Rima Shretta has more than 14 years of experience in global health and development in more than 20 countries spanning several regions. Her expertise focuses on health policy, systems strengthening and financing to improve access to health care in low and middle-income economies. She is currently the Policy and Financing Lead at the Global Health Group’s Malaria Elimination Initiative (MEI) at the University of California, San Francisco Global Health Sciences working on policy and resource mobilization in support of malaria elimination at national, regional and global levels. Prior to UCSF, Rima has held positions at Management Sciences for Health, the World Health Organization and the KEMRI/Wellcome Trust Collaborative Programme. She has served on various advisory groups, working groups and committees including the Roll Back Malaria Board as well as the Global Fund Technical Resource Panel. She is currently seconded by the MEI to the Asia Pacific Leaders’ Malaria Alliance (APLMA) based in Singapore supporting financing and resource mobilization for malaria elimination in the Asia Pacific region.
Q1. Could you briefly describe the results and what made you look into government expenditure trends in the first place?
As the disease becomes less “visible,” government funds for malaria are often diverted to other health priorities that are perceived to be greater health threats, risking a reversal of the recent gains made in malaria elimination.
Donor financing for malaria has declined between 2010 and 2013, and this trend is projected to continue for the foreseeable future. These reductions in external financing are even greater for the sub-set of malaria eliminating countries despite demonstrated evidence on the returns on investment from elimination. By nature, these countries have lower disease burdens and are often middle-income countries and therefore a lesser priority for donors. While domestic spending on malaria appears to be growing, it varies substantially in speed and magnitude across countries. As the disease becomes less “visible,” government funds for malaria are often diverted to other health priorities that are perceived to be greater health threats, risking a reversal of the recent gains made in malaria elimination. These changes come at a critical time when commitment to elimination will be crucial to paving the way to global malaria eradication.
A clear understanding of spending patterns and trends in donor and domestic financing is needed to uncover critical investment gaps and opportunities. We teamed up with the Institute for Health Metrics & Evaluation to look at the trends in Development Assistance for Health (DAH) and Government Health Expenditure (GHE) for malaria eliminating countries from 1990 to 2013 with projections to 2017. This is the first study that tracks DAH and GHE for malaria eliminating countries in a systematic way.
The findings demonstrate three periods for DAH for malaria: a period of moderate growth in the 1990s, accelerated growth of 97% in the first decade of the 2000s, and a decline of 65% since 2010. In the 35 countries included in this review, total financing for malaria grew from $179.5 million to $301.7 million between 2000 and 2013 of which DAH accounted for 19% in 2013. DAH began to decline in 2011, coinciding with the Global Fund’s decision to halt its 11th grant cycle. Between 2010-2013, DAH declined by 65% (from $176 million in 2010 to $62 million in 2013) in the 35 malaria-eliminating countries overall and is projected to further decline through 2017. The Global Fund was the largest external financier for malaria, providing 96% of the total external funding for malaria in 2013.
At the same time, GHE almost doubled between 2000 and 2010, ultimately resulting in about $249 million in 2014 (excluding South Africa as an outlier). In most countries, the upward trend has been maintained. However, GHE has not kept pace with diminishing DAH or rising national GDP rates, leading to a potential gap in service delivery needed to attain elimination.
DAH allocations by service delivery area are not uniform or consistent with epidemiological profiles or regional policies demonstrating the need for greater emphasis on allocative efficiency. Vector control continues to be the largest cost driver across all regions, followed predominately by treatment costs. Less than 10% of their malaria DAH is spent on surveillance, a key malaria elimination intervention.
The discourse on economic financing transition often assumes a linear relationship between economic growth as measured by GDP growth and health spending. Our findings show a wide variation in the GHE on malaria uncorrelated with GDP. While countries will need to increase their own spending on malaria beyond historical trends, substantive policy interventions also will be needed to ensure that malaria elimination is adequately financed in the short-term and that responsible and sustainable strategies are employed in the countries that are transitioning away from donor financing. In addition, it will be essential to ensure that available financing is effectively targeted to interventions that provide the best value for money.
Q2. How easy was it for you to obtain all the data that you needed for your article? What were the main obstacles?
DAH estimates for malaria elimination were built upon the Institute for Health Metrics and Evaluation’s Financing Global health 2015 database. Estimations of financing of particular program areas were based on keyword searches and through the collection of additional data from donors, when available. Some expenditures however, were unable to be allocated to the particular service delivery areas.
Data on GHE were obtained from the annual WHO World Malaria Report (WMR), which includes government expenditure (or budget information when expenditures are unavailable) obtained from countries’ national malaria control program. GHE data were only available from the WMR after 2008. These were triangulated with data published by David Pigott and colleagues in 2012, which collated co-financing data from the Global Fund grant proposals. Each data source has its own concerns. Government expenditure published in the WMR does not generally include spending on healthcare workers and capital costs. In addition, reports from different years are inconsistent, mostly due to weak or non-existing expenditure tracking systems in countries, impeding any temporal comparisons. The data reported by Pigott and colleagues reports the amounts budgeted for human resources, but these numbers are not actual expenditures. Obtaining data from the eighteen countries in this analysis that are ineligible to receive Global Fund financing is more challenging.
Q3. How could expenditure be better organized in your opinion?
There is a need to institute robust mechanisms for tracking health expenditures in countries as well as to collect data in “real-time”
There is a need to institute robust mechanisms for tracking health expenditures in countries as well as to collect data in “real-time” to allow timely policy responses to any changes in financing that may impact service delivery.
In addition, there is a need to move donor funding for malaria control away from an input model that mostly focuses on the procurement and distribution of commodities towards more support for operational improvements, capacity building in program management to ensure sustainability.
Q4. What are you currently working on?
I am currently working on developing the evidence base for resource mobilization in support of malaria elimination at national, regional and global levels. My work focuses on tracking financing trends, developing investment cases, assessing efficiencies and providing support to donors and countries to ensure successful financing transitions. I am currently seconded by the MEI to the Asia Pacific Leaders’ Malaria Alliance (APLMA) based in Singapore supporting financing and resource mobilization for malaria elimination in the Asia Pacific region.