Malaria fight in Africa needs better donor coordination and more financial help, says World Bank Chief
PARIS, September 8, 2005-On the eve of an international summit to help African countries make faster progress in their fight against malaria, the World Bank, and other partners are calling for a dramatic increase in the supply of insecticide-treated bed-nets to poor families, affordable access to new anti-malarial drugs, and improved monitoring of results, as part of a coordinated international campaign to help control a disease that kills more than a million people each year, and causes millions more to become sick.
Speaking ahead of the Bank-sponsored summit, which will bring together African health ministers, OECD development partners, development agencies, and other participants to mobilize additional support for African countries fighting malaria, World Bank President, Paul Wolfowitz, says the Paris conference is proof that, just a matter of months after the Group of Eight summit in Gleneagles, the international community is determined to help African countries gain the upper hand against a disease that mostly strikes children under the age of five.
Based on his recent travels in Africa and South Asia, where he said he had been struck by the reported progress that countries such as Eritrea, Madagascar, and India are making in controlling malaria, Wolfowitz says that evidence clearly showed that the mosquito-borne disease is completely preventable and treatable.
"It is a sad fact that malaria kills an African child every 30 seconds despite the existence of methods to both prevent and cure the disease," Wolfowitz said. We must act now, before the malaria parasite adapts and grows resistant to the insecticides and drugs we have available to us today."
In 1998, the World Bank and its international partners - World Health Organization, UNICEF, and the UN Development Programme - announced a "Roll Back Malaria" initiative intended to cut malaria rates in half in 12 years.
"Since then, additional donors and partners have joined this effort, including other development banks, donor countries, as well as the private sector, academia, NGOs and foundations," Wolfowitz noted. "Despite very good intentions, malaria is as much of a threat today in Africa, if not worse. Obviously, we must do better."
Last Thursday, the Bank's Board of Executive Directors approved a US$150 million health project grant for the Democratic Republic of Congo (DRC), a key feature of which is a US$30 million anti-malaria measure to help the DRC Government to rapidly increase numbers of long-lasting insecticide-treated bed nets available to people (aiming for two to three nets per household) and to treat malaria-infected patients promptly with more effective drugs, in a large portion of the country.
In late April, the World Bank unveiled a Global Partnership Strategy and Booster Program to counteract what it described as the 'inadequacy of global efforts to control malaria and the modesty of the Bank's current efforts relative to its potential.' The new malaria strategy acknowledges that while the World Bank was a key contributor to recent successes in malaria control, including those in Brazil, Eritrea, parts of India, and Vietnam, the Bank's activities were useful but not sufficient for success on a larger scale. Its efforts were severely hampered by under-staffing and under-funding. As the new approach now puts it, having digested the lessons of the last five years, the Bank realizes that "a different and more robust approach is needed for success."
Malaria impact heaviest in Africa
An ancient killer throughout the centuries, malaria affects more than 100 countries worldwide. Africa though is by far the worst-affected region with 85 percent of all deaths from malaria occurring there. This compares to 8 percent in Southeast Asia, 5 percent in the Eastern Mediterranean region, 1 percent in the Western Pacific, and 0.1 percent in the Americas. Globally, there are more than 500 million new cases of malaria a year, with one recent study putting the number of new cases from a particularly severe form of the malaria parasite called Plasmodium falciparum, at 515 million in 2002 alone.
The most severe forms of malaria cause organ failure, delirium, impaired consciousness and generalized convulsions, followed by persistent coma and death.
Malaria also blunts economic growth
It is estimated that in Africa alone, the economic burden is about US$ 12 billion annually. Malaria is estimated to slow economic growth in African countries by about 1.3% per year. The disease contributes not only to lost life and productivity but also hampers children's education and social development through both absenteeism and neurological disabilities associated with severe malaria. Malaria erodes growth, for example, when adults, debilitated by the disease, cannot work, and lose earnings. Furthermore, the education system becomes disrupted when children are either too sick to attend school, or their teachers are absent because of malaria-related illnesses.
"For many countries, controlling malaria is crucial to reducing the human suffering and deaths of mothers and young children, and securing economic growth," says Gobind Nankani, Vice President for the Africa region at the World Bank, and co-chair of the Paris malaria summit. "Controlling malaria in Africa will require long-term commitment, coordination, capacity building, and money. For example, the Global Fund for AIDS, Tuberculosis, and Malaria, has played a key role in increasing extra malaria funding since 2000, and the World Health Organization (WHO), and Roll Back Malaria (RBM) Partnership, have provided invaluable leadership. Nonetheless, it's estimated that at least US$1 billion extra a year will be needed to effectively control this infection on the continent."
Nankani says that malaria spending by African countries and development partners has increased over the past few years, but significant additional support, above and beyond what the Global Fund and others are already doing, will still be required to help developing countries achieve lasting country-wide impact. At the moment, malaria control can be sometimes limited to a handful of districts within countries. Just as importantly, especially as other development partners provide much needed increased support, will be their better coordination around country needs and programs. "Development partners really need to focus on better coordination on the ground in African countries, to be able to improve results, and help countries cross the threshold to where people are faced with far less malaria-related illness and lost earnings, " says Nankani.
In addition to the recent grant to DRC, the Bank's Board has also approved increased support to Eritrea. Project preparation is now underway in Zambia, Benin, Burkina Faso, and Mali along with a regional project that seeks to address cross-border issues, monitoring and evaluation, and other regional public health priorities.
Other countries where the Bank expects talks with governments in the coming months over increasing Bank support for malaria control include Ethiopia, Ghana, Kenya, Malawi, Nigeria, Senegal, Tanzania, and Uganda.
The new Bank malaria strategy notes that in Tanzania, for example, when the use of insecticide-treated bed nets for infants increased from 10 to more than 50 percent, child survival increased by 27 percent and anemia decreased by 63 percent. In Uganda, where no more than 15% of households have at least one mosquito net, there is a new sense of urgency about malaria control.
"Countries that are getting malaria slowly but surely under control show us how strong political leadership, community involvement, and the right tools such as treated bednets, residual indoor spraying, and anti-malarial drugs are essential ingredients in making malaria an entirely preventable and treatable disease," says Jean-Louis Sarbib, Senior Vice President for the World Bank's Human Development Network. " And the more you lessen the burden of treating malaria on the health system-in Zambia, for example, 40 percent of outpatients come to the hospital or to the clinics because of malaria-the more you automatically improve the ability of a country's health system to deal with other diseases as well."
Better donor coordination also key to fighting malaria
In addition to new financial help, the Paris malaria summit will also hear calls for more systematic donor coordination within the countries they work with. According to World Bank President Wolfowitz, a long-term vision for controlling malaria is essential on the part of both countries and development partners alike, if lasting reductions in malaria-related illnesses and deaths are to be achieved. Moreover, it will be crucial for all partners in the malaria fight to support a single agenda and coordinate assistance in order to deliver measurable results.
"As we move forward, we will want to apply the overarching principles of government ownership and partner collaboration around one common malaria control strategy at the country level. As we've all seen, no one partner can address the challenges of large scale malaria control alone, and having everyone working in tandem-bilateral, private sector, and multilateral partners, together with developing countries themselves-is imperative for success," says Wolfowitz.
The Bank President went on to say that the recent announcement of a Presidential Initiative by the United States was particularly welcome, and that combined with increased attention from the UK, EU, UN, the Global Fund for AIDS, TB and Malaria, and other partners in the Roll-Back-Malaria (RBM) Partnership,"the development community is on the right track and now needs to show concrete results."
Drug-resistant malaria worrisome
The World Bank hopes the Paris malaria summit will re-energize the international community to help provide African families with enough supplies of the right anti-malarial drugs, especially the new and effective ACT or Artemisinin-based Combination Therapy and also to invest in malaria research to ensure more effective prevention and treatment, including new drugs to which the malaria parasites will have no resistance and, hopefully, an effective malaria vaccine.
The need for a new generation of affordable anti-malarial drugs (ACT drugs is reinforced by evidence that malaria has made a resurgence because of resistance to traditional first-line anti-malarial treatments, such as chloroquine (CQ) and sulfadoxine pyrimethamine (SP or Fansidar) by Plasmodium falciparum, the parasite that causes a severe form of malaria. Faced with increasing resistance to these first-line treatments, countries are revising their anti-malarial drug policies and exploring alternative treatment options.
Experience in some areas of Southeast Asia has shown that artemisinin-based combination therapy can be successful in treating and reversing the spread of drug-resistant malaria. However, as the US$1-2 per course of treatment, ACTs are 10-20 times as expensive as the failed or failing chloroquine. Recent reports have identified a potential bio-medical crisis. For example, since the artemisinin-based drugs are the only first-line anti-malarial drugs appropriate for widespread use that still work against chloroquine-resistant malaria parasites, malaria's toll could rise even higher if resistance to artemisinin were allowed to spread.
The challenge is therefore two-fold: to facilitate the widespread use of artemisinin, while, at the same time, preserving its effectiveness for as long as possible. One promising solution to the challenge, according to the World Bank's Jean-Louis Sarbib, is a recommendation from Nobel-prize winning economist, Professor Kenneth Arrow, that the international development community recognize the effectiveness of ACT anti-malarial drugs as a 'global public good' and pay a global subsidy to protect the effectiveness of these valuable drugs.
Sarbib says the Paris summit will discuss the proposed subsidy for new anti-malarial drugs, especially Artemisinin-based Combination Therapies, and that the World Bank will work closely with Professor Arrow and his colleagues to further develop the design of the global subsidy.
"We believe the concept has strong merit and could potentially have a significant impact in terms of accessibility to treatment, delaying resistance and ultimately reducing malaria-related death and illness."
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