Global Malaria Control in the 21st Century: Title and subTitle BreakA Historic but Fleeting Opportunity

There is today more attention to and financing for malaria control than at least the past 4 decades. Following the collapse of the global eradication campaign in the early 1970s, malaria control programs around the world dwindled as funding dried up, technical guidance became confused and at times contradictory, and much of the global community seemed ready to accept that malaria was an unavoidable fact of life in tropical regions.¹ Gains that had been made in reducing the burden of the disease in Asia and Latin America eroded, while in sub-Saharan Africa, the already intolerable number of deaths began to increase as the primary means of defense, chloroquine, increasingly failed.²

Since the turn of the 21st century, however, there has been resurgence of focus on the burden of malaria and opportunities for its control. New tools such as long-lasting insecticide-treated nets³ and artemisinin-based combination therapies⁴ have proven highly effective in reducing morbidity and mortality, and there has been substantial investment in further innovation, from the discovery of a long-sought vaccine to the development of new treatments. Financing for malaria endemic countries to purchase and deploy these and other critical tools has increased dramatically with the advent of the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and the US President's Malaria Initiative, increasing 10-fold between 1998 and 2006.^{5 - 7} Unprecedented political attention has been devoted to the disease in both the global north and south.

This heightened commitment to malaria has been driven by a range of factors, including the global community's focus on African poverty and the HIV/AIDS pandemic, greater understanding of the economic as well as humanitarian costs of malaria, and consensus on the cost-effectiveness of malaria control.⁸ But, above all, politicians and philanthropists have been drawn to the problem of malaria by the notion that it is a so-called “quick win,” that investments can have a rapid and attributable effect on the burden of the disease and the welfare of those affected by it. This aspect of malaria control, unique among most development issues, is its greatest blessing and its greatest curse. With the money and attention that malaria control attracts comes an expectation that significant results will be quickly achieved and demonstrated. If those results are slow to materialize, there is a danger that investment will wane as quickly as it has waxed. Such was the case with the Global Eradication Program for which, after a series of setbacks, widespread exuberance rapidly turned to disillusionment and fatalism followed by decades of inaction.

There have been some important initial successes. For example, a program in the Lubombo Region of South Africa, Swaziland, and Southern Mozambique has reduced malaria prevalence by 50% to 90% over 5 years and is seeking to double the area covered by its activities.⁹ In Eritrea, a combination of insecticide-treated bed net distribution, indoor residual spraying with DDT, and community-based treatment with effective medicines reduced malaria morbidity by 84% between 2000 and 2004.¹⁰

However, in many areas the signs are less promising. Few countries have begun to approach the goals set by African leaders of, among others, providing 60% of pregnant women and young children with insecticide-treated bed nets and access to prompt, effective treatment by 2005.¹¹ Malaria grants provide, on average, the weakest results among the 3 diseases in the Global Fund's portfolio, with some countries in danger of losing substantial funding due to failure to deliver.⁹ Despite widespread policy changes and the availability of financing from the Global Fund and other donors, artemisinin-based combination therapies have been slow to replace chloroquine and other monotherapies on the shelves of clinics and pharmacies, leaving patients in jeopardy.¹²

The revitalized movement for global malaria control is therefore approaching a critical turning point. Three years out from the next major milestone (50% reduction in malaria mortality in Africa from 2000 levels) and with ample, if not yet sufficient, financing and political will at hand, the global community must now begin to demonstrate large-scale impact well beyond the scattered success stories to date. If it does, donor interest and funding will assuredly be sustained, initial progress will be consolidated and expanded, and the goal of rolling back malaria across Africa and the rest of the endemic world may at last be in sight. If it falls short in either scope or speed, funding may slow and recede, frustration and fatalism will grow, and the world will be in danger of slipping back into a terrible inertia while more than a million lives are lost each year due to malaria.¹³

How then can the necessary impact be achieved in the next several years? Many of the essential components are already in place. The focus now must be on 3 critical factors that are currently absent or in too short supply: leadership, management, and money.

The recent surge of attention to malaria control has come about in a largely decentralized manner, with a range of actors building support for the issue with little connection, and at times agreement, with one another. Although this approach has been successful in generating interest and resources, it has not proven effective in translating those resources into impact. Strong leadership is now needed in several areas if the current opportunities in malaria control are to be realized.

First and foremost, the goals for malaria control and the strategy to achieve them must be more clearly defined and articulated. The Millennium Development Goals, Abuja Declaration, and strategy of the Roll Back Malaria Partnership have served these roles to date, setting out to encompass most interests and perspectives. However, critical and difficult questions have gone largely unasked and unanswered. For example, should resources be allocated equally across endemic countries or weighted toward those that are in a stronger position to reduce the burden of the disease? Should the primary focus be to simultaneously target malaria wherever it occurs or to literally roll it back from its natural boundaries? If it is the former in either case, then it is important to be realistic about the limits of what can be achieved—malaria incidence in Burundi, for example, can only be reduced so much as long as there is a flow of people, and therefore parasites, to and from its neighbors. No population at risk of malaria should be ignored; rather, new leadership must provide clearer direction on the appropriate timing and scope with which each group of people should be reached.

Stronger leadership also is needed to coordinate the many constituencies involved with malaria control. As attention to malaria has grown, so has the number of donors and organizations contributing funding or advice. This proliferation, while at times welcome, has led to confusion and inefficiency in some countries, distracting staff and other capacity that would be better used toward implementation. Much more must be done to ensure that all involved in a given country are working toward common, locally defined priorities and strategies with a clear division of roles and responsibilities among them.

Leaders of endemic countries must also heighten the attention and resources they devote to malaria. In recent years, many African leaders have shown greater support for the fight against malaria, revitalizing national control programs and advocating for more vigorous action by the global community. Yet there is much more that they can and must do. Many countries continue to impose taxes, tariffs, and other costs on insecticide-treated bed nets and antimalarial medications, sapping the already limited resources of programs and individuals.¹⁴ Unlike HIV/AIDS, malaria is often not prioritized within government structures, with control programs often buried deep in the hierarchy of the ministry of health and not provided with sufficient support and staff capacity to achieve their objectives. And although international donors must meet the majority of the funding needs, endemic countries should devote more domestic resources to malaria control—few African governments have begun to approach their commitment of spending at least 15% of their annual budgets on health.¹⁵

In addition, greater leadership is needed for the provision of technical and policy guidance. Since the days of the quest for the source of the disease, the malaria community has been frequently riven by technical disputes. Too often, these debates have outlived the course of healthy, productive discourse and have hindered the actual implementation of control programs. Recent such drawn-out disputes, including over whether indoor residual spraying or insecticide-treated bed nets should be emphasized or whether insecticide-treated bed nets should be free or sold at subsidized rates, have undoubtedly held back progress in endemic countries. There is, thus, a need to more decisively resolve current and future technical issues, unify the community around clear evidence-based guidelines and policies, and effectively communicate those guidelines to those overseeing programs in endemic countries.

In the decades following the failure of the global eradication campaign, malaria control in most countries was superseded by other health priorities. Key human and technical resources were correspondingly reallocated, often leaving only token staff capacity in national malaria control programs. A study from the Muheza district of Tanzania, for example, found that the district health service had placed limited emphasis on malaria control, with none of the staff surveyed at 35 health centers having received any specific training on the disease.¹⁶ As a result, while funding for malaria control has increased dramatically in recent years, the basic management and systems capacity needed to use those resources effectively are not in place in many countries.

Recent successes in malaria have all been characterized by strong management and use of well-designed systems. The Lubombo Spatial Development Initiative has used a central computer database to manage thousands of insecticide spray personnel over a more than 13 000-km² area.¹⁷ In Eritrea, more than 13 000 community health workers, laboratory technicians, and military personnel were trained and used to implement coordinated prevention and treatment activities.¹⁰ The combined immunization–insecticide-treated bed-net distribution campaigns, which increased insecticide-treated bed nets ownership by 50% in Togo and by 60% in Niger, have been possible due to existing immunization infrastructure and because of the many volunteers and health workers mobilized and managed by the government, Red Cross, and other partners.^{18 - 19}

To achieve similar success in other areas, the management capacity of most malaria-control programs must be strengthened. The support these programs require, including hiring and training of managers, streamlining supply chain systems, and improving monitoring and evaluation, among others, do not attract the interest and imagination of donors as physical commodities do. This is evidenced by UNITAID, the international drug purchase facility, and the proposed global artemisinin-based combination therapies subsidy, both of which plan to finance only antimalarial medicines and not the many other inputs required to ensure their effective distribution and use.²⁰ But financing and expertise for the provision of much more extensive management assistance will have to be found if existing, let alone increased, funding for commodities is to have the desired impact. The Malaria Control and Evaluation Partnership in Africa, a Gates Foundation–financed initiative that has provided extensive management and technical assistance to the malaria control program in Zambia, has made an important contribution in this area that should be carefully reviewed and potentially emulated.

Efforts to mobilize additional management assistance should not be limited to the public sector. Several private companies, including Exxon Mobil and Anglo American, have provided key financing and capacity to support malaria programs in Africa. But the potential for the private sector to contribute to malaria control has only begun to be tapped. Private businesses, not the nonprofits and international agencies that typically assist programs, have the greatest expertise in management and systems. These businesses could be leveraged to not only advise and support national efforts but to actually manage critical components of programs. Endemic countries and other partners in the malaria community should more aggressively explore these opportunities through organizations such as Malaria No More, a nascent coalition of global business leaders dedicated to fighting malaria.

Although financing for malaria control has increased substantially in recent years, total resources still remain well below the levels necessary to achieve impact. One estimate suggests that roughly $3 billion is needed annually to implement comprehensive prevention and treatment programs across all endemic countries.⁶ In 2006, less than $1 billion was spent by all international and domestic sources.⁶ This underinvestment is not in the interests of donors. There is a readily identifiable threshold of coverage with key malaria interventions after which the transmission of the disease is interrupted and widespread impact on morbidity and mortality is achieved. As such, to be able to report the desired success and not just marginal results to their stakeholders, donors must ensure that funding in any given area is sufficient to reach that threshold, which it is currently not in most areas.

Equally important to the level of funding is its predictability and sustainability. Endemic countries are rightly hesitant to invest in infrastructure and systems for malaria control if financing may recede in subsequent years. To date, most donor commitments have been for 1 or 2 years, forcing countries to plan and budget more conservatively to mitigate the risk of future funding changes. To enable programs to aggressively plan for impact, the global community should ensure that financing is committed for at least 5 years and preferably longer.

Financing for malaria research must also increase. Although many effective tools are already available, new treatments will be needed as resistance inevitably develops to those currently in use and a vaccine, though not a panacea, would provide a major boost to control programs. Current funding for malaria research (measured per disability-adjusted life-year caused by the disease) is a quarter of that devoted to HIV/AIDS and a 10th or less of that spent on noncommunicable diseases.²¹ Even relatively modest increases in funding for research will help facilitate the success of malaria control programs in the medium-term. That funding should be committed not only to the development of new technologies but also to operational research to support and guide the implementation of programs. As programs expand throughout the endemic world, it is critical to evaluate which strategies work well and which do not and incorporate that learning into ongoing implementation. With a few exceptions, this work has not kept pace with the recent growth in control activity and should be emphasized in the coming years.

In 2004, the Center for Global Development convened a group of experts to draw lessons from global health interventions that have had a large-scale impact on the burden of disease and welfare of populations.²² For all of the 17 cases documented in the final report, ranging from the eradication of smallpox to HIV prevention in Thailand, strong leadership, sound management, and adequate, predictable financing were central to the success of the program.²² No malaria control program met the group's criteria.

Malaria control is no more challenging than many of the global health feats identified in that report. Malaria has been controlled in Australia, Europe, and North America; it is starting to be controlled in parts of Africa and Asia; and it can be controlled everywhere the disease still exists, no matter how poor or remote the location or population. The tools needed to achieve impact are available and the financing to purchase and deploy them is substantial and increasing. It is now up to the global community to put the final pieces in place—uniting around clear strategies and policies, tackling the comparatively prosaic challenges of effectively managing programs, and mobilizing the modest remaining resources needed—and at last begin rolling back malaria around the world. Millions of lives each year and the economic well-being of communities and countries depend on the ability to do so.