Global malaria programmes have helped to save an estimated 14 million lives between 2000 and 2024, but growing drug resistance is threatening to undermine years of hard-won gains, a new World Health Organization (WHO) report has shown.

Last year, the world recorded 280 million malaria cases and more than 600,000 deaths, with Africa accounting for 95% of the total burden. 

Nearly two-thirds of all infections and deaths occurred in just 11 African countries, underscoring the concentration of the disease in the world’s most vulnerable regions.

At a WHO press briefing on Tuesday, officials stressed that malaria elimination remains achievable even as the path narrows.

“It is good to recall that malaria can be eliminated,” said Dr Daniel Ngamije, director of malaria and neglected tropical diseases at WHO. “To date, 47 countries and one territory have been certified malaria-free.” 

But he warned that global momentum is slowing as multiple crises converge. Once-steady progress has stalled, driven by drug resistance, climate change, conflict, inequity and weakening health systems, according to the report.

Drug resistance intensifying

One of the most serious threats highlighted in the report is rising drug resistance, particularly to artemisinin, the backbone of first-line malaria treatment. Eight African countries have either confirmed or suspected partial artemisinin resistance, echoing earlier treatment failures, including the collapse of chloroquine’s efficacy in the late 20th century, said Dr Arnaud Le Menach, WHO’s unit head for strategic information for impact and lead author of the report.

Artemisinin partial resistance refers to a delay in clearing malaria parasites from the bloodstream following treatment with an artemisinin-based combination therapy (ACT). As a result, the artemisinin compound becomes less effective in eliminating all parasites within the expected three-day period among patients infected with partially resistant strains.

This resistance affects only one stage of the parasite cycle in humans, known as the ring stage. For this reason, WHO describes the phenomenon as “partial resistance,” reflecting its time-limited and cycle-specific nature. 

It remains unknown whether this resistance could evolve further, eventually affecting other parasite stages. Full artemisinin resistance has not been reported. Le Menach added that WHO is also detecting possible signals of declining efficacy in the partner drugs used alongside artemisinin.

Outside Africa, however, there are signs of progress. Countries such as Laos and Cambodia, once global centres of drug resistance, are now nearing malaria elimination. 

“So there is hope,” he said, noting that sustaining gains will require stronger community engagement, reliable diagnostics and tighter regulation to prevent the circulation of substandard malaria medicines.

“We have seen this story before,” said Dr Martin Fitchet, chief executive officer of Medicines for Malaria Venture (MMV). “The collapse of chloroquine in the 1980s and 1990s was not a medical issue it was a humanitarian disaster. We lost millions of lives, especially children. In fact, this was the reason MMV was founded in 1999, to ensure that through a public-private partnership, this should never happen again.”

“Today, we can see the red lights flashing again,” he said. “With resistant mutations rising in the African region, we need to prolong the resilience and effectiveness of malaria medicines.” He stressed the importance of taking the pressure off artemisinin-containing drugs and the partner drugs that support and protect them. 

“However, history and biology tell us that these measures will eventually be insufficient to prevent outright drug failure. At the end of the day, that is an evolutionary certainty,” Fitchet added. He added that long-term victory over malaria depends on developing the next generation of antimalarials. 

Progress is underway: Phase 3 data were recently presented on the first non-artemisinin therapy in 25 years, ganaplacide, combined with lumefantrine. 

Developed by Novartis in partnership with MMV, global research teams and donors, the combination known as GanLum has shown efficacy comparable to the current standard of care. Early evidence also suggests it may be able to kill drug-resistant parasites and block transmission, offering a critical new option at a time of growing resistance.

Funding shortfalls threaten progress

Funding shortfalls remain one of the biggest threats to malaria control. In 2024, an estimated $3.9 billion was invested in malaria prevention, less than half of what is required under WHO’s Global Technical Strategy for 2025.

This underfunding, combined with reductions in official development assistance, disruptions to health services, stockouts and delays in routine surveillance, poses “a severe risk” of increased outbreaks this year and next. “The main risk with the funding cuts is affected surveillance,” said Le Menach. “

This year, a lot of our surveillance and surveys have been affected, and there is a risk that information provided through surveillance will not be as accurate as it should be.”He added that initiatives are underway to ensure that key country-level surveillance functions can be maintained so data quality is not compromised.

Ngamije stressed that surveillance is central to malaria response. Member states have recommended it as a “co-intervention,” he said, because data-driven decision-making depends on tracking mortality, detecting outbreaks and measuring the impact of interventions.“

We cannot fight an enemy we do not know,” he said. “We cannot track the impact of our investment without surveillance. Investment in surveillance is part of the co-intervention to fight malaria.”Ngamije noted that when funding shrinks, countries often prioritise commodities such as medicines and diagnostic kits. “This makes sense,” he said. “But there should always still be resources to keep investing in surveillance.

Vaccine rollout

The vaccine rollout is another area where progress and pressure now collide. “We have seen a rapid uptake of vaccines,” said Dr Rafiq Okine, technical officer for malaria vaccines at WHO. “At the end of 2024, there were 17 countries that had introduced malaria vaccines.”

But he warned that the biggest challenge in 2025 will be navigating shrinking funding. Countries need sustained support to expand vaccination to all areas where it is needed most, he added. Without stable financing, vaccine introduction risks slowing just as demand is rising.

Image Credits: WHO.