Politicians and policy makers need to understand that malaria elimination should not take a business-as-usual approach. The most notable change will involve the evolution of a surveillance system linked to rapid response, robust epidemiological data, and sustained vigilance over a long time. Most countries aiming for elimination do not yet have the surveillance systems required for an elimination effort and will need to invest substantially to improve disease notification and analysis.104
Furthermore, the challenges of reaching the highly efficient operational levels8,10
that are needed to stop transmission will be great. Even if such a programme is undertaken with great precision, its success within a country is likely to be contingent on a commitment throughout an entire region of countries.
Nationally, political leaders will need to create an environment within which strategies to support elimination would operate successfully. The factors that would contribute to this enabling environment—such as well functioning health systems, community participation, sufficient skilled human resources, sustainable financing, a national and regional legal framework to facilitate elimination, and political stability—have not been discussed here but are reviewed in broad terms in other papers in this Series.13,22
Nevertheless, even for the elimination of one disease, planning needs to be approached systemically to be successful.105
We have not addressed the complex issues related to the national certification process of malaria-free status.6
We do, however, recognise that this process remains imperfect and needs more investigative modelling, new methods to measure transmission (or its absence), and empirical research to improve the specificity of the present recommendation to prove the absence of local transmission “beyond reasonable doubt”.6
Systematic reviews of surveillance and response methods, and case studies from countries that have recently eliminated malaria, are essential to build a stronger evidence-base and generate practical, context-specific recommendations for future guidance. Research to improve available methods for diagnosis, treatment, and vector control is also needed. Long-term research needs have been discussed elsewhere;106
short-term priorities should include the development of methods to assess the overall feasibility of elimination strategies, understand the epidemiology of asymptomatic infections, quantify effect sizes of imported infection risks, and compare cost-effectiveness of different surveillance and response models.
Although the GMEP has left a legacy of technical reports and guidelines, most were focused on epidemiological contexts in the Americas and Europe. The wealth of information available from the GMEP—one of WHO's best documented programmes—should be used to inform present and future elimination efforts, but a contemporary evidence base to support cost-effective decision making is only now beginning to be generated for the more complex transmission settings of sub-Saharan Africa and Asia. “The problem of finding an effective and economical method of [eliminating] malaria in tropical Africa has not yet been solved”, stated the WHO Expert Committee in 1957.9
With the subsequent shift away from elimination activities, the ensuing 50 years have not provided solutions, especially for sub-Saharan Africa where large-scale interventions have only been implemented for the first time in the past decade.22
In the absence of clear guidance, the decision to pursue malaria elimination might be made on a political basis without careful and rigorous assessment of the technical, operational, and financial feasibility of pursuing such a course.
Historically, it had been hoped that one approach could succeed everywhere as long as it was undertaken with “military precision”.107
An unfortunate consequence of this model was that it essentially replaced malariologists with technicians who were skilled in the logistics of directing insecticide spray campaigns but did not have a crucial understanding of the disease and its subtleties.108
Such a strategy was very successful in many settings, but the challenge of eliminating malaria in high-endemic regions will need more versatile and locally tailored, systemic approaches. Some have argued that elimination of malaria from a country can only be achieved through a global eradication effort109
since constant importation will otherwise make local elimination a precarious achievement. In the absence of such a global campaign, elimination in individual countries can be achieved and maintained only through robust surveillance and response combined with targeted vector control to eliminate residual or re-emerging foci. Although the GMEP needed great precision to achieve universal coverage with DDT, national elimination with the challenge of continued importation will require an equal level of precision for surveillance and response. The challenges nowadays are different from those faced by the GMEP and will need the development of new approaches, novel technologies, and sustainable financing to change the distribution of malaria prevalence progressively and to eventually eradicate the disease worldwide.