of stakeholder engagement encountered by the malaria program is an indication of the need for better governance of malaria in Ghana; the need for “the alignment of multiple actors and interests to promote collective action towards an agreed upon goal” of the malaria program [ 19 ]. Malaria control in Ghana has been managed by experts in the health sector. For the elimination and eradication of malaria, better governance of community health is essential. Bringing the various parties together to focus on malaria could both have a positive impact on reducing malaria morbidity and mortality further and could provide opportunities to delve into those other big questions.

In 2000, Ahwoi identified the need to promote popular participation by shifting processes of governance towards consultation, noting that:

The trends in Local Government Reforms and Decentralisation in Ghana today are quite clear. They are towards democratic local government structures and accountable systems of public administration that are able to deliver on the developmental demands of the people. There have been very positive achievements, but a lot also remains to be done. What we all ought to remember, however, is that decentralisation is a process, not an event. We must therefore not throw up our hands in despair when we confront obstacles. Ours is to devise strategies to overcome those obstacles [ 18 ].

Brinkerhoff and Bossert [ 20 ] identified four principles that could assist in changing the culture of governance of health systems. First, governance rules should ensure some level of accountability of the key actors in the system to the beneficiaries and the broader public. Second, health governance involves a policy process that enables the interplay of the key competing interest groups to influence policy making on a level playing field. Third, health governance requires sufficient state capacity, power, and legitimacy to manage the policy making process effectively. Finally, governance depends upon the engagement and efforts of non-state actors in the policy arena as well as in service delivery partnerships and in oversight and accountability.

Community health governance

A 2009 study noted that “Good governance in health requires the existence of standards, information on performance, incentives for good performance, and, arguably most importantly, accountability” [ 21 ]. Ackerman described accountability as “a proactive process by which public officials inform about and justify their plans of action, their behavior and results, and are sanctioned accordingly” [ 22 ]. District health systems governance should create accountability relationships between and within communities, district health authorities, and district political authorities. Effective governance of district health systems depends on better governance of community health in towns and villages in the district. Community health governance requires establishing accountability relationships between and within traditional leaders, elected local officials, civil society organizations, community-based organizations, and health care service providers. Community health governance offers the pathway to engaging all stakeholders in a systematic, sustained and dynamic manner.

For malaria, community health governance entails convening stakeholders in the community for several intersecting purposes: to determine what to do about mosquito breeding; to oversee activities to control mosquito breeding; to monitor progress in the control of mosquito breeding; to ensure the community has access to the diagnosis and treatment of malaria; to monitor the number of malaria cases and deaths from malaria; and to hold the malaria program staff and public officials (i.e., the District Assembly and the District Health Service) accountable. Community health governance would strengthen the mobilization and effective use of human and financial resources within the community and engender public-community partnership for health development, including malaria.

This notion of community health governance is clearly within the context of the national decentralization and development frameworks articulated in the Local Government Act of 1993 [ 17 ] and related subsidiary legislation, which aim to move “towards democratic local government structures, and accountable systems of public administration that are able to deliver on the developmental demands of the people” [ 18 ].

Ultimately, I argue for nurturing community health governance as an integrated component of the national malaria program. This supports a vision of communities with unified political leadership and established accountability relationships between community political leaders, civil society, and frontline service providers. Building these structures for malaria will benefit both malaria and other community health endeavors. To achieve the vision of community health governance, three key strategies are suggested, together with illustrative activities:

• Facilitate alliances between elected local officials (assembly, zonal council and unit committee members) and traditional leaders (chiefs and elders) in the communities to support and coordinate community malaria projects and programs, to oversee frontline malaria workers in the community, and to ensure efficient use of available resources
• Foster coalitions between community groups, religious groups, and other civil society groups
• Nurture community health governance by establishing accountability relationships between traditional and elected leaders, civil society, and frontline service providers
• Strengthen the SSSC’s capability to coordinate and oversee the implementation of malaria programs in the district through strategic and sustained technical support, continuing education, and logistical support
• Facilitate the development of a strategic policy framework for malaria and health
• Foster more unified leadership of the district health system through joint planning, monitoring of implementation and assessment of performance in malaria programs
• Recruit and develop DMOH for district health leadership
• Promote the development of district health and malaria strategies by bringing diverse components of the malaria program into a single district malaria implementation strategy with oversight from the SSSC of the DA

Given adequate institutional incentives, effective engagement can strengthen direct accountability relationships among communities, DAs and district health authorities [ 23 ].

In the medium term, improvement in some dimensions of malaria governance (such as coalition building, oversight and accountability) has the potential to enhance program implementation and result in better health outcomes. Effective community health governance has the capability to enhance the implementation of Ghana’s malaria program, to improve the chances of malaria elimination and eradication, and to engender community development.

District- and community-level health governance is the next logical step in the development of health systems in Ghana. The concept builds on the foundations of PHC policies and programs, community participation and village health committees, alongside the more recent development of district health systems. Community health governance is the mechanism to realize a true paradigm shift, from a medical orientation to a social determinants approach. Malaria would make an ideal test case for this. A paradigm shift to social determinants approach would enable a reorientation of how malaria is handled at the community, district, national and global levels.

This raises broader implications for consideration in Ghana, as well as in other African countries, and within the global malaria agencies. First, the Ghana malaria program must engage systematically and in sustained ways with key stakeholders in the districts in order to make progress towards elimination and eradication of the disease. This would require nurturing, fostering and facilitating alliances and coalitions among stakeholders and strengthening multisectoral action. The malaria program must invest in establishing accountability relationships within the communities and between the District Assembly, the district health authorities and the communities.

The analysis in this paper has some limitations due to its reliance on observations from a small number of interviewees in a single country and my personal experiences as a public health official during the past three decades. However, malaria programs in other African countries with similar governance systems may be able to learn from Ghana if it redirects towards community health governance. Similar district health systems exist in most former British colonies and decentralization is taking place in most of those countries. As a result, the specific country contexts for malaria programs are similar to what pertains in Ghana, making these proposals relevant and applicable.

Finally, improving malaria governance at the district level in African countries has implications for the governance of malaria at the global level. This analysis supports the necessity of rethinking “the malaria problem” by global malaria agencies. The continued high malaria burden is a fundamental problem for African societies. Malaria is a social problem, and an indicator of social underdevelopment, poor living standards, and unacceptable quality of life.

The urgent responses to the global COVID-19 pandemic should open the global policy window to enable consideration of fresh policy initiatives to more forcefully address the longstanding problem of malaria in Africa. Global malaria agencies must, as a matter of urgency and with unity of purpose, redefine malaria as a social problem and collectively adopt a social determinants approach to the development of national malaria programs.

Beyond opening the global policy window, COVID-19 also offers valuable lessons about strengthening local health systems and facilitating community organization in preparedness for the next pandemic. Redefining the malaria problem as a social one would expand the options for addressing the malaria problem beyond health care delivery to include community response. Strengthening district-level governance for malaria, however, will require additional research and understanding on a number of topics, as suggested in Box 1 , to help improve the evidence base on how to address malaria governance challenges in Ghana and beyond. With adequate institutional incentives, a community response initiative would facilitate the forging of relevant alliances and coalitions, engender the alignment of multiple stakeholders and interests to promote collective action, and lay the foundation for establishing community health governance. We may find a post-COVID-19 policy window that provides an opportunity to put community health governance on the global malaria policy agenda.

Topics for research on district-level malaria governance:

• Assess the coherence of national and district malaria elimination and control policies
• Assess the roles of community health committees in local malaria elimination efforts
• Identify effective approaches to strengthen accountability of malaria program to district stakeholders, including communities
• Define roles and relationships for the District Assembly, as a local democratic institution, and national malaria experts in setting district-level priorities and strategies for malaria
• Identify financing mobilization and management structures at community, district and national levels
• Identify effective strategies for cross-sectoral collaboration and strategic communications on malaria at the district level
• Identify effective approaches for mobilizing local authority figures (including traditional chiefs and medical practitioners) to support malaria elimination
• Assess the roles of women (and the impact of gender) and youth in local communities’ malaria elimination efforts

Supporting information

S1 file. rethinking malaria: "rethinking malaria in the context of covid–19," a global engagement organized by harvard university..

https://doi.org/10.1371/journal.pgph.0000764.s001

Acknowledgments

I am grateful to the interviewees who shared their observations and experiences with me as I developed this paper. I received feedback on early drafts of this article from members of the Working Group on Malaria Governance in the “Rethinking Malaria in the Context of COVID-19” global engagement. I appreciated the comments from representatives of several global health agencies who met with the Working Group and provided useful suggestions on how to improve this paper. (For a list of individuals comprising the Steering Committee, Working Group Co-Chairs, and an External Advisory Committee, please see the S1 File ). Professor Michael R. Reich and independent consultant Anya Levy Guyer assisted with revisions in response to journal reviewers.

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• Globally in 2022, there were an estimated 249 million malaria cases and 608 000 malaria deaths in 85 countries.
• The WHO African Region carries a disproportionately high share of the global malaria burden.
• In 2022, the Region was home to 94% of malaria cases (233 million) and 95% (580 000) of malaria deaths.
• Children under 5 accounted for about 80% of all malaria deaths in the Region.

Malaria is a life-threatening disease spread to humans by some types of mosquitoes. It is mostly found in tropical countries. It is preventable and curable.

The infection is caused by a parasite and does not spread from person to person.

Symptoms can be mild or life-threatening. Mild symptoms are fever, chills and headache. Severe symptoms include fatigue, confusion, seizures, and difficulty breathing.

Infants, children under 5 years, pregnant women, travellers and people with HIV or AIDS are at higher risk of severe infection. 

Malaria can be prevented by avoiding mosquito bites and with medicines. Treatments can stop mild cases from getting worse.

Malaria mostly spreads to people through the bites of some infected female  Anopheles  mosquitoes. Blood transfusion and contaminated needles may also transmit malaria. The first symptoms may be mild, similar to many febrile illnesses, and difficulty to recognize as malaria. Left untreated, P. falciparum  malaria can progress to severe illness and death within 24 hours.

There are 5 Plasmodium parasite species that cause malaria in humans and 2 of these species –  P. falciparum  and  P. vivax  – pose the greatest threat. P. falciparum is the deadliest malaria parasite and the most prevalent on the African continent. P. vivax is the dominant malaria parasite in most countries outside of sub-Saharan Africa. The other malaria species which can infect humans are P. malariae, P. ovale and P. knowlesi .

The most common early symptoms of malaria are fever, headache and chills.

Symptoms usually start within 10–15 days of getting bitten by an infected mosquito.

Symptoms may be mild for some people, especially for those who have had a malaria infection before. Because some malaria symptoms are not specific, getting tested early is important. 

Some types of malaria can cause severe illness and death. Infants, children under 5 years, pregnant women, travellers and people with HIV or AIDS are at higher risk. Severe symptoms include:

• extreme tiredness and fatigue 
• impaired consciousness
• multiple convulsions
• difficulty breathing
• dark or bloody urine
• jaundice (yellowing of the eyes and skin) 
• abnormal bleeding.

People with severe symptoms should get emergency care right away. Getting treatment early for mild malaria can stop the infection from becoming severe. 

Malaria infection during pregnancy can also cause premature delivery or delivery of a baby with low birth weight.

Disease burden

According to the latest  World malaria report , there were 249 million cases of malaria in 2022 compared to 244 million cases in 2021. The estimated number of malaria deaths stood at 608 000 in 2022 compared to 610 000 in 2021.

The WHO African Region continues to carry a disproportionately high share of the global malaria burden. In 2022 the Region was home to about 94% of all malaria cases and 95% of deaths. Children under 5 years of age accounted for about 78% of all malaria deaths in the Region.

Malaria can be prevented by avoiding mosquito bites and by taking medicines. Talk to a doctor about taking medicines such as chemoprophylaxis before travelling to areas where malaria is common.

Lower the risk of getting malaria by avoiding mosquito bites:  

• Use mosquito nets when sleeping in places where malaria is present
• Use mosquito repellents (containing DEET, IR3535 or Icaridin) after dusk
• Use coils and vaporizers.
• Wear protective clothing.
• Use window screens.

Vector control

Vector control is a vital component of malaria control and elimination strategies as it is highly effective in preventing infection and reducing disease transmission. The 2 core interventions are insecticide-treated nets (ITNs) and indoor residual spraying (IRS).

Progress in global malaria control is threatened by emerging resistance to insecticides among  Anopheles  mosquitoes. As described in the latest World malaria report , other threats to ITNs include insufficient access, loss of nets due to the stresses of day-to-day life outpacing replacement, and changing behaviour of mosquitoes, which appear to be biting early before people go to bed and resting outdoors, thereby evading exposure to insecticides.

Chemoprophylaxis

Travellers to malaria endemic areas should consult their doctor several weeks before departure. The medical professional will determine which chemoprophylaxis drugs are appropriate for the country of destination. In some cases, chemoprophylaxis drugs must be started 2–3 weeks before departure. All prophylactic drugs should be taken on schedule for the duration of the stay in the malaria risk area and should be continued for 4 weeks after the last possible exposure to infection since parasites may still emerge from the liver during this period.

Preventive chemotherapies

Preventive chemotherapy  is the use of medicines, either alone or in combination, to prevent malaria infections and their consequences. It requires giving a full treatment course of an antimalarial medicine to vulnerable populations at designated time points during the period of greatest malarial risk, regardless of whether the recipients are infected with malaria.

Preventive chemotherapy includes perennial malaria chemoprevention (PMC), seasonal malaria chemoprevention (SMC), intermittent preventive treatment of malaria in pregnancy (IPTp) and school-aged children (IPTsc), post-discharge malaria chemoprevention (PDMC) and mass drug administration (MDA). These safe and cost-effective strategies are intended to complement ongoing malaria control activities, including vector control measures, prompt diagnosis of suspected malaria, and treatment of confirmed cases with antimalarial medicines.

Since October 2021, WHO has recommended broad use of the RTS,S/AS01 malaria vaccine among children living in regions with moderate to high  P. falciparum  malaria transmission. The vaccine has been shown to significantly reduce malaria, and deadly severe malaria, among young children. In October 2023, WHO recommended a second safe and effective malaria vaccine, R21/Matrix-M. The availability of two malaria vaccines is expected to make broad-scale deployment across Africa possible. 

Questions and answers on the RTS,S vaccine .

Early diagnosis and treatment of malaria reduces disease, prevents deaths and contributes to reducing transmission. WHO recommends that all suspected cases of malaria be confirmed using parasite-based diagnostic testing (through either microscopy or a rapid diagnostic test).

Malaria is a serious infection and always requires treatment with medicine.

Multiple medicines are used to prevent and treat malaria. Doctors will choose one or more based on: 

• the type of malaria 
• whether a malaria parasite is resistant to a medicine
• the weight or age of the person infected with malaria 
• whether the person is pregnant.

These are the most common medicines for malaria:

• Artemisinin-based combination therapy medicines are the most effective treatment for P. falciparum malaria.
• Chloroquine is recommended for treatment of infection with the  P. vivax  parasite only in places where it is still sensitive to this medicine.
• Primaquine should be added to the main treatment to prevent relapses of infection with the  P. vivax  and  P. ovale  parasites. 

Most medicines used are in pill form. Some people may need to go to a health centre or hospital for injectable medicines.

Antimalarial drug resistance

Over the last decade, partial artemisinin resistance has emerged as a threat to global malaria control efforts in the Greater Mekong subregion. WHO is very concerned about reports of partial artemisinin resistance in Africa, confirmed in Eritrea, Rwanda, Uganda and, most recently, Tanzania. Regular monitoring of antimalarial drug efficacy is needed to inform treatment policies in malaria-endemic countries, and to ensure early detection of, and response to, drug resistance.

For more on WHO’s work on antimalarial drug resistance in the Greater Mekong subregion, visit the Mekong Malaria Elimination Programme webpage. WHO has also developed a strategy to address drug resistance in Africa .

Elimination

Malaria elimination is defined as the interruption of local transmission of a specified malaria parasite species in a defined geographical area as a result of deliberate activities. Continued measures to prevent re-establishment of transmission are required.

In 2022, 34 countries reported fewer than 1000 indigenous cases of the disease, up from just 13 countries in 2000. Countries that have achieved at least 3 consecutive years of zero indigenous cases of malaria are eligible to apply for the  WHO certification of malaria elimination . Since 2015, 12 countries have been certified by the WHO Director-General as malaria-free, including Maldives (2015), Sri Lanka (2016), Kyrgyzstan (2016), Paraguay (2018), Uzbekistan (2018), Argentina (2019), Algeria (2019), China (2021), El Salvador (2021), Azerbaijan (2023), Tajikistan (2023) and Belize (2023).

Countries and territories certified malaria-free by WHO .

Malaria surveillance is the continuous and systematic collection, analysis and interpretation of malaria-related data, and the use of that data in the planning, implementation and evaluation of public health practice. Improved surveillance of malaria cases and deaths helps ministries of health determine which areas or population groups are most affected and enables countries to monitor changing disease patterns. Strong malaria surveillance systems also help countries design effective health interventions and evaluate the impact of their malaria control programmes.

WHO response

The WHO  Global technical strategy for malaria 2016–2030 , updated in 2021, provides a technical framework for all malaria-endemic countries. It is intended to guide and support regional and country programmes as they work towards malaria control and elimination.

The strategy sets ambitious but achievable global targets, including:

• reducing malaria case incidence by at least 90% by 2030
• reducing malaria mortality rates by at least 90% by 2030
• eliminating malaria in at least 35 countries by 2030
• preventing a resurgence of malaria in all countries that are malaria-free.

Guided by this strategy, the Global Malaria Programme  coordinates the WHO’s global efforts to control and eliminate malaria by:

• playing a leadership role in malaria, effectively supporting member states and rallying partners to reach Universal Health Coverage and achieve goals and targets of the Global Technical Strategy for Malaria;
• shaping the research agenda and promoting the generation of evidence to support global guidance for new tools and strategies to achieve impact;
• developing ethical and evidence based global guidance on malaria with effective dissemination to support adoption and implementation by national malaria programmes and other relevant stakeholders; and
• monitoring and responding to global malaria trends and threats.
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Analysis of Global Research on Malaria and Plasmodium vivax

José antonio garrido-cardenas.

1 Department of Biology and Geology, University of Almeria, 04120 Almeria, Spain; se.lau@anedracj (J.A.G.-C.); moc.liamtoh@irbec_epep (J.C.-C.); se.lau@asemc (C.M.-V.)

José Cebrián-Carmona

Lilia gonzález-cerón.

2 Regional Center for Public Health Research, National Institute of Public Health, Tapachula, Chiapas 30700, Mexico; xm.psni@laznogl

Francisco Manzano-Agugliaro

3 Department of Engineering, University of Almeria, CeiA3, 04120 Almeria, Spain

Concepción Mesa-Valle

Background : Malaria is one of the infectious diseases of greatest interest to the scientific community and of greatest concern to international health authorities. Traditionally, the focus has been on Plasmodium falciparum , the parasite that causes the most severe form of the disease in Africa. However, in the last twenty years, the Plasmodium vivax parasite, responsible for a large number of cases in Latin America, the Middle East, South and Southeast Asia, the Horn of Africa, and Oceania, has also generated enormous interest due, among other things, to the published evidence that it can cause severe malaria. Methods : In this paper, the international scientific publication on malaria and P. vivax has been analyzed using the Scopus database to try to define global trends in this field of study. Results : It has been shown that events such as the emergence of resistance to certain drugs can break a trend. The important role of non-malaria-endemic countries such as the USA or Switzerland in malaria research is also evident. Conclusions : International cooperation will be essential for the eradication of the disease. Moreover, in this sense, the general vision given by the bibliometric analysis of malaria caused by P. vivax is fundamental to paint the picture regarding the current situation and encourage international cooperation and control efforts.

1. Introduction

Malaria is a disease that has affected the human population since ancient times. Today, it remains one of the infectious diseases with the highest morbidity and mortality rates, with 219 million estimated cases occurred worldwide in 2017, according to WHO, and half a million people dying each year worldwide, many of them children under five [ 1 ]. Because of this, a series of international programs have been initiated that aim to reduce and eradicate malaria, such as malERA, a research agenda for malaria elimination and eradication [ 2 ]. Human malaria can be caused by different species of the Plasmodium parasite. P. falciparum and P. vivax are the most important, with more than 95% of the cases diagnosed in the world, but there are others such as P. malariae , P. knowlesi , P. ovale wallikeri , and P. ovale curtisi [ 3 ].

P. falciparum is the most severe form of the disease in Africa, where more than 90 percent of all malaria cases occur. For this reason, this is the best-characterized species [ 4 ]. However, in recent years, the infections caused by P. vivax are increasing in significance because of evidence for severe malaria P. vivax infection [ 5 ]. In addition, P. vivax has recently received a large amount of attention, as it is the species with the largest geographical distribution, being reported fundamentally in Latin America, the Middle East, South and Southeast Asia, the Horn of Africa and Oceania [ 6 ]. This attention received by P. vivax is not only scientific, as illustrated by the increase in the number of published articles on this subject, but has also increased interest at the health level, trying to improve the diagnosis of malaria by these species or the specific treatments. The last factor that makes P. vivax a parasite of growing interest is its very hard elimination, with a high number of symptomatic relapses in malaria patients [ 7 ].

The malaria parasite is transmitted by a female Anopheles mosquito, inoculating sporozoites into the human host [ 8 ]. The sporozoites reach human liver cells, where they transform to give rise to another form called the merozoite. The merozoite reaches the erythrocytes, through the bloodstream, and multiples to produce new merozoites. Some of the merozoites released after the breakage of the erythrocytes are transformed into gametocytes. If the Anopheles mosquito bites an infected individual, then this is how the merozoites re-enter it. Inside the mosquito, in its midgut, sexual reproduction takes place, generating zygotes and developing into oocysts. These, as they grow and break, release sporozoites that invade the mosquito’s salivary glands. The parasite will then in the proper form to infect a new individual [ 9 ]. A fundamental difference in the life cycle of P. vivax is that it can successfully finish its development cycle in the mosquito at lower temperatures and faster than P. falciparum .

The complexity of the parasite’s life cycle, its great genetic variability, and the numerous mechanisms it can develop to avoid the host’s immune response, make it very difficult to find a vaccine to suppress human malaria [ 10 , 11 ]. In addition, the biology of P. vivax , as opposed to P. falciparum, makes it harder to control and eliminate and is the main reason for the higher vectorial capacity of P. vivax. Other reasons are related to the presence of hypnozoites (latent hepatic forms), which lead to multiple relapses and low parasites densities, which in turn makes diagnosis difficult and delays treatments [ 12 ]. On the other hand, there are no suitable experimental models for the analysis of a hypothetical vaccine. Despite this, finding a vaccine to eradicate malaria caused by P. vivax has become a fundamental objective for the WHO and the scientific communities around the world.

Bibliometric analyses provide fundamental scientific tools allowing for objective quantification of a scientific fact. These show the level of current knowledge in a scientific field by the compilation of data obtained from bibliographic databases. Bibliometrics facilitate comprehension and elaborates a real image of the research activity. In this study, the analysis of the international scientific publication on malaria and P. vivax has been raised to establish worldwide trends. It is essential for defining the research lines in malaria and creating synergies in order to achieve the WHO objective of eradicating malaria [ 13 ].

2. Materials and Methods

The evolution of the electronic age has led to the development of numerous scientific databases on the World Wide Web, which offer search facilities on a particular issue. Among them, some allow the opportunity to analyze citations from published works. The main scientific databases covering medical terms are PubMed, Scopus, Web of Science, and Google Scholar. PubMed focuses essentially on medicine and biomedical sciences, while Scopus, Web of Science, and Google Scholar cover most scientific fields. Usually, bibliometric studies are based on the keywords indexed by the published works. The main differences between these databases are PubMed (no limit), Scopus (30), Web of Science (15), and Google Scholar (no limit). However, in indexed journals and conference proceedings, there is usually a limit of about 6 keywords per published work so the limit of 15 is considered adequate for bibliometric works. However, PubMed’s search function, which is designed to search for medical documents, are exceptional and offer a service that other search engines do not. In this database, the search results can only be sorted by general characteristics such as publication date or author, and therefore, this is not very useful to get an overview of a topic [ 14 ]. Nowadays, mainly Web of Knowledge and Scopus allow large-scale downloads of bibliographic information from indexed publications and so most of the worldwide bibliometric works are based on one of these two databases. Scopus is the database that indexes the largest number of publications and conference proceedings when compared to the other three databases mentioned. Elsevier’s Scopus database is currently the largest abstract and citation database of peer-reviewed literature, and although another database, the Web of Science (WoS), is also available, it lists fewer titles whereas Scopus lists 84% of WoS titles compared to only 54% of Scopus tiles listed by WoS [ 15 , 16 ].

Scopus is usually considered the largest abstract and citation database of peer-reviewed scientific literature in the world. It contains more than 35,000 titles belonging to more than 10,000 publishers. For this reason, in order to analyze who, how, where, and what is being researched in a given scientific field, the most commonly used option is to use this database. Thus, it is common to find bibliometric works in many scientific fields using Scopus [ 17 , 18 , 19 ]. In short, Scopus is the most effective search engine and provides an overview of the subject. For extensive and in-depth research in the area of life sciences and closely related topics, PubMed should be considered as well [ 14 ]. For this reason, Scopus was the database of choice for this analysis.

In this work, a full search of the Elsevier Scopus database was conducted using TITLE-ABS-KEY (malaria and vivax ) as the search query. This resulted in 11,166 documents being obtained between 1916 and 2018, the last full year from Scopus database. It should be noted that varying the search criteria, or subsequent modifications of Scopus, can give significantly different results. That keywords entered by the author or publisher may not strictly conform to the subject matter of the articles should also be considered. Notwithstanding the previous, Scopus is considered a valid option for this type of analysis. In keyword analysis, terms with identical meanings were grouped together (e.g., Plasmodium vivax and P. vivax ), and terms that do not contribute to this analysis were discarded (e.g., article). The aspects that have been studied are the progression in the number of publications per year, the distribution of publications by institutions and by country, and the keywords ( Figure 1 ). For the detection of scientific communities, understood as the set of nodes connected to each other in a complex network, the software tool VOSviewer [ 20 ] ( http://www.vosviewer.com/ ) was used. This software has been used to create graphs in which each institution is represented by a node and the connections between two nodes represent the collaboration between the two institutions represented.

Methodology for searching the different analyses.

3. Results and Discussion

3.1. progression of scientific output.

The search returned 11,166 documents. Figure 2 shows the evolution trend of the number of documents on Plasmodium vivax and malaria since the first article was published. As shown in Figure 2 , the first article published on this is dated in 1916 [ 21 ]. This early entry in the first article shows the strong interest that the scientific community has placed on malaria over the years.

The trend of the number of publications in malaria and Plasmodium vivax , from the years 1916–2018.

The maximum number of annual publications was obtained in 2014, reaching a value of 646. The growth in the number of publications presents an exponential pattern, with an R 2 coefficient close to 1. There are two years in which the trend is interrupted, and therefore, the R 2 value is not even higher. These are the years 1946 and 1973. In these years, considering the trend line, the publications were higher than expected. The reason is that, on the one hand, in 1946, chloroquine was identified as a first-line blood schizontocide for P. vivax [ 22 ]. This led to an increased interest in malaria research and an increase in the publications. On the other hand, in 1973, there was intensification in the disease due to two reasons: the reduction in international aid programs from developed countries in the early 1970s, due to the lack of prospects for eradication; and the international economic crisis of 1973, which pushed up the price of insecticides. Between the years 2002–2010, the increase in the number of publications was three times greater than the whole previous period. This could be explained by the first malaria conference, Vivax Malaria Research: 2002 and Beyond, which took place in Bangkok, Thailand, 3–8 February 2002. This was a conference devoted entirely to Plasmodium vivax research and convened by the Multilateral Initiative on Malaria [ 23 ]. On the other hand, at the turn of the century, there was a general increase in funding for malaria control, and initiatives such as Roll Back Malaria, RBM, Partnership were born. This is a major worldwide platform for coordinated action towards a malaria-free world and is composed of international researchers, companies, and organizations.

3.2. Publication Distribution by Countries and Institutions

To get an overview of worldwide research on a specific subject, one of the aspects most considered is the study of publications by countries and institutions [ 24 ]. Note that when an article has several affiliations, the indexation implies that the article is attributed to each of them; therefore, the sum of articles by countries could be greater than the sum of articles obtained with the search term. Figure 3 shows the distribution by country of the scientific publication on malaria and P. vivax . In 159 countries, at least one article on P. vivax has been published, and 25 countries, with at least 150 publications, represent 75% of the total. Note that the same article may be signed by authors from different countries. Figure 4 shows the data on a world map with colors identifying the number of manuscripts that are published in each country. The United States of America, United Kingdom, and India, top the ranking with 2528, 1439, and 1383 publications, respectively. To normalize the results, the data have been referenced to the population of each country, based on the 2018 statistics obtained from the website [ 25 ] ( Table 1 ). In this case, it can be observed that there are 10 countries that publish at least 7 articles per million inhabitants. These are (ranked from highest to lowest): Switzerland, Australia, Papua New Guinea, United Kingdom, Netherlands, Thailand, Belgium, France, United States, and Sri Lanka.

Representation of the countries with the highest number of publications on malaria and P. vivax.

World map representing scientific publications by the intensity of color.

Leading countries in terms of scientific research and publication in terms of population and wealth cited.

In relative terms, Switzerland very high scientific output is striking. This can be explained by two reasons. First, Switzerland must be considered an international power in innovation. It is no coincidence that the development of an effective malaria vaccine is taking place in the country. The pharmaceutical industry is well established in this country, and there are numerous public and private research and development institutions around this type of industry [ 26 ]. On the other hand, Switzerland is home to international agencies and institutions concerned with global health care. The Swiss Agency for Development and Cooperation (SDC), an agency of the Swiss federal administration responsible for coordinating cooperation and humanitarian aid activities, and the World Health Organization, whose headquarters are in Geneva, stand out in this regard.

Finally, Table 1 also reflects the relative wealth of each country based on the value of GDP per capita (IMF data). Thus, it can be observed that the 10 countries studied above are divided into two groups. Seven high-income countries (Switzerland, Australia, United Kingdom, Netherlands, Belgium, France, and United States), with more than 40,000 GDP per inhabitant, and three low-income countries (Papua New Guinea, Thailand, and Sri Lanka), with less than 7000. The motivations in one or the other case are different. While in the former, the interest is purely scientific, for the latter it is a question of survival. In these three countries, malaria is an endemic disease, although in terms of survival, there is very little malaria in Thailand, and Sri Lanka has eliminated all malaria.

Figure 5 shows the 13 institutions with at least 180 publications on malaria and P. vivax . Of these, four are from USA (Centers for Disease Control and Prevention, National Institutes of Health in Bethesda, National Institute of Allergy and Infectious Diseases, and Armed Forces Research Institute of Medical Sciences known as AFRIMS), three are from the UK (the University of Oxford, Nuffield Department of Clinical Medicine, and London School of Hygiene and Tropical Medicine), two are from Thailand (Mahidol University and Shoklo Malaria Research Unit), two are Brazilian (Fundacao Oswaldo Cruz and Universidade de Sao Paulo), and one is Indian (National Institute of Malaria Research of India). Note that there may be several affiliations within the same institution but the database considers them separately respecting the decision of the authors.

Main institutions in terms of scientific publication in malaria and P. vivax.

As mentioned above, these five countries along with Australia, are the most relevant in scientific publications on this topic. In addition, it is surprising that among these, there is also an institution from Papua New Guinea. This is the Papua New Guinea Institute of Medical Research, also known as PNGIMR, that has the support of the World Health Organization (WHO). Figure 6 shows a distribution by communities of the main institutions. It can be observed that most institutions are grouped into a cluster whose central element is the faculty of tropical medicine of the Mahidol University (Thailand). Each line of union between the nodes represents the relationships established between the institutions. Thus, the relations are quite complex, and that they are observed not only between the different elements of this large cluster but also with the other institutions of the two additional minority clusters. The two smaller clusters are made up of the Papua New Guinea Institute of Medical Research and the Swiss Tropical and Public Health Institute, in one, and the Medicines for Malaria Venture (MMV) in the other.

Distribution by communities of the main institutions.

3.3. Keyword Analysis

In the analysis of the keywords, if one of them does not contribute anything to the study then it must be eliminated, e.g., “article.” In the second place, all terms that refer to the same concept must be grouped together, e.g., “ Plasmodium vivax ” and “ P. vivax .” Figure 7 shows, using a word cloud, that the 32 keywords are in more than 1000 publications on malaria and P. vivax . In Figure 7 , the relative size of each word is directly proportional to the number of times the keyword is present in the analyzed documents. As expected, Plasmodium vivax , human, and malaria, with 9826, 9428, and 8572, respectively, stand out.

Word cloud with the main keywords.

Among the 32 keywords with more than 1000 presences in the analyzed articles are two drugs, chloroquine and primaquine, present in 2395 and 1682 documents, respectively. Furthermore, 11 other keywords related to drugs are among the 160 most used keywords. These are ranked in order of their importance: quinine, mefloquine, artemisinin, artesunate, pyrimethamine, doxycycline, fansidar (actually, the trade name for sulfadoxine/pyrimethamine), artemether plus benflumetol, sulfadoxine, proguanil, and amodiaquine. Figure 8 shows that since 1946, the evolution of malaria and P. vivax research in relation to the different drugs. As already mentioned, the most important drug as keyword is chloroquine. Although considering only the last 5 years, the relative importance of primaquine is similar. This is because the WHO indications are that, in areas where chloroquine maintains its efficacy, this must be the drug used against malaria caused by P. vivax [ 27 ]. On the other hand, primaquine has been shown to be highly effective in acting against hypnozoites, which are the predominant latent forms in P. vivax . Furthermore, until recently, it was the only approved hypnozoiticide. For these reasons, to avoid relapses caused by it, the administration of primaquine is appropriate although there are threats from incomplete compliance with standards and the development of tolerance, although the real problem in the supply of this drug is its potential toxicity due to the deficiency, in patients, of the enzyme G6PD [ 28 ]. Figure 8 also shows the relative importance of different drugs at any given time. For example, mefloquine had a relative maximum in 2004 and how, subsequently, it has been losing relevance due to its scarce further use. On the contrary, artemisinin—and its derivative artesunate—has a fundamental importance in recent years, being the most effective drug against all forms of multidrug-resistant P. falciparum [ 29 ]. Other drugs such as fansidar (sulfadoxine/pyrimethamine) or proguanil have practically no importance in recent publications on malaria and P. vivax , highlighting the trend in the use of these in the treatment of the disease.

Time progression of antimalarial drugs in the fight against malaria caused by P. vivax.

Also, it can be seen that the five species of Plasmodium that have been shown to cause malaria in humans ( P. vivax , P. falciparum , P. malariae , P. ovale, and P. knowlesi ) are among the 100 most used keywords. Finally, five countries are also present among the most important keywords: India, Thailand, Brazil, China, and Papua New Guinea. These are countries where malaria caused by P. vivax is endemic and they are at the focus of many efforts by the international scientific community to eliminate malaria.

4. Conclusions

Malaria is still one of the world’s major health problems today; both for its extent and for the priority consideration it has received from public and private organizations concerned with human health. For this reason, malaria is a topic that is increasingly published in scientific journals with impact factors. Moreover, within this theme, malaria caused by P. vivax is currently receiving special interest. The present study has shown that the growth in the number of publications is exponentially curved, demonstrating the enormous interest that P. vivax causes in the international scientific community. This trend is only interrupted by two moments in history when interest in malaria has broken the norm. Thus, it becomes clear how bibliometric analysis of a given subject allows fundamental facts or moments to be identified. In this specific case, it is the discovery of a drug, chloroquine, which proved to be useful in the fight against malaria, and the rebound in the number of malaria cases in the early 1970s due to the relaxation of the alert level in the international scientific community.

On the other hand, the most important countries in terms of scientific publication have been identified. In global terms, the USA, UK, and India stand out above the rest. However, when a more exhaustive analysis is carried out, and both the population and the wealth of the country are considered, it is observed that there are other countries of greater relative importance. Thus, Switzerland has been found to be the country that devotes the most relative effort to the fight against malaria. This is no coincidence. This country is a biotechnological benchmark and is home to many international public and private bodies that have been working to eliminate malaria for decades. The identification of countries such as Switzerland highlights the importance of combining technological, scientific, and political efforts of public and private initiatives in the fight against the disease. This union of efforts is evidenced by the study of the relationships between the most outstanding institutions and scientists in the field of malaria and P. vivax . In most cases, there are collaborations that dilute the borders between rich countries that are devoting efforts to fight malaria, such as the UK, and countries where the disease is a real public health problem, such as Thailand.

Bibliometric studies not only give an overview of the current state of a scientific issue but can help to understand policy decisions and shape future scientific research. For this reason, an analysis of the keywords has been carried out allowing us to identify the main sectors in which the greatest efforts are being focused on research on malaria and P. vivax . Of these, studies on antimalarials stand out. The elements that define the lines of international economic investment and objectives in research projects are the progression of trends, the recommendations of the WHO, the updating of studies on the effectiveness of drugs, and the existence of resistance to them. It is important to have a general view of the subject in order to focus on the strategies that are still valid and to open up new promising lines of research.

Author Contributions

Conceptualization, J.A.G.-C. and F.M.-A.; methodology, J.A.G.-C., J.C.-C., and C.M.-V.; formal analysis, J.A.G.-C. and F.M.-A.; investigation, J.A.G.-C., L.G.-C., and C.M.-V.; writing—original draft preparation, J.A.G.-C. and J.C.-C.; writing—review and editing, L.G.-C., F.M.-A., and C.M.-V.

This research received no external funding.

Conflicts of Interest

The authors declare no conflict of interest.

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Malaria Prevention, Treatment, and Control Strategies

Malaria is a difficult disease to control largely due to the highly adaptable nature of the vector and parasites involved. While effective tools have been and will continue to be developed to combat malaria, inevitably, over time the parasites and mosquitoes will evolve means to circumvent those tools if used in isolation or used ineffectively. To achieve sustainable control over malaria, healthcare professionals will need a combination of new approaches and tools, and research will play a critical role in development of those next-generation strategies.

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Vaccine development, control strategies.

Malaria has a significant impact on the health of infants, young children, and pregnant women worldwide. More than 800,000 African children under the age of five die of malaria each year. Malaria also contributes to malnutrition in children, which indirectly causes the death of half of all children under the age of five throughout the world. Fifty million pregnant women throughout the world are exposed to malaria each year. In malaria-endemic regions, one-fourth of all cases of severe maternal anemia and 20 percent of all low-birthweight babies are linked to malaria. Scientists are working to better understand how malaria uniquely affects children and pregnant women and to develop new research tools, methods, and products appropriate for these populations.

The development of a safe and effective vaccine against malaria will be critical in malaria control, prevention, and eradication efforts. Currently, no licensed vaccine against malaria (or any parasitic disease that afflicts humans) exists. The complexity of the  Plasmodium  parasite and the lack of understanding of critical processes, such as host immune protection and disease pathogenesis, have hampered vaccine development efforts.

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Candidate malaria vaccine provides lasting protection in nih-sponsored trials.

Two NIH-supported trials of an experimental malaria vaccine in healthy Malian adults found that all three tested regimens were safe. One of the trials enrolled 300 healthy women ages 18 to 38 years who anticipated becoming pregnant soon after immunization. That trial began with drug treatment to remove malaria parasites, followed by three injections spaced over a month of either saline placebo or the investigational vaccine at one of two dosages.

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Drug Development

Antimalarial drugs, in combination with mosquito control programs, have historically played a key role in controlling malaria in endemic areas, resulting in significant reduction of the geographic range of malarial disease worldwide. Over the years, however, the emergence and spread of drug-resistant parasites has contributed to a reemergence of malaria, turning back the clock on control efforts. The need for new, effective drugs for malaria has become a critical priority on the global malaria research agenda.

NIAID-supported researchers are seeking to understand the molecular biology of the  Plasmodium  parasite and how it interacts with its human host at each stage in that cycle. Using that information, scientists hope to develop new drugs that block different molecular processes required for parasite survival and identify the mechanisms of emerging drug resistance.

Diagnostics

New and improved diagnostics are essential for the effective control of malaria. Currently, the most reliable technique for diagnosing malaria is, as it was throughout the last century, labor-intensive, relying on highly trained technicians using microscopes to analyze blood smears. Such microscopic analysis is time-consuming, variable in quality, difficult to use in resource-poor field settings, and cannot detect drug resistance. Therefore, NIAID supports research to develop easy-to-use tests that diagnose the malaria parasite causing an infection and identify its drug resistance profile.

Vector Management Approaches

Vector management tools such as insecticides, environmental modification, and bed nets have contributed greatly to successful malaria control efforts historically, but have faced setbacks in recent years due to factors such as the emergence of insecticide resistance in mosquitoes. NIAID is supporting research on new vector management strategies to prevent parasite transmission (from humans to mosquitoes and mosquitoes to humans) and reduce the mosquito population.

Summaries of Scientific Advances in Malaria Research

World malaria days.

April 25 marks the annual World Malaria Day. NIAID news releases each year offer summaries of the research being done. 

• NIAID Marks World Malaria Day - April 25, 2023
• NIAID Marks World Malaria Day - April 25, 2022

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•  &  Ana Rodriguez

Article 05 September 2023 | Open Access

Differences in catalase levels between malaria-infected individuals and uninfected controls: a systematic review and meta-analysis

Article 04 September 2023 | Open Access

The voltage-gated sodium channel, para, limits Anopheles coluzzii vector competence in a microbiota dependent manner

• Luisa Nardini
• , Emma Brito-Fravallo
•  &  Christian Mitri

Article 02 September 2023 | Open Access

Maize pollen diet enhances malaria mosquito longevity and infectivity to Plasmodium parasites in Ethiopia

• Shilimat Ayele
• , Teklu Wegayehu
•  &  Fekadu Massebo

Article 25 August 2023 | Open Access

Impact of malaria on glutathione peroxidase levels: a systematic review and meta-analysis

Molecular surveillance of plasmodium falciparum drug-resistance markers in vietnam using multiplex amplicon sequencing (2000–2016).

• Eduard Rovira-Vallbona
• , Johanna Helena Kattenberg
•  &  Anna Rosanas-Urgell

Article 10 August 2023 | Open Access

Serological evaluation of risk factors for exposure to malaria in a pre-elimination setting in Malaysian Borneo

• Isabel Byrne
• , Timothy William
•  &  Chris J. Drakeley

Article 19 July 2023 | Open Access

Bird community effects on avian malaria infections

• Juliana Tamayo-Quintero
• , Josué Martínez-de la Puente
•  &  Héctor F. Rivera-Gutiérrez

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