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It’s the most wonderful time of the year…is it still?

December 18, 2012 - 21:11 -- Bart G.J. Knols

Every year in December, the global malaria community eagerly awaits the World Malaria Report published by the World Health Organization. Every year countries around the world report their status of the disease, and year after year over the last decade the World Malaria Report was like a Christmas gift. Our collective efforts were paying off, both mortality and morbidity was on the decline, and scaling up of the tools yielded what we expected: A massive reduction in malaria. But this year’s end is different…

This year 104 countries provided data for the annual World Malaria Report and although the press release from WHO remains fairly optimistic in view of the data it got, it becomes evident that unless we’re facing up to the challenges (that regretfully increased in number), we ‘would need to prepare for major malaria resurgences’, according to Dr. Robert Newman, Director of the Global Malaria Programme at WHO.
The gains of increased international support and collaborative efforts of numerous stakeholders in malaria control have become evident: It is now estimated that 1.1 million lives were saved over the last decade as a result of our work. That is fantastic news of course. Also, some 50 countries have shown a massive decline in disease incidence, which provides an impression of the scale at which effects are noticed. The scaling up of ACT drug use and rapid diagnostic tests is equally impressive.
But then follows the ‘but’ that spoils our festive season. The global economic crisis has puts its claws in our control efforts now that funding levels have reached a plateau which is far below from what is needed. If at all we were to aggressively attack malaria we would need 5.1 billion $ per year – now we’re not even having half of that and support is dwindling.
But then, is it really the lack of funding that is undermining our efforts? Or do we see the first signs of donor fatigue and loss in faith that we will reach the Millennium Development Goals (zero deaths by 2015)? Are we spreading the (already meagre) resources too thin? What if our efforts had focused on a few countries and by now had eliminated malaria from a few African nations on the fringe of the malaria distribution? What if say Senegal and The Gambia would now be without malaria? Would the enthusiasm and confidence have been boosted in the same way we are dealing with Guinea worm and polio?
Another major problem lies in the fact that the number of LLINs distributed across Africa has gone down significantly: from 145 million nets in 2010 to a ‘mere’ 66 million nets in 2012. If the trend of less funding continues and the first ‘round’ of nets expires, then who will provide the much needed net thereafter? And although this is vital, how do we tackle mosquito resistance problems to pyrethroids, the only class of insecticides approved for net impregnation. With drugs the story is equally worrying as shown by the reduced efficacy of artemisinin in SE Asia published this year.
Equally worrying is the fact that the progress reported from the 50 countries mentioned above represent only a small fraction of the total number of cases worldwide. In the heartland of malaria (central and east Africa) the impact achieved is meagre and will be equally difficult to sustain.
We should be optimistic about the gains over the last decade but also realise that this brought us merely to lower levels overall. Going the last mile is the hardest and most costly one. Without a massive increase in resources (most notably financial resources) an a suite of new tactics and strategies the war is far from over – worse, the enemy will strike back with the same vengeance we witnessed during the 1970s-1990s. 


William Jobin's picture
Submitted by William Jobin on

Thank you Bart for your comments on the WHO annual report.

The malaria program of WHO is extremely important; it embodies the sum total of all our scientific and public health efforts, whether we study immunology or genetic engineering……So we should be carefully critical of what Dr. Chan is saying, it affects the lives of millions of people.

In brief, I think what we should ask of Dr. Chan and WHO in the future is to expand the fight with permanent methods, to refocus the effort, to set realistic goals, and to carefully measure impact……. The problems with the malaria effort of WHO do not require rocket science to fix, but they do require rational strategies and good management…….Key Points are:....

1. If WHO combined their efforts with creation of new water resources projects by the African Development Bank and the World Bank, they could gradually build malaria out of Africa, while also tapping another large source of funds through the loans from the Banks……

2. Your point Bart about a re-focusing of the WHO effort is a good one. Look at the numbers. The WHO budget of $2.3 billion per year is spread over 104 countries, for $22 million per country - and falling……

3. In contrast, the US Presidential Malaria Initiative, which is smaller, seems to be doing much better than WHO despite the Great Recession in the US. Their budget of $835,000,000 is spread over 15 countries, for $56 million per country - and rising……

4. WHO should develop accurate numbers, set realistic goals, and thus allow us to make relevant conclusions about the state of the fight against malaria. If they can’t do it for the whole world, they should at least do it for Africa where the problem is greatest……

5. Despite the budget differences, the relative impacts of WHO and the US PMI are hard to compare. Like the WHO annual reports, the US PMI annual reports lack data on impact, and instead stress only the effort they have made. This must be corrected if either group wants continued financial support……

6. WHO blames their shortage of funds on the global economic crisis. But donor fatigue might also be coming from the error WHO has made in setting impossible goals, and then not meeting them nor even measuring progress towards the goals. They do not give reliable reports on their global impact, only on the effort expended…... Furthermore they suffer from the general malaise of all UN agencies, abetted by the current failure of the UN to avoid war in Syria and Libya. I fear the UN is going the way of the League of Nations who failed to protect Ethiopia from the Italian invasion before the Second World War, and was then abandoned.

William Jobin Director of Blue Nile Associates