Key threats to progress.

 

The year 2024 was marked by significant biological, systemic and financial challenges. Antimalarial drug resistance and P. falciparum histidine-rich protein 2 and 3 (pfhrp2/3) gene deletions continued to compromise the effectiveness of case management, while widespread insecticide resistance reduced the impact of vector control tools. Anopheles stephensi further expanded its range and is now reported in nine African countries, heightening urban malaria risks. Beyond biological threats, climate change, conflict and humanitarian crises continue to drive malaria resurgence and disrupt essential services.

■ Globally in 2024, total investments in malaria control reached an estimated US$ 3.9 billion. Based on the 2025 GTS target of $9.3B, this corresponds to a projected shortfall of about $5.4B, with only 42% of required funding attained. 

■ Between 2010 and 2024, about 67% of malaria funding came from international sources, while endemic countries supplied 33%. In 2024, about 56% of malaria funding came from international sources, with endemic countries increasing their share to 44%.

■ Widespread uptake of ITNs has been credited with leading to a 70% reduction in malaria cases in Africa between 2000 and 2015. However, most of these ITNs were treated with insecticides from one class: pyrethroids. 

■ The effectiveness of ITNs is threatened by the development of resistance to pyrethroids, which has been confirmed in 48 of 53 countries reporting on pyrethroid resistance between 2020 and 2024.

■ New-generation nets (PBO and dual active ingredient) offer superior malaria protection over pyrethroid-only nets and are becoming more widely available.

■ As of 2024, malaria parasites with pfhrp2 gene deletions have been reported in 42 endemic countries. Viet Nam reported pfhrp2 gene deletions for the first time in 2024. Although the prevalence of pfhrp2 gene deletions is still low in most countries, it exceeds 15% in Brazil, Djibouti, Eritrea, Ethiopia, Nicaragua and Peru. WHO now recommends switching to non-histidine-rich protein 2 RDTs in areas where the prevalence of deletions exceeds 5%

The spread of antimalarial drug resistance in Africa is an acute concern 

■ Antimalarial drug resistance stands among the greatest threats to sustaining progress towards malaria elimination. History of the use of chloroquine and sulfadoxine–pyrimethamine shows how quickly resistance can reverse gains when it spreads undetected or unaddressed. 

■ In the GMS, the emergence of resistance became a unifying threat that drove large-scale investment, coordinated surveillance, rapid data sharing and policy change. Countries that were once the epicentre of resistance, including Cambodia, the Lao People’s Democratic Republic and Viet Nam, are now close to eliminating P. falciparum malaria. 

■ In Africa, P. falciparum Kelch13 (PfKelch13) gene mutations associated with artemisinin partial resistance have emerged from multiple independent origins and are spreading. Artemisinin partial resistance has been confirmed in Eritrea, Rwanda, Uganda and the United Republic of Tanzania, and suspected resistance has been reported in Ethiopia, Namibia, the Sudan and Zambia. In some high transmission settings, such as Uganda, more than half of parasites have been found to carry mutations associated with artemisinin partial resistance. 

■ Therapeutic efficacy studies (TES) indicate that artemisinin-based combination therapies (ACTs) are still able to cure most infections across Africa, but the repeated emergence and spread of artemisinin partial resistance point to rising drug pressure and increasing vulnerability of partner drugs, especially lumefantrine and amodiaquine, in a context where treatment depends on a limited number of combinations.

■ The private sector is a major source of malaria care in many endemic countries, with more than 60% of children with fever seeking treatment from private providers in Benin, Cameroon, Chad, the Democratic Republic of the Congo and Gabon. These outlets expand access to care, but limited diagnostic testing, presumptive treatment, incomplete courses and circulation of non-approved or poor-quality antimalarials create conditions that favour the emergence and spread of resistant parasites. 

■ In 2022, WHO launched its Strategy to respond to antimalarial drug resistance in Africa, aiming to improve detection and timely responses, delay the emergence of resistance to artemisinin and ACT partner drugs, and limit the spread of resistant parasites where they are already established. 

■ An effective response must be adapted to local contexts and reflect where people actually seek care, supported by strong regulation, better quality assurance and active engagement of providers across public and private sectors. Incorporating new tools and strategies, including the use of multiple first-line therapies, will be important to reduce drug pressure and slow the spread of resistant parasites. Several countries, including Burkina Faso, Eritrea, Malawi, Rwanda and Uganda, are now adapting the WHO strategy to their specific needs. 

■ Timely, high-quality surveillance of drug efficacy and resistance, expansion of molecular surveillance, rapid sharing of data and quality case management across both public and private sectors, supported by sustained financing and coordinated action across countries and sectors, are central to detecting and limiting the impact of resistance.

■ Originally native to parts of southern Asia and the Arabian Peninsula, the invasive mosquito species An. stephensi has been expanding its range over the past decade, with detections reported to date in nine African countries. In 2024, An. stephensi was reported for the first time in the Niger. ■ An. stephensi thrives in urban settings, endures high temperatures and is resistant to many of the insecticides used in public health. ■ In 2022, the WHO initiative to stop the spread of Anopheles stephensi in Africa was launched to raise awareness of this growing threat and catalyse existing efforts by WHO Member States and partners to stop the further spread of An. stephensi in Africa.

■ The zoonotic parasite P. knowlesi, initially found in monkeys, is known for its rapid and severe onset of infection, which has a human fatality rate of 1–2%. Globally, there were 2164 reported cases of P. knowlesi infection in 2024, a decrease of 34% compared with 2023, when 3290 cases were reported. Most of the cases (89%) were in Malaysia, followed by Indonesia (6%), Thailand (4%) and Cambodia (0.5%). 

■ In 2024, Malaysia reported 1927 cases – a 33% decline in indigenous P. knowlesi cases from 2023 – and three P. knowlesi deaths, down from 14 in 2023. 

■ The four P. knowlesi cases detected in malaria free Brunei Darussalam highlight the importance of maintaining strong surveillance systems.