April 24, 2014
To mark World Malaria Day 2014, and as part of Friends’ interview series, we spoke with Dr. Scott Filler, the Global Fund’s senior disease coordinator for malaria. From his office in Geneva, Dr. Filler highlighted progress in the fight against the disease as well as some of the most pressing challenges the world now faces, including artemisinin resistance in the greater Mekong region.
Friends: What would you say is the biggest need with respect to global malaria control?
Dr. Filler: The need for sustained, predictable financing is absolutely crucial. In 2013, about $1.9 billion  was spent on malaria control globally. Since 2002, the Global Fund alone has spent $8.8 billion  on the disease. But to defeat it, we will need additional resources.
As part of the Global Fund’s preparation for the Fourth Voluntary Replenishment, we worked with key partners at the national and international level, including Roll Back Malaria, to identify the total estimated global resource need for malaria for the next three year period; that number is $14 billion. This level goes well beyond that which is available through Global Fund resources alone, so clearly there is a significant funding gap that will need to be addressed.
Beyond funding, there are two additional threats to malaria control: insecticide resistance and drug resistance.
Friends: What are the things we need to do to address these challenges?
Dr. Filler: The biggest thing to remember is that you have to get ahead of malaria or malaria will get ahead of you.
The two important elements continue to be vector control and treating people as they become infected. However, we have to be more sophisticated than ever before in the fight. For example, we want to make sure everybody sleeps under a net, but that’s not enough — resistance with insecticide treated nets must also be addressed.
I think we also need to manage expectations. There is no silver bullet — we are, realistically, looking at a 20- to 30-year time horizon to defeat the disease.
Friends: But hasn’t there been great progress against malaria in the past decade?
Dr. Filler: Absolutely! And it’s very exciting. Just by looking at the World Health Organization’s most recent World Malaria Report we see that global malaria mortality rates have dropped 45 percent between 2000 and 2012; the number of cases of malaria have decreased 29 percent globally in that same time period. And, of the 99 countries that have endemic malaria, 67 are entering the malaria control phase and the rest are all pursuing an elimination strategy.
But we have to remember that progress against malaria is fragile. More than 90 percent of resurgence over the past 80 years were due, at least in part, to weakening of malaria control programs. It’s a cliché, but taking our foot off the gas pedal, even for a moment, could have devastating effects. Sri Lanka is an example where the epidemic, once controlled, reared its head. That country has since made amazing progress in recovering from its struggles with resurgence, but it still serves as a cautionary tale.
Lately, I’ve been spending a lot of time reviewing and re-reading what went wrong with the global fight against malaria in the late 1960s. We ran out of funding and political will. And, at the same time, we were faced with growing drug resistance. Sound familiar? The effects then were devastating. We can’t let that happen again.
Certainly, there’s been a sea change over the last 10 years; a break with complacency and a resurgence in malaria control. But we’re at an impasse now. The fight is not over and we must keep up the momentum.
Friends: What regions represent the greatest risk with respect to malaria?
Dr. Filler: The biggest concern remains sub-Saharan Africa. Places like the Democratic Republic of Congo and Nigeria are the heartland of malaria. About 90 percent of malaria-related deaths occur in Africa, far too many of them children under the age of five. Estimates suggest that a child dies every minute from the disease.
The Global Fund’s strategy is to continue an all-out attack on the malaria heartland. About 70 percent of our total funding for the disease goes to sub-Saharan Africa. We want to knock countries off, achieve elimination in more places and, in short, shrink the malaria map.
Friends: Last year, the Global Fund approved two regional initiatives related to malaria as part of the New Funding Model. Can you provide an overview of both and share any updates?
Dr. Filler: Last year, with the launch of the New Funding Model, the Global Fund allocated $100 million for the regional initiative in the greater Mekong — specifically Burma, Cambodia, Thailand, Vietnam and Laos — to help catalyze a coordinated response among partners to artemisinin resistance. Though national efforts to contain drug resistance in Southeast Asia have had some impact, urgent action is needed to fully eliminate resistant strains of the parasite and ensure that artemisinin-based combination therapy remains effective. The initiative is just ramping up, but, even as the program is helping to scale up control, there are new signals of resistance popping up.
The situation with the Mesoamerica and Hispaniola Regional Initiative is very different. It includes 10 countries: Belize, Guatemala, Honduras, El Salvador, Nicaragua, Costa Rica, Panama, Mexico, Haiti and the Dominican Republic. The goal of this initiative is aimed at eliminating malaria in this region by 2020 under the Global Fund’s New Funding Model, and to certify this region as “malaria free” by 2025. The Global Fund, which currently supports country-specific malaria grants in Nicaragua, Honduras, Guatemala, Dominican Republic and Haiti, has set aside this additional $10 million for the regional initiative to leverage activities already taking place at the country level, regionally and even globally.
This regional initiative couldn’t be timelier. If we look broadly at Latin America, malaria rates have fallen in nearly every country — often dramatically. Much of the region has already met the Millennium Development Goal for 2015 of reducing the number of diagnosed cases by 75 percent, and six countries have officially entered the pre-elimination phase. Of course, in some areas, there is still a long way to go. But for many countries in this region, malaria elimination is truly within reach. The fact that this effort is in a position to achieve rapid impact made it especially appropriate as an early applicant for the new funding model.
Friends: Recently, there have been some exciting announcements related to malaria vaccines research. Where do these fit in in terms of the global battle against the disease?
Dr. Filler: Certainly, it’s tremendously encouraging. RTS,S is the most developed. And the fact that there has been such a high rate of effectiveness with the PfSPZ Vaccine — announced last year by the National Institutes of Health — without bad side effects is further reason for hope.
But we have to bear in mind that vaccines are a long term proposition. We’re looking at 2015, at the earliest, before RTS,S becomes available. With respect to the other vaccines in the pipeline, we are 10 years out, at a minimum. And, of course, even when they do come on the market, vaccines won’t be 100 percent effective. Even the most successful ones protect only a small percentage of people from the parasite. So we must continue with a layered approach – using every tool in our arsenal — and absolutely cannot stop doing everything else we are already doing.
Friends: Prior to the Global Fund, you were at the President’s Malaria Initiative (PMI), which gives you an ideal viewpoint on how the two organizations work together. Do you think your prior role is helping you in your current position?
Dr. Filler: I do think my experience at PMI has been beneficial in my role here at the Global Fund over the past three years. Even during the time I’ve been here, I’ve seen an already strong collaboration and partnership grow and expand. The two organizations are truly able to achieve greater results together.
Friends: Can you speak to their collaboration? Do the two overlap at all?
Dr. Filler: I wouldn’t say that there is overlap between the two, rather they work synergistically. For instance, because the Global Fund has more financial resources, it is able to help scale up PMI programs. But remember, the Global Fund does not have on-the-ground resources. We work with our partners like PMI to provide the necessary technical assistance in country. And that creates a virtuous circle as PMI then provides invaluable feedback to the Global Fund Secretariat as to what it is learning on the front lines.
But we also work very closely in other ways. In developing its operational plans, PMI has always sought to complement the Global Fund, working in countries where we have a presence, and assessing what resources are currently available to determine any needs that remain unmet. We are all better able, then, to fill the gaps. Currently, all 19 PMI focus countries in Africa — as well as the two regional programs I referenced earlier in the Greater Mekong and Mesoamerica — receive substantial funding from the Global Fund.
The two organizations are intertwined in other important ways as well. The Global Fund and PMI often jointly plan procurement and supply chain management efforts, evaluations and surveys, and capacity building. In some countries, PMI sits on the Country Coordinating Mechanism. PMI also has a seat on the U.S. delegation of the Global Fund Board, helping to shape policy. And members of the Global Fund’s Technical Review Panel, which is responsible for assessing grant applications prior to Board consideration, include PMI staff. And now, moving from a rounds-based funding mechanism to one that is iterative, with the New Funding Model, we will have many more points for the two organizations to interact.
So, the bottom line is that we work very closely — and very collaboratively — together. It’s a powerful partnership, to say the least.
This post was originally published in April 2014.
 The Global Fund, http://theglobalfund.org/en/about/diseases/malaria.
 The Global Fund to Fight AIDS, Tuberculosis and Malaria Fourth Replenishment (2014 – 2016) Needs Assessment, at 10.
 WHO, World Malaria Report at 67.
 The Global Fund, http://www.theglobalfund.org/en/about/diseases/malaria/.