MALARIA ELIMINATION IN ZANZIBAR - Soper Strategies

the surveillance programs, response teams and other programs
associated with preventing the reintroduction of malaria.
Aid Volatility & Unpredictability
Securing steady financing for the ZMCP will be a serious
challenge regardless of the level of funding sought. Volatility is a
ubiquitous problem with Official Development Assistance (ODA)
for health. Lane and Glassman (2008) analyze the magnitude of
this volatility, illustrating that over the past decade health aid has
deviated by almost 20 percent from trend. Health aid to Rwanda,
for example, was roughly $27 million in the late 1990s, fell to
$4.5 million a few years later, then climbed again to $21 million
in 2006. Health aid and spending in Zanzibar has been volatile
over the past decade as well. ZMCP disbursements climbed from
roughly $250,000 to $3.2 million between 2004-2005, and then
back to $1.1 million in 2006. While the volatility of aid is a
challenge, so is the frequent deviation of disbursements from the
level of aid that was pledged. This deviation can often be large.
Celasun and Walliser (2008) found that, among International
Development Association (IDA) eligible countries between
1990-2005, deviations of disbursements from commitments
were on average 2-3 percent of GDP, and for some countries
as large as 10%. This lack of predictability poses problems for
donor-dependent health programs, but it is a particularly serious
challenge for malaria elimination/sustained control programs
such as that in Zanzibar. Predictable and consistent financing
are particularly important now for the ZMCP because the gains
that have been made are tenuous, and malaria could easily come
back on a wide scale if funding for key control and surveillance
activities slips for even a year or two. As it is extremely uncommon
for donors to commit to smooth and predictable funding,
Zanzibar will need to plan innovative solutions to the challenge
of financing its malaria program.
Changes in Government/Donor Priorities
Another reason why securing malaria financing will be
particularly challenging for Zanzibar is because, at very low rates
of malaria prevalence, the MOHSW will face significant pressure
to reallocate funds to other priorities. With tight budgets and
a vanishing impact of malaria on the health and wellbeing of
its population, the MOHSW will inevitably find it difficult to
protect malaria funding from diversion to other needs. Even
if the MOHSW is committed to continuous malaria funding,
donors are likely to begin prioritizing funding for diseases and
other issues that have a more direct and immediate impact
on public welfare. Of course, continued funding for malaria
programs will have an important impact on public health as it
will facilitate the prevention of malaria resurgence. Convincing
constituents and donors of the dangers associated with drawing
back malaria funding—a lesson that should be learned from
repeated episodes of resurgence—should be a top priority for the
Zanzibar MOHSW. It is important to point out, however, that
the urgency of continued funding need not be a negative message.
the ZMCP may choose to frame its fundraising efforts around
the life-saving benefit of continued control, even though malaria
is no longer widespread. This motivation should be familiar to
western donors, whose countries continue to vaccinate their
populations against absent diseases such as polio and measles.
3 | Financial Feasibility
Finally, just as successfully eliminating malaria and preventing its
reintroduction will require the continued focus and enthusiasm
of the ZMCP team and the Zanzibar population, the MOHSW
will have to fight fatigue and shifting priorities from the donor
community as well. Elimination programs require many years
of stamping out final malaria cases and donors may get tired of
funding the program as the time it takes to achieve elimination
lingers on. Donor foundations are also under constant pressure
to demonstrate the impact of their funding and to respond to
emerging priorities. As malaria imposes less of a public health
burden on Zanzibar, donors may be compelled to shift scarce
funds to other public health programs. This possibility has already
been made salient by the reluctance of PMI—a leading donor for
the ZMCP—to continue funding IRS campaigns in Zanzibar.
Traditional measures used by donors to allocate resources, such
as dollars per disability-adjusted life year (DALY), will make
elimination and sustained control programs appear unattractive
investments relative to other diseases. In order for malaria to
remain a priority, a new framework for prioritizing funding will
need to be adopted by governments and donors, incorporating
measures such as cost/benefit ratios and resurgence risk.
POTENTIAL SOLUTIONS
The severity of these financing challenges is evidenced by the fact
that some donors are already questioning the value of continuing
to fund malaria programs in low-prevalence areas such as Zanzibar.
It will be necessary for the Zanzibar government to work with
donors on developing new forms of financing more suitable
to an elimination program. Given the magnitude of malaria
program costs and the challenges of changing financing systems
and donors, it may be hard to fund all—or even the majority of
activities—through innovative mechanisms. However, the case
can probably be made to Zanzibar’s traditional donor agencies for
some continued funding of malaria programs. If new financing
methods can provide a solid foundation for ZMCP funding,
the pressure to secure traditional funding can be lessened and
the impact of withdrawal of traditional funding sources can be
mitigated. Also, a strong foundation of steady funding through
innovative sources can help ensure the maintenance of essential
malaria activities, such as surveillance and vector control in
known “hot spots.” If innovative financing can be secured for
those core interventions deemed necessary to prevent resurgence,
then an annual drop in funding devoted to less essential activities
will not impose a serious risk.
Fortunately, the idea that aid donors and recipients will need to
adopt “innovative financing for health” (IFH) is gaining currency
in the global health community and a number of examples of this
type of financing are being proposed. Most of the mechanisms
currently under discussion by the global community seek to
increase the magnitude and/or predictability of resources raised
from donors. While these approaches are a welcome addition to
the global health and malaria effort, they will not address the
challenges faced by sustained control and elimination programs
articulated above. These challenges require new mechanisms that
increase the predictability of funding disbursement rather than
funding generation. A number of such mechanisms, some of
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