In May 1998, the director-general of theWorld Health Organization (WHO)

announced a United Nations-led campaignto Roll Back Malaria (RBM), pledging tohalve malaria deaths by 2010. Today, RBMis at the halfway point and the WHO’s ownstatistics show deaths have actuallyincreased (see graph, right). For the severalhundred thousand children who died in theinterim, RBM is not just a failure but a fatalbetrayal by the United Nations.

How did this happen? The fundamentalreason is political: the WHO launched RBMto create an advocacy splash, but has subse-quently failed to ensure adequate funding.

The world’s foreign-aid donors — power-ful developed countries and the World Bank— have behaved with their usual parsimony,but the WHO has not been vocal enough tohold them to account. Aid funding formalaria control has barely grown.No wonderthe British Medical Journal recently calledRBM “a failing global health campaign”1.Without large increases in foreign aid, theleast-developed countries that are mostseverely affected by malaria can do little.Theyhave an average public-health expenditure ofbarely US$6 per person annually2.

This figure would be more had Africangovernments honoured their promise at aconference in Abuja, Nigeria, in 2001 tospend 15% of their budgets on health. Buteven if they had, the vast majority of malariacontrol in the poorest countries would stillneed to be paid for out of foreign aid.

So how much foreign aid is available tocontrol malaria? The WHO’s most recentestimate was that “approximately US$200

million was earmarked for malaria controlworldwide”in 2002, including both domesticand foreign-aid budgets3. This is roughlyconsistent with an estimate for 2000 by myselfand Vasant Narasimhan4 of $100 million,which counted only the foreign-aid budget.

Most recently, the Global Fund to FightAIDS, Tuberculosis and Malaria gave causefor optimism by pledging $895 million overtwo years, rising perhaps to $1.8 billion overfive years5. At an average rate of $360 millionannually, assuming full disbursement, thiswill be the largest increase in malaria-controlfunding for decades6.

But making significant progress willrequire billions of dollars annually, not millions. There is a precedent: malaria-

control funding in the 1960s did reach suchlevels7.RBM has said that Africa needs $1 bil-lion annually3.A more careful peer-reviewedestimate is that at least $1.6 billion is neededjust for malaria medicines in Africa alone8.

Add in the cost of disease prevention —such as bednets and insecticides — trainingand staff costs, and the fact that many of theworld’s malaria fatalities occur outsideAfrica9, and a fair guess for the worldwideprice tag must be at least $5 billion annually.

Thus, even with the advent of the GlobalFund,there is far too little foreign aid to com-bat malaria. This suggests that a more delib-erate, more aggressive strategy to drive updonor aid is needed.To start with, it would bedesirable to audit routinely how much eachdonor spends on malaria control, so thatprogress — or lack of it — can be tracked.

Tied up in red tapeAt the moment, attempts to obtain foreign-aid figures are hampered by bureaucracyand poor availability of accurate, up-to-datedata. Of 23 developed countries I surveyedin 2002, 13 seemed unable or unwilling todisclose their malaria-control funding, evenafter nine months and several reminders4.

For this article, I surveyed three major aiddonors: the World Bank, the US Agency forInternational Development (USAID) and

932 NATURE | VOL 430 | 19 AUGUST 2004 | www.nature.com/nature

Where did it all go wrong?International agencies have failed to meet theirown malaria performancetargets and should be held to account, says Amir Attaran.

Roll Back Malaria’s difficulties so far suggestthat major aid donors such as the World Bank

(pictured) are not rising to the challenge.

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Africans,a practice that is controversial.UNICEF says that it also invests “notable

sums” in programmes that strengthenhealthcare delivery in general and which maybenefit malaria control in the long run, suchas the training of healthcare workers andeducation campaigns. But it provided nofigures for what proportion of this invest-ment directly relates to malaria control.

This all raises hard questions about legiti-macy.The World Bank has said malaria slowseconomic growth in African countries by1.3% per year. Over 35 years, this equates to a32% reduction in GDP, worth in the range of$100 billion10. If the bank fails to fulfil its ownpledge on malaria control in Africa, whileobserving that its economies are so severelyaffected by the disease, is it actually doinginternational development? And if UNICEF,USAID and the World Bank cannot providedetailed audits of their malaria spending, isthat a transparent use of taxpayers’money?

One lesson is clear: congresses, nationalparliaments and ultimately the public needto ‘take back malaria’. Imagine if the man-agers of a project in a private company con-sistently missed their performance targets bya large margin. The company would be introuble,and it would sack the managers.

Exactly the same should be true of thepublic agencies and officials who have for sixyears missed their performance target toreduce and ultimately halve malaria deaths. Isuggest that legislators hold hearings intowhy the agencies have failed to roll backmalaria, and take the necessary action. If thatsounds harsh, weigh it against the number ofchildren whose lives were tragically lost in theinterim to a preventable,curable disease. ■

Amir Attaran is associate professor of population health

and law at the University of Ottawa, Canada, and associate

fellow at the Royal Institute of International Affairs, UK.1. Yamey, G. Br. Med. J. 328, 1086–1087 (2004).

2. Macroeconomics and Health: Investing in Health for Economic

Development (WHO, Geneva, 2001).

3. Africa Malaria Report 2003 (WHO/UNICEF, Geneva, 2003);

available at www.rbm.who.int/amd2003/amr2003/amr_toc.htm

4. Narasimhan, V. & Attaran, A. Malaria J. 2, 8 (2003).

5. www.theglobalfund.org/search/default.aspx?lang=

en&component=Malaria (accessed 15/06/04).

6. www.theglobalfund.org/en/files/factsheets/disbursement.pdf

(accessed 15/06/04).

7. Spielman, A., Kitron, U. & Pollack, R. J. J. Med. Entomol. 30,6–19 (1993).

8. Snow, R. W., Eckert, E., Teklehaimanot, A. Trends Parasitol. 19,363–369 (2003).

9. Hay, S. I., Guerra, C. A., Tatem, A. J., Noor, A. M. & Snow, R. W.

Lancet Infect. Dis. 4, 327–336 (2004).

10.McCarthy, F. D., Wolf, H. & Wu, Y. Malaria and Growth World

Bank working paper 2303 (World Bank, Washington, 2000).

The World Health Organization has pledged tohalve malaria deaths by 2010 — but it has yet tomake much progress.

a tiny quantity of malaria medicines.In personal correspondence, USAID said

that it spends about 34% of its $65.6-millionannual budget for malaria on treatment. Butit adds that it “typically does not purchase …[malaria] medicines other than in excep-tional or emergency circumstances”, and thatthe quantities are “not large”. It states that,instead, its strategy is “building the systems toprocure,manage,and use the drugs”.

Obsolete medicinesUNICEF does routinely buy and supplyantimalarials, but the amounts are trivial:just $3.7-million worth in 2003. Worse,most of that was spent on obsolete drugsthat, because of resistance, usually do notwork. Examples are chloroquine in Kenyaand sulphadoxine-pyrimethamine inBurundi, which are so ineffective neithergovernment sanctions their use. UNICEFspent only $1 million on more effectivedrugs, the artemisinin combination thera-pies, even though these are the RBM-endorsed standard.

A similar picture emerges for buying and supplying bednets and insecticides.UNICEF spent $17.3 million on these in2003. USAID could not provide breakdownsfor spending on each, although it spent $8.4 million in 2003 on a partnership with private contractor NetMark, which sells (not gives) bednets to impoverished

the United Nations Children’s Fund(UNICEF). The World Bank is the world’stop donor of foreign aid, USAID is the for-eign-aid agency of the world’s only super-power, and UNICEF is the world’s topchild-health agency. How much does eachspend on malaria?

A World Bank announcement on AfricaMalaria Day in April 2000 pledged between$300 million and $500 million towards theeradication of malaria in Africa. In an earlierstudy, I estimated that the bank earmarked$44 million of loans for malaria control aid in 2002 (ref. 4). For this article, the bankdeclined to supply me directly with data,but in a statement to Nature it claimed tohave earmarked loans totalling between$100 million and $150 million for malariacontrol since 2000. Beyond that, it is difficultto know how much else the bank is spendingon malaria. Its statement points to “non-earmarked monies” that may indirectly affect malaria (for example debt cancella-tion), but which it says are “difficult to quantify” because the bank does not trackdisease-specific details.

Whereas the World Bank supports acountry’s overall malaria-control budget,UNICEF and USAID tend to support dis-crete projects on the ground.Although RBMacknowledges that prompt and effective treat-ment are essential to reduce malaria deaths,neither UNICEF nor USAID buys more than

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