- El Salvador and Belize, certified as malaria-free countries, now face the challenge of sustaining elimination and preventing the reestablishment of the disease, especially in a region with high population mobility.
- With support from the IDB and partners, both countries have strengthened epidemiological surveillance, incorporated technological tools, and built capacity to rapidly detect and respond to potential cases.
- Their strategies reflect complementary approaches: El Salvador has integrated digital alerts into its health system to maintain clinical suspicion and trigger timely diagnoses, while Belize has reinforced surveillance and improved key indicators in diagnosis, treatment, and vector control to prevent reestablishment.
Eliminating malaria is not the end of the story. For El Salvador and Belize, the real challenge began after certification as malaria-free countries: consolidating progress and preventing the disease from returning. Both countries are part of a dynamic cross-border region characterized by high population mobility. In this context, sustaining elimination requires systems that can continuously detect, respond, and adapt.
The Inter-American Development Bank (IDB) and several international partners support both countries in this process through the Regional Malaria Elimination Initiative in Mesoamerica and the Dominican Republic (RMEI) by strengthening surveillance, the integration of technological tools, and the development of local capacities to sustain malaria-free status.
El Salvador: Using Digital Innovation to Respond to Suspected Cases
El Salvador was certified in 2021 as the first malaria-free country in Central America and has recorded no local cases since 2018. However, it continues to detect and manage imported cases (four in 2021, one in 2022, and seven in 2023), which keeps the risk of reestablishment alive.
Results from the first independent verification of RMEI targets confirm significant progress: 100% of confirmed cases evaluated in this phase received appropriate treatment within 24 hours of diagnosis, in accordance with national guidelines. In addition, all case investigations met quality standards, demonstrating the system’s ability to respond promptly to non-local infections.
However, in an elimination context, the challenge is critical: when a disease is no longer seen, diagnostic suspicion declines. To address this risk, the country has strengthened its surveillance network and invested in digital innovation integrated into the national health system.
Sustaining elimination requires embedding surveillance into routine clinical practice. For this reason, the Ministry of Health co-developed, together with RMEI, “Alerta SIS” a tool integrated into the electronic health record that triggers automatic reminders when a patient presents symptoms consistent with malaria and a recent travel history.
This tool prompts healthcare providers to request diagnostic testing and activates response protocols if the result is positive. In other words, it is a mechanism embedded in the routine care pathway, designed to sustain clinical awareness in a low-incidence context.
By 2025, “Alerta SIS” had been fully rolled out nationwide across El Salvador’s 31 hospitals and 654 primary healthcare facilities, becoming a piece of digital health infrastructure that strengthens surveillance and protects communities against multiple vector-borne diseases.
Belize: Strengthened Surveillance and Measurable Results
Belize was certified malaria-free in 2023 and has maintained zero local cases. However, the country recognizes that risk persists, and its post-certification strategy has focused on strengthening surveillance and systematically measuring performance across key indicators to keep cases at zero.
The proportion of suspected cases receiving diagnostic testing increased from nearly 3% in 2019 to 24% in 2025, according to a recent independent RMEI verification. This improvement is critical in an elimination context: early detection of any imported case is the first line of defense.
The quality of the information system has also improved. Laboratory reports meeting international standards increased from nearly 17% to 62%, enhancing the reliability of data for decision-making.
Treatment performance has been optimal: 100% of confirmed cases received therapy within 24 hours and completed treatment according to national guidelines. Although only two non-local cases were recorded during the evaluation period, the results demonstrate sustained operational capacity.
In vector control, the proportion of at-risk populations protected through indoor residual spraying or insecticide-treated nets increased from 28% to 69%, significantly narrowing the community protection gap.
Behind these results lies a structured strategy built on three pillars:
- Sustained political leadership to keep surveillance a national priority;
- Technical innovation, including an operational situation room for real-time analysis, an updated national surveillance manual, and six rapid response teams ready to investigate outbreaks; and
- Strengthened community capacity, with trained volunteers and health personnel able to detect suspected cases promptly.
Sustaining Elimination: Anticipating, Not Reacting
Belize and El Salvador demonstrate that elimination marks a transition into a new phase of permanent vigilance. One has consolidated measurable improvements in diagnosis, reporting, and vector protection; the other has strengthened system integration and digitalization to sustain clinical suspicion and timely response.
Both share a central principle: maintaining zero local cases is the result of systems that measure, adapt, and anticipate risk.
RMEI is funded by the IDB, the Gates Foundation, the Carlos Slim Foundation, and the Global Fund. The initiative works in coordination with the Pan American Health Organization (PAHO), the Executive Secretariat of the Council of Ministers of Health of Central America and the Dominican Republic (SE-COMISCA), Clinton Health Access Initiative (CHAI), and Proyecto Mesoamérica.