Several years ago, I was explaining the value of a measles-vaccination campaign to a doctor at a paediatric hospital in

northern Uganda, where, at that time, measles was endemic. The proposed campaign would control the disease and potentially enable the hospital to close the measles ward. The doctor responded that if there was also a campaign that controlled malaria he could “close the entire hospital”.

There is still no vaccine for malaria, but Uganda has adequate resources — as do many other countries — for a national campaign of several malaria interventions, including insec-ticide-treated bed nets and effective drugs. The challenge is to scale-up those services. Just as high levels of vaccination coverage led to clos-ing Ugandan polio and measles wards, rapid scale-up of prevention measures could end the malaria crisis in Africa. Slashing malaria cases and deaths would also free up vital resources for other diseases that have had too little atten-tion for too long.

This vision is in stark contrast to the experi-ence of recent decades, which have seen flag-ging global efforts and rising mortality from malaria. For a disease that still kills a million people a year, uses almost half of the clinic serv-ices in Africa, and reduces economic growth by up to 1%, controlling malaria may be the most important challenge in global public health.

But hope is arriving in Africa. The malaria

crisis is starting to yield to new tools and strate-gies made possible by a substantial increase in resources over the past ten years — from less than US$100 million to about $1 billion this year. With most resources coming from a few donors, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, the World Bank and the President’s Malaria Initiative, the current global goal — coordinated by the Roll Back Malaria (RBM) Partnership — is to halve the number of malaria deaths by 2010. However, these donors rely on a coun-try-led process of planning and goal setting, and many nations’ plans are not yet sufficiently ambitious in scope, intensity or timeliness to reach the 2010 target. Adequate funding for malaria control is an important first step, but unprecedented coordination, planning and operational sup-port will be required to achieve the goals.

Recent progress has come from applying four interventions: sleeping under insecti-cide-treated bed nets, spraying houses with insecticides, preventive treatment for pregnant women, and timely treatment of the sick with effective drugs. The RBM target is to reach 80% coverage with each of these interven-tions by 2010. Within one year of scaling-up these interventions in 2006, malaria hospital admissions of children fell by more than about 60% at selected facilities in Ethiopia1, Rwanda1,

Zanzibar2 and on the coast of Kenya3. Achiev-ing the overall targets for Africa by 2010 is a huge challenge, and scaling-up drug treatment is particularly daunting, but the widespread use of bed nets should reduce case numbers and ease the demand for drugs.

In response to this initial progress, the lead-ing public-health agencies attending the Bill and Melinda Gates Foundation malaria forum in Seattle last year boldly endorsed eliminat-ing malaria as a public-health and economic

problem. Bill and Melinda Gates went further and called for malaria eradication. But achiev-ing eradication is a decades-long project that will require new tools, including an effective vac-

cine (see page 1042).

Integrated preventionThe malaria community can learn a great deal from the scaling-up of vaccination pro-grammes for polio and measles. Ten years ago, about half-a-million children died of measles annually in Africa and many countries were endemic for polio. Since then, hundreds of millions of doses of vaccines have been deliv-ered, and cases and deaths for both diseases have fallen by more than 90%. Despite the lack of a malaria vaccine, these successes can serve as an important model and inspiration for rapid scale-up.

“The current global plan is to halve the number of malaria deaths by 2010.”

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The billion-dollar malaria momentFor years the global malaria effort has been asking for more resources. Now the field needs to figure out a systematic strategy for spending the money effectively, says Mark Grabowsky.

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Taking advantage of the existing deliv-ery systems for childhood vaccination is the most efficient method for rapidly scal-ing up malaria prevention. Measles vacci-nation campaigns occur every three years in most African countries. During these week-long campaigns, children under five years of age are vaccinated — these are the same children that need insec-ticide-treated bed nets. Giving out free bed nets to children and their caretakers when they attend the measles campaigns achieves rapid, high and equitable bed-net coverage at low cost4. These integrated campaigns are now the most common method for providing bed nets to Africans, with more than 40 million delivered over the past two years. During one week in December 2007 in Mali, more than 2.1 million nets were delivered along with measles vaccination, vita-min A and deworming medicine.

Even though periodic mass campaigns can rapidly achieve high coverage, because children are born every day, there is a need for ongo-ing bed-net distribution between campaigns. This can happen when a mother brings a child to a clinic for routine vaccination5. There are twenty countries in sub-Saharan Africa where infants have at least four vaccination visits to the health centre in the first year of life. But these visits are rarely used for malaria preven-tion. In Nigeria, where vaccination coverage of measles is close to 70%, bed-net coverage is less than 10%. If these vaccination visits were used to give out bed nets, coverage would eventu-ally rise to near target levels.

There are also opportuni-ties for malaria prevention when pregnant women come to a clinic for pre-natal care. Countries need to adopt these proven and efficient approaches to integrated delivery. This requires national malaria-control programmes to coordinate more with their col-leagues involved in other health programmes.

The challenge of treatmentMalaria prevention can build on these exist-ing strategies, provided that countries and donors pull together. But of the four 2010 tar-gets, achieving 80% rates of drug treatment is the greatest challenge. The difference in the ability to deliver prevention and treatment is illustrated in Sierra Leone. In 2006, in eight districts supported by the Global Fund, bed-net delivery was integrated into existing pre-vention services, and drugs and diagnostic kits were supplied to health centres.

After one year, 80% of children and 60% of pregnant women in Sierra Leone slept under a bed net. Virtually every clinic had adequate stocks of the recommended drugs for malaria treatment. However, only 4% of the children with malaria symptoms received appropriate treatment in a timely fashion (within one to two days of fever onset).

Malaria is a disease of poverty. Three-quarters

of the population in rural Africa lives in extreme poverty, as defined by the family only having the income to buy enough food to ward off star-vation. Free services at health facilities do not remove other barriers to reaching a clinic, such as transportation, or taking time away from work, growing food or fetching water. Integrat-ing treatment into clinic-based services, even if low-cost or free, will fail to reach many of the poorest. Improved access will require new approaches that are not clinic-based.

One proposal is to subsidize drugs at pri-vate pharmacies6. In theory, patients will ben-efit from local access to such shops and the presumed effects of private-sector competi-tion to lower prices. Better consumer educa-tion, such as placing recommended prices on product labels, may also improve access. But

recent findings suggest that this may still not be enough to reach those with other barriers to access, particularly children in poor families.

Evidence from pilot projects in Africa shows that new drugs can be effec-tively delivered to rural children within 48 hours of fever onset through either commu-nity-based volunteers or home-treatment kits7. But can such approaches achieve the ambitious 2010 targets? One example of success is in Ho District in Ghana where community workers — usually farmers and teachers selected by the community — were able to correctly deliver drugs to 75% of sick children7. But whether resource-poor government services can sup-port civil efforts in malaria care is unproven. Partnering with community-based groups such as the Red Cross may be the key to large-scale implementation. The Global Fund, therefore, encourages governments and civil society to submit coordinated but separate applications so they do not compete for resources.

As countries pursue the 80% coverage tar-gets, data are needed to relate coverage to the more important goal of halving deaths caused by malaria. In areas of moderate transmission — such as the Kenyan coast — even modest bed-net coverage may be able to reduce mor-tality by 50%. In areas of intense transmis-sion, that may not be enough. The only way to routinely relate coverage to impact is through systematic disease surveillance. Routine and

standardized monitoring is essential for a business-like approach to decision-mak-ing, but no such systematic surveillance data exists for malaria.

Monitoring is essential to protect our tools. Resistance to the pesticide DDT and the drug chloroquine contributed to abandoning malaria eradication in the 1960s. Today’s efforts also depend on two molecules: pyrethroids to treat bed nets and artemisinin for treatment. Resistance is widespread for the former and emerg-ing for the latter. Moreover, more money for drugs invites counterfeits, as seen in Asia and now in Africa. Achieving the

malaria-control goals, or elimination, risks failure if detection and response to resistance remain inadequate.

Secret weaponIn many ways, disease surveillance has been the secret weapon for polio and measles control, powering funding and informing decisions. An example is the regional monthly newsletter of measles cases. It allows countries, donors and planners to systematically monitor progress towards goals.

Without ongoing high-quality data it will be impossible to monitor progress and focus efforts on elimination or eradication. There are technical challenges to improving malaria surveillance, including the need to move away from presumptive to laboratory diag-nosis. But most of these challenges can be resolved with adequate investment, training and management.

As the global community scales up malaria control, it must ensure that all countries have adequate monitoring systems in place. None-theless, a country-based approach by itself is neither technically nor financially appropri-ate. There must also be regional laboratory networks that support country efforts, apply standardized monitoring techniques, rap-idly share findings and manage coordinated responses. This is particularly essential for monitoring drug quality. It would cost about $10 million annually to get useful, monthly, surveillance data and to support regional mon-itoring, laboratory and surveillance networks. Without it the billion-dollar malaria effort is flying blind. ■

Mark Grabowsky is at the Global Fund to Fight AIDS, Tuberculosis and Malaria, 8 Chemin de Blandonnet, 1214 Vernier, Geneva, Switzerland.

1. http://www.who.int/malaria/docs/ReportGFImpactMalaria.pdf

2. Bhattarai, A. et al. PLoS Med. 4, e309 (2007).3. Okiro, E. A. et al. Malar. J. 6, 151 (2007).4. Grabowsky, M. et al. Bull. World Health Organ. 83, 195–201

(2005).5. Grabowsky, M., Nobiya, T. & Selanikio, J. Trop. Med. Int.

Health 12, 815–822 (2007).6. Institute of Medicine of the National Academies Board

on Global Health. Saving Lives, Buying Time. Economics of Malaria Drugs in an Age of Resistance (Natl Acad. Press, Washington DC, 2004).

7. Ajayi, I. O. et al. Malar. J. 7, 6 (2008).

See Editorial, page 1030.

“Without high-quality surveillance, the

billion-dollar malaria effort is flying blind.”

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Bed nets are a key weapon against malaria.

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