In order to progress to global eradication, what's most important?

In several countries, malaria has been effectively suppressed by following the First Pathway. In this pathway the effort starts by ecological modifications which minimize mosquito breeding and biting. Once the modifications in mosquito ecology and human ecology have been made, then the ephemeral and costly drugs and biocides can be used efficiently. (These countries include the USA, Puerto Rico, Italy, the Holy Land, and Turkmenistan). Conversely, if the drugs and biocides are used first, the programs are doomed, such as the WHO, RBM and US PMI programs. Furthermore these programs come from outside the endemic countries, thus also keeping the expertise and commitment outside. As soon as the outside financing falters - as is happening now - the programs collapse..... The only countries which have successfully suppressed malaria have followed this First Pathway. None of the countries which have not followed it, but rather started with the seductive and expensive drugs and biocides, have been successful. The best pathway is clear, but unfortunately it doesn't look like WHO or PMI are going to change. So we should be prepared for another collapse in the global program, as occurred with the WHO program in 1969..... It would be nice to think that we learn from our mistakes, but apparently in WHO and the US PMI that is not true.

No one single factor is most important. Taking a holistic and systematic approach that includes all of the above, and more, is the only way to achieve sustainable control, and eventually eradication. We need to move out of our silos of vector control, disease management, environmental modification, etc., view "malaria" as a system that includes humans, mosquitoes, Plasmodium and the wider environment, and take coordinated multi-disciplinary action to address it. So for me, a holistic approach is the most important factor.

It will/would probably be important to deal with (inter alia) the hypnozoite parasite reservoir. However, see the June 2015 issue of "Trends in Parasitology".

Along with political commitment we need to improve efficiency of our programs. How do we do this? There are tools used by industry that could and should be utilized by modern malaria control programs. These include: rapid reporting systems; geolocation functions for both reporting incident cases, active case finding and where interventions are located; use of decision support systems to automatically generate implementation relevant and timely information to different levels of the system. In addition, more has to be done to improve the motivation of program staff and their leadership. Again lessons can be learnt from other spheres - industry often invests heavily in leadership and incentivization of the workforce. I personally think we are barking up the wrong tree expecting malaria elimination to be reached with a single drug, vaccine or insecticide. It is more about implementation in the right place at the right time with the right tool.