Influence of History, Geography, and Economics on the Elimination of Malaria: A Perspective on Disease Persistence in Rural Areas of Zambia

Document Type : Perspective


University of Zambia, School of Public Health, Department of Policy and Management, Lusaka, Zambia



The fight against malaria is currently ongoing in many countries where the disease is still endemic. The overall target is to eliminate malaria in all nations, regardless of their malaria burden, by 2030. Currently, the disease has been eliminated mainly in low-burden and unstable malaria areas globally. However, in high-burden countries, particularly in Africa, the disease is still not eliminated; some countries are even recording increases in incidence. This paper discusses why the disease is currently being eliminated in some countries and not in others using a historical and geo-economic perspective. It identifies gaps in the primary contemporary interventions in high endemic areas, particularly in rural constituencies where incidence of the disease is even higher. The key discussion point is that poor housing and behavioral patterns predispose rural dwellers to more malaria. Other risk factors include agricultural occupations, livestock keeping, and the fact that mosquito vectors in Africa thrive more in rural than urban areas. Combating malaria in rural African areas, therefore, requires radical transformative action to address the unique situations that currently enable the persistence of malaria beyond the contemporary, mainly indoor, and health facility-based interventions. Improving housing structures in rural Africa, which are mainly mud and thatched huts, to at least insect-proof standards is the recommended transformative action. Moreover, behavioral patterns, such as cooking outdoors in the evenings, must be modified to cooking in improvised insect-proof kitchens.


  1. Campbell CC, Steketee RW. Malaria in Africa can be eliminated. Am J Trop Med Hyg. 2011;85(4):584-585. doi:10.4269/ ajtmh.2011.11-0529.
  2. WHO. World Malaria Report. World Health Organization, 2017.
  3. Hay SI, Guerra CA, Tatem AJ, Noor AM, Snow RW. The global distribution and population at risk of malaria: past, present, and future. Lancet Infect Dis. 2004;4(6):327-336. doi:10.1016/s1473- 3099(04)01043-6.
  4. Nájera JA, González-Silva M, Alonso PL. Some lessons for the future from the Global Malaria Eradication Programme (1955- 1969). PLoS Med. 2011;8(1):e1000412. doi:10.1371/journal. pmed.1000412.
  5. Feachem RG, Phillips AA, Hwang J, et al. Shrinking the malaria map: progress and prospects. Lancet. 2010;376(9752):1566-1578. doi:10.1016/s0140-6736(10)61270-6.
  6. Majori G. Short history of malaria and its eradication in Italy with short notes on the fight against the infection in the mediterranean basin. Mediterr J Hematol Infect Dis. 2012;4(1):e2012016. doi:10.4084/mjhid.2012.016.
  7. Griffing SM, Tauil PL, Udhayakumar V, Silva-Flannery L. A historical perspective on malaria control in Brazil. Mem Inst Oswaldo Cruz. 2015;110(6):701-718. doi:10.1590/0074-02760150041.
  8. Ferreira MU, Castro MC. Challenges for malaria elimination in Brazil. Malar J. 2016;15(1):284. doi:10.1186/s12936-016-1335-1.
  9. Karunaweera ND, Galappaththy GN, Wirth DF. On the road to eliminate malaria in Sri Lanka: lessons from history, challenges, gaps in knowledge and research needs. Malar J. 2014;13:59. doi:10.1186/1475-2875-13-59.
  10. Wijesundera Mde S. Malaria outbreaks in new foci in Sri Lanka. Parasitol Today. 1988;4(5):147-150. doi:10.1016/0169- 4758(88)90193-7.
  11. Ratnapala R, Subramaniam K, Yapabandara MG, Fernando WP. Chloroquine resistant Plasmodium falciparum in Sri Lanka. Ceylon Med J. 1984;29(3):135-145.
  12. Larson E, Gosling R, Abeyasinghe R. Eliminating malaria: following Sri Lanka’s lead. BMJ. 2016;355:i5517. doi:10.1136/bmj.i5517.
  13. Simac J, Badar S, Farber J, et al. Malaria elimination in Sri Lanka. J Health Spec. 2017;5(2):60-65. doi:10.4103/jhs.JHS_25_17.
  14. Björkman A, Shakely D, Ali AS, et al. From high to low malaria transmission in Zanzibar-challenges and opportunities to achieve elimination. BMC Med. 2019;17(1):14. doi:10.1186/s12916-018- 1243-z.
  15. Malaria on isolated Melanesian islands prior to the initiation of malaria elimination activities. Malar J. 2010;9:218. doi:10.1186/1475-2875-9-218.
  16. Kar NP, Kumar A, Singh OP, Carlton JM, Nanda N. A review of malaria transmission dynamics in forest ecosystems. Parasit Vectors. 2014;7:265. doi:10.1186/1756-3305-7-265.
  17. Snow RW, Amratia P, Kabaria CW, Noor AM, Marsh K. The changing limits and incidence of malaria in Africa: 1939-2009. Adv Parasitol. 2012;78:169-262. doi:10.1016/b978-0-12-394303- 3.00010-4.
  18. The Global Fund Results Report 2018. en.pdf. Accessed December 23, 2019.
  19. Roll Back Malaria Partnership. RBM Partnership Strategic Plan 2018–2020.­gic-Plan-digital-JW-220218.pdf. Accessed December 23, 2019.
  20. Ministry of Health. National Malaria Elimination Strategic Plan 2017–2021. uploads/2017/06/NMESP_2017-21_email-version.pdf. Accessed December 23, 2019.
  21. Rodríguez JC, Uribe GÁ, Araújo RM, Narváez PC, Valencia SH. Epidemiology and control of malaria in Colombia. Mem Inst Oswaldo Cruz. 2011;106 Suppl 1:114-122. doi:10.1590/s0074- 02762011000900015.
  22. Nawa M, Hangoma P, Morse AP, Michelo C. Investigating the upsurge of malaria prevalence in Zambia between 2010 and 2015: a decomposition of determinants. Malar J. 2019;18(1):61. doi:10.1186/s12936-019-2698-x.
  23. Masaninga F, Mukumbuta N, Ndhlovu K, et al. Insecticide-treated nets mass distribution campaign: benefits and lessons in Zambia. Malar J. 2018;17(1):173. doi:10.1186/s12936-018-2314-5.
  24. Chanda E, Mukonka VM, Kamuliwo M, Macdonald MB, Haque U. Operational scale entomological intervention for malaria control: strategies, achievements and challenges in Zambia. Malar J. 2013;12:10. doi:10.1186/1475-2875-12-10.
  25. Hast MA, Chaponda M, Muleba M, et al. The impact of three years of targeted IRS with pirimiphos-methyl on malaria parasite prevalence in a high-transmission area of northern Zambia. Am J Epidemiol. 2019. doi:10.1093/aje/kwz107.
  26. Ministry of Health M, Central Statistics Office (CSO), PATH Malaria Control and Evaluation Partnership in Africa (MACEPA), the United States President’s Malaria Initiative (PMI), the World Bank, UNICEF, the World Health Organization, (WHO). Malaria Indicator Survey 2018. Lusaka, Zambia: PATH; 2019.
  27. Ministry of Health M, Central Statistics Office (CSO), PATH Malaria Control and Evaluation Partnership in Africa (MACEPA), the United States President’s Malaria Initiative (PMI), the World Bank, UNICEF, the World Health Organization, (WHO). Malaria Indicator Survey. Lusaka: Ministry of Health, 2015.
  28. Central Statistical Office, Ministry of Health, ICF International. Zambia Demographic and Health Survey 2013-14. Rockville, Maryland, USA: Central Statistical Office, Ministry of Health, ICF International; 2014.
  29. Wiedinmyer C, Dickinson K, Piedrahita R, et al. Rural–urban differences in cooking practices and exposures in Northern Ghana. Environ Res Lett. 2017;12(6):065009. doi:10.1088/1748- 9326/aa7036.
  30. Janko MM, Irish SR, Reich BJ, et al. The links between agriculture, Anopheles mosquitoes, and malaria risk in children younger than 5 years in the Democratic Republic of the Congo: a population-based, cross-sectional, spatial study. Lancet Planet Health. 2018;2(2):e74-e82. doi:10.1016/s2542-5196(18)30009-3.