Members of the international development and health communities gathered at the Washington, D.C., office of the Global Health Council Oct. 7 to launch a new framework for combating Malaria called the "Global Malaria Action Plan." An overview of the plan turned into a discussion on the challenges of implementing, measuring and expanding the $1.5 billion earmarked between 2004 and 2007 for malaria, which mainly effects sub-Saharan Africa and pockets of Asia.
The GMAP framework covers three phases of combating malaria - scale-up, sustained control and elimination - and ties them to a new goal of "universal coverage" and away from objectives targeting only pregnant women and younger children. But, with the broadening of goals come greater challenges to scaling anti-malaria programs. Specifically, issues of building local capacity, transparency in donor funding, and measuring program outcomes have lead to a backlog in disbursement of anti-malaria supplies and funding. Therefore, a relatively new development goal is encountering what seems to be an eternal challenge faced by the foreign assistances community.
You can't manage what you can't measure
Although the cost of controlling malaria have been well defined, the measurement of intervention outcomes needs improvement. In many cases, funding for malaria control has come as part of "a faith-based initiative" without the proper monitoring and evaluation components, said Matthew Lynch, vice chair of the Roll Back Malaria partnership.
Bed nets, insecticides and vaccines may seem like cures to the malaria epidemic but, Lynch argued, management skills and institutional capacity are the missing links to effective malaria interventions.
This raises a major dilemma: Without good supply chain managers and systems, how do governments and companies distribute long-lasting insecticide-treated nets?
Building local capacity takes time and well-trained health professional are in demand globally. This global migration of skilled health professionals to better-paying markets in the west has been a concern in South Africa. Inversely, if the health professionals are narrowly trained in just anti-malaria techniques, their career prospects could diminish once anti-malaria initiatives show success.
One possible solution to the challenge of developing and retaining local capacity is cross-training health workers to tackle other issues such as HIV/AIDS and tuberculosis. All health subfields would benefit from pooling resources to build sustainable health systems in malaria affected countries. Additionally, better-managed health services may retain their experienced workers.
Another key issue is for malaria-affected nations to acquire disease surveillance systems. Lynch cited his previous work during a malaria outbreak in Kyrgizstan for the U.S. Agency for International Development.
"When I got there, each district had its own epidemiologist who mapped out the malaria hotspots," he said, adding that with the proper data and local knowledge, the only intervention needed was to ship insecticide to the Kyrgyz government to control the outbreak.
Using the right technology, surveillance personnel may quickly allocate the proper resources to control outbreaks or kickstart prevention programs. This happened, for instance, as part of a partnership between the Peruvian Ministry of Health, USAID and U.S. based software developer Voxiva. The company's "Health Watch" technology allows government officials closest to an event the ability to gather data on disease outbreaks in real time at low cost through cell phones or landlines.
Broadening donor funding and priorities
Towards these challenges GMAP's authoring body, the RBM partnership, is advocating a 75 percent increase in donor spending for malaria in 2009. Many anti-malaria programs simply do not have enough money to effectively measure and build capacity, according to the framework.
With such programs, "one-off" disease control strategies such as the use of bed nets and vaccines, would be more effective and medical professionals could handle other health needs.
The tracking and coordination of money for malaria also poses a challenge. Lynch reckoned that the increased attention to malaria from church groups and foundations has increased available funding but not data on how money is being spent. This causes a predicament for institutional donors, in terms of deciding how much funding to allocate for anti-malaria efforts as opposed to other development goals. The lack of transparency in funding sources may also cause duplicated efforts.
Perhaps the transparency issue can be resolved by establishing a self-reporting "clearing house" for private, non-governmental and multilateral sources of funding in order to better coordinate efforts. Eradicating malaria will take more than simple technologies and fundraising campaigns to reach GMAP's goal of "universal coverage," but a holistic approach that layers people, systems and technology just might work.