Advocating for Malaria Elimination: Learning from the Successes of Other Infectious Disease Elimination Programmes

"Many other infectious diseases have been targeted by globally-coordinated elimination advocacy campaigns, and advocacy has been considered an essential component of the success of other disease elimination programmes. What can the malaria community learn from these successes?"

To address this question - and with a focus on the push to not just control malaria but to eliminate it - the authors of this paper undertook a selective review of infectious disease elimination programmes to identify successful elements of advocacy that could be applied within the context of malaria. Searches were conducted on peer-reviewed databases (e.g., Medline, Web of Science), elimination programme websites, lead organisation websites (e.g., World Health Organization, or WHO) and internet search engines (e.g., Google). Key elements (footnote numbers have been removed from the excerpts below) are:

1. A global elimination plan, supported by international health bodies - e.g., "[T]he global push to eliminate lymphatic filariasis (LF) began in response to a 1997 World Health Assembly (WHA) resolution to eliminate LF by 2020. Subsequent development of the Global Programme for the Elimination of Lymphatic Filariasis (GPELF) created a momentum that resulted in 34 countries establishing elimination programmes....[E]ffective disease elimination programmes typically involve elimination plans, which have a number of common elements:
   • Clearly-defined targets: existing elimination plans define 'elimination' and identify a specific target, and time frame for achieving this target;
   • Defined strategy: effective plans provide a defined, evidence-based, technical strategy for working towards elimination, with backing from key stakeholders such as those in the areas of technical support and programme management. For example, GPELF provides an elimination strategy focusing on mass drug administration with defined targets and timeframes...;
   • Widely endorsed...by international bodies such as the World Health Assembly and key regional and national bodies...;
   • [T]arget local needs and...[are] adjusted to incorporate changes in technology, or emerging challenges. A factor attributed to the success of polio elimination in India is tailoring of the Global Polio Eradication Initiative (GPEI) to the local context, and combining this with innovative social mobilization approaches...;
   • Incorporates an endgame plan: endgame management is a key challenge for elimination programmes, especially maintaining political and financial support as the burden of disease diminishes. The Polio Eradication & Endgame Strategic Plan 2013-2018 ensures that this period is coordinated globally, and investments and elimination can be sustained in the longer term...;
   • Promotes international and regional collaboration: implementing elimination plans in border areas between endemic countries require[s] collaboration between countries, balancing national strategies with regional, or globally coordinated plans..."
2. Thorough costings and tools to support the business case - e.g., "To ensure potential donors have confidence in elimination plans, GPEI regularly invites donors to provide ongoing input...";
3. An approach that is positioned within a development framework - e.g., "In the early stages of polio elimination programmes in India and Pakistan, disparity between well-funded polio services and other health services which were poorly funded contributed to community mistrust in elimination programmes, which hampered programme success. Since this period, polio elimination plans have ensured that elimination programming augments existing health services....There are many opportunities to integrate malaria elimination advocacy within a development framework and create synergies with the development community. Malaria impacts heavily on MDG 4 (reduce child mortality) and 5 (improve maternal health), and addressing malaria has demonstrated benefits on all causes of child mortality. In addition, reducing the malaria burden can lead to improvements in health care systems, poverty, and economic development... Malaria elimination also has the potential to align with other areas of development, such as housing improvements, water, sanitation and hygiene (WASH) programmes and climate change adaptation...";
4. Core elimination advocacy messages - e.g., "'Finish the Fight' reminded donors and supporters of the importance of the endgame in polio elimination. 'Give a Human Face to Leprosy' reminds audiences about the ongoing burden of leprosy in affected countries....RBM [Roll Back Malaria] provides an example of advocacy messaging 'Sustain Gains, Save Lives: Invest in Malaria'. Such messages could be adapted for elimination advocacy, for example 'Sustain Gains Made, Protect Lives, Invest in Malaria Elimination'. Effective messages need to be: clear compelling and concise; consistent and convincing; simple and direct; and frequently reinforced by a variety of sources. Powerful language can create a sense of urgency, but should not resort to sensationalism or overpromise, as these may diminish the impact of the message and the programme. Impact can be enhanced by combining messages with a human face and a visually interesting campaign...";
5. Provision of advocacy tools for partners - e.g., "[T]he GPELF was supported by the LF Support Center, which provided a Fundraising and Advocacy Toolkit for its partners. This contains a comprehensive range of advocacy materials, such as 'Top 10 Communication Messages', a 'Checklist for Preparing an Effective News Release', and '10 Tips for Writing Letters to Government Officials'....[P]rovision of templates and key messages can ensure that elimination campaigns utilize consistent messaging. In addition, tools can increase the number of partners participating in advocacy activities, via building capacity or confidence to engage in advocacy...";
6. Extensive and effective community engagement - e.g., "During the early 2000s, there were a number of setbacks to polio elimination in India and Pakistan. Children in poor Muslim areas with poor sanitation were more likely to be missed in immunization activities due to poor understanding about the need for repeated vaccinations and emerging suspicions about programme safety. Widespread media campaigns and intense social mobilization were initiated in response....The experience from the polio elimination programme highlights how advocates for elimination can benefit from working with specialists in community engagement, social mobilization and communications. Experience from specialists in this area indicates that time required for effective community engagement is often underestimated - it is important that these processes are given adequate time and budgeting in the design phase. Strategies for engaging communities should be flexible, and adaptable to suit diverse cultural, sociopolitical, geographical and health characteristics of communities..."; and
7. Strong partnerships - e.g., "Partnerships typical of effective elimination programmes involve broad engagement, comprising major international bodies such as WHO [World Health Organization] or UNICEF [United Nations Children's Fund], national ministries of health, major donors, research and technical experts, and NGOs [non-governmental organisations]....The Asia-Pacific Malaria Elimination Network (APMEN) is an example of a country-led regional collaboration that aims to support countries adopting malaria elimination as a national or sub-national goal. APMEN works closely with RBM, global agencies, such as WHO, and many regional partners in academic, development, NGO and private sectors..."

The concluding section of the paper summarises the lessons learned as outlined above, stressing the importance of advocacy as a tool the global malaria community should turn to in the shift from control of the disease to elimination of it. The authors observe that the malaria community has a history of developing messages and communications tools; now, they say, this work should be extended to incorporate elimination targets. Furthermore, "there are a number of global and regional malaria partnerships that could provide a platform for elimination advocacy - these partnerships need to be provided with the mandate to focus on elimination, with a clear structure of coordination." Along the lines of collaboration, the authors reiterate their suggestion that advocates for malaria elimination build synergies with other types of health and social programming and engage with communities to build support and optimise local implementation to support long-term programming. "The global malaria community needs to work together, ensuring the early steps towards the end goal of malaria elimination are taken."