AMF – Reflecting on 2023 and looking ahead to 2024

Rob Mather, CEO, AMF, 25 November 2023

2023 has been a very busy year for AMF, more on 2024 later.

Impact

AMF’s team of 13 is in the middle of a nine-month period during which we are distributing, with partners, 90 million nets to protect 160 million people in seven countries: Chad, the Democratic Republic of Congo, Nigeria, South Sudan, Togo, Uganda, and Zambia.

The impact of these nets is expected to be, ± 20%, 40,000 deaths prevented, 20 million cases of malaria averted and a US$2.2 billion improvement in local economy (12x the funds applied). When people are ill they cannot farm, drive, teach – function, so the improvement in health leads to economic as well as humanitarian benefits.

This is a terrific contribution from the tens of thousands of donors who have contributed US$180 million over the last two years, and the many partners with whom we work that make possible the distribution of these life-saving nets.

We received our millionth donation recently, a nice milestone. Our total funds raised is now US$543 million.

But these numbers are not as important as the impact numbers once all the nets we have funded in our 19 years and can currently fund, have been distributed and have had their impact: 250 million nets funded and distributed, 450 million people protected, 185,000 deaths prevented, 100 to 185 million cases of malaria averted and US$6.5 billion of improvement in local economies.

Many recognise the impact of AMF’s work, yet we still have significant immediate funding gaps that are over US$300m. While this number seems daunting, every US$2 matters as that funds another net and allows two more people to be protected when they sleep at night, so no support is too small or inconsequential.

Partnerships are crucial to what we do

We work with partners at every stage of our work: funding nets; ensuring operations proceed effectively and nets are distributed as intended; and monitoring net use, performance and impact. Over the last few years we have strengthened relationships with key organisations that have allowed AMF to contribute more and work faster and more effectively.

AMF has strong partnerships with the Global Fund and the US’s President’s Malaria Initiative, and we work together closely to ensure net distributions are fully funded. None of us can work alone. Typically AMF funds nets for a distribution and the Global Fund or PMI funds the non-net costs. Non-net costs are shipping and transport costs, household registration activities to ensure each household receives the right number of nets, and the distribution of the nets themselves.

Nets are always distributed in partnership with national health systems. This is because all households in a regional or nationwide distribution are visited in the pre-distribution registration phase to establish how many nets are needed per individual household, and this work involves visiting hundreds of thousands or millions of households and needs a work force that only a national system can provide.

A final set of partnerships in-country that are very important for AMF’s work are those with independent monitoring partners with whom AMF contracts to carry out data-driven monitoring of all phases of a distribution.

AMF’s focus has been, and still is, on nets

This focus on nets is not accidental. Long-lasting insecticidal nets are the most effective way of preventing malaria. Malaria-carrying mosquitoes typically bite between 10 o/c at night and two in the morning so if people in malarious areas are protected when they sleep at night, the impact on malaria transmission is significant. In the environments in which nets are distributed, they will frequently develop holes and rips and tears, but because the nets are covered with insecticide they remain 99+% effective. This is because the mosquito does not do an aerobatics manoeuvre through a hole, but instead lands on the nets and walks to the hole picking up insecticide as it does so, and that causes knockdown – the mosquito dies.

AMF has developed over 15 years an expertise in selecting the right type of net for a given distribution. It is not one net type fits all, as different areas, regions and countries have different levels of insecticide resistance (this has developed over the last twenty years and particularly the last five) and other factors that influence a specific net choice. These net choices materially affects the impact of the nets in the communities being protected.

Operations is at the heart of AMF’s work

Operations takes up the majority of AMF’s time and is our focus. We often say that you cannot mess up, per se, on the amount of money you raise but boy can you mess up on operations if you don’t get that right. Huge attention has gone into this area over many years, learning lessons, improving and refining what we do, to ensure that the distributions we fund have nets reach recipients as intended, accountably so and with comprehensive data at the household level to evidence it.

We focus on planning as it sets operations off on the right track; we focus on building strong relationships and strong procedures with operating partners as that ensures things run smoothly; and we focus on ensuring comprehensive and reliable data are collected as that delivers evidence of outcome.

We monitor all stages of a distribution, from planning, through household registration and net distribution to post-distribution monitoring of net presence, use and condition. AMF funds this monitoring. We like to say that we monitor the living daylights out of what we do! This is because we believe monitoring improves outcomes as it can influence behaviour, allows us to learn lessons so that we can adjust if necessary and improve and, crucially, it is a necessary mechanism to ensure we have high levels of confidence in knowing what has happened in a distribution. AMF funds and controls this work.

Recently in the Togo distribution, our monitoring partner, GRASE Population, identified a village that had been registered for distribution but nets had not been given out when they should have. Our monitor contacted the national program, who were grateful to be informed, and who immediately made arrangements to ensure the village received nets during the ‘mop up’ phase of the distribution.

A small but growing team that punches above its weight

2023 has seen AMF’s focused team grow to 13, with the addition of seven new team members – Alicja, Richard, Neil, Jeremy, Izabel, Helena and Eliette. We are delighted to have team members not only in the UK but now also in the US (Boston), Kenya (Nairobi), Germany (Dresden) and South Africa (Cape Town).

2023 has been an important year for malaria vaccines

Outstanding scientific progress has meant for the first time in human history we have vaccines for a parasitic disease. The impact of these first vaccines will become known over time. They are a welcome addition to the malaria control toolkit.

We hope one day a vaccine, or a gene-drive technology solution, might be a silver bullet.

One way we find it helpful to think about a vaccine is to consider performance along four parameters, with a strong benchmark being the polio vaccine: % efficacy, proportion of the target population that can benefit from the vaccine, number of doses that need to be administered and the need or otherwise to refrigerate the vaccine, so called ‘cold chain logistics’. The latter two parameters can have a material impact on cost. For polio: 100%; 100%; one administration only; and no cold chain logistics. For the two malaria vaccines, 35% − 65%; a subgroup only, albeit an important one of 6-18 month olds; three doses one month apart and a fourth a year later; and refrigeration is required.

The fervent hope is that the remarkable achievement of these scientists will be developed further.

2024 to 2026 are shaping up to be challenging years

There is already a significant shortfall in funding for malaria control activities, including for net distribution programmes so miraculous things will have to happen in the coming year if we are to get anywhere close, globally and across all funding partners, to where we need to be to be able to drive malaria impact numbers down. Counterfactually of course, if the funding that is being brought to bear was not there, the number of people affected by malaria would be horrifically higher. Currently there are ~620,000 deaths a year from malaria and 250 million people fall sick.

The Global Fund is the world’s largest funder of malaria control activities and has a funding replenishment round every three years, with funding provided by global governments, that determines the funds it has available across three disease areas: HIV/Aids, malaria and TB. The target for the 2024 to 2026 period was raising US$18 billion, largely to stand still. The funding achieved was US$15.7 billion. The shortfall will have major ramifications and we are already seeing the impact in planning in the Democratic Republic of Congo, one of the two countries in the world worst affected by malaria, for the 2024 to 2026 programme. Currently only 65% of the nets desperately needed will be able to be funded. We have never had this low a percentage of funding at this stage, with limited additional funding forecast.

But we are positive, and gaps make us work harder.

We must remember that enormous progress was made in reducing the impact of malaria over a 15 year period from 2000 to 2015 with a 60% reduction in malaria deaths and two thirds of that being down to the distribution of the humble bednet.

Aside gaps in funding, we face challenges of increasing costs in some areas (COVID didn’t help) and insecticide resistance is on the rise. New net products have been and are being developed to deal with this and progress in some areas is excellent.

We never tire of reminding people that every US$2 net matters as it protects two people when they sleep at night. And given the funding gaps, we put each of those US$2 to work straight away when they come in.

You

If you are interested in joining or continuing the fight against malaria in 2024, thank you.