Financing malaria.

The faltering of progress towards malaria elimination follows a plateauing in international financing since 2010. Despite calls for increased international financing, this will be hard to achieve. Both developed country donors and developing countries with malaria face severe fiscal constraints in expanding malaria funding in the next few years. Simply exhorting countries to spend more is unlikely to be successful, just as the Abuja declaration was not, and the developing countries with most malaria burden suffer from weaker economic growth and less capacity to increase domestic financing. One major prospect for substantial new financing is China, but this may depend on established funders yielding influence in the global financing architecture to China and other emerging economies. This argues for greater emphasis on spending available financing better, but improving the impact of international funding is not straightforward. It is associated with significant transaction costs for recipients, impairs the ability of the WHO to coordinate global efforts, and may pressure recipient countries to focus more on commodities and easy wins instead of investing in health systems and management capacity. While more should be done to mitigate these perverse effects, much of this is the unavoidable price of such generosity and the inevitable need for accountability to funders. Ultimately, countries must do more with their own spending, which is often under-counted, but usually far exceeds the international contribution. The experience of Sri Lanka, El Salvador, and China-three countries that eliminated malaria-provides two pointers. First, achieving early and widespread treatment of most malaria cases, which is not the case in much of high burden Africa, may be critical to sustain accelerated elimination. Second, such coverage requires health systems that prioritize access for all services and conditions. Public opinion surveys indicate that this is consistent with what much of the affected population wants, prioritizes, and is willing to finance through higher taxes, which points to weaknesses in accountability of policy to people. International funders could do better to heed what affected populations want and let local partners be responsive to their own public's preferences.