Global Malaria Control:
U.S. and Multinational Investments and Implementation Challenges
GAO-06-147R, Nov 16, 2005
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Each year, hundreds of millions of people are sickened with malaria and more than 1 million people die. Over 80 percent of all malaria deaths occur in Africa, most of them in children under the age of 5. This burden continues despite the existence of relatively simple, safe, effective, and inexpensive methods to prevent and treat malaria. The U.S. government supports the efforts of malaria-endemic countries to control malaria, both directly through agencies such as the U.S. Agency for International Development (USAID) and indirectly through its contributions to multinational organizations such as the Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria (Global Fund) and its participation in the Roll Back Malaria (RBM) Partnership. However, concerns have been raised that current global malaria control efforts may not be as effective as they could be. In light of these concerns, Congress asked us to examine U.S. involvement in global efforts to combat malaria. In this report, we (1) describe investments that have been made by the U.S. government to support the implementation of national malaria control programs in malaria-endemic countries, both directly and in partnership with other organizations; and (2) describe key challenges to the implementation of national malaria control programs and strategies for addressing those challenges.
The U.S. government's direct investments to support implementation of national malaria control programs in endemic countries--through USAID and CDC--are exceeded by its indirect investments through partner organizations, particularly the Global Fund. More than $68 million of USAID's fiscal year 2004 malaria budget--which increased from almost $30 million in fiscal year 2000 to almost $80 million in fiscal year 2004--was used to provide a range of implementation support, such as updating national prevention and treatment policies and supporting distribution of malaria-related commodities, including ITNs, insecticides, and medications. Almost $6 million of CDC's fiscal year 2004 global malaria budget--which increased from $9 million in fiscal year 2000 to more than $13 million in fiscal year 2004--was used to provide implementation support to national programs, including ITN, IPT, and treatment initiatives. In fiscal year 2004, the U.S. government's indirect investments through the Global Fund alone exceeded all direct investments to support implementation of national malaria control programs. We estimate, based on total Global Fund commitments for malaria control, that more than $142 million of the U.S. government's fiscal year 2004 contribution to the Global Fund goes to support malaria control grants. Using U.S. and other donor contributions, the Global Fund has, as of September 1, 2005, committed to provide more than $1.7 billion over the 5-year course of the malaria grants it has approved. The U.S. government's indirect investments through contributions to U.N. agencies and other multinational organizations also provide support to national malaria control programs. However, in the case of these organizations it is not possible to attribute a specific amount of their malaria funding to the United States. Key challenges to implementation of national malaria control programs include inadequate human resources, specifically, widespread shortages of adequately trained technical and clinical staff; insufficient financial resources for program implementation, donor support activities, and procurement of commodities; coordination challenges, including difficulties coordinating the activities of a range of partners in malaria-endemic countries; and challenges related to limited production, procurement, and distribution capacity for key commodities such as ACTs and long-lasting ITNs (also known as LLINs). Key strategies that are being used to tackle these challenges include addressing human resource and access-to-care issues through training of community health workers and integration of malaria program activities into antenatal care clinics and immunization programs; securing additional funding--particularly from the Global Fund--to support implementation of national programs and obtaining technical assistance from U.S. agencies and partner organizations to help ensure that this funding is used effectively; improving global and local commodity production capacity--particularly for ACTs and LLINs--by reducing or eliminating applicable taxes and fostering technology transfer to local manufacturers, among others; and addressing commodity distribution and use issues through strategies such as using a mix of ITN distribution mechanisms to target different populations, prepackaging medications, and employing extensive community education efforts.