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Written Testimony
House Committee on Foreign Affairs
Subcommittee on Africa and Global Health
Testimony of Nils Daulaire, MD, MPH
President & CEO, Global Health Council
April 25, 2007

Dr. Daulaire

Chairman Payne, Representative Smith and distinguished members of the Subcommittee, thank you for inviting me to testify before you today on "Africa Malaria Day: Leveraging Progress, Highlighting Opportunities." My name is Dr. Nils Daulaire. I am the President and CEO of the Global Health Council, the world's largest membership alliance of health professionals and service organizations dedicated to saving lives and improving the health of the world's poorest two billion citizens.

The Global Health Council convenes and facilitates constructive dialogue among U.S. and international global health stakeholders on topics ranging from HIV/AIDS to child health to neglected tropical diseases. Working in partnership with our diverse members, the Council also advocates for sound policies and effective programs that will lead to better and more equitable health around the world. I speak before you representing not only the Council and our membership, but as an active partner within the broader community committed to the global effort to reduce malaria's burden.

Before I begin, Chairman Payne, let me thank you for your long-standing commitment to Africa and global health. You have a notable history of supporting global health priorities and keeping the needs of developing countries as a part of our national dialogue, and your commitment to social justice is deservedly famous among those on the front lines delivering essential health care services to the world's poor. Representative Smith, your efforts to address the modern tragedy of obstetric fistula have improved the quality of life of hundreds of thousands of women and your decades of work on behalf of children's health is much appreciated. This Committee's bipartisan collaboration reinforces the global health community's conviction that saving lives knows no party lines. On behalf of the Council's 350 member organizations working in over 100 countries across the globe and the millions whose lives are improved by U.S. Government investments, we thank you.

Today - April 25 - is Africa Malaria Day. It is also the United States' first observation of Malaria Awareness Day, as declared by President and Mrs. Bush at the White House Summit on Malaria in December 2006. This May, the 192 member states of the World Health Organization will convene in Geneva and vote on a resolution to establish Malaria Day, an international observation that acknowledges malaria as a continuing global challenge, not just one restricted to Africa. These observances, atop countless global declarations and commitments in recent years, confirm that malaria stands at center stage as both a global health threat and a global health opportunity.

But I do not need to remind you that this is not just about a single day. Tomorrow, another three thousand children will die from malaria, and again the day after that, and the day after that. For the parasite that causes this deadly disease, every day is malaria day.

Progress

As a public health physician who has worked for more than 30 years to improve health care in the developing world, I take great joy in the resurgent attention, resources and progress in fighting malaria over this past decade. After too many years of sterile debate, there is growing consensus about what works for prevention, diagnosis and treatment of malaria. Resources to fight malaria, from governments such as the United States and from major foundations such as the Bill and Melinda Gates Foundation, have grown considerably. Public-private partnerships have emerged, and now corporations and multilateral institutions are working together to develop new technologies and improve prevention tools and treatments. Afflicted countries are addressing social, political and economic barriers to essential commodities and interventions. The world has recognized the toll that malaria takes on people in poor countries and is poised to respond.

A New Malaria Environment

I will remind you that this is not the first time that the world has attempted to conquer malaria. In 1955, the World Health Assembly adopted the goal of malaria eradication - something that seemed quite possible because it had been achieved in the United States just four years earlier. However, controversies over technical interventions, over-emphasis on a single-minded approach that aimed to spray our way to success, and a lack of sustained investments left much of the developing world without the strategies, resources and supplies truly needed to protect people. Efforts slipped, and malaria came roaring back, often in deadlier, more resistant forms. As a result, tens of millions - mostly young children and pregnant women in Africa - perished needlessly.

Fast forward through 20 years of relative political indifference and inadequate resources, and we come to the current period in which the malaria environment has evolved in ways previously unimagined. Allow me to highlight just a few of those dramatic changes.

1. Knowledge Base: With more than 23 malaria vaccine candidates in the technology pipeline, a new single-dose combination therapy treatment recently announced, renewed evidence of the positive impact of indoor residual spraying and the development of longer-lasting insecticide-impregnated bed net technology, the arsenal of malaria prevention and treatment options is growing stronger by the day.

2. Funding: In fiscal year (FY) 1998, U.S. Government bilateral spending on malaria was only $39 million, mostly through the US Agency for International Development (USAID) and the Centers for Disease Control and Prevention (CDC). Additional resources were dedicated at the agency level, mostly to research, at the National Institutes for Health and the Department of Defense. However, in 2002, the U.S. made its first contribution of $300 million to the Global Fund to Fight AIDS, Tuberculosis, and Malaria - the innovative multilateral financing mechanism to support interventions targeting the three highest-profile global infectious diseases. Since then, U.S. global malaria spending has steadily risen, culminating with the 2005 announcement of the President's Malaria Initiative (PMI), a five-year, $1.2 billion commitment targeting 85% coverage and a two-thirds mortality reduction in 15 African countries. In just 10 years, U.S. Government spending on bilateral malaria programs alone has grown nearly ten-fold. For this, our community applauds the United States' generosity and global leadership.

3. Programs & Results: Since 2003, three major malaria programs have emerged providing more than $1 billion for malaria programming in the hardest hit countries. The Global Fund to Fight AIDS, TB and Malaria is the single largest source of global malaria funding, providing two-thirds of all international financing. The Fund has approved $2.6 billion in grants for 117 malaria programs over five years in 85 countries and $833 million has been disbursed so far. The World Bank Malaria Booster Program will commit approximately $500 million in IDA allocations over three years to support countries ready to improve and expand their malaria control efforts. The President's Malaria Initiative (PMI) has disbursed $165 million for malaria control programs in seven of the 15 priority countries and, as you have just heard from Admiral Ziemer, program rollout has been swift and effective, with positive program results for initial targets.

Investments are on track to save lives. Global Fund malaria grants have distributed 18 million insecticide-treated bed nets to protect families from malaria and reached 5.3 million patients with artemisinin-based combination therapies (ACTs). In just 18 months of operation, the PMI has purchased over 1 million ACT treatments, protected over 3 million people through spraying campaigns and distributed over 1 million bed nets. These programs are being integrated with other health programs on the ground, strengthening health systems and reaching those in need.

Simple versus Comprehensive Approaches

Malaria is a complex organism that goes through many shape-shifting forms in its complex life cycle as it travels from human to mosquito and back to human. Simple approaches aimed at just one aspect of this life cycle have routinely failed, as the DDT spraying of the 50s and 60s showed. This is why a comprehensive approach has finally become the standard that experts and implementers have agreed upon. This approach addresses both the mosquito vector, through environmental control, indoor residual spraying, insecticide-impregnated bed-nets and even new biotechnology-based efforts, as well as the human stages of the malaria life-cycle, through early case detection and treatment with effective drugs, intermittent prophylactic treatment of pregnant women, and efforts aimed at vaccines that will block malaria at various stages of its life-cycle within the human body. We have finally come to face facts, and no longer do we take seriously any approaches that say we can stop malaria with just one intervention.

Partnership

A comprehensive approach requires addressing malaria from many angles, and much of the progress of the last decade can be credited to a specific strategy - Partnership. This includes every combination of collaboration between donor governments, developing country governments, private industry, local communities, non-governmental organizations, philanthropic organizations, and individuals. Partnerships have crossed sectors and disciplines focusing on every aspect of malaria from research and product development to program implementation and evaluation. Partnerships between international non-governmental organizations and developing country governments and between local civil society organizations and multinational corporations, and the traditional partnerships between national governments are all proving indispensable to the global effort to stop malaria. Collaborations are capitalizing on partners' respective advantages and accelerating progress at a remarkable pace.

Because the other speakers will be elaborating on other kinds of partnerships, I will focus briefly on the collective action taken by malaria advocates - both globally and domestically - and their essential role in sustainable progress in this field. A decade ago, it would have been difficult to identify more than a handful of full-time malaria advocates and their efforts certainly were not coordinated in any formal manner. Stakeholders recognized that progress against a growing burden was stunted without a single, strong voice for malaria. Globally, partners including the World Health Organization, UNICEF, the World Bank and the UN Foundation launched the Roll Back Malaria (RBM) Partnership in 1998. Since that time, the Partnership has served as a hub for global advocates, disseminating otherwise isolated intelligence and coordinating partner activities. The Global Health Council is honored to have been invited to serve as the co-chair of the newly created advocacy working group of the Partnership, ensuring that advocates are aware of the broader political climate while providing a forum where local realities can guide global policy discussions.

National malaria advocacy networks have emerged in France, Belgium, the UK, Cameroon, Mozambique, Ghana, Mali, Kenya and Ethiopia. In the United States, the Global Health Council convenes the Malaria Roundtable, a space for US-based malaria advocates to gather and exchange information and opportunities to advance the malaria agenda. Through the Roundtable, advocates have developed a common platform and promoted full funding for U.S. malaria investments as well as called for transparency, accountability and results from the programs they support. Advocates also coordinate with the broader global health and development community, recognizing that in many ways, we share the same overarching agenda.

Mr. Chairman, I bring your attention to the 2007 malaria community statement that I ask be submitted for the record. The statement is just one of the tangible demonstrations of partnerships among diverse organizations in this area of global health The statement is signed by 45 organizations declaring a commitment to sustainable progress against malaria. To put the growth of the community in perspective, I point out that the 2005 community statement included only nine signatures representing groups that were most active at that time.

The Roll Back Malaria Partnership and national and local advocacy networks allow those with real programmatic and technical expertise in malaria control to establish a presence in policy circles and among the increasingly aware public. This sense of community demonstrates that we value progress over protected agendas; increased capacity over individual credit; and saving lives over stagnant debates. Today's partnerships demonstrate that our commitment to reducing the global burden of malaria is stronger than any single segment of the agenda.

Current Priorities

Mr. Chairman, on behalf of the Global Health Council and the broad U.S. community of organizations working against malaria, I invite you to consider our future agenda and Congress' role in working in partnership with the community to sustain the progress that has begun The current agenda of U.S. malaria partners includes the following:

• Funding: U.S. malaria partners support robust U.S. investments in global malaria efforts. This is defined as a foreign operations appropriation of $440 million in fiscal year (FY) 2008, including full-funding for the President's Malaria Initiative as well as a $1.3 billion contribution to the Global Fund to Fight AIDS, TB and Malaria, of which an estimated 27%, or $351 million, would go to malaria grants. This funding should be complemented by resources administered by the Department of Health and Human Services, primarily through the Centers for Disease Control and Prevention (CDC) as well as agency-level allocations for research at the National Institutes for Health and through the Department of Defense.
• Technical Approach: U.S. malaria partners support interventions working across the spectrum of attack points that I have already outlined, and that are most appropriate for the local environment, health system and culture. It also includes complementing investments in commodities with parallel investments in technical assistance and non-technical interventions, Experts from the U.S. Agency for International Development (USAID), CDC and the World Health Organization (WHO) play critical roles in these technical activities and help create stronger health infrastructures in developing countries by sharing their knowledge. We ask that Congress continue to support technical assistance programs.
• Comprehensive Approach: Malaria partners promote the continuum of malaria programming. While we massively scale up the deployment of the tools we have today against malaria, we must also invest in new and better tools for tomorrow. The Bill and Melinda Gates Foundation has been a vital contributor to this effort, but the U.S. Government must also be fully engaged. Research and development (R&D) of easy-to-use diagnostics, better insecticides, new medicines and an effective vaccine are all critical components in a comprehensive battle against this persistent scourge. The comprehensive approach is also defined by the engagement of all sectors - public and private, social and business, health and non-health - affected by malaria.
• Sound Program Architecture: Malaria partners promote efficient and effective bilateral and multilateral programs. This includes a commitment to strong program leadership, transparent processes and accountability. In addition, service delivery practices such as supply chain management is but one example of "best practices" we cannot afford to ignore. We all recognize, and Admiral Ziemer has highlighted, that these malaria control programs must be developed and strengthened within the context of the national and local health care systems on which they will always rely, and which they should help to reinforce. We hope that Congress will partner with us in order to put our public investments to the best use.
• Results-Driven: U.S. malaria partners demand results from the programs they support. We ask for Congress' help in making sure that the results of our work together is measured in real health outcomes -- ultimately lives saved-- rather than outputs and process indicators.
• Harmonization: Keeping with the theme of partnership, malaria partners support the principle of seamless coordination, or at least complementary approaches, among the host of initiatives and funding streams present in communities and countries. Conflicting program guidance and deliverables and other bureaucratic strings attached to funding take time and attention away from the important work of program delivery. And, of course, these programs should ultimately be designed and delivered by national governments and local implementers who know best what works for them. We need Congress to help ensure that there is harmonization among U.S.-funded programs as well as play a role in setting standards for coordinated reporting of international development assistance.

These are principles and priorities frequently stated and commonly agreed upon. But, they must translate from rhetoric to reality. This requires a commitment carried beyond Africa Malaria Day, Malaria Awareness Day or any other single observance. Will the U.S. Congress provide the support necessary to ensure that, over time, the world will not again give up the fight against malaria and allow this scourge to continue to claim a million lives every year? The malaria civil society community is your eager partner in such a commitment.

ontingencies for Future Success

As we celebrate the partnership for malaria over recent years, I remind you of two important factors that will determine how long this positive trend will last.

First, we must put malaria's current favorable status in context of the broader global health and development agenda. As I mentioned, bilateral malaria funding has grown nearly ten-fold in just over a decade. By doing so, it has joined global AIDS as a U.S. and international priority: just these two diseases together account for about $5 billion of the total $6.8 billion that the U.S. currently invests in global health. We applaud these investments as necessary; however, by themselves they are not sufficient. While advocacy, planning and policy at the global level tend to be issue-specific, these threats to good health and economic and social stability do not occur in isolation. In reality, the same women who receive preventive malaria therapy during pregnancy may die during child birth because of failures to invest in other core maternal and child health programs. The same communities where children now sleep under bed nets made available through the PMI, the Global Fund and a host of country-led campaigns to guard against malaria are the same children at high risk of dying from pneumonia, diarrhea of a lack of immunizations, leading causes of child mortality that are addressed in separate programs and funded by separate streams and donors.

We must not pit global health issues against each other. To do so is shortsighted and costs lives. The challenge before those of us who understand the fundamental importance of addressing the full set of core global health issues is how best to support malaria control efforts without taking resources from other equally vital core health accounts; we cannot rob Peter to pay Paul.

Rather, we must illustrate the fact that our best intentions and investments may be undermined by overly narrow vertical approaches, rather approaches that are comprehensive and complementary. Our aim must be to use these efforts to help build and maintain robust national health systems capable of delivering a range of essential programs, and lasting well beyond the attention span of international donors. After years of contradictory and isolated approaches to malaria treatment and prevention, advocates and implementers have learned that success will not be sustained if individuals have only one aspect of their health addressed adequately while neglecting others. Beyond the scope of this hearing, I encourage the Subcommittee to explore ways to address this issue through a comprehensive, sustainable strategy. And I would note again that the efforts led by Admiral Ziemer under the Presidential Malaria Initiative have been laudable in their attention to these important linkages.

The second consideration that I submit to the Committee - and the malaria community - is that we not simply bask in this moment of political will and resource growth, without considering the future beyond the next Global Fund grant round or beyond the PMI's initial five years of support. As equally responsible partners, we must ask: What will the U.S. Government's malaria program look like post-PMI, or in its next generation? Now that we have increased global resources, what other challenges need to be addressed? Are these initial results sustainable? Are all the people in need able to access proven interventions?

What we cannot afford is to repeat history and give up on malaria before the job is completed. We saw the effect of this kind of short-sighted response when we withdrew global investments in malaria control in the 1970s. Instead, if the U.S. Government sees fit to commit to stopping malaria worldwide, in full partnership with other developed country leaders, affected communities and the advocacy community, all partners will be able to elevate strategies for sustainability.

CONCLUSION

On Africa Malaria Day 2007 and the first US Malaria Awareness Day, much remains to be done and complacency on any part of the malaria agenda threatens progress to date. However, we should be encouraged by the opportunity before us. On this day, I have just come from the White House where President and Mrs. Bush have reiterated their commitment; you have convened this important congressional hearing to review the opportunities for sustainable progress; there are 45 (mostly) U.S. organizations mobilized around a single statement of support; public awareness is growing, and as we will see this evening, even American Idol is on board; political will is strong; and we are moving toward results. We are achieving all of this in the only way possible - through partnership, leadership and with a collective eye on the future.

Mr. Chairman, I thank you again for your leadership on Africa where the brunt of the malaria burden is experienced, and on addressing the host of global health issues that stunt the development of people and nations around the world. The Global Health Council and the malaria community look forward to working with you to continue, accelerate and sustain progress against malaria and save millions of lives.

Thank you