Background The post-2000 period in South America presents a striking divergence in malaria epidemiology: Ecuador achieved a >99% reduction in malaria incidence approaching elimination, while Venezuela experienced one of the most severe resurgences in modern public health history. We examined the association between governance factors, health policies, intersectoral coordination, and malaria control outcomes by comparing the national experiences of Ecuador and Venezuela. Methods We conducted a comparative ecological study using epidemiological data from WHO World Malaria Reports and PAHO updates (2000–2023), integrated with political stability indices, health expenditure data, GDP per capita, poverty rates, and crude-oil price series from World Bank and CFR databases. A joinpoint (segmented) regression model was applied to each country’s log-transformed malaria incidence time series to identify statistically significant inflection points and estimate annual percentage change (APC) per segment. A multi-dimensional framework assessed governance, health-system capacity, surveillance infrastructure, intersectoral coordination, and community engagement. We also examined systemic fragility through concurrent infectious disease trends (diphtheria, measles, tuberculosis) in Venezuela. Use of AI language models is declared in the Methods. Results Ecuador reduced cases from 106,641 (2001) to 757 (2023), a 99.3% reduction. The joinpoint model identified two significant inflection points (2008, 2014) delineating three phases of declining trend (APC: <InlineEquation ID="IEq1"><EquationSource Format="TEX">$-34.2\%$</EquationSource><EquationSource Format="MATHML"><math><mrow><mo>-</mo><mn>34.2</mn><mo>%</mo></mrow></math></EquationSource></InlineEquation>, <InlineEquation ID="IEq2"><EquationSource Format="TEX">$-12.5\%$</EquationSource><EquationSource Format="MATHML"><math><mrow><mo>-</mo><mn>12.5</mn><mo>%</mo></mrow></math></EquationSource></InlineEquation>, <InlineEquation ID="IEq3"><EquationSource Format="TEX">$-1.2\%$</EquationSource><EquationSource Format="MATHML"><math><mrow><mo>-</mo><mn>1.2</mn><mo>%</mo></mrow></math></EquationSource></InlineEquation>). Venezuela experienced a 1,217% increase from 35,500 (2000) to a peak of 527,627 (2018); a single joinpoint at 2014 marked a shift from non-significant endemic transmission (APC: <InlineEquation ID="IEq4"><EquationSource Format="TEX">$+2.8\%$</EquationSource><EquationSource Format="MATHML"><math><mrow><mo>+</mo><mn>2.8</mn><mo>%</mo></mrow></math></EquationSource></InlineEquation>, <InlineEquation ID="IEq5"><EquationSource Format="TEX">$p = 0.12$</EquationSource><EquationSource Format="MATHML"><math><mrow><mi>p</mi><mo>=</mo><mn>0.12</mn></mrow></math></EquationSource></InlineEquation>) to explosive resurgence (APC: <InlineEquation ID="IEq6"><EquationSource Format="TEX">$+84.6\%$</EquationSource><EquationSource Format="MATHML"><math><mrow><mo>+</mo><mn>84.6</mn><mo>%</mo></mrow></math></EquationSource></InlineEquation>, <InlineEquation ID="IEq7"><EquationSource Format="TEX">$p < 0.001$</EquationSource><EquationSource Format="MATHML"><math><mrow><mi>p</mi><mo><</mo><mn>0.001</mn></mrow></math></EquationSource></InlineEquation>), temporally coinciding with the global crude-oil price collapse and ensuing fiscal contraction. Post-2018 case declines in Venezuela are accompanied by concurrent surveillance collapse, mass emigration, and reduced care-seeking, suggesting underreporting rather than epidemiological improvement. Pearson correlations with malaria incidence were observed for political stability index (<InlineEquation ID="IEq8"><EquationSource Format="TEX">$r = -0.85$</EquationSource><EquationSource Format="MATHML"><math><mrow><mi>r</mi><mo>=</mo><mo>-</mo><mn>0.85</mn></mrow></math></EquationSource></InlineEquation>), health expenditure (% GDP, <InlineEquation ID="IEq9"><EquationSource Format="TEX">$r = -0.78$</EquationSource><EquationSource Format="MATHML"><math><mrow><mi>r</mi><mo>=</mo><mo>-</mo><mn>0.78</mn></mrow></math></EquationSource></InlineEquation>), poverty rate (<InlineEquation ID="IEq10"><EquationSource Format="TEX">$r = +0.82$</EquationSource><EquationSource Format="MATHML"><math><mrow><mi>r</mi><mo>=</mo><mo>+</mo><mn>0.82</mn></mrow></math></EquationSource></InlineEquation>), and crude-oil price (<InlineEquation ID="IEq11"><EquationSource Format="TEX">$r = -0.89$</EquationSource><EquationSource Format="MATHML"><math><mrow><mi>r</mi><mo>=</mo><mo>-</mo><mn>0.89</mn></mrow></math></EquationSource></InlineEquation>) in Venezuela. These correlations should be interpreted with caution given potential confounding and collinearity among indicators. Comparison across five governance-resilience domains using PAHO/WHO operational criteria shows systematic differences between countries. Resurgence of diphtheria (>1,600 cases), measles (>7,300 cases), and tuberculosis (near-doubling of incidence) in Venezuela occurred concurrently with the malaria resurgence. Conclusions Health-system resilience and governance quality appear to be associated with the relationship between macroeconomic shocks and epidemiological outcomes. The strong collinearity between political stability and commodity-price cycles in Venezuela precludes definitive attribution to either factor independently. Technical interventions may be insufficient without stable governance, protected financing, and institutional continuity. Recommendations aligned with the PAHO malaria elimination framework are provided.

Political stability, health system resilience, and macroeconomic shocks as factors associated with malaria control outcomes: a comparative analysis of Ecuador and Venezuela (2000–2023)

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2026年6月20日

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Jose Daniel Sanchez Redroban,
Maria Cristina Mideros Mora,
Melissa Jaramillo Pérez

摘要

Background

The post-2000 period in South America presents a striking divergence in malaria epidemiology: Ecuador achieved a >99% reduction in malaria incidence approaching elimination, while Venezuela experienced one of the most severe resurgences in modern public health history. We examined the association between governance factors, health policies, intersectoral coordination, and malaria control outcomes by comparing the national experiences of Ecuador and Venezuela.

Methods

We conducted a comparative ecological study using epidemiological data from WHO World Malaria Reports and PAHO updates (2000–2023), integrated with political stability indices, health expenditure data, GDP per capita, poverty rates, and crude-oil price series from World Bank and CFR databases. A joinpoint (segmented) regression model was applied to each country’s log-transformed malaria incidence time series to identify statistically significant inflection points and estimate annual percentage change (APC) per segment. A multi-dimensional framework assessed governance, health-system capacity, surveillance infrastructure, intersectoral coordination, and community engagement. We also examined systemic fragility through concurrent infectious disease trends (diphtheria, measles, tuberculosis) in Venezuela. Use of AI language models is declared in the Methods.

Results

Ecuador reduced cases from 106,641 (2001) to 757 (2023), a 99.3% reduction. The joinpoint model identified two significant inflection points (2008, 2014) delineating three phases of declining trend (APC: $-34.2\%$ $- 34.2 %$ , $-12.5\%$ $- 12.5 %$ , $-1.2\%$ $- 1.2 %$ ). Venezuela experienced a 1,217% increase from 35,500 (2000) to a peak of 527,627 (2018); a single joinpoint at 2014 marked a shift from non-significant endemic transmission (APC: $+2.8\%$ $+ 2.8 %$ , $p = 0.12$ $p = 0.12$ ) to explosive resurgence (APC: $+84.6\%$ $+ 84.6 %$ , $p < 0.001$ $p < 0.001$ ), temporally coinciding with the global crude-oil price collapse and ensuing fiscal contraction. Post-2018 case declines in Venezuela are accompanied by concurrent surveillance collapse, mass emigration, and reduced care-seeking, suggesting underreporting rather than epidemiological improvement. Pearson correlations with malaria incidence were observed for political stability index ($r = -0.85$ $r = - 0.85$ ), health expenditure (% GDP, $r = -0.78$ $r = - 0.78$ ), poverty rate ($r = +0.82$ $r = + 0.82$ ), and crude-oil price ($r = -0.89$ $r = - 0.89$ ) in Venezuela. These correlations should be interpreted with caution given potential confounding and collinearity among indicators. Comparison across five governance-resilience domains using PAHO/WHO operational criteria shows systematic differences between countries. Resurgence of diphtheria (>1,600 cases), measles (>7,300 cases), and tuberculosis (near-doubling of incidence) in Venezuela occurred concurrently with the malaria resurgence.

Conclusions

Health-system resilience and governance quality appear to be associated with the relationship between macroeconomic shocks and epidemiological outcomes. The strong collinearity between political stability and commodity-price cycles in Venezuela precludes definitive attribution to either factor independently. Technical interventions may be insufficient without stable governance, protected financing, and institutional continuity. Recommendations aligned with the PAHO malaria elimination framework are provided.