Address by Regional Director on the occasion of Malaria Elimination Certification by the Government of Sri Lanka
30 November 2016, Colombo, Sri Lanka
Hon’ble Minister of Health, Nutrition and Indigenous Medicine, H.E. Dr Rajitha Senaratne; Secretary of the Department, Mr Anura Jayawickrama; Director General of Health Services, Dr P.G. Mahipala; WHO Representative Dr Jacob Kumarasen; Staff and field workers of the Directorate of Health Service, who made this possible; Communities in far flung areas of Sri Lanka, who were proactive in their approaches; Friends from the media; Congratulations to you all.
We are here this morning to mark and celebrate Sri Lanka’s success, your success. This is a significant moment in the global effort to eliminate malaria. Following adoption of the Sustainable Development Goals and the mission of Ending Malaria by 2030 by the Head of States at the historic UN meeting in September 2015, Sri Lanka became the second country in quick succession to Maldives in the South-East Asia Region to achieve malaria-free status. This landmark victory represents the largest lower middle income country in the malaria endemic tropic to achieve elimination. I cannot overstate the magnitude of this achievement.
It is my honour to congratulate Your Excellency, the Minister of Health, Nutrition & Indigenous Medicine, Dr Rajitha Senaratne, who led this historic success and the staff of the Department of Health and most importantly the workers in the field, the front line workers, that made this possible and urge you to maintain your resolve.
On September 5, 2016 I already had the privilege of announcing, in the 69th Regional Committee, that WHO has officially certified Sri Lanka as malaria free. For the first time in its two hundred-year battle against malaria, Sri Lanka documented zero transmission for three consecutive years and qualified for this certification.
It is important for us today to go into the details of the country’s battle against malaria, to understand how such a unique achievement was possible in a developing nation with all its complexities and challenges.
In my view seven key factors have contributed to Sri Lanka’s extraordinary success.
First, a Strong Health System. Sri Lanka has some of the best indicators of health, on par, in some cases, with developed nations. Sri Lanka’s case detection in malaria accounted for around 97% of cases found and treated by the health system. This in itself is a major achievement.
Second, Focussed approach for Disease elimination for Malaria: Sri Lanka’s experience shows that a focussed approach to disease elimination remains a key to success. The universal health care system deserves much credit, but it is not enough by itself. Indeed, when a focussed strategic approach to malaria elimination was withdrawn in the late 1960s in Sri Lanka, the disease soared back from a few cases to millions.
Third, Inclusive health reaching all: Sri Lanka has demonstrated a visionary commitment to equitable access in communicable disease control. Immigrants, along with all other residents, are covered for malaria screening and treatment. Also, no region within the country, including those that were declared conflict zones, were denied malaria prevention outreach. The policy of ‘leaving no one behind’ in the context of malaria elimination indicates Sri Lanka’s commitment to equity in health and a response grounded in human rights.
Fourth, Conflict is not an excuse for public health: important factor in Sri Lanka’s success with malaria elimination is that it has not allowed civil conflict interfere with disease elimination. Sri Lanka’s achievements were made despite the challenges posed by the protracted armed conflict in the country, which began in the early 1980s. By 2000, Sri Lanka’s eight conflict-affected districts accounted for the majority of malaria infections, as anti-malaria efforts and primary health services buckled from decades of conflict.
In response, integrated vector control and treatment interventions were scaled up in the conflict-affected districts by the Anti-Malaria Campaign (AMC) Directorate and the regional malaria teams, often in partnership with non-governmental organisations and the army.
Fifth, Co-ordination and communication across sectors: Coordination across different sectors played a key role. Whenever there is a risk of malaria entering the country, whether through refugees, business travellers or fisherfolk, multi stakeholders come together for testing and treating. The security forces, airport authorities, private citizens, government are all united in their determination to keep the disease from coming back. These examples of cooperation in public health have valuable lessons for regions around the world.
Sixth, Effective partnership: Sri Lanka has gained a lot from transformative international partnerships – not only between the North and South but also South-South partnerships. The country has benefited from its partnerships with WHO, IOM, UNICEF, UNHCR, Roll Back Malaria, International Red Cross, Sri Lankan Red Cross, MSF and the Global Fund, and in turn has served as a best practice example for all its partners.
Seventh: Evidence based response to disease - Doing basics of Disease elimination right: Sri Lankan campaign began not only with an ambitious vision, but was sustained by very concrete steps. These included surveillance and active case detection, comprising both parasitological and entomological surveillance, and using mobile malaria clinics; treatment and health education and case management; vector control with integrated vector management and widespread use of bed nets; and strong policy actions and advocacy. An involved private health sector, advocacy among medical professionals, decentralized control, and an excellent cadre of field staff and coordination at every level were essential to achieve the spectacular decline in transmission. Instead of continuing to treat at-risk groups as passive recipients of government largesse, communities were also encouraged to take ownership and get involved.
Excellencies, Ladies and gentlemen,
Sri Lanka’s success did not come overnight:
Malaria has cast a long shadow for much of Sri Lanka’s history, particularly in the late 19th and early 20th centuries. Colonial authorities transformed large swathes of the countryside to meet the needs of modern farming and infrastructure projects, causing intensification of epidemic and endemic transmission. Major epidemics occurred every few years. The 1934-1935 malaria epidemic for example, killed around 80,000 people, approximately 1.5 percent of the population.
Following independence in 1948, it was clear that a determined effort to end the disease was necessary. By the time the World Health Assembly launched the global malaria eradication campaign in 1955, Sri Lanka had already made some important gains: the case-load had declined and transmission was being interrupted. In keeping with Sri Lanka’s commitment to further progress, the government was quick to join the global campaign and consolidate its gains.
A regional pioneer in adopting new techniques for indoor residual spraying or IRS, in combination with case detection, treatment and surveillance, Sri Lanka recorded just 6 cases of Malaria by local transmission in 1963. Sri Lanka, it appeared, was on the brink of a historic victory. But subsequent abandonment of eradication programme at global level and scaling back of efforts at Sri Lanka, had its toll. Low level of IRS, reduced surveillance and weakened human resources for targeted work led to the resurgence of malaria, with about 1.5 million cases in 1967-1969. Once again malaria infected whole villages and re-established itself in once-endemic areas. Sri Lanka had to struggle and live with this scourge for another 30 years.
The late 1980s ushered in the scaling up of anti-malaria efforts in the middle of some big epidemics. 1986-1987 brought more than 600,000 cases of malaria annually. A turnaround began in 1999–2000.. Across the country, malaria vector control, surveillance, and treatment interventions were scaled up. Malaria incidence fell dramatically in subsequent years — more than 90% reduction in four years’ time and a 99% reduction over eight years. There was a 68% reduction in 2000–01 alone. In 2008, for the first time, there were no indigenous malaria-related deaths in Sri Lanka. Then came the final success and Zero local transmission in the next few years.
Sri Lanka’s success has important messages for the rest of the world.
1. Integrated approach:
Lanka’s Anti-Malaria Campaign (AMC) Directorate jettisoned single vector-control methods in favour of integrated vector management. This integrated approach relied on several carefully selected interventions, including vector control in major irrigation and agriculture projects, rigorous entomological surveillance leading to targeted spraying in high-risk areas, new classes of insecticides for Indoor residual spraying, insecticide-treated nets and larval control, and strengthened parasitological surveillance for active case detection combined with rapid response compounds.
This kind of multi-sectoral approach was a tectonic shift in the history of global health for developing countries, and this kind of approach is fundamental to the achievement of Sustainable Development Goals in the future.
Thirdly, it has shown that no matter what the level of income, and no matter what the climate or geography, real and lasting change is possible with committed political leadership and proactive community involvement.
Whether in Sub-Saharan Africa or South-East Asia, Sri Lanka’s triumph over malaria has been watched and applauded. I have no doubt at all that Sri Lanka’s achievement will be a source of inspiration and learning in the global battle against malaria, while the country benefits economically from being malaria-free. Research has shown that eliminating the disease improves economic prosperity.
As we celebrate today it is also important to remember that there is no room for complacency. Zero transmission means zero time to let down our guard.
Ensuring that the country remains malaria free and is protected from reintroduction of malarial parasites requires continued efforts of surveillance within the country and efforts to help make neighboring countries malaria free as soon as possible. Unless we act wisely and rapidly, Sri Lanka has a high risk of re-establishment of malaria.
Sri Lanka’s situation remains a litmus test for the entire public health community. I am confident that the country will continue to remain vigilant, and I commit WHO’s full support to Sri Lanka’s ongoing anti-malaria campaign.
I wish you the very best in your determination to keep Sri Lanka malaria-free. Sri Lanka’s achievement is an example of how malaria control can be done right, and how countries can be freed of this burden.
My congratulations once again to Your Excellency, Dr Rajitha Senaratne, the Department of Health, its staff here and across the field, and thousands of those who have worked to see this historic day.