“If the malaria control program(s) I manage receives 5% of its current funds 5 years from now, would the maximum level of transmission reduction we have achieved during that time be maintained 5 years later?”
I admire those who implement malaria interventions: they plan budgets, distributions, monitoring, diagnosis and consider a myriad of social and economic factors that interact for effective anti-malaria programs. They directly improve the health of individuals and literally save lives.
However, I am concerned that many of those strategies cannot be sustained because of the widely-recognized reasons: dwindling financial and political support that will occur at some point in the future. They will not contribute to “shrinking the malaria map.” These programs are not planning ahead, and the consequence will be at best a return to the status quo and possibly worse.
If we could anticipate an escalating level of support for malaria interventions on a global scale, elimination or sustainable control might be reached. But it is likely that resources to attain this goal globally will not be available simultaneously. Therefore, the limited resources must be used strategically: in order to accomplish and maintain malaria reductions, existing resources must be shifted from areas in which risk has been reduced/eliminated and moved elsewhere. The pot of money simply is not sufficiently large.
If you do not accept this given, then the remainder of this blog will make absolutely no sense. However, if you realize that such reductions are inevitable (regardless of what you think about the prospects of elimination or eradication ) I would like you to consider a categorization scheme for malaria control projects that describes the sustainability of programs and whether they contribute to a global strategic plan.
This is a simple method, the logic of which I hope I can make apparent. Ask the following question of your program, ponder the scenario, and come up with an answer of one word or phrase. “If the malaria control program(s) I manage receives 5% of its current funds 5 years from now, would the maximum level of transmission reduction we have achieved during that time be maintained 5 years later?” There are three reasonable responses:
“Yes!” Congratulations! You are working on a 5/5/5 project. You are on a realistic course toward sustainable control. You may foresee that scaled-up activities will not always be needed because a shift to focused control and surveillance measures will reduce expenses. 95% of the funds you currently have can be applied elsewhere. You may have encouraged changes in human behaviors that reduce risk, and it is reasonable to expect that these will continue. Less diagnosis and treatment cost will be required. Perhaps the vector abundance will be reduced because of durable land use modifications. You may have eliminated the vector in an area where reintroduction can be prevented economically.
“No.” You are working on a program that can end only in reversal of the advances you have made. As long as there are people, parasites and people, the potential to return to “normal” transmission levels exists. This response indicates that while significant benefit may accrue to the individuals who receive treatment and interventions, the program cannot be considered a part of efforts to eliminate malaria nor can they be sustained. The activities of your program are a benevolent contribution to health. While the resources - including will - are available, the program will provide needed protection. When they diminish?
Your answer might be a bit more nuanced than the dichotomy above. For example, “No, but I believe that it is sustainable.” For this to be logical, some of the following must be true: 1. You will achieve elimination in your region, and the current level of funds and means to maintain suppression will be available until malaria is eradicated globally. 2. Reduced program funding will continue to limit transmission because of greater efficiency of measures or an uncontrolled occurrence (e.g. fewer imported cases, deployment of a vaccine, better housing, climate change). More bang for less buck. Perhaps, but that is out of your control. 3. It is impossible to reduce transmission to an acceptable level in 5 years. Fair enough. Why? And if not, how long?.
Do you have a 5/5/5 program? If we are going to “shrink the malaria map,” could someone please post an example of such? Ask your colleagues: do they know of such programs? Can we name an example of even one?