The elderly population and economic growth have been a contentious topic among researchers. Regardless of the economic growth rate, the population and its growth have a stimulating influence on economic development. This study aims to explore the relationship between the elderly population and economic growth in 15 Asian countries, based on secondary data gathered from the WDI (World Development Indicators) from 1961 to 2021. This research contributes to filling the empirical gap, capturing the Granger causality concerning the relationship between the elderly population and economic growth in the Asian context in a single study. The empirical findings highlighted a one-way Granger causality from economic growth to the elderly population for India, Japan, Malaysia, and Singapore while vice versa for Bangladesh, China, and Pakistan. Furthermore, for Nepal, there is a two-way Granger causality, while there is no Granger causality for remaining countries. To the best of the authors’ knowledge, this study has been the first to investigate the relationship between the elderly population and economic growth for Asian nations, using a lengthy data series and a Granger causality test. The main findings will assist the governments, policymakers, and foreign investors in effective decision-making in this regard. The elderly population of a country can either be a blessing or a burden . The ADBLin and Wang  highlighThe objective of this paper is to identify the relationship between economic growth and ageing population in Asian countries. Cross-country empirical studies investigating the relationship between ageing populations and economic growth in the Asian region are limited. As such, this research differs from existing studies to date and contributes to the literature in three ways.Firstly, this research study covers numerous countries in the Asian continent, with the latest data collected over a long period. Only a very few studies have been conducted so far for the Asian region, even for a short period. Thus, this study is unique in terms of the extent to which the countries and years are covered. Secondly, a country-wise analysis has been conducted for all the countries considered, which would allow the researchers to compare the behaviour of the two variables among various countries. The study findings provide valuable insights into the effectiveness of the policies implemented by various governments in the past years. Finally, the economic boom experienced over the past few decades by most Asian countries resulted from a large portion of working-aged people contributing to the economy. Most of them have reached or are reaching their old age at present. Findings in this study would be beneficial for such nations to implement policies to get the aged to continue contributing to the national economies or propose initiatives where there is a tendency to do so.The rest of the paper is structured in the following manner. Section 2 presents a review of previous studies on the association between the elderly population and economic growth. The data and methodology are detailed in Section 3. The empirical results and their interpretations are presented in Section 4, and the study concludes with policy implications in Section 5.By 2030, the global ageing population, particularly in Asia, is expected to reach at least 30% of the total population . While iEven though the growing proportion of elderly people in the population may not enhance economic performance in the short term, it may contribute to economic growth in the long run. This could be attributed to the accumulation of capital and assets, and the consumption patterns of the elderly in developing nations. Specifically, the increase in life expectancy and age of retirement may improve the employability of elderly workers, hence increasing their household income and consumption. Therefore, the elderly population has a favourable impact on economic growth according to findings of previous scholars –14. NeveIn terms of the South Asian region, India and Bangladesh have a record high of over 8% of the ageing population in the region. However, as Huang, Lin  showed, China’s economic growth rate during the past three decades was among the highest globally . HoweverOne of the Asian region’s heightened growth potentials relies on Southeast Asia, where it showcases more than 67% of the ageing population. This is where even the population above 60 continually works within the society, primarily on some entrepreneurial ventures, especially in countries such as Thailand, Taiwan, and Indonesia, where the ageing population continues to work past their prime years. Countries such as Japan tend to have a very high orientation towards work, and this is illustrated by their focus on having a high level of life expectation . AccordiOver 6%–15% of the ageing population is evident in the volatility of Asian societies, as  highlighIt is well known that the elderly population in East Asian countries plays a vital role in economic prosperity. In contrast, the working elderly population in this region exceeds the working younger population . Moving Macroeconomic performance in Asia, and especially East Asia, is closely monitored by variations in age structure brought on by demographic shifts, according to Bloom, Canning . FurtherAccording to conventional economic theory, an ageing population may decelerate/slow down the economy. An ageing population is a factor that can dampen economic expansion, according to the life cycle theory advanced by Modigliani . The lifIn addition, according to Solow’s growth theory, an ageing population makes it harder for a nation to maintain steady economic growth. If the population’s age distribution is constant/stays the same, it can be assumed that the economic growth is stable or the economy is steady. Nonetheless, the age structure of an economy is unpredictable as the population ages. As such, this scenario is practicable only when the economy moves closer to its stable state. According to this view, a country’s economy would suffer if its population continues to age .According to Mohd, Ishak , the risRašticová, Birčiaková  show thaMany empirical studies have examined the ageing population’s impact on economic growth, with contradictory findings. Studies have identified a negative correlation between an ageing population and economic growth, and one such research was by Brendan and Sek . They usIn contrast, research studies have shown a positive correlation between ageing population and economic expansion, as per Brendan and Sek . AccordiThis research questions about the relationship between the elderly population and economic growth. Furthermore, the objective of this paper is to identify the relationship between economic growth and ageing population in Asian countries. As a result, this study differs from earlier research and adds to the body of knowledge in three ways.To begin, this research study spans several Asian countries, using the most recent data collected over a long period of time. Even for a brief period, very few studies have been conducted thus far for the Asian region. In light of how extensively the countries and years are covered, this study is exceptional. Furthermore, a country-wise analysis has been conducted for all the countries considered. Accordingly, this research contributes to filling the empirical causality by capturing the Granger causality concerning the research problem. Granger causality is a method for determining the relationship between two variables. "Causality" is related to the cause and effect concept, but it is not the same. It is a statistical concept based on forecasting.Although there is sufficient literature on the relationship between the elderly population and economic growth, it is known that the relationship changes as a result of short-term and medium-term policy implementations as well as other macroeconomic conditions. As a result, the model developed in this study fills a gap in the literature that has yet to be filled.This study was reviewed and approved by Sri Lanka Institute of Information Technology (SLIIT) Business School and the SLIIT ethical review board. Study used the secondary data sources and the data file used for the study is presented in t-1, Yt-2, etc., then it can be argued that X Granger causes Y and potentially Y also Granger causes changes in X [This section reveals the research method, the method of data collection, and the economic model to be followed for conducting this research. The Granger causality approach was utilised for this study. Here, two stationary covariance variables, X and Y, are monitored across t periods. If it can be proved the significant influence of lagged values of a variable X in a regression model of Y that depends not just on X but also on its own lagged values Yges in X . The stuWhere the unidirectional causation between elderly population (EPOP) and per capita gross domestic product growth rate (PGDPGR) is stated if the sum of estimated coefficients on lagged EPOP is statistically different from zero and the sum of estimated coefficients on lagged PGDPGR is not statistically different from zero . If the This section reports the main findings of the empirical approach. First, the summary provides the descriptive statistics, then the results of the unit root test and lag length criteria, respectively. Finally, the results of the Granger causality test are provided.Prior to the Granger causality analysis, researchers tested for the stationarity of the per capita GDP growth rate and the elderly population. Accordingly, the Dfuller unit root test was developed by David Dickey and Wayne Fuller in 1979 and the Pperron unit root test was introduced by Peter C. B. Phillips and Pierre Perron in 1988 were employed in the study. The null hypothesis of the Dfuller test is that there is a unit root, which implies that the data series is not stationary. The alternative hypothesis is generally stationarity or trend stationarity but can vary depending on the version of the test being used. The null hypothesis of the Pperron test is that the variable contains a unit root, and the alternative is that a stationary process generated the variable. Researchers first performed a Dfuller unit root test for the per capita GDP growth rate variable. Except for Myanmar, the per capita GDP variable was stationary at the first level for 14 Asian nations. Myanmar stopped moving after the first per capita GDP growth rate difference (DGDP). The elderly population variable was then subjected to the same test, and the researchers discovered that Pakistan was unit roots in the elderly population’s first difference (DEPOP). At the second difference (DDEPOP), all 14 remaining nations became stationary.The Pperron unit root test for the per capita GDP growth rate variable was then carried out by researchers as a next step. While Myanmar became stationary at the first difference (DGDP) of per capita GDP growth rate, the per capita GDP growth rate variable was stationary at the first level for 14 remaining countries, similar to the Dfuller test. The Pperron test was then applied to the elderly population variable, and it was discovered that Pakistan has unit roots in the elderly population’s first difference (DEPOP). The second difference in the elderly population (DDEPOP) caused the other 14 countries to become stationary.To carry out the causality test meaningfully, it is important to determine the optimal lag length. To discover the optimal moments and model lag order, lag selection criteria can be leveraged to calculate selection order statistics. First, the appropriate measures are identified. Lag selection criteria report the final prediction error (FPE), Akaike’s information criterion (AIC), Schwarz’s Bayesian information criterion (SBIC), and the Hannan and Quinn information criterion (HQIC) lag order selection statistics. Akaike’s FPE criterion provides a measure of model quality by simulating the situation where the model is tested on a different data set. The optimal lag length in the VAR specification is determined based on AIC, SBIC, and HQIC. According to Liew , the optAccording to Stationarity and stability are two crucial presumptions regarding the data variables and the system as a whole that support the validity of multivariate and bivariate modelling in terms of the VAR model. The employed variables’ stationarity has already been established. According to formal definitions, the VAR model is stable if all the coefficient matrix’s eigenvalues are less than 1 . BecauseThe Granger causality approach was used to examine the structures of the causal relationships between variables. The Granger causality test is a statistical hypothesis test used to determine whether one time series can forecast another.The results of the Granger causality test are reported in For Nepal, there is bidirectional causality between the elderly population and economic growth, which contradicts the results of Dawson and Tiffin  and ThorIn Bangladesh, China, and Pakistan, elderly population growth is found to Granger cause the economic growth. In India, Japan, Malaysia, and Singapore, economic growth is found to Granger cause of the elderly population growth. On the one hand, elderly population growth may be beneficial or detrimental to economic growth, and economic growth may influence elderly population growth. As a result, some Asian economies that achieve low levels of economic growth may not be affected by elderly population growth but rather by other factors such as political instability and a lack of investment. On the other hand, some Asian economies that achieved high rates of economic growth may have done so, not because of elderly population growth but because of other factors, according to Tsen and Furuoka . Non-dirResults confirm the presence of multiple factors which need to be considered when analysing the elderly population growth and the impact on economic growth. As noted before, the relationship between these two variables tends to be much more complex, when analysing countries with high population density, such as China, which is predicted to reach the highest economic growth in 2030 in Asia . Hence, Lin and Wang  highlighThis paper has summarised the results of the relationship between the elderly population and economic growth in the Asian region. Key actors like governments, development organisations, human rights organisations, and charities in the Asian region could better understand the elderly population and economy through this study to give priority to the elderly and countries’ economies. In addition, the study can assist to identify ways to lessen and manage the risks that the elderly population and government face .The results of the Dfuller and PPerron unit root test statistics show that, generally, the elderly population are non-stationary at levels one and two, but becomes stationary after taking the second difference. The economic growth is stationary at the first level except for Myanmar.The lag selection criteria show that the majority of the criteria chose a lag length between one and zero as the optimal lag length. Therefore, all subsequent analyses will be performed using the optimal lag length of this result.Furthermore, the study estimates the Granger causality between the elderly population and economic growth. On the one hand, for Nepal, there is bidirectional Granger causality between the elderly population and economic growth. For Bangladesh, China, and Pakistan, the elderly population is found to Granger cause economic growth but not vice versa. On the other hand, for India, Japan, Malaysia, and Singapore, economic growth is found to Granger cause elderly population but not vice versa. For Indonesia, Iran, Korea, Myanmar, Philippines, Sri Lanka, and Thailand, there is no evidence of Granger causality between the elderly population and economic growth.The relationship between the elderly population and economic growth is not definitive. On the one hand, elderly population growth may be beneficial or detrimental to economic growth, and on the other hand, economic growth may influence elderly population growth.Considering the elderly population is on the rise and there being certain limitations on the resource definition, the following policy implementation will be much more suitable for the Asian continent. According to Deloitte , an inhePrimarily, countries with a high share of elderly population should focus on structural reform policies that do not push up the cost of the elderly population and pass the burden to the government. In particular, the ADB  positionThe second policy reform for the elderly population in the more demographically congested countries is to focus on reorientating the special protection systems towards alleviating poverty. This can be primarily through creating a strong intergenerational flow of wealth, fiscal sustainability, and social security measures . The repThe third, population-related policy implications are much more valid for cultures with developing economies, where the focus is on data consensus. Especially, through creating storage systems for data development, policies protecting the vulnerable groups of society, and the continuous analysis of demographical change. With such a data-oriented, evidence-backed strategy, one can really relate to how the elderly population can either be a benefit or a burden. Yang, Zheng  highlighThe majority of secondary data used in this study were obtained from the WDI. However, Due to the lack of accurate data from 1961 to 2021. Researchers of this study could only obtain data for a few countries. Furthermore, by introducing new concepts and approaches, this study can serve as an initiative to expand future studies’ research strategies to other regions. In this study, we derived these findings using only two variables and as it provides a framework for future research in this field, future researchers will be able to add other demographic and economic variables and carry out further studies. In this regard, including variables such as dependency ratio, savings rates and household income could provide better economic insights. At the same time, moderator variables such as educational level, technological advancement, and quality of life could be useful to understand the relationship between the elderly population and economic growth to a much larger extent. Even at this level, the findings of this study will be helpful during policy implementations by governments and other policymaking bodies since the effectiveness of policies devised for Asian countries in the past could be identified from this research.S1 Appendix(XLSX)Click here for additional data file.S2 Appendix(DOCX)Click here for additional data file.S3 Appendix(DOCX)Click here for additional data file.S4 Appendix(DOCX)Click here for additional data file.


Progress in developing competency-based training in One Health has revealed coverage of various topics across fundamental, technical, functional, and integrative domains. Ensuring that employers value the unique characteristics of personnel trained in One Health will likely require demonstration of its usefulness, accreditation, and continuing professional development. These needs led to the conceptual framework of a One Health Workforce Academy (OHWA) for use as a platform to deliver competency-based training and assessment for an accreditable credential in One Health and opportunities for continuing professional development.One Health is defined as an integrated, unifying approach that aims to sustainably balance and optimize the health of people, animals and ecosystems; this approach attracts stakeholders from multiple sectors, academic disciplines, and professional practices. The diversity of expertise and interest groups is frequently and simultaneously framed as  from 24 countries reported differences in their perspectives on the relative importance of competency domains of the One Health approach. More than 90% of the respondents would seek to acquire a competency-based certificate in One Health, and 60% of respondents expected that earning such a credential would be rewarded by employers. Among potential barriers, time and funding were the most cited.Respondents (This study showed strong support from potential stakeholders for a OHWA that hosts competency-based training with opportunities for certification and continuing professional development. The One Health approach arose from a growing realization that many human pathogens emerge from animal populations, while environmental systems mediate the potentiality and severity of spillover from one species to another, including amplification and spread resulting in pandemics –3. HowevThe current One Health workforce consists primarily of individuals who self-identify as working within the One Health framework at the intersection of human health, animal health, and environmental or ecosystem health . In mosthttps://onehealthworkforceacademies.org) is designed to provide international access to high-quality, readily available training materials and resources to engage One Health trainees at all levels, to support a community of practice, and to provide a repository of best practices for faculty members teaching the One Health approach. The future utility of this virtual academy platform is expected to be informed by the results of the current study. The OHWA was designed with international visibility in mind, offering information delivered through live, interactive, web content and a collection of unique resources in terms of quality and orientation toward career advancement. Given the mission of the OHWA to promote the development, delivery, institutionalization, accreditation, and employer recognition of training and educational activities in alignment with One Health knowledge, competencies and perspectives, the specific objectives include the following:Supporting international and regional institution networks invested in training, employing, and empowering competent and credentialed One Health workforce personnel.Supporting international and regional networks of faculty members and scholars to improve in their ability to fulfill their responsibilities in research, pedagogy, and practice of One Health.Supporting communities of practitioners across academic disciplines and professions aligned with One Health.Articulating international and regional career pathways through accredited credentials, attestation, and continuing profession development for in-service One Health employees.Supporting employers seeking opportunities to engage trained preservice students and in-service employees in One Health.Partnering with international agencies   to leverEmployees who are certified in One Health are expected to work collaboratively to prevent pathogen spillover events, detect disease outbreaks, and respond to pandemics and other threats to global health security using the One Health approach . While sThe purpose of this study was to investigate stakeholder needs and expectations for the OHWA and to align the objectives of the academy with the priorities of trainees, faculty, employers, and One Health practitioners. The results of the survey will directly inform further development of the OHWA. The study was designed to characterize potential barriers and benefits associated with an online academy for delivering training, assessing competence, and attesting qualifications for entering and prospering in the One Health workforce. We also sought to understand the demand for One Health training and the relative importance of various competencies in the educational configuration of One Health.The study was implemented through the One Health Workforce Consortium, which consists of the Africa One Health University Network (AFROHUN) , the SouN = 97) from September 2020 to December 2020. The survey was subsequently further refined, and the final draft of the protocol and questionnaire was submitted to the Institutional Review Board (IRB) of the University of California, Davis, for further review; this protocol was exempt from the need for additional review beyond the initial IRB approval. The IRB also reviewed and approved the human participant recruitment flier and the conduction of the survey in an online platform to ensure that the research was conducted according to international policy guidelines required for collecting information in a nonidentifiable way. The study protocol consisted of a single set of questions to be answered by participants. The IRB-approved research protocol used the online tool SurveyMonkey (https://www.surveymonkey.com/r/OHWASurvey). Information about consent to participate in the research was provided on the first webpage; consent was required before a respondent could access the questionnaire. Those who did not provide consent were excluded from the survey. In the pilot phase, we estimated that the survey questions could be answered within 15 min. The survey platform allowed language translation, which was provided upon request. This functionality was used to create French, Vietnamese, and Thai versions of the survey, which were generated using gold-standard translation practices, including translation and back-translation. Responses to the formal survey were collected from May 2021 to November 2021.The research protocol and questions to be included in the stakeholder survey were drafted by a small group of global researchers funded by USAID to implement specific aims under the training and empowerment objective of the OHW-NG project . The draIn soliciting participants from AFROHUN and SEAOHUN countries, we emphasized the need to include potential employers of graduates of the existing One Health training programs. Additionally, active key members of the AFROHUN and SEAOHUN were asked to share the survey with diverse members of their extended networks, with special consideration to sharing across multiple relevant sectors, including private, public, and education sectors as well as nongovernmental organizations (NGOs). While network participants were not excluded from taking the survey, a framework was provided to each key network member to generate diversity in respondents, including requesting dissemination of the survey outside of the academic sector. In addition to AFROHUN and SEAOHUN participants, we invited participants from institutions of higher learning that offer academic and professional degrees in the health sciences and have already integrated the concepts of One Health into their curriculum or who are planning to do so . Through an internet search, we identified several institutions that have implemented certificates, diplomas, and master’s and doctorate curricula in One Health. For example, the University of Edinburgh in Scotland offers a Master of Science in One Health , and theThe survey was completed by 231 participants from 24 countries. Their country of employment and affiliation with One Health University Networks (OHUNs) are reported in Table Employment opportunities advertised specifically for those trained in One Health are currently rare, consistent with respondent reports; fewer than 20% of participants noted that their current place of employment had hired or planned to hire individuals specifically trained in One Health. However, when we asked participants to predict the situation 5 years in the future, more than 80% indicated that their employers would likely recruit One Health-trained personnel  ‘collaboration and partnership’, ‘communication’, and ‘infectious disease management’ Table . Those wth and 5th most important skills, respectively. This might indicate that those in the public sector value ‘technical’ skills over ‘functional’ skills. Similarly, those in the public sector were the only group in which ‘qualitative methods in One Health’ were not listed in the bottom three. There were only a few significant differences in sector rankings of the competencies according to a 95% confidence interval (p = 0.05). For example, regarding the importance of ‘research’, 59.09% of those in the public/governmental sector ranked it as ‘very important’, whereas 82.05% of those in the education sector ranked it as ‘very important’. However, the weighted averages were not entirely dissimilar, as many governmental employees (31.82%) rated ‘research’ as ‘moderately important’.Regarding the weighted average of skills and competencies, ‘collaboration and partnership’ and ‘communication’ were ranked in the top three skills across all sectors, with the exception of the public/governmental sector. Those in this sector selected the following three skills as the most important: ‘outbreak investigation’, ‘infectious disease management’, and ‘risk assessment and mitigation’. ‘Collaboration and partnership’ and ‘communication’ were 4Figure More than 90% of participants expected that a competency-based credential such as a One Health certificate earned after training and assessment would be beneficial for the workforce. However, only approximately 60% expected that current employers and supervisors would reward such a credential with promotion, merits, and/or placement in positions of decision-making regarding One Health-oriented programs Fig. . When exTo obtain further fine-grained understanding of the survey responses, particularly those from AFROHUN and SEAOHUN member countries, the responses were examined by country of employment. There were no significant differences in responses. This can be attributed to the skewedness of the sample to a few countries, which will be discussed in the limitation section.The survey revealed broad support for a OHWA to host competency-based training toward a credential and for continuing education and professional development. The survey revealed a diverse stakeholder landscape across sectors with diverse requirements and needs for continuing professional development in the use of the One Health approach. Despite this diversity, the results indicated strong interest among individuals in earning a credential and continuing professional development in One Health. The survey also indicated resounding understanding of the importance of developing such a workforce both for organizations and prevention of future pandemics.However, the survey indicated a gap in current organizational support to complement and bolster the interest of individuals. Despite expectations for both the need to hire those trained in One Health and that such training will benefit the workforce, employers are not specifically attempting to recruit individuals with One Health skills. Despite the widespread understanding that One Health training is beneficial to the workforce, most relevant employers are not currently requiring One Health-specific training for continuing professional development or other on-the-job training requirements. Additionally, the survey suggested that employees do not expect to be rewarded for such One Health training and that there is a diverse perception of necessary skills to address One Health-based challenges to global health security. These issues highlight the need to sensitize employers to the One Health approach and for increased visibility of the competency-based approach to One Health training.The survey highlighted respondents’ perceptions of the importance of a collection of One Health skills and competencies to their employer. A critical result of the survey was that the competency ‘gender’ was described as the least important to the employers of respondents and had the highest numeric weighted average. We examined this low ranking by sector and found that those working in NGOs did not rank gender in the bottom three competencies. However, all other sectors did. While the survey did not collect further qualitative data regarding the explanations for this difference, the results emphasize not the absolute importance of competency per se but rather the need to build awareness of gender as a critical One Health skill at the institutional/organizational level moving forward.Surprisingly, the competency ‘biodiversity and ecosystem services’ was ranked relatively low regarding its perceived importance to employers as well as its perceived importance (by respondents) in preventing pandemics. In terms of importance to employers, this competency was ranked second lowest (22/23) using the weighted average. In addition, ‘biodiversity and ecosystem services’ was ranked third-lowest regarding importance in preventing pandemics, behind only gender and implementation science. Historically, environmental and ecosystem contexts have been a neglected aspect of the One Health paradigm , 26. ThiThe survey results highlight practical aspects of workforce development and training for further investigation, including articulation of goals toward accredited competency-based training in One Health. The majority of respondents were interested in obtaining a certificate in One Health as well as accessing training materials through an online platform. However, the barriers to using or accessing such materials included time, which underscores a reoccurring challenge of training in-service professionals. Another common barrier was willingness or ability to pay. This challenge highlights the importance of considering funding during the design of future credentialed training programs, with consideration for sustainability and equity in the delivery of training programs. In many cases, respondents reported already being required to attend training in continuing professional development and other on-the-job training. Given that time and costs were identified as barriers, it will be important to design training programs that complement or are synergetic with existing employer requirements. These results will also be useful for parallel efforts at the international level, including the WHO-WOAH-FAO-UNEP partnership, which is developing competency-based field epidemiology training programs based on the One Health approach.The survey used a snowball sampling method. This sampling method was chosen to emphasize the qualitative approach of this study to examining particular types of employees working within the One Health context. The participant sample was nonrandom because we actively encouraged key network participants to share the opportunity to participate among their respective networks. This method was chosen to ensure that the survey was disseminated to those working in One Health outside of our own network. In addition, those disseminating the survey were encouraged to share the survey broadly outside of educational institutions to obtain representation from other groups, including employers.The survey reached many countries and included representation from diverse sectors; however, some countries and sectors were represented more strongly than others. It is unclear why Kenya and Malaysia had high response rates, but we suspect that there was more vigorous sharing of the opportunity to participate in the research from the university partners in these countries, resulting from our snowball approach. Additionally, the high level of engagement from those in the education sector was not surprising, given that the AFROHUN and SEAOHUN are composed of universities.The survey was likely disseminated only to participants already familiar with One Health. Based on our survey aims, we do not consider this a source of bias because the purpose of the survey was to investigate potential stakeholders of the OHWA. However, the next step is to investigate the perceptions and interest of more distant parties, such as those largely unaware of the One Health approach but working in public health, ecology, social sciences, or other related professions and disciplines. A specific source of bias may be associated with use of the AFROHUN and SEAOHUN and their preconceived expectations of earning a One Health credential. Almost all network participants indicated interest in earning credentials through the OHWA. This group can be considered our closest stakeholders and represents only the first level of outreach for the development of a globally recognized training platform.The training and empowerment of personnel needed to secure global health requires interdisciplinary and interprofessional understanding and collaboration . A One H


Background context: Scoliosis is a three-dimensional deformity of the spine with the most prevalent type being adolescent idiopathic scoliosis (AIS). The rotational spinal deformation leads to displacement and deformation of the ribs, resulting in a deformity of the entire chest. Routine diagnostic imaging is performed in order to define its etiology, measure curve severity and progression during growth, and for treatment planning. To date, all treatment recommendations are based on spinal parameters, while the esthetic concerns and cardiopulmonary symptoms of patients are mostly related to the trunk deformation. For this reason, there is a need for diagnostic imaging of the patho-anatomical changes of the chest and trunk in AIS. Aim: The aim of this review is to provide an overview, as complete as possible, of imaging modalities, methods and image processing techniques for assessment of chest and trunk deformation in AIS. Methods: Here, we present a narrative literature review of (1) image acquisition techniques used in clinical practice, (2) a description of various relevant methods to measure the deformity of the thorax in patients with AIS, and (3) different image processing techniques useful for quantifying 3D chest wall deformity. Results: Various ionizing and non-ionizing imaging modalities are available, but radiography is most widely used for AIS follow-up. A disadvantage is that these images are only acquired in 2D and are not effective for acquiring detailed information on complex 3D chest deformities. While CT is the gold standard 3D imaging technique for assessment of in vivo morphology of osseous structures, it is rarely obtained for surgical planning because of concerns about radiation exposure and increased risk of cancer during later life. Therefore, different modalities with less or without radiation, such as biplanar radiography and MRI are usually preferred. Recently, there have been advances in the field of image processing for measurements of the chest: Anatomical segmentations have become fully automatic and deep learning has been shown to be able to automatically perform measurements and even outperform experts in terms of accuracy. Conclusions: Recent advancements in imaging modalities and image processing techniques make complex 3D evaluation of chest deformation possible. Before introduction into daily clinical practice, however, there is a need for studies correlating image-based chest deformation parameters to patient-reported outcomes, and for technological advancements to make the workflow cost-effective.  The most prevalent type of scoliosis is adolescent idiopathic scoliosis (AIS), a spinal curvature affecting previously healthy adolescents during the pubertal growth spurt. Scoliosis is defined as a spinal deformity with a radiographic Cobb angle of more than 10 degrees in the coronal plane. It is, however, more accurately characterized as a 3-dimensional (3D) deformity of the spine in the coronal, sagittal, and axial planes ,3. Due tThe chest deformation in AIS can cause significant impairment in self-image, and functional impairments of the shoulders, ribs, and scapula, as well as the cardiopulmonary system, depending on the severity of the disease . These pRoutine diagnostic imaging is used for measuring the severity and progression of the spinal curvatures in scoliosis. The diagnostic methods currently used in the evaluation of scoliosis include conventional radiography, biplanar radiography, magnetic resonance imaging (MRI), computed tomography scans (CT), 3D ultrasound, and surface topography. In clinical practice, the diagnosis and management of scoliosis are often only based on two-dimensional images (2D), a lateral and posteroanterior radiograph . MoreoveFor decades, all treatment recommendations for AIS patients have been based on spinal parameters, while the esthetic concerns, cardiopulmonary symptoms and maybe even the paraspinal pain of patients are mostly related to the trunk deformation. Because of significant technological advancements, systematic evaluation of chest deformation is now becoming available for clinicians treating AIS patients. With these advances in various fields, there is a need for a comprehensive update on (innovative) methods available to systematically evaluate chest deformation in AIS.In this narrative review, we examine the literature to explore various ways of quantifying the deformity of the chest in adolescent idiopathic scoliosis with different imaging techniques. The purpose of this section is to give an overview of the different acquisition techniques that are used for imaging the chest deformity in scoliosis, along with their advantages and disadvantages. The most widely used imaging modality is radiography, and other modalities are biplanar stereo-radiography, CT, MRI, surface topography and 3D spinal ultrasound . A generAIS can be diagnosed and managed effectively with radiographs for both initial diagnostic imaging evaluations and follow-up . With raBiplanar stereo-radiography  is a low-dose radiographic method that uses an ultra-sensitive multi-wire proportional chamber detector . This syCT addresses the limitations of conventional radiography by providing accurate 3D reconstructions, which is crucial for visualizing the complex osseous abnormalities of scoliosis . It provMRI is used when certain features such as pain, neurological symptoms or an atypical curvature pattern and abnormalities of the spinal canal are present in the patient’s symptoms, and for preoperative screening for neural axis abnormalities . As a reBody surface topography is a photogrammetric technique that deals with the reconstruction of shapes, sizes, and mutual positions of objects based on photograms . It is mThis imaging method is rarely used and, to date, is primarily a research technique for assessment of spinal curvatures. The 3D ultrasound method was developed in an attempt to reduce radiation exposure for AIS patients since it can be used to safely monitor curve progression over time without the need for repeated radiographic examinations at short intervals . TherefoVarious different methods exist to measure the deformity of the thorax in patients with AIS. These methods and parameters are, however, still very advanced and primarily used in research for pulmonary function, and lung volumes prior to scoliosis surgery. Furthermore, advanced imaging including the complete chest is rarely repeated after surgery because of concerns about radiation exposure. For this reason, there is very limited evidence on the relevance of the various chest deformity parameters, especially for those that are not part of the major pediatric spine study groups. The Scoliosis Research Society glossary does not include thorax deformity measures and their respective correlations with spine deformity. Harris et al.  and EaswDifferent imaging modalities focus on different parts of the anatomy. There are four main image types from which the parameters are measured: coronal 2D images, axial 2D images, sagittal 2D images, and 3D images. Most of the parameters describe the sternum or the ribs in reference to the spine. Often the ratio of a certain distance or angle from the vertebra/sternum and the ribs to both sides is calculated. This review focuses more on the measurement technique than on anatomical details. Therefore, it was decided to divide the parameters that can be measured by structures that are used and metrics that were measured.Sagittal diameter and sternovertebral distance: These are two parameters for measuring the sagittal depth. The sternovertebral distance is the anterior–posterior distance between the posterior midpoint of the sternum and the anterior point of the apical vertebra . The sagVertebral translation: This is a measure of the lateral displacement between the spine and the sternum. For a healthy person, where the sternum is in front of the spine, this distance is zero. Vertebral translation measurements have been used for pre- and postoperative comparison of the thorax as well as in research for comparison with other parameters. A correlation of the vertebral translation with the coronal Cobb angle has been shown by Easwar et al. . The verSpinal intrusion ratio: This parameter represents the sagittal intrusion of the thoracic spine into the chest and has been demonstrated to be related to the size of the airways ,23. SIr Distance measurements:Angle from sternum to apical vertebra: This angle is provides information about the chest wall deformity. It is measured by drawing a lateral line through the sternum and a posterior–anterior line through the apical vertebra. In a healthy person, the line through the vertebra crosses the sternum at its center, and the angle is 90 degrees. The smaller the angle the more severe the deformity. The angle from the sternum to apical vertebra has been used to compare the pre- and postoperative shape of the thorax. Significant correlations between this angle and the coronal curve severity have been found .Midline deviation: This is the angle between the anterior–posterior line and a line that connects the anterior midpoint of the sternum with the posterior point of the foramen. In older studies, a significant correlation between the coronal curve severity and the midline deviation has been shown . More reThoracic rotation: This is another way to measure the angle between the vertebra and the ribs . It is mAngular measurements:There are several ways to measure the relative positions of the sternum to the spine. It is known that in a healthy chest, the spine and the sternum are in a central position, thus in the midsagittal anatomical plane. In persons who suffer from AIS, both the sternum and spine rotate away from the midline.Distance measurements:Posterior hemithoracic symmetry ratio: This ratio can be measured on an axial image of the thorax. A line is drawn through the anterior tips of the ribs where they are connected to the vertebra. Then the distance is measured from the connection point to the vertebra and the border of the hemithorax is measured. In a symmetrical thorax, the distance is equal in both directions. The ratio of the distances is 1. The more the thorax is deformed, the bigger the difference in the distances and the more the ratio is different from 1 .Apical vertebral body rib ratio and sternum rib ratio: An anterior–posterior radiograph is sufficient to measure the apical vertebral body rib ratio. From the apical body, the distance to the lateral borders of the ribs is measured in both directions . While KAngular measurements:Rib hump and chest wall angle: The rib hump and the chest wall angle are both an indicator of rib rotation. The chest wall angle is measured on the anterior part of the rib , whereasInclination angle : This anIn order to evaluate scoliosis and deformities, various image processing techniques are used, such as segmentation, 3D reconstruction techniques and deep learning.Segmentation of the various structures in the chest can be performed manually, semi-automatically or fully automatically. For the spine, Thalenga et al.  describeTo assess chest deformation, Shantanu et al. presented an automated segmentation technique of the ribs based on CT images. In this technique, the first step includes the deletion of peripheral artefacts, such as external air and the skin. Next, the image becomes binarized, by applying a threshold filter at each CT voxel. After applying some morphological operations and taking into consideration that in the upper thoracic region, the rib density (number of ribs in a specific area) is higher and that the ribs are smaller than in the middle thoracic region, the compactness factor (which gives information about the density of the ribs) of the inner contour of the peripheral fat region on each slice is used to differentiate between the upper thoracic region and the rest of the lower thorax, as well as the abdomen. To finalize this method, an estimation procedure of the rib structure is applied. The proposed method is limited by the use of empirically selected parameters from a CT images subset .Many imaging modalities acquire a 2D representation of the body. However, from these images, it is almost impossible to evaluate the 3D deformation of the chest. That is why previous research studies have focused on visualizing the spine, ribs and thoracic area in 3D from modalities such as biplanar radiographs or CT.For biplanar radiographic images, several publications propose methods to reconstruct a 3D image of the chest. Similar to the spine reconstructions, this needs user input to determine anatomical landmarks. This process is prone to differences in image interpretation and variability between users, and is time-consuming. Vergari et al.  developeWhile various imaging software packages are available for 3D chest reconstructions of CT images, an interesting method, not yet used for scoliosis, is the rib centerline extraction method. Lenga et al.  proposedDeep learning techniques can be used for image recognition, classification, detection and prediction in AIS and are rapidly reducing the time-consuming work required of experts. In general, research into deep learning techniques to measure chest parameters remains scarce, but some research has focused on using deep learning to aid in quantifying chest deformity as well as measurement of the spine ,36. DeepBecause the main consequences of AIS for patients are not related to the spine, but to the deformation of the trunk and mostly the chest, the methods for quantification of chest deformity need to be further improved. This narrative review provides an overview of imaging modalities, methods and image processing techniques for assessment of chest deformation in AIS. Due to its narrative design, this overview prone to selection bias; however, this design permits a wider and more inclusive overview of technological advancements in imaging methods to quantify chest deformation in AIS. After evaluating different modalities, metrics and processing techniques, several aspects to focus on in further research into the quantification of the 3D deformation of the chest can be identified. The risk of bias in the selection of individual studies remains, however, a limitation of this study. In general, it is very hard to decouple spinal and thorax deformities. Especially spinal rotation affects many parameters. It is sometimes difficult to determine if it is actually rib deformity, rib displacement or spinal deformity that is measured . AIS patIn conclusion, because of significant technological advancements, systematic evaluation of chest deformation is becoming available for clinicians treating AIS patients. There is, however, a need for studies correlating image-based chest deformation parameters to patient-reported outcomes. Furthermore, in contrast to the conventional 2D radiography-based spinal parameters, 3D evaluations are more complex and require more time for quantification of anatomical parameters. Further advancements in automatic 3D image evaluations are first needed before complex chest deformity evaluations can be introduced into daily practice.


Sustainable implementation of telemonitoring in health care is challenging, especially if one aims to scale up telemonitoring initiatives nationwide. The National collaborative eHealth program in the Netherlands is supporting the nationwide upscaling of telemonitoring in 3 clinical domains by implementing telemonitoring in all Dutch university medical centers (UMCs). The chosen telemonitoring concepts are (1) telemonitoring solutions in the domain of cardiology, (2) telemonitoring solutions providing care from a distance in obstetrics, and (3) telemonitoring solutions monitoring vital functions in hospital wards.The aim of this study is to evaluate the upscaling of telemonitoring in Dutch university hospitals in order to gain a better knowledge of the process, methods, and outcomes of nationwide upscaling strategies. Our hypothesis is that by the completion of the Citrien program’s scale-up, telemonitoring will be operational in all UMCs but not normalized in routine care.A before-and-after study will be conducted to assess upscaling. The theoretical frameworks used are the framework for nonadoption, abandonment, scale-up, spread, and sustainability; the Normalization Process Theory; and a project management tool Project Canvas. The primary outcome of the study is the degree of normalization to which health care providers at UMCs consider telemonitoring a part of their routine practice, measured using the Normalization MeAsurement Development tool (NoMAD). Our secondary outcome is the uptake of telemonitoring at the Dutch UMCs, using management data from UMCs’ business intelligence systems query.Data will be collected between May 2020 and December 2022. Results were retrieved in June 2023. UMCs’ business intelligence systems are queried for data for the secondary outcome measures. There is a risk that the UMCs will not be able to provide this management information. The laws and regulations governing telemonitoring in the Netherlands are changing, with the Electronic Data Exchange in Health Care Act (Wet elektronische gegevensuitwisseling in de zorg) and the European Health Data Space Act expected to positively influence implementation and upscaling.The Citrien program is a nationally coordinated change management program that is scaling up telemonitoring across contexts and settings. This study will produce original data on the uptake and upscaling of telemonitoring at Dutch UMCs. Future initiatives to implement eHealth in the health care sector may be guided by the wide range of success factors, obstacles, and experiences collected through this program. The network itself may be of great value impacting future acceleration of eHealth initiatives.DERR1-10.2196/45201 Telemonitoring in health care can be defined as the use of IT to monitor a patient’s status remotely -3. TelemSignificant advantages for patients, the economy, and society could result from widespread telehealth adoption . For exaHence, sustainable adoption, implementation, and subsequent upscaling of telemonitoring initiatives in hospital settings remains challenging nationwide -12. AlthImplementation of telemonitoring in the Dutch medical landscape is still rather limited, focusing on use in pilots and research settings ,16. To dIn the Netherlands, the Ministry of Health, Welfare and Sports (HWS) has called upon the university medical centers (UMCs) to take the lead in shaping the digital health landscape, ensuring sustainable health care . Over thThe UMCs in the Netherlands—8 in 2019 and 7 at the moment—act as a knowledge and network partner for nonuniversity hospitals. An effective scaling up of telemonitoring  at UMCs could affect roughly 70 additional nonuniversity hospitals in the Netherlands. Within this program, a strong implementation network has emerged, aiding UMCs in being more successful in jointly scaling up telemonitoring with other hospitals and care settings .The aim of this study is to evaluate the upscaling of telemonitoring in Dutch university hospitals in order to gain a better knowledge of the process, methods, and outcomes of nationwide upscaling strategies.Our hypothesis is that by the completion of the Citrien program’s scale-up, telemonitoring will be operational at all UMCs, although it has yet to become normal practice among health care providers.To evaluate the success in scaling up of 3 telemonitoring concepts across settings, flexibility in vendor and concept selection is deemed necessary. This is required to better adapt to existing variations in hospital settings from a technical, organizational, financial, and cultural perspective while simultaneously safeguarding outcome end goals. A before-and-after study will be conducted to assess the degree of successful upscaling.In order to describe essential elements of the Citrien program—including the intervention, target group, application design, and implementation choices—the framework for nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) will be used . The NASGiven that this protocol describes the scaling up of 3 telemonitoring projects at 8 university hospitals, the descriptions of all of its essential elements are very lengthy. We, therefore, have appropriately explained the analysis of key elements in accordance with the NASSS framework in Whether end users  integrate telemonitoring into daily care  is a socio-technical issue. An implementation framework such as the NASSS does not provide sufficient insight. To measure normalization, we, therefore, have used the Normalization MeAsurement Development (NoMAD) questionnaire, which is based on Normalization Process Theory (NPT). According to the NPT, a normalization process is a result of individual and group behaviors and entails the embedding and integration of health care innovations into everyday treatment.According to the theory, 4 constructs play a central role in generating the work of implementation:Coherence of the innovation with the goals of daily routineCognitive participation as a process of enrollment and engagement of individual participants and groupsCollective action by individuals and groups to apply the innovation in daily routineReflexive monitoring through which participants in the implementation process evaluate and appraise the use of the innovation in practiceThe NPT successfully aids in the conceptual understanding of implementation processes and outcomes across a wide variety of health care settings .The brief self-report NoMAD questionnaire was designed in accordance with the general approach of the NPT for the goal of detecting factors likely to influence normalization processes . The queA project-based approach  in the Netherlands. The diverse concept of telemonitoring among cardiology patients, high-risk pregnancies, and for in-patients undergoing continuous monitoring of vital signs using wearables is implemented and researched. For all concepts chosen, differences in the target population or chosen technology (or both) may exist to fit the existing infrastructures and hospital strategy. In the Netherlands, different electronic health records (EHR) are in use by the UMCs. To facilitate interoperability, different requirements must be met to accommodate upscaling of the concepts. UMCs were free to opt for stand-alone solutions, although embedding technology into the existing EHR is a well-known enabler for implementation. Although the technology supply model is open to UMCs, the participating UMCs had to comply to the vision of the Citrien program, choosing trusted suppliers with validated, reliable, secure, and scalable solutions.Collaboration within the Citrien program supported the project leaders in preparing a business case for their own organization. To analyze barriers and enablers for scaling up telemonitoring locally, UMCs used methodologies they were most experienced with. The Citrien program supported the analysis and drafting of implementation strategies by exchanging best practices among project leaders.This Citrien program is aligned with relevant initiatives such as information standards and regulations on secure exchange of health data. Part of the program’s strategy is to strengthen and foster cooperation within the UMCs and to foster cross-UMC partnerships while implementing various telemonitoring initiatives. Overarching issues related to scaling up such as reimbursement, screening new technologies for viability and suitability, procurement of devices, and privacy aspects were tackled by the UMCs in a joint effort. Typical of the Citrien program was the monitoring of change over a period of 2 years. Project leaders kept track of progress every month during their meetings.Upscaling of telemonitoring is operationalized as the actual use (uptake) and normalization of telemonitoring. Effectiveness is expressed in the degree of uptake and normalization of the use of telemonitoring at the UMCs. Data will be aggregated in a protective collaborative web-based environment created for this purpose and managed by the chair of the steering group (MS) and the principal investigator (HG).The primary outcome is the degree of normalization to which health care providers consider telemonitoring to be a part of their routine practice, as measured by the NoMAD questionnaire . The NoMWe make a pragmatic choice for a purposeful sample of respondents without performing a power calculation. Citrien program project leaders within each UMC recruited participants for each telemonitoring project to take part in the survey. The local project leader within each UMC sent a standardized invitation email to 10 self-selected health care professionals involved in the adoption of a telemonitoring project, containing the objective of the study and a link to a web-based survey. We aimed for a total of 10 respondents per project and consequently 30 respondents per UMC. This is a pragmatic choice because project leaders have noted at this stage of the scale-up that not more than 10 care providers are involved in the telemonitoring projects. Three reminders were sent. The local project leaders and the researcher were both unable to determine who had filled out the questionnaire. The questionnaire did not collect any email or IP addresses. The questionnaire responses could not be linked to specific individuals.The secondary outcome is the uptake of telemonitoring in Dutch UMCs, as measured by (1) the absolute number of patients using telemonitoring within each UMC and (2) the percentage of patients using telemonitoring compared to the number of patients eligible for telemonitoring.These data are management data or business intelligence data. Patients are not actively being included. This study observes the nationwide coordination of implementation and scale-up practices carried out on a daily basis.t test. All statistical analyses will be conducted using SPSS software .The results will be presented as a summary of the outcome measures sorted by UMC and telemonitoring project, using frequencies, medians, and percentages for categorical factors and means and SDs for continuous measures in order to have as much information as possible available for exploration and nonparametric analysis. For evaluation of NoMAD data, we will use the Wilcoxon signed-rank test. To evaluate the secondary outcome measures within each UMC, we will use a 2-tailed paired The primary outcome measure is a questionnaire administered to health care professionals. It is a nonburdensome questionnaire that is completed voluntarily and anonymously. Health care professionals are not subjected to any actions, nor are any behavioral rules imposed.The secondary outcome measure is management information collected retrospectively. No data are collected from patients, and no actions or behavioral rules are imposed on patients. The use of telemonitoring is always and only in the context of patient care. The reason for monitoring is not different but only the method of delivery is in a digital manner.The Medical Ethics Review Committee Amsterdam UMC exempted this study from ethical review. The study protocol is registered on the Open Science Framework .The baseline assessment was carried out from May 2020 to January 2021. Data on scaling up are collected quarterly. The final results were retrieved in June 2023. Data collection will be carried out under governance of the project leaders at every UMC. The findings are likely to be available in the second half of 2023.This study will define the degree of uptake of telemonitoring at Dutch UMCs and elucidate how it is normalized in the daily routine of health care professionals. This protocol is important as it describes the theoretical framework that will be used and activities that will be performed. Evaluating the implementation of 3 telemonitoring projects at all university hospitals of the Netherlands provides the opportunity to provide a better understanding of the process, methods, and outcomes of a nationwide implementation of strategies.While launching this initiative, we thoroughly analyzed the scale-up’s challenges and created tailored implementation plans and strategies for each UMC. However, we are unable to completely control all variables and influences in this real-world evaluation study. This implies that there remains a degree of uncertainty about the effectiveness of the scale-up program. If unforeseen circumstances arise despite carefully planned implementation actions and plans, the effect of the Citrien program may be underestimated. Thus, maybe the impact of the Citrien program could be overestimated if there are favorable changes in the health care environment that are unrelated to the Citrien program and accelerate the scale-up of telemonitoring. Nonetheless, it is interesting to evaluate this in a systematic approach.Although not likely, limitations may also occur as a result of data collection; for example, when too few responses are received for the primary outcome measure. We can send additional reminders and request project leaders to exercise leadership in this situation.The UMCs’ business intelligence systems are queried for data for the secondary outcome measures. Although the outcome measures are actual fundamental parameters, there is a risk that the UMCs will not be able to provide this management information. It is crucial to acknowledge this and communicate the lesson that has been taught if this happens.Nationwide upscaling of telemonitoring in different target groups requires a range of technologies and suppliers. The Citrien program aims to contribute to important preconditions, such as writing a business case, providing insight into barriers and enablers, and designing implementation strategies. With a pragmatic approach, Citrien aims to provide insight in, and solutions for, various barriers such as interoperability, reimbursements, adjustments in care paths, privacy policies, and procurement policies. These initiatives were carefully and purposefully developed in light of the variables that affect nationwide upscaling, which were identified in a recent scoping review on upscaling telemonitoring .The laws and regulations governing the use of telemonitoring in the Netherlands are subject to change. The legal responsibility in monitoring patients remotely was still unclear at the start of this program. From 2023, the Electronic Data Exchange in Health Care Act (Wet elektronische gegevensuitwisseling in de zorg) mandates digital data exchange among health care providers. This also affects the processing of telemonitoring data. In the near future, European Health Data Space Act will also be enacted . These rFinally, there are other eHealth scale-up initiatives in the Netherlands. In order to encourage eHealth activities outside of hospitals, the government has incentive regulations for eHealth in primary care . A coaliThe Citrien program is a nationally coordinated change management program in the eHealth domain, now scaling up telemonitoring across situations and settings. We expect that this study will yield unique evidence about the use and upscaling of telemonitoring in Dutch UMCs. This study protocol could serve as inspiration for others who would like to implement a similar programmatic intervention for nationwide scale-up of applications, such as a digital ward or artificial intelligence–driven decision support. The success factors, barriers, and experiences collected in this program could guide future projects that aim to implement eHealth in the health care sector. The Citrien network itself may be of great value impacting future acceleration of eHealth initiatives.


The global burden of malaria seems unabated. Africa carries the greatest burden accounting for over 95% of the annual cases of malaria. For the vision of a world free of malaria by Global Technical Strategy to be achieved, Africa must take up the stakeholder's role. It is therefore imperative that Africa rises up to the challenge of malaria and champion the fight against it. The fight against malaria may just be a futile or mere academic venture if Africans are not directly and fully involved. This work reviews the roles playable by Africans in order to curb the malaria in Africa and the world at large. Plasmodium falciparum, Plasmodium vivax, Plasmodium ovale, Plasmodium malariae, and Plasmodium knowlesi are known to cause malaria in human; however, P. falciparum is the most prevalent and deadlyP. falciparum is the most dominant species in Africa, which accounts for majority of the malaria morbidity and mortalityP. ovale is primarily concentrated in sub-Saharan Africa and islands in the western Pacific P. vivax is mainly found in Asia, Latin America and in some parts of AfricaP. knowlesi is concentrated in Southeast AsiaP. malariae has a wide global distribution, being found in South America, Asia, and Africa, but not as prevalent as P. falciparumP. falciparum and P. vivax are the most threatening speciesMalaria is a vector-transmitted disease that has continually plagued humankind for years. Five species of the malaria parasite-The World Health Qrganization (WHO) estimated a global prevalence of 241 million cases in 2020 where sub-Saharan Africa once again took the top spot with more than 95 % of the global burden A lot of factors affect the level of malaria infection across the malaria endemic regions. Such factors include but not limited to age; immunity; genetic diversity of the host; genetic diversity of malaria parasites and the regional climatic conditions P. falciparum transmission are: temperature of 30–33°C and a daily rainfall in the range of 15–17 mm The climatic condition of a region is an important factor that affects the transmission and level of malaria infection. It is the most significant factor that affects the intensity of parasite transmissionThe host genetic makeup is very essential in malaria infection as it accounts for approximately 25% of the total variability in malaria severity P. falciparum infection can lead to the development of acquired immunity in the host. The immunity is said to be mediated by immunoglobulin G (IgG) against variant surface antigens (VSA) from the parasite on the surface of parasitized erythrocytesP. falciparum and consequently prevents the spread of resistance P. falciparumP. falciparumFurthermore, the polymorphism in glycophorin receptors in Dantu genetic blood variant is of essence in protection against malaria in Africans. Glycophorin is a sialoglycoprotein of the membrane of red blood cells which plays a role in the invasion of the red blood cells by malaria parasites P. falciparum accounts for about 99.7 % of the malaria cases in Africa 10 while P. vivax is concentrated in the Horn of Africa, comprising Djibouti, Eritrea, Ethiopia, Somalia, and Sudan P. falciparum. There is growing prevalence of P. vivax in Africa where not less than 44 countries have reported it P. falciparum species in sub-Saharan Africa, the malaria burden is higher there. The genetic diversity of malaria parasites is important in the elimination and control strategies. With the recent increase in the prevalence of P. vivax, policies and programs of malaria should capture other species of malaria in order to have a holistic approach in the fight against malaria in the African region.According to the WHO, Anopheles mosquitoes responsible for Plaasmodium transmission are A. gambiae, A. funestus, A. pharoensis. A. squamosis, A. coustani and A. ziemanni. This is characteristic of the mosquitoes in Africa and invariably responsible for the huge malaria burden in Africa A. stephensi further complicates the issues. A. Stephensi is an Asian species that thrives in urban centres in Africa. It was responsible for a malaria outbreak in Djibouti, East Africa in 2012 The transmission of malaria parasite by mosquito is elevated in areas where the mosquitoes have lifespan long enough to allow for completion of malaria parasite lifecycle and also the mosquitoes human-biting habit. Examples of the female Between 2000 and 2015, there was a commendable decline in malaria morbidity and mortality by 42% and 66% respectively. That made malaria to move from number one (17%) to number four (10%) cause of death in children under 5 years in sub-Saharan Africa 12 . AccordiA lot of strategies has been used to tackle malaria head on in Africa, which could be preventive or non-preventive. Among the preventive strategies are: sleeping under insecticide treated nets, keeping the environment clean, mass literacy programs, use of outdoor/indoor insecticide sprays, use of mosquito repellants and use of prophylactics while non-preventive strategies involve mainly the use of artemisinin-based combination therapies (ACTs)Considering the gains made so far and the challenges therein, African WHO member states have adopted a framework from 2016–2030, to guide them to achieving a malaria-free Africa i. Reducing malaria mortality rates by at least 90%;ii. Reducing malaria case incidence by at least 90%;iii. Eliminating malaria from at least 20 malaria-endemic countries;iv. Preventing re-establishment of malaria in all Member States that are malaria-free.The gains made in malaria control seems to be gradually lost as a closer look at the morbidity figures shows that the reduction in prevalence has stalled 2. A lot of factors are working against the commendable malaria programs. These confounding factors are the reasons Africa remains the region with the highest burden with no significant progress in malaria prevalence .The use of drugs is important for timely treatment of malaria. In Africa, access to drugs is usually complicated by a lot of confounding factors such as natural barriers  which reduces accessibility to health facilities; corrupt officials who would rather divert free drugs for other purposes than give them to intended targets; poor orientation of the populace about the need for prompt treatment and the cost of the drugs especially ACTs in the face of underlying poverty The proliferation of fake medicines in Africa is a public health crisis that has not been properly managed. Antimalarials could be substandard, degraded or falsified and can lead to treatment failure/resistance, death and financial losses resulting from a sub therapeutic exposure of the parasites to the drug Prompt malaria diagnosis is essential for effective treatment especially in preventing development of severe malaria and consequent death. Even though in sub-Saharan Africa, rapid diagnostic tests (RDTs) are becoming increasingly the most used method to test for malaria Malaria control and elimination is complicated by the presence of asymptomatic malaria population with low parasite density which serve as reservoirs for malaria transmission Because of the poor diagnosis and lack of awareness, some of the malaria control strategies are either abused or misused. Abuse is more common with the antimalarials. Oftentimes, there is little, poor or no diagnosis before malaria treatment and incompletion of treatment. This leads to poor parasite clearance, recrudescence and potential resistance development. The poor parasite clearance in patients increases malaria transmission as they serve as reservoirs for onward transmission to others More so, there is low compliance to a lot of malaria programs that have been rolled out. For instance, according to Dr Matshidiso Moeti, WHO Regional Director for Africa, regardless of the recommendation of at least 3 doses of sulphadoxine pyrimethamine (IPTp-SP) as intermittent preventive treatment in Pregnancy (IPTp), only a paltry 19 % of eligible pregnant women complied in Africa in 2016 30.P .falciparum artemisinin resistance in Africa st 2014 recommended the urgent tackling of the antimalarial resistance in Southeast Asia before it spreads to Africa Historically, the development of resistance to antimalarials like the antifolates (sulfadoxine and pyrimethamine) and quinolines (chloroquine and mefloquine) originated from Southeast Asia and spread westwards to India and then to Africa Recently, mosquito resistance to the commonly used classes of insecticide, pyrethroids, organochlorines, carbamates and organophosphates has been reported A lot of commendable malaria projects with timelines are rolled out regularly, but once the funding period elapses, all the gains made from such projects are lost Although efforts are ongoing in improving the healthcare systems in Africa, they are still below the level recommended by the WHO Other challenges that frustrate actualization of Africa free malaria are: favorable climate for mosquito growth, poverty, literacy level of the populace, poor building structures that encourage indoor mosquito bites, insurgence that render people homeless and vulnerable to mosquito bites “What can I do as a stakeholder to win the war against malaria?” Until this question is objectively answered by every stakeholder, the quest to win the war against malaria may be a mirage or impossible.Every African has a stake in the burden of malaria. One is either infected or affected. Whichever spot one takes, the impact is huge. Every African is a stakeholder in the fight against malaria; therefore all hands must be on deck to win the war. Everybody should ask himself/herself the big question, The government can come to the discussion table with industries, agencies and parastatals to fashion out the role each could play in raising awareness and funding malaria projects in Africa. In 2012, the Tanzanian Prime Minister, Hon Mizengo Pinda launched a Malaria Safe program and reached out to 32 Tanzanian companies for participation in the program This group stands as a bridge to the gap in actualizing the vision 2030 of global malaria strategy. The role of research and development for health in eradicating poverty and economic growth cannot be under-estimated 82,83. The roles of researchers include but not limited to doing effective research to continually find ways to control malaria such as antimalarials and insecticides; demystifying the meaning of malaria; communicating results or findings to the masses and/or advising governmental and non-governmental agencies on approaches to adopt. Currently, a lot of research has been done on malaria, but it is pathetic to note that majority of these studies are done by non-Africans or outside Africa. Research in Africa has historically faced the challenge of poor funding, inadequate mentorship etc., which adversely affects research in Africa The researchers in Africa should form a formidable network between them and the industries so that the dynamics in malaria can well be taken care of.No doubt, there are several commendable malaria programs that have been or yet to be rolled out. Regrettably, some of the intended targets do not benefit from some of the programs as a result of information gap. Sensitization of the masses through the right media channel is therefore important to making people understand the benefits from such projects. Such media channels could be radio, television, print media or social media. It is commendable to note that some media houses have slots for malaria programs and their impacts on reducing malaria prevalence have been significant Recently, the use of the social media has been on the rise. According to the recent global statcounter, Facebook accounts for at least 80 % of the total social media usage in Africa 87 . AfricanThe print media is another platform to disseminate malaria programs. With the e-versions of newspapers, communication of programs to the target audience has become easier and cheaper.The fan-base of most celebrities is rapidly growing in Africa. The celebrities could be sportsmen and women, entertainers etc. This provides a readily accessible platform for fans and others to get tips about malaria and other diseases that are preventable and treatable in Africa. The celebrities are followed by their fans on the social media and on the field of play. Therefore, the African or non-African celebrities can play a huge role by passively or actively disseminating the information about malaria. The voice of Yvonne Chaka Chaka of South Africa has been noticeable in this context. As a singer, she has been championing the fight against diseases and she has risen to become a UNICEF goodwill ambassador for malaria in Africa. Innocent Idibia, a popular musician from Nigeria has also used his voice through several malaria campaign programs. Novelty matches can be organized and dedicated to raise awareness or fund for the malaria projects in Africa as was exemplified in 2009 in a game between Ghana and Mali For sustainable fight against malaria in Africa, the corporate organizations in Africa also have to play a critical role through corporate social responsibilities. They can do this by ensuring regular diagnosis and treatment of their staff and donation of insecticide treated nets to the public. They can also fund research by the academia in order to combat the ever-dynamic disease. The good news is that some corporate bodies in Africa are already doing so. Said Salim Bahresa and Co (SSB), an East African flour mill in Tanzania is noted for donating insecticide treated nets, rapid diagnostic kits and drugs to her employees since 2008, and since 2006, Mr Zake of Standard Chartered Banks has been funding the distribution of nets to about 17 sub-Saharan African countries Although some companies have keyed into this noble project, many are still left behind. It is therefore recommended that companies especially the pharmaceuticals should, as a matter of necessity, incorporate research funding and combating epidemics like malaria as a core component of their social responsibility. More so, funding of research and development has been abysmally poor in Africa. Except for South Africa where private businesses contribute up 40% in R and D, in other countries, they contribute poorly, as low as 0.1% The generality of Africans is supposedly involved in the fight against the scourge of malaria rightly or wrongly. It is therefore pertinent that everybody knows his/her role in the fight. The most important approach to malaria control is prevention. This could be either at the level of preventing mosquito breeding or mosquito bites to prevent transmission. The masses can simply prevent breeding of the mosquitoes by keeping the environment clean, clearing/avoiding pools of stagnant and exposed water bodies. They can also consistently sleep under mosquito nets as prescribed by the WHO. Each African should champion malaria advocacy programs at the family level, which will be a formidable bottom-up approach in the fight against malaria.Malaria is not abating and this is indeed a worrisome trend. The current situation is surmountable if the entire key players are actively involved. The role of the aforementioned stakeholders cannot be overemphasized. Africa has to rise up and start telling their stories themselves. Foreign aids are inevitable as no nation survives independently; however, Africans have to take the centre stage in solving their problems. Malaria control and indeed a world free of malaria is achievable only if the core stakeholders, Africans step up their games. These stakeholders' roles must be taken seriously by all involved in order to achieve the vision 2030 of a world free of malaria.