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