54862 No. 144 October 1999 Findings occasionally reports on development initiatives not assisted by the World Bank. This article is one such effort. The views expressed here do not necessarily reflect the views of the World Bank Group, the Government of Ghana, or the banks and NGOs mentioned. The Roll Back Malaria Partnership: Defining the role of the World Bank Background the problem Malaria kills over one million people, and causes 300-500 million episodes of illness each year. The majority of the 3,000 deaths each day, and ten new cases every second occur in Africa. The disease not only takes a high human toll; it also impedes development. Malaria has economic impacts through labor efficiency and land use; adversely affects school attendance, performance and cognitive ability; and translates in monetary costs in terms of expenditures by households and the public health sector. The poor are affected most, as they have less access to services, information and protective measures (e.g. nets, screens, prophylaxis), and have less power to avoid living or working within malaria-affected areas. Malaria is on the rise. While efforts to control malaria in the past fifty years have achieved a decline in malaria mortality and morbidity in some regions, the gains have often not been sustained (e.g. Madagascar, Sri Lanka, Central Asia). Emerging drug and pesticide resistances threaten to reduce the availability of effective and affordable prevention and treatment of malaria. Recent epidemics indicate a resurgence of the disease in previously low-risk areas (e.g. the highlands of Kenya), and climate changes are expected to lead to further changes in intensity of transmission. While there is no magic bullet for malaria, a range of cost-effective interventions exist, namely antimalarials for treatment, prophylaxis, insecticide treated materials and residual spraying with insecticide. New tools are available and are continually being developed, such as treatment for severe malaria, rapid diagnostic tests, and combination drug therapy to prevent resistance. As access to prevention, diagnosis and treatment are essential to reducing the burden, malaria can only be effectively controlled within the context of broader health sector development. The main strategies for addressing malaria are timely care-seeking, diagnosis and effective treatment, the use of prophylaxis during pregnancy, and the use of insecticide-treated bednets and/or materials. Something can be done concerted action The global Roll Back Malaria effort was announced by the heads of WHO, UNICEF, UNDP, and the World Bank in November 1998. The proposed initiative responded to requests from the Organization of African Unity ( OAU ) for assistance from the international community to help address the malaria problem effectively in their countries, and requests from Heads of State directly to WHO and the World Bank. The Roll Back Malaria (RBM) partnership consists of malaria-affected countries, UN agencies, the private sector, industry, OECD countries, development banks, NGOs, research entities, and the media. The initiative aims to reduce global malaria mortality by 50 percent by the year 2010. There are six core elements to the strategy to achieve this goal: (i) early detection; (ii) rapid treatment; (iii) multiple means for prevention; (iv) well-coordinated action; (v) a dynamic global movement; and (vi) focused research. A key ingredient to an integrated and coordinated approach within RBM is the identification and recognition of the comparative advantages of each partner involved at the global, regional, and country level, and the development of mechanisms at the country level to translate strategies into action across sectors. The Roll Back Malaria Partnership serves as an example of how a global priority can more effectively and efficiently be addressed. Approaches and mechanisms being developed will be applicable to other global priority public health concerns, such as HIV/AIDS. The need for collaboration, coordination and cross-fertilization with the HIV/AIDS community is well recognized, and both global initiatives recognize opportunities to make advances through a multi-sectoral approach. Identifying the Role of the World Bank In order to begin to define the World Bank's contribution to the RBM aim of a sustainable response to malaria, and to acquire an overview of the country-specific and cross-country needs and opportunities for achieving a sustainable reduction in malaria, six Joint Consultation Missions were undertaken by the World Bank, WHO, and UNICEF. The missions took place from November 1998 to March 1999, and included six countries in Eastern and Southern Africa: Kenya, Uganda, Tanzania, Ethiopia, Malawi, and Mozambique. The contiguous grouping was selected to enable the assessment of cross-country needs and opportunities. The mission teams comprised expertise in malaria control, health systems development, public health, and World Bank operations. Preparations and preliminary work for the missions had been done by local consultants, who also participated during the 5-7 working days the team had in each country. The Joint Consultation team met with key informants including government officials, health sector staff, researchers, NGOs, and manufacturers. Country counterparts were very positive about the joint approach of the agencies involved, and supported the effort to define the mechanisms of partnership within RBM. The missions highlighted the impact malaria has in each of these countries as a leading cause of hospitalization, outpatient care-seeking, death and illness. They concluded that malaria control activities can (and should) be integrated within more existing and upcoming World Bank operations. While more resources are ultimately required, it also became clear that in many cases existing resources were being underutilized, as the public health sector does not have the capacity to absorb and effectively employ the available resources. Potential World Bank contributions within the Global RBM Partnership were identified by the Missions as follows: · Incorporate malaria more effectively into Health, Nutrition percent Population (HNP) Sector Programs · Include tax, trade and regulation issues (e.g. for bed nets, insecticides and pharmaceuticals) in Bank and IMF operations (in Country Assistance Strategies, Policy Framework Papers) · Support the involvement of the private sector in malaria control (foster partnerships with the International Finance Corporation, support appropriate pharmaceutical policies, support social marketing initiatives) · Apply the Bank's ability to work across sectors, i.e. follow up to opportunities to address malaria in non-health sectors (e.g. education, infrastructure, environment) · Consider the role of Health Impact Assessments in avoiding increased malaria risk resulting from infrastructure investments in Africa · Increase disbursements for malaria as absorptive capacity is expanded, and obstacles to resource flows are addressed. One of the objectives of the Joint Malaria consultations was the identification of cross-country needs and opportunities. Issues identified concerned common borders, as well as potential gains in economies of scale due to production, supply, research and training. Support to local networks and access to information was also identified. Most of these activities would not be very costly, and other partners (e.g. WHO, NGOs, research institutes) within the RBM partnership have a greater comparative advantage supporting this aspect of the response. The Bank intends to contribute through strengthening and building upon existing regional institutions who are in a position to support cross-country efforts. A Development Grant Facility (DGF) funding of $1 million for 1998/99 helped establish a regional RBM Secretariat in Africa. The DGF grant for 1999/2000 will support the RBM Technical Resource Networks in Africa. In addition, the Malaria Team within the Africa Region works to ensure that Task Teams are aware of cross-country experiences, issues and opportunities. Putting partnership into practice As a follow-up to the missions, the Malaria Team collaborated with Country Teams to develop some concrete country examples of innovative approaches to address malaria, and employing the Bank's comparative advantages within the Partnership. Progress to date has been made in Ethiopia, Eritrea, Tanzania, and Mozambique ­ within the health sector as well as non-health sector operations. While the missions were a first practical step towards working in partnership on the ground, it became very clear that partnership does not establish itself naturally. Producing some successful "partnership examples" and disseminating these experiences will affect the way the Malaria Team does business in the HNP Sector. Similarly, cross-sectoral approaches are not well-institutionalized, and the Malaria Team seeks to produce and disseminate enough examples to ensure that such approaches can become the norm. Lack of funding is not the key constraint. In most cases the problem is getting the money to flow effectively. The Team identified numerous operations with large undisbursed balances which could be channeled to support malaria initiatives. One hypothesis is that contracting out to NGOs and the private sector, and stronger partnerships with WHO and UNICEF on the ground can improve the absorption of resources. If countries are persuaded to prioritize national efforts to reduce the malaria burden, it would in most places be possible to readily increase the allocation towards those efforts - whether through HNP operations, Education operations, Early Childhood Development, or even Infrastructure Operations. Malaria has been recognized as a corporate priority. Increased recognition of its impact on development efforts, combined with the appreciation that there are effective interventions to control malaria, should result in additional efforts by all Country Teams in malaria-affected countries. The Malaria Team held an intentional workshop in June on the opportunities to address malaria through the infrastructure operations, and a meeting will be held in December 1999 on addressing malaria through the education sector. In addition to the increased operational focus on malaria, the Bank is involved within the private-public partnership "New Medicines for Malaria Venture" (MMV). This is a joint venture between pharmaceutical companies and the public sector to create the incentives to continually develop new drugs for malaria. The Development Economics Research Department of the Bank is working with WHO, Harvard University, the London School of Hygiene and Tropical Medicine, and the African Economics Research Consortium under the Multilateral Initiative on Malaria (MIM) to better understand the economics of malaria. Conclusion The current challenges for the institution include institutionalizing mechanisms of partnership; integrating malaria effectively in health sector reform and sector-wide approaches; effectively working across sectors; and accommodating regional/cross-country approaches. What next? To institutionalize working in partnership, the Malaria Team has agreed with the core RBM Partners to focus the spotlight on some evolving country examples. In these settings, it will work proactively to demonstrate that the partnership in action will result in more than the sum of its parts for clients. It will capture and widely disseminate the lessons learned in these "spotlight countries". The Team is also working to develop guidance to operational staff in tax and tariff issues, the role of subsidies for nets and insecticides, pharmaceutical logistics, investments in environmental vector control, and increasing access to treatment outside the health sector (such as through schools and agricultural extension). It is also pursuing, together with Environment sector colleagues and WHO, the role of Health Impact Assessments within Environmental Impact Assessments to mitigate the increased malaria risk which can result from irrigation, the extension of roads, urban development, water and sanitation, and activities which result in population movement. The combination of these efforts should help further define the role of the Bank in such a global partnership, and improve its capacity to impact upon some of the public health concerns which undermine human development. Most significantly, these efforts should help to Roll Back Malaria in Africa. For more information, please contact Julie McLaughlin, Rm. J10-064, World Bank, 1818 H Street NW, Washington DC 20433. Tel. no. : ( 202) 458-4679; e-mail address : Jmclaughlin@worldbank.org