World Malaria Day
Today is World Malaria Day (it used to be called African Malaria Day). A posting on The Lancet Global Health Network asks where next for malaria? and looks at how the billions of dollars from The Gates Foundation to tackle malaria is being spent, including concerns from some experts that any advancements may not reach the people who need them most. I have also copied for you below, a Lancet Comment by Raymond Chambers, Rajat Gupta, and Tedros Adhanom Ghebreyesus published today which focuses on responding to the challenge to end malaria deaths in Africa. And of course we have our own section on malaria in our article collection which have been written by students. I think that you will find all of these items very useful as malaria is such a massive global health challenge that has recently got a lot of renewed attention thanks to a recent announcement by the Gates Foundation that malaria should be eradicated. Rhona
Lancet Comment: Responding to the challenge to end malaria deaths in Africa
With World Malaria Day, April 25, 2008, the international community-led by UN Secretary-General Ban Ki-moon-throws its weight behind an ambitious campaign to expand access to a comprehensive set of malaria-control interventions in sub-Saharan Africa with the aim of ending malaria deaths on the continent in the near future.
The first wave of the effort will be to fund and deliver about 250 million long-lasting insecticide-treated bednets to achieve universal access for malaria-endemic populations by Dec 31, 2010. This goal applies not only to pregnant women and children aged less than 5 years, as previous efforts sometimes have, but to all people at risk of malaria. Although we will lead with bednets, near-zero mortality can only be achieved with a comprehensive approach that includes targeted spraying of insecticides, provision of effective medicines, and expanded delivery through community health workers and other means. We must make these efforts simultaneously.
The world has seen ambitious plans before that have fallen far short of achieving their goals-the 2005 Abuja target of 60% of people in sub-Saharan Africa using essential malaria control interventions, to name just one. (1) So why is this effort any different? We now have clear instances of country-level success in sub-Saharan Africa, mounting political will, expanded resources, and more effective approaches than ever before. Together, these factors make aggressive new goals achievable.
Last month, WHO reported that cases of malaria in Rwanda decreased by 64% and deaths by 66% between 2005 and 2007 among children aged less than 5 years.2 Ethiopia, meanwhile, saw reductions of 51% in deaths and 60% in cases in the same age group. (2) These remarkable outcomes were achieved through expanded access to malaria control, primarily long-lasting insecticide-treated bednets and artemisinin-based combination therapies.2 But how did these programmes work? And why should we expect these successes to translate to a continent-wide scale-up in the next 32 months?
The case of Ethiopia is especially informative, because this is the first time such significant achievements have been recorded over such a large geographical area in sub-Saharan Africa. In the face of widespread scepticism, Ethiopia managed to distribute more than 20 million bednets-two for every household in malaria-prone areas-largely through a vast network of community health workers established to strengthen the routine health system.
The achievement of these results in just 3 years proves that malaria control can be quickly and effectively scaled up. Combining bednets with rapidly expanding access to artemisinin-based combinations and diagnostics, Ethiopia’s scale-up model deserves careful study and dissemination. Although multiple factors have contributed to success in Ethiopia, there are arguably four main contributing components: a catalytic moment, demand for universal coverage, pragmatic donor response, and innovative problem-solving.
In 2003, Ethiopia experienced its worst malaria epidemic on record. Despite warning signs, the country found itself ill-equipped to deal with the crisis. The number of malaria cases rose from 6 million to about 12 million, with an estimated 100000 child deaths.
The epidemic spurred the government to rethink its approach. Recognising that successful malaria control needed adequate scale, Ethiopia made a bold proposal in early 2005: it would achieve universal coverage with long-lasting insecticide-treated bednets by distributing 20 million in 3 years in the hope of reducing malaria-related deaths by 50%. Rather than making do with the money available, Ethiopia made a compelling case for the money it needed. The required US$160 million was almost three times the previous national malaria-control budget; and some people viewed this request as
Donors responded not just to the urgent need, but also to committed leadership and a sound plan grounded in the technical realities of the disease. Additional resources totalling over $200 million were made available by a consortium of partners including the Global Fund to Fight AIDS, Tuberculosis and Malaria, the World Bank Booster Program for Malaria Control, the UK Department for International Development, the Dutch Government, the Carter Center, and others. (3) Ethiopia took advantage of flexibility built into both Global Fund and World Bank processes to frontload funding. Rather than disbursing its grants over 5 years, the country drew down on the pledged funds to finance its ambitious bednet-distribution programme in 1-2 years.
Procurement of intervention is often a rate-limiting factor, but Ethiopia negotiated reduced fees with and outsourced much of the purchasing of bednets to UNICEF to increase speed and coordination. Most of the monies flowed directly to UNICEF, so funds did not have to be disbursed first from the Global Fund to the government and then back to a procurement agent. At the same time, significant investments were made by the government and partners to build in-country procurement capacity for the post scale-up phase. These decisions expedited the delivery of bednets by 21 months or more.
Now is the moment to aim for results like those in Ethiopia and Rwanda throughout Africa. With the successful replenishments of the Global Fund and the World Bank’s International Development Association, as well as the prospect of increased resources from the US, UK, and other G8 governments, malaria-endemic countries should no longer limit their aspirations to small-scale, incremental progress. Ethiopia proves that large-scale success is achievable in a short time.
Donors must also be willing to assume greater risk by encouraging and funding ambitious programmes while showing increased flexibility in their processes and procedures. And both parties must plan early for the maintenance and eventual elimination phases so that donor support does not flag as malaria deaths are reduced. The pieces are increasingly in place to achieve the Secretary General’s vision for universal coverage and make rapid gains toward ending malaria deaths in Africa. With one child dying every 30 s from malaria in Africa, we have not a moment to lose.
(1) Roll Back Malaria Partnership. The Abuja declaration and the plan of action. April 25, 2000:
http://www.rollbackmalaria.org/docs/abuja_declaration.p…
(2) WHO. Impact of long-lasting insecticidal nets (LLINs) and artemisinin-based combination therapies (ACTs) measured using surveillance data, in four African countries. January, 2008:
http://www.who.int/malaria/docs/ReportGFImpactMalaria.pdf
(3) World Bank. Ethiopia-protection of basic services project: project appraisal document. May, 2006:
http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2006/05/04/000160016_20060504110123/Rendered/PDF/35121.pdf