Disease Deadbeats

Malaria Journal, Vol. 2, No. 8, April 2003, Online

Five years ago, a coalition of international development agencies, including the World Bank and the World Health Organization (WHO), founded the Roll Back Malaria initiative (RBM), a global effort to combat resurgent malaria in the many countries afflicted by the disease. Since then, the world has witnessed a deluge of pledges and promises. Twenty heads of state from Africa, where 90 percent of the approximately one million malaria-related deaths per year occur, pledged to cut fatalities in half by 2010 and called on external donors for $1 billion in assistance. Almost every major aid agency promised new funds. These contributions pushed financing for malaria control to unprecedented levels, from $64 million in 1998 to a promised $750 million by the end of 2000.

At the launch of RBM at the United Nations in 1998, then WHO Director-General Gro Harlem Brundtland highlighted the severe impediments malaria poses to economic and social development. But, she declared, "we believe we can do something about it. We do not talk of eradication — that was tried some decades ago — it succeeded in some continents but failed severely on others. We are aiming at a concerted action to significantly reduce mortality and morbidity from this disease."

In late 2001, economists and health experts calculated that by 2007 the cost for global malaria programs would range from $1.5 billion to $2.5 billion per year. However, in 2002, external reviewers of the RBM initiative found that international funding had reached only $130 million, even though malaria remained a serious and worsening threat. They also reported that many donors believe money is not the problem in malaria control.

In a recent issue of the online Malaria Journal, Vasant Narasimhan of Harvard University Medical School and Amir Attaran of the Carr Center for Human Rights Policy grapple with the disconnect between cost estimates, ambitious donation pronouncements, and the actual sums spent on malaria-related programs. Their conclusions are simple and depressing: Pledged donations are far lower than what most experts believe is needed; many pledges are not disbursed in full; and current program-management and accounting systems are so poor that no one can learn precisely what is being spent by whom, where, and on what. Using data from 2000 and 2002, these researchers uncover an annual average of only $ 98.9 million in grants and loans from all major donors — less than 7 percent of the amount supposedly needed to implement existing antimalaria programs worldwide. Less than 40 percent of the total sum was directed to Africa.

Narasimhan and Attaran find that many donors remain unrepentant about their lax financial reporting habits. Fewer than half of the agencies responded to the authors’ survey on uses of public funds in development assistance. Only the World Bank maintains a transparent system that tracks obligations and transactions. Using the bank’s own data, the authors calculate that although the World Bank promised "up to $500 million more… for the fight against malaria in Africa" early in the pledging spree, $490 million of that amount remained "uncommitted and unspent" by 2002. Nor had the bank listed any new African malaria projects in its future plans.

The authors also challenge donors who express condescending skepticism about local "absorptive capacity" (a euphemism for the ability of local officials to spend donor funds effectively). Narasimhan and Attaran pose their own question about "donor capacity": Are funding agencies able to act in accordance with their own promises?

Sadly, these findings are not surprising. In many domains — from the fight against malaria and HIV/AIDS to the debates over free trade — collaboration between the industrial world and developing countries often peaks at the pledging stage. Political leaders and development agencies in rich nations seem unwilling to produce full-cost estimates of the amount of money required to tackle expensive problems, particularly if such projections would create additional pressure for donors to give generously.

Malaria is more closely linked to global poverty than any other disease. The RBM prescription — insecticide-treated bed nets for prevention; prompt and effective treatment, especially for pregnant mothers and young children; and special efforts for epidemics and emergencies, including war — may or may not halve deaths by 2010. Nonetheless, the failure to track well-publicized RBM pledges is particularly reprehensible. Malaria and poverty will persist as donor commitments recede.