Patrick Adams writes…

A number of countries have made great strides in terms of malaria control, resulting in reductions of over 50% in the number of malaria cases in more than a third of affected countries.

According to the World Malaria Report 2009, the progress was made possible by major increases in donor country contributions to the Global Fund, leading WHO Director General Dr Margaret Chan to declare that “development aid for health is working”.

The report notes, however, that funds for malaria “are disproportionately concentrated on smaller countries with lower diseases burdens”. The report recommends that, in order to maintain the gains made to date, “more attention be given to ensuring success in large countries that account for most malaria cases and deaths”.

Yet more worrying, some experts say, is the possibility that donor contributions may have peaked. Last February, it was announced that the Global Fund faces a $5 billion shortfall through 2010. In order to address the gap, the fund would impose a series of “efficiency cuts”, “uncertainty cuts” and “delays”. Reporting on the Global Fund’s 20th board meeting in Addis Ababa last month, policy analyst David Wendt speculated that these measures could put at risk more than US$ 1 billion of the US$ 2.64 billion of approved Round 9 budgets.

“The prospects for increasing donor contributions to the Global Fund are small,” says Dr Matthew Lynch, director of the Global Program on Malaria at the Johns Hopkins Bloomberg School of Public Health. “Given the delays associated with Rounds 9 and 10, even maintaining the current GFATM funding levels is going to be a stretch.” And though the funding level for Round 10 has yet to be determined, he says, “it’s not likely to be huge”.

Lynch adds that while the US government “is doing a lot,” and the President’s Malaria Initiative (PMI) is “fully-funded and doing a very good job,” these bilateral contributions represent just a fraction of Global Fund amounts. The global recession may be partly to blame, he says. But even so, the basic donor-recipient paradigm has to change.

“I do still believe ‘cautious optimism’ is appropriate,” says Lynch, referring to WHO Director General Dr Margaret Chan’s reaction to the global report findings. “Mortality levels are declining. There are two more years to run on Round 8 funds. And I think we will demonstrate some substantial returns-on-investment. But countries are going to have to recognize those returns-on-investment and start shouldering more of the financial load.”

Richard Tren, director of Africa Fighting Malaria, has been among the more vocal advocates calling for more domestic funding for malaria. He has said that external funding alone will not be sufficient, and, along with many others, he’s questioned the distribution of limited aid dollars on wealthy countries like China and India.

China is the third-richest nation overall, India the fifth. In the Global Fund’s 9th round of funding since 2002, China’s total funding request for a malaria “National Strategy Application” (NSA) was roughly $ 176.5 million. (An NSA is a funding channel that allows countries to request support for strong existing national HIV/AIDS, TB and/or malaria strategies). Meanwhile, India requested more than US$ 113 million for malaria.

But are these countries indeed “rich”? In per person terms, China is poorer than 132 countries; India is poorer than 166. Both have space programmes, but both also have extreme poverty.

Regardless, says Lynch, it’s clear that relying on donors will be increasingly risky for endemic country governments. It’s also likely, he says, that even households will need to make contributions as well. “Malaria elimination is a long-term goal, which means a long haul for maintaining high net coverage. The era of the free nets campaign may be rapidly drawing to a close.”