DOC 1.1

3^RD MEETING OF THE GLOBAL ROLL BACK MALARIA PARTNERSHIP

THE ROLL BACK MALARIA
PARTNERSHIP AND WHO'S
RBM PROJECT

AN INTRODUCTION

The Roll Back Malaria Global Partnership is committed to enabling people to halve the burdens they experience as a result of malaria by the year 2010 through

• Intensified application of existing tools for malaria control
• Use of insecticide-treated mosquito nets and materials by all children and women in endemic areas
• All persons at risk of malaria to be able to access, and use, effective treatment ideally within 8 hours, and certainly within 24 hours, of the onset of symptoms
• All pregnant women at risk to receive preventive (PIT) therapy
• All countries (and communities) at risk of malaria epidemics to be able to respond effectively within one week of an outbreak being confirmed
• development and rapid deployment of novel, cost effective products, approaches and interventions.

The World Health Organization's Roll Back Malaria Cabinet Project has been established to optimise the impact of the Global Partnership to Roll Back Malaria and to ensure the effectiveness of WHO and associated bodies in that partnership.

The Cabinet Project's outputs, over the period 1998-2001, are:

1. A WHO-wide RBM strategy -- with its emphasis on Roll Back Malaria functioning within, and contributing to, Health Sector Development -- that is used at all levels within WHO, and is used as the basis for a consistent and effective response.
2. Global Partnership functioning at all levels, around agreed strategies, to maximise the effectiveness of rolling back malaria in countries.
3. More effective WHO support to capacity development and country action.
4. Research agenda and product development that respond to country needs.
5. Support to community action to roll back malaria through societal movements for better health.
6. Operational systems for monitoring and tracking global and national-level progress with Roll Back Malaria.

This draft document describes the evolving relationship between the RBM partnership and the WHO project. It will be updated and presented at the 3^rd meeting of the Global Partnership to Roll Back Malaria

David Nabarro
Manager
WHO Roll Back Malaria Cabinet Project
Geneva: December 1999

Launched in October 1998, the Roll Back Malaria partnership is committed to halving the global malaria burden by 2010, and sustained reduction subsequently. The Director-General of WHO established the Roll Back Malaria Project earlier in the year to ensure a unified WHO-wide contribution to the global effort – to contribute to health sector development and poverty reduction, and to suggest means to reduce the burdens of other diseases in poor communities. The project also took on the role of secretariat to the partnership. A budget of US$20 million was approved for the Project's preparatory phase (July 98 – Dec. 99). Six key planned outputs have evolved through the preparatory phase:

1. Communication of the RBM concept, strategy, approach and progress, and advocacy to mobilise political commitment and resources;
2. National authorities, development partners and other groups supported as they establish country-level partnerships in support of action to RBM;
3. Technical guidance for action to Roll Back Malaria ensured, through help to develop in-country capacity (for operational research and evidence-based decision making) and provision of consistent, good quality advice as appropriate;
4. Applied research to develop new, or modify existing, interventions to RBM, supported and new products (for diagnosis, treatment and/or prevention) developed;
5. Intensifying outcomes of RBM action through social movements for health: development of medium term strategy;
6. National authorities are enabled to track progress, monitor actions to RBM – and evaluate their impact.

During its first 8 months, the RBM project received only one fifth of its biennial budget. In the past year it has been heavily dependent on support from the UK, Norway, the Netherlands, Sweden, Belgium and the World Bank, as well as WHO regular budget funding. Despite delayed receipt of significant funding, an intense process of consensus building was initiated within all levels of WHO, national governments, research and NGO communities and among development agencies. Principles for the RBM Movement were established – building on malaria control efforts of the past three decades, but going further to establish the malaria burden as a critical development issue. However, as we have only recently had the resources to support essential activities at country level, progress has been significantly slowed.

The Cabinet Project has made considerable progress during the preparatory phase:

• Widespread commitment to the global partnership and movement
• An outline strategy for RBM action, agreed within WHO and many partner organisations
• An advocacy plan based on the principles of the movement and its strategy, with particular emphasis on encouraging community- and country-led initiatives
• Statements of intent and plans of action developed by numerous malaria-affected countries
• Development agencies supporting RBM action throughout the world:
• RBM being established in Mekong, Central Asia, South Asia, Southern Africa, Amazonas, Sahel, Eastern Mediterranean
• Over 20 countries actively mobilising resources and implementing RBM action,
• An additional 30-plus countries negotiating their plans to roll malaria.
• Special emphasis to rolling back malaria within complex emergencies
• Mechanisms for consistent technical support established in priority technical areas, with full involvement of WHO regional offices
• Effective research on new malaria treatments and a public-private partnership (MMV) for new product discovery established, with support from the project;
• An innovative information system for partners based on the World Wide Web
• Imaginative approaches established to bring commercial entities into the partnership
• Establishment of the outline of a mechanism for monitoring RBM progress

The global partnership will need substantial additional resources in 2000 - 2001 as it helps countries implement RBM actions that contribute to a many-fold increase in the proportions of people who avoid malaria infection or are able to access effective treatment when unwell.

The Challenge Malaria is a significant impediment to human development in poor countries. Each year there are more than 300 million episodes of acute malaria illness, primarily affecting the world's poorest populations. Over a million people die each year of the disease and most of them are children. Severe episodes can result in as high as a 25% loss of household earnings Malaria-affected countries lose as much as 6% of their GDP (gross domestic product) as a result of the disease GNP Per capita (1995) Index of Malaria Intensity Figure 1: Malaria is most intense in the world's poorest nations. Source: J.Sacks Malaria death rates have started to rise in Africa Over the last three decades malaria-related death rates have fallen in many regions, particularly Latin America and Asia. As we reach the end of the 20th century, the global death rates due to malaria are no longer reducing and are even on the rise again in Africa. This reflects the emergence of drug resistant parasites, climate changes, population movements and a reduction in public health capacity within national health services. Vector control using persistent organic pollutants – such as DDT – is undesirable because of its adverse consequences for human health and the environment. Some countries have stopped using DDT for mosquito control Because the alternatives are more expensive they have not been able to prevent epidemics. Currently available interventions are, when properly used, cost-effective in reducing the malaria burden within poor communities The malaria burden could be halved through evidence-based decisions, detection of - and rapid response to – epidemics, use of insecticide-treated bednets, early diagnosis, and prompt effective treatment of malaria cases Sustained availability of these interventions requires effective health sectors, able to empower communities to tackle a range of priority health problems.

The Response:   Roll Back Malaria

In the mid-1990s, the Heads of State in the Organisation for African Unity called for renewed efforts to tackle malaria in their continent. WHO and World Bank responded: WHO, in particular, supported accelerated malaria control activities in African countries.

When preparing to stand as WHO's Director General during 1997, Dr Brundtland resolved to build on the work being undertaken within Africa. She proposed a Global Initiative to Roll Back Malaria, reducing the malaria burden faced by poor people through developing health sectors and supporting inter-sectoral action.

She anticipated a long-term global effort (ten to fifteen years), concentrating on improving people's access to malaria control tools of proven success. At the same time new products would be studied and developed – through research and public/private partnerships. The effort would be led by governments of malaria-affected countries, and supported by a range of development agencies, commercial entities, research groups and civil society, all working in partnership. WHO would serve as one of the partners and, at the same time, support the partnership at country, regional and global level.

Within WHO, the RBM initiative was backed through a special mechanism. A five-year Project was established by WHO in July 1998 shortly after Dr Brundtland took office. It has substantial regular budget support, reports to WHO's Cabinet, and is expected to pioneer new ways of working within the organisation. Within weeks, WHO's Cabinet had agreed the plan for the project's 18 month preparatory phase (till December 1999) with a total budget of $20 million.

The Partnership

Dr Brundtland stimulated high level political support for the RBM initiative through interactions with several Heads of State, including those of the G8 nations. Some weeks later, on October 30^th in New York, the Executive Director of UNICEF, President of the World Bank, and Administrator of UNDP joined her in founding the global partnership to Roll Back Malaria and fully committing their organisations to the initiative's goals. The partnership was further consolidated at the first Partner's meeting in Geneva during December 1998.

In recent years, malaria control efforts in many countries have been undertaken under adverse circumstances – under-funded, short staffed, and lacking the commodities they need to be effective. Initially there was some concern that the Roll Back Malaria approach failed to take account of these realities.

Personnel involved in malaria control, speaking out on behalf of those at risk of malaria, hoped that the RBM initiative would enhance ongoing activities essential for effective malaria control in countries. This was particularly relevant in the African region where control programmes were being accelerated through special grants of $10 million per year in 1997 and 1998. The RBM initiative was not set us as a new mechanism for transferring funds. Instead, it was designed to get the best possible results from the efforts of all currently involved in malaria control, to achieve these results through the development of health and other government systems, and to encourage a substantial increase in the resources available to help reduce people's malaria burdens.

In late 1998, the World Bank's newly established malaria group initiated a series of "rapid consultations" with governments and partners in Africa (Kenya, Uganda, Tanzania, Malawi, Mozambique and Ethiopia). These were designed to help the Bank consider how it might be able to invest more in actions that would reduce the malaria burden. National Government, WHO, UNICEF and bilateral development agency personnel also took part in these consultations. Working together, partners were able to start analysing how action to Roll Back Malaria might best be initiated at country level. The consultations revealed real scope for partnership action to address malaria through health sector reform and inter-sectoral action. They indicated a vital need for co-ordination of existing support to country action and building on promising approaches – such as the integrated management of childhood illness (IMCI).

Building Consensus

Early in 1999, concepts for RBM were agreed as a result of extensive debates within WHO regions, among partners, (particularly the World Bank and UNICEF) with representatives of the research community (particularly the Multilateral Initiative on Malaria). Concepts were also debated within WHO headquarters, with the WHO Executive Board, and with potential resource contributors. Frequent meetings between the HQ team, the WHO Africa Regional Director and personnel based at the African Regional Headquarters in Harare led to agreement that existing initiatives on Malaria in Africa would be fused with Roll Back Malaria and taken forward as Roll Back Malaria in Africa.

Project staff then worked with regional colleagues to establish an overarching strategy for the effort to Roll Back Malaria and principles that could be adopted by organisations participating in Roll Back Malaria. The clarification of concepts, strategy and partnership principles, provided the foundation for the first materials for communicating RBM to a wider audience, to be used as a basis for advocacy. The draft brochure for action to Roll Back Malaria "One half of malaria deaths can be prevented in the next 10 years" was first distributed in mid-March 1999, and was pre-tested in Southern Africa. It has proved to be remarkably popular.

The strategy envisaged movements to Roll Back Malaria, at multiple levels. Within countries a wide range of committed organisations, working within a common country-level strategy, would take on RBM action. Within each country partners – with the national government as the principle partner – would support the movement. One of the other partners, WHO, had a particular role to play as provider of technical support, broker of resources and monitor of progress.

There would be a particular place for commercial entities that accept the principles described above: the project explored ways in which commercial entities could become more involved in supporting country Roll Back Malaria action (through public-private partnerships). One oil company is a major contributor to rolling back malaria in a country within WHO's European region: other companies in the mining, oil exploration, agriculture, tourism, advertising and distribution sectors are contributing to RBM action at country level. Companies involved in pesticides, pharmaceuticals and diagnostics also contribute to Rolling Back Malaria at the multiple levels.

The strategy was debated and adapted to the local context through a series of "consensus building and inception meetings". These involved health and finance officials from malaria-affected countries, representatives of partner development agencies and others could discuss and debate how they would like to intensify action to roll back malaria in their countries.

The first took place in the Mekong region early in March, with the combined support of WHO and UNCEF working as an alliance. Vietnam, Thailand and China indicated how they could share their successful experiences with Laos, Cambodia and, most importantly, Burma. Countries agreed to prepare more detailed plans and identify resource needs before the end of 1999.

Country and regional personnel discussed their questions about Roll Back Malaria at the four African sub-regional consensus building and inception meetings held between March and April in Abidjan, Nairobi, Yaounde and Maputo. These involved several weeks of preparation by personnel from WHO regional and country offices, the World Bank, UNICEF, the WHO project, and other partners. With over 300 participants from more than 40 countries, they provided excellent opportunities for dialogue and discussion, and provided a platform from which country teams, with support from the national officials of development agencies, could work on what they intended to do at the country level. There were several requests for the project to provide resources to priority malaria control actions in countries.

The consensus and inception meeting for South Asian countries took place in early May, with intensive dialogue about the feasibility of adopting the RBM concepts throughout the region. The consensus meeting for Central Asian Republics and Kazakhstan took place from June 7^th – 9^th It revealed the potential for joint working to limit the impact of malaria epidemics, and was followed by an inter-regional meeting to expand this co-operation to countries of the WHO Eastern Mediterranean region in August. Consensus-building in the Americas was consolidated at a meeting of Amazonas countries during October 1999 with major emphasis on the role of indigenous people's organisations in implementing RBM action.

Consensus Achieved but Issues still to be resolved

By mid-May 1999 the RBM concepts, strategy, and partnership principles, as well as the approach of the social movement, had been endorsed during six consensus meetings. At the World Health Assembly the consensus was reflected in statements by delegations during the debate and briefing on the Roll Back Malaria partnership. Most were impatient to take forward country level Roll Back Malaria action, using resources raised in-country, and seeking additional funds as grants or loans where possible. Some delegations and observers who wanted to accelerate the phase out of persistent organic pollutants expressed concern about the continuing use of DDT. Others stressed that insecticides are vital for the effective control of malaria epidemics and that DDT is the most cost-effective. The controversy is set to continue for some years. The resolution which defined WHO's contribution to the RBM partnership was passed without incident.

However, delegates from countries who contribute to development assistance questioned whether the emphasis on action through partnerships at country level could succeed when similar attempts to establish sector wide approaches to health development had only proved successful in a limited number of countries. Several questioned whether the strategy might result in stronger and more autonomous malaria control units, undermining efforts at health sector development? Delegates also asked questions about technical issues. They wondered whether the available interventions do have the potential to halve the global malaria burden. They asked whether they be affordable at community level. Delegates asked questions about whether WHO, with its decentralised structure, will be able to quickly harmonise its technical support for malaria control, and work effectively within the context of other partners' agendas.

WHO's Composite Workplan

All WHO's Executive Directors and Regional Directors had indicated their backing for technical, institutional and political aspects of the WHO approach to Roll Back Malaria. This enabled project staff to started work, in April 1999, on a work-plan for WHO's overall contribution to the global RBM partnership. Subsequent work-plan redrafts reflected the increasing involvement of WHO departments in this endeavour. They also reflected the significant institutional transformations within WHO that will also need to be taken forward if initiatives like RBM are to achieve maximum impact. Early drafts of the work-plan were discussed with partners and with resource contributors. They formed the basis of submissions to potential contributors for the Cabinet Project. Significant funds arrived in WHO in late August. These filled a serious funding gap, which was inhibiting WHO's ability to support the intensification of RBM action at country level, to support intervention studies and to back the newly established Medicines for Malaria venture.

Taking stock of progress with rolling back malaria in Africa

Figure 2: Molaria Mortality in Africa

The second meeting of the global RBM partnership was hosted by the WHO Regional Director for Africa and the Cabinet Project in Harare on 30^th June and 1^st July. The meeting considered how best to take forward RBM action in Africa into 2000. There was intense involvement of partners from national governments, development agencies and banks, bilateral donors, multilateral organisations, NGOs, research institutions and bodies and the private sector. Critical issues – such as how partners could most appropriately finance RBM action, how private sector groups could participate in country partnerships, means to catalyse the social movement, links between health sector reform and rolling back malaria - were examined carefully and important new approaches emerged. These are being reflected in national intentions for intensive action to RBM.

July 1999 onwards – challenges for the partnership

Following the sub-regional consensus meetings, national governments worked with WHO regional offices, UNICEF, the World Bank and UNDP, development agencies, regional banks, commercial entities and NGOs to establish processes for taking forward action to Roll Back Malaria. Progress, by country, is reported in document 1.4 in this series.

At around this time, it became clear that if these processes were to act as a foundation for effective long term action, partners would need to work together to address several challenges:

1     A Massive Effort is needed over the next ten years if communities are to be enable to halve their malaria burden

Partners have made RBM project staff aware of the need for a massive intensification of effort

• to prevent those at risk from being affected by malaria, through better access to, and use of, insecticide-treated mosquito nets, and – where appropriate – control of mosquitoes through focused insecticide spraying and environmental control measures;
• to protect pregnant women exposed to malaria through intermittent treatment with anti-malarials;
• to ensure that persons with malaria, particularly children in endemic areas, and all affected by malaria epidemics, can access effective diagnosis and treatment – ideally within eight hours of symptoms, and certainly within 24 hours;
• to ensure that in all communities at risk of malaria epidemics, outbreaks are detected and responded to effectively within a week of onset.

This "scaling up" (perhaps by a factor of 30 in parts of Africa) will need to be undertaken through effective movements involving a range of organisations active at community level, building on existing initiatives (such as the Integrated Management of Childhood Illness), supported through better functioning health systems and inter-sectoral development. To make it possible, significant additional human and financial resources will be required: ideally resources will be made available within the context of sector-wide support for health sector action, or through other pro-poor development strategies. At the same time, extreme under-funding of the existing malaria control programmes in some countries inhibits officials from planning and implementing new and imaginative responses.

2     The massive effort calls for strong and consistent commitment from all partners at the highest level – including national governments

The Heads of State in many countries and the chief executives of several international agencies have indicated their full commitment to Roll Back Malaria. The challenge is to ensure that the commitment is maintained, with continued attention, on the part of all concerned, to checking progress at regular intervals and chasing up all those involved to ensure that the extra effort is being made. To encourage sustained commitments, partners need to ensure sustained, focused and effective advocacy. The forthcoming Summit Meeting on Malaria (April 24^th and 25^th), hosted by President Obasanjo of Nigeria, is an important next step in sustaining high level commitment to tackle the problems of malaria in Africa.

3     Governments and other partners want help to catalyse effective country-level partnerships in support of community RBM movements

There is an increasing volume of requests from governments and other partners working within countries for help with catalysing joint action by all partners within an agreed strategy and plan, based on a reliable analysis of the current malaria and health system situation. Partners want to be able to establish plans which are feasible given the capacity within national and local health systems: this poses massive challenges when publicly-financed health systems are severely under-funded or have only limited capacity to take on new (albeit priority) initiatives. Partners want to be sure that the joint action, which is initiated in support of Roll Back Malaria, takes account of these health system realities – whether the health system is operating effectively, or is severely threatened (eg by economic pressures or a complex emergency).

There has been particular interest in the potential for promoting social movements. This should increase as a result of the extra political commitment and advocacy undertaken by partners. However, several national governments and other partners have indicated that additional human and financial resources are needed to initiate movements given that many of the organisations wishing to participate lack the necessary resources to do so. Development agency partners are starting to mobilise additional resources for country-level Roll Back Malaria action though want to be sure that the strategies and action plans being developed by country-level partnerships offer a reasonable likelihood of contributing to effective RBM actions and, in the longer term, desired outcomes. They have a particular interest in the kinds of strategies and plans that are being developed by country-level partnerships.

4     Partners want help to build in-country technical capacity to support effective RBM action

The variability of the malaria situation within countries – over time, and from place to place - calls for the ready availability of consistent technical expertise. This is needed to guide the appropriate combination of methods for preventing malaria infection (including the use of insecticide treated materials and/or insecticide spraying, the place of toxic insecticides like DDT, and the efficacy of environmental control measures). It is needed to establish appropriate policies and protocols for treating persons who are infected (including appropriate diagnostic measures and anti-malarial medication). It is needed to ensure the best use of information and resources in predicting, and then designing a response to, malaria epidemics. This includes the use of health and geographic information, and the priority to be given to responses within and outside a range of health care systems. Expertise is also needed to help partners establish the best way to use additional resources for health (or, perhaps, for infectious diseases – or even, specifically, for malaria) to support Roll Back Malaria action.

Expertise within many malaria-affected countries is severely limited, and partners seek help from WHO regional offices, or from external organisations with an understanding or regional issues. Currently, the demand for expertise is high. The challenge is to make this expertise available in ways that strengthen in country capacity and provide guidance of the quality and relevance needed to help plan the best use of additional resources. Currently demand outstrips supply in several critical technical areas, and within a number of malaria-affected countries. Means to ensure the availability of this expertise are now being developed in ways that (a) strengthen capacity within countries and regions, and (b) are not wholly dependent on personnel from external agencies. The emphasis is on regional technical support networks.

5     Links between issues being faced within communities as they attempt to Roll Back Malaria, and the priorities of national and international research organisations

During the last few years the malaria research community has sought to establish effective networks which help ensure that the strategies of research funding organisations and the units they support match the needs of communities affected by malaria. The co-sponsored Tropical Disease Research Programme has undertaken pioneering work: it has, for example, initiated a multi-centre study to establish the efficacy of different anti-malarial combination therapies, a programme to develop cost-effective malaria diagnostics, and strategies for the effective treatment of malaria in the home.

The recently established the Multilateral Initiative on Malaria (MIM) has transformed the way in which malaria researchers in industrialised countries and African nations work together on common issues. New public-private partnerships such as the Medicines for Malaria Venture have provided a mechanism which brings together both private pharmaceutical concerns and the international public sector to pursue common interests. Networks to focus global efforts for vaccine research have been established and should hasten the process through which effective candidates are identified.

The success of the Roll Back Malaria partnership will depend on the research endeavours delivering their expected results. The challenge, for the partnership, is to maintain effective links with the research community and to help mobilising the funds needed to support them.

6     Tracking progress, monitoring action and assessing impact

If they are to make the most effective contribution to rolling back malaria, governments and other partners need to be able to track the progress of country partnerships - confirm that they are moving forward as planned, or to identify difficulties and attempt to overcome them. They want to be able to monitor progress with the implementation of actions necessary to Roll Back Malaria. They need evidence that these actions are having an impact on the malaria burden, and to assess the impact. The challenge is to ensure that systems for tracking progress are effective and are used by all partners, and to seek opportunities for obtaining information on the agreed minimum group of indicators relevant to rolling back malaria. At the same time, reliable systems for monitoring impact have to be put in place.

Partners Respond the to the challenge

At the time of writing this report, there are many signs that partners are working together intensively to address these challenges. The February Partners' meeting will provide an opportunity for taking stock of progress, for reviewing the priority challenges for the partnership and for considering what more can be done to address them.

One outstanding issue is the level of additional resources that will be required for the success of efforts at country level to Roll Back Malaria. It is estimated that the partnership will need to mobilise an additional amount of well over $300 million per year in support of country action (some estimates put the figure at $500 million, and during 2000 the RBM Project will attempt to establish a more reliable figure). A further sum will be needed to support intervention studies and product development. Some of these funds will be required by the Cabinet Project: its budget has tentatively been set at $55 million per year in 2000 and 2001. (The figure may change once the WHO-wide work-plan for rolling back malaria in 2000 and 2001 has been completed). However, present indications suggest that the project will require a substantial increase in available resources (compared with $20 million for the 1998 – 1999 biennium) if it is to be able to support an effective WHO-wide contribution to the work of the global partnership to roll back malaria.

WHO Roll Back Malaria Cabinet Project: Progress Reports

The succeeding papers describe the progress of activities WHO's RBM Cabinet Project. Papers 1.2 and 1.3 indicate the progress of activities and achievements in relation to the six intended "outputs" of the Roll Back Malaria Cabinet Project established in the Cabinet Project logical framework and workplan as developed in July 1998 and modified in early 1999. They also indicate the income of the Cabinet Project over time and the pattern of resource use by each output. Information on progress with country level RBM partnerships is contained in paper 1.4. This introduction will be updated as a result of inputs from partners and will be presented at the February 2000 partners' meeting.