United States Government Accountability Office

Washington, DC 20548 

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

 1

The 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 

 GAO-06-147R Global Malaria Control 
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. 

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 Bénin, Eritrea, Ethiopia, Ghana, Kenya, Malawi, Mali, Nigeria, Sénegal, 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. 

 United States), the research and academic community, the private sector, nongovernmental 

organizations (NGO), and foundations.

2

WHO’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. 

3

Assessment reports for Bénin, Mali, and Sénegal were in French. For these countries we relied on 

structured interviews. 

4

We 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. 

2 GAO-06-147R Global Malaria Control
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 

Source: GAO. 

CDC

(implementation

support and 

research)

NIH

(research)

USAID

(implementation

support and 

research)

Indirect U.S. funding

(U.S. contributions to multinational organizations 

– not targeted specifically to malaria)

Direct U.S. funding

(Funding for U.S. agency 

malaria programs)

UN agencies

UNICEF, WHO, 

and others 

(implementation

support and 

research)

Other multinationals

Development banks 

– such as 

the World Bank 

(implementation

support)

Global Fund

(implementation

support)

U.S. federal funding 

for malaria control

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 sulfadoxinepyrimethamine (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. 

 5

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

6

In 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. 

3 GAO-06-147R Global Malaria Control
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 

• improved and prompt access to effective treatment, 

• increased use of locally appropriate means of mosquito control, 

• early detection of and response to malaria epidemics, and 

• 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 

 7

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

4 GAO-06-147R Global Malaria Control
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. 

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 longlasting 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 

5 GAO-06-147R Global Malaria Control
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 

6 GAO-06-147R Global Malaria Control
Enclosure I 

1

Global Malaria Control: U.S. and Multinational 

Investments and Implementation Challenges

Briefing for Congressional Staff

Updated

7 GAO-06-147R Global Malaria Control
Enclosure I 

2

Introduction

Each year, hundreds of millions of people are sickened with malaria and

more than 1 million people die, despite the existence of relatively

simple, safe, effective, and inexpensive methods to prevent and treat 

malaria. Over 80 percent of all malaria deaths occur in Africa, most in

children under the age of 5 and pregnant women.

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 and partnership with multinational organizations such 

as the Global Fund to Fight HIV/AIDS, Tuberculosis, and Malaria (Global 

Fund) and the Roll Back Malaria (RBM) Partnership.1

Concerns have been raised that current global malaria control efforts

and U.S. involvement in those efforts may not be as effective as they 

could be. 1The Partnership—created in 1998—includes representatives from malaria-endemic countries, the Global Fund,

multinational development organizations, donor countries (including the United States), the research and academic

community, nongovernmental organizations (NGO), foundations, and the private sector.

8 GAO-06-147R Global Malaria Control
Enclosure I 

3

Objectives

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. 

2. Describe key challenges to the implementation of

national malaria control programs and strategies for 

addressing those challenges. 

9 GAO-06-147R Global Malaria Control
Enclosure I 

4

Scope and Methodology

For the purposes of our report, we did not include basic and clinical research to develop 

new tools to combat malaria (such as vaccines) in our review of implementation support

activities. 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, the Department of Health and Human Services’ (HHS) 

Centers for Disease Control and Prevention (CDC) and National Institutes of Health

(NIH)—and for 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,1 and the

World Bank.

We interviewed officials from these and other agencies and 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. We have taken into account any issues related to 

the comparability of financial data—such as budget time frames—and other data, and

noted them in these slides as appropriate. 

1WHO’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. 

10 GAO-06-147R Global Malaria Control
Enclosure I 

5

Scope and Methodology (continued)

1Assessment reports for Bénin, Mali, and Sénegal were in French. For these countries we relied on structured

interviews. 

To describe key implementation challenges and strategies for addressing those 

challenges, we reviewed a series of comprehensive country assessments conducted by 

the RBM Partnership with the assistance of U.S. agencies and others. The missions

were conducted in Bénin, Eritrea, Ethiopia, Ghana, Kenya, Malawi, Mali, Nigeria, 

Sénegal, Sudan, Tanzania, Uganda, Zambia, and Zimbabwe.1

In addition, we conducted and analyzed a series of structured interviews—conducted 

via e-mail—with officials from USAID country and regional mission offices and CDC 

field staff in the same countries, with the following exceptions: (1) The USAID field office

in Zimbabwe does not provide support for malaria control. (2) Of these countries, CDC 

has field staff only in Kenya, Malawi, Tanzania, and Uganda. We conducted 19

structured interviews in total.

We interviewed other officials from U.S. 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.

11 GAO-06-147R Global Malaria Control
Enclosure I 

6

Background

U.S. Federal and Other Sources of Funding for Global Malaria 

Control Efforts

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

Other sources of funding for malaria control programs and research include

other donor nations, philanthropic foundations (particularly the Bill and Melinda 

Gates Foundation), and private-sector companies

U.S. federal funding

CDC

(implementation

support and 

research)

NIH

(research)

USAID

(implementation

support and 

research)

Source: GAO.

Indirect U.S. funding

(U.S. contributions to multinational organizations 

– not targeted specifically to malaria)

Direct U.S. funding

(Funding for U.S. agency 

malaria programs)

UN agencies

UNICEF, WHO, 

and others 

(implementation

support and 

research)

Other multinationals

Development banks 

– such as 

the World Bank 

(implementation

support)

Global Fund

(implementation

support)

U.S. federal funding 

for malaria control

12 GAO-06-147R Global Malaria Control
Enclosure I 

7

Background (continued)

Prevention Strategies for Malaria Control

Prevention strategies that target the mosquitoes that carry the malaria parasite

include

• Using insecticide-treated bed nets (ITN)

• Spraying the interior of homes with small amounts of insecticides—a practice

known as indoor residual spraying (IRS) 

• Other options such as using insecticides to control mosquito larvae

Prevention strategies that use medication to prevent malaria include

• Intermittent preventive treatment (IPT) with sulfadoxine-pyrimethamine (S/P) in

pregnant women 

The appropriate mix of prevention strategies for a particular setting varies

according to factors such as

• The local pattern of mosquito and malaria parasite resistance to different

insecticides and medications

• The local pattern of disease transmission

• Operational feasibility and sustainability

Note: There are currently no vaccines available to prevent malaria.

13 GAO-06-147R Global Malaria Control
Enclosure I 

8

Background (continued)

Treatment Strategies for Malaria Control

The key medications for treating people with uncomplicated malaria in

developing countries include

• Artemisinin-based combination therapies (ACT)1

• Amodiaquine

• Chloroquine 

• S/P

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 key medications and are 

not used in all countries. 

The appropriate medication for a particular setting varies according to factors

such as

• The local pattern of malaria parasite resistance to different medications

• The type and severity of the malaria infection

• The age and pregnancy status of the patient

1The artemisinin components of ACTs are extracted from the plant Artemisia annua.

14 GAO-06-147R Global Malaria Control
Enclosure I 

9

Background (continued)

Consensus Agreement of U.S. Agencies and Partner 

Organizations on Approach to Malaria Control 

National malaria control programs and the support that donors

provide should be tailored to the specific needs and practical 

realities of each malaria-endemic country

The four key approaches to malaria control are 

1. Improved and prompt access to effective treatment

2. Increased use of locally appropriate means of mosquito control

3. Early detection of and response to malaria epidemics

4. Improved prevention and treatment of malaria in pregnant women 

15 GAO-06-147R Global Malaria Control
Enclosure I 

10

Background (continued)

Comprehensive National Malaria Control Programs

Comprehensive national malaria control programs involve a range of 

activities, including selecting appropriate prevention and treatment 

strategies, implementing those strategies on a large scale, and

conducting surveillance, monitoring, and evaluation activities

The specific mix of appropriate prevention strategies and treatment 

strategies varies across countries, and sometimes across regions

within a country

Global and local factors can affect implementation of national programs

• Global factors: Global funding, production capacity for malaria-related

commodities (including ITNs, insecticides, and medications), development of

new technologies, and political factors

• Local factors: Local disease epidemiology, economic situation, infrastructure,

human resources, and cultural and political factors

16 GAO-06-147R Global Malaria Control
Enclosure I 

11

Objective 1: U.S. Investments in Malaria Control 

Summary of Direct and Indirect Investments

The U.S. government’s direct investments to support implementation of

national malaria control programs—through USAID and CDC—are 

exceeded by its indirect investments through partner organizations, 

particularly the Global Fund

• More than $68 million of USAID’s FY04 malaria budget, which increased from

almost $30 million in FY2000 to almost $80 million in FY04, was used to provide 

implementation support

• CDC officials estimate that almost $6 million of the agency’s FY04 global malaria

budget, which increased from $9 million in FY2000 to more than $13 million in 

FY04, was used to provide implementation support

• In FY04, U.S. indirect investment through the Global Fund alone exceeded all 

direct investments to support implementation of national malaria control

programs—we estimate that more than $142 million of the U.S. government’s

FY04 contribution to the Global Fund supports malaria control

17 GAO-06-147R Global Malaria Control
Enclosure I 

12

Objective 1: U.S. Investments in Malaria Control 

USAID Malaria Budget by Office and Fiscal Year

In FY04, USAID obligated roughly $56 million to support implementation of programs

in Africa1—almost $41 million through mission offices and an estimated $15 million 

through the agency’s Bureau for Global Health (BGH)

1USAID also supports malaria control programs in Asia, Latin America and the Caribbean, and Europe.

$0

$10

$20

$30

$40

$50

$60

$70

$80

$90

FY 2000 FY 2001 FY 2002 FY 2003 FY 2004

Bureau for Global Health and other central Bureaus

Country mission offices

Regional mission offices

U.S. dollars, in millions

Source: GAO analysis of USAID data. 

USAID’s malaria budget has increased since FY2000

18 GAO-06-147R Global Malaria Control
Enclosure I 

13

Objective 1: U.S. Investments in Malaria Control 

USAID Malaria Obligations (FY04) by Type of Investment and Top 

Recipients

More than $68 million (86%) was used to provide implementation support for 

national malaria control programs

More than $50 million—roughly 63%—provided implementation support through NGOs. Top

recipients included

• Academy for Educational Development — $9.5 million

• Population Services International — $5.6 million

More than $18 million—roughly 23%—provided implementation support through 

partnerships with CDC, multinational organizations, and national ministries of health. Top 

recipients included

• WHO — $8.6 million

• CDC — $5.5 million

Almost $9 million (11%) was used to support research and development efforts for

new medications and vaccines. Top recipients included Walter Reed Army

Institute of Research, Malaria Vaccine Initiative, and Medicines for Malaria Venture

More than $2 million (3%) was used for USAID internal administrative and staff 

costs

19 GAO-06-147R Global Malaria Control
Enclosure I 

14

Objective 1: U.S. Investments in Malaria Control 

USAID Implementation Support Activities1

USAID implementation support covers a broad range of activities

including 

• Supporting updates to national prevention and treatment policies, including training

technical and clinical staff, and developing surveillance and monitoring systems

• Supporting commodity distribution programs, including using vouchers to subsidize

the cost of nets to individuals and some direct purchasing of commodities

• Supporting national efforts to obtain additional funding from other organizations, 

particularly the Global Fund

1Unless otherwise noted, the implementation support activities described on slides 14 through 18 were reported 

in March 2005 by 36 USAID mission offices and USAID’s BGH. The reported information may not capture all 

activities conducted.

20 GAO-06-147R Global Malaria Control
Enclosure I 

15

Objective 1: U.S. Investments in Malaria Control 

USAID Implementation Support Activities—Prevention Support

(FY04)

32 of 36 USAID mission offices and the BGH reported providing a range of 

support for implementation of prevention programs, such as

Supporting implementation of specific types of prevention strategies

• ITNs—29 mission offices (21 of 23 in Africa) and the BGH

• IRS—10 mission offices (5 of 23 in Africa) and the BGH

• IPT in pregnant women—16 mission offices (16 of 23 in Africa) and the BGH

Providing subsidies or distributing vouchers to support ITN programs

• 13 mission offices and the BGH

Training technical and clinical staff regarding prevention

• 12 mission offices

Conducting community education or social marketing programs for ITNs and IPT

• 10 mission offices

Supporting updating of national prevention policy to include IPT

• 8 mission offices and the BGH1

1The BGH reported that, as of March 2005, a total of 21 countries have adopted IPT, 6 of those in 2004.

21 GAO-06-147R Global Malaria Control
Enclosure I 

16

Objective 1: U.S. Investments in Malaria Control 

USAID Implementation Support Activities—Treatment Support

(FY04)

33 of 36 USAID mission offices and the BGH reported providing a range 

of support for implementation of treatment programs, such as

Supporting updating of national treatment policy to recommend ACTs for people

with uncomplicated malaria

• 18 mission offices and the BGH1

Developing monitoring or surveillance systems to detect drug resistance and

epidemic outbreaks to guide changes to national treatment policies

• 21 mission offices and the BGH 

Training technical and clinical staff regarding treatment

• 21 mission offices

Directly purchasing ACTs for treatment

• 6 mission offices

1The BGH reported that, as of March 2005, a total of 29 countries have changed their national treatment policy.

22 GAO-06-147R Global Malaria Control
Enclosure I 

17

Objective 1: U.S. Investments in Malaria Control 

USAID Implementation Support Activities—Supporting

Commodity Distribution and Direct Commodity Purchases (FY04)

Support for commodity distribution1

• USAID supported various commodity distribution efforts, including programs that 

provide vouchers to subsidize the cost of nets to individuals, such as

• NetMark (a USAID initiative focused on public-private investment to increase 

ITN use), which spent $318,000 to subsidize the cost of nets

• Subsidized ITN distribution through antenatal care clinics in Benin

• Community-based distribution of treatment through NGOs in Rwanda

Direct commodity purchases

2

• 20 of 36 USAID mission offices reported commodity purchases totaling almost $5.7

million

• Almost $4.9 million for prevention commodities, including more than $4.1 

million for long-lasting insecticidal nets (LLIN), which are preferable because 

they can remain effective for as long 5 years, in comparison with traditional 

ITNs which require retreatment with insecticide roughly every 6 to 12 months

• Roughly $830,000 for malaria medications, including almost $500,000 for ACTs

1Systematic data are not available on the quantities of various commodities provided with USAID support. 2Updated data on FY04 commodities purchases were reported by mission offices to the BGH in May and June 2005.

23 GAO-06-147R Global Malaria Control
Enclosure I 

18

Objective 1: U.S. Investments in Malaria Control 

USAID Implementation Support Activities—Other Support (FY04)

Supporting national efforts to develop Global Fund malaria grant

applications in order to obtain additional financial resources

• 23 mission offices and the BGH

Providing salary support for in-country staff working within the national

malaria control program

• 8 mission offices and the BGH

Supporting integration of malaria commodity distribution and 

community education programs into antenatal care settings

• 14 mission offices and the BGH

24 GAO-06-147R Global Malaria Control
Enclosure I 

19

Objective 1: U.S. Investments in Malaria Control 

USAID Implementation Support Activities—Data on Results

Systematic data on malaria-specific outputs, outcomes, and impacts resulting from 

USAID investments are not readily available, in part due to resource constraints

• USAID requires mission offices to report annually on missionwide activities, but 

comprehensive malaria-specific reporting is not required

• According to USAID officials, collecting nationally representative data on key impact 

indicators—such as all-cause mortality in children under age 5—is time consuming 

and expensive; for example, national impact surveys cost $1 million or more and are

conducted roughly every 4 years1

• Mission offices collect data on outcomes—such as percentage of children under age 

5 with access to treatment—and outputs—such as numbers of people trained—but 

systematic reporting of these data to USAID’s central bureaus is not required

Specific USAID-supported initiatives report additional information, such as

• NetMark reported that 56% of households in Senegal in 2004 owned a net or ITN 

• A national malaria control project in Eritrea2 reported a 63% drop in malaria cases

from 1999 to 2003

1USAID has streamlined survey tools to evaluate malaria impact more regularly. 2Funded primarily through the World Bank and implemented with USAID technical assistance to the national 

Ministry of Health.

25 GAO-06-147R Global Malaria Control
Enclosure I 

20

Objective 1: U.S. Investments in Malaria Control 

CDC Global Malaria Budget and Types of Investments

CDC’s global malaria budget increased from $9 million in FY2000 to more

than $13 million in FY04 

CDC estimates that of the agency’s FY04 global malaria budget

• Almost $5.7 million was used to provide implementation support1

• About $3.5 million was used to support basic research efforts

• Almost $4.2 million was used for program support functions within CDC as well as

mandatory costs such as rent and utilities

CDC supports its global malaria control activities with additional funding

from within the agency, other federal agencies (particularly USAID), and 

external organizations (such as the Bill and Melinda Gates Foundation). 

This funding ranged from more than $3 million in FY2000 to almost $7

million in FY04

• This funding is used almost entirely to provide implementation support

1The amounts of CDC’s global malaria budget used to support implementation and basic research are estimates

because CDC does not track its malaria funding according to these breakdowns.

26 GAO-06-147R Global Malaria Control
Enclosure I 

21

Objective 1: U.S. Investments in Malaria Control 

CDC Implementation Support Activities

CDC provides a range of technical assistance to support national malaria 

control programs—including ITN, IPT, and treatment initiatives—such as

• Operational research to validate the effectiveness of different malaria 

prevention and treatment strategies

• Surveillance, monitoring, and evaluation to support updating of national

prevention and treatment policies and assess program effectiveness

• Support for data collection on insecticide and medication resistance patterns

• Surveillance to detect malaria outbreaks that might signal an epidemic

• Human resources support

• Training for malaria control staff 

• Posting of CDC staff to other organizations (such as WHO’s RBM Department) 

• Participation in global coordination mechanisms

• Community education

• Support for design and expansion of national prevention and treatment

initiatives, including commodity distribution programs1 such as a free mass

ITN distribution campaign in Togo

1However, CDC does not directly purchase commodities for distribution. 

27 GAO-06-147R Global Malaria Control
Enclosure I 

22

Objective 1: U.S. Investments in Malaria Control 

Indirect Investments—Global Fund Malaria Funding

The Global Fund is a key source of funding for implementation of

national malaria control programs—particularly the purchase of

commodities—but it does not provide technical assistance for the

implementation of the grants it funds

• As of September 1, 2005, the Global Fund has committed to provide more than 

$1.7 billion for malaria control over the 5-year course of existing malaria grants

• Of the funding currently available to grantees, almost $358 million has been 

disbursed and more than $537 million remains available

• More than $435 million from Global Fund malaria grants has been used or is

currently budgeted to purchase ACTs and ITNs

We estimate that more than $142 million of the U.S. government’s FY04 

contribution to the Global Fund supports malaria control programs

• Because 31% of all Global Fund commitments have been for malaria grants, we

estimate that 31% of the U.S. government’s $459 million contribution to the Fund 

in FY04 supports malaria control grants1

1U.S. contributions to the Global Fund represent about 28% of all donor contributions since the Fund’s creation

in January 2002. 

28 GAO-06-147R Global Malaria Control
Enclosure I 

23

Objective 1: U.S. Investments in Malaria Control 

Indirect Investments—Global Fund Commitments, 

Disbursements, and Commodity Budgets for Malaria Grants

Note: The sum of commodity budgets and remaining funding does not add to total signed grant amounts

due to rounding.

Source: GAO analysis of Global Fund data as of September 1, 2005, except for ACT budgets which are as of August 29, 2005.

Signed malaria grants

Additional approved commitments for malaria 

(contingent on grant performance and availability of funds)

Budgeted for artemisinin-based combination therapies (ACT)

Budgeted for insecticide-treated nets (ITN)

Remaining grant budgets

Estimated amount of current grant budgets for 

commodity purchases (U.S. dollars, in millions)

Grant funding

($358

Disbursed)

$852

($537

Not disbursed)

$231

(ACTs)

$459

(other)

$204

(ITNs)

More than 

 $435 million

 is currently budgeted 

 to purchase ACTs

 and ITNs 

 Remaining grant

 funding for malaria

 control – may support

 commodity purchases

 including ACTs and ITNs

Breakdown of Global Fund commitments for

malaria (U.S. dollars, in millions) – totaling more

than $1.7 billion

$895

29 GAO-06-147R Global Malaria Control
Enclosure I 

24

Objective 1: U.S. Investments in Malaria Control 

Indirect Investments—Global Fund Commitments and

Disbursements for Malaria Grants, as of September 1, 2005

The Global Fund has signed malaria grants worth almost $895 million

• The Global Fund has disbursed almost $358 million of this amount, 86% of this since

January 20041

• Almost $136 million was disbursed in 2004

• Almost $173 million was disbursed January 2005 through September 1, 2005

• Almost $655 million (73%) from signed grants is for countries in Sub-Saharan Africa

The Global Fund has approved an additional $852 million for later years

(years 3 through 5) of existing malaria grants, but these funds are not yet

available to grantees

• This funding is contingent on grant performance and availability of funding

• More than $93 million of this funding has already met the performance requirements

but is awaiting signing of grant agreement extensions

Global Fund officials expect new malaria grants will be approved during

the current round (number 5) of applications

1The first Global Fund disbursement for a malaria grant was in February 2003.

30 GAO-06-147R Global Malaria Control
Enclosure I 

25

Objective 1: U.S. Investments in Malaria Control 

Indirect Investments—Commodity Budgets from Global Fund 

Malaria Grants

More than $231 million from signed grants is budgeted to purchase ACTs1

• Orders for almost $93 million worth of ACTs have been placed since 2003

More than $204 million from signed grants is budgeted to purchase 

almost 46 million ITNs2

• Orders for almost $56 million worth of ITNs (almost 13 million) have been placed

• Almost 84% of funds budgeted for ITN purchases are for LLINs

Global Fund officials did not have readily available data on budgets for 

medications other than ACTs or data on insecticide purchases, but told

us that they are working on systems to track these data

1ACT budget totals were reported by the Global Fund, as of August 29, 2005. 2ITN budget totals were reported by the Global Fund, as of September 1, 2005.

31 GAO-06-147R Global Malaria Control
Enclosure I 

26

Objective 1: U.S. Investments in Malaria Control 

Indirect Investments—Global Fund Efforts to Facilitate 

Procurement of Preferred Commodities

The Global Fund is facilitating ACT and LLIN procurement by allowing

grantees to

• Reprogram approved grants to switch from other medications to ACTs

• Reprogram approved grants to switch from ITNs to LLINs

• Make payments to manufacturers or procurement agents directly from Global Fund 

accounts

• Request funding advances to offset costs of switching to ACTs and LLINs

32 GAO-06-147R Global Malaria Control
Enclosure I 

27

Objective 1: U.S. Investments in Malaria Control 

Indirect Investments—Summary of Other Partners

Malaria-specific commitments (2000-April 2005) of $100

million to $150 million. Additional Bank lending for 

malaria implementation support is available, and the Bank 

has committed to make $500 million to $1 billion available

over the next 5 years. 

Strengthening national health

sectors

The World Bank

Average malaria budget of almost $23.5 million/yr for

2004 and 2005

Clinical and operational research 

as well as training activities

Special Programme for

Research and Training 

in Tropical Diseases

Average budget of more than $340,000/yr in 2004 and

2005 for malaria activities

Quality assurance and evaluation

of mosquito control technologies

such as LLINs and insecticides

WHO Pesticide 

Evaluation Scheme 

(WHOPES)

Average budget of almost $63 million/yr for 2004 and

2005

Policy and strategy formulation, 

and capacity strengthening

WHO’s RBM 

Department

Average budget of almost $12 million/yr for 2004 and

2005, but shortfall was about 50% in 2004 (about 97% of 

budget comes from voluntary contributions) 

Coordination of RBM partner 

efforts to support expansion of

global malaria control efforts

RBM Partnership

Secretariat 

Implementation support, direct Almost $39 million in malaria expenditures in 2004 

commodity procurement, and 

procurement services

UNICEF

Funding1 Focus U.N. agencies and 

multinationals

1Because U.S. government general contributions to these organizations are not targeted to malaria, it is not 

possible to attribute a specific amount of their malaria funding to the United States. Instead, we present malariaspecific funding for each organization as a whole. 

33 GAO-06-147R Global Malaria Control
Enclosure I 

28

Objective 2: Key Challenges to Implementation of 

National Malaria Control Programs

1. Inadequate Human Resources

2. Insufficient Financial Resources

3. Coordination Challenges

4. Commodities Challenges—Production, Procurement, and 

Distribution Capacity

5. Limited Surveillance, Monitoring, and Evaluation Capacity

6. National Challenges

• Knowledge gaps at the community level 

• National leadership issues

• Weak health systems infrastructure—Access-to-care issues

Note: These challenges were identified, in part, through structured interviews with USAID and CDC officials

working in 13 countries and two regional offices in Sub-Saharan Africa.

34 GAO-06-147R Global Malaria Control
Enclosure I 

29

Objective 2: Key Challenges to Implementation 

Inadequate Human Resources

Staff shortages and lack of necessary skills and training

• Most countries reported shortages in numbers of adequately trained staff

• Shortages were reported for general malaria control program staff, staff with

specialized skills such as supply chain management, and clinical staff at 

various, and sometimes all, levels of the health system

• National malaria control programs in several countries reported a lack of senior

management staff

Examples of reported consequences

• Delays in implementation and inadequate health care delivery

• Technical staff diverted from their responsibilities to take on budgeting and 

planning responsibilities

• Inappropriate use of medications for treatment 

• Resistance among some clinical staff to dispensing recommended medications

35 GAO-06-147R Global Malaria Control
Enclosure I 

30

Objective 2: Key Challenges to Implementation 

Insufficient Financial Resources

Lack of funding for program implementation and donor support 

activities, including

• Updating of national prevention and treatment policies

• Establishment of monitoring, evaluation, and surveillance systems

• Capital investments—such as the purchase of equipment for IRS programs—

needed to support effective policy implementation

Examples of reported consequences

• Delays in implementation of updated prevention and treatment policies

• Limited capacity to expand a newly integrated policy involving the coupling of

ITN use with IPT

• Inability of programs to purchase a sustainable supply of insecticides, spray 

equipment, and vehicles for mobilization of spray teams needed to effectively

implement IRS programs

• Limited use of available research and monitoring and evaluation data to make

program implementation more effective

36 GAO-06-147R Global Malaria Control
Enclosure I 

31

Objective 2: Key Challenges to Implementation 

Insufficient Financial Resources (continued)

Lack of funding for commodity procurement, distribution, and consumer

purchase

• High up-front costs for newer commodity types

• ACTs are 10 to 20 times more expensive than other malaria medications

• LLINs cost more up front (although they may cost less over time)

• Inability to provide sufficient subsidies to promote consumer purchases

• Costs due to national tariffs/taxes on commodities and raw ingredients

Examples of reported consequences

• Higher overall program costs related to newer commodities

• Barriers to access to commodities resulting from out-of-pocket costs to

individuals—in one country, ITN sales increased significantly only after the

subsidized price was reduced to about $0.65 per ITN

• Supply problems caused by high tariffs—in one case, a 75% tariff on imported 

ITNs virtually cut off international supply and overwhelmed local manufacturers, 

leading to a local shortage of ITNs

37 GAO-06-147R Global Malaria Control
Enclosure I 

32

Objective 2: Key Challenges to Implementation 

Coordination Challenges

Difficulties in coordinating across a range of partners in malariaendemic countries, including

• Ministries of Health across national, regional, and local levels, as well as 

national officials from other sectors (such as agriculture)

• U.S. agency and partner organizations

• Relevant private-sector companies

• The research community

Examples of reported consequences

• Disconnects between national prevention and treatment policies and local 

implementation

• Convoluted implementation of combination therapy across national and 

international partners

• An ITN subsidy policy that may not most effectively reach the most vulnerable 

groups

38 GAO-06-147R Global Malaria Control
Enclosure I 

33

Objective 2: Key Challenges to Implementation 

Commodities Challenges—Production Capacity

ACTs—Global production capacity shortages due to

• A single ACT product—manufactured by Novartis—having been prequalified

through WHO’s Prequalification Project

1

• Limited information available to generate reliable demand forecasts

• Lag time of 9 to 12 months from cultivation of plants to finished products

• Insecure supply with large-scale cultivation primarily limited to China and 

Vietnam—Novartis reports that almost all of its supply comes from one company

Examples of reported consequences

• Producers reluctant to base investments on existing demand forecasts

• Long delays from time orders are placed to delivery

• Products sometimes not available for purchase

• Some countries choosing not to purchase recommended ACTs or to delay 

changes in national treatment policies until ACT supply is more predictable

Global and local production capacity shortages are also reported for 

LLINs, with similar consequences

1As an interim measure, WHO has given time-limited approval, based on review of quality and manufacturing data, 

for the purchase of several other ACT products that have not yet completed the full prequalification process.

39 GAO-06-147R Global Malaria Control
Enclosure I 

34

Objective 2: Key Challenges to Implementation 

Commodities Challenges—Procurement and Distribution 

Capacity

Ineffective/inadequate forecasting and stock management due to

• Lack of staff experienced with supply chain management

• Inadequate infrastructure for large-scale commodity procurement and

distribution

• Limited national capacity to ensure the quality of imported and locally

manufactured commodities

• Inadequate information systems to track commodity stocks at various levels of 

the health system

Examples of reported consequences

• Frequent shortages of S/P in certain locations despite available national supply

• Some cases of substandard or poor quality ITNs and drugs being sold

40 GAO-06-147R Global Malaria Control
Enclosure I 

35

Objective 2: Key Challenges to Implementation 

Commodities Challenges—Procurement and Distribution 

Capacity (continued)

Procurement procedural delays due to

• Delays in signing of agreements between government ministries and a

procurement agent

• Global Fund procurement standards

• Nontransparent Ministry of Health procedures for purchasing commodities using

Global Fund monies

• Lengthy customs clearance processes for commodities

Examples of reported consequences

• Recommended drugs being replaced with less appropriate choices 

• Procurement delays of 1 month or more—which have been especially 

problematic in emergency situations such as epidemic outbreaks—due to 

lengthy customs clearance procedures

41 GAO-06-147R Global Malaria Control
Enclosure I 

36

Objective 2: Key Challenges to Implementation 

Limited Surveillance, Monitoring, and Evaluation Capacity

Surveillance and monitoring system weaknesses

• Limited data on insecticide and drug resistance patterns

• Weak epidemic surveillance systems

Examples of reported consequences

• Need for investments by U.S. agencies and other partners to gather resistance

data to inform updates to national prevention and treatment policies

• Delays in epidemic detection resulting in high rates of morbidity and mortality

Program evaluation limitations

• Lack of systematic information on donor support activities

• Lack of sufficient baseline data on country situation before program expansion

Examples of reported consequences

• Limited ability to assess impacts and outcomes that can be attributed to malaria

control programs

42 GAO-06-147R Global Malaria Control
Enclosure I 

37

Objective 2: Key Challenges to Implementation 

National Challenges

Knowledge gaps at the community level

• Limited awareness of malaria signs and symptoms and appropriate use of 

medications for treatment

• Lack of knowledge about prevention tools, including ITNs, IRS, and IPT

• Disparities in awareness and ITN use between urban and rural areas

National leadership issues

• Lack of political support for malaria control in some countries

• Lack of government authority, particularly for national malaria control programs

• NGOs operating independently of national policies in some countries

Weak health systems infrastructure—Access-to-care issues

• Limited number of clinics, laboratories, and trained staff in rural areas

• Poor rural transportation infrastructure

• Delayed access to appropriate treatment—in one country, fewer than 5% of

patients were treated within 24 hours of the onset of fever

43 GAO-06-147R Global Malaria Control
Enclosure I 

38

Objective 2: Key Strategies for Addressing

Implementation Challenges

According to USAID and CDC officials working in Africa, various

strategies are being used to address implementation challenges faced 

by national malaria control programs

1. Strategies for Addressing Human Resource and Access-to-Care

Issues

2. Strategies for Securing and Effectively Using Additional Funding

3. Strategies for Improving Commodity Production and Procurement 

Capacity for ACTs, ITNs, and LLINs

4. Strategies for Addressing Commodity Distribution and Use Issues

44 GAO-06-147R Global Malaria Control
Enclosure I 

39

Objective 2: Key Strategies

Addressing Human Resource and Access-to-Care Issues

Training community health workers

• Multiple countries are training large numbers of community health workers or 

health extension workers (e.g., 25,000 in Ethiopia) to deliver malaria prevention 

and treatment services at the local level—training includes skills such as

appropriate diagnosis of malaria, delivery of medications, appropriate use of

ITNs, and health education

Integrating malaria program activities into antenatal care clinics, immunization

programs, and other services

• USAID, CDC, and partners are supporting efforts to integrate malaria

commodity distribution and community education programs into antenatal care

clinics and immunization programs

• This integration leverages and strengthens existing health care services

• It also provides malaria control services at a key point of access to care 

that is used by pregnant women and children under age 5

• Malaria programs are being integrated with some national efforts to expand HIV

services

45 GAO-06-147R Global Malaria Control
Enclosure I 

40

Objective 2: Key Strategies

Securing and Effectively Using Additional Funding

Supporting the implementation of national programs with funding from existing

Global Fund grants and/or applying for additional Global Fund grants

• Most countries are using Global Fund grants—or have submitted new grant 

applications—to support ACT, ITN (including LLIN), IRS, and IPT initiatives

Seeking funding from the World Bank, other multinational organizations, donor 

nations, and the private sector to support implementation of national programs

Obtaining technical assistance from U.S. agencies and others to help secure 

additional funds and develop local capacity to effectively use those funds

• U.S. agencies and partner organizations reported playing a key role in

supporting national efforts to secure additional Global Fund resources

• These agencies and organizations also provided technical expertise and 

developed local capacity to ensure that Global Fund and other available 

resources are used effectively

46 GAO-06-147R Global Malaria Control
Enclosure I 

41

Objective 2: Key Strategies

Improving Commodity Production and Procurement Capacity for

ACTs, ITNs, and LLINs

The Global Fund will, at a country’s request, make direct payments to ACT, ITN, 

and LLIN manufacturers to facilitate procurement processes1

Improving demand forecasting for ACTs—with USAID and other support—by 

anchoring estimates to data from partners and countries

Using risk capital from USAID to promote local cultivation of Artemisia annua and 

develop local production capacity for ACTs—Kenya and Tanzania

Using risk capital from USAID to promote increased net production by local

manufacturers—NetMark reports $0.61 of private investment for every $1 the

program invests

Fostering the transfer of LLIN production technology to local net manufacturers

Advocating to reduce or eliminate national taxes on imported nets and raw 

materials used in local production of ITNs and LLINs

1In its 2004 report Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance, the Institute

of Medicine recommended a global subsidy of $300 million to $500 million per year to cover the costs of ACTs, 

but such a mechanism has not yet been established.

47 GAO-06-147R Global Malaria Control
Enclosure I 

42

Objective 2: Key Strategies

Addressing Commodity Distribution and Use Issues

Using a mix of ITN distribution mechanisms—including free distribution, vouchers

and other subsidies, and commercial sales targeted to different populations

Providing LLINs to address need to re-treat traditional ITNs every 6 months

Bundling nets with re-treatment kits

Using regional warehousing and buffer stocks to prevent shortages of ITNs

Prepackaging medications with age and culturally appropriate instructions to 

encourage patients to take the full treatment course

Using rapid diagnostic tests to promote rational use of limited ACT supplies

Targeting IRS activities to regions prone to epidemic outbreaks

Rotating use of insecticides to counter development of resistance to insecticides

Employing extensive community education efforts, including training local drug

retailers and pharmacists on appropriate use of ACTs and teaching mothers and 

local health care providers how to recognize signs and symptoms of malaria and

use ACTs and ITNs

48 GAO-06-147R Global Malaria Control
Enclosure I 

43

Concluding Observations

The amount of funding available to support implementation of national

malaria control programs in endemic countries has increased in recent 

years, in part due to increased investments by the U.S. government,

both through such organizations as the Global Fund and through its

own agencies. Since the beginning of 2004, the Global Fund in 

particular has become a key source of funding; however, it does not 

provide technical assistance to its grantees. 

Endemic countries continue to face significant challenges to 

implementing their malaria control programs. Many report limited

financial and human resources and still require technical assistance to

develop the capacities needed to use available funding effectively.

USAID and CDC, along with various U.N. agencies, have begun to 

address some of these challenges and have provided technical 

assistance, but more remains to be accomplished.

49 GAO-06-147R Global Malaria Control
Enclosure II 

Comments from the Department of Health and Human Services 

50 GAO-06-147R Global Malaria Control 
Enclosure II 

51 GAO-06-147R Global Malaria Control
Enclosure III 

Comments from the U.S. Agency for International Development 

52 GAO-06-147R Global Malaria Control 
Enclosure III 

53 GAO-06-147R Global Malaria Control
Enclosure III 

54 GAO-06-147R Global Malaria Control
Enclosure III 

(290436) 

55 GAO-06-147R Global Malaria Control
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