An inside look at how WHO develops global malaria guidance
Dr Kevin Marsh
Chair of the WHO Malaria Policy Advisory Committee
How did the decision to establish the WHO Malaria Policy Advisory Committee (MPAC) come about?
The decision to form the MPAC came from a desire to establish a clearer, more transparent system for the development of global policy recommendations on malaria. The initial push came from Rob Newman, the Global Malaria Programme’s (GMP) previous director, who wanted to ensure that there was a systematic and deliberate process for ensuring that policy recommendations were informed by a careful review of existing evidence by a group of experts with a wide range of experience. After a series of consultations to define the terms of reference and select members, the first MPAC meeting was held in January 2012.
What is the role of MPAC now?
MPAC formally advises GMP and the WHO Director General on malaria policy. The committee is comprised of 15 members with a wide range of experience representing different disciplines in malaria and with experiences ranging from policy to research to implementation. We meet every 6 months to review evidence and advise on whether new policy recommendations are needed. The global community has been very supportive of MPAC from the outset, but there were some people that said, “How can a group of 15 people possibly cover all of these topics?” And of course that is right, but that was never the intention for how MPAC would work.
The decision to form the MPAC came from a desire to establish a clearer, more transparent system for the development of global policy recommendations on malaria.
Dr Kevin Marsh
To ensure our recommendations to WHO are robust, we also often ask other key groups – both within and outside the malaria field – to participate. Together with the GMP Secretariat, MPAC will assemble standing technical expert groups or evidence review groups to help guide thinking around high priority areas in need of a policy decision. In addition, the MPAC meetings are open; anyone can register and attend. We have sometimes up to 80 people in the room, and we really welcome and encourage contributions from the floor, whether it’s questions or position statements. We also have a number of standing observers representing key partners, regional representatives, national programmes, and funders. There are a lot of active contributors, which is critical. Because in the end, policy is only relevant if it is useful to the people that have to implement it.
How are new members selected?
Anyone can apply or be nominated at any time, and we also issue calls for new members from time to time when there are open seats to fill. We keep a database of people who are interested in joining, and we refer to that database whenever there are vacancies on the committee. When we select a new member, we try to be as diverse and representative as possible in all terms: disciplines, geography, implementation vs research experience, and so on. The key requirement is that the group as a whole must be able to listen to, assess, and distill research evidence to form policies that are useful and can be effectively implemented in countries. Naturally, the group has been very diverse, and includes people that have been heads of malaria control programs and leaders of large research groups.
At this year’s meeting, it was pointed out that progress in the malaria fight has continued despite the fact that funding has plateaued over the last several years. Why do you think this is the case?
Well, let’s look first at the good news. Since 2000, we’ve seen an incredible increase in funding for malaria – from a couple hundred million dollars a year to more than US$ 2 billion. Funding levels have obviously plateaued over the last several years, but what is really striking is when you look at the trends for uptake of important tools like bednets, indoor residual spraying, and preventive therapies. Coverage with these tools has continued to steadily increase throughout this same time period. To me, that implies that we might be getting more efficient using a fixed amount of money.
We know for certain that we need substantially more funding to realize the full potential of the interventions we have, particularly in terms of reaching malaria elimination.
Dr Kevin Marsh
You cannot continue to have constant improvement in coverage with flat funding, but it’s really encouraging to see steady improvement with no real sign of the trends slacking off. What you can’t say, of course, is whether those trends wouldn't have been even steeper with more funding. Maybe it speaks to the absorptive capacity – that the amount of money we had at the time was about right for what countries could absorb, in terms of implementation capacity.
That doesn’t mean we should be complacent – it’s just an interesting observation. We know for certain that we need substantially more funding to realize the full potential of the interventions we have, particularly in terms of reaching malaria elimination. The majority of malaria cases are in 13 African countries with very high malaria transmission and coverage gaps with these tools. So clearly much remains to be done. We also know we are facing the possibility of drug resistance spreading and insecticide resistance getting worse. These potential threats are always in the background, and we need to be realistic.
Do you think the current malaria research agenda is aggressive enough to address these potential challenges?
Whenever we’re asked the question “Are we doing enough?” the answer is always no (laughs). You always want new drugs to be available more quickly, vaccine development to happen faster, and so on, but I think progress is good. New funding from the Gates Foundation and others has had a very positive effect on product development, and new private-public partnerships and groups like the Malaria Eradication Research Agenda (malERA) are driving the agenda. Options are increasing, additional technologies are being developed, the research community is developing new approaches like gene editing, which is basically engineering mosquitoes to be resistant to malaria parasites. There is quite a lot to be excited about.
You have been the chair of the MPAC since its inception in 2012. What has your experience in this role been like?
I just want to say that I’ve found it really enlightening and enjoyable to be working as a part of WHO over the years. WHO as an organization is absolutely critical to the global health sector, and it’s important that researchers, policymakers and funders recognize the fundamentally important role of the organization in pursuing a robust global health agenda. It’s worrying to see that global funding for WHO is somewhat precarious. It’s great that other large funders have been stepping in and supporting WHO activities, but we also need to see increased Member State contributions to WHO so that it can continue the important work of setting global standards and guidance across diverse health sectors.