In May, governments committed to reduce malaria cases by 90 percent by 2030. Adam Pitt asks whether there is enough financial support for the latest round of malaria goals to be successful
There was great fanfare in July with the announcement that the first malaria vaccine had been approved by the European Medicines Agency, which followed hard on the heels of countries agreeing that they could all but eliminate malaria by 2030.
The 68th World Health Assembly Resolution on the WHO Global Technical Strategy and Targets for Malaria, which was passed in May 2015, supports ambitious plans to reduce malaria cases and deaths by 40 percent by 2020 and by 90 percent by 2030.
But while the targets are laudable, investment, including both international and domestic contributions, will need to increase substantially above current annual spending of US$2.7 billion.
“To meet the 2020 target of a 40 percent reduction in malaria cases and mortality rates, an estimated US$6.4 billion will be needed per year, and in meeting the 2030 target, we will need to raise US$8.7 billion per year,” says Philippe Duneton, Deputy Executive Director of UNITAID, a global health initiative with a focus on HIV-AIDS, tuberculosis and malaria.
Funding is already the biggest obstacle in malaria eradication, limiting research for more robust antimalarial tools as well as access to existing and advanced interventions for malaria elimination.
Malaria kills 580,000 people a year (one person every minute) with an estimated 3.4 billion people–almost half the world’s population– considered to be at risk of contracting the disease with transmission still reported in 97 countries. It also has a debilitating effect on economies with workers needing repeat and prolonged treatment.
“The cost of eliminating malaria by 2030 is high but the return on investment could see a potential 3 billion malaria cases averted, over 10 million lives saved, and US$4 trillion in additional economic outputs over the next 15 years,” says Fatoumata Nafo-Traoré, Executive Director of the Roll Back Malaria Partnership.
The Global Fund to Fight AIDS, Tuberculosis, and Malaria, which is also part of the Roll Back Malaria Programme, has invested more than US$7 billion on malaria from the US$27 billion disbursed by international organisations for use in fighting AIDS, tuberculosis, and malaria endemics. In terms of funding malaria, its contributions amount to almost 50 percent of the global total. Christoph Benn, Director of External Relations at the Fund, is optimistic that the upward trajectory for malaria financing will continue.
“International funding for malaria control and elimination reached US$2.7 billion in 2013, a threefold increase since 2005 and this is a reflection of a strong commitment that has seen huge progress made in recent years,” says Benn. “New advances in science and better implementation of programmes have given the global community the historic opportunity to completely remove malaria as a threat to global health.”
Working with UNITAID, the Global Fund launched a US$450 million Affordable Medicines for Malaria pilot in eight African countries in 2009, which after five successful years, has been integrated into the Global Fund’s financial cycles.
“In addition to UNITAID’s contribution of US$210 million, the Global Fund provided US$100 million for a campaign to promote awareness about the benefits of artemisinin-based malaria treatments,” says Duneton. “This was well received, and the market share of quality-assured products now exceeds 40 percent in some pilot countries. The price for quality-assured products has also been cut from US$10-15 per treatment to an average of US$1, making these potentially lifesaving drugs available to millions more people.”
As well as the use of malaria nets and effective anti-malarial drugs, there has been a major change in how programmes are implemented, says Dudley Tarlton, Health and Development Programme Specialist at the United Nations Development Programme in Geneva.
“At the United Nations Development Programme we’ve been helping the development community see malaria not just as a health issue, but as a challenge driven to a great extent by social determinants such as housing quality, agricultural practices, infrastructure development and environmental management,” says Tarlton. “By approaching malaria as a much more holistic development issue, the millions of people who are affected by living in an endemic country can be taken into consideration when planning responses to the disease that are relevant to the local environment. This includes those not directly infected.”
Benn also points to the progress in malaria research making the goal of eradicating malaria more achievable with the European Medicines Agency’s recommendation in July that the UK drug manufacturer GSK’s new vaccine candidate, RTS,S or Mosquirix, be licensed for use by young children at risk from the mosquito-borne disease in Africa.
“The vaccine will be extremely important in Africa and Southeast Asia, where the social and economic tolls of the disease are arguably at their greatest. It is estimated that 90 percent of all deaths are in Africa, but there are also 219 million non-fatal cases, so there is much work to do,” adds Tarlton.
While other vaccines tackle viruses or bacteria, RTS,S is designed to prevent malaria caused by the Plasmodium falciparum parasite, which is most prevalent in sub-Saharan Africa. The GSK research has shed light on the protein that enables the malaria parasite to invade and take over red blood cells and how it then infects the liver.
The next step for the vaccine candidate will be for the World Health Organization to formulate a policy recommendation on the use of the vaccine in national immunisation programmes. And while keen to point out that the Global Fund does not fund research, Benn welcomes the European Medicines Agency’s positive scientific opinion about the vaccine but stressed that its effectiveness depends on it being used alongside a wide range of other tools to fight the disease.
“The Global Fund remains cautiously optimistic about the new RTS,S vaccine candidate,” says Benn. “This could be enormously beneficial in further reducing the impact of the disease, alongside mosquito nets treated with insecticide, indoor spraying, prompt diagnostic testing, and effective anti-malarial medicines.”
Further research may lead to a more effective vaccine to achieve the 2030 goals but this will depend on galvanising more funding from the donor community. Malaria is now a priority for the Bill & Melinda Gates Foundation, which through its multi-year malaria strategy adopted in 2013, Accelerate to Zero, is focusing its efforts on the belief that interrupting transmission is not enough, and that to achieve full eradication, new drugs and strategies must consider how the disease is biologically and ecologically different around the world. Strategies must also move beyond the clinical, to a complete parasitologic cure.
Benn agrees a more concerted effort will be needed but the goal is too important to disregard.
“Progress against the disease over the past decade demonstrates that with commitment from all involved to expand and intensify efforts, malaria can be transformed into the manageable and treatable disease that it is.”