Global Malaria Control: U.S. and Multinational Investments and	 
Implementation Challenges (16-NOV-05, GAO-06-147R).		 
                                                                 
Each year, hundreds of millions of people are sickened with	 
malaria and more than 1 million people die. Over 80 percent of	 
all malaria deaths occur in Africa, most of them in children	 
under the age of 5. This burden continues despite the existence  
of relatively simple, safe, effective, and inexpensive methods to
prevent and treat malaria. The U.S. government supports the	 
efforts of malaria-endemic countries to control malaria, both	 
directly through agencies such as the U.S. Agency for		 
International Development (USAID) and indirectly through its	 
contributions to multinational organizations such as the Global  
Fund to Fight HIV/AIDS, Tuberculosis, and Malaria (Global Fund)  
and its participation in the Roll Back Malaria (RBM) Partnership.
However, concerns have been raised that current global malaria	 
control efforts may not be as effective as they could be. In	 
light of these concerns, Congress asked us to examine U.S.	 
involvement in global efforts to combat malaria. In this report, 
we (1) describe investments that have been made by the U.S.	 
government to support the implementation of national malaria	 
control programs in malaria-endemic countries, both directly and 
in partnership with other organizations; and (2) describe key	 
challenges to the implementation of national malaria control	 
programs and strategies for addressing those challenges.	 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-06-147R					        
    ACCNO:   A41657						        
  TITLE:     Global Malaria Control: U.S. and Multinational	      
Investments and Implementation Challenges			 
     DATE:   11/16/2005 
  SUBJECT:   Budget controllability				 
	     Drugs						 
	     Health research programs				 
	     Infectious diseases				 
	     Internal controls					 
	     International organizations			 
	     International relations				 
	     Investments abroad 				 
	     Locally administered programs			 
	     National policies					 
	     Research programs					 
	     Preventative health care services			 
	     Africa						 
	     Global Fund to Fight AIDS, Tuberculosis,		 
	     and Malaria					 
                                                                 

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GAO-06-147R

November 16, 2005

The Honorable Judd Gregg

Chairman

Committee on the Budget

United States Senate

The Honorable Russell D. Feingold

Ranking Minority Member

Subcommittee on African Affairs

Committee on Foreign Relations

United States Senate

The Honorable Tom Coburn

Chairman

Subcommittee on Federal Financial Management,

Government Information, and International Security

Committee on Homeland Security and Governmental Affairs

United States Senate

The Honorable Sam Brownback

United States Senate

Subject: Global Malaria Control: U.S. and Multinational Investments and
Implementation Challenges

Each year, hundreds of millions of people are sickened with malaria and
more than 1 million people die. Over 80 percent of all malaria deaths
occur in Africa, most of them in children under the age of 5. This burden
continues despite the existence of relatively simple, safe, effective, and
inexpensive methods to prevent and treat malaria.

The U.S. government supports the efforts of malaria-endemic countries to
control malaria, both directly through agencies such as the U.S. Agency
for International Development (USAID) and indirectly through its
contributions to multinational organizations such as the Global Fund to
Fight HIV/AIDS, Tuberculosis, and Malaria (Global Fund) and its
participation in the Roll Back Malaria (RBM) Partnership.1 However,
concerns have been raised that current global malaria control efforts may
not be as effective as they could be. In light of these concerns, you
asked us to examine U.S. involvement in global efforts to combat malaria.

1The RBM Partnership was created in 1998 to coordinate and increase the
scale of global efforts to reduce the burden of malaria. The RBM
Partnership includes representatives from malaria-endemic countries,
multinational development organizations, the Global Fund, donor countries
(including the United States), the research and academic community, the
private sector, nongovernmental organizations (NGO), and foundations.

In this report, we (1) describe investments that have been made by the
U.S. government to support the implementation of national malaria control
programs in malaria-endemic countries, both directly and in partnership
with other organizations; and (2) describe key challenges to the
implementation of national malaria control programs and strategies for
addressing those challenges.

For the purposes of our report, we reviewed only activities that support
the implementation of national malaria control programs. Support for basic
and clinical research to develop new tools (such as vaccines) to combat
malaria was outside the scope of our review. To describe U.S. investments
to support implementation of national malaria control programs, we
reviewed financial and program documentation for U.S. agencies-including
USAID and the Department of Health and Human Services' (HHS) Centers for
Disease Control and Prevention (CDC) and National Institutes of Health
(NIH)-and for multinational organizations to which the U.S. government
contributes-including the Global Fund, the United Nations Children's Fund
(UNICEF), the World Health Organization's (WHO) RBM Department, the RBM
Partnership Secretariat,2 and the World Bank. We also interviewed
officials from these agencies and other organizations that support malaria
control efforts. We checked the financial and program data for reliability
and determined that they were sufficiently reliable for our purposes.

To describe key implementation challenges and strategies to address those
challenges, we reviewed a series of comprehensive country assessments
conducted in Benin, Eritrea, Ethiopia, Ghana, Kenya, Malawi, Mali,
Nigeria, Senegal, Sudan, Tanzania, Uganda, Zambia, and Zimbabwe.3 In
addition, we conducted-via e-mail-structured interviews with officials
from USAID country and regional mission offices, as well as CDC field
staff, in 13 of these countries.4 We also interviewed other officials from
U.S. agencies and partner organizations and reviewed the literature on
implementation of malaria control programs. We did not independently
evaluate the reported challenges and strategies to address those
challenges. We performed our work from January 2005 through November 2005,
in accordance with generally accepted government auditing standards.

2WHO's RBM Department is responsible for WHO's global malaria control
efforts, and is one organization within the RBM Partnership. The RBM
Partnership Secretariat is a separate organization that is part of the
support structure for the RBM Partnership itself.

3Assessment reports for Benin, Mali, and Senegal were in French. For these
countries we relied on structured interviews.

4We conducted 19 structured interviews in total. We did not interview
officials in the USAID field office in Zimbabwe because that office does
not provide support for malaria control. In addition, within these
countries, CDC has field staff only in Kenya, Malawi, Tanzania, and
Uganda.

Background

USAID, CDC, and NIH are the primary agencies that receive U.S. funding for
global malaria control efforts.5 USAID primarily provides support for
implementation of national malaria control programs but also supports some
basic research. CDC provides a mix of implementation support and funding
for basic research activities. NIH supports malaria research and training
of malaria researchers in endemic countries, but does not provide
implementation support.6 The U.S. government also funds global malaria
control efforts through its contributions to multinational organizations
including the Global Fund, agencies within the United Nations (UN)
system-such as UNICEF and WHO's RBM Department-and development banks such
as the World Bank. (See fig. 1.) Other donor nations, philanthropic
foundations, and private-sector companies also provide significant funding
to support global malaria control efforts.

Figure 1: U.S. Federal Funding for Global Malaria Control Efforts

Malaria is transmitted to people by mosquitoes that carry the malaria
parasite. Malaria control involves both preventing the disease and
treating people who have been infected. Malaria can be prevented by
targeting the mosquitoes that transmit malaria or by using medication to
prevent malaria infections. The primary prevention strategies that target
mosquitoes include using insecticide-treated bed nets (ITN) and spraying
the interior of homes with small amounts of insecticides, known as indoor
residual spraying (IRS). Intermittent preventive treatment (IPT) with
sulfadoxine-pyrimethamine (S/P) in pregnant women is the primary
prevention strategy that relies on the use of medication. Currently, there
are no effective vaccines that can be used to prevent malaria.

5The Department of Defense also provides support for malaria control,
focusing primarily on research.

6In June 2005, the U.S. President announced an initiative that, in
addition to existing U.S. funding, would provide $1.2 billion over 5 years
to support increased malaria control efforts in 15 or more African
countries.

The key medications for treating people with uncomplicated malaria in
developing countries include artemisinin-based combination therapies
(ACT),7 amodiaquine, chloroquine, and S/P. Some of these medications are
available in or used in combination with each other. ACTs are preferable
in many countries due to widespread parasite resistance to chloroquine and
increasing resistance to S/P, particularly in Africa. However, ACTs are 10
to 20 times more expensive than the other medications and are not used in
all countries.

The RBM Partnership currently endorses a four-pronged approach to malaria
control. This approach, which represents the consensus of all partners,
including USAID and CDC, consists of

           o  improved and prompt access to effective treatment,
           o  increased use of locally appropriate means of mosquito control,
           o  early detection of and response to malaria epidemics, and
           o  improved prevention and treatment of malaria in pregnant women.

There is broad agreement among U.S. and international malaria control
experts that national malaria control programs, and the support that
donors provide to those programs, should be tailored to the specific needs
of each malaria-endemic country. Because of the complex nature of malaria
transmission, the appropriate prevention and treatment strategies vary
across countries, and sometimes across regions within a country, depending
on multiple factors such as local patterns of mosquito and parasite
resistance to different insecticides and medications.

Results in Brief

The U.S. government's direct investments to support implementation of
national malaria control programs in endemic countries-through USAID and
CDC-are exceeded by its indirect investments through partner
organizations, particularly the Global Fund. More than $68 million of
USAID's fiscal year 2004 malaria budget-which increased from almost $30
million in fiscal year 2000 to almost $80 million in fiscal year 2004-was
used to provide a range of implementation support, such as updating
national prevention and treatment policies and supporting distribution of
malaria-related commodities, including ITNs, insecticides, and
medications. Almost $6 million of CDC's fiscal year 2004 global malaria
budget-which increased from $9 million in fiscal year 2000 to more than
$13 million in fiscal year 2004-was used to provide implementation support
to national programs, including ITN, IPT, and treatment initiatives. In
fiscal year 2004, the U.S. government's indirect investments through the
Global Fund alone exceeded all direct investments to support
implementation of national malaria control programs. We estimate, based on
total Global Fund commitments for malaria control, that more than $142
million of the U.S. government's fiscal year 2004 contribution to the
Global Fund goes to support malaria control grants. Using U.S. and other
donor contributions, the Global Fund has, as of September 1, 2005,
committed to provide more than $1.7 billion over the 5-year course of the
malaria grants it has approved. The U.S. government's indirect investments
through contributions to U.N. agencies and other multinational
organizations also provide support to national malaria control programs.
However, in the case of these organizations it is not possible to
attribute a specific amount of their malaria funding to the United States.

7The artemisinin components of ACTs are extracted from the plant Artemisia
annua.

Key challenges to implementation of national malaria control programs
include inadequate human resources, specifically, widespread shortages of
adequately trained technical and clinical staff; insufficient financial
resources for program implementation, donor support activities, and
procurement of commodities; coordination challenges, including
difficulties coordinating the activities of a range of partners in
malaria-endemic countries; and challenges related to limited production,
procurement, and distribution capacity for key commodities such as ACTs
and long-lasting ITNs (also known as LLINs). Key strategies that are being
used to tackle these challenges include addressing human resource and
access-to-care issues through training of community health workers and
integration of malaria program activities into antenatal care clinics and
immunization programs; securing additional funding-particularly from the
Global Fund-to support implementation of national programs and obtaining
technical assistance from U.S. agencies and partner organizations to help
ensure that this funding is used effectively; improving global and local
commodity production capacity-particularly for ACTs and LLINs-by reducing
or eliminating applicable taxes and fostering technology transfer to local
manufacturers, among others; and addressing commodity distribution and use
issues through strategies such as using a mix of ITN distribution
mechanisms to target different populations, prepackaging medications, and
employing extensive community education efforts. Enclosure I contains
briefing slides on our findings.

Agency Comments and Comments from the World Bank

We provided a draft of this report to HHS, USAID, and the World Bank. In
its written comments, HHS did not indicate whether it agreed with the
information we presented in our draft report. The agency stated that
continued research to develop new medications, insecticides, and a malaria
vaccine is critical for long-term efforts to control malaria. HHS noted
that in addition to their support for malaria control in Africa, U.S.
agencies support malaria control efforts in other regions of the world.
Although the challenges we describe were identified primarily by officials
working in Africa, our report provides information on all U.S. investments
to support implementation of malaria control programs, not just those in
Africa.

USAID also provided written comments, in which it generally agreed with
the information we presented in our draft report and highlighted the
contributions that the agency has made toward improving malaria-endemic
countries' ability to expand their malaria control programs. However,
USAID expressed concern that the complexity of some of the issues we
discussed in our draft report, such as supporting updating of national
prevention and treatment policies and the subsequent implementation of
those policies, was not adequately addressed. We agree that expanding
malaria control programs is highly complex and challenging, and a section
of our report is focused on identifying the key challenges and strategies
that are being used to address those challenges. USAID also provided
additional information about the 5-year, $1.2 billion malaria initiative
recently announced by the President and updated information in our draft
report, most notably regarding the number of countries that have switched
their treatment guidelines to recommend ACTs and have adopted IPT
prevention policies.

HHS, USAID, and the World Bank all provided technical comments, which we
incorporated where appropriate. In its technical comments, the World Bank
noted that there is need for predictable, medium- to long-term financing
for malaria control programs, but that financing from donor nations tends
to be short term and unpredictable. We have reprinted HHS's written
comments in enclosure II and USAID's written comments in enclosure III.

                                   - - - - -

We provided your staff with the information contained in this report on
August 25, 2005. We agreed with your staff to issue a report to you
containing the information we provided. We are sending copies of this
report to the Secretary of State, the Secretary of Health and Human
Services, the Administrator of the U.S. Agency for International
Development, and other interested parties. We will also make copies
available to others upon request. In addition, the report will be
available at no charge on GAO's Web site at http://www.gao.gov.

If you or your staff have any questions about this report, please call me
at (202) 512-7119. Contact points for our Offices of Congressional
Relations and Public Affairs may be found on the last page of this report.
Martin T. Gahart, Assistant Director; Chad Davenport; Keyla Lee; J. Alice
Nixon; and Roseanne Price made key contributions to this report.

Marcia Crosse

Director, Health Care

Enclosures - 3

           Comments from the Department of Health and Human Services

          Comments from the U.S. Agency for International Development

(290436)

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