CEMAC: More than 310 billion CFA francs invested in malaria between 2018 and 2022, but unsatisfactory results

“In Cameroon alone, a minimum of 200 billion CFA francs is being spent yearly for the fight against malaria since 2019. The needs are enormous. External funding is quite substantial, except that the mobilisation of domestic resources is low. As a result, this external aid falls far short of what is needed,” points out Dr Djibril Moubarak, a specialist in health financing and policy. He believes that the funds reported by the OECD represent only part of the overall funds allocated to the fight against malaria for the five countries.

An analysis of World Bank data, with a few exceptions, shows cumulative global external funding of more than US$466 million (more than CFAF 220 billion) received over the same period by these countries. A comparison of the OECD and World Bank data shows that Cameroon is the country that has received the most external financing between 2018 and 2022. This amounted to more than USD 250 million (more than CFAF 150 billion) over 5 years. This represents an average of at least 30 billion CFA francs per year in external funding received from this range of donors. With a peak of 44 billion CFA francs in 2022. Chad and CAR follow in the rankings.

The disease persists

In Cameroon, the Ministry of Health is pleased to report that the overall prevalence rate fell from 30% to 24% between 2011 and 2018. However, despite the funding received for the fight against malaria in the period from 2018 to 2022, the prevalence rate has risen to 26.1% in 2022. Data reported by health facilities also indicate that in 2023, malaria accounted for 28% of consultations and 7% of all deaths. These figures place the country among the top 11 most affected by malaria in the world, and the third most affected country in Central Africa (12.6% of cases in 2020). Despite multiple campaigns to distribute impregnated mosquito nets (Milda), intermittent preventive treatment (IPT) for pregnant women and seasonal chemoprevention Cameroon remains among the top 11 most affected by malaria in the world.

In another World Bank database, similar to that of WHO, Cameroon recorded an average incidence of 235.46 cases per thousand inhabitants at risk between 2018 and 2022. The country is presented as the second most affected by malaria in the Cemac zone, behind CAR.

Overall, according to the WB/WHO databases, the incidence of malaria varies between 203 and 329 cases per thousand inhabitants between 2018 and 2022 in these low- and middle-income CEMAC countries. Furthermore, a comparative analysis between the data on the incidence of malaria in Cameroon relayed by the WB/WHO and those of the National Malaria Control Programme (nmcp) reveals a discrepancy in the figures. While the official figures are low, they do show an evolution in the incidence and number of cases over the target study period, and an increase in the mortality rate recorded in 2019, 2020 and 2021.

According to OECD data, funding for CEMAC countries continued to flow in 2020 during Covid-19, reaching USD 47 million (more than 28 billion CFA francs) in Cameroon, even as the number of malaria deaths rose (4121, nmcp). « When Covid-19 hit in early 2020, it overwhelmed health systems, lockdowns disrupted service provision, and critical resources were diverted from the fight against HIV, tuberculosis and malaria to fight the new virus. The Global Fund fought back and ramped up investments to help countries respond to the pandemic,” explains Benjamin Szlakmann, Head of Communications and External Relations at the Global Fund.

In addition to the external funding received to fight malaria effectively, there are also funds injected by the State as part of the national budget and contributions from the general public through the payment of medical expenses. These funds are still considered insignificant in the fight against the disease. In Cameroon, the Ministry of Public Health has a budget of 255,281 billion CFA francs for the 2024 financial year. The institution pointed out on 25 April 2024 that 336.95 billion CFA francs are needed to successfully carry out the actions set out in its National Strategic Plan to combat malaria for the period 2024–2028 (5 years, from the date of the launch of the National Malaria Control Plan).

The CEMAC countries are still a long way from achieving the objective of the Abuja Declaration of 2000, which recommends that all signatory countries devote 15% of their national budget to the Ministry of Health each year. « The budget allocated to health varies between 4% and 6% of the national budget in Cameroon. As a result of our very limited finances, we are becoming dependent on external funding,” laments Dr Djibril Moubarak. From one CEMAC country to another, these budgets represent less than 8% of national budgets, and will vary between 3.1% and 7.7% in 2024.

The fight against malaria is underfunded, yet the ravages are real and severe in the CEMAC countries. « Business as usual will not end malaria as a public health threat by 2030 in Central Africa and beyond. To end malaria, we must accelerate access to life-saving tools  to those who need them most, especially children under 5 and pregnant women in malaria-endemic countries’, argues Benjamin Szlakmann. He notes that according to the latest report from the Global Fund (September 2024), deaths from malaria have fallen by 28% over the last ten years, between 2002 and 2022. In the absence of measures to combat malaria, deaths would have risen by 90% and cases of malaria by 79% over the same period, notes the institution.

Perfusion of external funding

« We give to those who know how to use the money offered. I’m going to give where I get more results. There are other criteria involved, such as geopolitical and security calculations. It’s not just about health, » says Professor Paul Batibonak a diplomat. He goes on to say that funding is conditional on internal weaknesses. Dr Djibril Moubarak adds that when a country has a fairly solid structure like Rwanda, it is difficult for a partner to impose certain things on it.

But at the Global Fund, we defend ourselves. Benjamin Szlakmann points out that the Global Fund operates with a high degree of transparency and accountability in all its work, and has zero tolerance for corruption or embezzlement. In his view, the organisation differs from others in that it gives countries (or groups of countries) an allocation and asks countries to describe how they intend to use these funds rather than asking for applications and then determining an amount per country based on the merits of the various proposals received.

Zero Cash

According to Lucien Bate, the Administrative Focal Point for the mechanism coordinating funding to fight malaria, tuberculosis and HIV in CAR, this modus operandi does not seem to apply in CAR, which has been considered a Difficult Intervention Context by the Global Fund for more than ten years. He explains that in this country, which records an average of 4,000 cases of malaria per day (2022), the Global Fund is applying the “ Zero Cash” additional safeguard policy. In practice, the principal recipients of grant funds awarded to CAR are directly designated by the institution, and no national institution can receive cash to carry out activities in the field. The grant funds allocated to the CAR are managed by two international NGOs, World Vision International and the French Red Cross.

The involvement of these NGOs is unfortunately hampering the fight against this disease in CAR, because the staff of these international NGOs can only go to areas considered by their system to be safe zones. This limits the fight in certain parts of the country. “The key indicators for the fight against this disease show that a major effort needs to be made if we want it to have an impact on the population in general, pregnant women and children under 5, who bears the brunt,” says Lucien Bate.

The Global Fund, which is applying a ‘zero cash’ policy in CAR, where malaria is considered the leading cause of morbidity and mortality, provides 65% of all international funding for malaria control programmes. These investments focus on scaling up essential malaria prevention and control interventions, such as the distribution of insecticide-treated mosquito nets and malaria treatment programmes.

In Gabon, where the incidence of malaria has risen from 228.91 per 1,000 inhabitants in 2021 to 230.53 in 2022 (WB and WHO), the Global Fund database does not show any funding awarded to this country of around 2 million inhabitants (WB 2024) for the fight against malaria for the 2017–2019 and 2020–2022 cycles. However, data collected by C4ADS indicates that over 5 years, this country has received nearly 46 million CFA francs from the WHO and the Bill and Melinda Gates Foundation for this cause.

This absence of funding from the Global Fund is justified by the institution’s decision to suspend funding for HIV and malaria due to an ‘unsatisfactory level of performance’. For the 2023–2025, allocation period, this major partner allocated Gabon funding of around USD 3 million (more than CFAF 1 billion). The Global Fund says it has reconsidered its decision after “careful reflection on the burden of both diseases and renewed commitment from the government of Gabon”. The international organisation points out that funding is dependent on performance and carefully monitored and verified results.

« The fight against malaria is a major battle for the countries of sub-Saharan Africa, which account for 95% of the malaria burden in these countries. What is described here as weak is in fact the slowness in achieving the objectives’, explains Dr Djibril Moubarack. According to this specialist in health financing and policy, there are several other factors that may explain this slow progress. He cites socio-economic factors, poverty levels, education, and the political and security contexts that destabilise the supply of healthcare.

invested in malaria Fund Management

While countries receiving external funding find that the total pot of money mobilised in each round is always insufficient to carry out all the operations planned in the field. These countries are accused of failing to meet their commitments to their donors because of their unsatisfactory performance. Yet, according to Benjamin Szlakmann, national funding plays an essential role in achieving a lasting impact invested in malaria. “At least 15% – and up to 30% in some countries – of Global Fund allocations are subject to these co-financing requirements. The partner countries most affected by malaria are also committed to making solid and sustainable progress in the fight against malaria, » he adds.

In a letter dated 9 October 2020, the Global Fund informed the Cameroonian government of its decision to withdraw €9 million from Cameroon’s allocation for the 2017–2019 period. This decision was motivated by the fact that Cameroon was not going to fully meet its co-financing commitments for the 2018–2020 period. The Global Fund announced the reduction of funding to four grants, including the CMR-M-MOH state malaria grant (€7.6 million).

In CAR, the problem of mismanagement of funds earmarked for the fight against malaria was also raised. Lucien Bate points out that there have been cases of expenditure considered by the Global Fund to be ineligible, and twice in succession the burning of drug depots. “The Global Fund has asked principal recipients to reimburse,” he points out. He highlights that the under-utilisation of funds is one of the management problems leading to the loss of large sums that could be used to improve the fight against malaria.

« Given that resources are never sufficient, prioritisation should be as effective as possible and be more demanding in the choice of different interventions invested in malaria. There is a tendency to repeat the same activities without taking the time to assess the real impact,” laments Dr Djibril Moubarak. He suggests that a truly multisectoral approach should be put in place. He recommends mobilising domestic resources and ensuring that resources are prioritised meticulously and intelligently.

The Cameroonian Ministry of Public Health has been approached several times as part of this collaborative effort, which began in March 2024, to no avail. The focal points of the multisectoral coordination committees (Ccm) in Chad, Congo and Gabon have also been contacted, to no avail. The Executive Director of the NGO Impact Santé Afrique was also contacted, to no avail.

Mélanie Ambombo, Jérôme Baïmélé, Mathias Mouendé Ngamo

This work was carried out as part of the 2nd cohort of the Survey Project on the Governance of Natural Resources in Central Africa (ODACA), initiated by ADISI-CAMEROUN, with technical support from DataCameroon.