Inside Look: Q&A with MEI’s Rima Shretta and IHME’s Joe Dieleman to explore their new research on tracking malaria financing

According to a study published July 27 in Malaria Journal, global financing for malaria elimination is declining at a time when it remains crucial to eradicating the disease. Researchers at the UCSF Global Health Group’s Malaria Elimination Initiative (MEI) and the Institute for Health Metrics and Evaluation (IHME) suggest that while government funding for malaria elimination has been increasing in many malaria-eliminating countries since 2000, this increase in domestic financing does not fully bridge the gap from the decline in donor funding that emerged after 2010.

For this study, the MEI teamed up with IHME to better understand past and future trends in donor and domestic financing for malaria elimination. IHME researchers built on their Financing Global Health (FGH) database by collecting data from organizations that channel development assistance for health (DAH) to 35 countries actively pursuing malaria elimination. (DAH is defined as the financial and in-kind contributions for maintaining and improving health in low-and middle-income countries.) In addition to assessing overall levels of financing for malaria in the 35 eliminating countries, the MEI and IHME categorized the activities and interventions on which DAH was spent. They also estimated Government Health Expenditure (GHE) on malaria.

Financing experts Rima Shretta and Joe Dieleman sat down with us to discuss the findings and the potential implications for achieving a malaria-free world.

1. Rima, what prompted you and the MEI’s economics and financing team to look into donor and government financing trends for malaria elimination?

Global malaria incidence and deaths have dramatically declined since the year 2000—by 41% and 62%, respectively, according to the World Health Organization (WHO). During this same timeframe, 17 countries eliminated malaria—six of which have been certified malaria-free by the WHO. This period of progress corresponds with unprecedented levels of political and financial commitment for malaria from donors. However, more recently, donor financing for malaria declined between 2010 and 2013. These reductions in external financing are even greater for the subset of countries eliminating malaria because they have lower disease burdens and are often lower-middle or middle-income countries and are therefore a lesser priority for donors. While domestic spending on malaria appears to be growing, it varies substantially in speed and magnitude across countries. As the disease becomes less “visible,” government funds for malaria are often diverted to other health priorities that are perceived to be greater health threats, despite the risk of resurgence. Changes in financing trends come at a critical time when commitment to elimination will be crucial to paving the way for global malaria eradication.

2. What is new about this study?

Rima: This is the first study that tracks DAH and GHE for malaria-eliminating countries in a systematic way from 1990 to 2014 with DAH projections to 2017. Publications have looked at tracking DAH generally or for specific areas, such as HIV and maternal, child, and newborn health. This study uses a more comprehensive set of data sources and enhanced methods to track DAH and GHE. Our research helps uncover critical financing gaps and opportunities to invest in malaria elimination.

3. Joe, you lead the Financial Resources for Health research team at IHME, which focuses on tracking development assistance for health, health expenditure by disease, and government health expenditure. What went into obtaining and working with the data you needed for this study?

We had four main aims in our analysis of these 35 malaria-eliminating countries:

• Track DAH for the prevention and treatment of malaria from channel to recipient country or region, from 1990-2013;
• Generate DAH estimates for the prevention and treatment of malaria by activity or program area for the same time period;
• Estimate GHE for malaria from 2000-2014; and
• Estimate DAH projected financing from 2014-2017.

We built upon our FGH 2015 database to come up with DAH estimates for malaria elimination. Estimates to more precisely describe how resources were allocated, through 13 malaria activities or program areas, were based on keyword searches and the collection of additional data. However, we were unable to allocate all expenditure to specific program areas. These data were forecasted through 2017 in order to provide “real-time” monitoring of expenditures.

We obtained data on GHE from the annual WHO World Malaria Report (WMR), which includes government expenditure (or budget information when expenditures are unavailable) gathered from country-level malaria programs. These were triangulated with data from Pigott et al., which collated co-financing data from Global Fund grant proposals.

4. What are the main study findings and is there anything surprising about the results?

Rima: In the 35 malaria-eliminating countries included in this review, total financing for malaria grew from $179.5 million to $301.7 million between 2000 and 2013, of which DAH accounted for 19% in 2013. DAH declined by 65% between 2011 and 2014 in the 35 countries overall and is projected to further decline through 2017. At the same time, GHE almost doubled between 2000 and 2010—with the upward GHE trend having maintained or increased between 2008 and 2014.

Among the countries included in the study, DAH increased along all program areas starting in 2003 and peaked in 2010 at over $176 million. Treatment, diagnosis, and vector control (indoor residual spraying and bed nets), and, to a lesser extent, health system strengthening and surveillance grew at faster rates than other service delivery areas—consistent with recommendations for malaria elimination. In most countries, the ratio of DAH expenditure on diagnosis versus treatment increased after 2008. A notable exception is Thailand, with 25% of expenditure on treatment but very little on diagnosis. Expenditure on vector control peaked in 2010 and comprised 80% of total malaria DAH expenditure in some countries, such as Bhutan. A large proportion of the funds could not be allocated over any of the program areas, particularly from 2008 and 2011 (14%).

One surprising finding was that expenditure on surveillance—a key malaria elimination intervention—actually decreased overall between 2010 and 2013. Less than 10% of malaria DAH in these countries was spent on surveillance, despite being a core pillar of WHO’s Global Technical Strategy. We were also surprised at the large degree of variation in GHE on malaria and that domestic spending is not correlated with GDP, indicating that greater economic growth does not always lead to increased domestic spending on malaria. This finding clearly challenges the assumption that many donors are using to prioritize recipient countries—that countries will spend more on health as they develop economically. We also were surprised to see that malaria expenditure is not directly associated with disease risk, as measured by annual parasite incidence (API).

5. This research identified an increase in DAH for malaria in these 35 malaria-eliminating countries between 2000 and 2010, followed by a decline between 2010 and 2013. Could you tell us more about these findings and whether any countries stand out?

Joe: Our findings demonstrate three distinct periods for malaria DAH in the eliminating countries: first, a period of moderate growth in the 1990s; second, a 33-fold increase over the course of the next 10 years; and third, a decline of 65% from the peak in 2010 to 2013. More specifically, DAH began to decline in 2011. We project that DAH in these 35 countries will further decline through 2017.

The largest declines in DAH were seen in China, which was 90% externally financed in 2010 but saw a major reduction to only 10% in 2013. The Democratic People’s Republic of Korea and the Solomon Islands also had declines in DAH of over 25%. Nonetheless, despite this downward trend, external funding was 11.5-fold higher in 2013 than in 2000. Although the majority of funding in the 35 countries comes from domestic sources, DAH still plays an important role in the delivery of health interventions.

6. How does DAH for malaria compare to DAH for other health focus areas?

Joe: Our most recent Financing Global Health report showed that total DAH has remained relatively constant since 2010. We estimated that in 2016, DAH (for all health focus areas) reached $37.6 billion dollars. This is only 10% greater than in 2010. During this period, DAH for malaria to all countries—including the 35 eliminating countries in this study—increased by $90 million, but comprised only 6.6% of total DAH in 2016. Of this $2.5 billion, 21% was for treatment and 16% was for malaria-related health system strengthening.

7. Why is this study important? What are the implications?

Rima: The findings demonstrate a growing uncertainty about the future availability of DAH for malaria in eliminating countries. At the same time, while GHE has steadily increased, it has not kept pace with declining DAH—particularly in middle-income countries—increasing the risk of deadly and costly malaria resurgences arising from funding gaps. The study highlights the need for sustainable financing solutions, including the need for responsible transitions from external financing until the economies of these countries have sufficiently grown to fill the gap. In addition, there is a need to revise the model of donor funding for malaria away from financing inputs that mostly focuses on the procurement and distribution of commodities towards investing in support for operational improvements, capacity building in program management, improved disease and intervention surveillance, as well as knowledge generation and sharing to strengthen the impact of elimination interventions.

8. What can countries do to fill the gap between available resources and programmatic need until government allocations catch up with the financing transition?

Rima: There are several complementary ways for countries to fill the gap. The Addis Ababa Action Agenda calls on a number of resource mobilization efforts encompassing aid, domestic public resources, and support from the private sector. Many national governments are considering raising health budgets by improving the capacity to raise tax revenue, including the implementation of Pigovian or sin taxes. In the Philippines, a 2012 Sin Tax Reform Bill that increased taxes on tobacco and alcohol generated USD $2.3 billion within two years, increasing the Department of Health budget by 63% in 2015. This revenue has freed up resources which can be used for aggressive elimination of malaria and other diseases.

Countries and the development community are getting more creative about how to finance health. More and more financing institutions, including multilateral development banks, have shown a willingness to engage in blended financing mechanisms that incorporate concessional loans and buy downs from traditional donors. These performance-based mechanisms have great promise in the interim until GHE catches up with GDP increases.