Turning the tide against malaria in high-burden African countries: Trends, threats, and solutions.

Despite decades of progress, malaria continues to impose an outsized health and economic burden in High Burden to High Impact (HBHI) countries. Using World Health Organization (WHO) data from 2015-2024, we analyzed epidemiological trajectories with the Mann-Kendall (MK) trend test, which handles heteroscedastic data, identified persistent bottlenecks, and assessed the effectiveness of current strategies. Actionable solutions have also been proposed for better control. Our analysis reveals sustained increases in malaria cases in five HBHI countries, namely Nigeria (MK statistics = 3.94, p = 0.002), the Democratic Republic of the Congo (MK statistics = 3.76, p = 0.002), Cameroon (MK statistics = 3.40, p = 0.005), Uganda (MK statistics = 2.86, p = 0.02), and Mali (MK statistics = 2.50, p = 0.04). Mortality trends remain heterogeneous and mostly non-significant across settings. These countries are facing the emerging of WHO biological threats to malaria control (antimalarial drug resistance, insecticide resistance, pfhrp2 gene deletions, and Anopheles stephensi invasion), which intersect with silent challenges such as climate change, armed conflict, and population displacement, likely further complicating control efforts. Cabo Verde was recently certified malaria-free, underscoring that elimination remains attainable. A priority strategic recommendation emerging from this work is the strengthening of integrated, real-time malaria surveillance and response system, as well as the need to evaluate the impact of emerging hurdles (e.g., climate change). Achieving the WHO Global Technical Strategy target of ≥90% reduction in malaria burden by 2030 in HBHI countries is ambitious but feasible if locally driven, multisectoral solutions are implemented with urgency and sustained commitment.