GFO Issue 461, Article Number: 5
ABSTRACT
This article draws attention to a major problem impeding the rollout of malaria vaccines in Africa. It draws attention to a double standard in global health: whereas wealthier countries easily spend money on pricey vaccines, African countries have to consider cost-effectiveness, even when the vaccines have proven to be successful. The article argues that the issue is one of equality rather than just cost or efficiency. It urges world leaders to view malaria vaccinations as a moral duty rather than just a financial one.
As the historic rollout of the long-waited malaria vaccines begins across Africa, a polarizing debate has emerged—not over the science or the efficacy of these vaccines, but over the question of funding. At the heart of this debate lies a troubling double standard: Would this conversation even be happening if malaria were killing children in Europe or North America?
Several donors, including the Global Fund to Fight AIDS, Tuberculosis and Malaria, have raised concerns regarding its affordability and accessibility. Peter Sands, Executive Director of the Global Fund in his report to the Global Fund Board during its meeting held in Lilongwe, Malawi, from 20–22 November 2024, raised concerns about malaria vaccine funding being “non-fungible.” In other words, countries cannot reallocate that money to other malaria tools—such as long-lasting insecticidal nets (LLINs), seasonal malaria chemoprevention (SMC), or diagnostics—even if those alternatives might seem more cost-effective in certain settings.
“At a time when we are confronted by daunting challenges in containing malaria given the combined impact of climate, conflict, resistance and inadequate financial resources, it is problematic that we cannot be confident that countries are making optimal trade-offs in the deployment of malaria vaccines versus other tools,” Sands noted. “Indeed, the current funding arrangements for malaria vaccines do not permit such trade-offs.”
Malaria continues to be a serious health threat, particularly in the African region. According to the World Health Organization (WHO), the region accounted for 94% of malaria cases and 95% of deaths globally in 2023. Children below the age of five years account for 76% of all malaria deaths in the African region. Countries with the leading cases of malaria in 2023 were Nigeria (26%), the Democratic Republic of the Congo (13%), Uganda (5%), Ethiopia (4%) and Mozambique (4%). Against this backdrop, critics argue that the current debates over funding for malaria vaccines misses a larger point. The issue is not simply about trade-offs or maximizing cost-effectiveness—it is about justice. For many in low-income, malaria-endemic countries, especially across Africa, the very idea that funding for a historic public health breakthrough should be constrained raises uncomfortable questions. Chief among them: Would this debate even exist if malaria were a threat to children in high-income countries?
A symbol of long-awaited inclusion
For many Africans, the malaria vaccine represents more than a new intervention—it symbolizes long-overdue recognition and inclusion in global health priorities. The suggestion that African countries must justify receiving this vaccine, while children continue to die from preventable mosquito bites, is seen as deeply slighting. If malaria were killing hundreds of thousands of children in the Global North, the global response would likely be urgent and unified, with funding flowing freely to support universal rollout across all tools—nets, treatment, and vaccines alike.
This frustration is rooted in longstanding inequities. During COVID-19, wealthy nations raced to secure vaccines for their populations, spending billions before a single dose reached much of the Global South. No one questioned whether mRNA vaccines were the most cost-effective approach—they simply asked how soon they could get them. Why should proven, safe, and impactful malaria vaccines be held to a different standard?
There’s also a high risk of discouraging the researchers who have spent decades working toward this breakthrough. To now hesitate on deployment due to cost-effectiveness debates undermines their contributions and sends a demoralizing message. But these discussions are not new. Similar arguments surfaced during the early years of HIV treatment. Due to cost constraints, some people were offered only prophylaxis where available, rather than full treatment. The lessons of history warn us: delaying access based on economic calculations often comes at the expense of lives.
The numbers back it up
According to WHO, mathematical models show that adding the malaria vaccine RTS,S/AS01 to existing prevention and treatment strategies can significantly reduce illness and death, especially in areas with higher malaria transmission. In regions where 10% to 50% of children aged 2 to 10 years are infected, the RTS,S/AS01 vaccine could prevent between 417 and 448 deaths per 100,000 fully vaccinated children—a reduction of up to 19% in malaria deaths among children under five. The benefits are less pronounced in areas with lower transmission, but the impact remains notable.
Cost modeling suggests the vaccine is economically viable, particularly in high-burden areas. At $5 per dose, it costs between $28 and $59 to prevent one case of malaria, and between $97 and $103 per disability-adjusted life year (DALY) averted. Even at $10 per dose, the vaccine remains cost-effective in priority regions.
A second vaccine, R21/Matrix-M, has also been evaluated and shows even higher efficacy in some models. It could prevent up to 398,000 cases and 733 deaths per 100,000 vaccinated children, with particularly strong results in moderate- to high-transmission settings. At an estimated price of $3 per dose, it offers an excellent value-for-money proposition.
Delivery strategies—whether age-based, seasonal, or a mix—have all demonstrated substantial public health benefits with minimal variation in cost-effectiveness.
Lessons from the global North
Wealthy nations routinely prioritize vaccines over more “cost-effective” alternatives when facing health threats at home. In 2015, the UK introduced the Meningococcal B (MenB) vaccine for infants—even though its own advisory body, the Joint Committee on Vaccination and Immunisation (JCVI), deemed it not cost-effective at £75 per dose. Public and political pressure led to its adoption anyway. Today, MenB cases have declined—but debates continue over whether the resources could have saved more lives elsewhere in the health system.
The United States offers a similar lesson. Before the arrival of HPV vaccines like Gardasil and Cervarix, cervical cancer rates had already fallen sharply thanks to widespread Pap smear screening. Yet in 2006, the U.S. approved the costly vaccines—priced at $150–190 per dose—for routine use. While adding long-term value, the vaccines imposed substantial new costs on health budgets.
Pneumococcal conjugate vaccines (PCVs), such as PCV10 and PCV13, have been widely adopted in high-income countries despite their high costs. These vaccines target pneumococcal diseases, which can also be addressed through non-vaccine interventions like improved hygiene and antibiotic treatments. However, the adoption of PCVs is driven by their effectiveness in reducing disease burden and long-term healthcare costs.
Another example: Pneumococcal conjugate vaccines (PCVs), like PCV10 and PCV13, are widely used in high-income countries despite their high price tags. These vaccines prevent diseases that can also be addressed through hygiene improvements and antibiotics. Yet the biomedical route was prioritized for its perceived effectiveness.
These cases reveal a global double standard. When diseases threaten populations in the North, affordability takes a back seat to urgency, innovation, and symbolic value. But when it comes to the South, the emphasis shifts to caution, cost-efficiency, and budgetary constraints.
The real choice
At its core, this is not simply a debate between bed nets and vaccines. It is a debate about who holds the power to make life-or-death decisions—and under what conditions. The focus should not be diverted; saving children's lives must remain at the very top of global health priorities.
Although proponents are justifiably urging for increased flexibility in funding, the manner and timing of criticisms aimed at the malaria vaccine may inadvertently strengthen ongoing global disparities—where vital interventions for the poorest children globally face more rigorous financial evaluation than those in richer countries.
According to WHO, all strategies matter in the fight against malaria. The organization recommends use of a mix of interventions, as all interventions including that of vaccines offer partial protection. However, in high-burden areas such as Africa, the principles of equity and effectiveness should steer decision-making. Additionally, African governments should take a leading position in financing malaria vaccine rollout—not merely requesting aid, but by actively and consistently contributing to safeguard the health and lives of their citizens.
Vaccines as a test of solidarity
The malaria vaccine rollout is not just a medical milestone it is a moral one. And the global health community must treat it as such.
Vaccines are never just about biology and funding. They are about values. When we question whether African children “deserve” vaccines based on funding formulas, we risk institutionalizing inequity.
Instead of turning this moment into a budgetary dilemma, global leaders and more specifically African leaders must recognize it as a test of solidarity. If we fail that test after decades of delay, we confirm what too many already suspect: that African lives are valued less in the global health order.
And that, more than any inefficiency, would be the real scandal.
As the historic rollout of the long-waited malaria vaccines begins across Africa, a polarizing debate has emerged—not over the science or the efficacy of these vaccines, but over the question of funding. At the heart of this debate lies a troubling double standard: Would this conversation even be happening if malaria were killing children in Europe or North America?
Several donors, including the Global Fund to Fight AIDS, Tuberculosis and Malaria, have raised concerns regarding its affordability and accessibility. Peter Sands, Executive Director of the Global Fund in his report to the Global Fund Board during its meeting held in Lilongwe, Malawi, from 20–22 November 2024, raised concerns about malaria vaccine funding being “non-fungible.” In other words, countries cannot reallocate that money to other malaria tools—such as long-lasting insecticidal nets (LLINs), seasonal malaria chemoprevention (SMC), or diagnostics—even if those alternatives might seem more cost-effective in certain settings.
“At a time when we are confronted by daunting challenges in containing malaria given the combined impact of climate, conflict, resistance and inadequate financial resources, it is problematic that we cannot be confident that countries are making optimal trade-offs in the deployment of malaria vaccines versus other tools,” Sands noted. “Indeed, the current funding arrangements for malaria vaccines do not permit such trade-offs.”
Malaria continues to be a serious health threat, particularly in the African region. According to the World Health Organization (WHO), the region accounted for 94% of malaria cases and 95% of deaths globally in 2023. Children below the age of five years account for 76% of all malaria deaths in the African region. Countries with the leading cases of malaria in 2023 were Nigeria (26%), the Democratic Republic of the Congo (13%), Uganda (5%), Ethiopia (4%) and Mozambique (4%). Against this backdrop, critics argue that the current debates over funding for malaria vaccines misses a larger point. The issue is not simply about trade-offs or maximizing cost-effectiveness—it is about justice. For many in low-income, malaria-endemic countries, especially across Africa, the very idea that funding for a historic public health breakthrough should be constrained raises uncomfortable questions. Chief among them: Would this debate even exist if malaria were a threat to children in high-income countries?
A symbol of long-awaited inclusion
For many Africans, the malaria vaccine represents more than a new intervention—it symbolizes long-overdue recognition and inclusion in global health priorities. The suggestion that African countries must justify receiving this vaccine, while children continue to die from preventable mosquito bites, is seen as deeply slighting. If malaria were killing hundreds of thousands of children in the Global North, the global response would likely be urgent and unified, with funding flowing freely to support universal rollout across all tools—nets, treatment, and vaccines alike.
This frustration is rooted in longstanding inequities. During COVID-19, wealthy nations raced to secure vaccines for their populations, spending billions before a single dose reached much of the Global South. No one questioned whether mRNA vaccines were the most cost-effective approach—they simply asked how soon they could get them. Why should proven, safe, and impactful malaria vaccines be held to a different standard?
There’s also a high risk of discouraging the researchers who have spent decades working toward this breakthrough. To now hesitate on deployment due to cost-effectiveness debates undermines their contributions and sends a demoralizing message. But these discussions are not new. Similar arguments surfaced during the early years of HIV treatment. Due to cost constraints, some people were offered only prophylaxis where available, rather than full treatment. The lessons of history warn us: delaying access based on economic calculations often comes at the expense of lives.
The numbers back it up
According to WHO, mathematical models show that adding the malaria vaccine RTS,S/AS01 to existing prevention and treatment strategies can significantly reduce illness and death, especially in areas with higher malaria transmission. In regions where 10% to 50% of children aged 2 to 10 years are infected, the RTS,S/AS01 vaccine could prevent between 417 and 448 deaths per 100,000 fully vaccinated children—a reduction of up to 19% in malaria deaths among children under five. The benefits are less pronounced in areas with lower transmission, but the impact remains notable.
Cost modeling suggests the vaccine is economically viable, particularly in high-burden areas. At $5 per dose, it costs between $28 and $59 to prevent one case of malaria, and between $97 and $103 per disability-adjusted life year (DALY) averted. Even at $10 per dose, the vaccine remains cost-effective in priority regions.
A second vaccine, R21/Matrix-M, has also been evaluated and shows even higher efficacy in some models. It could prevent up to 398,000 cases and 733 deaths per 100,000 vaccinated children, with particularly strong results in moderate- to high-transmission settings. At an estimated price of $3 per dose, it offers an excellent value-for-money proposition.
Delivery strategies—whether age-based, seasonal, or a mix—have all demonstrated substantial public health benefits with minimal variation in cost-effectiveness.
Lessons from the global North
Wealthy nations routinely prioritize vaccines over more “cost-effective” alternatives when facing health threats at home. In 2015, the UK introduced the Meningococcal B (MenB) vaccine for infants—even though its own advisory body, the Joint Committee on Vaccination and Immunisation (JCVI), deemed it not cost-effective at £75 per dose. Public and political pressure led to its adoption anyway. Today, MenB cases have declined—but debates continue over whether the resources could have saved more lives elsewhere in the health system.
The United States offers a similar lesson. Before the arrival of HPV vaccines like Gardasil and Cervarix, cervical cancer rates had already fallen sharply thanks to widespread Pap smear screening. Yet in 2006, the U.S. approved the costly vaccines—priced at $150–190 per dose—for routine use. While adding long-term value, the vaccines imposed substantial new costs on health budgets.
Pneumococcal conjugate vaccines (PCVs), such as PCV10 and PCV13, have been widely adopted in high-income countries despite their high costs. These vaccines target pneumococcal diseases, which can also be addressed through non-vaccine interventions like improved hygiene and antibiotic treatments. However, the adoption of PCVs is driven by their effectiveness in reducing disease burden and long-term healthcare costs.
Another example: Pneumococcal conjugate vaccines (PCVs), like PCV10 and PCV13, are widely used in high-income countries despite their high price tags. These vaccines prevent diseases that can also be addressed through hygiene improvements and antibiotics. Yet the biomedical route was prioritized for its perceived effectiveness.
These cases reveal a global double standard. When diseases threaten populations in the North, affordability takes a back seat to urgency, innovation, and symbolic value. But when it comes to the South, the emphasis shifts to caution, cost-efficiency, and budgetary constraints.
The real choice
At its core, this is not simply a debate between bed nets and vaccines. It is a debate about who holds the power to make life-or-death decisions—and under what conditions. The focus should not be diverted; saving children's lives must remain at the very top of global health priorities.
Although proponents are justifiably urging for increased flexibility in funding, the manner and timing of criticisms aimed at the malaria vaccine may inadvertently strengthen ongoing global disparities—where vital interventions for the poorest children globally face more rigorous financial evaluation than those in richer countries.
According to WHO, all strategies matter in the fight against malaria. The organization recommends use of a mix of interventions, as all interventions including that of vaccines offer partial protection. However, in high-burden areas such as Africa, the principles of equity and effectiveness should steer decision-making. Additionally, African governments should take a leading position in financing malaria vaccine rollout—not merely requesting aid, but by actively and consistently contributing to safeguard the health and lives of their citizens.
Vaccines as a test of solidarity
The malaria vaccine rollout is not just a medical milestone it is a moral one. And the global health community must treat it as such.
Vaccines are never just about biology and funding. They are about values. When we question whether African children “deserve” vaccines based on funding formulas, we risk institutionalizing inequity.
Instead of turning this moment into a budgetary dilemma, global leaders and more specifically African leaders must recognize it as a test of solidarity. If we fail that test after decades of delay, we confirm what too many already suspect: that African lives are valued less in the global health order.
And that, more than any inefficiency, would be the real scandal.
