Research Article: Assessing Strategy and Equity in the Elimination of Malaria

Date Published: August 3, 2010

Publisher: Public Library of Science

Author(s): Naman K. Shah

Abstract: Naman Shah critiques the malaria elimination agenda, arguing that it may only be feasible and equitable in limited settings.

Partial Text: After the 2007 Bill & Melinda Gates Foundation meeting at which malaria eradication was declared back on the table [1], the charity was joined in its call by the World Health Organization (WHO) director general, the United States National Institutes of Health, and the Clinton Foundation, among others. A Gates-funded Malaria Elimination Group (MEG) has been convened [2], health ministers have delivered rousing speeches advocating elimination efforts, and scientists and policymakers have published eradication agendas and ideas. The impact of sustained advocacy is evident in the Global Malaria Action Plan that was commissioned by Roll Back Malaria and written by the Boston Consulting Group. The plan outlines a US$110.5 billion strategy for malaria control, including elimination and long-term eradication [3].

Literature of late would lead one to infer that success in malaria elimination will be determined by the application of current interventions and the development of novel ones. According to the MEG’s malaria elimination prospectus, more than 30 countries are either planning to or attempting to eliminate malaria [7]. The plan suggests that high population coverage of control tools (artemisinin combination therapies, rapid diagnostic tests, indoor residual spraying, and insecticide-treated bed nets) can eliminate malaria in these countries. For other areas, namely high-transmission zones, new control methods are deemed necessary in order to eliminate malaria. Malaria interventions are vital to reducing the economic and health burden of the disease. But can the application of biomedical tools explain long-term changes in malaria incidence?

The brunt of malaria burden, as with many diseases, is borne by the most disadvantaged members of society [16]. Since the distribution of the burden is unfair, one might assume any anti-malaria activity improves equity—i.e., the benefits are equally distributed among members of a community. Empirical studies of who profits from the distribution of public goods (whether drugs or bed nets), however, suggest programs tend to favor those who are better off [17]. The 200-plus page MEG malaria elimination prospectus devotes a section to “equity impact” [7]. Unfortunately, the extent of analysis is a blanket claim that “…elimination programs will, by reaching remaining segments of the population, almost surely prove to be equity enhancing”. While the actual elimination of malaria would be equitable, elimination may fail, and meanwhile elimination programs may not distribute benefits more equitably than present efforts. Most gains of equity in the receipt of goods would result from successful universal coverage, which is already part of many control strategies and not unique to elimination. Overall, the appraisal is limited. Disease targeting alone will not ensure equity; a more complex consideration of equity in malaria elimination is needed.

The elimination of malaria using control tools may be feasible and equitable in limited settings. However, these assumptions may not be valid globally. The potential cost of not addressing these concerns includes a great waste of effort, funds, and goodwill.



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