As malaria cases dwindle and we approach elimination, will malaria programs be integrated into broader disease control efforts? Integration is all the rage, but what does it mean for disease eradication efforts?
The arguments for and against vertical versus horizontal, siloed versus integrated programming sometimes misses the point when it comes to disease eradication. Eradication is by nature a time-bound and focused activity. Without a clear, reasonable target date, eradication will not happen, but disease control will linger until some financial or other event causes us to drop the ball completely and cases start rising again. This might sound familiar to those who were around for the malaria eradication efforts that floundered in the 1960s.
We may have been premature to start talking about malaria eradication a few years ago, but the discussion is needed about the state of malaria programming as pre-elimination and elimination are being reached in many countries. We must begin looking around for the resources for that last push toward eradication. In the absence of a dedicated malaria eradication effort – a vertical program if you will – will be be able to organize the efforts needed for the final step?
Let’s draw some lessons from guinea worm. From the start in the 1980s programs were established that were called National Guinea Worm Eradication Programs, not guinea worm programs or guinea worm control programs, but eradication programs. A specific date was set – 1995, and in most cases a dedicated team of people went to work on a well defined set of interventions from the national to regional to district to community levels.
Where the guinea worm effort faltered was when countries tried to ‘integrate’ it with other disease control or primary health care services. Work became unfocused and ten or more years were added to what should have been a straight-forward march to elimination in these countries by 1995. What this meant in Nigeria was that the pace slowed, but at least was continual, and now 18 years after the original target date was finally declared free of the disease. In Ghana, with guinea worm hidden amongst the duties of pluripotent district disease control officers, cases began to rise again.
Already some countries that are in a high level of control and witnessing major drops in incidence and mortality have combined their malaria programs into a broader disease control unit or department. There are hints that donors may wish to focus more on high burden areas for major scale-up and control. All partners must be willing to ensure that both the funds/resources as well as the organizational infrastructure (systems) are in place to guarantee elimination in each endemic country.