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Where did it all go wrong?

International agencies have failed to meet their own malaria performance targets and should be held to account, says Amir Attaran.

In May 1998, the director-general of the World Health Organization (WHO) announced a United Nations-led campaign to Roll Back Malaria (RBM), pledging to halve malaria deaths by 2010. Today, RBM is at the halfway point and the WHO's own statistics show deaths have actually increased (see graph). For the several hundred thousand children who died in the interim, RBM is not just a failure but a fatal betrayal by the United Nations.

How did this happen? The fundamental reason is political: the WHO launched RBM to create an advocacy splash, but has subsequently failed to ensure adequate funding.

The world's foreign-aid donors — powerful developed countries and the World Bank — have behaved with their usual parsimony, but the WHO has not been vocal enough to hold them to account. Aid funding for malaria control has barely grown. No wonder the British Medical Journal recently called RBM “a failing global health campaign”1. Without large increases in foreign aid, the least-developed countries that are most severely affected by malaria can do little. They have an average public-health expenditure of barely US$6 per person annually2.

This figure would be more had African governments honoured their promise at a conference in Abuja, Nigeria, in 2001 to spend 15% of their budgets on health. But even if they had, the vast majority of malaria control in the poorest countries would still need to be paid for out of foreign aid.

Roll Back Malaria's difficulties so far suggest that major aid donors such as the World Bank (pictured) are not rising to the challenge. Credit: D. BRACK/STOCKPHOTO.COM
The World Health Organization has pledged to halve malaria deaths by 2010 — but it has yet to make much progress. Credit: P. VIROT/WHO

So how much foreign aid is available to control malaria? The WHO's most recent estimate was that “approximately US$200 million was earmarked for malaria control worldwide” in 2002, including both domestic and foreign-aid budgets3. This is roughly consistent with an estimate for 2000 by myself and Vasant Narasimhan4 of $100 million, which counted only the foreign-aid budget.

Most recently, the Global Fund to Fight AIDS, Tuberculosis and Malaria gave cause for optimism by pledging $895 million over two years, rising perhaps to $1.8 billion over five years5. At an average rate of $360 million annually, assuming full disbursement, this will be the largest increase in malaria-control funding for decades6.

But making significant progress will require billions of dollars annually, not millions. There is a precedent: malaria-control funding in the 1960s did reach such levels7. RBM has said that Africa needs $1 billion annually3. A more careful peer-reviewed estimate is that at least $1.6 billion is needed just for malaria medicines in Africa alone8.

Add in the cost of disease prevention — such as bednets and insecticides — training and staff costs, and the fact that many of the world's malaria fatalities occur outside Africa9, and a fair guess for the worldwide price tag must be at least $5 billion annually.

Thus, even with the advent of the Global Fund, there is far too little foreign aid to combat malaria. This suggests that a more deliberate, more aggressive strategy to drive up donor aid is needed. To start with, it would be desirable to audit routinely how much each donor spends on malaria control, so that progress — or lack of it — can be tracked.

Tied up in red tape

At the moment, attempts to obtain foreign-aid figures are hampered by bureaucracy and poor availability of accurate, up-to-date data. Of 23 developed countries I surveyed in 2002, 13 seemed unable or unwilling to disclose their malaria-control funding, even after nine months and several reminders4.

For this article, I surveyed three major aid donors: the World Bank, the US Agency for International Development (USAID) and the United Nations Children's Fund (UNICEF). The World Bank is the world's top donor of foreign aid, USAID is the foreign-aid agency of the world's only superpower, and UNICEF is the world's top child-health agency. How much does each spend on malaria?

A World Bank announcement on Africa Malaria Day in April 2000 pledged between $300 million and $500 million towards the eradication of malaria in Africa. In an earlier study, I estimated that the bank earmarked $44 million of loans for malaria control aid in 2002 (ref. 4). For this article, the bank declined to supply me directly with data, but in a statement to Nature it claimed to have earmarked loans totalling between $100 million and $150 million for malaria control since 2000. Beyond that, it is difficult to know how much else the bank is spending on malaria. Its statement points to “non-earmarked monies” that may indirectly affect malaria (for example debt cancellation), but which it says are “difficult to quantify” because the bank does not track disease-specific details.

Whereas the World Bank supports a country's overall malaria-control budget, UNICEF and USAID tend to support discrete projects on the ground. Although RBM acknowledges that prompt and effective treatment are essential to reduce malaria deaths, neither UNICEF nor USAID buys more than a tiny quantity of malaria medicines.

In personal correspondence, USAID said that it spends about 34% of its $65.6-million annual budget for malaria on treatment. But it adds that it “typically does not purchase ... [malaria] medicines other than in exceptional or emergency circumstances”, and that the quantities are “not large”. It states that, instead, its strategy is “building the systems to procure, manage, and use the drugs”.

Obsolete medicines

UNICEF does routinely buy and supply antimalarials, but the amounts are trivial: just $3.7-million worth in 2003. Worse, most of that was spent on obsolete drugs that, because of resistance, usually do not work. Examples are chloroquine in Kenya and sulphadoxine-pyrimethamine in Burundi, which are so ineffective neither government sanctions their use. UNICEF spent only $1 million on more effective drugs, the artemisinin combination therapies, even though these are the RBM-endorsed standard.

Under pressure: sub-Saharan Africa bears the brunt of malaria's scourge. Credit: I. BERRY/MAGNUM PHOTOS

A similar picture emerges for buying and supplying bednets and insecticides. UNICEF spent $17.3 million on these in 2003. USAID could not provide breakdowns for spending on each, although it spent $8.4 million in 2003 on a partnership with private contractor NetMark, which sells (not gives) bednets to impoverished Africans, a practice that is controversial.

UNICEF says that it also invests “notable sums” in programmes that strengthen healthcare delivery in general and which may benefit malaria control in the long run, such as the training of healthcare workers and education campaigns. But it provided no figures for what proportion of this investment directly relates to malaria control.

This all raises hard questions about legitimacy. The World Bank has said malaria slows economic growth in African countries by 1.3% per year. Over 35 years, this equates to a 32% reduction in GDP, worth in the range of $100 billion10. If the bank fails to fulfil its own pledge on malaria control in Africa, while observing that its economies are so severely affected by the disease, is it actually doing international development? And if UNICEF, USAID and the World Bank cannot provide detailed audits of their malaria spending, is that a transparent use of taxpayers' money?

One lesson is clear: congresses, national parliaments and ultimately the public need to ‘take back malaria’. Imagine if the managers of a project in a private company consistently missed their performance targets by a large margin. The company would be in trouble, and it would sack the managers.

Exactly the same should be true of the public agencies and officials who have for six years missed their performance target to reduce and ultimately halve malaria deaths. I suggest that legislators hold hearings into why the agencies have failed to roll back malaria, and take the necessary action. If that sounds harsh, weigh it against the number of children whose lives were tragically lost in the interim to a preventable, curable disease.


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Attaran, A. Where did it all go wrong?. Nature 430, 932–933 (2004).

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