Responding to malaria in urban areas: a new framework from WHO and UN-Habitat

Dr Abdisalan Noor leads the Strategic Information for Response unit within WHO's Global Malaria Programme. He is also the technical lead for the development of the new Global framework for the response to malaria in urban areas.

Malaria is normally considered a disease that impacts people living in rural areas. Why are WHO and UN-Habitat now focusing on malaria in urban settings?

First of all, we know that malaria is and will continue to be a major problem in rural areas. So today and into the future, malaria is likely to be concentrated among rural populations. Having said that, we are also seeing a rapidly urbanizing world in which most people in malaria-affected countries will soon be living in urban areas. If you take the example of Nigeria, which accounts for about a quarter of the global burden of malaria, nearly half of the population is already living in urban areas.

Overall, we expect that well-planned urbanization will reduce the transmission of malaria through, for example, the destruction of aquatic habitats of mosquitoes and expanded access to health care. However, unplanned urbanization will likely result in a malaria disease burden that is disproportionately high among the urban poor; they are at greater risk of becoming infected, less able to access quality health services, and suffer the most from the impact of becoming ill. Approaches that work to reduce disease burden in rural areas may not work in urban settings, or may need to be implemented at a smaller, more targeted scale. The use of granular data, therefore, becomes essential.

The invasion of mosquito species that adapt easily to urban environments may heighten the risk of malaria and other vector-borne diseases in these areas. WHO recently launched an initiative to stop the spread of one such species, Anopheles stephensi, in Africa.

Taken together, the response to malaria in urban areas is one that needs to be driven by how we manage urban development itself, and then we can build other interventions on the back of that, especially when it comes to prevention.

Rate of urban growth of population in Africa and Asia

What is the aim of the new framework, and who is the target audience?

The new Global framework for the response to malaria in urban settings is designed to provide guidance to city leaders, health programmers and urban planners as they work to control and eliminate malaria in a rapidly urbanizing world. For each urban context, the strategic use of data can inform effective, tailored responses and help build resilience against the threat of malaria and other vector-borne diseases.

Under the umbrella of the New Urban Agenda, which is aligned with the Sustainable Development Goals, the framework calls for strong partnership and a multi-programme approach. And, for this reason, WHO has collaborated with UN-Habitat to jointly develop and disseminate this framework. The framework was developed as part of a Memo of Understanding between WHO and UN-Habitat signed in 2021 aimed at improving urban health.

Is there a specific intervention needed to address this issue?

There is not one specific intervention for this area of work. The malaria response should be embedded into the broader urban development plan, as well as the broader urban health agenda.

The framework acknowledges that malaria in urban areas must be part of the urban development discourse, and the malaria prevention response is built on the management of the urban environment. So, for example, adequate housing, piped water, better drainage and a cleaner environment contribute to malaria reduction in a much more fundamental way than some of our malaria interventions.

And so, we are shifting the discourse and thinking around the urban malaria response to one that is critically multisectoral; it is a response that is very much led by urban governments, and not something that falls only within the purview of national malaria control programmes, whose role is to provide technical support to the overall malaria response.

While some key interventions, such as diagnostics and treatment, are needed in urban as in rural settings, the framework focuses on challenges in providing access to quality healthcare - particularly for the urban poor. When it comes to prevention, mass distributions of bed nets and indoor residual spraying (IRS) in urban settings are not likely to be rational or cost-effective; there will need to be a move towards a microstratification approach in which data on malaria risk and its determinants at granular and operationally relevant levels are used to tailor interventions to the local context.

Has WHO issued specific recommendations to control malaria in urban settings?

First, it is important to differentiate between what WHO considers "recommendations" and the guidance provided in this framework. WHO recommendations are based on a strict process of evidence and trials from other sources, which are then published in WHO's consolidated guidelines.

After WHO has published recommendations, the expectation is that they are adapted by countries to their specific context. Through the new framework, we are trying to: a) tap into the existing malaria recommendations and explain how they can be adapted for urban settings, and; b) emphasize the role that environmental management can play in controlling the built environment so that development in urban settings is geared towards "building out" malaria and other vector-borne diseases. Importantly, the framework highlights the need to integrate responses to both malaria and other vector-borne diseases in urban settings.

What are some of the challenges associated with responding to malaria in urban settings?

There are many challenges. We are dealing with a very clever set of vectors and parasites that cause malaria transmission. We are dealing with the challenges of social inequity - an issue found in both rural and urban settings. We are dealing with rapid and often unplanned urbanization in malaria endemic countries. And then, of course, we are dealing with a lack of financial and other resources.

There are also challenges related to high levels of human mobility. As people infected with malaria move into urban settings, they can put a strain on local health systems and can also contribute to sustained malaria transmission within some urban communities. However, these imported malaria cases are often poorly captured in surveillance systems. Until the publication of this framework, there had been a lack of globally endorsed guidance on how to address malaria in urban areas; there was no clear guidance for countries.

But there are also major opportunities ahead of us.

• First, there is an increased recognition that the future of humanity is one in which urbanization will play a significant role. Models estimate that in a decade or 2, most of the global population will live in an urban environment. This has led to a need to start thinking about how to create healthy cities and healthy lives within those cities.
• Secondly, the urban environment is where most national economies are based; it is where you have some of the most highly skilled employees and a significant private sector presence. These skills and sectors can be leveraged to respond to a particular threat - in this case, malaria in urban areas. Urban settings are also increasingly becoming technological hubs, and innovation can be brought to bear on this particular challenge.
• Finally, there is a clear recognition that our current approach of doing the same things in both urban and rural areas will not work well in most instances, and we need new approaches.

Are there other key messages from the framework that you would like to share with readers?

This framework recognizes that the rate of urbanization is happening everywhere, and particularly in malaria-endemic settings. It is aligned with WHO's call for interventions that are data-driven and tailored to the local context.

The framework acknowledges that malaria prevention should be built firmly on a foundation of managing the urban environment holistically. As such, it recognizes the critical role played by urban governments and the importance of integrating urban malaria responses within the broader urban health agenda. And it spotlights the importance a multisectoral approach, with communities at the centre.

We know that malaria transmission is often concentrated in pockets within urban areas; interventions and strategic approaches must be designed to respond to what is essentially focal malaria transmission in most settings.

And we need to be cognizant of the fact that there are several other vector-borne diseases in urban settings that also have similar transmission patterns. We will achieve our most effective results if we integrate malaria responses with broader efforts to address these other diseases.

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