Challenges in tracking global malaria spending
Authors: Joey Brooke, Devi Sridhar
Journal: The Lancet Infectious Diseases (2019)

In The Lancet Infectious Diseases, Joseph Dieleman and colleagues describe how global malaria spending has changed between 2000 and 2016, using data from 106 malaria-endemic countries. They analyse the proportions of government spending, out-of-pocket spending, and prepaid private contributions to total malaria spending, including the costs for treatment seeking, care, and drugs. Although total annual malaria spending has increased in this period to US$4·3 billion, they conclude that we are still off meeting target annual funding by 2020 by $2·3 billion. If we take these results at face value, we can see development assistance for malaria increased by 30·2% from 2000 to 2010. Since then, it has decreased annually by 1·9%, but by 2016, development assistance was nonetheless contributing to 56·5% of total malaria spending.1Dieleman JL Haakenstad A Harle AC et al.Tracking spending on malaria by source in 106 countries, 2000–16: an economic modelling study.Lancet Infect Dis. 2019; (published online April 25.)http://dx.doi.org/10.1016/S1473-3099(19)30165-3PubMed Google Scholar Although out-of-pocket spending appears to have decreased from 26% (2000) to 13% (2016) of total malaria spending, it has actually seen an absolute increase of $249 million.1Dieleman JL Haakenstad A Harle AC et al.Tracking spending on malaria by source in 106 countries, 2000–16: an economic modelling study.Lancet Infect Dis. 2019; (published online April 25.)http://dx.doi.org/10.1016/S1473-3099(19)30165-3PubMed Google Scholar Whereas absolute government expenditure has increased between 2000 and 2016, its percentage contributions have decreased from 55% (2000) to 28% (2016).1Dieleman JL Haakenstad A Harle AC et al.Tracking spending on malaria by source in 106 countries, 2000–16: an economic modelling study.Lancet Infect Dis. 2019; (published online April 25.)http://dx.doi.org/10.1016/S1473-3099(19)30165-3PubMed Google Scholar However, these findings should be read with attention to the limitations of the underlying data and analysis. We highlight two in particular. First, in two of the study's main sources, data availability for aggregate government spending did not include spending on malaria inpatient and outpatient care. These figures had to be calculated separately, by means of estimates on volume of care and prices for treatments. Although relying on estimates is widely used in global health, there is concern that we have become too reliant on them and should instead be investing in strengthening the capacity to produce quality data where it is absent.2Byass P The imperfect world of global health estimates.PLoS Med. 2010; 7: e1001006Crossref PubMed Scopus (54) Google Scholar, 8Tichenor M Sridhar D Metric partnerships: global burden of disease estimates within the World Bank, the World Health Organisation and the Institute for Health Metrics and Evaluation.Wellcome Open Res. 2019; 4: 1-19Crossref PubMed Scopus (20) Google Scholar We welcome the creation of credible estimates of total malaria spending, as well the authors' initial steps towards identifying areas to improve data quality, but providing specific recommendations on what these improvements should consist of and how to achieve them should be an important point in all discussion sections for papers relying on such estimates. Second, volumes of care were calculated on the basis of public treatment seeking and specifically treatment seeking for fever, and this method was also used for out-of-pocket spending calculations. However, use of fever as part of the methodology for estimating malaria cases has been widely criticised for contributing to the overdiagnosis and mistreatment of malaria;2Byass P The imperfect world of global health estimates.PLoS Med. 2010; 7: e1001006Crossref PubMed Scopus (54) Google Scholar in particular, in malaria-endemic countries, most individuals presenting with fever are prescribed antimalarials.3Leslie T Mikhail A Mayan I et al.Overdiagnosis and mistreatment of malaria among febrile patients at primary healthcare level in Afghanistan: observational study.BMJ. 2012; 345: 5-9Crossref Scopus (59) Google Scholar, 4Onchiri FM Pavlinac P Singa BO et al.Frequency and correlates of malaria overdiagnosis and treatment in western Kenya.Lancet Glob Health. 2014; 2: 45Summary Full Text Full Text PDF Google Scholar, 5Joshi R Colford JM Reingold AL Kalantri S Nonmalarial acute undifferentiated fever in a rural hospital in central india: diagnostic uncertainty and overtreatment with antimalarial agents.Am J Trop Med Hyg. 2018; 78: 393-399Crossref Scopus (67) Google Scholar, 6Reyburn H Mbatia R Drakeley C et al.Overdiagnosis of malaria in patients with severe febrile illness in Tanzania: a prospective study.BMJ. 2004; 329: 1212-1215Crossref PubMed Scopus (489) Google Scholar These overestimations are likely to inflate the amount of out-of-pocket spending because they capture visits for fever, rather than visits for malaria alone. Estimations of total malaria spending are valuable, as they fill a major gap in our knowledge of how malaria prevention and treatment is financed. Although it is useful to know that there is a difference in spending patterns related to a country's malaria status, these estimations do not always translate into directly relevant information at the country and district levels.7Nankabirwa J Zurovac D Njogu JN et al.Malaria misdiagnosis in Uganda implications for policy change.Malar J. 2009; 8: 1-9Crossref PubMed Scopus (105) Google Scholar For example, one policy implication that Dieleman and colleagues stress is the need for an increase in government contributions to total malaria spending. Although we can all agree that more money would be beneficial, there are no clear suggestions on how this can be achieved, particularly in low-income countries. Rather they highlight some of the constraints such as poor tax collection, low population income, and corruption.9Mackey TK Kohler JC Savedoff WD et al.The disease of corruption: Views on how to fight corruption to advance 21st century global health goals.BMC Med. 2016; 14: 1-16Crossref PubMed Scopus (39) Google Scholar The other important finding from this study is the absolute increase in out-of-pocket contributions to total malaria spending. Dieleman and colleagues highlight the increased affordability of malaria drugs and applaud the global effort to reduce costs. However, the burden of out-of-pocket payments is still high for the 500 million people living below the poverty line in malaria-endemic countries.1Dieleman JL Haakenstad A Harle AC et al.Tracking spending on malaria by source in 106 countries, 2000–16: an economic modelling study.Lancet Infect Dis. 2019; (published online April 25.)http://dx.doi.org/10.1016/S1473-3099(19)30165-3PubMed Google Scholar One action that a health minister could take to address out-of-pocket spending would be to expand prepayment mechanisms to cover costs, such as health insurance or fee exemption schemes. This strategy must be approached with care, as certain approaches to extending prepayment mechanisms can undermine national progress toward universal health coverage. In the case of private prepayment systems for health, financial protection is shaped by demand, which depends on one's willingness to purchase the item and ability to pay for it.10Hellowell M Appleby J Taylor M What models of funding are best for a healthy and just society?.BMJ. 2018; 361: k2566Crossref PubMed Scopus (1) Google Scholar Individuals might understand the need for insurance; however, a large proportion of the population affected by malaria will not be able to afford the premium (ie, membership fee), exacerbating health inequity within the country, a defining principle of universal health coverage. To conclude, although we welcome the creation of estimates for spending, more work needs to be done translating the findings of these types of financing studies into actionable and concrete strategies for governments and donors. Ultimately, some reflection is needed on how tracking financing data can help shift funding patterns to suit specific country's needs, and thus produce tangible results towards malaria control and eradication. We declare no competing interests. Tracking spending on malaria by source in 106 countries, 2000–16: an economic modelling studyTracking global malaria spending provides insight into how far the world is from reaching the malaria funding target of $6·6 billion annually by 2020. Because most countries with a high burden of malaria are low income or lower-middle income, mobilising additional government resources for malaria might be challenging. Full-Text PDF Open Access