The UK is a major player in anti-malaria programmes. Last year it spent almost US$400 million, and planned increases next year would bring that to nearly $750 million, making the UK the third largest international donor after the USA and the Global Fund. That is a massive amount of money, and UK’s spending watchdog, the National Audit Office (NAO), has been looking to see whether it is being well spent or whether it could be used better.
The UK is spending its money on pretty much the same things as most donors - bednets, rapid testing, affordable drugs, research - and although the NAO report says its bilateral programmes are well chosen, it puts its finger on some of the tricky aspects of these interventions - tricky for all actors, not just the UK - where it feels things could be done better.
There are issues, for instance, about bednets. British aid money has paid for nearly 25 million insecticide-treated nets since 2010, and the numbers distributed are tracked and monitored. So far, so good. But receiving bednets is not the same as using them, and when they looked more closely at specific countries, they found that while the number of households in Tanzania and Nigeria owning nets had dramatically increased, the number of those families whose young children actually used the nets had increased very little.
Clearly no one can force anyone to sleep under a net or use it for their children, but the report urges that the supply of nets should be “more consistently supported by timely information campaigns to increase net usage”.
There is also a sustainability issue with bednets, because they do not last for ever, and when the donated nets wear out there has to be a plan in place for their replacement. And here the auditors found a bit of a black hole. “In Nigeria,” they say, “donors have almost met their aim to provide some 60 million free nets… the first free nets issued in 2010 are already reaching the end of their expected life and replacement is becoming a critical issue. We found no evidence that a clear and resourced strategy for replacement of all nets was in place when the mass distribution was planned.”
Free nets drive manufacturers out of business?
Worse still, they found that the free distribution had created an expectation that nets would continue to be free, and also that it had so reduced demand for the commercially available nets that some manufacturers had gone out of business. They did find one initiative that might help, a voucher scheme in Tanzania which allowed recipients to buy from commercial sources and pay a bit extra if they wanted a better choice of nets, but say the success of that project has yet to be evaluated.
David Schellenberg, professor of Malaria and International Health at the London School of Hygiene and Tropical Medicine, told IRIN this was a long-running debate. “In the pre-Global Fund days,” he says, “it was felt that we should be supporting the private sector to provide insecticide-treated nets. But with the advent of the Global Fund, and a realization of how effective the nets could be, there was a sharp move away from the private sector to making nets almost a human right, rather like vaccination…. But if you don’t have an eye to the private sector, you are not getting the full picture at all.”
NAO also takes up the issue of private sector involvement in drug sales and diagnostic testing. The new rapid testing kits are quick and simple to use and in Senegal, for instance, where they were very widely adopted, the identification of who actually did and did not have malaria reduced the number of cases prescribed malaria drugs by 57 percent, meaning better treatment and considerable potential savings. Yet the tests are not as widely available as they could be, even in public health facilities. Private pharmacies hardly use them at all. In some countries it is illegal for them to do testing, but in countries like Nigeria and the Democratic Republic of Congo, with their huge burden of malaria, private drug shops are where some 90 percent of patients get their treatment.
“Progress requires influencing country authorities to allow testing by retailers,” says the report. “We consider that the Department (for International Development) should move as quickly as possible to specific plans with quantified targets for national scale implementation.”
Professor Schellenberg sees an underlying tension in the report between wanting the UK as a donor to deliver the necessary commodities - nets, drugs, testing kits - as effectively as possible, and seeing the need for programmes to be sustainable in the long term. The report points out that currently around 73 percent of the costs of malaria programmes are paid by international donors, and notes that there has recently been some falling away of funding since the early days of the Global Fund - an ominous development when malaria notoriously rebounds as soon as control programmes end. Sustainability, it says, “depends on strengthening the capability of public health systems to control malaria, and the need for donors to leverage developing country resources for health, rather than substitute for them.”
Schellenberg agrees. “Systems are only going to be delivered in a sustainable way,” he told IRIN, “if national governments are encouraged from the outset to take control. It’s very easy to invest a lot of money in the most cost-effective tools, and they will have benefits when they are delivered. But as soon as you take your foot off the gas, malaria is going to come bouncing back. You need the tools; they are required, but they are not sufficient. You can do more good if you take the long-term view and help governments build systems so that these commodities continue to be procured and delivered from their own resources.”