Malaria: the stall nobody expected
For fifteen years the world drove malaria down with a $5 net. Then, around 2019, the cheapest win in global health stopped winning. This is what the data shows.
This is one of the great success stories of twenty-first-century global health — and then it isn't.
In 2000, malaria killed an estimated 864,000 people a year, most of them children under five in sub-Saharan Africa. Over the next two decades that number fell hard: to 578,000 by 2015, and to 567,000 by 2019. A third of the annual death toll, gone.
The tool that did most of the work costs about five dollars.
An insecticide-treated bednet is among the lowest cost-per-life-saved interventions ever measured — the reason malaria control became the textbook case for spending where the money goes furthest. Hundreds of millions of nets went out. Incidence followed deaths down: from about 80 cases per 1,000 people at risk in 2000 to 58 by 2019. The cheap thing worked.
Look closely at the years just before 2020, though, and the fall is already losing steam.
Between 2015 and 2019 deaths barely moved — 578,000 to 567,000, a rounding error next to the drop that came before. Incidence flattened too. The easy gains were saturating. The line was quietly running out of road before anything dramatic happened.
Then came 2020.
COVID-19 disrupted net campaigns, diagnosis, and treatment across the endemic world. Malaria deaths jumped to 621,000 — the first real increase in a generation — and incidence ticked back up to 60 per 1,000. A pandemic of one disease had set back the fight against another.
The story people expected was a COVID dip and a rebound. That is not what happened.
Five years on, malaria has not recovered. Deaths in 2024 stood at about 610,000 — essentially where they were in 2012. A decade of progress, erased and not regained. Incidence has kept climbing, to 64 per 1,000, higher than at any point since 2011. The nets are still shipping. The line is going the wrong way.
Why does the cheapest win in global health stall while you keep buying it?
Three forces, mostly. Mosquitoes evolved resistance to the pyrethroids the nets are treated with, so each net saves fewer lives than it used to. Populations in the highest-burden countries kept growing, so holding the *rate* steady means more cases. And funding never scaled to match. The marginal net is doing less work than the first — the cost per life saved is quietly rising as the problem gets harder.
There is a genuinely new tool. After a century of effort, two malaria vaccines — RTS,S, recommended by the WHO in 2021, and R21 in 2023 — are now rolling out to children in the worst-hit countries.
But a vaccine is a complement to the net, not a replacement, and it arrives into the same headwinds of resistance and thin financing. The lesson the chart teaches is the uncomfortable one behind this whole dashboard: a cheap, proven intervention does not stay winning on its own. The wins have to be re-bought, every year, against a problem that pushes back.