Thank you Senator Coburn for the opportunity to submit written testimony for this important hearing on the subject “Bilateral Malaria Assistance: Progress and Prognosis,” 2pm Thursday 19th January 2006, Senate Committee on Homeland Security and Government Affairs Subcommittee on Federal Financial Management, Government Information and International Security (FFM).

This testimony is a follow-up report to a previous one: “The Blind Hydra-USAID Policy Fails to Control Malaria” to the FFM on May 12, 2005, submitted by Roger Bate.

SUMMARY

Recent news from the United States Agency for International Development (USAID) has lent new hope to the fight against malaria. On Wednesday December 14, 2005 USAID announced far-reaching reforms to its malaria control program, partly in response to pressure from legislators, malaria scientists and informed commentators.

USAID claims it will allocate nearly half of its budget to the purchase of commodities, such as insecticides and drugs. Fifteen million dollars has also been pledged to indoor residual spraying of insecticides, an extremely effective mechanism for reducing the burden of malaria. Additionally, the agency has promised to shut down all minor programs that spend less than $1.5 million annually; it will also restrict and consolidate malaria control planning strategies to Washington, rather than outsourcing this responsibility to its various missions around the world. Finally, and perhaps most important of all, the Agency has promised to disclose publicly details of contracts, budgets and outcomes of its malaria efforts on a website. USAID is right to have made this policy shift; it shows that the Agency is willing and capable of change in the face of increasing pressure from legislators and malaria experts.

Before the FFM Subcommittee eight months ago, Roger Bate voiced concerns on how USAID’s policy at the time was failing to control malaria. In that testimony, Bate urged USAID to take many of the steps it has taken now to restructure its malaria control programs. However, there is still more room for improvement. The agency must move quickly to enact these changes as millions continue to die annually from this largely preventable and curable disease. For some years, USAID’s malaria control strategies have often been plagued with ambiguous outcomes, and little to no measurable success in saving lives.

With USAID’s vow to move toward “greater effectiveness,” this committee must ensure that does not simply announce changes; it must implement them too.

As 2006 unfolds, promises of bringing life saving interventions against malaria must be kept and all funds pledged must be accounted for--the millions who suffer from this debilitating disease deserve no less.

THE STATE OF MALARIA IN THE WORLD

The United States successfully tackled and eradicated malaria in the 1950s through wealth creation, better nutrition, window screens and DDT insecticide spraying. However for many other malarial countries, the battle against malaria continued. The malaria scourge continues to kill over one million children every year, mostly in sub-Saharan Africa, and affects millions more in parts of Latin America and Asia.[1]

To date, the most effective proven methods of halting the spread of malaria have been a combination of primarily indoor residual spraying (IRS) of insecticides, and secondly insecticide treated nets (ITNs) for prevention as well as the use of effective drugs for treatment. Government and private entities in South Africa and Zambia have long employed these methods and have witnessed first hand startling reductions, as much as 70-90%, in their malaria rates.

In October 1998, USAID in partnership with the World Health Organization (WHO), the World Bank, UNICEF and other prominent international health groups launched the Roll Back Malaria (RBM) program. With millions allocated to its implementation, this multilateral initiative pledged to halve malaria deaths by 2010, but annual deaths from malaria worldwide are now higher than when the initiative began, possibly by about 10%.[2]

The primary culprits of RBM’s failure are clearly its core players: USAID, WHO, UNICEF, World Bank among others. Their combined failure is typified in their perennial inability to employ, beyond a marginal scale, any of the most proven methods of malaria control. For instance, for many years, RBM failed to promote the use of IRS and the historically maligned but singularly effective insecticide, dichloro-diphenyl-trichloroethane (DDT). In addition, some donors, such as USAID, were reluctant and then sluggish to assist with the roll out of artemisinin-based combination therapy (ACT).[3]

Each year Congress earmarks a specific sum for USAID to spend on malaria. Reflecting greater concern with rising malaria mortality rates, that sum has increased from nearly $14 million in 1998 to $90 million in 2005. Yet, this commendable monetary commitment has not translated into any measurable results in lowering malaria rates on the ground. Unnecessary bureaucratic interference, data monitoring flaws, deficiencies in organization, accountability and transparency as well as poor intervention policies have long prevented this global health organization from being effective in malaria control.

“BLIND HYDRA” TESTIMONY BY ROGER BATE REVISITED: POLICY RECOMMENDATIONS

In April 2005, Senator Sam Brownback (R-Kansas) introduced the Eliminate Neglected Diseases (END) Act to Congress that mandates a minimum of fifty-five percent of program budgets for commodity purchasing. Senator Brownback found USAID’s recurrent inability to reduce malaria rates appalling, especially as malaria is a curable and preventable disease. Subsequently, he made it clear that USAID’s internal guidelines for malaria control undergo drastic reevaluation.

Both Roger Bate’s May 12, 2005 testimony to this Subcommittee and his September 14, 2004 testimony to the House Committee on International Relations before that, echoed these very same sentiments. Bate stated explicitly then that if USAID failed to heed the call to restructure its malaria control program, it would have to bear the risk of Congress reallocating its malaria budget to another agency.

After a careful and comprehensive analysis of USAID’s malaria program, four key areas in need of serious revision became immediately apparent: first, funding of life-saving commodities; second, consolidation of malaria control programs; third, improving transparency, accountability and measurement; and fourth, involvement of local institutions.

1. Funding of life-saving interventions: 5-7% of USAID’s $80 million malaria funding was being used for the purchase of life-saving interventions such as mosquito netting, insecticides and drugs. By its own admission: “USAID typically does not purchase drugs other than in exceptional or emergency circumstances…”[4] Additionally, it was most troubling that USAID adhered to this statement: “IRS [Indoor Residual Spraying] is not a major focus of programs,” despite the wealth of available scientific literature which proves the effectiveness of this method.[5] 
   
   Disregarding sound scientific advice appeared to be an increasing characteristic of the Agency, and no case depicts this better than the Agency’s refusal to use DDT, an extremely effective spatial repellent for vector control. Rather, USAID has continued to promote malaria control through bed net marketing. Bed net marketing and distribution has not succeeded in reducing malaria rates. This is primarily because it is unknown how many people will regularly sleep under the bed nets provided. Ubiquitous in Bate’s testimony was the message that funding spraying programs, buying bed nets and purchasing effective drugs should be the Agency’s first priority. Bate stated: “USAID should provide funding so health ministers that want to eradicate malaria from their districts with IRS can buy necessary chemicals and equipment, and USAID should stop using inaccurate environmental opposition to IRS to thwart these ministers. USAID must adopt, rather than shun, these common sense approaches to malaria funding, if Agency officials are serious about stemming the malaria pandemic.” [6] 
   
   
2. Consolidation of its Malaria Programs: Second, USAID was urged to desist from spreading its funds too thinly across numerous countries and programs. By operating malaria programs in over thirty countries in the developing world with insufficient funding (funds average less than $1.5 million per country), no one program is in a position to successfully tackle a problem as large as malaria. In recognition of this Bate acknowledged, “the fractured and confusing organization of USAID’s malaria efforts constitutes a key obstacle to focused and effective programming. USAID manages resource constraints by diffusing funds thinly across numerous countries, which hampers efforts to make significant strides in any one place.” To cure itself of this undesirable trait, the Agency must “…consolidate …resources and expand the scope of its programs in fewer countries. That means prioritizing funding by both the extent of a country’s malaria funding and the likelihood that programs will succeed. Countries lacking the political will and local institutions must be bypassed for ones that have the right structures but are simply lacking the resources.”  Aside from the obvious advantage of improving overall effectiveness, consolidation of malaria programs and funds will ensure that “information is readily available through a centralized network and not scattered between central headquarters, country missions, private voluntary organizations (PVOs) and contractors.”[8] 
   
   
3. Transparency, Accountability and Measurement: Most of USAID’s deficiencies in performance are in fact symptoms of a greater problem--that is, its lack of transparency. USAID has been singularly secretive with details of procurement operations, program budgets, performance evaluations and contracts. In previous testimony, Bate pointed out: “The Agency’s transparency deficiency is evident not only in its refusal to release details of contracts it uses to allocate its $80 million malaria endowment, but also in the vague and ambiguous information it does provide.” Bate’s co-researcher Benjamin Schwab found it extremely difficult to secure any information on the organization’s contracting and disbursement process. For example, the Yellow book, an online record available to the public, designed by USAID to provide a complete listing of the contracts and supplies of live-saving materials distributed during the course of the year has not been updated since 2001. Moreover, no evaluation reports or documents concerning USAID’s malaria activities have been recorded on the publicly available database, also known as the Development Experience Clearinghouse. Notwithstanding, the limited information that was found revealed disturbing insights into USAID’s malaria activities.
   
   From all indications, the vast majority of USAID malaria funding either never left the United States--used primarily for conferences and advice giving efforts--or funded the employment of U.S. citizens. As Bate testified: “Although exact figures are unclear, USAID spends a significant percentage of international development funds on domestic goods and services. Data from USAID’s Buy American Report, the best available assessment, indicates that over the last decade, between 70 and 80 percent of funding appropriations were directed to U.S sources.” [9] 
   
   Furthermore, the Agency’s malaria program has been built largely on flawed measurement systems. Data regarding its own projects and financial commitments are grossly inadequate both for designing effective projects based on past experiences and managing existing ones. To upgrade organization and data management, USAID was asked to publish a website similar to that of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), which would hold all technical information: contracts, grants and cooperative agreements, budget and implementation plans. Such an action will in one swoop put an end to many of the criticisms leveled against the Agency for conducting its development operations under the table.
   
   
4. Involvement of Local Institutions: For years USAID has funneled money towards U.S contractors to build capacity in other countries. Since local institutions must comply with Washington based decisions to maintain funding, the danger is that they may simply adopt U.S. determined strategies so as not to lose funding. This system undermines subsequently the concept of project ownership. Not surprising, these programs are rarely sustainable and once U.S. funding is withdrawn, the project soon collapses. Clearly, a long-term solution cannot be achieved when only a quick fix is being provided. To promote sustainability, USAID must lessen its support for U.S contractors in favor of empowering indigenous organizations to build capacity in their own countries. By increasing direct grants to these groups, capacity building efforts in the health sector have a much greater chance of succeeding, and staying successful. [10] 

USAID: NEW REFORMS FOR MALARIA CONTROL PROGRAMS

USAID’s new policy reforms this December appear to have closely followed the recommendations issued in the “Blind Hydra” testimony and those offered by most concerned malaria experts. According to a USAID press release issued on December 14, 2005, the new reforms “will effectively combine all USAID malaria activities into a single, strategic effort.” [11]  Specifically:

• Lifesaving Drugs and Supplies: Beginning in fiscal year 2006, 40 percent of USAID’s budget will be directed to the purchase of life-saving drugs and supplies - insecticides and equipment for spraying, insecticide-treated bed nets, artemisinin-combination therapies (ACT) and diagnostics, drugs for intermittent preventive treatment of pregnant women, and drugs for severe malaria.
• Indoor Residual Spraying (IRS): 25 percent (or $15 million) of the malaria budget will pledged in fiscal year 2006 towards indoor residual spraying in malaria-affected countries.
• Country Program Funding: To promote effectiveness, minor programs operating at levels insufficient to achieve measurable results will be terminated in favor of sponsoring programs which can make a greater impact on saving lives. Beginning in fiscal year 2006, no developing country malaria program will be funded at less than $1.5 million; minimum funding for country programs will rise to at least $2.5 million in 2007.
• Malaria Program Transparency: Rigorous measures to promote transparency will be undertaken. Information on program budgets, inputs, outputs, and outcomes will now be posted on a publicly-accessible USAID website.

FUTHER POLICY RECOMMENDATIONS AND CONCLUSION

In response to the announcements from USAID, Senator Brownback publicly applauded the policy change. He is hopeful that these new policy guidelines, especially the emphasis on providing the necessary live-saving supplies, would significantly help the fight against malaria. Such a policy would diminish the rate of mortality, and eventually lead to the eradication of malaria in Africa .

In addition, Africa Fighting Malaria (AFM) openly welcomed the policy changes and acknowledged the importance of allocating more funds towards Indoor Residual Spraying. AFM noted that the new system of providing data and monitoring the results would allow for a better method to judge the progress.

The “Kill Malarial Mosquitoes Now! (KMMN) coalition which presented USAID in October with an international declaration calling for two thirds of the agency’s budget to be used to buy life-saving commodities also joined in the praise.

The euphoria generated from USAID’s announcements is expected, even desirable; however, only time will tell if it is justified. Careful scrutiny and monitoring of USAID activities by legislators and malaria experts must continue. This will ensure that USAID’s stated changes are actually enacted. Skepticism stems from a disquieting sense of déjà vu. Not since the testimony of Anne Peterson in September 2004, then Assistant Administrator for Global Health, has the USAID provided additional statistics or program evaluation. In the ensuing months after Peterson’s testimony, little or no actual action was taken. It has been another eight months since the hearing in May, and USAID shows only rhetorical commitments as progress. This begs the question of how long it will take USAID to activate its own recent policy changes. Legislators should remain vigilant and ensure that the agency follows through on its promises swiftly. 

It is unclear from the proposed reforms if USAID will take appropriate measures to upgrade its organizational systems and diminish its reliance on U.S. contractors. The struggle against malaria requires successful collaboration with external experts and the indigenous communities we seek to help. USAID should put more emphasis on cooperating with other agencies that have a successful record with fighting malaria, and with the indigenous communities. By doing so, USAID will be fulfilling its mission to help locals sustain programs in their own country.  

Finally, USAID must better define its role in the health arena both at the country level and at the global level. As a provider of health funds and programs to national governments, USAID has a unique role in helping countries with practical health-sector development and disease-specific programs. As one of the largest financiers of health care in developing countries, USAID must stay involved in the global health agenda, and must never undermine that process with a lack of transparency and a lack of appreciation for the full scope of the disease it sets out to tackle.

Thank you.

Roger Bate is a resident fellow at AEI and a director of Africa Fighting Malaria. Richard Tren is a director of Africa Fighting Malaria.

AEI Research Assistant Kathryn Boateng provided significant help in researching this written testimony.

Notes

[1] Bate R. and Schwab B. 2005. “The Blind Hydra: USAID Policy Falls to Control Malaria” AEI Working Paper May 2005. Paper also presented as government testimony before the Senate Committee on Homeland Security and Government Affairs Subcommittee on Federal Financial Management, Government Information and International Security, May 12, 2005, Washington. Copy of Testimony available at: http://www.aei.org/publications/filter.all,pubID.22508/pub_detail.asp, accessed 10/12/2
[2] Attaran, A. 2004. “Where Did It All Go Wrong” Nature 430: 932-3
[3] Bate, R. 2006. “Fighting Malaria-The Right Way” The Examiner, January 9
[4] Bate R. and Schwab B. 2005. “The Blind Hydra: USAID Policy Falls to Control Malaria”
[5] Ibid.
[6] Ibid. 
[7] Ibid.
[8] Ibid.
[9] Ibid.
[10] Ibid. 
[11] “USAID Reforms Agency Malaria Programs for Greater Effectiveness” USAID Press release, December 14, 2005. Available at: http://www.usaid.gov/press/factsheets/2005/fs051214.html, accessed 01/010/2006.
[12] “Brownback applauds USAID Policy Change: Agency improves management of funds dedicated to fighting malaria”, Wednesday, December 14, 2005, Senator Brownback Press Release. Available at: http://brownback.senate.gov/pressapp/record.cfm?id=249754