the roll back malaria program

1 Todd Mercural-Chapman (2014)

The Roll Back Malaria Partnership

Abstract

Malaria remains one of the deadliest diseases on the planet, claiming nearly 1 million

lives annually. Nearly half the world’s population remains exposed (3 billion people). Ninety

percent of contractions and deaths from malaria occur in Africa and the most at-risk are

children under five and the elderly. Malaria is the number one killer of children globally.

Economists estimate a loss of $12 billion USD in GDP annually due to the disease through both

direct and indirect costs.

This paper explores a history of malaria control and eradication efforts culminating in

Roll Back Malaria Partnership (RBM) hosted by the World Health Organization from 1998 to

present. The paper will look at RBM’s history, structure, vision, and goals, and provide analysis

and evaluation of its efforts to-date. This exploration will show that, while great gains have been

made in the fight against malaria, there is much work to do by RBM internally and externally in

order to meet its own goals.

Introduction

Despite a century of effort on a global scale, malaria remains one of the deadliest diseases

on the planet, claiming nearly 1 million lives annually. Nearly half the world’s population

remains exposed (3 billion people). Ninety percent of contractions and deaths from malaria occur

in Africa and the most at-risk are children under five and the elderly. Malaria is the number one

killer of children globally. Economists estimate a loss of $12 billion USD in GDP annually due

to the disease through both direct and indirect costs.


Efforts have varied since the late 19th century, with competing approaches of control and

eradication, preventive and curative. Success from all approaches has waxed and waned, with

the most dramatic success seen in the mid-20th century through the use of DDT on interior spaces

in vulnerable communities. Malaria during a 20-year period was eradicated in a number of

places, including North America, Europe, and parts of South and Central America. For a number

reasons logistical, political and cultural, malaria efforts have been rebuffed in Africa and Asia.

In 1998, the World Health Organization (WHO) partnered with UNICEF, the World

Bank, and UNDP to create the Roll Back Malaria Partnership (RBM), a global network of

governments, NGOs, foundations, private businesses, and research institutions to combat malaria

using a combination of previous efforts in a coordinated fashion. Their goal is to eventually

eradicate malaria for good while strategically employing control, prevention and curative tactics

in the interim.

The initiative was universally applauded at the outset and a flurry of financial pledges

were made by governments across the globe, but from the outset to its fifth year RBM was

plagued by financial insufficiency because few, if any, made good on their pledges, including

one of its founding partners, the World Bank. The financial situation has improved considerably

since 2004, but even its projections for 2012-2015 showed a gap of multiple billions of dollars.

In 2006, RBM underwent a “change initiative” to reorganize and revisit its vision and strategy.

Great gains have been made, with over one million lives saved through the effort. New

technologies in insecticide treated nets (ITNs) and vaccines for children have made a great

difference, as has the policy to ban monotherapy treatments in favor of combined-therapy

medicines (ACTs) to thwart drug resistance. Development of a vaccination is rapidly

progressing with a goal of availability in 2015.


Despite the gains, RBM continues to struggle for adequate funding to meet its ambitious

goals. Experts in the literature make a number of recommendations for improvements to the

program: re-evaluate the undervalued role of generalists and social scientists in the network to

better understand the cultural, economic, political and medical obstacles to combatting malaria;

increase the priority of environmental management as a preventive and eradicative tactic (and

explore new types of environmental management); and invest in better medical and death data

collection in endemic countries to ensure accurate measurement of outcomes.

Background & History/Nature of the Problem/Extent of Risk

Malaria is a vector-borne disease prevalent mainly in wet and human tropics which develops

by alternating between human hosts and female Anopheles mosquitos. While it has been

eradicated in many parts of the world, including North America, it remains one of the most

devastating diseases in the world, killing between one and three million people of the 300-500

million cases annually, 90 percent of which live in subs-Saharan Africa. Two-thirds of the

inhabitants of sub-Saharan Africa are exposed. Malaria is also the number one cause of death of

African children, killing one every 40 seconds due in part to their lack of immunity. The other

largest cohorts of victims are pregnant women and the elderly. The daily loss of young life is

2,000 despite being a preventable and curable disease (Tren, 2006; Pattanayak et al., 2006;

Duthe, 2008). There are four strains of malaria: morbidity and mortality depend upon both

epidemiological context and particular strain, although plasmodium falciparum remains the most

lethal, accounting for 75% of malaria deaths (Duthe, 2008). Currently, 3.3 billion people are at

risk in 109 countries (GMAP, 2009)

The World Health Organization (WHO) estimates that nearly 30% of malaria victims come

from countries affected by complex emergencies, meaning they have been displaced from their


homes because of natural disaster, conflict, or war. This dynamic increases their chances of

contracting the disease because they are unable to engage in preventive practices or access

curative resources (Whyte, 2000). Despite the staggering available statistics, malaria deaths

remain the most difficult to count for myriad reasons: its greatest cohort of victims, children,

also have underdeveloped immune systems and so it is difficult to isolate a single cause of death

because the symptoms of malaria are common among a host of diseases; malaria causes

vulnerability to other diseases; rural populations lack access to medical care facilities where they

can be diagnosed and treated; many people self-treat using a variety of "traditional" healing

methods; and many deaths are never officially documented because they occur in rural villages

with no infrastructure and little communication with the outside world (Iley, 2006).

Many researchers have studied the social and economic impact of malaria at various levels of

society. For individual families there are the direct costs of lost time at work and the cost of

treatment and the indirect costs of lost work efficiency, time, and, more specifically for children,

"nutritional deficiencies, cognitive and educational disabilities, and physical retardation"

(Pattanayak et al., 2006). At the national level, economists estimate that malaria decreases

annual per capita GNP growth by 0.25-1.30% in tropical countries (Guerin et al., 2002; Sache &

Malaney, 2002). Lost GDP in Africa is estimated at $12 billion USD annually (Sachs &

Malaney, 2002).

A growing body of research shows the symbiotic relationship between malaria proliferation

and deforestation/environmental destruction, climatic change and poverty. To create a linear

chain of causality between these aspects of the larger malaria problem is impossible, and

researchers have devised numerous names, including biocomplexity, to describe what they see as

the comprehensive framework required to understand malaria. "Human social systems,


economic activities, interactions with the environment, and lifestyles represent some of the key

domains of interaction that affect infection and disease risk (Wilson, 2001). Poverty can lead to

deforestation/environmental destruction through desperate acts of survival, leading to a climatic

change which invites malaria, or environmental destruction through other causes can perpetuate

poverty and thus increase vulnerability to disease. Both are possible simultaneously, resulting in

a self-perpetuating poverty-deforestation cycle.

Malaria is highly reliant upon environmental conditions and so is greatly affected for better

and for worse by alterations of any type and cause to ecological environment. Precipitation,

temperature, vegetation, land-use, development, etc. can all affect the capacity of malaria

vectors. Deforestation is seen by many researchers as particularly important in understanding

malaria because it is often a precursor to other land use changes that increase vector capacity.

Pattanayuk et al. (2006) identify "five potential pathways" through which deforestation affects

malaria infection and transmission:

1. Deforestation changes the ecology of a disease and its options for hosts

2. Deforestation can affect climate at local, regional, and global scales because changes to

the carbon cycle effect temperature and moisture levels

3. Deforestation is the first step in a chain of land-use changes

4. Deforestation is accompanied by migration and other behavioral changes; migration

means more vulnerable populations (or "less-immune") might move to higher risk areas;

transient populations remain out of reach to the medical community

5. Ecosystem change affects antibiotic resistance to malaria because the parasite is allowed

to evolve and adapt genetically

Deforestation is not a purely environmental or ecological concern, however. Deforestation

and other environmental alterations have significant economic development threads. The

development activities that result from deforestation lead to productive activities in the short-

term, but the benefits are largely enjoyed by populations who are less dependent upon the forest

for every day food and products and who have access to proper medical care.


A case study in the Lake Victoria Basin in East Africa illustrates the complexity of malaria

well. Wandiga et al. (2010) found through their own and existing data that climate change had

altered the slimates of highland areas in East Africa and that the resulting temperature increases

had enabled malaria vector mosquitos to find new habitats, resulting in a higher frequency and

severity of malaria epidemics. Most of the populations living in the highlands of East Africa

have historically low immunity to malaria, and so the new exposure brought by a change in their

environment has been particularly devastating and disproportionate when compared to other

areas in the basin whose climates have not changed dramatically or who already have some level

of immunity. Poverty in the highland areas coupled with distance to nearest medical facilities

have complicated efforts to respond.

History of Response Efforts

Early malaria control strategies focused on eradication beginning in the late 19th century

and the effects of using mosquito nets and draining marshes was noticeable, but the ability to

scale efforts at the global scale needed were hindered by financial and logistical constraints.

Experts in the first half of the 20th century were divided into two camps in terms of best strategy:

one camp preferred large-scale vector control and drug distribution while the other camp

preferred slower, localized approaches and case management. "While the first group achieved

spectacular successes, such as the interruption of malaria and yellow fever transmission during

the construction of the Panama Canal and the elimination of the introduced highly efficient

African vector Anopheles gambiae in Brazil, sustainability seemed to require the solid public

health foundations envisaged by the second approach" (Najera, 2011). While efforts to use

chemical sprays indoors had been tried, the invention of DDT opened a new door to sustainable


eradication – other sprays required weekly applications and vectors returned when the spraying

stopped. Single sprays of DDT had longer lasting effects and malaria did not return when the

spraying stopped (Livadas, 1952). Encouraged by the early success of DDT, the World Health

Organization (WHO) adopted the Global Malaria Eradication Program (GMEP) in 1955 to

coordinate resources among 28 participating countries, and the themes running through its

controversial beginning still exist in the modern debate.

Advocates of the eradication approach highlighted the emergence of mosquito resistance

to DDT that, in their view, necessitated the launch of the GMEP before the world lost its

most promising weapon. They also argued that eradication was, in the long term,

financially more attractive than control. Conversely, critics of the campaign doubted the

feasibility of eradication in vast areas that had poor communications and adverse

environments and that lacked public health systems. They also emphasized the poor

understanding of the implications of undertaking a malaria eradication campaign, both in

terms of its cost and of the risk to the population posed by lost immunity if protection had

to be interrupted (Najera, 2011).

During the program's existence, malaria was successfully eradicated from Europe, North

America, the Caribbean and parts of Asia and South-Central America through indoor spraying

applications of DDT – of the 143 endemic countries were freed of malaria by 1978. Africa was

largely unaffected and is now home to 80-90% of all current malaria cases and deaths (Tanner &

Savigny, 2008). The eradication ethos perpetuated through GMEP came at a cost however: the

demonization of control methods resulting in the abandonment of all malaria intervention

methods other than indoor spraying. Throughout the 1960s, a number of problems and

limitations with indoor residual spraying and the eradication approach in general became

apparent, namely a resurgence of malaria in some places and the realization that there was no

way of knowing if the last vector had been eliminated. And, while GMEP was one of the first

global health programs of its kind and created some powerful global, regional and national

networks that previously did not exist, its implementation often came without regard for cultural


and social differences, resulting in a refusal to participate in some localities (Najera, 2011). By

the end of the 1960s, an interest in control measures returned as it became apparent that

eradication would not succeed in some places and that the global battle against malaria required

long-term vision rather than a short-term program.

The renewed focus on control efforts was hindered by a number of forces in the 1970s

and 80s, including economic crises, oil shortages and rising energy costs, lack of institutional

support and natural disasters, all which contributed to more direct causes of resurgent malaria

outbreaks such as poverty and deforestation through exploitation of natural resources. Programs

since have been fragmented and reactionary, focused on a combination of preventive control

tactics as outlined in this table, which shows the full range of efforts thus far:

Response Type Benefit Limitations

Insecticide-Treated

Bed Nets (ITNs)

and Long-Lasting

Insecticide-Treated

Nets (LLINs)

Preventive/

Control

Prevents infection while

people sleep; encourages

healthy levels of rest

Historically difficult to

maintain because of short

effective lifespan; only

recent technology removes

maintenance burden from

impoverished end-user;

historically expensive, not

enough for entire vulnerable

population

Indoor Residual

Spraying (IRS)

Preventive/

Eradication

Effectively controls

mosquito vector

Controversial because of

chemicals used (DDT);

difficult to know when

100% eradication is

achieved

Environmental

Management

(draining marshes,

reforestation, etc.)

Preventive/

Eradication

Best vector control;

Responds to growing

resistance to insecticides &

anti-malarials

Takes time; political, social,

economic, cultural barriers

Vaccine Preventive/

Control

Creates

immunity/eliminates risk in

vulnerable populations

Research still needed;

widespread availability

unlikely until 2016 or later

Local Awareness

Campaigns

Preventive

& Curative/

Control

Understanding of risk and

nature results in appropriate

response and willing

Traditional and cultural

dynamics hinder acceptance

of scientific knowledge;


investment

Case Management Curative/

Control

Prompt chemoprophylaxis

proven effective response

Lack of access to treatment;

drugs unaffordable

All of the preventive control and eradication methods are "predominantly supply-side" which

means that program managers and government officials are largely making the decisions about

on-the-ground implementation rather than the vulnerable populations they are trying to protect.

An exception can be made for the environmental management tactic where the behavior and

practices of inhabitants affect their own level of exposure to malaria, for better or for worse.

This exception highlights the tactic's importance as proper management requires support,

education and participation of local stakeholders.

Roll Back Malaria Partnership (RBM)

The Roll Back Malaria Partnership (RBM) was founded in 1998 as a joint effort between

the World Health Organization (WHO), World Bank, United Nations Children Fund (UNICEF),

and the United Nations Development Plan (UNDP) to create a coordinated global network to

combat malaria and has since grown to include over 500 partners working at all levels and in all

disciplines. Partners include endemic countries and their multi- and bi-lateral development

partners, international and local NGOs, research institutions, private corporations and businesses

and private foundations. Its focus is predominantly in sub-Saharan Africa.

As described earlier in the history and background of malaria and response efforts, the

period following the end of the GMEP was a dark and difficult time for endemic countries, with

many resurgences of the disease and a host of inter-related events, forces and dynamics which

exacerbated the vulnerability in endemic countries. The lessons learned from the GMEP and

subsequent years informed the need for and formation of a more comprehensive (preventive,


curative, control and eradication), collaborative (engaging stakeholders from the community

level to the international level), and committed (indefinite, evolving, self-reflective and long-

term) effort. RBM attempts to meet its goal through a three tiered strategy: “1) control malaria

to reduce the current burden and sustain control as long as necessary, 2) eliminate malaria over

time country by country and 3) research new tools and approaches to support global control and

elimination efforts,” (GMAP)

It’s vision is to reach “universal coverage” of vulnerable populations and create “a world

free from the burden of malaria” with more specific targets aligned with Millennium

Development Goal 6 and others determined through consensus of the partner network.

Specifically, its targets as outlined in the Global Malaria Action Plan, devised to provide a

framework around which all partners can operate in a coordinated fashion, are:

By 2010:

80% of people at risk from malaria are using locally appropriate1 vector control

methods suchas long-lasting insecticidal nets (LLINs), indoor residual spraying (IRS)

and, in some settings, other environmental and biological measures;

80% of malaria patients are diagnosed and treated with effective anti-malarial

treatments;

in areas of high transmission, 100% of pregnant women receive intermittent

preventive treatment (IPTp); and

the global malaria burden is reduced by 50% from 2000 levels: to less than 175-250

million cases and 500,000 deaths annually from malaria.

By 2015:

universal coverage continues with effective interventions;

global and national mortality is near zero for all preventable deaths;

global incidence is reduced by 75% from 2000 levels: to less than 85-125 million

cases per year;

the malaria-related Millennium Development Goal is achieved: halting and beginning

to reverse the incidence of malaria by 2015; and

at least 8-10 countries currently in the elimination stage will have achieved zero

incidence of locally transmitted infection.

Beyond 2015:

global and national mortality stays near zero for all preventable deaths;


universal coverage (which translates to ~80% utilization) is maintained for all

populations at risk until local field research suggests that coverage can gradually be

targeted to high risk areas and seasons only, without risk of a generalized resurgence;

and countries currently in the pre-elimination stage will achieve elimination. (GMAP)

Structure

(image source: rbm.who.int)

RBM Board & Executive Committee

The RBM board consists of 20 voting members including representatives of all seven

constituencies (malaria endemic countries, multilateral development partners, private sector,

OECD donor countries, foundations, NGOs and academia) and two ex-officio members. As with

any organization’s board, its role is to determine the strategic direction of the partnership,


approve it budgets and workplans, advocate, ensure adequate resources, monitor ongoing

progress, and resolve organizational or partnership issues as they arise. The executive committee

sets the Board agenda and oversees the Secretariat.

RBM Secretariat

The Secretariat carries out the day-to-day operations of RBM in terms of administration and

operations in pursuit of the Partnership's goals and objectives. Similar to the role of “executive

staff” in a nonprofit or NGO, the Secretariat ensures the Partnership is functioning and working

toward its goals and carries out advocacy efforts by overseeing the implementation of the plans

and programs by the Sub-Regional Networks and the Working Groups.

Sub-Regional Networks (SRN)

Because Africa is such a large continent which also accounts for 80-90% of the world’s

vulnerable population, sub-regional networks were created to provide support to and coordinate

the efforts of local partners. Sub-Regional Networks exist in Central (9 countries), East (13

countries), Southern (10 countries) and West Africa (16 countries). Members are primarily in-

country and regional Partners who meet quarterly to coordinate the individual country plans and

are accountable to the Secretariat. The Partners are the “boots on the ground” of the network,

carrying out their respective portions of the regional or local plan in their separate entities.

Working Groups


Working groups are also comprised of Partners but are organized and promote Partner alignment

around topic areas rather than geography. The topic areas are: communication, vector control,

monitoring and evaluation, malaria case management, malaria in pregnancy, and financing and

resources. The role of the working group is to “harmonize Partner efforts at the global and

country level” and “generate alignment on complex strategic issues.” The particular structures

and purpose of each of these working groups is outlined on the RBM website.

The Forum

The last major structure is the Forum, which is considered the complete assembly of all

constituencies of RBM partners which occurs every two years to adopt long-term vision and

goals and have high-level discussions and debate about progress.

This diagram illustrates the value chain created by the Partnership and the roles of each

of the entities in the process:

(So

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e: B

ost

on

Co

nsu

ltin

g G

rou

p)


Policy and Program Analysis

The RBM partnership has hired independent evaluators on three occasions (2002, 2009, 2013) to

provide comprehensive evaluations of the program’s progress and provide recommendations for

the future. These formal evaluations have focused on four major objectives of the Partnership:

1. Progress Towards GMAP Milestones

2. Assess Strengths and Weaknesses of RBM Structures

3. Response to Previous Evaluations

4. Positioning RBM through to GMAP II and post MDG-2015

The most recent evaluation, interestingly enough, did not focus on the statistical goals stated

in the GMAP, only mentioning that the response thus far has been “remarkable” and that “global

malaria morality is estimated to have declined by 25% since RBM’s founding and one million

lives have been saved” (2013 External Evaluation, p. 41). Rather, these evaluations have

focused almost exclusively on the internal operations of the organization. How well does the

Partnership function? How do the different components work together? Is everyone playing

their role? How can they improve internally?

Here is an example of their analysis:

The RBM Partnership has successfully carried out its mandate to convene,

coordinate, and facilitate communication with key stakeholders. This has led to a

significant contribution to the impressive progress made towards achieving the

objectives of the GMAP. RBM’s strong advocacy has helped to place and keep

malaria on the international agenda. RBM’s support for timely and pertinent

planning, resource mobilization, and M&E technical assistance has helped

improve national malaria control program efforts. Though less successful, the

efforts to strengthen national capacity building in the areas of procurement and

supply chain management, health information and regulatory systems, and the

development of more and larger traditional and innovative funding streams have

partially contributed to strengthening the international and national malaria

response. The RBM Partnership’s platform for the exchange of ideas, strategies,

best practices, and progress reports has motivated the necessary stakeholders to

come together in the fight against malaria to look for ways to push the agenda

forward.


Other researchers and evaluators are less inclined to gloss over the “less successful” meat

of the Partnership as described above.

Freeman & Robbins (2003) refer to “disease deadbeats” in Malaria Journal, noting that,

despite universal support for the initiative and an understanding that the cost for global malaria

programs would reach into the billions per year (starting at $1.5B and progressively increasing),

funding had only reached $130 million after four years and accounting systems were so poor that

it could not be determined how much had been spent by whom and for what. The World Bank

itself had offered up to $500 million early in the pledge making phase but had yet to make good

on $490 million of it by 2002.

In 2012, the RBM itself published this table of financing gaps amounting to 25-50% from

year to year leading up to the 2015 milestone while also praising pledge countries for their

incredible efforts:

Williams et al. (2003) found that in the first five years, the role of social science in the field

of malaria were far from realized. The important theoretical frameworks brought to the malaria

discussion and response implementation by anthropology, sociology, economics, political

science, demography and communications had not been considered as integral despite each of

their abilities to “understand how human behavior is shaped and modified in the global context

by a vast array of influences…For example, the essence of a medical anthropological perspective

is an appreciation of the complexity of culture and the realization that specific aspects such as


health beliefs and behaviors cannot be understood in isolation but need to be looked at in relation

to their larger historical, economic, social, political and geographical contexts.” I have not found

in the literature or in the formal external evaluations that this has been addressed or improved

upon.

Pattanayak et al. (2006) appreciated the RBM’s synthesized approach which includes both

control and eradication measures, understanding that vaccine development (also supported by

Loucq et al. (2011) of the PATH Malaria Vaccine Initiative) will still take time and so

appropriate control measures are necessary in the interim. Their concern is that deforestation as

a problem and environmental management has been enough of a priority nor on an appropriate

scale. The emphasis has been placed on insecticide treated nets (ITNs) which, despite

advancements in technology, remain unaffordable to many and older models already distributed

require frequent retreatment which rural villagers should not be expected to carry out. Filinger et

al. (2009) note that the “current best practice” of malaria control, which emphasizes ITNs and

over-reliance on drugs increases the likelihood that resistance will develop and that larval source

management should be added to the list of tactics employed in environmental management.

“Vector control in Africa should target all stages of the mosquito life cycle, yet for the past 50

years it has focused almost exclusively on adult mosquito control. ITNs have not only saved

thousands of lives; they have also restored confidence in vector control in Africa. However,

adult-based methods are limited in what they can achieve because adult mosquitoes feed outside

hoses and before sleeping hours.”

Up until 2011, despite the fact that most malaria deaths are those of children under the age of

five, there was a dearth of medicines designed specifically for children, but the RBM partnership

with Novartis, which had successfully delivered ACTs (artemisinin combination-based therapy)


to adults has successfully begin mass distribution of medication for children. ACTs for adults

were made the exclusive form of treatment by RBM in an effort to prevent the development of

drug resistance to monotherapies. This policy has been successful.

Finally, Duthe (2008) calls for better demographic and health data collection in endemic

countries due to limited gains in much of sub-Saharan Africa and a need to properly measure the

outcomes of global malaria efforts. “Without precise medical data, death by malaria is difficult

to diagnose…In most African countries, no civil records are kept outside the major cities: most

children are not registered at birth, death registration is incomplete and reported ages at death are

not always reliable. In addition, cause-of-death from health infrastructures are of poor quality. In

rural areas, few people are seen by a doctor before they die, and no autopsy is performed after

death. In 2001, only four countries of sub-Saharan Africa produced high-quality national data on

causes of death.”

Conclusion

Great gains have been made, with over one million lives saved through the effort. New

technologies in insecticide treated nets (ITNs) and vaccines for children have made a great

difference, as has the policy to ban monotherapy treatments in favor of combined-therapy

medicines (ACTs) to thwart drug resistance. Development of a vaccination is rapidly

progressing with a goal of availability in 2015. Despite the gains, RBM continues to struggle for

adequate funding to meet its ambitious goals. Experts in the literature make a number of

recommendations for improvements to the program: re-evaluate the undervalued role of

generalists and social scientists in the network to better understand the cultural, economic,

political and medical obstacles to combatting malaria; increase the priority of environmental

management as a preventive and eradicative tactic (and explore new types of environmental


management); and invest in better medical and death data collection in endemic countries to

ensure accurate measurement of outcomes.


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