In 2015, the World Health Organization (WHO) reported that among the 106 countries with malaria transmission in 2000, more than half had achieved at least a 75% reduction in new cases. The Global Fund’s investments have been, and continue to be, a key driver of this success. Dedicated funding for malaria has dramatically reduced the malaria burden and sustained these reductions. Future investments could continue this positive impact: the 2017-2022 Global Fund Strategy aims to achieve progress toward a world free of the burden of HIV/AIDS, tuberculosis, and malaria. To attain such a vision, investments in malaria must fully align with the WHO Global Technical Strategy for Malaria that seeks to eliminate malaria in at least 35 countries by 2030 and prevent re-establishment in malaria-free areas. The WHO estimates that 21 countries are in a position to achieve malaria elimination by 2020.
The Global Fund Board recently approved a revised methodology for its 2017-2019 allocations. Similar to the current methodology, a formula based on disease burden and income level will be used to calculate the initial country allocations for each disease. These initial allocations will be adjusted by a series of qualitative factors which have yet to be determined, but which may include willingness to pay, past program performance, and absorptive capacity.
The formula-based allocation is problematic for countries that are on the trajectory to eliminate malaria. By definition, these countries have lower disease burdens, and many are middle-income countries and are therefore marginalized by the formula. The Strategy, Investment, and Impact Committee (SIIC) of the Global Fund – now called the Strategy Committee (SC) – has proposed using malaria burden data from 2000 to avoid punishing successful countries that have recently reduced malaria incidence. However, in many of the countries that have substantially lowered their case burden – such as Bhutan, Guatemala, Indonesia, and Lao PDR (see Lancet article) – the decline in cases began before 2000 and, with respect to Indonesia, cases actually increased after 2000. Therefore, using burden data from 2000 does not adequately address countries’ needs to reach zero and prevent reintroduction.
The Global Fund has historically allocated about 7% of its portfolio to malaria-eliminating countries, but under the current funding model, the Global Fund now allocates about 5%. In this current allocation period, 2014-2016, it was estimated that the eliminating countries would experience a 31% decrease in national allocations – a serious shortfall at a time when maintaining the gains and achieving elimination are in sight. Although most national governments in eliminating countries provide nearly 80% of funding for malaria efforts, The Global Fund’s investments often fill a critical gap in providing access to care to high-risk populations, otherwise not supported through domestic efforts. The consequence of under-funding eliminating countries could result in costly and deadly resurgences, backsliding on the progress made with previous investments.
Notwithstanding its focus on high burden countries, The Global Fund has the opportunity to work with partners in achieving the global malaria elimination targets. First, The Global Fund should apply cogent qualitative adjustments in a transparent manner to demonstrate that it will not abandon countries that have used resources wisely and worked hard to drive down malaria. For malaria, this would mean including adjustments such as malariogenic potential, or the potential of introducing new malaria cases. This could be used as an important qualitative factor for malaria-eliminating countries that, despite having low transmission, are at high risk of having malaria surges. Second, The Global Fund should align its additional catalytic investments to support two focus areas in the fight against malaria that would otherwise be under-funded in the current allocation methodology:
- countries with the potential of eliminating malaria by 2020; and
- areas of multi-drug resistance in the Greater Mekong Subregion.
What could these two catalytic investments look like? Investing in countries that can eliminate malaria in the next five years will require a shift from funding mostly malaria commodities, like long-lasting insecticidal nets and malaria treatment, to investing in surveillance systems that are the cornerstone of an elimination program and often require intensive training, information technology, and human resources. Robust surveillance provides programs with an understanding of the gaps in tackling malaria – particularly among high-risk populations – as well as information about where to smartly target interventions.
The Global Fund’s malaria elimination systems investments are central in its new strategy framework under the second objective to “build resilient and sustainable systems for health” as well as a key pillar of the WHO Global Technical Strategy. Such an investment would also be an investment in health security. This is particularly true in the Greater Mekong Subregion where artemisinin resistance, according to the WHO, is a regional public health disaster and “the spread or independent emergence of artemisinin resistance in other parts of the world could pose a major health security risk as no alternative antimalarial medicine is available” (source: here). The Global Fund’s investments in surveillance could extend beyond malaria and help fortify a rapid response against other emerging infectious diseases.
The incremental financing required to support these systems is relatively small. In Sri Lanka, the prevention of re-introduction program has a cost of about USD 0.50 per capita with a very compelling return on investment of 13 to 1. On the other hand, if the country’s malaria program stumbled because of a funding gap, the country would lose out on an estimated $170 million in lost economic output over five years.
When considering global malaria goals and trends, it is tempting to view low burden countries as low priority. This is a serious mistake. Success in these countries is a crucial step towards eventual success in higher burden countries and, ultimately, success in realizing a malaria-free world. While the allocation formula is here to stay for the next allocation period, the SC at its meeting in mid-June needs to ensure transparency in The Global Fund’s application of qualitative adjustments and secure previous investments by agreeing to a focus on malaria elimination in its catalytic investments. This would be a game-changer for countries that are pushing the boundaries of what we thought was possible.
Rima Shretta and Erika Larson are with the Global Health Group at the University of California, San Francisco.