World Bank intensifies anti-malaria effort in Africa

from World Bank
Published on 24 Apr 2006
An African child dies of malaria every 30 seconds.
Three hundred die each day in the Democratic Republic of Congo alone.

In Kenya, malaria is blamed for one out of every four child deaths.

In many countries, the mosquito-borne disease is the "leading killer of African children," says World Bank Public Health Specialist Suprotik Basu.

But even though no vaccine as yet exists for malaria, the disease is completely preventable and completely curable if contracted - a "fixable problem," says Basu.

Boosting Prevention and Treatment

A year ago, the World Bank announced it would revitalize its commitment to the global anti-malaria effort by helping to cut Africa's 850,000 malaria deaths in half by 2010, and in half again by 2015.

The Bank launched the Global Strategy and Booster Program and committed US$500 million to a three-year intensive first phase to accelerate progress against malaria in Africa.

"It's a 10-year fight," says Gobind Nankani, Vice President of the Bank's Africa Region. "Our goal is both to prevent the disease and to ensure the population at risk has access to timely medical help."

Now, on the sixth anniversary of Africa Malaria Day, the Bank is on track to commit US$405 million in 20 of the world's hardest hit countries. The list of countries is not closed however - the Booster Program is ready to consider countries' requests to complement the efforts of other partners, according to Maryse B. Pierre-Louis, the Lead Health, Nutrition, Population Specialist and Coordinator of the Bank's Booster Program.

To date, four projects, in Eritrea (US$2 million), DR Congo(US$ 30 million), Niger(US$10 million) and Zambia (US$20 million), have been approved by the Bank's Board, and another 10 projects are in the pipeline.

This effort is long overdue, says Pierre-Louis.

"We are no longer in the business of just incremental activities for malaria control - we are in the business of scaling up for impact."

She says the goal of the Bank's Booster program is to help countries work with various groups to meet malaria-reduction targets and particularly to curb child deaths from the disease.

Working with its partners in the Roll Back Malaria Partnership - a 90-member organization that includes the World Health Organization, UNICEF, the Global Fund, US Agency for International Development, and the Bill & Melinda Gates Foundation - the Bank wants to reach at least 60 percent of sufferers in the following groups:

- People who have contracted malaria to ensure they have access to affordable and appropriate treatment within 24 hours of the onset of symptoms

- People at risk - particularly children under 5 and pregnant women - to provide them with protective personal measures such as insecticide treated nets

- All pregnant women to ensure they have access to intermittent preventive treatment.

By 2010, the Booster Program aims to protect 80 percent of the at-risk population from contracting the disease, and treat 80 percent of malaria patients with effective medicines within one day of symptoms.

By 2015, the goal is to reduce malaria deaths by 75 percent compared with 2005 levels.

Pierre-Louis says the Bank will capitalize on its relationship and macro-economic dialogue with African governments to ensure the Booster Program becomes sustainable in the long run.

"To this end, we will continue to encourage them to dedicate increasing resources to malaria control and other public health programs in future budgets, and to work toward health, educational and other goals the Bank considers key in their efforts to reduce poverty," Pierre-Louis adds.

Nets & Spraying

The Booster Program promotes several interventions, including: insecticide treated nets and indoor residual spraying (spraying the walls of homes), which will kill mosquitoes in homes and reduce the number of malaria-carrying mosquitoes in the overall environment; and new, more effective medicines that will improve treatment for the disease, says Basu, who himself contracted malaria in Zambia on Africa Malaria Day in 2005.

Insecticide-treated nets cover people while they're sleeping. They can't always stop mosquitoes from biting, but kill mosquitoes that land on the net, so they can't infect another person, says Basu.

Bed nets treated with insecticides have not been used on a large scale in Africa, he says. But studies have found that if 60 percent or more of the population in a given area sleeps under insecticide treated bed nets, malaria will decrease overall and as many as one-quarter of all child deaths will be prevented.

"What we're trying to do is get past these critical thresholds, so that the nets not only protect individuals, they protect entire villages," says Basu.

Spraying indoors is also very effective, where appropriate, according to the Bank's strategy, which has been backed by World Health Organization and US Centers for Disease Control and Prevention experts.

India and East Asia have decades of experience with indoor spraying, but it has never been done extensively in Africa, because of the logistical difficulty of maintaining spray programs and because of political and environmental concerns.

Spraying the walls of homes with an insecticide is most effective when the mosquitoes that carry malaria are indoor-resting - meaning they bite someone, then rest indoors, Basu says.

"If you spray indoors, you will see a lack of mosquitoes within the next day. It's dramatic, and the effects can last for months," says Basu.

"The debate on whether or not to spray has heated up over the past year," he says. "Some of our clients are examining options to put more emphasis on spraying than they have in the past. Spraying went out of style, so to speak, for the past 15 or 20 years, because of all the controversy around DDT, which is just one of many insecticides used for spraying. The international community is now revisiting the balance between spraying and other activities.

"There's a need for a rational mix, but this is a country-specific issue - there's no room for dogma on this," he says.


According to the World Health Organization, the standard drugs for treating and preventing malaria, chloroquine and sulfadoxine pyrimehamine, are cheap - pennies per dose - but increasingly ineffective against the malaria parasite.

The Booster Program , along with key partners, will help governments purchase the more effective artemisinin combination therapy (ACT) - about 15 to 20 times as expensive as choloquine. That amounts to about 80 cents a treatment course for a child and $1.25 to $1.50 for an adult - significant expenditures in poor countries.

"We have the new drugs now, but the challenge is, how do you afford them on a sustainable basis? And how do you get them out? Resources are always limited, and there are difficult tradeoffs to make - sometimes, a country can't do everything, everywhere," says Agnes Soucat, Lead Economist in the Africa Region, who is leading the Booster efforts in Ethiopia and Rwanda.

The new ACT treatment requires more than one dose and is temperature sensitive, posing compliance and logistical difficulties, she says.

Private Sector Key to Reaching Population

While governments will ultimately be accountable for implementing the Booster Program, the Bank will work with the private sector to get nets, spraying, and medicine to as many people as possible, says Basu.

"Government reach is limited, but like many Bank projects we don't stop because government reach is limited. We try and find ways to expand beyond their reach. And key among these ways is tapping into private sector delivery channels," says Basu.

"Most people in Africa get treatment in the private sector - 70 to 80 percent of all malaria patients never see a public facility," he says.

"In this context, if we stuck with the public sector, we're only having an impact on 20 percent of the population, which is not a very good approach. So we've got to find ways to encourage public-private interfaces within the overall government strategy on malaria control, to get the corner drug vendor in Nigeria to stock the appropriate drug.

"In Nigeria, the government is trying to work with Patent Medicine Vendors - essentially private corner drug vendors - to make sure there are proper stocks, the drugs are subsidized, and they're not giving counterfeits," Basu says.

Eva Jarawan, Lead Health Specialist and Team Leader on the Nigeria Malaria Control Booster Project, says the Booster Program gives the Bank an opportunity to address overall child mortality in Africa.

"Malaria, as one of the leading causes of child mortality, is an obvious entry point, but we'll also assist countries to tackle child health more broadly," she says.

Pierre-Louis says partners and countries are now uniting for results. "We're seeing that success is possible, but not easy. It's now time to take those successes to scale. Together with our partners, we'll work with countries to do just that, and be accountable for the results."