Global Health and Diplomacy — WINTER 2014
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Stretching The Dollar For Global Health: Maximizing The Impact Of Investments In Malaria
Dr. Fatoumata Nafo-Traoré

Executive Director, the Roll Back Malaria Partnership (RBM)

In 2000, international funding for malaria was estimated to be less than US $100 million. Thanks to increased political leadership, donor commitment and coordination, we have seen that number increase significantly, to just under US $2 billion in 2013. Domestic financing for malaria has also increased, from US $436 million in 2005 to US $522 million in 2012.

The result has been nothing short of tremendous. According to the most recent World Malaria Report, released in December 2013 by the World Health Organization (WHO), these resources have helped to avert an estimated 3.3 million deaths between 2001 and 2012 - 69 percent of which were in the 10 countries with the highest malaria burden in 2000, and 90 percent of which were estimated to be children under the age of 5. Since 2000, we've seen malaria mortality decrease by 45 percent globally and 49 percent in Africa, contributing to a 20 percent reduction in child mortality and helping drive progress against the Un Millennium Development Goal (MDG) 4.

But we are at a treacherous juncture. Despite unprecedented advancements and scale-up of life-saving interventions, WHO's most recent numbers indicate that approximately 207 million cases of malaria still occur around the world each year, claiming the lives of 627,000 people. These preventable infections and deaths translate into Malaria WINTER Billions of dollars lost to governments and societies through healthcare costs and decreased productivity. In Africa alone - where 90 percent of global malaria deaths occur - the disease is estimated to cost a minimum of US $12 billion in lost productivity each year.

While global malaria financing, including international and domestic commitments, reached an estimated US $2.5 billion in 2012, this number is still less than half of the estimated minimum of US $5.1 billion required each year through 2020 for global malaria control efforts.

Recently, the Global Fund to Fight AiDS, Tuberculosis and Malaria held their 4th Replenishment Conference in Washington, D.C. to garner financial investment for 2014-2016. Led by countries like the U.S., the U.K. and France, many countries and foundations demonstrated their commitment to global health by increasing their pledges to the world's largest donor, resulting in approximately US $12 billion raised. These extra funds will certainly help advance efforts against the three leading infectious diseases, by strengthening health systems in high-burden countries, but alone they will not close the funding gap we face.

It is with such constrained resources that we enter the last 700+ days until the December 2015 deadline of the MDGs, requiring us to work more boldly and collaboratively than ever to identify innovative opportunities to maximize the impact of our investments, so we can continue to save lives.

As a medical professional who has dedicated her career to development, i have seen the global health landscape change drastically. I have witnessed the impact that scientific advancements and political leadership have had on some of the hardest-to-reach communities around the world. But what resonates the most is just how far the dollar can be stretched to optimize its value and maximize its return.

While serving as Minister of Health in Mali, i traveled to Cuba, where i met with the President and top officials from the Ministry of Health. Together, we traveled the island nation, visiting tertiary and community-level health facilities. I left Cuba with a greater understanding of social healthcare and an overwhelming belief in the power of working at the household and community-level. This experience validated for me the importance of government investment in quality and accessible healthcare to reduce the system-Wide, economic and social burden of disease, and it helped influence a health policy change in my native Mali that included the implementation of a Community Health Center (CHC) approach and Mutual Heath Organizations (MHOs) that made quality services accessible at community-level.

There has been growing evidence of the positive impact of MHOs, particularly in African countries. In Mali, for example, early research found that those enrolled in MHO schemes were 1.7 times more likely to have their fever treated in a modern health facility, three times more likely to use oral rehydration salts or seek modern care for their children under five years with diarrhea and twice as likely to make at least four prenatal visits during pregnancy, compared to those not enrolled. Participants were also twice as likely to use an insecticide treated net (iTn) during pregnancy and in order to protect their under-five year olds.(1)

Countries like Rwanda and Ethiopia also provide good examples of doing more with less. Both countries exemplify the impressive gains that can be made against global health with strong leadership, a well-organized system and clear lines of accountability. In Rwanda, for example, World Bank figures show that with an increase of just 14.6 percent on health expenditure, from 9.1 percent of the total government budget in 2002 to 23.7 percent in 2011, the country has made drastic advances against leading indicators of poverty and disease. As domestic expenditures have increased to $135 per capita, malaria incidence has decreased from 573,686 cases in 2006 to 208,858 cases in 2011. This incremental change in investment towards national healthcare has resulted in approximately 50 percent contraceptive prevalence in 2010. 98 percent of pregnant women completed at least one antenatal visit and there has been a decrease in maternal mortality by more than 200 per 100,000 live births between 2005 and 2010. In turn, these advances have helped to spark greater economic development which has resulted in a nearly $5.5 billion increase in Gross Domestic Product (GDP) between 2002 and 2012.

In Ethiopia, where i served as the WHO Country Representative for a number of years, promising results have been achieved addressing many leading health challenges with just 14.6 percent of total government expenditure being spent on health. Malaria mortality decreased to just 936 reported deaths in 2011, and maternal mortality decrease by 200 per 100,000 live births between 2005 and 2010. With increased health expenditure of less than $20 per capita by the government between 2002 and 2011, the World Bank's most recent figures show that the government not only prevented disease and saved lives, it offered hope to communities and helped to create a more vibrant society.

The evidence is clear that we can do more with less, particularly when we work together to integrate health services at the community-level. Never before has it been so important for us to do so. This will require an increased investment in human capacity, continued political leadership Integrated development planning and a comprehensive, multisectoral approach, with all sectors engaged at varying levels in global health efforts.

This will include continued engagement with the private sector, which has played a critical role to help scale-up lifesaving interventions and reduce the financial burden of disease on often struggling governments.

Global gold producer AngloGold Ashanti is an example of the powerful role the private sector can play in malariacontrol efforts. In 2004 alone, malaria accounted for 22 percent of all deaths in Obuasi, where the group is based in Ghana. The associated medical cost to the company for their employees and dependents infected with malaria was estimated at US $2.2 million a year, with roughly US $55,000 being spent each month on treatment alone. In response, and in partnership with the Ghana Health Service, the national Malaria Control Program and the local municipality, under the Ministry of Health, AngloGold Ashanti implemented a comprehensive malaria control initiative in 2005. By 2009, the treatment cost per month spent by the company dropped to just US $ 9,800, and average monthly work days lost due to malaria fell from 6,983 in 2005 to 282 in 2009. The company's efforts also helped Ghana unlock additional resources for malaria programs through a US $138 million grant from the Global Fund to Fight AiDS, Tuberculosis and Malaria to scale-up interventions. For the first time ever, a private company was asked to be the principal recipient for a Global Fund grant in Africa.

We must also use evidence more strategically to maximize value for money. This will require an improvement in the effectiveness and efficiency of malaria interventions by collecting information on best operational practices, ensuring equity in universal coverage, systemizing an approach that facilitates information gathering and knowledge sharing between governments, communities and individuals, and purchasing more economically-sound resources. In order to do this, we will need to strengthen the ties between research and implementation at the national-level to ensure educated decision making for smart investments and effective, evidence-based programming.

Our programs and policies are working, and they've allowed us to make tremendous progress in certain development areas. Global poverty continues to decline, more children than ever are attending primary school, child deaths have dropped dramatically, access to safe drinking water has been greatly expanded and targeted investments in fighting malaria, AiDS and tuberculosis have saved millions of lives. But these advances are partial and fragile, if we don't continue to invest wisely in our proven, cost-effective tools, we will lose the advances we've made.

A priority of the United nations Secretary-General, malaria is recognized as one of the Un's MDGs, and it impacts all eight. Malaria has consistently been among the best global health investments, saving lives and accelerating progress in other development areas by reducing school absenteeism, fighting poverty and improving maternal and child health. As we move forward in the direction of our goals, malaria control and prevention must be thoughtfully integrated into broader national health development plans to ensure not only greater value and maximal impact, but also efficiency and sustainability of programs.

Beyond being morally compelling, malaria - and health more generally - is a solid economic investment. When we invest in health, we invest in communities and advance the broader development agenda. As we move forward, withan eye on 2015 and beyond, let us not be overcome by the challenges remaining but be encouraged by the opportunity to work collectively, with bold conviction, to make our investments go farther in delivery of the promises we've made to the people of the world.

REFERENCES

1. Franco LM, Diop FP, Burgert CR, Kelley AG, Makinen M, Simpara CHT. Effects of mutual health organizations on use of priority health-care services in urban and rural Mali: a case- control study. Bull World Health Organ 2008, 86: 817-908.

2. World Malaria Report 2013. Geneva, World Health Organization, 2013

3. Business investing in Malaria Control: Economic Returns and a Healthy Workforce for Africa. Geneva, Roll Back Malaria Partnership, 2011 (RBM Partnership Progress & impact Series, no. 6).
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