While financing for malaria control has increased as part of international commitments to achieve the Millennium Development Goals (MDGs), new research shows total global funding is 60% short of the US$4.9 billion needed for comprehensive control in 2010. But while this headline is bad news for the malaria community, there is also some much needed good news—that 21 countries, including 12 in Africa, have now received adequate or near-adequate donor assistance for effective malaria control. The findings are published in an Article Online First (www.thelancet.com) and in upcoming Lancet, written by Professor Bob Snow, Malaria Public Health and Epidemiology Group, Centre for Geographic Medicine, KEMRI—University of Oxford—Wellcome Trust Collaborative Programme, Kenyatta National Hospital, Nairobi, Kenya, and colleagues. The study was funded by the Wellcome Trust.
The authors assessed the level of malaria risk and the resulting financial requirements for 93 malaria-endemic countries. An analysis of external donor assistance for malaria control was done for the period 2002 to compute overall and annualised per-person at-risk-funding commitments. Annualised malaria donor assistance was compared with independent predictions of funding needed to reach international targets of 80% coverage of best practices in case-management and effective disease prevention. Countries were ranked in relation to biological, economic, and unmet needs to examine equity and adequacy of support by 2010.
The researchers found that international financing for malaria control has increased by 166% (from $0•73 billion to $1•94 billion) since 2007 and is broadly consistent with the malaria risks across recipient countries. Importantly, African countries that bear the brunt of malaria burden worldwide have enjoyed the largest amount of external assistance since 2007; however, countries outside of Africa where Plasmodium vivax continues to pose a major threat to control ambitions are not nearly as well funded.
21 countries* have reached adequate assistance to provide a comprehensive suite of interventions by 2009, including 12 countries in Africa. However, this assistance was inadequate for 50 countries representing 61% of the worldwide population at risk of malaria—including ten countries in Africa and five in Asia that coincidentally are some of the poorest countries. Conversely, some countries with large populations at risk have economies that could support malaria control ambitions from domestic resources—notably India and China, as well as two African countries, Equatorial Guinea and Gabon. Whether international donor assistance should be provided to these countries needs further discussion between donor agencies and national governments.
The Roll Back Malaria (RBM) global business plan states that it needs about $4•9 billion in 2010, including the need to ensure rapid scale-up of campaigns for universal access to existing interventions in 43 sub- Saharan African countries and India. The authors say: "Our assembly of external donor support to 93 malaria-endemic countries shows that, in an average year since 2002, $1•9 billion has been provided as a contribution to scaled malaria control. This funding has increased by 166% since 2007 but is 60% below what RBM has estimated is needed worldwide."
"Poor countries with inadequate donor assistance and large sectors of their population at risk of malaria must remain the focus of attention if global ambitions for malaria control are to be realised. Our analysis identified 10 African countries and 5 in Asia that are short of necessary funds and have low domestic income," says lead author Professor Bob Snow.
Snow adds: "While this analysis has the inevitable plea for more money, this new money can be better targeted using risk maps and maps of national capacities to support national disease control."
The authors conclude: "Any decline in malaria funding commitments will run the risk of a resurgence of malaria in countries that have enjoyed the benefits of this funding to provide protection from malaria since 2002. Sustained funding in these countries is crucial or $9•9 billion invested since 2002 will have been in vain."
In a linked Comment, Prof Anne Mills, London School of Hygiene and Tropical Medicine, London, UK, highlights the importance of studying how external funding combines with internal funding to address areas of concern, saying that donor funding may be low in some cases because the recipient country itself funds malaria control.
Along with the study authors, Prof Mills also points out the difficulty that donor assistance to strengthening health systems—needed to implement malaria control—is not captured by this new research. She concludes: "Both of these problems emphasise the need to look in a much more comprehensive fashion at financing needs for country health systems, and to avoid the distorting effects of the current MDG structure which has set up different health communities in competition with each other."
Professor Bob Snow, Malaria Public Health & Epidemiology Group, Centre for Geographic Medicine, KEMRI-University of Oxford-Wellcome Trust Collaborative Programme, Kenyatta National Hospital Grounds (Behind NASCOP) Nairobi, Kenya T) +254 20 2715160 / 2720163 / 2719936 / +254 0722 523 323 E) rsnow@nairobi.kemri-wellcome.org
Dr Anne Mills, London School of Hygiene and Tropical Medicine, London, UK. T) +44 (0) 207 927 2354 E) anne.mills@lshtm.ac.uk
For full Article and Comment, see: http://press.thelancet.com/malfunding.pdf
Notes to editors: *The 21 countries are: Afghanistan, Azerbaijan, Benin, Ivory Coast, Dominican Republic, Equatorial Guinea, Gabon, Gambia, Georgia, Iran, Liberia, Malawi, Papua New Guinea, Rwanda, Sao Tome and Principe, Sri Lanka, Suriname, Swaziland, Vanuatu, Zambia, ZImbabwe
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The Lancet