The 58^th World Health Assembly’s Malaria Control Resolution – A Comment.

Africa Fighting Malaria supports the prominence given to malaria and malaria control at the recent World Health Assembly (WHA).  While the resolution marks a small improvement in the rhetoric on malaria control, there are still a number of worrying factors in the resolution and a number of structural problems in the way in which the WHO approaches malaria control.

AFM welcomes the resolution’s specific mention of indoor residual spraying as a malaria control intervention.  Two items of the WHA are steps in the right direction.  The first urges the Member States:

to support indoor residual insecticide spraying, where this intervention is indicated by local conditions;

The second requests the Director-General:

to provide evidence-based advice to Member States on the appropriate use of indoor residual insecticide spraying, taking into account recent experiences around the world.

These two paragraphs could mark the beginning of the end of many years of WHO advocacy against IRS and the use of insecticides in general.  Specifically, we were heartened during the debate on malaria to hear several countries from southern Africa forcefully reminding the various UN representatives and Member States that they were using DDT in IRS programs.  In most Southern African states, IRS remains the most effective means of controlling malaria.

AFM is also heartened that the resolution calls for greater inter-country cooperation in malaria control.  Arguably the most successful malaria control program at the moment is the inter-country effort of South Africa, Swaziland and Mozambique.  Mosquitoes do not recognise political boundaries and increased trade and movements of people between malarial countries requires better coordination or control programs. 

Notwithstanding these positive developments, we are concerned about several aspects of the WHA.

First in March of this year, a paper by Dr. Robert Snow and several other malariaologists published in the leading scientific publication, Nature, claims that the WHO has underestimated the extent of malaria cases and deaths around the world.  The paper suggests that not only are the RBM goals on the reduction of death and disease from malaria not going to be met, but that the burden of malaria is actually increasing.

Second, shortly before the 58^th WHA, the World Health Organisation released the World Malaria Report.  The report calls for increased funding for malaria control because, according to the media release that accompanied the report, one of the reasons that the RBM goals have not been met is a lack of funding.

Third, the resolution seems to have changed the Roll Back Malaria targets and goal.  When RBM was set up in 1998,  the ultimate goal was halving the burden of malaria (which we take to mean disease and deaths) by 2010.  As a means of achieving this reduction in disease, RBM’s Abuja declaration set a target of ensuring that 60% of pregnant women and children under the age of 5 have access to preventive and curative measures for malaria.  The WHA resolution now states that the target is that “80% of those at risk of, or suffering from, malaria benefit from major preventive and curative interventions by 2010…”

These three instances reveal deep and disturbing flaws within Roll Back Malaria.  As the Snow paper indicates RBM has put little effort into actually tracking the progress of program.  The World Malaria Report itself admits that no attempt was made to collate data on malaria cases and deaths until 2002, four years after the program began.  The report also asserts that data on malaria in Africa, where more than 80% of cases and deaths occur, should not be relied upon. This all begs the question as to how the WHO could set a target of reducing the burden of malaria by 50% in the first place, when they didn’t know what the baseline incidence was and have not made any effort to track their progress.  Nonetheless RBM complains that the reason it is not meeting its targets is because it does not have enough money, and then WHO changes its targets from the original ones.  There is a very high probability based on this behaviour that RBM will keep shifting targets so that it can announce in 2010 that RBM has been a success.  

This practice is like journeying to a city, say Shanghai, without knowing from where you are starting and where Shanghai is, and then travelling without map or compass. Five years into the journey you complain that the reason you are not yet in Shanghai is not because you don’t where you are going or where you are but because you don’t have enough money to get there.  And then you decide that really Shanghai isn’t your goal after all, Bucharest is.  So then you set out for Bucharest.  At this rate at the end of ten years when you find yourself in Boston, you’ll declare that ultimately Boston was your goal, and you have made a successful journey.

This trend of setting targets without any real idea of how to achieve them or how to track needs to stop.

WHO also fails to address other fundamental flaws.  Malaria control is beset structural problems that began during the 1970s when both the WHO and UNICEF called for the decentralisation of malaria control.  Dismantling the vertical malaria control programs that had dedicated funding and personnel and conducted good operational research on their programs in favour of malaria control through primary health care sparked the rise in malaria cases around the world.  Malaria is a highly complex disease and requires dedicated structures to combat it.  Strengthening primary healthcare should not come at the expense of vertical healthcare programs that are successful.

We are concerned that the section of the resolution calling for greater ‘community participation’ and ‘multisectoral collaboration’ could be used to further entrench the idea that malaria control should be conducted at a primary healthcare level and not by dedicated public health teams.

Despite the limited progress in including IRS in the WHA, we remain sceptical about the real progress that this resolution will bring to malaria control on the ground, especially  given the reluctance of the donor community (with the possible exception of the Global Fund for AIDS, TB and Malaria) to fund effective malaria control.

The fight goes on.