Achieving Malaria Eradication: ‘The Devil is in the Detail’
What is the best way to improve health in developing countries: by targeting (and hopefully eradicating) specific diseases, or by improving national health systems? For Veronique Lorenzo the answer lies in a combination of both.
To mark World Malaria Day 2015, two Heads of Units from the European Commission’s Development and Research Directorates share their thoughts on how health and research can be improved in developing countries, and what they believe needs to be done to eradicate malaria.
The recent Ebola crisis has raised many questions regarding the health sector in developing countries and the role the international community can and should play in supporting this sector.
Ms Lorenzo is the Head of Unit for Education, Health, Research and Culture at the European Commission’s International Cooperation and Development Directorate (DEVCO). Should we target (and hopefully eradicate) specific diseases, or improve national health systems "what’s best? […] After two years in this job I’m starting to think it’s the wrong way of asking questions.”
In the multiannual framework 2014-2020, DEVCO has a currently approved budget of 2.6 billion EUR for health. Sixty percent of this is used to support national bilateral programmes across 17 countries. These are complemented by investments in the Gavi Alliance and the Global Fund to Fight AIDS, Tuberculosis and Malaria.
“The Global Fund has become the major health player in many countries, so several times the size of our bilateral programmes. GAVI is considerably smaller and more targeted on immunisations. But we’re doing a lot of efforts to try and bring together these different strands so that they are coherent with the country strategies to strengthen the health system,” explained Ms Lorenzo.
“A lot more vague and difficult to see and to measure, is the improvement of the health system. What is it? It’s a number of elements of modules that need to work together well. And it’s a long-term investment and complex engagement. If the elements don’t work together then the system doesn’t work,” she added. The main components of the health system include an effective health workforce, access to medicines, infrastructure and logistics, financing and management, and policies. If all of these are in place then this is what will result in a functioning health system.
In April 2001, African Union Heads of State signed the Abuja Declaration pledging a target to allocate at least 15% of their budgets to the health sector. Yet, ten years later only two of the signatories had achieved this target. In fact, many low-income countries invest below 8% of their budget in health. Some complementary funding for health comes from donors and funds; in Zimbabwe the Global Fund finances a quarter of the country’s overall health budget.
The European Commission works with health ministries to support and stimulate countries in domestic resource mobilisation, as in the long-term, improved health financing will need to come from countries themselves. “In countries that are resource rich, it’s a question of better allocation of resources. So it’s about dialogue and it’s about convincing and advocating for more investment in basic services in human development and in health in particular. It works. And this is part of what our delegations do,” said Ms Lorenzo. Staff in delegations are on the front-line communicating with ministries, civil society, private sector, and other actors present in a country to shape opinion and influence policy.
In the short-term, programmes like Gavi and the Global Fund can generate results and make a dent in the fight against diseases. However, over time it’s becoming clear that they too depend on health systems.
For example, many of the malaria endemic countries have very weak health systems, “which makes obviously the implementation of either the prevention tools or the treatment tools very challenging,” explained Line Matthiessen, Head of the Fighting Infections Diseases and Global Epidemics Unit of the EC’s Research and Innovation Directorate-General.
“So we’ve reached a critical stage now where these funds are changing the way they look at things and they look at systems. And they’re looking a lot more to integrate within existing systems and contribute to strengthening those systems,” explained Ms Lorenzo. “So it’s interesting to see that shift in conception and a lot of strategic thinking going into the future of these funds and how they can evolve to go beyond just the immediate service delivery, to serve the broader health agenda.”
But in order to ensure the right to universal healthcare, it’s not just health systems that will need improving. The Ebola crisis also brought to light that developing countries need to advance their own research capabilities. “It was difficult to get clinical trials up and running,” noted Dr Matthiessen.
25 April will mark the eighth World Malaria Day. While globally, malaria mortality rates have been reducing there are still almost 100 countries with on-going malaria transmission, and over 500,000 deaths were reported in 2013.
|Find out more about malaria eradication in the Global Health in EC Development Cooperation where you can view a video of an event held at the European Parliament on "Eradicating Malaria Through Innovation: Where Next After 2015".|
The recent rise in drug resistant malaria parasites is making the disease difficult to treat. In order to eradicate malaria a vaccine will be necessary, but Dr Matthiessen explained that there is little incentive for pharmaceutical companies to develop this as the financial return will be limited – affected populations lack the funds to pay for even the production costs. Both big and small & medium- sized enterprises are encouraged to participate in the research projects to join the different approaches of the private and public sector to tackle the problem. “That is how we can try to combine and use public money to share the financial burden of developing new drugs, better diagnostic tests, as well as new tools to fight the mosquito vector and vaccines that could efficiently protect people.”
|Find out more about local production of medicines in the Voices & Views on Local Production of Generic Medicines in Africa.|
Since 2002 the EU has directly invested over EUR 188.7 million into malaria research projects, making it one of the top five global funders. Also in 2003, 15 EU Member States launched the European and Developing Countries Clinical Trials Partnership (EDCTP); a pioneering initiative funded by the EU (EUR 200 million) as a response to the global health crisis* and the EU commitment to achieving the UN Millennium Development Goals.
EDCTP has forged a new long term sustainable research partnership between European and sub-Saharan African countries.By the end of 2014 it had funded 34 malaria clinical trials for improving the efficacy of treatments and developing potential vaccines. A second programme (EDCTP2) was launched in 2014 for a period of ten years, with an increased investment of EUR 683 million.
The new programme will support the clinical development and testing of new or improved medical treatments and preventions for HIV/AIDS, tuberculosis, malaria and other poverty-related diseases in populations that are most affected by these diseases. It has been extended to also include more neglected diseases like river blindness, sleeping sickness, and bilharzia. At this time 13 African countries** and 13 European countries*** have formalised their membership in the new EDCTP Association, focusing on the need to develop clinical research capacities in Sub-Saharan Africa.
** Burkina Faso, Cameroon, the Republic of the Congo, the Gambia, Ghana, Mali, Mozambique, Niger, Senegal, South Africa, Tanzania, Uganda, and Zambia.
“We have just launched last year, the second phase of EDCTP, which is now really a true partnership between Europe and the Sub-Saharan African countries,” explained Dr Matthiessen. “So jointly they are setting the research priorities and they are jointly responsible for the implementation of the programme.” Participating countries are also expected to put forward funding for the clinical trials, thus ensuring that they are investing into their own systems. To date it has trained over 500 African scientists, while also assisting with regulatory set-up.
* Caused by the three main poverty-related-diseases, HIV/AIDS, malaria and tuberculosis.
For more information: