Kiszewski et al. paint a stark picture of the potential funding gaps for malaria control programming in endemic countries. Based on data available between 2000-03, the authors found that only 4.6% of approximately $1.4 billion of projected annual funding needs were available from domestic sources in African countries. With notable exceptions including Cameroon, Malawi and South Africa, most countries could contribute less than 2-3% of the total malaria programming needs, e.g. 0.1% in Kenya, 0.5% in Mozambique, 1.1% in Nigeria and 2.6% in Mali. Even if domestic contribution (which includes out-of-pocket expenditure) doubles, triples or quadruples, the gap will remain.
Obviously there are large scale donor programs addressing this gap but none can do it alone. Recently around 55% of support from the Global Fund to Fight against AIDS, TB and Malaria has gone to sub-Saharan Africa and roughly a quarter of total GFATM funding has been allocated for malaria projects. This needs to be viewed in light of the fact that $7.7 billion has been committed by GFATM over the six annual rounds of funding to date. GFATM hopes to more than double its annual commitments, but this will not meet the malaria resource gap.
The US President’s Malaria Initiative hopes to work up to a $300 million annual contribution to 15 sub-Saharan countries. The World Bank’s Malaria Booster Program is targeting specific countries with good size grants, such as $180 million for Nigeria over 5 years. The Bill and Melinda Gates Foundation is funding major malaria research and expand use of existing tools. UNICEF has mobilized funds and bilateral donors to make a major contribution to meeting needs for insecticide-treated nets. NGOs in industrialized countries have been supporting this with net fund raising campaigns. An innovative taxation on air travel has brought UNITAID into the malaria arena. But is this enough?
The big challenge is sustaining funding levels. Although the GFATM is developing mechanisms for a rolling continuation of grants with good performance, grants that don’t perform or are mismanaged can be canceled. A key factor in determining performance is the strength of the health system. Kiszewski and colleagues do acknowledge that ‘program costs’ such as training, communications, monitoring and infrastructure account for 14.1% of the malaria funding needs.
The GFATM itself stresses health system strengthening (HSS) through monitoring and evaluation tools and that “funding for HSS activities can and should be applied for as part of disease components.”
Some HSS problems are deep and chronic as pointed out by MSF who has documented the health worker crises in many African countries. Therefore the question remains, will donors commit not only to addressing the malaria resource gap on a sustainable basis, but also to strengthening the underlying health system which is crucial for managing those malaria resources?