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Submitted by Doctor Michel ODIKA on
Today, the foundations exist for malaria-affected countries to mount a response commensurate with the challenge of reversing - the disease the most concrete proof that malaria is a problem with a solution… Unfortunately, malaria still illustrates some enormous and often frightening divides: - between the number of people exposed and the number being protected; - between what we could be doing to curb the expansion of the disease and what is actually being done. BREAKING NEW GROUND First of all, it bears reminding that the crucial question is not how many dollars governments spend on addressing malaria. Rather, breaking new ground suggests that HOW, FOR WHAT and FOR WHOM money is spent matters considerably. Why? Plausible and credible answer: When money is scarce, the effects of errors, whether by omission or by commission, are disproportionately amplified. Particularly in resource-constrained settings where the envelope devoted to the malaria response is very small, every dollar that is allocated sub-optimally tends to make a significant difference in terms of mortality/morbidity reduction… MEASURING THE GAP To date, few malaria-affected countries, notably those in sub-Saharan Africa (the hardest-hit region), have produced estimates based on sound evidence of where spending is needed (1). Similarly, few have mechanisms (2,3,4) through which connecting actors from converging sectors agree on estimates and priorities and allocate resources accordingly. In addition, donor countries have their own priorities and these often fall short of complying with recipient countries' priorities. As a result, there is a significant mismatch between spending and actual needs. In recent years, some donors have increased their aid in response to the need for building capacity to tackle malaria. A question now being asked can be summarized as follows: Why does capacity building (3) seem to be lagging so far behind the increase in aid? The answer is complex. However, two crucial fact(or)s stand out. First, donors' policies often limit the scope for using their aid. To illustrate, if this aid comes in the form of money, it is frequently tied to conditions that require currency exchange and purchase of imported goods - i.e. drugs - not necessarily responsive to the real challenges - e.g. hygiene, sanitation and prevention. If it comes in another form, it predominantly consists of foreign technical assistance or foreign-managed construction of health facilities. Second, countries' needs are mostly for core budget expenditures that are mainly local - i.e. wages for nurses, physicians and other personnel - and are recurring. Clearly, there is now strong and consistent evidence that current malaria spending patterns are inefficient and ineffective. Another question now being asked is exactly this: What can be done about it? CLOSING THE GAP The money spent from all sources on providing malaria-affected countries with the full range of services remains far short of meeting people's needs and expectations. Otherwise said, a comprehensive, effective, innovative and evidence-based response to malaria critically depends on sustained growth in annual funding until the disease is reversed - the goal set out in the Millenium Declaration (New York, September 2000). In the worst-affected countries, advocacy to boost and sustain political will and commitment remains crucial. Also crucial is making far better use of funding flows that are available. That basically means streamlining the flow of financial resources to the front lines of the disease, putting it to optimal use and providing malaria-related services. Unfortunately, too many countries, most of them in sub-Saharan Africa, still experience a disconnection between where money is most needed (hygiene, sanitation and prevention) and where money is most spent (curative medicine, counterfeit drugs included). To help identify funding requirements, Malaria Observatories (2,3,4), once established, could be helpful in improving estimates, modelling and projections. Nevertheless, spending decisions in any particular country should be based on assessments of that country's unique circumstances and needs. Additionally, financial efforts should be reviewed in terms of resources and programmes, their cost-effectiveness, where more effort (sanitation and prevention) might be focused. What else? It is also crucial to recognize that an estimate has its limitations, due to limited availability of data and inherent uncertainty about the future... ULTIMATELY... Today, there is no convincing evidence that growing spending on malaria automatically results in better outcomes in terms of mortality/morbidity reduction. However, this offers perspectives for transforming and adapting the response to malaria, which is much more limited in a context of shrinking government budgets and disinvestment. Consequently, there must be action on two key fronts. First, money must be spent where it can be most efficient and effective (1). Second, malaria-affected countries must stay on course and scale up efforts to build capacity (3). Doctor Michel ODIKA (Congo-Brazzaville) 1. Malaria response: spending money where it most helps ( 2. Malaria Observatory ( 3. Malaria observatories: premium on capacity-building and building-capacity ( 4. Malaria observatory: timely public health intelligence (