Spending on fight against malaria may not provide good value

15 Nov 2013 11:43 AM

The Public Accounts Committee publishes its 28th report on the fight against malaria.

  • Report: The fight against Malaria (HTML)
  • Report: The fight against Malaria (PDF)
  • Public Accounts Committee
  • The Rt Hon Margaret Hodge MP, Chair of the Committee of Public Accounts, today said:

    “We welcome the Department for International Development’s commitment to tackling malaria, which affected 219 million people in 2010 and led to 660,000 deaths. This disease particularly affects low income countries with weak public health systems.

    “However, we are concerned that spending by DFID on measures to combat the disease, rising each year to £500 million a year by 2015, may not provide good value as the Department does not have good enough infrastructure everywhere to manage the expenditure effectively.

    “There is also a question mark over the Department’s targeting of its spending and its prioritization of resources. About half of the total number of malaria cases worldwide occur in just two countries - Nigeria and the Democratic Republic of Congo - but the Department has been spreading its resources across 17 countries.

    “It now agrees it should do more work in these two countries and less in the others, but has yet to complete an analysis which would ensure well-informed decisions on where to focus resources. The Department needs a clearer understanding of how cost-effective its programmes are in different countries.

    “Cuts in funding carry their own risks. When less money was spent on anti-malaria programmes in Zanzibar, the prevalence of the disease rose again quickly.

    “On the other hand, long-term commitments to combating malaria– clearly necessary if progress is to be sustained – can create an equally long-term dependence on UK funding.  DfID need to plan and support long term sustainable programmes to combat malaria for which developing countries can take responsibility themselves.

    “DfID must ensure their actions do not have unintended consequences. The Department, for example, wants to instil the routine use of bed nets by people in malaria-affected countries, but the mass distribution of free or subsidised bed nets can damage local businesses selling locally produced nets.

    “It is also essential that the Department make the most of quick, cheap and easy diagnostic tests to increase the number of people who can be quickly diagnosed and effectively treated. This could lead to a halving of the current expenditure on drugs.”

    Margaret Hodge was speaking as the Committee published its 28th Report of this Session which, on the basis of evidence from the Department for International Development, examined the Department’s work to control malaria.

    Malaria is a mosquito-borne infectious disease. It is transmitted by mosquitoes drawing infected blood from one person and transmitting it to others. In 2010 there were around 219 million malaria cases worldwide, leading to some 660,000 deaths.

    Malaria particularly affects low-income countries with weak public health systems; it is also a significant factor in constraining their economic growth.

    The Department’s spending to combat malaria will increase from £138 million in 2008-09 to nearly £500 million by 2014-15.  In the absence of a fully effective vaccine, the Department’s strategy is to reduce new infections through distributing proven malaria controls, such as insecticide treated bed nets, and to reduce deaths and illness through supplying drugs to treat infected people.

    The Department plans to undertake a mid-term review of its malaria programme by the end of 2013.

    The Department does not presently allocate its resources according to need  We recognise the scale of need on malaria, but at the same time it is an important value for money consideration that spending takes account of the relative scope for impact in different countries.

    About half of the total malaria cases worldwide are in Nigeria and the Democratic Republic of Congo, but the Department spreads its resources across 17 countries. The Department now agrees that it should be doing more in these two countries and less in other countries. The Department has been concerned about the ability of some of its country offices to expand, and the effectiveness of its operations in different country offices varies, but the Department represented these to us as “teething problems”. 


    Recommendation:  Following its mid-term review, the Department should improve its prioritisation of funding between countries, so it targets its resources on those countries where the need is greatest and expenditure is most effective.

    The Department does not yet understand sufficiently the variations in cost-effectiveness between each of its country programmes. The Department has reduced the costs of the products it buys, such as bed nets.  But it does not have a clear understanding of how cost-effective its programmes are in different countries. As malaria takes different forms in different regions, the Department tailors its approach to local contexts, and it is working to improve its data on spending and impacts in different locations. Drops in funding for anti-malaria programmes can also carry risks: the prevalence of malaria rose again quickly in Zanzibar in the past following the ending of anti-malaria programmes.  The Department must use data intelligently to avoid experiences such as this.

    Recommendation:  Before the next Spending Review, the Department must be able to compare its cost-effectiveness at country level, to identify scope for further gains in value for money. In low prevalence countries, the Department should work with its partners, including the World Health Organisation, to focus on unit cost benchmarks for effective control systems, as well as for treatment.

    The Department has not been sufficiently selective in allocating money to its country offices.  The Department has not been able to rigorously select the best interventions in distributing the increased resources. In 2010, the Department designed a competitive bidding process for its country based teams. However, it gave the teams little time to submit bids, and it then accepted all the bids received. Different solutions are needed in different contexts, for example, not just the use of bed nets for prevention. The Department considers that it knows generally what works in combating malaria but accepts the need to keep pushing to improve value for money.

    Recommendation: The Department should make clear that it expects its country based teams to consider wider options across well-targeted malaria prevention, diagnosis and treatment activities, and it must allow sufficient time for these teams to develop their funding bids. 

    The Department’s on-going growth in expenditure to combat malaria risks creating protracted dependency on UK funding.  UK funding to control malaria has been rising over a period in which global funding has been levelling off. Many African governments under-spend on health compared to the commitments they have made, for example in the 2001 Abuja Declaration. This reflects a dependency on international aid funding to support their health programmes.  We heard of anecdotal examples of the Department’s staff securing non-UK resources, but this appeared to be the exception rather than the norm.

    Recommendation: The Department should require country-based staff to design programmes that require the government of each country to contribute to the programmes funded, and to seek additional non-UK resources.

    The mass distribution of free or subsidised bed nets suppresses local commercial markets. The Department feels that it is 15 to 20 years away from being able to transfer responsibility for bed net provision and replacement to the private sector. The Department wants to instil the routine use of bed nets by populations in malaria affected countries, while encouraging people to buy their own nets, to reduce the degree to which these are funded by donor organisations. In the meantime, commercial suppliers of bed nets in developing countries need public and private demand for their products to develop sustainable markets.

    Recommendation: The Department should develop its programmes to avoid suppressing local commercial markets for “paid-for” bed nets, through targeting its free distributions on those who would not otherwise pay for bed nets.

    The Committee also heard evidence that nets secured from western suppliers were often of an unsuitable size despite the availability of more appropriate products within the local market.  The provision of free nets sourced from Western suppliers were therefore less than ideal whilst also having the unintended consequence of damaging the local business through the provision of free nets in competition with locally produced nets.
    Recommendation: The Department should aim to procure bed nets on a local basis where a failure to do so might have a damaging long term impact upon the objectives of the project being supported.

    The Department has not yet made the most of easy to use rapid diagnostic tests to increase the number of people who can be quickly and correctly diagnosed for malaria.  The development of inexpensive rapid diagnostic tests—small, lightweight disposable blood tests which allow accurate diagnosis of cases without access to microscopes—is an important and effective advance.  These devices have halved the unnecessary use of malaria drugs in trials. However, there has been a reluctance to extend the use of these tests in the private sector. The Department was concerned as to whether shopkeepers would use the tests as they had a financial interest in selling the drugs to treat malaria. The Department considers there is now evidence to merit at least piloting these devices in the private sector.

     Recommendation: The Department should extend its support for rapid diagnostic tests to the private sector on a national or regional scale as well as using public sector outlets. It should do so in countries where competent private sector vendors exist, to seize the unquestionable benefits this would bring.