Editorials

Global campaign to eradicate malaria

Roll Back Malaria has achieved a high profile but little real action

Three years have passed since the launch of Roll Back Malaria, the global campaign to halve the burden of malaria by 2010, and one year since its high profile African summit in Abuja.¹ The campaign has had two major successes. Firstly, it has built an impressive partnership of the United Nations and development agencies, the World Bank and International Monetary Fund, governments, the private sector, researchers, and non-governmental organisations. Secondly, it has raised the visibility of this neglected diseaseone that causes at least 3000 deaths a day and that slows economic growth by 1.3% per year in endemic areas.¹ But it has not yet produced a major impact where it matters mostat the ground level in the world's poorest countries.

Participants from these countries therefore showed understandable impatience at the campaign's fourth global partners meeting, hosted last month by the World Bank in Washington DC. Many complained that things were moving far too slowly. The partnership's credibility, they told the BMJ, now rests on its ability to translate its promises and pledges into malaria control programmes that have an immediate and measurable effect.

A general consensus exists in the global health community that the Roll Back Malaria strategy makes technical sense. The focus is on early detection and prompt treatment of cases of malaria, the detection and control of epidemics, vector control using bed nets treated with insecticide, and the prevention and treatment of malaria in pregnancy. So what has stopped this strategy's widespread implementation, and what can be done to remove the obstacles? The meeting provided some answers to these questions.

A major stumbling block has been money. Donor fatigue and parsimony have led to major shortfalls in funds for control programmes. To achieve its aim of halving the health and economic burden of malaria by 2010, the donor community must allocate new resources of at least $1bn each year.² This is not yet happening. Roll Back Malaria must convince donors that this would be money well spent. Aside from cutting deaths and disability from malaria, such an investment in malaria control will pay for itself within one year, since it will boost the gross domestic product of affected countries (D Jamieson, presentation at meeting).

But donations alone will be useless if the money is not adequately disbursed. For example, the World Bank has publicly promised major assistance to malaria control, in the form of International Development Association loans. At the previous Abuja summit it pledged $500m. But many argue that this money remains just a pledge, and that nobody at ground level has seen it. At the Washington meeting, Dean Jamieson, director of the programme on global health and education at the University of California Los Angeles, asked: "What is the rate of disbursement? How much is actually going out? What is the level of commitment of bank staff's time to dealing with malaria?"

One of the challenges to the campaign is therefore to increase the transparency of this resource allocation and flow. At the moment, nobody knows how much has actually been committed, where it has gone, and whether it is even funding projects with measurable benefits. Perhaps what we need, argued the campaign's project manager David Alnwick, are "malaria engineers" to work at ground level in procuring and disbursing the money.

At the Abuja summit the African heads of state called on their development partners to cancel in full the continent's debts to free up resources for malaria control. This call was repeated in Washington, but it remains largely ignored. Last year, for example, the International Monetary Fund asked Nigeria for $1.6bn in debt repaymentsfive times more than the country's total annual health budget. Roll Back Malaria is unlikely to achieve its goal unless debt reduction forms part of its core strategy.

Perhaps the greatest cause of frustration among the meeting's participants was the fact that we have some of the tools needed to cut malaria deaths quicklysuch as insecticide treated bed nets and effective drugsbut little has been done to ensure their widespread availability. For example, four randomised trials in Africa have shown that treated nets reduce deaths from malaria in children aged under 5.³ But in most endemic countries less than 10% of the population sleeps under such a net, and reimpregnation rates are low, reducing the effectiveness of the intervention. There are certainly unanswered questions about the best way to distribute nets and real fears about the growing resistance of the malaria parasite to drugs. Yet there was no dissent at the meeting from the view that the scarcity of nets and drugs is costing lives. A public-private partnership was recently shown to be successful in Tanzania at increasing net ownership and reimpregnation.⁴ These sorts of partnerships, much championed by Roll Back Malaria, need to be massively scaled up in other affected regions.

One problem with huge global partnerships is that as they expand they end up being accountable to nobody. One function of reporting their meetings and activities is to expose them to some sort of scrutiny and help them become accountable to those they serve. After next year's meeting of Roll Back Malaria, we expect to have much better news to report: a huge increase in the funds that reach affected communities, impressive debt reduction, many more people sleeping under insecticide treated nets, and the greater availability of medicines for treating malaria.

Gavin Yamey, deputy editor. 

wjm, Western Journal of Medicine, 221 Main St, San Francisco, CA 94120-7690, USA (gyamey{at}bmj.com)