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Can *Any* Malaria Control Program Pass “The 5/5/5 Test?”

February 24, 2010 - 02:06 -- Mark Benedict

“If the malaria control program(s) I manage receives 5% of its current funds 5 years from now, would the maximum level of transmission reduction we have achieved during that time be maintained 5 years later?”

I admire those who implement malaria interventions: they plan budgets, distributions, monitoring, diagnosis and consider a myriad of social and economic factors that interact for effective anti-malaria programs. They directly improve the health of individuals and literally save lives.

However, I am concerned that many of those strategies cannot be sustained because of the widely-recognized reasons: dwindling financial and political support that will occur at some point in the future. They will not contribute to “shrinking the malaria map.” These programs are not planning ahead, and the consequence will be at best a return to the status quo and possibly worse.

If we could anticipate an escalating level of support for malaria interventions on a global scale, elimination or sustainable control might be reached. But it is likely that resources to attain this goal globally will not be available simultaneously. Therefore, the limited resources must be used strategically: in order to accomplish and maintain malaria reductions, existing resources must be shifted from areas in which risk has been reduced/eliminated and moved elsewhere. The pot of money simply is not sufficiently large.

If you do not accept this given, then the remainder of this blog will make absolutely no sense. However, if you realize that such reductions are inevitable (regardless of what you think about the prospects of elimination or eradication ) I would like you to consider a categorization scheme for malaria control projects that describes the sustainability of programs and whether they contribute to a global strategic plan.


This is a simple method, the logic of which I hope I can make apparent. Ask the following question of your program, ponder the scenario, and come up with an answer of one word or phrase. “If the malaria control program(s) I manage receives 5% of its current funds 5 years from now, would the maximum level of transmission reduction we have achieved during that time be maintained 5 years later?” There are three reasonable responses:


“Yes!” Congratulations! You are working on a 5/5/5 project. You are on a realistic course toward sustainable control. You may foresee that scaled-up activities will not always be needed because a shift to focused control and surveillance measures will reduce expenses. 95% of the funds you currently have can be applied elsewhere. You may have encouraged changes in human behaviors that reduce risk, and it is reasonable to expect that these will continue. Less diagnosis and treatment cost will be required. Perhaps the vector abundance will be reduced because of durable land use modifications. You may have eliminated the vector in an area where reintroduction can be prevented economically.


“No.” You are working on a program that can end only in reversal of the advances you have made. As long as there are people, parasites and people, the potential to return to “normal” transmission levels exists. This response indicates that while significant benefit may accrue to the individuals who receive treatment and interventions, the program cannot be considered a part of efforts to eliminate malaria nor can they be sustained. The activities of your program are a benevolent contribution to health. While the resources - including will - are available, the program will provide needed protection. When they diminish?


Your answer might be a bit more nuanced than the dichotomy above. For example, “No, but I believe that it is sustainable.” For this to be logical, some of the following must be true: 1. You will achieve elimination in your region, and the current level of funds and means to maintain suppression will be available until malaria is eradicated globally. 2. Reduced program funding will continue to limit transmission because of greater efficiency of measures or an uncontrolled occurrence (e.g. fewer imported cases, deployment of a vaccine, better housing, climate change). More bang for less buck. Perhaps, but that is out of your control. 3. It is impossible to reduce transmission to an acceptable level in 5 years. Fair enough. Why? And if not, how long?.


Do you have a 5/5/5 program? If we are going to “shrink the malaria map,” could someone please post an example of such? Ask your colleagues: do they know of such programs? Can we name an example of even one?


William Jobin's picture
Submitted by William Jobin on

Good thinking, Mark.

The realism you show in your 5/5/5 goal is the primary element lacking in all the current malaria control programs operating in Africa, including those under WHO and PMI, - the Presidents Malaria Initiative under USAID. Most of the literature shows that the people starting these projects seem to think that success for three or four years is all they need to show. Thus they use drugs and bednets, which unfortunately require continuous funding.

But I can suggest some strategies which would achieve your goals in Africa.

One is permanent improvements in housing. Bart Knols is already onto this. If you improve a house - with better night-time ventilation, screens on the doors and windows, and blockage of holes in the eaves and ceiling where anophelines enter, then you cause a permanent drop in malaria transmission for the folks living in that house. And the householder could do this himself, with a happy increase in the value of his house.

A second sustainable strategy is to eliminate anopheline breeding sites around communities, through drainage, or filling of depressions which otherwise hold water temporarily after rains, the definition of an Anopheles gambiae breeding site. This approach is being developed by Prof. Elfatih Eltahir at MIT, along with Arnie Combes in Niger. The other side of this approach is to only build new communities some distance from breeding sites, about 5-10 km.

A variation on elimination of breeding sites, is to connect them all by ditches and deepen them so that they permanently support fish populations which feed on anopheline larvae.

These techniques were detailed in 1982 in " A manual on environmental management for mosquito control," WHO Offset publication no 66. But I fear none of the malaria folks currently in Geneva have read this.

Notice that I do not even mention drugs or bednets as sustainable strategies, because I doubt that they would fill your 5/5/5 requirements. Yet these are the main thrusts of WHO and PMI. And the long-dreamed about vaccines look like they will have to be repeated every few years, hardly a sustainable strategy.

A third strategy I would suggest, is to change agricultural and irrigation practices. For instance new irrigation systems are sometimes planned to include three crops per year, thus keeping the canals, fields and drains full of water year-round, including the worst of the malaria transmission period. Thus mosquitoes breed year round.

Building a simpler system with only one irrigated crop per year, with perhaps a dryland crop during the other seasons, would reduce the mosquito breeding by at least 2/3, and if the fields were left fallow during the peak mosquito breeding season, perhaps reduce malaria transmission even more. This simpler system might also reduce income for farmers, but would not be so expensive to build, and would not saddle them with as much debt. In the long run, it is smarter to plan an irrigation system which also protects the farmers health.

An even simpler approach is to put in adequate drainage in existing irrigation systems, and do simple, annual maintenance. Most irrigation systems are built without adequate drains, and little or no maintenance.

I hope you get some more responses Mark. But I wonder when sustainability will come into the WHO malaria control vocabulary?

Waiting and hoping,

Bill Jobin
Blue Nile Associates

William Jobin Director of Blue Nile Associates