The elimination endgame for malaria

Published: 23 October 2019

Could a dedicated financing facility bridge the gap for malaria? 

In 2019, together with The Global Fund for AIDS, Tuberculosis & Malaria, the Bill & Melinda Gates Foundation and the President’s Malaria Initiative, Social Finance set out to explore this question. Together, we wanted to understand if and how a dedicated financing facility could accelerate and sustain the achievement of malaria elimination targets. In this piece, we reflect on some key learnings and the opportunity ahead.

Successful control programmes can interrupt transmission and have enabled progress in elimination (reduction to zero cases in a defined geographic area) of infectious diseases like measles, malaria and polio, saving and improving billions of lives. However, the argument for eradication (complete and permanent worldwide reduction to zero cases) is not simply a moral one.

These diseases take a huge financial toll too, in the cost to health systems and the days of school and work that are lost to sickness — a burden that is disproportionately borne by low and middle-income countries. Eradicating a disease helps improve lives and in turn, grow these economies. However, complete disease eradication is no mean feat, with only one human pathogen so far globally eradicated (smallpox).

When it comes to malaria, globally, countries are closer to elimination than ever before. Despite this progress, a number of countries are struggling to reach their elimination targets and funding is, as always, a key factor. Historically, as malaria prevalence has receded, so too has donor funding available to the eliminating country.

Fewer malaria cases means an increase in cost per case and a reduced incentive to invest in malaria specific programmes as the burden of disease (and therefore perceived risk of malaria) becomes much lower. This means that any progress made becomes fragile and elimination goals remain ever elusive. As Bill Gates put it in his recent letter to England’s Chief Medical Officer Dame Sally Davies, Fighting a disease, after all, is sort of like fighting a fire: If you only put out some of it, the rest will come roaring back’.

So, what have we learnt about elimination funding, and how could a dedicated financing facility help bridge the gap for malaria?

Firstly, a coordinated multi-donor strategy is necessary to focus available resources and prioritise countries for disease elimination.

The malaria burden falls heavily on low- and middle-income countries, keeping communities in a cycle of poverty and meaning already strained domestic resources are rarely sufficient to reach elimination. Current donor funding is not only insufficient for elimination but the way it is deployed also needs to change. A dedicated facility for elimination would have the benefit of reducing fragmentation of donor funding and increasing knowhow — gathering intelligence and learning about what works for elimination.

However, finding agreement between big donors on strategic focus (e.g. set of priority countries) for elimination funding is key. This prioritisation needs to balance feasibility (some countries are much closer or have stronger political support than others) and value (some countries are more at risk of rapid resurgence) to see maximum impact from any elimination financing facility.

Choosing to go after elimination where it is a feasible goal will be the most cost-effective way in the long-term to fight a disease such as malaria. Like a number of infectious diseases, malaria is a constantly moving target, with growing resistance to the treatments and insecticides currently used. So, over time, if we don’t make elimination gains by shrinking the malaria map, we’ll need new tools to fight the disease and in turn, more money to fund elimination.

Secondly, a pooled funding mechanism that can operate across borders will be particularly important for elimination of transmissible diseases like malaria

Malaria knows no borders — so incentivising both domestic and cross-border coordination is vital for reaching zero cases. In many cases, it is cross-border transmission that hampers elimination progress. Border regions often have a higher malaria prevalence than other areas due to limited access to health services, difficulties in deploying prevention programmes to hard-to-reach communities, often in difficult terrain, and cross-border movement of people.

Effective elimination responses therefore need cross-border collaboration and political commitment to address these issues. Pooled outcomes funding for regional malaria elimination objectives could incentivise and de-risk cross-border funding from neighbouring countries (for example, if South Africa were to contribute outcome-funding, payable only on the achievement of malaria elimination in border areas of Mozambique). By contrast, grant assistance traditionally tends to be allocated to country programmes. So, we need flexible mechanisms that can target funding in a way that is not restricted by national borders, in fact it incentivises cross-border collaboration.

Finally, outcomes-based approaches can provide the operational flexibility required to get from low incidence to elimination.

Elimination requires an adaptive approach, responding to changing on-the-ground needs in order to quickly and effectively manage active malaria hotspots and localised resurgence. This requirement for flexibility lends itself well to an outcomes-based approach that pays for the achievement of agreed elimination outcomes (or interim outcomes such as sub-national elimination). In this model, funding is flexible and can be deployed quickly to respond to needs rather than being tied to pre-defined inputs. An outcomes focus also elevates the importance of putting data-collection and analysis at the heart of programme delivery.

Elimination challenges can be quite distinct and vary from country to country. Ringfenced funding is one thing, but malaria elimination programmes need to be context specific, and it remains to be seen whether programmatic responses can be standardised across a coordinating facility’. One funding approach may not meet the varying financing challenges in elimination countries, so we need to be smarter in how we put together these funding facilities with a range of financing options. Finding the country archetypes’ with common elimination challenges will help match the most impactful financing instruments to each scenario and maximise the learning opportunity of a coordinated elimination facility.

We were delighted to see that the Global Fund secured its $14 billion funding target at its replenishment conference earlier this month. However, more funding alone won’t solve the problem; the way in which funding is delivered will be key to ensuring that elimination programmes are held accountable for results. We look forward to seeing how the Global Fund progresses plans for this exciting elimination financing facility — and to further innovation in funding mechanisms that can help grow the list of eradicated infectious diseases.

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