Political stability and health system resilience as determinants of malaria control: A comparative analysis of Ecuador and Venezuela (2000-2023)

Background: The post-2000 period in South America presents a striking paradox in malaria epidemiology: Ecuador achieved >>99 % reduction in malaria incidence approaching elimination, while Venezuela experienced one of the most severe resurgences in modern public health history. This study examines the systemic determinants underlying this divergence. Methods: We conducted a comparative case study analysis using epidemiological data from WHO and PAHO reports (2000-2023), integrated with political stability indices, health expenditure data, and governance indicators from World Bank databases. A multi-dimensional analytical framework assessed political stability, health system capacity, surveillance infrastructure, international cooperation, and community engagement strategies. Results: Ecuador reduced malaria cases from 106,641 (2001) to 757 (2023), achieving 99.3 % reduction through sustained political commitment (Political Stability Index: -0.34), consistent health expenditure (7-8 % GDP), robust surveillance systems (SIVE-Alerta), and strategic binational cooperation. Venezuela experienced a 1,217 % increase in cases (35,500 in 2000 to 467,421 in 2019) associated with political instability (PSI: -1.19), health expenditure collapse (8.1 % to <1.18 % GDP), exodus of >>30,000 healthcare workers, surveillance system dismantlement, and expansion of illegal gold mining affecting 100,000 people. Venezuela accounted for >>50 % of regional cases and 73 % of malaria deaths by 2019, with massive case exportation threatening regional elimination goals. Conclusions: This analysis demonstrates that health system resilience--defined as capacity to withstand political and economic shocks--is the fundamental prerequisite for successful disease elimination. Technical interventions, regardless of sophistication, fail without stable governance, sustained investment, and institutional continuity. The Venezuelan crisis exemplifies how state collapse creates synergistic conditions for explosive disease transmission and regional destabilization. Global health strategies must integrate governance and political stability indicators into risk assessment frameworks for disease elimination programs.