Roll back malaria what are the prospects?
David Alnwick1
Malaria kills a child somewhere in the world every 30 seconds. The majority of the deaths it causes occur in Africa. Malaria is a major factor in Africas high rate of infant and maternal mortality, of low birth weight, of school absenteeism, and of low productivity in farming and other work. It afflicts primarily the poor, who tend to live in malaria-endemic areas and in dwellings that offer little or no protection against mosquitoes. By sapping peoples health, strength and productivity, malaria further marginalizes and impoverishes them.
Malaria affects many of the countries that are also reeling from the HIV/AIDS pandemic. Africas future development is inextricably linked to the prevention and control of both these diseases. At last there are strong signs of major new international political commitment to tackling both malaria and HIV/AIDS. This is seen in the discussions at the United Nations Security Council in January of this year on HIV/AIDS, at the Abuja Summit on Malaria in April, and the Declaration of the Okinawa G8 Summit in July. Malaria and HIV/AIDS must not be seen as competing priorities. Ways must be found to strengthen efforts to control both of them, so that progress in one area carries over into the other.
There is now a real possibility that the resources available to tackle malaria will increase substantially, perhaps tenfold, during the next few years. Some of these new resources must be invested in the search for new and better technologies. An effective vaccine would certainly be a breakthrough, but even in the most optimistic scenario, such a product will not be available for widespread use within the next five years. The question is what to do in the meantime.
We have today a number of reasonably effective and cheap technologies which, if widely applied, could result in a major reduction of the burden of malaria. None of them are perfect, but technical limitations are not the main problem. The most pressing need now is for mechanisms which allow the majority of the most affected families to use the available technologies in the near future. When such mechanisms exist, it should be relatively simple to add to the technologies in use or replace them with new ones as they become available.
In highly endemic situations found in sub-Saharan Africa, three interventions could be introduced within a year or two, even where the health infrastructure is very poor. These are distribution and use of insecticide-treated bednets, rapid first-line treatment of all suspected malaria cases, and routine intermittent presumptive malaria treatment of all pregnant women. These combined could halve the burden of malaria in the most vulnerable population groups. If they were linked to improvements in mosquito control and in the diagnosis, treatment and referral of complicated malaria cases, the burden of poor health and death due to this disease could be reduced even further.
Most of these highly cost-effective interventions have been available for over a decade, but, with the exception of a very small number of countries in South-East Asia and Africa, none of them has yet been applied on a big enough scale to make much difference to malaria incidence, morbidity or mortality. There have been three main obstacles.
First, the network of public sector health facilities, largely focused on curative care, has tended to play a conservative and restrictive role rather than empowering the full range of potential actors and partners to take action on a large scale. Government health agencies have a proper and necessary function in setting standards and monitoring epidemiology and the effectiveness of control measures. Public sector hospitals and health facilities are likewise indispensable. But it is unlikely that the public sector alone will be able to make bednets and insecticides available to all who need them, or to ensure that all children have access to an effective first-line drug to treat malaria. New ways of using the energy and skills of communities, and new ways of harnessing the power of the private sector will have to be used to achieve these objectives.
Second, during the 1990s there has been a concentration of effort in the poorest countries on health sector reform, with a shift away from what was seen as the vertical disease-oriented approach. Health sector reform and sector-wide approaches were certainly needed, but they do not appear to have had much impact on malaria or HIV/AIDS. Reductions in malaria morbidity and mortality, together with HIV/AIDS and other diseases which are undermining social and economic development, must be key outcomes by which the effectiveness of health systems and health reforms are measured.
Third, the last decade of malaria control in most poor endemic countries can be characterized as one of testing the effectiveness and feasibility of various interventions on a small or medium scale. These activities were supported mainly by ministries of health and nongovernmental organizations. There are too few models of large scale public/private partnerships in which the strengths of both sectors are harnessed to bring effective malaria control technologies to entire populations.
A tenfold increase in resources will not translate into a tenfold improvement in malaria control unless there are major changes in organization and approach. At present there is thought to be insufficient capacity to absorb in a transparent and accountable way a large increase in resources at local level. Qualified human resources are said to be scarce. One solution is to train more health workers and ensure that they are properly paid, and this is now starting to happen in a number of countries seriously affected by malaria. At the same time, new ways must be found to channel resources for malaria control to where they are needed by using the energies and talents of the people living in the areas concerned. Two possibilities hold great promise. One is to make intensive and creative use of new information technology for training local people in delivering selected malaria control activities and documenting and sharing information on their impact. The other is to set up a franchise system to channel funds and supplies efficiently to local communities; this would provide ways of both financing the necessary activities and ensuring their quality.
Adequately organized and supported, the programme briefly outlined above would make a formidable impact on malaria. 
1 Chief, Health Section, Programme Division, UNICEF, New York. As of January 2001: Manager of the Roll Back Malaria Project, World Health Organization, 1211 Geneva 27, Switzerland.
Ref. No. 00-0978