Table 4 Current challenges to scaling-up malaria control.

I. Community and household

Limited demand for malaria prevention and treatment due to lack of information, high cost, or physical inaccessibility; lack of community engagement in malaria control.

II. Health service delivery

Shortage and maldistribution of appropriately qualified staff; inadequate supply of consumables including malaria drugs, diagnostic tests, insecticide; lack of equipment and infrastructure including poor accessibility of health services; poor-quality diagnosis and treatment in public and private sectors; weak technical guidance, programme management and supervision; inequities in programme reach.

III. Health sector policy and strategic management

Weak national malaria control programmes; weak drug policies and supply systems; inadequate communication with the private sector and regulation of retail drug sales and fake drugs; weak incentives to use inputs efficiently and respond to user needs and preferences; reliance on external funding reduces flexibility and ownership; donor practices overload country management capacity

IV. Public policies cutting across sectors

Taxes and tariffs on import of malaria-related commodities; decentralization policies place responsibility where technical capacity is weak; inflexible government bureaucracy (civil service rules and remuneration; centralized management); poor availability of communication and transport infrastructure

V. Environmental and contextual characteristics

Governance and overall policy framework: corruption, weak government, weak rule of law and enforceability of contracts; political instability and insecurity; low priority attached to social sectors; weak structures for public accountability; lack of free press. Physical environment: climatic and geographic predisposition to disease; physical environment unfavourable to service delivery.