Tropical Health Matters

“Incidence of malaria in Gambia has plunged thanks to an array of low-cost strategies, offering the tempting vision of eliminating this disease in parts of Africa, a study published Friday by The Lancet said,” according to AFP. The Gambia now joins four countries featured in the World Malaria Report that “reduced the malaria burden by 50% or more between 2000 and 2006–2007.” The four, Eritrea, Rwanda, Sao Tome and Principe, and Zanzibar (in the United Republic of Tanzania), are distinguished by “relatively small populations, good surveillance, and high intervention coverage.”

Reuters explained that, “Providing pregnant women and children with insecticide-treated bed nets has sharply cut malaria deaths.”  The findings raise hopes that, “Other parts of Africa could eliminate the disease as a public health problem in a region where malaria kills a child every 30 seconds.”

Gambia News carried a caution in comments by David Conway, one of the authors of the Lancet article who said, “We have seen that it has gone down and stayed down. There is no evidence of an upsurge but we are aware that with an infectious disease you can never know for sure.” This caution is relevant bearing in mind this year’s World Malaria Day theme – a disease without borders.

Achievements in the Gambia have been facilitated by grants in Rounds 3 and 5 from the Global Fund in which its performance has been ‘A’ and ‘B1’ respectively. Neighboring Senegal also had Global Fund malaria grants, but it experienced serious grant performance problems not long ago, reinforcing the caution that malaria is waiting at the Gambia’s borders.

While the Gambia may not be able to eradicate malaria all by itself, as implied in a February 2008 article in The Observer, it is certainly on track for elimination using available control technologies.  Even though eradication is not on the immediate horizon, the government official quoted in The Observer was on target when she said, “My government has therefore not relented in waging a continuous war against the disease. We have also embraced all policies and implemented all programmes formulated by the WHO and its sister UN agencies on malaria prevention and control.” Other nations with larger malaria burdens need to be as vigilant as The Gambia.

“National Health Accounts (NHA) is a tool being used today in more than 50 low- and middle-income countries as a framework for measuring total public and private national health expenditures. NHA methodology tracks the flow of funds through the health sector, from their sources, through financial institutions, to providers and functions,” according to Health Systems 20/20 (Abt Associates). Of particular interest is tracking the influence of donor funding on malaria programming.

The 2006 NHA for Rwanda published by Health Systems 20/20 shows that the total funds from public, private and donor sources for malaria rose from about $25 million in 2003 to $43 million in 2006. The proportion coming from donor sources rose is both absolute and proportionate terms from 38% to 50%.  Household sources increased from 29% to 44%, while public sources decreased from 24% to 5%.Overall malaria spending accounted for 14% of total health expenditure in 2006 (HIV was 24%).

It is likely that the bulk of the donor support came from the Global Fund, from which Rwanda received a malaria grant in Rounds 3 and 5. The US President’s Malaria Initiative did not develop its first Malaria Operations Plan for Rwanda until 2007. A NHA for Rwanda in 2008 would therefore, likely show even greater malaria expenditure as well as a greater donor proportion of funding.

Health Systems 20/20 presented the Rwanda NHA Malaria results at the recent Conference of the American Public Health Association, and expressed that, “While these findings show the positive effects of national policies, such as the focus on bed nets and donor coordination, increased malaria funds have not reduced overall household financial burden. The Government and its partners intend to use such findings to inform future resource allocation decisions.”

They acknowledged that additional study is needed to determine why household expenditure rose, although one migh speculate that higher costs of anti-malarials through private pharmacies might contribute to the problem. On the positive side, the World Malaria Report 2008 includes Rwanda among the “four countries/areas (that) reduced the malaria burden by 50% or more between 2000 and 2006–2007, in line with WHA targets.” One assumes that the increase in malaria funding did help achieve these targets.

At the same time, contributors to the current issue of the WHO Bulletin debate the question of donor support for health. Kirigia and Diarra-Nama argue for a weaning from donor reliance as follows:

Armed with a clear vision and backed by effective programmes for improving economic efficiency of public and private expenditure; identifying and pruning unproductive public expenditures; strengthening of tax administration systems; creating an environment for enabling private health sector growth; and boosting health development governance, countries of the African region have a high probability of weaning off donor funding for health in this century. Pursuit of such a noble vision should be supported by an enabling macroeconomic and political (i.e. internally secure) environment.

In contrast Ooms & Van Damme believe that, “Even if some countries of the African region might be able to wean themselves from international health aid, others obviously cannot: they need increased aid, urgently.” This may be especially true for malaria and the move to universal LLIN and ACT coverage as Rwanda reaches toward elimination of the disease. Unfortunately until such time as eradication becomes feasible, there needs to be constant attention to a balanced and equitable donor, national government and household commitment to funding malaria control.