A Tale of Two Diseases: Tuberculosis Control and Malaria Eradication in China

Last month, the World Health Organization declared that China has achieved the Millennium Development Goals target of reversing tuberculosis (TB) incidence by 2015.  According to a recent study published by the Lancet, between 1990 and 2010, China more than halved the prevalence of smear-positive TB. The achievement prompted the WHO representative in China to note that “over the last 20 years, China has been the single country that has shown the biggest gains in TB control in the world.” The Lancet piece attributes China’s success in TB control to the government’s commitment to the WHO-recommended program called directly observed therapy, short course or DOTS. What the article failed to note was the important role played by other international agencies such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, the largest international health cooperation program in China.

From 2003 to 2013, China has received $366 million from the Global Fund, accounting for 10 percent of the organization’s TB-specific disbursements—indeed, in 2011, Global Fund money accounted for 30 percent of total TB funding in China. With financial support from the Global Fund, China was able to increase the TB case-detection rate from only 30 percent in 2002 to 80 percent by the end of 2005. Before the Fund left China in 2013, the Fund also underwrote the lion’s share of efforts in Chinese provinces to treat and manage multi-drug-resistant TB.

In the same vein, the Global Fund money has allowed China to shift its priority from malaria control to malaria elimination. In its one decade presence in China, the Global Fund has supported the distribution of 4.5 million insecticide-treated mosquito nets, particularly long-lasting insecticidal nets, to China.  In 2002, the country had 25,520 malaria cases and 42 malaria-related deaths. With the distribution of these nets, now malaria cases and related fatalities in China have dropped markedly to 7,855 and 19, respectively.

Juxtaposing these two successful stories, however, may overlook a crucial difference between them. In 2002, prior to the injection of the Global Fund money, China had one of the highest TB burdens in the world. With more than 1.3 million new cases of tuberculosis every year, China accounted for 14 percent of global incident cases of TB. Comparatively, China only accounted for 0.007 percent of the global malaria cases and 0.004 percent of the malaria-related deaths at the same time. Despite these very low levels of malaria, the Global Fund, in 2003, allocated 9.2 percent of its total Round One funding for malaria control in China—this was at a time when malaria was killing a child in Africa every thirty seconds.  Indeed, during the 2002-12 period, the Fund disbursed $115.7 million in China just to reduce the number of malaria deaths by 23. True, the magnitude of the decline in malaria cases and related deaths in China was higher than the global average in the same period, but the raw number is quite unimpressive. Indeed, even if we attribute the drop entirely to the Fund money, one would still wonder whether it was wise to spend an average of $5 million for every malaria-related fatality that was prevented in China.

A comparison of the role of the Global Fund in China’s fight against TB vis-à-vis malaria therefore clearly reveals the uneven progress in grant performance in China.  In the case of malaria, there is a low value for money problem. And as Jia Ping and I contend in our new working paper, this is just one example of the deeply mixed legacy that the Global Fund has left behind China.