Global Networking Against Malaria

Roll Back Malaria Must Not be Allowed to Fail!

The editorial below from The Lancet makes the much needed point that failure of Roll Back Malaria caused by withdrawal of donor support and focus on "political correctness" must be avoided. Donor support must be forthcoming not only monetarily but also in terms of support for operations with methods that actually work to reduce incidence of malaria and for support for research on parasites, vectors and malaria epidemiological situations, which are quite diverse and often necessitate strategies individually tailored to the local situation.

A valid point to make about the first sentence in this article is that the definition of the term "failure" as it applies to malaria control has changed greatly during the 35 years from 1965-2000. In the 1960's, a "failure" was any sort of sustained transmission of malaria, even at a low level. Eradication efforts were deemed to be "failures" even when they had reduced cases to a small number of P. vivax cases and had eliminated P. falciparum. During the 1980's and 1990's, the term, "failure," came to be used much less, even when describing situations in which malaria case numbers have increased exponentially to hundreds of thousands of cases in regions that had merely a few thousand cases during active control efforts. Few have described the widespread cessation of active case detection (replaced by passive case detection that is capable of detecting many fewer cases) during the late 1980's and the 1990's as a "failure." Why? It seems odd that the term "failure" is rarely used to describe resurgence of malaria involving many thousands of cases, and sometimes renewed P. falciparum transmission, under decentralization and emphasis on case treatment, whereas some writers, often the proponents of decentralization and reduced emphasis on vector control, were only all too happy to describe low levels of malaria cases under active control efforts as "failure." Charts and information about cessation of vector control and the results thereof are available for Peru, Sri Lanka, and Colombia.

 Editorial Volume 356, Number 9229 : 12 August 2000

Donor responsibilities in rolling back malaria
Lancet 2000; 356: 521

The previous global campaign to eradicate malaria failed. This WHO-led campaign lasted from 1955 to 1969. A new campaign, Roll Back Malaria (RBM), was launched in October, 1998. It must not be allowed to fail. Malaria accounts for more than a million deaths annually. Since the mid-1960s malaria itself is estimated to have slowed economic growth in highly malarious areas by 1·3% per year. If not for this negative growth, Africa's gross domestic product would be US$100 billion greater than it is now.

Can the new campaign succeed? It has, at least, gained much support. A key feature of RBM is that it is a partnership--of four core partners (WHO, UNICEF, the World Bank, and UNDP) and national governments, other UN bodies, non-governmental organisations, and the private sector. By the third global RBM meeting in March this year, there were 93 partners. The overall aim is to halve the burden of malaria by the year 2010 through four critical actions: enabling everyone at risk to sleep in a mosquito-free environment, mainly through use of insecticide-treated bednets; prompt diagnosis and treatment (within or near the home, as reported in today's Lancet on p 550, for example); antimalarial therapy for all pregnant women at risk of malaria; and early identification and effective response to epidemics. Programmes are to be country specific and implemented through existing systems.

The African Summit on RBM in April this year in Abuja, Nigeria, was perhaps the first time heads of states met to discuss a specific disease. They resolved to reach 60% coverage for the first three critical actions by the year 2005. In response to their call for US$1 billion per year of new resources for RBM, they received pledges of an additional $300-500 million a year from the World Bank, and Can$10 million (US$6·5 million) over 5 years from the Canadian International Development Agency. Although well short of requirements, these offers represent recognition of the need for budgetary support, not just technical assistance.

The G8 countries have also pledged support for malaria control. With such encouraging starts, why should there be concern now about the likelihood of failure? Epidemiology, entomology, genetics, health-care delivery, and a range of other operational issues all contribute to the technical complexity of malaria control, which partners seem not to appreciate. Why, for example, has UNICEF proposed support for chloroquine for Burmese towns along the Thai border? [note: This is a region with a large amount of multidrug resistance in P. falciparum] Why did USAID threaten Belize with withdrawal of support if it continued with use of DDT? Donors may not see that short-term support or sustainability through cost recovery are at odds with scientific reasoning. When USAID stopped support to Tanzania for bednets after 5 years, it left a community especially vulnerable to malaria because the protection of bednets had reduced immunity to the infection. And in poor areas few people can pay towards their bednets, but nets work much better when used by the entire community. Grants rather than loans are needed. Even so, as the World Bank has admitted, there remains the difficulty of weak capacity for implementation.

It is time for RBM to switch focus from the campaigning to implementation of malaria-control activities. Things must be done right this time, which means first knowing what is right and operationally feasible. A recommendation was made at a meeting of malaria scientists in June at the Center for International Development at Harvard University for all projects to first pass scientific and operational scrutiny by an external multidisciplinary expert review panel, who would assess projects according to scientific norms. Proposals for projects would still come from the field, so there is no danger of detracting from local ownership or partnerships, a concern that led to vehement dissent by UNICEF about having a review panel. That organisation has yet to approve the consensus document for guiding RBM drawn up at Harvard.

The RBM partnership is in principle well founded, but partners must realise that for the programme to succeed money cannot be squandered on flawed projects. Scientific rigour of projects should not take second place to their political correctness. RBM should not fear constructive independent review.

The Lancet

Last Modified 19 August 2000

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