Rwanda held its First Rwanda Malaria Forum on the theme, “Towards Malaria Pre-Elimination: How to Sustain Achievements and Get to Zero Malaria Deaths in Rwanda,” from the 26-28 September at the Serena Hotel in Kigali. Rwanda is currently working to control malaria and towards pre-elimination by 2017. The objective of the forum was “to review, align, and coordinate strategies according to the current malaria situation and articulate tangible actions that will be taken to accelerate the process on how to get to zero death due to malaria” (RMOPDD, 2012). Over the course of three days, officials from the Rwandan Ministry of Health and local partners listened to presentations by malaria professionals from organizations and countries around the world. Topics of discussion included prevention, case management, epidemiological surveillance and M&E, and cross-border collaboration.
Rwanda has achieved significant reductions in the burden of malaria, especially in the last two years. Between 2005 and 2010, malaria incidence decreased by 96%, morbidity declined by 87%, mortality fell 74%, and slide positivity rate was reduced by 71%. However, gains are fragile. Rwanda experienced a nationwide upsurge in malaria cases when the failure to replace long-lasting insecticide-treated bed nets in 2009 led to a decline in effective universal coverage. Further, Rwanda’s malaria profile is still very uneven. 40% of the malaria burden is concentrated in one district, while 10 districts retain 80% of the burden. Eight of the 10 high-burden districts are located on the border with neighboring countries. Rwanda faces the challenge of controlling malaria in the context of cross-border movement and importation of malaria.
The global history of malaria response has experienced three distinct phases. In light of the success with eradicating other illnesses, the international community turned to malaria. Yet efforts with malaria eradication failed and the international community settled on the less ambitious goal of control. Recently, the global community has been challenged to finally eliminate this old scourge. Unlike eradication, which is a permanent reduction on a global scale of a specific agent, such as a parasite, elimination is defined as “interruption in a defined geographical area of local mosquito-borne malaria transmission, i.e. zero incidence of locally-contracted cases” (WHO, 2010). Elimination requires continued measures to prevent re-establishment of transmission, and the use of the phrase “towards elimination” implies a series of steps to reach it. There is a conceptual and programmatic shift that occurs as countries move from control to elimination: approaches expand from country to regional; interventions are replaced by cross-border initiatives and change from universal to focal; the focus on commodities procurement and management shifts to systems strengthening, particularly of information and M&E systems; cases are classified as imported, no longer autochthonous; and detection becomes active instead of passive.
As we know, malaria elimination requires time and commitment. Rwanda can learn a lesson from Morocco, a country that took more than 50 years with many lapses to finally achieve elimination. Many countries have experienced a plateau as commitment stalls and focus shifts in response to progress. To build upon a previous challenge made by Melinda Gates in 2007, I urge volunteers and partners to re-motivate themselves to continue the fight against malaria, not only through challenging times when movement stalls, but perhaps more importantly, when momentum wanes as countries progress towards elimination. Peace Corps Volunteers have demonstrated their unique role and understanding of the last mile; perhaps we have a new last mile where we can establish ourselves as countries near the finish line towards elimination. Sustained gains and continued effort is how elimination will be achieved. Peace Corps Volunteers- continue to be a voice of encouragement and example of determination in the marathon towards elimination. In the aftermath of the First Malaria Forum in Rwanda, we eagerly await the release of the Malaria Strategic Plan for the period 2012 to 2017, a document that will define the malaria field in Rwanda and determine the direction of our efforts.