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Advocacy for Malaria Prevention, Control, and Research in the Twenty-First Century

ABSTRACT

TOP ABSTRACT INTRODUCTION UNPRECEDENTED PROGRESS COORDINATED EFFORTS A NEW POLICY ENVIRONMENT A NEW ADVOCACY COMMUNITY ELEMENTS OF SUCCESS FUTURE PROSPECTS REFERENCES

 
Until recent years, public interest and political investment in malaria prevention, control, and research have been stagnant. The global malaria agenda is now experiencing an unprecedented time of public and political will and momentum. At the heart of this favorable period lies a nascent, but increasingly sophisticated, global advocacy effort that has contributed to new and expanded malaria funding, programs, and technology. This paper reviews the elements of malaria’s rise to political and public prominence, tracks the increase in funding and policy commitments to malaria over the past decade, and comments on an evolving policymaking progress, increasing transparency and accountability in program governance, and the impact of philanthropic investments in malaria advocacy. In addition, the principles of sound advocacy are described along with the mechanisms that will underlie sustained pro-political momentum for malaria research, resources, and results.

"Today, we have begun to write the final chapter in the history of malaria. We have raised hopes and expectations of our people—we must not let them down. We cannot afford to let them down."

—His Excellency Olusegan Obasanjo, President of Nigeria, Abuja Summit 2000

INTRODUCTION

TOP ABSTRACT INTRODUCTION UNPRECEDENTED PROGRESS COORDINATED EFFORTS A NEW POLICY ENVIRONMENT A NEW ADVOCACY COMMUNITY ELEMENTS OF SUCCESS FUTURE PROSPECTS REFERENCES

 
Malaria’s history traces back millennia, causing illness and death throughout the tropical and temperate world, including in the United States until 1951.¹ Global efforts to control, eliminate, and, ultimately, eradicate malaria where possible have ebbed and flowed with periods of marked progress followed by disinvestment and, as a result, a return or worsening of this environmentally fueled infectious disease.^2–4 Recent years, however, represent a period of renewed investment in antimalaria efforts. A favorable environment has emerged for global health, more broadly, and for malaria, specifically, after a period of political disenchantment and lack of support when science was lost in politics.^5,6 Our premise is that a newly formed advocacy community has, at least in part, been a driver of this new interest. This resembles similar issues of global public health importance in the 20th century, including the March of Dimes, which was created in 1938 to defeat poliomyelitis,⁷ the United Nations Children’s Fund (UNICEF), which was established after WWII to provide food and medicine to children affected by the war,⁸ and ACT-UP, a nonviolent direct-action coalition that began in 1987, using dramatic acts of civil disobedience and vocal demonstration, to focus U.S. Government attention on the AIDS crisis,⁹ that all took root with the seminal efforts of a core group of advocates for their respective causes.

Thus, the purpose of this paper is to review recent events that have brought malaria prevention, control, and research greater public recognition and political support as well as to describe the principles of sound advocacy (research, communication, policy, results) and the mechanisms that underlie the increased and sustained pro-political momentum for malaria research, resources, and sustainable results.

UNPRECEDENTED PROGRESS

TOP ABSTRACT INTRODUCTION UNPRECEDENTED PROGRESS COORDINATED EFFORTS A NEW POLICY ENVIRONMENT A NEW ADVOCACY COMMUNITY ELEMENTS OF SUCCESS FUTURE PROSPECTS REFERENCES

 
Since the late 1990s, new and expanded funding, programs, technology, and advocacy have contributed to an unprecedented time of public and political will toward malaria. At the beginning of the 21st century, U.S. spending on malaria control was just $39 million, mostly through the U.S. Agency for International Development (USAID) and the Centers for Disease Control and Prevention (CDC). Additional resources were dedicated at agency level, mostly to research, at the National Institutes of Health and the Department of Defense. In 2002, the U.S. approved 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.¹⁰ Since then, U.S. global malaria spending has steadily risen, culminating with the 2005 announcement of the President’s Malaria Initiative (PMI), a 5-year, $1.2 billion commitment targeting 85% coverage and a two-thirds mortality reduction in 15 African countries.¹¹

U.S. efforts have been paired with comparable commitments by other donor governments, as evidenced by a series of G8 country pledges, the creation of the World Bank Malaria Booster Program in 2005, and direct program support and research investments by philanthropic foundations [The Group of Eight (G8) is an international and informal forum for the governments of Canada, France, Germany, Italy, Japan, Russia, the United Kingdom and the United States that meets annually to discuss issues of mutual or global concern, including economic and social development, energy, environment, foreign affairs, health, justice, law enforcement, labor, terrorism and trade]. In 2007, the Global Fund estimated disbursements of $1.2 billion, while governments of affected countries planned to spend $300 million. The World Bank Malaria Booster Program and the PMI were scheduled to add another $400 million. Total expenditures in 2007 (pending) will be exponentially higher than in 2000.¹² More recent estimates show funding increasing to $767 million for the next few years, including PMI and the World Bank.¹³ Current combined global spending on malaria control between 1999 and 2007 is estimated to be $1.9 billion, an unprecedented commitment by the U.S. and global partners to fight this scourge (Table 1). Nonetheless, global spending still falls 35–40% short of global need, estimated to be between $2.9 and $3.2 billion.¹⁴

Furthermore, combination therapies have replaced mono-therapies as the World Health Organization (WHO) recommended treatment strategy.¹⁷ These breakthroughs are primarily due to Artemisia annua, a Chinese herb used for >2000 years to treat fevers. Research has shown artemisinin, the active ingredient extracted from the Sweet Wormwood bush (Chinese,

COORDINATED EFFORTS

TOP ABSTRACT INTRODUCTION UNPRECEDENTED PROGRESS COORDINATED EFFORTS A NEW POLICY ENVIRONMENT A NEW ADVOCACY COMMUNITY ELEMENTS OF SUCCESS FUTURE PROSPECTS REFERENCES

 
Paradoxically, although there has been progress in malaria policy development, program implementation, and contributions from research, each of these areas has often been separated from the other. The ensuing "silo effect" has stymied cohesiveness and synergy from developing from within the malaria community. Only in recent years have the control and research communities attempted coordination, resulting in a global movement toward reducing the global burden of malaria. Many of these efforts are coordinated through the Roll Back Malaria (RBM) Partnership, launched in 1998 by the World Health Organization, the United Nations Children’s Fund (UNICEF), the United Nations Development Program (UNDP), and the World Bank to provide a coordinated global approach to fighting malaria.⁶

One of RBM’s first accomplishments occurred in April 2000, when senior representatives of 44 of Africa’s 50 malaria-affected countries met in Abuja, Nigeria, for the Africa Summit. Although previous research and programs to reduce malaria’s devastation in developing countries were part of long-standing, albeit lower-profile, efforts, the "Abuja Summit" represented malaria’s arrival to the global stage of public and policy priority. The most notable outcome of the Summit was a consensus statement, known as the Abuja Declaration, whereby African nations committed to halve malaria mortality by 2010.⁵ This declaration was accompanied by a call for health-systems strengthening and resources on the order of $1 billion per year to achieve their goals. Granting that the Abuja Declaration is a political rather than epidemiologic statement, it has rallied countries and organizations to a common goal: action against a perennial scourge.

The RBM Partnership mission is to provide an essential space for coordination and convening among the universe of malaria scientific, programmatic, and policy stakeholders. Over time, these subcommunities have come together to serve as advocates raising awareness, securing resources, and delivering results for the still-evolving global malaria agenda.

At the international level, there have been great strides in the development of rapid diagnostic tools, new drugs, vector control approaches, and vaccine testing. These advances will make possible the effective management and prevention of severe malaria, particularly in children. Such efforts have been led by the Multilateral Initiative on Malaria (MIM), a consortium of scientists and research organizations from African and northern countries aiming to develop and improve tools for malaria control. The rotating Secretariats for MIM since its inception in 1997 have been at the Wellcome Trust, London; Fogarty International Center, NIH, Bethesda, MD; Karolinska Institute and Stockholm University, Stockholm; and at the African Malaria Trust Network, Dares Salaam. Advocacy for malaria research has been an important MIM activity.²⁹

A NEW POLICY ENVIRONMENT

TOP ABSTRACT INTRODUCTION UNPRECEDENTED PROGRESS COORDINATED EFFORTS A NEW POLICY ENVIRONMENT A NEW ADVOCACY COMMUNITY ELEMENTS OF SUCCESS FUTURE PROSPECTS REFERENCES

 
A decade ago, malaria-control stakeholders faced the first-order challenges of raising awareness and securing nominal resources. Today, those financial and political challenges have been somewhat overcome partially due to the efforts of a small group of malaria stakeholders. Equally influential, however, has been the impact of critical shifts in malaria policy making, program governance, and philanthropic investments in advocacy. First, national and global policy making processes are increasingly open, allowing participation by a larger pool of stakeholders rather than the historically closed process involving only the government and private interest groups. The expanded participation of civil society is evident in the United States and throughout Europe and Africa. Second, major programs such as the President’s Malaria Initiative (PMI) and the Global Fund have placed emphasis on themes of governance, transparency, and accountability, making tracking of investments easier and accessible by a broad stakeholder range. Finally, philanthropic investments in advocacy have increased the pool of active stakeholders. These investments are best documented by the efforts of the Bill & Melinda Gates Foundation, whose grantmaking has increased the number of individuals and organizations engaged in malaria-specific advocacy since 1998 from just a handful of well-meaning, but overcommitted and under-resourced, advocates to an increasingly sophisticated set of networks of developed-and developing-country professionals and community leaders. For example, during the period from 2004 to 2006, 76 malaria grants, totaling $580.7 million, were approved by the Gates Foundation. This included eight grants, valued at $29 million, specifically for malaria advocacy. An additional 10 grants totaling $20 million supported broader global health advocacy, of which malaria was a component (N. Bates, personal communication). These advocates are complemented by a similarly financially infused community of malaria researchers and program implementers, also supported by the Gates Foundation, a variety of public–private partnerships and developed country governments.

New resources and a growing field of policy actors mandate mature advocacy, i.e., the active promotion of a long-term, coordinated, comprehensive global malaria agenda executed by the full spectrum of malaria stakeholders. This evolved effort includes accurate and timely communication, ongoing investments in further developing the evidence base through research, well-financed policies that are informed by this research, and results that justify continued attention and investment. Throughout malaria’s history, any one of these four essential components may have existed, but only now do they operate in such a synergistic manner.

The global malaria advocacy and financing picture today gives reason for optimism, as the outlook is more positive than it was just 10 or even 5 years ago. But what does this horizon portend 5 or even 10 years from now? How does the malaria advocacy community capitalize on the current resource momentum and translate it into tangible, sustainable results? Will malaria continue its current trajectory of resource growth? Or will it succumb to the familiar fate of its past and that of other core health areas, such as child health and family planning, which, despite the availability of evidence-based, cost-effective, and on-the-shelf interventions, fail to reach those in need? In 10 years, will malaria advocacy and financing suffer from stagnant funding, public ambivalence, and political avoidance? In this context, and even assuming sufficient financial resources, does the malaria advocacy community know what to do and how to do it well? Is there substance behind the current political momentum? These are the new questions at hand that the malaria advocacy community must address to stop the perennial economic burden and cause-and-effect cycle of malaria disease and poverty.

A NEW ADVOCACY COMMUNITY

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In response to the new, antimalaria-favorable environment, malaria stakeholders are challenged to be effective in the increasingly inclusive, yet ultimately political, processes and interact with the ever-expanding universe of malaria stakeholders constructively. This includes promoting both individual agendas as well as a larger, shared community agenda. Take a classic malaria intervention debate—indoor residual spraying (IRS) versus insecticide-treated bed nets (ITNs)—that has caused disruptive infighting and rifts within the community and has undermined the community’s reputation among external stakeholders. For the sake of malaria’s longevity as a policy priority, these respective views must be presented unbiased in the context of a larger, more comprehensive agenda.

Unites States-based groups, such as the CORE Group, with its support of national partnerships and collaborations throughout Africa, and Families USA, with its charge to promote increases in NIH global health research funding, must communicate and coordinate with organizations such as PATH, which is working toward the world’s first malaria vaccine. To the malaria agenda’s benefit, such coordination is occurring today, being facilitated at the global level by the RBM Partnership and executed at national levels by country-specific coalitions such as the Global Health Council–sponsored Malaria Roundtable in the United States, the Kenya NGO/Private Sector Alliance Against Malaria (KeNAAM), or one of the newly launched European malaria advocacy networks (Table 2).

ELEMENTS OF SUCCESS

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(1) Translate commitments to action. In the past 7 years, numerous targets, declarations, and commitments have been made at global, regional, and national levels (Table 3). Summits and meetings rarely adjourn without a document stating a new vision or strategy to address malaria. Although these public statements are important symbols of commitment and solidarity, they quickly become impotent when they remain only words and are not translated into tangible next steps and not assigned as any particular stakeholder’s responsibility, therefore, remaining unfulfilled.

(3) Expand the community of support. The way forward in malaria advocacy must acknowledge the context in which malaria is experiencing the current resource growth. Malaria occurs in the same communities where women die during childbirth and children under the age of 5 die daily from conditions largely preventable through immunization and basic antibiotic treatment. People living with AIDS and others without access to clean drinking water often succumb to malaria. Although these conditions do not occur in a vacuum, their advocacy frequently does.

Advocacy for malaria prevention, control, and research requires a holistic view of the disease and an understanding of the socioeconomic and political circumstances in which malaria exists. In a world reliant on the same workers, systems, and advocates, shared resources and integrated approaches are practicable, given the finite resources available.

Malaria’s agenda must at least coordinate, if not merge, with a broader, encompassing global health agenda. Recently, the VOICES Project through Johns Hopkins University hosted a series of advocacy workshops in Zambia which brought together AIDS activists to share lessons learned with newly established malaria advocacy networks. Through this exercise, malaria advocates benefited from the locally relevant lessons learned of the AIDS community, and AIDS activists themselves expanded their agenda to include malaria, for which the science on HIV co-infection is rising. The Malaria Consortium, with offices throughout sub-Saharan Africa and headquarters in London, has played a similar role with VOICES in Mozambique. As a majority of malaria deaths are among pregnant women and young children, the reproductive and maternal–child health communities are a ready source of additional support. Beyond health, malaria must find its place among development, economic, and foreign policy discussions. For a disease that causes the African continent an economic loss estimated at $12 billion per year,¹² it is short-sighted to not recognize the economic burden of malaria.

(4) Establish a long-term vision. Malaria’s U.S. and global resources are growing at a time when overall global health and international development spending are experiencing significant and unprecedented increases. It is critical to demonstrate the empirical evidence of progress in malaria prevention, control, and research, without which future resources may be diminished or withheld. Malaria’s sustainability cannot be subject to the personal preferences or inherently finite political life spans of political leaders. Malaria was understood to be a priority of Paul Wolfowitz, the head of the World Bank who stepped down in Summer 2007. Malaria was also a priority of the late Lee Jongwook, former Director General of the World Health Organization. The PMI, which has delivered promising initial results in its first 2 years of operation, is by definition a "presidential" initiative. Its leadership is politically appointed and, therefore, likely to change as of November 2008. In the same way that mosquitoes know no border, their transmission of malaria will not halt with the change of an administration. Malaria’s interest must be institutionalized, not just personalized. As a result, it is critical to establish a bipartisan cadre of malaria policy champions as well as a strategic plan for the malaria agenda that persists through elections and political highs and lows. A globally accepted framework for malaria prevention, control, and research should inform advocacy efforts. The grooming of long-term political leadership and a universal strategy framework must be approached through and be executed with a goal of sustainability.³⁰

FUTURE PROSPECTS

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Despite successful eradication in most Northern and Western countries, malaria is likely to remain a persistent health concern in the tropical regions of the developing world. Although malaria control and research efforts have been underway for nearly a century, much has changed in the past decade, even in the past 2 years since the last AJTMH Malaria Supplement.³¹ In that time, a malaria advocacy community has emerged and begun to evolve. There is an old adage that "success has many mothers." It would be presumptive to state that the period of grace in which malaria exists today is due exclusively to superior advocacy by the malaria community. Critical analysis or "lessons learned" of the successes and/or failures of malaria advocacy efforts and organizations would serve well to inform future efforts and investments in malaria prevention, control, and research advocacy. However, it is certain that malaria’s continued prioritization is dependent on advocacy characterized by the execution of a sophisticated agenda by a broad community of stakeholders in the context of a long-term commitment and coordinated approach to reducing the global burden of malaria.

Received April 9, 2007. Accepted for publication October 3, 2007.

Acknowledgments: The authors thank Joel Breman, Martin Alilio, the Journal’s editors, and the anonymous reviewers for their thoughtful comments and suggestions on drafts of this paper. Any opinions, expressed or implied, and errors of fact contained herein are the sole responsibility of the authors and do not represent the official policies of the authors’ affiliate organizations.

^* Address correspondence to James Herrington, Fogarty International Center, Bldg. 31, Rm. B2C11, National Institutes of Health, Bethesda, MD 20892-2220. E-mail: herringtonj{at}mail.nih.gov

Authors’ addresses: Nicole Bates, Global Health Council, 1111 19th Street, NW, Suite 1120, Washington, D.C. 20036, Telephone: +1 (202) 833-5900, Fax: +1 (202) 833-0075; E-mail: nbates{at}globalhealth.org. James Herrington, Fogarty International Center, National Institutes of Health, 31 Center Drive, MSC 2220, Bldg. 31, Room B2C11, Bethesda, MD 20892-2220, Telephone: +1 (301) 496-4784; Fax: +1 (301) 480-3414; E-mail: herringtonj{at}mail.nih.gov.

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TOP ABSTRACT INTRODUCTION UNPRECEDENTED PROGRESS COORDINATED EFFORTS A NEW POLICY ENVIRONMENT A NEW ADVOCACY COMMUNITY ELEMENTS OF SUCCESS FUTURE PROSPECTS REFERENCES

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in ISI Web of Science Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via ISI Web of Science (1) Google Scholar Articles by Bates, N. Articles by Herrington, J. PubMed Articles by Bates, N. Articles by Herrington, J.