Time to take control

| 28 Feb 2008

"The billion-dollar malaria effort is flying blind," declares Mark Grabowsky in a Commentary on page 1051 of this issue. And given that Grabowsky is malaria coordinator of the Global Fund to Fight AIDS, Tuberculosis and Malaria, which disburses almost half the US$1 billion spent annually on malaria control, we might do well to listen.

Grabowsky argues that, above all, malaria control requires data: to assess the present situation, to target control measures and to evaluate their effectiveness. He also says that an adequate surveillance programme would cost as little as $10 million a year. Yet that money has not been forthcoming; malaria managers still lack even the most rudimentary information.

The surveillance problem is symptomatic of a wider failure in basic project management. The 'international' malaria effort is actually a hotch-potch of fragmented, country-level projects funded by multiple donors, with little regional and international coordination. Such leadership would normally be provided by the World Health Organization (WHO), as it has done to great effect in the fight against measles and polio. But the WHO-led Roll Back Malaria initiative is mired in bureaucracy and anything but effective.

That management problem, in turn, reflects a still deeper issue: the agencies involved in the malaria fight, including the WHO, have for too long been driven largely by advocacy. It's true that advocacy was a supreme need a decade ago, when malaria control was off the radar and gathering a mere $100 million a year. But that mindset has persisted even as the funding has multiplied tenfold.

Take the good news spin put on recent studies showing that bed nets and drugs cut the malaria burden by as much as half in Zanzibar, Ethiopia and Rwanda. That sounds dramatic. But it's hardly unexpected, as the low malaria transmission rates in these countries make the disease comparatively easy to control. And in the meantime, silence surrounds the lack of a single win in high-transmission areas such as the Democratic Republic of the Congo or Nigeria, which account for half the malaria mortality in Africa.

Yes, on-the-ground conditions are difficult, as is reported in Zambia, the flagship of international efforts. But the international malaria effort is still geared towards maintaining donor support instead of getting teams into the field gathering data and delivering basic items such as bed nets. That's why almost no country is near to meeting Roll Back Malaria's target of having 80% coverage with bed nets and drugs by 2010; why malaria is still killing more than 1 million people every year; and why the global control effort is way off track to meet the internationally agreed goal of halving malaria deaths by 2010.

Such goals are undeniably ambitious. But they are a spur to action — and in line with what the WHO has already achieved with measles and polio. What the malaria effort urgently needs now is leadership, and a shift from spin to substance and results.