Twenty-fifteen will be a pivotal year for malaria efforts. Key global strategies for malaria, such as the World Health Organization’s Global Technical Strategy for Malaria, will be launched, discussion is well underway about how malaria fits within the new Sustainable Development Goals, and the Global Fund will be revisiting its own strategy. Over the past decade, incredible progress has been made in driving down the global malaria burden. These achievements have spurred a critical conversation about how to support countries in eliminating malaria, with the view that global malaria eradication could be possible by 2040. But with all these grand plans, an important question remains: how will elimination be funded and sustained?
The Global Fund to Fight AIDS, Tuberculosis and Malaria is the largest financer of malaria around the world. They are also by far the largest contributor of money to countries working toward elimination, including significant investments to regional malaria elimination efforts – $10 million to Latin America to eliminate malaria in 10 countries by 2020, and $100 million for the greater Mekong sub-region to halt the spread of artemisinin resistance. Both investments are invaluable in the fight against malaria. But last year with the launch of their New Funding Model (NFM), the Global Fund reworked the way funds are allocated for malaria in order to focus on high-burden, low-income countries. Because eliminating countries, by nature, have low malaria burdens and are typically middle income countries, these nations may be at risk of losing an important source of funding for their malaria elimination efforts.
Preliminary analysis suggests there will be an overall 21% decrease in financial resources going to eliminating countries under the Global Fund’s NFM. This may be problematic for three main reasons. First, decreasing funding to countries, even middle income countries (where 41% of people at risk for malaria live) may hurt the national malaria programs’ ability to maintain progress towards malaria elimination. A study conducted by the WHO and Results for Development provides evidence that we cannot assume a middle income country will increase investment in health as GDP rises. Even if a country begins to shift financing for malaria programs from donor to domestic sources, government politics and bureaucracy tends to make it slow process, and malaria programs in eliminating countries may be weakened in the meantime.
Along the same lines, if a country can pay for certain health interventions, it does not mean it will. When malaria transmission is reduced and the risk of malaria seemingly disappears, governments often shift money into higher priority issues. However, as countries reach zero malaria cases, malaria programs need continued investment through elimination and afterwards, to prevent reintroduction. This is a similar challenge faced by diseases that are preventable by vaccine – many communities don’t see measles or polio because of well-funded and effective immunization programs.
Second, a decrease in funding has the potential to weaken malaria programs and lead to resurgences. In the 1960s, Sri Lanka was down to just the last few cases when the government slowed the momentum in the malaria fight. The weakening of the malaria program led to one of the deadliest resurgences in recent history. Sri Lanka has not had any local transmission since 2012, but it has taken decades and countless efforts and additional resources for Sri Lanka to get back down to zero cases. Although Sri Lanka has seen recent success, their potential for another resurgence remains and we congratulate the Global Fund in continuing to support to Sri Lanka.
While the Global Fund does support some elimination efforts in low-burden countries, the malaria allocations under the NFM favor a traditional way of telling an impact story — the story of delivering commodities and saving lives. But we are in a new world where ‘success’ should be redefined: is it just about saving lives or can impact also include progress towards the end-game of elimination and eventual eradication? Indeed, funding sources need to be diversified and alternative financing mechanisms should be explored, but as the Global Fund revisits its strategy in 2015, they should think through how their investments can reflect a new reality – one where countries are supported in their pursuit of elimination and are working towards the broader goals set out in the Global Technical Strategy, Sustainable Development Goals and Bill Gates’ call for malaria eradication in his lifetime.
Brittany Zelman is a Policy and Communications Analyst at UCSF Global Health Group’s Malaria Elimination Initiative