A Strategic Approach to Malaria
December 24, 2014
Since 2000, there have been impressive, historic gains in malaria control. An estimated 3.3 million lives have been saved world-wide, a function of elevated political commitment and enhanced international mobilization that featured more than a tripling of the dollars invested in programming – roughly $3 billion per year today – and a steep rise in R&D commitments, to roughly $600 million. According to the WHO World Malaria Report 2014, the malaria target contained in the 6th Millennium Development Goal has been achieved. Against this backdrop, a new consensus has taken shape around the need to transition from emergency control to an overarching goal of global elimination of malaria. This shift in thinking is shared among many key institutions, and is reflected in the forthcoming WHO Global Technical Strategy and Roll Back Malaria’s Global Malaria Action Plan 2.
On December 8, CSIS organized a day-long conference, “A Strategic Approach to Malaria,” to examine what an elimination approach implies; what challenges, tradeoffs, and uncertainties it faces; and what it will demand politically, financially, scientifically, and institutionally. Over the course of the day, panelists paid special attention to the type of strategy that will be most effective, how best to address constrained financing, the central importance of militaries, the rising significance of the Mekong Subregion, the promise of the current pipeline of new technologies, and the threat of resistance. On the occasion of the conference, CSIS published four focal papers, while the Kaiser Family Foundation, at our request, also published an excellent companion analysis of malaria financing.
The day’s discussion was rich and wide-ranging. A few select themes were, in my view, most compelling.
First, the transition to malaria elimination is in reality several transitions.
The massive investments of the past decade have brought progress to a tricky “mid-game” point, in which success itself – getting halfway up the mountain -- can soften the sense of urgency and lower incentives to bring programs to full scale. To move forward towards full scale elimination therefore requires a redoubling of high-level political effort, in an already highly competitive environment (with HIV/AIDS and TB, among others, vying for attention and resources).
Further, the malaria transition is a shift from emergency response to long-term elimination, with a heightened emphasis on putting in place essential basic health infrastructure, with all that implies. It involves shifting from a universal approach to providing emergency services to a decentralized, distributed approach that prioritizes communities that are acutely impacted and looks beyond the short-term, emergency response to rooting out the parasite from the human reservoir. That ambitious enterprise requires finer tools, far better data, and careful discrimination.
The malaria transition must further cope with considerable uncertainty, risk, and hope. The threat of resistance to essential tools and treatments is real and rising. Finances will at best grow modestly, which de facto generates higher pressures to improve efficiencies and better measure true health impacts. There is a promising pipeline of new vaccines, therapies, and diagnostics, which could significantly advance elimination; however, as with all R&D endeavors, this will require time and considerable resources without a guarantee of success
Second, for better or for worse, the malaria fight is concentrated among a few powerful, committed institutions: the Global Fund to Fight AIDS, Tuberculosis, and Malaria (the Global Fund); the US President’s Malaria Initiative; the UK Department for International Development; and the Bill & Melinda Gates Foundation (BMGF). Asian and African state leadership councils have become increasingly important.
Among these interests, the United States is the standout. Whether in encouraging partners in Asia and Africa to do more, or pressing UN agencies and the Global Fund to be strong and continue to innovate, high-level U.S. leadership – backed by bipartisan support in Congress – remains the sine qua non for continued progress. Such concentration of power and responsibility in global malaria efforts is both an opportunity and a vulnerability. If aligned closely, the United States, the Global Fund, BMGF, and others can be highly impactful in advancing elimination. Inversely, a slackening of U.S. resolve could have a very negative, deflationary effect.
Third, there is a sober realism that the resources available for global programming will at best grow slowly above the present $3 billion mark, until or unless the countries burdened with malaria – especially those with higher means – make a greater commitment within their national budgets. But how to motivate and engage these countries to make that choice is the dominant political and diplomatic challenge.
There will be continued calls for spending more wisely and shaping markets better to pay less for inputs. To achieve either of these outcomes however will require an intensified effort. Operational research to reveal which investments yield the best health impacts takes time and diverts scarce resources away from programs. Significant cost savings may be elusive: experts caution against assuming it will be easy or simple to lower market prices for bed nets, spraying, and therapies. If anything, some future new technologies may add costs.
Fourth, militaries – the U.S. military as well as the forces of Asia and Africa – are integral to global malaria elimination. Militaries are often acutely vulnerable to infection. They can become a vector to their families and other parts of society, which has been a driving motivation for military involvement in malaria response efforts in the past. They also have exceptional reach into remote border areas where there are large mobile populations, limited health infrastructure, and rising resistance, making partnerships with militaries all the more important to reaching an elimination goal.
The time is ripe for expanding collaborations. The U.S. military has long recognized the threat malaria poses, and has consequently developed deep field research and programmatic experience and assets, concentrated in its overseas medical research laboratories, training and logistical capacities, and data systems. As a matter of policy, senior DoD officials made clear at the December 8 conference that the U.S. military is “all-in” in support of a global elimination strategy which could both advance U.S. troop readiness, strengthen partner country civilian and military institutions, and build collaborations with the Global Fund and non-governmental groups. In the Mekong Sub Region, those opportunities are growing. At the CSIS conference, the Vietnamese military surgeon general outlined his government’s priority to enlarge its own internal civil-military malaria efforts, combined with partnerships with the U.S., the Global Fund, and others. Thai and Myanmar civilian malaria directors each affirmed how important civil-military cooperation is to their respective countries; progress is underway in Thailand, while at an early point in Myanmar.
In closing, while significant challenges remain to the ambitious goal of malaria elimination, I was impressed December 8 by the dynamism, depth of expertise, confidence, and optimism of the several hundred malaria experts assembled for the day.