Leadership interview: The RBM Partnership has set new ambitious goals
Interview with Dr Robert Newman, Director of the World Health Organisation's Global Health Programme and with Mr David Brandling-Bennett, Deputy Director of the Malaria program at the Bill & Melinda Gates Foundation
The RBM Board recently approved changes in the targets of RBM's key strategic document - the Global Malaria Action Plan. Dr. Robert Newman, Director of WHO's Global Malaria Programme and Mr. David Brandling-Bennett, Deputy Director of the Malaria program at the Bill & Melinda Gates Foundation shed light on these developments and how they may shape the next few years of global malaria control efforts.
1. How useful has the GMAP been to the global malaria control effort?
Mr Brandling-Bennett: The GMAP has served to galvanize the malaria community, including both endemic countries and funders, and as an overall guide to what needs to be done during the next 5 years and beyond to achieve the long-term goal of elimination. The GMAP was intentionally developed with input from all members of the community, under the leadership of RBM. There has been remarkable unanimity about the value and importance of GMAP in reaching for the ambitious objective of universal coverage.
2. Why was this update needed at this point in time and what exactly changed?
Dr Newman: The purpose of revisiting GMAP's objectives and targets was to do a reality check on where we are, 10-years into RBM, a few years into the GMAP and only 5-years away from the Millennium Development Goals.
The overall objectives have not changed. We have kept the international goal of reducing malaria cases globally by 75% between 2000 and 2015. With regard to deaths, however, there have been some important differences. The World Health Assembly has called for a 75% reduction in the number of malaria-related deaths in 2015, when compared to 2000. When the Global Malaria Action Plan was developed, that goal was made more ambitious. It called for achieving "near-zero preventable" malaria deaths by 2015. The malaria community has always struggled with the concept of "preventable" deaths. Originally, it referred to deaths occurring at the facility level. In this revision of the GMAP, the Partnership has dropped the word "preventable" because in reality every malaria death is preventable and has affirmed its intention to strive for "near-zero" malaria deaths by 2015.
Reducing malaria deaths to "near-zero" is the right goal, a goal that we need to make every conceivable effort to achieve. But, let us be clear, it is also a wildly ambitious goal. The achievement of the first decade of Roll Back Malaria, which we can take a lot of pride in, is modest compared to what we are asking ourselves to do in the next five years. I have sometimes referred to what we are trying to do as putting a person on the moon. That was incredibly ambitious and what was required to ultimately achieve it was an extraordinary effort of everyone's time, money and focus. When a man walked on the moon, there was a collective celebration. The achievement of near-zero deaths from malaria will be a similar achievement and similar celebration but we won't get there if we don't put similar efforts and resources.
3. How will these more ambitious targets affect the people who are exposed to the disease?
Mr Brandling-Bennett: Over the next years, we expect to see far fewer cases and zero reportable deaths from malaria, which will significantly impact those people living in endemic areas. There should be much less malaria as a result of better coverage with interventions. We are committed to making sure that everyone sleeps under a net or in a space that has been sprayed with indoors residual spraying, that women receive IPTp so that their pregnancies are protected, and that everyone who gets malaria, particularly pregnant women and children, get prompt treatment so that they can recover without any adverse effects from malaria.
4. In the process of revisiting GMAP's targets, partners also discussed what will be required en route between now and 2015. What have been the major outcomes?
Dr Newman: I am pleased about the emphasis that has been placed on accurate diagnosis of malaria and on treatment of confirmed malaria. About a year and half ago WHO changed its recommendation on diagnosis. It recommended that every suspected case in malaria receive a diagnostic test and that treatment be reserved for confirmed malaria cases. This paradigm change reflects the progress made over the past 10 years, as a result of which malaria is a less common cause of fever than it was a decade ago.
Another new addition to the GMAP's objectives and targets has been the emphasis on surveillance. We cannot defeat an infectious disease like malaria, without knowing where that disease is. I often liken the era of trying to defeat malaria without universal diagnostic testing as trying to face one's enemy blindfolded. We knew where our cases of fever were but we did not know, without diagnostic testing, where confirmed cases of malaria were. In an era of resource constraints, the RBM target of achieving accurate surveillance of malaria in all endemic districts is absolutely critical.
5. What are the main threats to success?
Mr Brandling-Bennett:In the current economic situation both endemic and industrialised countries may find it difficult to put in the resources that are needed. So the challenge is to sustain and build upon what we've accomplished and obtain adequate resources to do that.
The other concern is that as malaria declines it may no longer be perceived as a problem. But obviously it needs to be because if we back off from sustaining the measures that are called for in the GMAP's priorities and targets, malaria will come back as it has in the past. Donors tend to shift their attention from one global problem to another. Malaria has commanded a lot of attention in the past 5 years and we need to make sure that it does not go out of fashion. There are many challenges in malaria control that need to be addressed but we cannot afford to take our eye off the targets because if we do that, the disease will come back.
6. What needs to be done to achieve the updated RBM objectives?
Dr Newman: The strategy and the requirements have been laid out in the GMAP, which is a comprehensive Partnership framework. We now need to make it clear that these requirements are not theoretical or optional. If the resource requirements for malaria control globally are in the order of $6 bln a year and the resources available are $2 bln then we can be sure that we will not achieve our targets. It isn't possible to take a disease like malaria, provide a third of the estimated funding and still expect that the disease reduction targets will be reached.
There is enough money in the world. I think that it is not too much to ask for a total of 6 billion USD annually to save an additional 781 000 lives a year. This investment goes far beyond malaria. We need to keep in mind that without achieving the goals for malaria, particularly in the African context, we cannot achieve the health-related MDGs, especially the goal on child survival.
As a Partnership, we have chosen the ambitious path, but with that comes an enormous responsibility. We have achieved incredible successes and should celebrate them. But we face some very stiff challenges ahead to convince the world that not only do we have to maintain the investments to continue distributing life-saving commodities but also that we also need to up that investment. We need to fill the current gap in financing and spend those resources both on life-saving commodities and in a complementary fashion on building capacity and surveillance systems and preventing the emergence of drug and insecticide resistance. Only then can we really reach the incredibly ambitious and aspirational goals that we have set for ourselves.