Tropical Health Matters

The 30^th African Union (AU) Heads of State Summit at its headquarters in Addis Ababa, Ethiopia provided an important opportunity to bring the challenges of infectious diseases on the continent to the forefront. Led by the African Leaders Malaria Alliance (ALMA), two major activities occurred, raising greater awareness and commitment to fighting neglected tropical diseases (NTDs) and recognizing the contributions countries have made in the fight against malaria.

For many years ALMA has maintained Scorecard for Accountability and Action by monitoring country progress on key malaria interventions. It later added key maternal and child health indicators.  At the AU Summit ALMA announced that NTD indicators would be added to the scorecards which are reported by country and in summary.

The scorecard will now “report progress for the 47 NTD-affected countries in sub-Saharan Africa in their strategies to treat and prevent the five most common NTDs: lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminths and trachoma. By adding NTDs to the scorecard, African leaders are making a public commitment to hold themselves accountable for progress on these diseases.”

In the press release Joy Phumaphi, Executive Secretary ofALMA, explained that, “Malaria and NTDs both lay their heaviest burden on the poor, rural and marginalised. They also share solutions, from vector control to community-based treatment. Adding NTDs to our scorecard will help give leaders the information they need to end the cycle of poverty and reach everyone, everywhere with needed health care.” This will be an opportunity to demonstrate, for example, that, “In 2016, 40 million more people were reached with preventive treatment for at least one NTD than the year before.”

The combination is based on the logic that NTDs and malaria are both diseases of poverty. Malaria and several NTDs are also vector-borne. Also community platforms are a foundation for delivering needed drugs and supplies to tackle these diseases. Ultimately the decision shows that Heads of State are holding themselves accountable for progress in eliminating these diseases.

At a malaria-focused side meeting of the AU Summit Dr. Kebede Worku (Ethiopia’s State Minister of Health) shared that his government has been mobilizing large amount of resources to the fight against malaria which has led to the shrinking of morbidity and mortality since 2005. He also stressed that Africans should be committed to eliminate malaria by the year 2030. “Failing to do so is to repeat the great failure of 1960s faced at the global malaria fighting.”

The highlight for the malaria community at the Summit was the recognition of six countries that have made exemplary progress in the past year. The 6 countries that are leading the way to a Malaria-Free Africa by 2030 are Algeria, Comoros, Madagascar, the Gambia, Senegal, and Zimbabwe, recognized by ALMA for their sharp decline in malaria cases. Madagascar, the Gambia, Senegal and Zimbabwe Reduced malaria cases by more than 20 percent from 2015 to 2016. Algeria and Comoros are on track to achieve a more than 40 percent drop in cases by 2020.

H.E . Dr. Barnabas Sibusiso Dlamini, the Prime Minister of the Kingdom of Swaziland, whose King and Head of State is the current chair of ALMA, warned all endemic countries that, “When we take our eyes off malaria, the cost for our countries is huge. Yet if we increase our efforts to control and eventually eliminate malaria, the yield we get from it is tremendous. It is time that we dig deep into our pockets and provide malaria programmes with the needed resources.”

Mentioning the need for resources raises a flag that calls on us to be a bit more circumspect about progress. IRINNews notes that this is a critical time in the fight against malaria, when threatened funding cuts could tip the balance in an already precarious struggle. IRIN takes the example of Zambia to raise caution. They report that the results of malaria control and the government efforts have been uneven. While parasite prevalence among small children is down almost by half in some areas, many parts of the country have seen increases in prevalence

IRIN concludes that, “For now, the biggest challenge for Zambia will be closing the gap in its malaria elimination strategy, which will cost around $160 million a year and is currently only about 50 percent funded – two thirds from international donors and one third from the Zambian government. Privately, international donors say the government must spend more money on its malaria programme if it is to succeed.” Cross-border transmission adds to the problem.

Internal strife is another challenge to malaria success. “The recent nurses’ strike which lasted for five months may have cost Kenya a continental award in reducing the prevalence of malaria during the 30th African Union Summit in Ethiopia on Sunday.” John Muchangi in the Star also noted that, “However, Kenya lost momentum last year and a major malaria outbreak during the prolonged nurses’ strike killed more than 30 people within two weeks in October.”

Finally changes in epidemiology threaten efforts to eliminate malaria in Africa. Nkumana, et al. explain that, “Although the burden of Plasmodium falciparum malaria is gradually declining in many parts of Africa, it is characterized by spatial and temporal variability that presents new and evolving challenges for malaria control programs. Reductions in the malaria burden need to be sustained in the face of changing epidemiology whilst simultaneously tackling significant pockets of sustained or increasing transmission. Many countries like Zambia thus face both a financial and an epidemiological challenge.

Fortunately ALMA is equipped with the monitoring and advocacy tools to ensure that its members recognize and respond to such challenges. The Scorecards will keep the fight against the infectious diseases of poverty on track.

The Demographic and Health Surveys has released a brief on key indicators from the Ghana Malaria Indicator Survey of 2016. While much of the malaria community is discussing the elimination framework and processes, the reality is that many high burden countries are still trying to scale up basic interventions to achieve universal coverage.

The overall prevalence across the country in children aged 6-59 months at the time of the survey was 27% using Rapid Diagnostic test and 20% using microscopy.  Among children reporting fever in the previous two weeks care/advice was sought for only 72%. Although only only 30% received some sort of blood based diagnostic test, 61% of the febrile children were given the antimalarial artemisinin-based combination therapy drugs.

Children are still being treated without the benefit of parasitological testing, a key procedure highlighted in WHO case management guidelines. Presumptive treatment for malaria without testing means that a child could inappropriately receive antimalarial drugs and die of another underlying febrile illness. Appropriate testing and adherence to test results is one of the main areas of focus of Ghana’s grants from the US President’s Malaria Initiative. Improved testing is also an important element in Ghana’s current Global Fund support. Clearly more value for money is needed from these inputs.

Preventive measures as documented in the MIS fare somewhat better., but at present only 73% of households own an insecticide treated bednet. When considering the recommended 1 net for every 2 household members, the indicator drops to 50%. Concerning the typical ‘vulnerable’ populations, we see that only 52% of children below the age of 5 years slept under an ITN the night before the survey; only 50% of pregnant women did likewise.

Malaria prevention in pregnancy results reflect the fact that Ghana has promoted at least three IPTp doses for around ten years. Most pregnant women (78% ) had received the previously recommended minimum of two doses, and now 60% have received at least three doses.

One of the important issues stressed in WHO’s new malaria elimination framework is stratifying the country by prevalence to the lowest level possible in order to plan appropriate interventions. Fortunately the Ghana 217 MIS key indicator brief does stratify prevalence and intervention coverage by region.  Prevalence through RDT testing ranges from nearly 5% in the urbanized greater Accra area to 44% in the Central Region. Interestingly ITN use is nearly 20% higher in Central than greater Accra.

Hopefully future planning in Ghana will build on this stratification. Better mobilization of donor, national and private sector resources will address likely issues of stock-outs and increase the likelihood of universal coverage of basic interventions that is needed to move the country along the road to malaria elimination.

In 2013 national/domestic funding accounted for 20.4% of the US$2.6 billion in global support used to control and eliminate malaria, although it is not clear whether this is governmental, private or a mix.[i] The 2016 World Malaria Report (WMR) reports that, “Total funding for malaria control and elimination in 2015 is estimated at US$ 2.9 billion.[ii] This total represents just 46% of the Global Technical Strategy for Malaria 2016–2030 (GTS) 2020 milestone of US$ 6.4 billion.”

If domestic funding at the previous rate were to meet this milestone, endemic countries would need to put forward $US1.3 billion themselves, not to mention the fact that domestic funding may be needed even more as uncertainties increase in bilateral and multi-lateral sources. Of the coming from governments, US$ 612 million was direct expenditures through national malaria control programmes (NMCPs) while US$ 332 million was expenditures on malaria patient care. While domestic funding for malaria in African countries has increased in absolute terms over the years, it still remains a smaller proportion of total funding.[iii]

Governments in endemic countries characterized by a large portion of the poor, may in fact not contribute a fair share of malaria expenditure. Households are often said to bear the brunt of malaria financing through out-of-pocket expenditure for both treatment and prevention. While we do not have specific figures for malaria, we note that the overall out-of-pocket (OPP) expenditure by households in Nigeria for health care averaged 69.3% between 2010 and 2014.[iv]

Ghana has a national health insurance scheme that may reach up to two-thirds of the population. Costs of fever/malaria episodes therefore should covered by membership, although one is required to pay annual premiums.[v] Still a large portion of the population still pays out-of-pocket.

Although malaria funding from all sources has been increasing over the years, it has recently stagnated at a level approximately 45% of that level targeted to eventually eliminate the disease.  In many countries households still bear the brunt of malaria costs, both for treatment and prevention.

Benefits of investments in interventions like community health workers do help bring malaria care closer to the community at a cost people can afford.[vi] More financial support is needed to scale these up, especially by mobilizing in-country governmental, corporate and non-governmental resources.

[i] Kates J and Wexler A. Global Financing for Malaria: TRENDS & FUTURE STATUS.

Kaiser Family Foundation, December 2014 http://kff.org/report-section/global-financing-for-malaria-introduction/

[ii] World Health Organization. World Malaria Report 2016. ISBN 978-92-4-151171-1. Geneva: World Health Organization, 2016

[iii] Korenromp EL, Hosseini M, Newman RD, Cibulskis RE. Progress towards malaria control targets in relation to national malaria programme funding. Malaria Journal 2013, 12:18 Page 2 of 9 http://www.malariajournal.com/content/12/1/18

[iv] World Health Organization. Global Health Expenditure Database: Nigeria. Accessed 6 February 2017. http://apps.who.int/nha/database/Key_Indicators_by_Country/Index/en?COUNTRYKEY=84700

[v] Tawiah T, Asante KP, Dwommoh RA, Kwarteng A, Gyaase S, Mahama E, Abokyi L, Amenga-Etego S, Hansen K, Akweongo P, Owusu-Agyei S. Economic costs of fever to households in the middle belt of Ghana. Malar J. 2016 Feb 6;15:68. doi: 10.1186/s12936-016-1116-x.

[vi] Sunguya BF, Mlunde LB, Ayer R, Jimba M.. Towards eliminating malaria in high endemic countries: the roles of community health workers and related cadres and their challenges in integrated community case management for malaria: a systematic review. Malar J. 2017 Jan 3;16(1):10. doi: 10.1186/s12936-016-1667-x.

The Global Fund Observer (aidspan) has provided information on the 2017-19 allocations by the Global Fund to Fight AIDS, TB and Malaria. Here we take a closer look at the malaria component.

Overall malaria grants account for $US 3.3b or 32% of total funding for the period. This includes 71 countries as follows:

• 41 countries in WHO’s Africa Region
• 6 in the Eastern Mediterranean Region
• 7 in the Americas
• 10 in Southeast Asia
• 7 in the Western Pacific

2017-2019 GFATM Allocation

The Global Fund Observer also noted that the GFATM board is very much aware of risks to these grants. An example comes from the management pharmaceuticals. Risks can be found along the whole supply chain process. The GFATM found that, “artemisinin-based combination therapies (ACTs) are more commonly targeted for theft or illegal diversion than are antiretrovirals (ARVs) or medicines for opportunistic infections (OIs).”

In fact the GFATM has identified 40 high or very high risk countries, most of which overlap with the list receiving current grant allocations. Therefore while we praise the provision of needed malaria funds for the upcoming three years, we also call on the Global Fund managers, country coordinating mechanisms, grant recipients and watchdogs in civil society and the media to ensure these grants continue to save lives from malaria.

No one knows for certain the full implications of Britain’s narrow vote to leave the European Union (EU). Since Britain has been a major player in malaria research and development aid, questions naturally arise of whether the British exit (Brexit) from the EU will affect development aid and global research generally and malaria aid and research specifically.

Earlier this week the Brookings Institution examined the ways that a Brexit could affect Africa. Here are some of the possibilities adapted to malaria –

• Volatility in the global economic market will affect not only the British economy but also those of malaria endemic countries, possibly reducing the reducing available funds for national contributions to malaria control at home, a major goal for sustaining malaria control and elimination
• Britain specifically may not be able to sustain its financial contributions to malaria aid through the Global Fund, bilateral malaria programs and of course it would no longer contribute to the European Development Fund which currently stands at nearly 15% of its total.
• The British economy which like all modern nations depends on trade would be affected by the need to renegotiate hundreds of trade agreements around the world. Less trade likely means less income and less development aid.

In both 2014 and 2015 the United Kingdom contributed 8% of the total contributions received by the Global Fund to fight HIV, TB and Malaria. In addition “UK’s official development assistance (ODA) is expected to rise to £11.3bn when it hits the 0.7% target. With a population of about 63 million, the figure works out at roughly £137 per Brit.” In 2012 the malaria component was estimated at 2%.

Patrick Vallance and Tim Wells examine the importance of global collaboration on malaria research. This requires the free flow of researchers and their needed supplies across national borders, especially malaria research that has had to date a pan-European character. They describe the collaboration needed “between commercial and non-profit organizations, and between academic science and medicine. Without such partnerships, advances in fighting this deadly disease would not have been possible.”

Vallance and Wells give the example of “GSK’s research site in Tres Cantos, Spain. The lab operates with the support and advice of a broad range of actors, including GSK, the Wellcome Trust, the European Union, and MMV (Medicines for Malaria Venture), as well as various other product-development partnerships and academic centers.” Such efforts may be jeopardized when permits for malaria scientists to work in other countries are more difficult to obtain.

There may be other aid mechanisms too, the Commonwealth Secretariat being one. During World Malaria Day in 2012 the Commonwealth Secretariat pledged to assist in sustaining the gains made in tackling malaria.  We hope that Brexit will not become an exit for malaria commitments and saving lives.

World Malaria Day 2015 is continuing a 3-year theme of promoting continued financial resource commitment to control and eliminate the disease. Investing in malaria can take many forms, the most obvious of which is the large donor agency grants from the Global Fund (GFATM), the US President’s Malaria Initiative (PMI), DfID, and the World Bank Malaria Booster Program, a name a few. International and local businesses and corporations also provide a share usually through their corporate social responsibility and employee health projects.

Cost recovery systems are not uncommon

The global financial crisis that began in 2008 lingers in many corners of the world, and has caused thoughtful concern since then about how global disease control efforts can be sustained. In relation to malaria, this concern must take account of the fact that when interventions (ITNs, ACTs, RDTs, IPT) are scaled up and sustained, incidence will drop and the nature of programming and financial commitments will change. A greater emphasis on surveillance, identification of hotspots, response to epidemics, and import of cases from neighboring countries will take the foreground. All this will still require financial support, but where will it come from?

Many of the frontline malaria elimination countries in Africa do not receive external financial support but rely on their own national treasury. As incidence in other endemic countries drops, will the same be expected of them? It is important therefore to look at the current pattern on national commitment to funding malaria control and eventual elimination, including whether countries are devoting 15% of their annual budgets to health. Unfortunately in many countries household out-of-pocket expenditures for malaria services form the bulk of national funding for the disease, a major burden in terms of health equity.

medicine shops are a common place for out-of-pocket malaria expenditures

Cost recovery schemes have been tried in Burkina Faso. Rwanda has instituted community insurance programs. Yet these efforts still put a major financial burden on the poor. Ironically, while the poor pay more, the rich, both individuals, and corporations (national and multi-national) in malaria endemic countries conduct illicit financial transfers out of the country or evade local taxes.

Ultimately the challenges of political accountability for results and financial management within countries to citizens, domestic civil society and other non-state actors must be resolved if governments are going to take on a growing role for eliminating the malaria burden within their borders. Monetary investments alone cannot eliminate malaria. Political will must also be invested to close financial gaps, mobilize resources from various sectors and create a true partnership to end malaria.

(A longer version of this article will appear in the March 2015 issue of Africa Health.)

In New York on 12 December 2014, a new global coalition of more than 500 leading health and development organizations worldwide was launched to advocate for universal coverage (UC) and urged “governments to accelerate reforms that ensure everyone, everywhere, can access quality health services without being forced into poverty.” This marked Universal Health Coverage Day which fell on the “two-year anniversary of a United Nations resolution … which endorsed universal health coverage as a pillar of sustainable development and global security.”

According to WHO delivery of UC involves four components:

1. A strong, efficient, well-run health system
2. Affordable care
3. Accessible care
4. A health workforce with sufficient capacity to meet patient needs

To this list we might add a functioning and timely procurement and supply management system, and not trust people to read between the lines on component #1 to consider this need.

While much attention in malaria control is appropriately on prevention through various vector control measures, we cannot forget the importance of prompt and appropriate case management, especially as cases decline (according to the new 2014 World Malaria Report) and case detection assumes greater importance.

In 2000 Roll Back Malaria sponsored the Abuja Summit where targets were set for malaria intervention coverage. The goals were established at 80% for insecticide-treated nets (ITNs), intermittent preventive treatment and prompt and appropriate malaria treatment. In 2009, the United Nations declared a goal of universal coverage for ITNs. The potential for UC in malaria case management remained vague, but the new international push for US can certainly include malaria. It would not be coming too late because as we can see from the chart, many endemic countries are far from adequate malaria treatment coverage, let alone UC.

Frequent surveys help us track progress toward RBM goals and UC – Demographic and Health Survey, Malaria Information Survey, Multi Indicator Cluster Survey. Their helpfulness depends on the questions asked. The 2013 MIS from Rwanda gets closest to finding out what is really happening (Chart 2). We might infer a sequence of events that while not everyone seeks care for their febrile child, those who do are screened by the health worker (including volunteer community health workers); those suspected of malaria are tested (microscopy in clinics, RDTs in communities); and only those found positive are given ACTs.

Equity is a major concern for advocates of UC. Health insurance is one method to address this. In Ghana around 60% of people have taken part in the National Health Insurance Scheme, but only around 5% in Nigeria where 60% of health expenditure comes from out-of-pocket purchases. Rwanda has a system of mutuelles – community insurance schemes. Insurance does not meet the full need for malaria case management, and thus efforts to expand outlets for affordable quality malaria medicines through the Affordable Medicines Facility malaria (AMFm) was piloted in several countries.

A combination of approaches is needed to achieve UC in malaria case management. Public and private sources are requires. Low cost, subsidized and free care must to be part of the mix. Over half a million people, mostly children, are still dying from malaria annually. Solving the UC challenge for malaria is crucial.

In response to donor criticism of human rights issues in one malaria endemic country and because of subsequent possible links with future donor cooperation, a prominent government official of that country was quoted as saying, “We don’t like to blackmail others. It’s very dishonest, very irresponsible and unfriendly of persons to attach behavior of another community to their sharing resources.”  (Reuters) This complaint ironically comes from a country that is on record as having squandered Global Fund resources.

Are donors under obligation to ‘share’ their resources with anyone regardless of their ‘behavior’, not just in the field of human rights, but also financial accountability? No country is forced to share its resources, and while all could do more, remarks like those above from recipients add fuel to the fire of those who would be happy to curtail foreign aid all together.

Burkina Faso contributes to malaria drug supplies

It is unfortunate that many countries are highly dependent on donors to solve problems like HIV, malaria TB, NTDs and NCDs for the foreseeable future. But a solution to the perceived manipulation by donors would of course be a greater commitment of domestic resources to solve these problems.

One country that is seeking a good balance is Burkina Faso. While the country does receive major support from the Global Fund and the US President’s Malaria Initiative for its fight against malaria, Burkina Faso is stepping up to play its own part.  Government has in recent years steadily increased its financial support to buy malaria commodities from $2 million to over $4 million annually in the past few years.

Relative to donor amounts this contribution may seem small, but the point is the willingness of the government to step up and help its own people. These additional government funds have played a crucial role in filling medicine and commodity gaps that naturally occur when donor supply schedules do not match needs at a given time.

The fight against malaria will be won by having more action oriented governments like Burkina Faso and fewer complainers and embezzlers.

As countries begin to see the benefits of sustained malaria intervention, they worry that they may be punished by donor agencies for their success. For example, The Tanzania Daily News reports that, “HEALTH officials in Zanzibar have said that the Islands are likely to experience problems in the fight against Malaria should major donors, including Global Fund and the United States government pull out from financing the project.”

Zanzibar is nearing pre-elimintion malaria transmission levels but is dependent on donor funding to maintain progress. The Daily News specifies that, “The US through its President’s Malaria Initiatives (PMI) remains the leading financier with 56 per cent of the funds received for the malaria campaign. Global Fund is 40 per cent, WHO and UNICEF two per cent; other donors 1.97 per cent; and Zanzibar government is 0.03 per cent.”

Health officials did clarify the actual situation by saying that, “We are happy that PMI has not shown any indication to pull out, but we must prepare ourselves and look for alternative financiers should the US stop supporting Malaria programme.” A look at the latest grant progress report for Zanzibar at the Global Fund website had only a report from August 2012 for Round 8 Malaria Grant that was made near the end of Phase 1 of the grant.

It is not clear if Phase 2 of the Global Fund grant has been or will be funded, but we know that the GFATM has been going through financial difficulties and changes.  This is likely why Zanzibar health managers are worried. The last grant rating was files back in 2011 and gave the program a ‘B2’ rating which is cause for caution and possibly hints at reasons why Phase 2 is in limbo.

PMI reports that donor support and Zanzibari leadership, “has resulted in a dramatic decrease in malaria prevalence in Zanzibar. However, persistence of malaria transmission in surrounding areas (Tanzania mainland and Kenya) leaves the island vulnerable to sudden outbreaks and the re-establishment of ongoing, perennial malaria transmission.” Even though Zanzibar is an island, it is still vulnerable, and any withdrawal of support would negate and reverse gains made. For example, PMI explains that Zanzibar is a place where “Malaria Early Epidemic Detection System (MEEDS) … an innovative mHealth system” is being tested.

Pre-elimination not only requires sustaining existing interventions, but also implementing new ones like MEEDS in order to maintain necessary surveillance that will ultimately document whether malaria elimination has succeeded. As PMI notes, “MEEDS and Coconut Surveillance are helping Zanzibar to identify and treat many otherwise undiagnosed malaria cases, identifying hot spots and transmission patterns, and responding rapidly to new outbreaks.^ These mHealth applications are helping Zanzibar to sustain the remarkable gains it has made against this dangerous and debilitating disease.”

Also, “maintaining and continuing to reduce malaria transmission will require ongoing education for both health care providers and residents to reinforce the importance of using preventive measures,” as the public and health workers perceive the drop in prevalence according to Bauch and colleagues. Malaria prevalence in Zanzibar has been less that 1% for over 6 years, and we need to continue to reduce it.

Interventions in the final phases of malaria elimination may not be as dramatic or visible as distributing millions of insecticide treated bednets, but they are just as essential.  We need to maintain support in all endemic countries until we see malaria elimination through to its conclusion. Otherwise years of intervention will be wasted, and new lives will be lost.

The latest edition of Global Fund Observer (#218) from AIDSPAN raised a lingering question about the Funds founding principles – what is country ownership and how is it practiced? The thoughts range from the more altruistic – let the country decide what it needs to do and we’ll give the money – to the more crude, though not stated as such – give the country enough rope (money) to hang itself.

Another founding principle involved the Global Fund seeing itself as only a financial mechanism, not a technical one like the World Health Organization or UNICEF.  AIDSPAN demonstrates how over time, while still not providing direct technical assistance, decisions from the Technical Review Panel and the Global Fund Board, among others, can be seen clearly as offering a technical guidance that must be heeded if funds are to flow.

In short AIDSPAN has shown how the Global Fund itself has taken a more directive role, though often based on programmatic evidence and advocacy from those who have a stake or experience. We also need to look at th other side of the coin – within the country, who owns the Global Fund process?

A major overhaul of Country Coordinating Mechanisms (CCMs) some years ago was stimulated by the realization that government agencies are not the sole representatives of their countries and peoples.  While civil society and non-governmental organizations were expected to play a role in CCMs, they were often ignored and rarely had major roles in deciding on and implementing Global Fund sponsored programs in their countries.  Sometimes the advocacy mentioned by AIDSPAN was prompted by CSOs and NGOs not being heard within their own countries.

AIDSPAN mentions changes that the Global Fund has strongly suggested such as having dual track principle recipients (PRs) representing government and the non-governmental sectors.  While this may have represented a somewhat heavy hand from Geneva, the results sometimes reflected the status quo ante and NGO PRs were often relegated to less well funded aspects of programming such as behavior and social change.

Global Fund recipient countries represent a wide diversity of political systems in various stages of evolution.  It would be naive to expect that country ownership really embodies democratic participation of all stakeholders, public, private and NGO, in decision making and implementing on an equal footing – and no one really believes that is fully possible in at present.  Still it is a long term goal and a principle that should guide funding decisions as much as the quality of the technical content of proposed activities.

In the meantime we can look for additional ways and means to hold countries accountable for their health and social programming decisions. A good example is peer influence from the African Leaders Malaria Alliance (ALMA) which regularly publishes a scorecard of progress toward key health indicators. This freely available score card shows for example, in the first quarter on 2013 only six countries meeting the criteria of good financial management set by the World Bank. In the countdown to 2015, only eight countries are on track in terms of breastfeeding coverage.

As AIDSPAN observes, “But one has to acknowledge that, in the process, the concept of ‘country ownership’ is certainly evolving. Perhaps it will evolve further under the new funding model.” We hope the concept evolves along lines of full and equal partnership among all stakeholders within a country – that all sectors and peoples within a country will truly ‘own’ and thus influence the decision and actions around programs supported through the Global Fund.