Winning the Fight Against Malaria at All Costs

Recently, Dr. Mark Dybul, the newly appointed executive director of The Global Fund to Fight AIDS, Tuberculosis and Malaria, wrote an impassioned plea in The Huffington Post, underscoring the urgency of funding disease prevention and treatment programs throughout the world.

"When health professionals working in cities, towns and rural areas in countries around the globe can take action to actively limit the spread of infectious disease, everyone benefits," Dybul contended. "Not just the patients, who maintain or regain their health, and not just their families which are immediately affected. It is also the larger communities and regions and countries whose economies and social fabric thrive on a healthy population."

Dybul's article comes on the heels of the World Health Organization's World Malaria Report 2012, which revealed an alarming reduction in global funding for malaria prevention and control between 2010 and 2012. A mosquito-borne disease, malaria impacted 219 million people globally in 2010, killing 660,000, mostly children under five. Yet both WHO and anti-malaria campaigns remain convinced that malaria can be both prevented and treated.

Indeed, according to WHO's report, malaria mortality rates plummeted 26 percent globally between 2000 and 2010; there was a 33 percent decline in the WHO African Region alone. WHO estimates that during the same decade, enhanced intervention efforts helped avert 1.1 million malaria deaths. However, the "global slowdown" in anti-malaria funding now threatens progress, putting the Millennium Development Goal (MDG) of zero malaria deaths by the end of 2015 further out of reach.

Easing the Global Malaria Burden

When discussing the global malaria burden, we are talking about 14 countries where the disease is endemic, accounting for approximately 80 percent of cases. WHO African Region nations like Nigeria, Democratic Republic of Congo, United Republic of Tanzania, Uganda, Mozambique, and Cote d'Ivoire continue to be hardest hit. In fact, WHO estimates 103 million cases occur in these six countries, where children under five and pregnant women are most at risk.

While 90 percent of malaria deaths happen on the African continent, the burden is certainly not limited to Africa alone. For instance, India is the southeast Asian nation where malaria is most prevalent, with approximately 24 million cases annually. Perhaps not surprisingly, there is also a direct correlation between nations with the highest malaria rates and the highest poverty levels.

Of course, WHO's report maintained that 50 out of the 99 countries where malaria transmission is ongoing will be able to achieve a 75 percent reduction in cases by 2015. That would be in keeping with goals established by the World Health Assembly and Roll Back Malaria, and would include countries in the African Region. However, while those 50 countries account for an estimated seven million malaria cases, that number is only a tiny fraction (3 percent) of the total.

To make matters worse, the 58 countries that submitted their data sufficiently make up only 15 percent of total cases throughout the world. In other words, 85 percent of malaria cases are occurring in the other 41 countries, where malaria surveillance systems remain inadequate. Last April, WHO launched its T3 initiative to test, treat and track malaria outbreaks using new surveillance manuals.

Behind the Slowdown

When it comes to funding the fight against malaria, the good news is that both international disbursements and national funding for controlling this disease have increased steadily in recent years. International disbursements hit $1.84 billion in 2012, while national government funding reached $625 million in 2011.

However, WHO estimates that $5 billion will be needed annually for the next decade to bring about universal access to malaria interventions in the 99 countries with ongoing transmission. And in 2011, total global funding amounted to less than half of that total at $2.3 billion. As WHO's report concluded, this means "millions of people continue to lack access to preventive therapies, diagnostic testing, and quality-assured treatment."

According to Dr. Scott Filler, a senior adviser on malaria at The Global Fund, the slowdown in funding was due primarily to the cancellation of a round of disbursements. "There was limited funding available through Transitional Funding Mechanism, and there were no funds in many on-going grants to replace long-lasting insecticidal nets," Filler said by email.

As to whether this will prevent the malaria-related MDG from being attained, Filler offered some perspective. "The goal was always aspirational," he stated, "so managing expectations is important. There is always a difficult balance between encouraging donors to commit to a cause and setting achievable targets. This is an age-old debate."

At this point, we must wait until June, when the Finance and Operational Performance Committee will meet again, to determine whether the recent funding slowdown will persist this year.

Casting a Wider Net

Beyond funding, WHO reported a drastic reduction in the delivery of long-lasting insecticidal nets (LLINs), and to a lesser extent, indoor residual spraying programs. In sub-Sahara Africa, for instance, 145 million LLINs were delivered in 2010, but only 66 million were provided last year. Preventing a considerable malaria resurgence would require massive efforts to raise that number, especially since LLINs must be replaced every few years to maximize their effectiveness.

LLINs remain an inexpensive but critical weapon in the malaria fight. WHO predicts 780 million people in this disease-ravaged region require LLINs to achieve universal access, meaning 150 million nets would need to be delivered each year.

Filler maintained that we are not experiencing a substantial impact from the funding slowdown yet. "But LLIN cohorts are aging," he warned, "and there have been examples in the past where LLINs age, are not replaced in a timely fashion, and this has led to resurgence of diseases." Filler cited Rwanda and Zambia as examples.

In light of WHO's findings, campaigns like Nothing But Nets remain focused on remote regions where the disease is endemic. Chris Helfrich, director of Nothing But Nets, told The InterDependent by phone, "The report made clear that long-lasting insecticidal nets are a critical tool to fighting malaria and the ultimate goal of malaria eradication." Helfrich added, "It also sends a signal to us that we need to redouble our efforts to send nets to help families in need."

Right now, Nothing But Nets is primarily concerned with sending as many high-quality LLINs as possible to malaria-ravaged areas, particularly within the WHO African Region. In 2012, the campaign distributed its one millionth net to refugees in Africa; overall, Nothing But Nets has helped provide more than 7 million bed nets to families across Africa in the past six years.

Other organizations share Nothing But Nets' priorities in the anti-malaria crusade. The Malaria Consortium, for example, an international non-profit working to eradicate this disease in sub-Sahara Africa and southeast Asia, has reported the distribution of 2.9 million LLINs throughout Nigeria, Uganda, and Mozambique. They are also engaged in actively training thousands of health workers at the community level. Meanwhile, the non-profit Malaria No More has distributed 2.7 million nets to cover 5 million people in 13 African nations, in addition to launching campaigns that educate the public on the importance of net use.

Fighting for a Future

Of course, there are other major concerns in the global fight against malaria. For example, WHO reported anti-malarial drug resistance in four southeast Asian nations -- Cambodia, Myanmar, Thailand, and Vietnam. There have also been reports from 64 countries of mosquito resistance to an insecticide used in controlling this disease. Yet the bigger picture in the quest for malaria eradication revolves around raising funds, both to achieve universal intervention access and to prevent widespread malaria resurgence.

As Filler explained, "This is a critical moment. Our gains will be lost if we do not move forward to defeat these diseases. We can't stop now. We have a historic opportunity to completely control these diseases. It is 'invest now or pay later.' We need to seize the moment."

(Cross-posted on The InterDependent)