����������������������������� ��������������������� ������������� �������������������������������� ������������������������ ��������������� ������������ �������������� ��������������������� ������������������������������������� ��������������������������������� ������������������������ ���� ���������������������� First published by Earthscan in the UK and USA in 2005 Copyright © 2005 by the United Nations Development Programme All rights reserved ISBN: 1-84407-226-6 paperback For a full list of publications please contact: Earthscan 8–12 Camden High Street London, NW1 0JH, UK Tel: +44 (0)20 7387 8558 Fax: +44 (0)20 7387 8998 Email: [email protected] Web: www.earthscan.co.uk 22883 Quicksilver Drive, Sterling, VA 20166-2012, USA Earthscan is an imprint of James and James (Science Publishers) Ltd and publishes in association with the Interna- tional Institute for Environment and Development A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data A catalog record has been requested This publication should be cited as: UN Millennium Project 2005. Coming to Grips with Malaria in the New Mil- lennium. Task Force on HIV/AIDS, Malaria, TB, and Access to Essential Medicines, Working Group on Malaria. Photos: Front cover Giacomo Pirozzi/UNICEF; back cover, top to bottom, Christopher Dowswell/UNDP, Pedro Cote/UN, Giacomo Pirozzi/Panos Pictures, Liba Taylor/Panos Pictures, Jørgen Schytte/UNDP, UN Photo Library, Giacomo Pirozzi/UNICEF, Curt Carnemark/World Bank, Pedro Cote/UN, Franck Charton/UNICEF, Paul Chesley/Getty Images, Ray Witlin/World Bank, Pete Turner/Getty Images. This book was edited, designed, and produced by Communications Development Inc., Washington, D.C., and its UK design partner, Grundy & Northedge. The Millennium Project was commissioned by the UN Secretary-General and sponsored by the UN Development Group, which is chaired by the Administrator of the United Nations Development Programme. The report is an independent publication that reflects the views of the members of the Task Force on HIV/AIDS, Malaria, TB, and Access to Essential Medicines, Working Group on Malaria, who contributed in their personal capacity. This publica- tion does not necessarily reflect the views of the United Nations, the United Nations Development Programme, or their Member States. Printed on elemental chlorine-free paper Foreword The world has an unprecedented opportunity to improve the lives of billions of people by adopting practical approaches to meeting the Millennium Develop- ment Goals. At the request of the UN Secretary-General Kofi Annan, the UN Millennium Project has identified practical strategies to eradicate poverty by scaling up investments in infrastructure and human capital while promoting gender equality and environmental sustainability. These strategies are described in the UN Millennium Project’s report Investing in Development: A Practical Plan to Achieve the Millennium Development Goals, which was coauthored by the coordinators of the UN Millennium Project task forces. The task forces have identified the interventions and policy measures needed to achieve each of the Goals. In Coming to Grips with Malaria in the New Millennium, the Working Group on Malaria of the Task Force on HIV/ AIDS, Malaria, TB, and Access to Essential Medicines proposes an operational framework for scaling up integrated packages of effective antimalarial inter- ventions with the aim of improving health nationally while also promoting economic development locally—an emphasis that is echoed in Investing in Development. An integral part of this framework is building stronger national health systems as a platform for delivering essential antimalarial and other health commodities and services. This report highlights the importance of free provision of insecticide-treated bednets, application of residual insecticides, and provision of effective antimalarial medicines and diagnostics to those at risk of malaria. Adequate information systems for health and effective manage- ment skills at all levels of the health system are paramount to effectively allo- cating resources, monitoring program performance, and evaluating the extent to which the health-related Millennium Development Goals are realized. iv Foreword Funding for malaria control remains far below the $2–$3 billion required per year to achieve the desired impact. Closing this resource gap is, however, possible with the combined efforts of donor nations and endemic countries. This report has been prepared by a group of leading experts who contrib- uted in their personal capacity and volunteered their time to this important task. I am very grateful for their thorough and skilled efforts and I am sure that the practical options for action in this report will make an important contribu- tion to achieving the Millennium Development Goals. I strongly recommend it to anyone who is interested in the role of malaria control within a compre- hensive development framework. Jeffrey D. Sachs New York January 17, 2005 Contents Foreword iii Working group members ix Preface xi Acknowledgments xiii Abbreviations xiv Millennium Development Goals xvi Executive summary 1 1 Introduction 9 The Millennium Development Goal and target for malaria 10 Organization of this report 11 2 The resurgence and burden of malaria 13 Health burden 15 Economic and social burden 19 3 Review of major initiatives and institutional policies for malaria control 22 Global Malaria Eradication Program 22 Global Malaria Control Strategy 22 Harare Declaration on Malaria Prevention and Control 23 Multilateral Initiative on Malaria 23 Roll Back Malaria initiative 24 Abuja Declaration on Roll Back Malaria 24 Medicines for Malaria Venture 25 Global Fund to fight AIDS, Tuberculosis, and Malaria 25 vi Contents 4 Malaria control strategies 27 Disease prevention strategies 27 Disease management strategies 31 Epidemic prevention and control strategies 36 Information, education, and communication strategies 38 Monitoring and evaluation 39 5 Examples of successful scale-up of malaria control programs 41 Tigray region of Ethiopia 42 Highlands of Madagascar 43 Viet Nam 44 South Africa 45 Tanzania 47 Lessons learned 50 6 Priority challenges for scaling up malaria control programs 52 Strengthening health systems 54 Human resources capacity 54 Social mobilization of communities 55 Partnerships 55 Programmatic challenges 56 7 Developing a global plan to achieve the Millennium Development Goal target for malaria 59 Conditions for achieving a sustained impact 59 Developing a global plan for reducing the burden of malaria 60 Components of a global plan 61 Needs assessment: costing and financing 67 Resource mobilization: needs assessment at the global level 69 Resource mobilization: needs assessment at the country level—Ethiopia 70 8 Monitoring and evaluation 72 Monitoring and evaluation of health programs 72 Malaria-related Millennium Development Goal, targets, and indicators 73 Coverage measures 74 Main approaches to data collection for monitoring malaria control 74 Monitoring the effectiveness of antimalarials and insecticides 78 Developing geographic information systems and remote sensing 78 Cost-effectiveness of service provision 79 Linkage of malaria monitoring with poverty alleviation 79 9 Research and development to meet current and future needs 81 Antimalarial medicine development 81 Contents vii Malaria diagnostics 82 Malaria management in young children 83 Malaria vector 84 Malaria vaccines 86 10 Recommendations 88 1. Establish a realistic and measurable target on malaria 88 2. Enhance political commitment at country and global levels 89 3. Strengthen health systems at national and district levels 89 4. Develop human resources for program implementation 90 5. Promote social mobilization and community participation 90 6. Provide effective antimalarial supplies and commodities 90 7. Apply an integrated package of interventions 90 8. Scale up malaria control efforts to national level 91 9. Promote social and economic development 91 10. Incorporate malaria prevention and treatment approaches into school curricula 92 11. Develop surveillance systems for early detection of malaria epidemics 92 12. Promote partnerships for malaria control 92 13. Secure affordable access to the latest medical and therapeutic discoveries 92 14. Invest in research and development on malaria control tools 92 Appendix 1 Estimated costs of scaled-up malaria control efforts in Ethiopia, 2005–15 94 Notes 117 References 119 Boxes 4.1 WHO-recommended combination therapies 35 5.1 District-level health intervention systems in Tanzania 50 8.1 Goal 6: Combat HIV/AIDS, malaria, and other diseases 74 9.1 Artemisinin combinations in development 82 Figures 5.1 The number of treated malaria patients at different healthcare levels has risen from 1992 to 1998 in the Tigray region of Ethiopia 43 5.2 Malaria morbidity fell as vector control rose between 1992 and 1999 in Viet Nam 45 5.3 Under-five mortality in Rufuji and Morogoro Districts, Tanzania, was significantly reduced by using an evidence-based approach 49 viii Contents Maps 2.1 Malaria remains firmly entrenched in tropical developing countries, 2004 14 2.2 Resistance to commonly used antimalarials is widespread, 2004 16 4.1 Malaria epidemics between 1997 and 2002 added to a heavy health burden in Africa 37 5.1 The government of Madagascar began a campaign against malaria in 1989 that protected 2.3 million inhabitants a year with CQ and DDT and contained malaria by 2000 44 5.2 Malaria incidence and prevalence in the Lubombo region is reduced by indoor residual spraying with effective insecticides and the use of effective treatment (ACT) 48 Tables 7.1 Costs of a package of malaria control interventions in Sub-Saharan Africa 68 A1.1 Population at risk for malaria by weight group in Ethiopia, 2005–15 94 A1.2 Total number of fever episodes by weight group in Ethiopia, 2005–15 96 A1.3 Management of uncomplicated malaria by treatment and weight group in Ethiopia, 2005–15 97 A1.4 Cost of managing severe malaria in Ethiopia, 2005–15 99 A1.5 Cost of intermittent preventive treatment of malaria during pregnancy, laboratory equipment and reagents (diagnosis), and antimalarial drug policy change and follow-up in Ethiopia, 2005–15 100 A1.6 Selective vector control in Ethiopia, 2005–15 102 A1.7 Epidemic prevention and control; information, education, and communication; advocacy; behavioral change; and monitoring and evaluation in Ethiopia, 2005-15 105 A1.8 Institutional strengthening and human resource capacity building in Ethiopia, 2005–15 106 A1.9 Operational research activities in Ethiopia, 2005–15 109 A1.10 Program management costs in Ethiopia, 2005–15 110 A1.11 Summary costs of malaria prevention and control in Ethiopia, 2005–15 112 A1.12 Underlying assumptions for calculating requirements for malaria prevention and control in Ethiopia (organized by table) 113 Working group members Task force coordinators Awash Teklehaimanot, Professor of Clinical Epidemiology, Mailman School of Public Health and Center for Global Health and Economic Development, The Earth Institute at Columbia University, United States Burt Singer, Charles and Marie Robertson Professor of Public and Inter- national Affairs, Woodrow Wilson School of Public and International Affairs, Princeton University, United States Members of the Working Group on Malaria James Banda, Senior Advisor, Roll Back Malaria Partnership Secretariat, World Health Organization, Switzerland Chris Hentschel, Chief Executive Officer, Medicines for Malaria Ven- ture, Switzerland Kamini Mendis, Senior Advisor, Roll Back Malaria Department, World Health Organization, Switzerland Maria Veronicah Mugisha, Director, Epidemiology and Public Hygiene, Ministry of Health, Rwanda José Ribeiro, Head, Section of Medical Entomology, Laboratory of Malaria and Vector Research, National Institute of Allergy and Infec- tious Diseases, National Institutes of Health, United States Allan Schapira, Coordinator, Roll Back Malaria Department, World Health Organization, Switzerland Brian Sharp, Director, Malaria Research Program, Medical Research Council, South Africa