Appendix 3: Assumptions behind Current Burden, Coverage and Funding Estimates
Appendix 3 explains the data sources and methodology used to arrive at the estimates for burden, intervention use and funding for years up to 2008. These estimates for the global level are presented in Part I: Malaria Today and for four regions (Africa, The Americas, Asia-Pacific, and Middle East and Eurasia) in Part III: Regional Strategies. For a discussion of projected estimates of interventions and costs beyond 2008, please see Appendix 4.
Current Burden Estimates
Burden data estimates the number of malaria cases and malaria deaths. These variables provide a starting place to assess the morbidity and mortality of malaria across countries and regions.
Baseline burden estimate. In 2006, the RBM Partnership, led by the Monitoring and Evaluation Reference Group (MERG), developed a consensus estimate of global malaria deaths and cases by region to serve as the 2000 baseline for the RBM targets. This work was published in Jamison DT, Breman JG et al, editors. Disease Control Priorities in Developing Countries Conquering Malaria. Oxford University Press and the World Bank; 2006 in the chapter by Breman JG et al. on Conquering Malaria. The global number of malaria cases is estimated for 2002 and global deaths from malaria for 2000. The GMAP uses the Breman 2000 and 2002 baseline data on burden to report burden at a global level and at a regional level.
The specific range of 350 – 500 million cases per year was validated by work by Korenromp E in Malaria incidence estimates at country level for the year 2004 – Proposed estimates and draft report. Geneva, Roll Back Malaria, 2005 and is within the inter-quartile range reported by Breman. The 2000 estimate of 1 million deaths globally is closely related to the 804,000 deaths in Africa estimated by Rowe AK et al in The burden of malaria mortality among African children in the year 2000. International Journal of Epidemiology, 2006, 35:691-704.
2006 burden estimate from WHO World Malaria Report 2008. In September 2008, the World Health Organization released its latest World Malaria Report (WMR) 2008. The WMR 2008 contains information on burden, policies, coverage and funding for 109 malaria endemic countries as of 2006. In the report, WHO uses an updated and revised methodology to estimate the incidence of malaria outside the African Region. Annex 1 of WMR 2008 describes the methodology.
This new methodology results in fewer malaria cases than previously estimated in the Americas, Eastern Mediterranean, Europe, Southeast Asia and Western Pacific regions. The main reason for the difference is the use of a new estimation method, based on adjusting case reports. The lower figures derived by the new method have been approved by WHO regional and country offices, and they are consistent with the views of some other authors that have found previous estimates to be too high (e.g. in the Western Pacific Region).
WMR estimates of the numbers of cases and deaths in Africa are not significantly different from previous estimates. All recent, published estimates of malaria burden are surrounded by wide uncertainty intervals, and the intervals obtained in various studies overlap. Thus the 212 million cases estimated for the African Region in WMR 2008 are about the same as the 210 million and 230 million previously obtained in separate studies by Snow et alSnow NW et al. The public health burden of Plasmodium falciparum malaria in Africa: deriving the numbers. Bethesda, Maryland,
USA, Fogarty International Center / National Institutes of Health, 2003 (The Disease Control Priorities Project (DCPP) Working Paper
Series No. 11).
and Korenromp.Korenromp E. Malaria incidence estimates at country level for the year 2004. Geneva, World Health Organization, 2005 (draft).
Click for source Likewise the 801,000 deaths lie within the range 700,000 - 1.6 million published by Snow et al.Snow NW et al. The public health burden of Plasmodium falciparum malaria in Africa: deriving the numbers. Bethesda, Maryland, USA, Fogarty International Center / National Institutes of Health, 2003 (The Disease Control Priorities Project (DCPP) Working Paper Series No. 11).
Methodology for updating burden estimates. Experts in this field agree that the methods for evaluating malaria burden and trends, and the underlying data, can be improved further. RBM partners, including WHO, are continuing to improve and align estimates of malaria burden worldwide. MERG has two teams tasked with updating and aligning future morbidity and mortality estimates for the RBM Partnership.
Estimates of current interventions
Reviewing the most recent data on number of interventions is essential to identify where countries are today (or as recently as possible) in providing interventions to their populations. It also will show the gaps that need to be filled to achieve universal coverage with all interventions. The methodology for estimating future intervention needs is covered in Appendix 4.
Scope of estimates. In the GMAP, global and regional interventions were calculated bottom-up based on data from 109 malaria-endemic countries for the major intervention types (LLINS / ITNs, IRS, diagnostics, treatment). Data reported was for the most recent year available (2006), although not all countries reported data for 2006.
Data sources. The primary data source was the WHO World Malaria Report 2008 (WMR) because the WMR includes both program data reported by countries and survey data from recent household surveys. In the GMAP, program data was used to estimate the number of interventions for two reasons. First, while household surveys are an effective way to assess local usage, the results are less readily aggregated and compared across entire countries and regions. Second, program data has the advantage that it covers all 4 major interventions whereas survey data mostly covers LLINS / ITNs and treatment interventions. When it existed, data from household surveys was reported in the GMAP as well to provide a more wholistic picture of trends in intervention utilization.
The WMR data was supplemented with data from the RBM Commodities Services database when available. The commodities data was compiled by the RBM Partnership. This data includes national procurement figures provided by pharmaceutical companies and international organisations. The procurement figures are considered a good proxy for national coverage figures even if they tend to overestimate coverage. This problem was considered minor as only a small number of coverage figures were derived using procurement figures (5 countries for LLINS / ITNs and 20 countries for treatment).
For countries where both the World Malaria Report and RBM data were not available, the plan assumed zero coverage for these countries. The data sources are summarized in Table A.1.
Table A.1: Availability of country data by intervention
|Intervention||Countries with WMRa program data||Add. countries with RBMb commodities data||Total number of countries with data|
|LLINs / ITNs||78||5||83|
a) World Malaria Report 2008. Geneva, World Health Organization, 2008.
b) Roll Back Malaria Partnership
Adjustments were made to the WHO WMR data to calculate the number of interventions for the GMAP estimates:
- Countries were reassigned from the six WHO regions (AFRO, AMRO/PAHO, EMRO, EURO, SEARO, and WPRO) to the 4 regions used in the GMAP (Africa, The Americas, Asia-Pacific, and Middle East and Eurasia). See Table A.8 for regional assignments by countries.
- Often multiple variables were available for the same intervention in the WMR (e.g. both detailed and aggregated variables). In countries where a detailed split between variables is not available, the aggregate intervention figure per country was used.
- In countries where program data is not available, commodities data from the RBM Commodities database was used for the closest year.
The above adjustments explain 100% of differences between the coverage data used in the WMR and the GMAP. Figure A.1 provides an example of the differences between the WMR and GMAP estimates for the number of LLINs / ITNs distributed in Africa.
Figure A.1: Reconciliation of WMR and GMAP data for LLINs / ITNs in Africa
Source: World Malaria Report 2008. Geneva, World Health Organization, 2008.
Description of calculations for each intervention. The GMAP primarily states the level of interventions in terms of absolute numbers of interventions required because this variable is the most relevant for those making purchasing decisions.
LLINS / ITNs. The figures for LLINS / ITNs are calculated as follows:
- Number of interventions: each LLIN is effective for 3 years and any other ITN for 1 year. Based on this assumption, the total number of nets was calculated as being equal to the sum of 3 years of LLINs (2004-2006) and 1 year of ITN (2006).
- People covered: one LLIN or ITN is needed for every two people at risk. Therefore, the total number of LLINS / ITNs is multiplied by 2 to estimate the total number of people covered.
IRS. The figures for IRS are calculated as follows:
- Number of interventions: the number of households sprayed. The figure is derived from the number of people covered by IRS divided by the average household size of each country (or 5 when average household size was not available).
- People covered: the number of people covered by IRS was provided by the WMR. If this information was not available, this variable was estimated by multiplying the number of households covered by the average household size of each country (or 5 when average household size was not available). Following consultation with WHO - Global Malaria Program, manual corrections were made to the WHO World Malaria Report 2008 data for South Africa and Botswana to correct obvious data errors.
Diagnostics. The figures for diagnostics are calculated as follows:
- Number of interventions: the combined sum of the number of microscopy slides examined and the number of Rapid Diagnostic Tests (RDTs) examined. The reasoning is that although RDTs are increasingly becoming an effective diagnostic tool, microscopy slides are still the most frequent tool used.
- People covered: the number of people covered equals the number of diagnostic tests performed.
Anti-malarial treatment. The figures for anti-malarial treatments are calculated as follows:
- Number of interventions: For anti-malarial treatments outside of Africa, estimates of the number of drugs are calculated based on the combined number of ACTs and any other first line anti-malarial treatment. In Africa, where ACTs are the recommended treatment for P. falciparum malaria, only the number of ACTs were counted.
- People covered: the number of people covered equals the number of treatments provided.
Current Funding Estimates
This section presents the scope, data sources and hypothesis used to assess the current malaria funding (up to 2007) and estimated funding for 2008.
Scope of funding estimates. Estimates of current levels of funding for malaria are presented at the global level in Part I – Chapter 4: Funding for Malaria Today and at the regional level for the four regions of GMAP (Africa, The Americas, Asia-Pacific, and Middle East and Eurasia) in Part III: Regional Strategies.
Global Estimates. Part I – Chapter 4: Funding for Malaria Today presents figures aggregated at the global level for:
- Total malaria funding for implementation for 2007 including: funding from major international donors Major international donors include the Global Fund, the World Bank, the President’s Malaria Initiative (PMI), USAID, UN Agencies, European Union and other bi-laterals. , national government spending by endemic countries and spending by private households.
- Evolution of funding from major international donors between 2004 and 2007 as well as estimates for 2008.
- Evolution of funding for R&D between 2003 and 2007.
As there are significant differences in the amounts and timing between pledges and actual disbursements, figures in GMAP represent annual disbursements (as opposed to commitments) when they were available. This is intended to match the availability of funds as closely as possible to when intervention could be purchased or money used for program costs. When information was not available about disbursements, data on budgets or commitments was used.
Regional Estimates. Part III – Regional Strategies presents a regional allocation of current malaria resources. Figures presented in this chapter represent 2007 regional disbursements including national government spending from endemic countries and funding from major international donors (all listed above except USAID projects other than President’s Malaria Initiative (PMI) for which country or regional allocation was not publicly available). As private household spending was estimated at the global level only, this amount is excluded from figures presented in the regional chapters.
Figure A.2 illustrates the link between global figures presented in Part I: Malaria Today and regional figures presented in Part III: Regional Strategies of the plan.
Figure A.2: Reconciliation of global and regional funding data
Source: World Malaria Report 2008. Geneva, World Health Organization, 2008 (Government, UN Agencies, Bilaterals, EU), the Global Fund website, PMI operational plans, USAID website, World Bank Booster Program.
Data Sources. No single data source provided a comprehensive assessment of current funding so estimates were built from different sources. The summary below describes the data sources and the methodology for each of the major types of malaria funding: Malaria-endemic country spend, Private household spend, and Funding from international donors.
Malaria-endemic country spend (2007). Information on malaria endemic-country spend are data reported by each country to WHO and gathered in the WHO World Malaria Report 2008. The data represents total government malaria budget reported to WHO. 2007 data was used when available. As only a few countries reported 2007 information, data from previous years was used (mostly 2006 but also 2005 when 2006 was not available). When none of these figures where available, government malaria budgets reported in the Needs Assessments developed with the support from the RBM Harmonization Working Group were also used. The total amount might be underestimated as figures for only 71 countries were available. These 71 countries represent ~84% of global malaria deaths.
Private household spend (2007). Figures for private household spend are based on estimated size of private market for drugs ($130M) and insecticide-treated nets ($150M). Private drug spend assumes treatment volume of 10 million ACTs, 396 million monotherapies with fully-loaded cost of US$ 0.75 pediatric ACT, US$ 1.50 adult ACT, US$ 0.3 monotherapy. Private spend for insecticidal nets assumes US$ 107 million in net sales with distribution costs of 37.5% of sales.
Funding from international donors (2004-2007 and 2008 estimate). Funding from international donors was calculated for each of the major donors: the Global Fund, the President’s Malaria Initiative, the World Bank, bilaterals and other donors.
- The Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM). Data from the GFATM for 2004-2007 represent disbursements for malaria grants (Rounds 1 to 7) reported by the fund on its publicly available databaseThe Global Fund data
Click for source accessed in June 2008. Figures are allocated to each country and region. Estimates for 2008 are based on disbursements that already occurred in 2008 plus an allocation of 2008 grants not yet disbursed (assuming disbursements of remaining round 1-7 approved grant amounts occurs evenly over time until grant end year).
- President's Malaria Initiative (PMI) and Other USAID. PMI figures for 2006-2008 are based on actual budgets from country operational plans available on PMI's websitePMI data
Click for source accessed in July 2008. PMI funding is focused only on 15 sub-Saharan African countries. Other USAID data are based on estimated budgets for malaria projects others than PMI available on USAID websiteUSAID data
Click for source accessed in July 2008.
- World Bank. World Bank figures are the actual disbursements of the Booster Program Phase I provided by the Bank for 2006 and 2007. Estimates for 2008 are based on actual disbursements until June 2008 to which estimated disbursements provided by the World Bank for the period July-December 2008 were added. Other World Bank general health or development projects include funding for malaria but are not taken into account in this analysis since this funding cannot be easily allocated to malaria. The Bank’s malaria project in India has not been included since the first disbursements will start at the end of 2008.
- UN Agencies, European Union, Other bilaterals. Data used for these three sources of funding are those reported by countries to WHO for the World Malaria Report 2008. For estimating the 2007 amount, 2007 data was used when available. As only a few countries reported 2007 data, 2006 data was used as a proxy for most countries. Numbers used for 2004-2006 were those reported to WHO without adjustments. For 2008 estimate, it was assumed that the same amount as estimated for 2007 would be provided.
- Other sources of funding. Countries also reported to WHO "Other sources of funding" corresponding to external funding support outside the donors mentioned above. As no identification of sources was possible with this data, it has not been used in this analysis, which focused primarily on the major international donors. Other sources of funding (i.e. coming from regional banks or regional institutions etc.) could increase the funds presented in this analysis.
Spending on malaria Research and Development. Figures correspond to disbursements for malaria R&D. Funding from the Bill and Melinda Gates Foundation assumes that grants are evenly disbursed for the calendar year in which they are active. National Institutes of Health (NIH) funding is based on actual spend for 2003-2006 and budget projections for 2007-2008.NIH data
Click for source Other funding for R&D by the private sector companies, US Department of Defense, Wellcome Trust, and others is assumed to hold flat at US$ 165 million based on the Malaria R&D Alliance reported funding estimate for 2004.