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Malaria Africa Caprara Global EconomyGlobal Economy and Development at BROOKINGS Policy Paper 2012-05 and DevelopmentGLOBAL VIEWS at BROOKINGS PHOTO: © ARNE HOEL / WORLD BANK Impacts of Malaria Interventions and their Potential Additional Humanitarian Benefits in Sub-Saharan Africa David Caprara Nonresident Fellow, Global Economy and Development Brookings Institution Ken Ballen President Terror Free Tomorrow OCTOBER 2012 THE BROOKINGS INSTITUTION 1775 MASSACHUSETTS AVE., NW WASHINGTON, DC 20036 2 Acknowledgements The authors recognize Raymond Chambers, United Nations Secretary General’s Special Envoy on Malaria; General James L. Jones, former U.S. National Security Advisor; and the World Health Organization for their important contributions to this research. The Brookings Institution is a private non-profit organization. Its mission is to conduct high-quality, independent research and, based on that research, to provide innovative, practical recommendations for policymakers and the public. The conclusions and recommendations of any Brookings publication are solely those of its author(s), and do not reflect the views of the Institution, its management, or its other scholars. Support for this publication was generously provided by the MCJ Foundation. Brookings recognizes that the value it provides is in its absolute commitment to quality, independence and im- pact. Activities supported by its donors reflect this commitment and the analysis and recommendations are not determined or influenced by any donation. Introduction Over the past decade, the focused attention of African nations, the United States, U.N. agencies and other multilateral partners has brought significant progress toward achievement of the Millennium Development Goals (MDGs) in health and malaria control and elimination. The potential contribution of these strategies to long-term peace-building objectives and overall regional prosperity is of paramount significance in sub-regions such as the Horn of Africa and Western Africa that are facing the challenges of malaria and other health crises compounded by identity-based conflicts. National campaigns to address health Millennium Development Goals through cross-ethnic campaigns tackling basic hygiene and malaria have proven effective in reducing child infant mortality while also contributing to comprehensive efforts to overcome health disparities and achieve higher levels of societal well-being. There is also growing if nascent research to suggest that health and other humanitarian interventions can result in additional benefits to both recipients and donors alike. The social, economic and political fault lines of conflicts, according to a new study, are most pronounced in Africa within nations (as opposed to international conflicts).1 Addressing issues of disparate resource allocations in areas such as health could be a primary factor in mitigating such intra-national conflicts.2 However, to date there has been insufficient research on and policy attention to the potential for wedding proven life-saving health solutions such as malaria intervention to conflict mitigation or other non-health benefits. U.S. and Global Investment Impact In 2001, the administration of President George W. Bush escalated the global campaign against HIV/AIDS, tuberculosis (TB) and malaria by issuing the “founding pledge” to The Global Fund to Fight AIDS, Tuberculosis and Malaria (“Global Fund”) followed in 2003 by a $15 billion five-year pledge to combat these three leading communicable diseases. Following bipartisan congressional authorization of the U.S. Leadership Against HIV/ AIDS, TB and Malaria Act of 2003 (P.L. 108-25) executing this commitment, the President’s Malaria Initiative (PMI) was established in 2005 to increase global malaria funding through a five-year, $1.2 billion investment. PMI set the goal to reduce mortality from malaria by 50 percent in fifteen African focus nations through insec- ticide-treated mosquito nets (ITNs), indoor residual spraying, treatment therapies and prevention for pregnant women.3 The substantial PMI resource allocation, together with other global and African government funding, was authorized in a manner to enhance alignment with country priorities and integration within national health systems.4 The commitments were significantly increased again in July 2008 through the Lantos-Hyde Act (P.L. 110-293) authorizing $48 billion for global efforts to fight HIV/AIDS, TB and malaria over five years including $5 billion for bilateral malaria programs and an additional $2 billion for contributions to the Global Fund. In 2009, President Barack Obama further expanded these bipartisan commitments under his Global Health Ini- tiative, a six-year, $63 billion effort promoting enhanced coordination and integration of the streams of global health programs with increased country ownership.5 These national commitments have been leveraged by in- creasing commitments and ownership by African nations and the global donor community, including an October 2007 call by the Bill and Melinda Gates Foundation for global commitment to eradication of malaria.6 Global malaria control targets have been adjusted upward by the Roll Back Malaria partnership with the World Health Organization (WHO) with the aim of reducing global malaria deaths to near zero along with reducing cases by 75 percent (from 2000 levels) by the end of 2015. The aggressive performance targets would be met by a combination of universal access to preventive measures (such as long-lasting treated nets and indoor residual spraying), full access to case management (including at community level), public and private sector coordina- tion, and stepped up malaria surveillance systems.7 According to a joint USAID and Centers for Disease Control and Prevention 2012 report to Congress: “Over the past five years, many African countries have reported substantial progress in reducing their burden of malaria. Mortality in children under five years of age has fallen dramatically across sub-Saharan Africa in associa- tion with a massive scale-up of malaria control efforts with insecticide-treated mosquito nets (ITNs), indoor residual spraying (IRS), improved diagnostic tests, and highly effective antimalarial drugs. Evidence is growing that the cumulative efforts and funding by the President’s Malaria Initiative (PMI), national governments, The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), the World Bank, and many other donors are having an effect, and that the risk of malaria is declining. In fact, according to the World Health Organization’s 2011 World Malaria Report, the estimated number of global malaria deaths fell from about 985,000 in 2000 to about 655,000 in 2010, with most of this reduction occurring in sub-Saharan Africa.”8 Independent evaluation surveys reported progress in 11 countries supported by PMI in reducing under-five mortality. The report to Congress further noted: 5 “Although multiple factors may be influencing the decline in under-five mortality rates, there is growing evi- dence that the scale-up of malaria prevention and treatment measures across sub-Saharan Africa are playing a major role in these unprecedented reductions in childhood mortality.”9 African Leaders Malaria Alliance According to the WHO, 81 percent of the global malaria burden is in Africa. Through the African Leaders Ma- laria Alliance (ALMA) over 40 heads of state and governments across the region have banded together to collec- tively address the burden of malaria. ALMA holds twice yearly meetings at the African Union tracking progress and addressing bottlenecks in malaria prevention and control. ALMA’s efforts have had an effect. The WHO reported in 2011 that eight African nations achieved a 50 percent reduction in malaria cases or admissions and deaths with an added four nations achieving 25 to 50 percent re- ductions. “In all countries,” the WHO report found, “decreases (in malaria cases and deaths) are associated with intensive malaria control activities.”10 For this assessment of malaria interventions and impacts, six countries of eastern (Kenya, Tanzania, Rwanda and Ethiopia) and western (Nigeria and Senegal) Africa were identified from the President’s Malaria Initiative (PMI) focus countries for further analysis. Another two southern African countries (South Africa and Botswana) were included from the current Administration’s “Global Health Initiative Plus” nations. Figure 1: Malaria and Health Intervention Indicators in Selected Sub- Saharan African Nations National Public Sector Reduced Financing Operational malaria Neonatal Community 2011 (Health Population LLIN deaths by mortality case man- as % Total at Risk coverage >50% by 2010 (per agement Govt. Protected (% of at risk 2010 (vs 1000 live Country (Malaria) Expenditure) by IRS population) 2000) births) Botswana 17.0 20 7 19 Ethiopia 13.3 48 55 35 Kenya 7.3 5 100 28 Nigeria 5.9 0 32 40 Rwanda 20.1 16 92 29 Senegal 11.6 64 27 South Africa 11.4 99 18 Tanzania 12.9 17 78 26 Source: African Leaders Malaria Alliance Scorecard 2012. Legend: Green (target achieved or on track), Yellow (progress, but more effort required), Red (not on track), Grey (no data/not applicable). All eight countries have made significant progress in malaria control. Five of the nations examined (Kenya, Ethiopia, Rwanda, Nigeria and Senegal) are implementing community case management for malaria control. Five countries achieved over 50 percent long lasting insecticidal net (LLIN) operational coverage by mid-2012 (Kenya, Ethiopia, Rwanda, Tanzania
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