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Dr. Stefano Lazzari, M.D.
Senior Health Adviser, The Global Fund to Fight AIDS, TB and Malaria
April 25, 2007
House Committee on Foreign Affairs, Subcommittee on Africa and Global Health

Chairman Payne and Ranking Member Smith, and distinguished members of the House Subcommittee on Africa and Global Health, I would like thank you for convening this hearing on the occasion of Malaria Awareness Day, and for inviting me to testify on behalf of the Global Fund to Fight AIDS, Tuberculosis and Malaria. The timing of this hearing and the topic selected, "Leveraging Progress for Sustainable Advances" is particularly relevant. I am honored to be here to present to you a brief overview of the Global Fund support of malaria control programs, particularly in sub-Saharan Africa, on the progress we have made so far, and on the challenges still ahead of us.

To fully appreciate the progress made recently in the global fight against malaria, it may be useful to consider the status of malaria control at the end of the last century. There was a history of failed malaria initiatives or successful ones for which donor funding was not sustained. Beginning with the Global Program for Malaria eradication in 1957, there was a ten-year period of strong technical leadership and sufficient funding to eliminate malaria in 24 countries and achieve spectacular reductions in others. However, as resistance to DDT and chloroquine developed, the goal of malaria eradication was abandoned and in 1969 the World Health Organization (WHO) was forced to redirect the global strategy towards the more achievable goal of malaria control. Funding was reduced, national malaria control programs declined and malaria returned. The diminished control efforts were accompanied by lack of surveillance systems and the progressive disappearance of malaria experts and country staff.

The turn of the century has brought about a fundamental change in malaria control. The launch of the Roll Back Malaria (RBM) Partnership in 1998 marked the first attempts to provide a coordinated global approach to fighting malaria but little could be achieved without substantial and sustained funding for national malaria control programs. Through the combined efforts of the malaria community, control of malaria has now finally emerged as a global public health priority and a key requirement for achieving the Millennium Development Goals, particularly the child mortality goal. Since 2000, there has been a revolution in the resources and tools available to fight malaria. These include new drugs, new long-lasting bednets, new rapid diagnostics and a recommitment to indoor residual spraying. Industry is rapidly scaling up manufacturing of malaria commodities, availability of drugs and bednets is increasing, and prices are falling. With the launch of several global initiatives, including the President's Malaria Initiative, the Global Fund, the World Bank Malaria Booster Programme and others, substantial resources have become available in support to national malaria control programmes. But as funding grows and options for interventions expand, there is an increasing realization of the importance of non-financial barriers, such as technical support, procurement capacity and program management. Financial incentives particularly around performance based funding have also provided a focus to deal with these technical issues and flexibly fund the gaps in existing programs.

The Global Fund to fight AIDS, Tuberculosis and Malaria.

Created in 2002, the Global Fund has quickly become a leading force in the fight against AIDS, TB and malaria. In its first five years, it has committed a total of US$ 7.1 billion to 136 countries around the world, making it the largest international financer of efforts to control TB and malaria and among the first three largest funders of HIV/AIDS programs. Currently, the Global Fund provides two-thirds of all international financing for the fight against the disease.

The United States is by far the Global Fund's largest single donor, although European Union member states together give more than half of the Fund's support. A total of 51 countries are donors to the Global Fund, in addition to a number of private foundations, corporations and individuals. The 2007 US appropriation of US$724 million is an increase of US $179 million or 33 percent over the U.S. contribution for 2006. With this new contribution, total U.S. financing for the Global Fund has now reached US$ 3 billion, which equals 29 percent of all paid-in contributions and firm pledges to date.

The resources available for malaria control have increased substantially with the creation of the Global Fund. To date, the Global Fund has approved a total of US$ 2.6 billion to support 117 malaria grants in 76 countries worldwide. Of this total, US$ 1.7 billion has been approved for supporting malaria control efforts in 41 African countries. A total of US$ 950 million has been disbursed to countries to date. In 2006, the Global Fund provided 64% of all international resources for malaria.

The amount of funds disbursed is largely a function of the time since grant start and grant performance. The Global Fund approach to measuring grants performance includes a rigorous evaluation of achievements against individual country targets, based on what is realistic to achieve in a specific timescale. Progress is monitored on a regular basis and reviewed at the time of Phase 2 renewal, which is usually 18 months after grant signing.

Programme Areas for Global Fund Malaria Grants

Following the principle of national ownership, the priorities, goals and targets for the grants are established by the grantees and the technical approaches are reviewed by the independent Technical Review Panel (TRP). The technical approaches proposed include indoor residual spraying (IRS), insecticide treated nets (ITNs), intermittent preventive treatment for pregnant women (IPTp), and treatment for malaria according to the national treatment guidelines. In Africa, these treatment guidelines usually recommend artemisinin combination treatments (ACTs) as first line therapy. This country-driven process encourages funding not just for commodities, but also for other country priorities, such as strengthening and sustaining delivery systems.

In light of the need to rebuild basic infrastructure and capacities, in the first three funding Rounds, non-commodity costs accounted for up to three-quarters of total funds approved. That is, for every dollar approved for commodities, an additional two to three dollars was requested and approved for other costs such as infrastructure, operations, and grant management. This is not surprising given the long-term neglect of malaria infrastructure in these countries and the needs for rapid scale-up. Currently, around 60% of the resources for malaria grants are destined to capacity building and health system strengthening.

While in the majority of malaria grants the Principal Recipients (PRs) are government institutions and in some cases UN agencies, more than twenty percent have gone to NGOs, foundations and faith-based organizations. And even where governments and UN organizations have received grants as principal recipients, the funds are frequently directed to community-based or faith-based organizations as sub-recipients, recognizing that they are better positioned to deliver community-based services and reach the hard-to-reach populations. Examples include the Churches Health Association of Zambia (CHAZ) that is acting as PR for HIV, TB and malaria grants totaling nearly US$ 41 million and other FBOs in The Gambia, Ghana, Senegal, Sierra Leone and Tanzania that are acting as sub-recipients of Global Fund malaria grants. Some grantees also support nationwide involvement of the private sector to deliver subsidized services, such as social marketing of antimalarial drugs in Cambodia and Madagascar and for ITNs in Tanzania.

Programmatic Results Against Targets

Combining all the planned country targets, during their lifetime, the current malaria grants will finance the procurement and distribution of 109 million insecticide treated bed nets and deliver 264 million arteminisin combination treatments (ACTs). Results as of December 1st 2006 include the distribution of 18 million bed nets and the delivery of 23 million effective treatments for malaria.

Overall, Global Funds grants that have completed evaluation of their first phase of 18 months of implementation across all three diseases have reached 94 percent of their programmatic targets. Though some malaria grants have shown an initial slow pace of implementation, most have rapidly caught up and even exceeded targets after the initial 18 months. One example is Ethiopia which was behind at 18 months but exceeded the targets by months 24.

The initial relatively slow rate of implementation of malaria grants is most likely the result of weaknesses in the health systems and in their capacity to deliver services after years of neglect. As the infrastructure and supply bottlenecks have resolved, a rapid catch-up has usually been observed. As a result, the total number of malaria treatments and bednets delivered has accelerated over time. Once the infrastructure has been built and start-up issues addressed, it is reasonable to assume that ACTs and LLINs will continue to be delivered at these higher rates.

The lesson is that key to further success in malaria is capacity building and health system strengthening in African countries, through improved management, logistics, planning and the full involvement of civil society, including the private sector and community-based and faith-based organizations.

Grant Approvals in Rounds 5 and 6.

Malaria grants have been approved at a relatively lower rate than HIV and TB grants in recent Rounds. For Rounds 1-4, the approval rates for malaria applications were approximately 40%, equal to or greater than the approval rates for HIV and TB applications. However, for Rounds 5 and 6, the rate of malaria grant approval has fallen to 24% and 31%, somewhat below the rate for HIV grants and substantially lower than the rate for TB grants. The most common reasons stated by the TRP for the non-approval of the Round 6 grants were weak performance on existing grants, failure to adequately respond to prior TRP comments, and unclear links to the national strategy. If lower rates of grant approval reflect relatively poor past performance, then we can anticipate that the recent accelerated performance of malaria grants and the efforts to provide the required technical assistance will be reflected in a higher rate of grant approval in future rounds.

Encouraging Signs of Early Success

Every year, 350-500 million cases of malaria occur worldwide, and over one million people die, most of them young children in sub-Saharan Africa. The Global Fund was created to finance a dramatic turn-around in the world's response to HIV, TB and malaria, providing developing countries with the resources they need to turn the tide against the three diseases. Although many grants are still at the early stages of implementation, there are some encouraging signs of the success and measurable impact on malaria.

1. Comprehensive Malaria Programme in Zanzibar

Zanzibar has received Round 1 and 4 Global Fund grants to fight malaria with a total lifetime budget of USD $9.6 million for the implementation of a comprehensive program of malaria prevention and treatment. Between 2003 and 2006, US$5 million was disbursed to the malaria program to deliver ITNs, IRS and ACTs. Zanzibar also benefits from multiple funding channels and involvement of multiple partners, including USAID, Italian Cooperation, WHO, UNDP, and UNICEF. In early 2006 the President's Malaria Initiative also joined the effort.

Scale-up included delivering 300,000 LLINs to women and children, extensive coverage with IRS, improved diagnostic services and funding of NGOs for improved community-based services. As a result, Zanzibar has seen the number of malaria cases and deaths decline by over 80%. There were over 400,000 malaria cases reported in 2004 in Zanzibar; by 2006 it was under 60,000. As a consequence, in 2006, Zanzibar had an excess of ACTs and it is anticipated that future demand (and costs) for ACTs will remain lower.

2. Indoor Residual Spraying (IRS) in Southern Africa

The Lubombo Spatial Development Initiative is an ongoing collaborative project of the governments of Mozambique, South Africa and Swaziland. The communities in this high malaria risk area include some of the poorest in the region, with high unemployment levels. The region has a population of approximately four million and has historically been a zone of endemic malaria, particularly on the Mozambique side, which had over 400,000 cases per year. The bordering areas in South Africa and Swaziland are the places in these two countries at highest risk for malaria.

Global Fund malaria grants proposals totaling US$42.7 million were approved in Rounds 2 and 5. The main activities include IRS with DDT, strengthening surveillance and health system capacities, and providing prompt and effective malaria treatment. More than 90% of households in target zones in Mozambique were protected by IRS with DDT. Beneficiaries included 3.8 million people in South Africa and 140,000 in Swaziland, and more than 90% of households in target zones in Mozambique were protected by IRS.

Recently published data from the intervention areas show a significant reduction in parasite prevalence, measured by cross-sectional hematological surveys, after the implementation of IRS in southern Mozambique. Substantial reductions in notified malaria cases were reported in South Africa (from 41,000 cases in 2000 to less than 2,000 cases in 2005) and in Swaziland (from 4,000 cases in 2000 to 200 cases in 2005). Due to the success in reducing malaria transmission in the target area, the demand for anti-malarial drugs was significantly lower than anticipated, resulting in 100% coverage of health facilities with ACT drugs against an initial target of 50%.

3. Nationwide ITN delivery in Eritrea

Eritrea has conducted nationwide distribution of ITNs, supported by $2.6 million in Round 2 funding. So far, household coverage with at least one ITN has reached 60% with 50% of households having at least two ITNs. Since program start in 2003, there has been a substantial decline in malaria cases and deaths among both children and adults. This program has been approved for an additional $5.3 million for Phase 2.

Addressing Constraints in Malaria Control

In spite of these early successes, constraints to malaria programmes implementation still exist in many countries. They are being addressed by a combination of in-country actions and improved coordination at international level.

• In-country Synergies: Wherever possible, synergies and integration with existing disease control or health care services are being explored. For example, delivery of malaria commodities can be integrated into existing national delivery systems. Using ante-natal clinics to deliver intermittent presumptive therapy (IPT) has taken advantage of the existing high attendance at ante-natal clinics and has not required building new infrastructure. Another example is delivery of ITNs through established community-based programs, such as immunization campaigns. The Global Fund has supported this approach in Niger, Angola, Kenya, Rwanda and Liberia where nationwide campaigns have delivered over 8 million nets through 2006. However, delivery of ACTs is less suited to benefit from such integration. It requires a well functioning national system of clinical health care, supply chain management, regulatory systems, second-line care, and drug-resistance monitoring. These systems can only be developed over time and with substantial investment.

• Working with other Technical and Financial Partners: The Global Fund is a financing mechanism which relies heavily on shared responsibility with recipients and technical partners, as well as industry, NGO and faith-based organizations. The malaria community, under the leadership of the Roll Back Malaria Partnership, is now better organized to respond to requests for technical assistance and capacity building. The partnership has revitalized its working group structure and is coordinating support to countries. A specific effort is being made through the RBM Partnership Harmonization Working Group and other initiatives to support struggling existing grantees and for the preparation of Round 7 applications.

  The launch of the United States President's Malaria Initiative in 2005 and investments by several other donor countries further strengthened the global partnership with a promise to significantly increase funding available for malaria control programmes worldwide. The Global Fund welcomes these new investments. Strong collaborative ties have been established and support to countries that are recipient of both GF and PMI grants is being coordinated. Yet, we are still far from filling the estimated annual need of US$ 3 billion to effectively drive back malaria globally.

• Voluntary Pooled Procurement: The Global Fund Secretariat, at the request of the Board, is now exploring options for providing common procurement services to countries. This approach would offer countries an alternative procurement pathway while country systems are being developed. Depending on the level of pooling of orders, such a system might reduce supply bottlenecks through better forecasting, lower prices through volume purchasing and lower transaction costs by centralizing some elements of the supply chain.

• Addressing health system delivery bottlenecks: While funding was the largest and most obvious barrier to malaria program scale-up, the availability of funds has now uncovered other rate-limiting steps. Weak health systems, particularly the lack of human resources, poor health infrastructure and weak procurement and supply management systems, are strong impediments to the successful delivery of health services.

  The Global Fund recognizes the importance of improving public and private health systems for the successful implementation of its grants and for future sustainability of disease control activities. Over half the support provided by the Global Fund to grantees is already going towards strengthening, directly or indirectly, national health systems. The Global Fund Board is currently discussing a background paper and decision point that will set the framework for future investments by the Global Fund in health system strengthening. A coordinated effort by multiple partners is paramount, as improving health systems requires a major investment on the long-term that cannot be met by a single donor. Several international funding institutions, including the WHO, the World Bank and GAVI, are also reviewing their policies and strategies for health systems strengthening, and are ready to join forces with the GF to tackle this new challenge.

Conclusion

Over the last five years, malaria has been transformed from a largely neglected disease to one which has well-funded national programs showing initial successes and a framework for an effective partnership. This remarkable change has been caused by three related developments: improved tools to prevent and treat malaria; large additional financing available to scale up malaria programs, and a global effort to coordinate and assist countries' efforts to strengthen their malaria control programmes. The Global Fund is providing substantial new resources for a comprehensive and balanced approach to malaria prevention, treatment and systems building. Grant recipients are now able to access funds, identify and finance gaps, reach delivery targets and receive follow-on funding.

Rapid scale-up of malaria interventions is possible and can produce quick results, as shown by a number of early successes across a range of malaria control programs. The implementation of well-designed and funded malaria control programmes can lead to a dramatic reduction in disease burden. Some malaria interventions, such as ITNs and IPTp, can be scaled-up quickly by integrating them into existing delivery systems. Others, such as diagnosis and treatment using ACTs, require building and sustaining specific malaria capacity as well as generic health care and support systems.

As funds increase and options expand, there is an increasing realization that non-financial barriers, such as lack of qualified human resources, limited technical support, weak procurement and distribution systems and program management, are becoming barriers to success.

Adequate financial resources for commodities are an essential but not a sufficient basis for successful malaria programs. Due to years of neglect, the start-up phase involves considerable infrastructure and capacity building. Grantees require time to develop efficient systems to receive and spend funds and successfully implement programs.

While the Global Fund has become the largest single malaria donor, these advances are happening in a broader context. There are at least three new major funding mechanisms and bilateral support is increasing, providing unprecedented levels of new funding. Importantly, there is improved coordination between donors and with technical partners. A revitalized RBM Partnership is expanding and taking on the role of a global coordinating mechanism. Most importantly, we have political will and commitment for malaria control. Governments of poor nations and rich nations are now more focused on the urgency and prospects for tackling malaria than they were five years ago. Together, these new developments have brought hope that the burden of malaria can be dramatically reduced in large parts of Africa, including in the most remote and poor populations, and even eliminated as a public health problem in some areas within the next decade.