The Malaria Burden in Africa 
Malaria kills over 1.1 million people—most of them children under five years old—every year 1. More than 80% of these deaths occur in sub-Saharan Africa. Malaria is the biggest killer of African children, and half those deaths could be avoided if their caretakers had access to diagnosis and affordable drugs 3. Pregnant women and their unborn children are particularly vulnerable to this disease and it is a major cause of perinatal mortality, low birth weight, and anemia. As noted by WHO, malaria’s public health impact is compounded by high economic costs4 . In Africa alone, the total yearly economic burden of malaria is estimated at about US$12 billion. Comparative figures reveal even more clearly how malaria undermines economic development. Annual economic growth between 1965 and 1990 averaged only 0.4% in malarious countries, less than one-fifth of the figure for malaria-free nations, which grew an average of 2.3% per year over the same period (Sachs and Malaney, 2002). Although the disease is preventable and curable with available technologies, coverage with effective interventions has remained tragically low, particularly among poor and rural populations.
Malaria also has a significant impact on reaching key MDG targets in countries. - Education: Malaria is a leading source of illnesses and absenteeism in school-age children and teachers
- Child Mortality: Malaria is a leading cause of child mortality in endemic areas
- Maternal Health: Malaria causes anemia in pregnant women and low birth weight in infants
- Nutrition: Approximately half of the malaria deaths in children can be attributed to the compounding effect of malaria and malnutrition.
But, there is hope-- recent developments in countries such as Eritrea, Niger, and Zambia remind the world that significant progress is possible, but needs to be taken to scale through a joint effort of partners and countries. What is the Booster Program? On April 25, 2005, The World Bank Global Strategy and Booster Program for Malaria Control was launched as a renewed commitment to achieve, in collaboration with partners, the global Roll Back Malaria Targets of halving the world’s malaria burden by 2010. Immediately after, the Africa Region of the World Bank translated this strategy into an outcomes-driven assault on malaria in Africa. The Booster Program is a country-led effort designed to augment and reinvigorate existing programs, and does not constitute an independent initiative. This effort will build on a revitalized Roll Back Malaria Global Partnership (RBM) and complement the efforts of other partners both at national and regional levels in an effort to bring malaria under control. The Booster Program is planned to last ten years, including an intensive phase spanning the Bank’s fiscal years 2006–2008, meaning July 1, 2005 through June 30, 2008, during which the Bank will contribute to an aggressive effort to achieve control of malaria. The decade-long timeline reflects the difficulty of fighting this entrenched, deadly disease in Africa. It is important to stress that long-term financial and institutional commitments from governments and partners alike will be required to sustainably reduce malaria prevalence. During the initial three-year Intensive Phase, the Program will assist approximately 20 sub-Saharan countries in achieving the Abuja targets by 2008. The core target setting in the Booster Program is grounded firmly in the Bank’s country-specific dialogue, as part of the project preparation and supervision process. Each country, based on their RBM Strategic Plan and health sector strategy more broadly, will be assisted to set ambitious but achievable targets in accordance with country-specific baseline data, monitoring and evaluating capacity, and service delivery opportunities. The private sector is envisaged to play a key role in expanding and sustaining intervention coverage. Bank Task Teams will assist countries in preparing programs that respond directly to gaps in country strategic plans. Achievement of the targets in the national plan will be a joint effort with all RBM Partners in the country. The Booster Program’s first three-year phase corresponds to the three-year IDA 14 cycle and its success is measured against contribution to meeting the targets set in Abuja during the African Heads of State Conference on Rolling Back Malaria in 2001. As the Booster Program supports national malaria control strategic plans, the Bank’s role is one of partner, along with other donors, who together with the Government will work to achieve the targets of the national plan. Key outcome indicators include increased coverage of preventive technology and vector control (such as insecticide treated bednets (ITNs) and indoor-residual spraying (IRS) where appropriate, intermittent preventive treatment (IPT), and access to prompt and effective treatment. Scaling-Up for Impact (SUFI): Unlike many other public health problems, malaria cannot be satisfactorily controlled with incremental methods because its vectors are too efficient. Indirect measures, including the long-tried approach of strengthening the general health system, without concurrent and aggressive malaria control, amounts to business as usual—yielding limited progress, to judge by the results in Africa over the last decade. Successful malaria control requires bold, decisive steps to obtain high coverage quickly. Accordingly, the Booster Program is working to support clients implementing effective interventions such as ITNs and effective treatment (including ACTs) , facilitating sufficiently high coverage to ensure large scale impact. The Bank’s efforts fit within the broader framework of the RBM partnership and will build on the recent progress in Africa to increase coverage of essential interventions. The Program: The Bank’s approach is proactive while supporting country leadership and ownership. In the initial three-year intensive phase the Booster program will commit approximately US$500 million in IDA allocations to support countries willing and ready to improve and expand their malaria control efforts. In addition, a Regional Allocation is proposed to address issues that have cross-border externalities (operations research, resistance surveillance, anti-counterfeiting measures, et cetera), multi-country malaria control activities, and coordination and implementation bottlenecks across the region. At the end of the initial three years, it is expected that a stock-taking review will be conducted to formulate an expanded second phase program that will seek to consolidate the gains achieved and extend control to remaining endemic areas. Design: Exact Booster Program activities and targets will depend on the needs and baseline coverage levels of individual countries. The health sector is not necessarily the only entry point for supporting malaria control efforts. Indeed, a number of sectors such as education, infrastructure, and water and sanitation can play a significant role in controlling malaria and linkages for joint work programs in these areas will are being explored. The Booster Program has a two-pronged approach: - A serious up-front effort by the World Bank to help countries control the disease, using a combination of proven interventions
- Design malaria control programs in countries to complement ongoing efforts by the Bank and other partner to strengthen and improve overall health systems
Key Features of the Booster Program 1. Implementation Flexibility - No fixed prescription: approaches and targets will vary from country to country depending on the specific context (national strategic plans)
- Free choice from existing Bank instruments, such as Sector Wide Approaches (SWAp), and/or free standing operation
- Reliance on existing instruments and institutions at country and regional levels
2. Regional Component - To address cross-country and cross-border issues.
3. Results Based - Strong M&E support will be provided nationally and regionally through a clear strategy, focused monitoring, and allocation of resources.
4. Complementarity Country Selection: Approximately 20 countries are currently proposed for inclusion in the Booster Program’s first phase. Selections are based primarily on the readiness assessments made by the Roll Back Malaria (RBM) partnership in 2003, which divided countries into three categories. Most countries in the first category—those most ready to take action—are included in the Booster Program. The list is meant to be indicative and is not closed. The Bank will also exploit windows of opportunity when interest is expressed by other countries, which is why some in categories II and III are also included among the countries where the Booster Program has begun. World Bank Country Directors and their country teams will take the initiative in developing malaria programs as an integral part of their country programs. One Year Later: Turning Strategy into Action One year later, we are turning strategy into action in the Africa Region, with a results focused program that seeks to scale-up malaria control to achieve disease control impact: Commitment: Five projects have been approved by the World Bank Board of Directors, in the Democratic Republic of Congo, Eritrea, Niger, Zambia, and Burkina Faso. Preparations are moving rapidly in eight countries ( Senegal, Ethiopia, Kenya, Mozambique, Benin, Nigeria, Sudan, and Malawi) and a regional program (The Senegal River Basin Booster, as part of a larger Senegal River Basin Infrastructure Project, covering Senegal, Mali, Mauritania and Guinea). The Bank has also established a resource team based in Washington that manages the program for the region. The Malaria Implementation Resources Team (MIRT) is responsible for overseeing quality and monitoring of The Booster Program for the Africa Region, for providing support as needed to task teams preparing and implementing malaria control activities in the region and serves as the main interface of the Program with external partners and the media. Building on Partnership: The success of the Booster Program depends on strong partnerships, with each partner maximizing its comparative advantage. The Program is firmly embedded within the Roll Back Malaria Partnership, to which the Bank remains entirely committed. We are working with partners such as, UNICEF, Exxon Mobil, WHO,, USAID/PMI, the Global Fund, the Gates Foundation and Civil Society Organizations, to name a few. Internally, we are collaborating with a number of sectors outside of health to address key cross sectoral issues in malaria control. Donor Harmonization: Through the Roll Back Malaria Partnership, we are leading an effort to develop a comprehensive framework to harmonize for impact at the country level for malaria control in collaboration with countries and donors. At country level, we are working with RBM Partners to support countries in developing their strategic plans, around which support can be harmonized and sustained. A framework paper on Harmonizing for Impact in Malaria Control is currently being finalized in collaboration with all partners in the RBM Partnership. The paper identifies ways to increase aid effectiveness for malaria control by harmonizing development assistance among donors. It emphasizes aid alignment with country-led strategies and local financing mechanisms. Focusing on Results: The key to maintaining and being held accountable for results under the Booster Program, is an effective monitoring and evaluation strategy. Through the Booster we are working with partners at the global, regional, and country levels to ensure that we keep the focus on outcomes as opposed to inputs. To this end, the Bank has developed a results-monitoring matrix –The Malaria Indicator Template-that tracks dollar inputs against concrete results - such as insecticide-treated net utilization, and access to effective treatment. Through this matrix, we are not only monitoring Bank support, but also that from other partners and from the countries themselves, to monitor the impact of our combined investments on clear outcomes in malaria control. This matrix has already been presented to partners through the RBM Monitoring Evaluation Reference Group (MERG), to reach consensus on the way forward. 
1. Roll Back Malaria. WHO and UNICEF, 2005. The World Malaria Report. Geneva, WHO, 2005. 2. Malaria is a potentially deadly disease caused by infection with the Plasmodium parasite. Plasmodium is transmitted to humans through the bite of infected Anopheles mosquitoes. Four species of malaria parasites can infect humans: Plasmodium falciparum, the deadliest and most common form in sub-Saharan Africa, P. vivax, P.malariae, and P.ovale. Climatic conditions in the sub-Sahara are unfortunately favorable for highly efficient vectors such as A. gambiae and A.funestus. For further details see: www.who.int 3. Sylvia Meek. 2005. Tackle Malaria Today Give Tomorrow a Chance. UK House of Commons. All-Parliamentary Group on Malaria. 4. WHO/AFRO, Malaria Control Unit, Annual Report, 2004. 5. The Abuja targets were originally set for 2005, a schedule now widely regarded as very difficult to achieve in many countries. Broadly speaking, they call for at least 60% utilization of effective malaria prevention and treatment. 6. Since 2003, some countries may have moved to another category.
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