After years of historic progress, the battle against malaria is stalling. There were an estimated 219 million cases in 2017, up from 217 million the year before. That was the top finding of the World Malaria Report 2018, which was released by the World Health Organization (WHO) and partners, including the Global Fund, on 19 November. (See article in this issue for other perspectives on the report.)
In addition to that sobering trend, the report highlights that more than two-thirds of all malaria cases worldwide last year were concentrated in India and ten African countries: Burkina Faso, Cameroon, Democratic Republic of the Congo, Ghana, Mali, Mozambique, Niger, Nigeria, Uganda and Tanzania.
“We have made extraordinary progress in the fight against malaria, but without more resources, greater innovation and better execution we risk a resurgence in the highest burden countries,” said Peter Sands, Executive Director of the Global Fund.
Following from these findings, WHO’s new ‘High Burden to High Impact’ response was launched simultaneously with the 2018 report. The response will target the eleven high-burden countries with a multi-pronged approach intended to stimulate greater action and investment, leading to better outcomes in the short and longer term.
The response is outlined in a brief document from WHO, which is heavy on aspirations and buzzwords, but remains light on tangible details.
The core of the response is a set of four “key elements” or “pillars,” as described by WHO:
- Galvanizing national and global political attention to reduce malaria deaths;
- Driving impact through the strategic use of information;
- Establishing best global guidance, policies and strategies suitable for all malaria-endemic countries; and
- Implementing a coordinated country response.
In addition to the key elements, “High Burden to High Impact” is guided by four principles, as described by WHO:
- Country-owned, country-led, and aligned with the Global Technical Strategy for Malaria 2016-2030 (GTS), the health-related Sustainable Development Goals, national health goals, strategies and priorities;
- Focused on high-burden settings;
- Able to demonstrate impact;
- Characterized by packages of malaria interventions, with a foundation in primary health care.
The WHO-published materials about the response describe it as “country-led,” but there is little in the way of demonstrated country leadership in the currently available literature. In fact, all of the quotes printed in the materials come from WHO and the RBM Partnership to End Malaria leadership, who sit in Geneva. And the most defined example of how countries will lead, in the WHO announcement of the response, is a short section on the importance of domestic financing, which does not reference any specific commitments yet made.
As for the practicalities of the WHO malaria response for Global Fund grants in the eleven countries, it remains to be fully understood how the response will be operationalized. There does not appear to be any funding associated with the response, nor are there many publicly available details on the specific mechanisms through which the key elements will be approached.
One area of interest to Global Fund recipient countries and CCMs is that there is an expectation that grant flexibilities will be leveraged as part of the response. Dr. Scott Filler, Malaria Team Leader for the Technical Advice and Partnerships Department at the Global Fund Secretariat, commented: “As the ‘new approach’ leverages data for better targeting and decision making, this will necessitate changes to programming – our Global Fund systems remain ready and flexible to implement and support any such perturbations to current strategies.”
In terms of what would be considered success for the approach, that is vaguely defined as well. The attainment of the GTS targets is held up as the primary measure of success. However, there are secondary measures of success, according to the WHO document. These include, “the more efficient and effective use of resources,” leading to increased domestic commitments to malaria over time, and “better malaria control,” which will yield, “demographic, social and economic benefits.” There is no specified method for assessing these secondary measures, based on the available literature reviewed by GFO.
Countries with malaria burdens that are not included in the 11 target countries defined for this response should keep an eye on the program, as the WHO describes this first group of 11 countries as “trailblazers.” Accordingly, the lessons learned there will be applied, “in due course, to all countries with high transmission of the disease.”