Business and Malaria: A Neglected Threat? · 4 Summary and key findings Introduction Malaria is a serious threat to humanity. Centuries of effort to mitigate its impact have borne

World Economic Forum

Global Health Initiativein cooperation with

June 2006

COMMITTED TO IMPROVING THE STATE

OF THE WORLD

Business and Malaria: A Neglected Threat?

The views expressed herein do not necessarily reflect the views of theWorld Economic Forum.

World Economic Forum91-93 route de la CapiteCH-1223 Cologny/GenevaSwitzerlandTel.: +41 (0)22 869 1212Fax: +41 (0)22 786 2744E-mail: [email protected]

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REF: 050706

This report was written by:

David E. Bloom, who is the Clarence James Gamble Professor of Economics and Demography atthe Harvard School of Public Health; Lakshmi Reddy Bloom, who is an information systemsconsultant and head of Data for Decisions; and Mark Weston, who is an independent policyconsultant and researcher. The authors thank Laura Altinger of the World Economic Forum, GlobalCompetitiveness Programme; Francesca Boldrini and David Kim of the World Economic Forum,Global Health Initiative; Kevin Chan, Shan Liu, Anthony Kiszewski, and Andrew Spielman of HarvardUniveristy and Linda Harrar of Linda Harrar Productions for their very useful comments andguidance and are indebted to Helen Curry and to Om Lala and Larry Rosenberg of HarvardUniversity for their helpful assistance.

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The World Economic Forum seeks to harness thepotential of public-private partnerships to addresstoday’s global challenges. The Global HealthInitiative was launched in 2002 to respond to theglobal threat posed by the three major diseases:HIV/AIDS, tuberculosis (TB) and malaria. Inpartnership with UNAIDS, the World HealthOrganization and the Stop TB and Roll BackMalaria Partnerships, we asked our network ofmember companies to step up to the challenge,and to bring their resources to bear to increasethe quality and quantity of private sectorresponses in the fight against HIV/AIDS, TB andmalaria.

Today, the global fight against malaria is enjoyingunprecedented momentum, in terms of increasedfunding, political support and greater convergenceon policies and programming. What role can thebusiness community play in this context? What isthe impetus for private sector action, and what isstill needed in order for their contributions to trulymake an impact? An important dimension of theGHI is to monitor and report on the businessresponse to HIV/AIDS, TB and malaria. Our latestreport, Business and Malaria: A Neglected Threat?seeks to examine some of these questions,through an analysis of a survey of over 8,000business leaders from over 100 countries. Thereport provides us with clues on how businessesview the threat of malaria, and where they believethe responsibilities for action lie.

The report’s analysis shows that in sub-SaharanAfrica, 72% of companies are reporting a malariaimpact, with 39% perceiving these impacts to beserious. The challenge now is to use this buddingunderstanding to catalyse effective businessinterventions against malaria. Complementary to thisreport, the GHI’s Guidelines for Employer-BasedMalaria Control Programmes provides practical toolsfor companies to plan and implement malaria controlprogrammes, and our case study library outlines indetail best-practice examples of how companies haveresponded to the challenge of fighting malaria.

We would like to thank David Bloom at the HarvardSchool of Public Health and his team for their work onthis report, and David Kim, the GHI’s Manager forAfrica and Malaria, for his assistance in designing thereport and managing its production. We also wouldlike to express our appreciation to the Bill and MelindaGates Foundation for their support to this report andsincerely thank the report’s reviewers for their time,insightful input and advice.

We hope this report will help to foster a greaterunderstanding of the potential for private sectorengagement in the fight against malaria.

Richard SamansManaging Director,Centre for Public-Private PartnershipWorld Economic Forum

Foreword

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Summary and key findings

Introduction

Malaria is a serious threat to humanity. Centuriesof effort to mitigate its impact have borne fruit insome regions, but the disease remains a resilientfoe in many countries. Responsible for at least onemillion deaths each year, malaria has persisted inlarge regions of the world and resurged in othersin recent decades as resistance to drugs andpesticides has spread.

So far, governments have been responsible formost malaria control efforts. Many governments,however, lack the resources for effectiveprevention and treatment, which has led to callsfor greater private sector involvement.

For some firms, involvement in malaria control islikely to be in their best interest. Poor health canaffect businesses directly, through its impact onworkers, customers and corporate reputation.Although the academic literature is thin, there issome empirical evidence that malaria has directlyimpeded business activities, and several largecorporations have engaged in malaria control inorder to limit its impacts on them.

Poor health can also affect businesses indirectlyby holding back a country’s economy; malaria hasbeen found to have significant indirect impacts oneconomies.

For many businesses, on the other hand, such asthose that export most of their production or thatsell primarily to other firms or to communitiesuntouched by the disease, malaria will notsignificantly affect their customer base. In addition,although it is clear that workers with malaria areproblematic for a business (due to lassitude,absence and even death), businesses may decidethat local labour surpluses mean that it is lessexpensive to deal with these problems than toinvest in the health of their workers.

This report discusses the impacts of malaria onbusiness. Part One describes malaria and outlinesprevention and treatment methods. It also looks atthe international response to the disease. Part Tworeviews the academic literature on the impacts ofmalaria on economies and businesses. Part Threeof the report presents data from the WorldEconomic Forum’s annual Executive OpinionSurvey. The survey polls the views of over 8,000business leaders in over 100 countries. In the pastthree years, it has included questions on thebusiness impacts of malaria. Part Four of thereport discusses the actions the private sector cantake to combat malaria, and reviews examples ofbusiness malaria programmes. The final sectionmakes some recommendations for businessesconsidering engagement in malaria control.

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economies of countries with high malariaprevalence grew 1.3 percentage points less peryear than other countries between 1965 and1990. Other studies find smaller effects.

• Several companies report that malaria has hadsevere impacts on operating costs in recentyears. In a survey in Ghana, where malaria isendemic, 30 per cent of business leaders whoresponded reported that the disease had had astrong impact on productivity.

Business concerns over malaria: theExecutive Opinion Survey

• 22 per cent of business leaders who respondedto the World Economic Forum’s ExecutiveOpinion Survey in 2004 report that malariacurrently affects their business. 10 per centreport serious impacts.

• In Sub-Saharan Africa, 72 per cent ofrespondent firms reported current impacts in2004, with 39 per cent perceiving theseimpacts to be serious.

• Respondents think the future toll of the diseaseis likely to be similar to its current effect. (seemap 1). However, concern over the futureincreased somewhat between the 2004 and2005 surveys.

• In countries with at least some malaria, 40 percent of firms expect impacts within the next fiveyears.

Key findings

The challenge of malaria

• Nearly half the world’s people live in areas that arevulnerable to malaria. Sub-Saharan Africa andSouth and South East Asia are the most affectedregions. In countries where the disease is endemic,pregnant women and children are most at risk. Inepidemic areas, both adults and children are atrisk.

• Although effective prevention and treatmentmethods are available, these are inaccessible tomany individuals who need them. Resistance topesticides and drugs has contributed to anincrease in malaria prevalence in some regions inrecent decades.

• The World Health Organization believes that,despite a spate of new initiatives such as theGlobal Fund to Fight AIDS, Tuberculosis andMalaria, global financing for malaria control isinadequate.

Why malaria matters for businesses

• Health problems affect businesses both directly,through their impact on employees, customers,and corporate reputation, and indirectly, throughtheir effect on economies.

• Data on the effects of malaria on economies andbusinesses are weak. Some southern Europeaneconomies grew rapidly following malariaeradication, and one major study found that the


Map 1 – Predicted future impact of malaria, 2005

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Recommendations

• Not all firms need to act on malaria. Businessesshould begin by identifying a need, likeliest toappear where government action has provedinadequate. An accurate assessment of theproblem is key to developing an effectiveresponse.

• Firms should not go it alone in malaria controlefforts. Governments, non-governmentalorganizations, other companies and businessassociations may all have specialist knowledgethat would strengthen a company’sprogramme.

• Programmes should begin by targetingemployees. The most immediate effects ofmalaria on firms are likely to derive from itsimpact on workers. Workers are also an easilyaccessible segment of the population forcompanies.

• If expanding programmes to include workers’families or communities, firms should be carefulto define the programmes’ reach and tomanage expectations.

• If encouraging contractors or suppliers toengage in malaria control, firms should assistthem by sharing policies and materials.

• Long-term evaluation of the impact and cost-effectiveness of programmes is key to theircontinued success.

• Firms in countries with both epidemic andendemic malaria are significantly moreconcerned than those where malaria is onlyendemic. This could be because epidemicmalaria takes a greater toll on adults orbecause the unpredictability of epidemicsmakes it harder for firms to prepare for them.

• Worldwide, HIV/AIDS and tuberculosis causeslightly more concern to businesses thanmalaria. However, in countries where malaria ispresent, business concern over future malariaimpacts is higher than business concern overfuture TB impacts in countries with TB (i.e., allcountries).

• Concern over malaria is reduced in countriesthat are perceived to be generally well-governed and that have a socially responsibleprivate sector. It appears that businessesbelieve both they and their governments have arole to play in malaria control.

Business action on malaria

• Many of the resources needed for malariacontrol match the skills and capabilities ofbusinesses.

• Several major businesses have taken action onmalaria, and have benefited from theconsequent development of new businesscontacts, the promotion of worker andcustomer loyalty, and the protection ofworkforces and, to some extent, markets.

• Even if malaria is affecting customers, however,some individual businesses may not bemotivated to take steps to combat it. Theycould, with good reason, see malaria as aproblem that affects all businesses, and that itwould not be cost-effective to take expensiveactions that would lead to little benefit thatspecifically accrues to the business itself.


The epidemiological background

• There are 350 to 500 million clinical episodes ofmalaria each year. The disease causes over 1million deaths and is the eighth most importantdisease in terms of lost disability-adjusted lifeyears (DALYs).1

• Nearly half of the world’s population lives invulnerable areas. Episodes of the disease inSub-Saharan Africa, which hosts the mostdeadly malaria-transmitting mosquito and themost deadly malaria parasite, account for 54per cent of cases but 90 per cent of fatalities.Children below the age of four in the regionaccount for 82 per cent of malaria deaths andlost DALYs worldwide.2

• Some regions, including Sub-Saharan Africaand South and South East Asia, have seenincreases in malaria in recent decades asresistance to pesticides and drugs has spread.

• Control efforts in other regions, such asSouthern Europe, Latin America and theCaribbean, have greatly reduced the threatposed by malaria.

What is malaria and how is it transmitted?

Malaria has been a scourge of humanity formillennia. Ancient Chinese and Sanskrit medicaltexts described its symptoms and Hippocratesreferred to the disease in the 4th Century BC.3

Despite advances in both prevention andtreatment in the 20th Century, malaria is still amajor killer today, and deaths from the diseasehave increased in the past three decades. 3.2billion people – almost half the world’s population– live in areas where the disease is either endemicor epidemic.4 It affects 107 countries, most ofthem tropical. Malaria causes over a million deathseach year (2 per cent of the global total of deaths),with hundreds of millions of clinical episodes perannum.

The name malaria comes from the Italian, meaning“bad air”; it was once thought that the dank airover marshes caused malaria infections. In 1880,scientists discovered that it is transmitted by bitesfrom female Anopheles mosquitoes carrying thePlasmodium parasite.

There are four types of Plasmodium parasite, ofwhich two are widespread in the developingworld. By far the most deadly is Plasmodiumfalciparum, which causes nearly all malariafatalities. This is the most common parasite inSub-Saharan Africa, Haiti, Southeast Asia andPapua New Guinea. A second type, thePlasmodium vivax parasite, causes over 80 millionepisodes of malaria each year, but only a smallfraction of deaths. It is more prevalent in Asia,Oceania and Latin America than in Africa.5

The symptoms of malaria, which usually occurbetween nine and fourteen days after an infectivebite, include high fever, chills and vomiting. Anacute infection can cause death via cerebralmalaria or respiratory distress. Repeated infectionscan kill via severe malarial anaemia andhypoglycaemia.6 Malaria also makes its victimsmore vulnerable to other potentially lethalinfections such as acute respiratory diseases anddiarrhoea. If malarial anaemia results in bloodtransfusions, there is also a risk of HIV/AIDS,hepatitis B or hepatitis C infections.

Who is at risk?

Most of those who die of malaria are children, andmost of those children live in Sub-Saharan Africa.Every 30 seconds, malaria kills an African child.7

Adult fatalities are more rare. The effect of malariaon adults differs in endemic and epidemic regions.In endemic areas – generally tropical and sub-tropical regions – people contract the diseaseregularly throughout their lives. Beginning at theage of five years, individuals who have survivedchildhood infections gradually build up resistance.In endemic areas, therefore, most cases in adultsare asymptomatic, with very few resulting in death.

In regions where malaria transmission is not stableand occasional epidemics occur, both adults andchildren are vulnerable because neither build upresistance. Epidemics occur because of climaticanomalies and changes, social upheaval such assudden migrations, or migration by a group to anendemic area. Regions that border endemic areassuch as southern Africa, the Sahel and northernIndia are among the most vulnerable to epidemics.Malaria epidemics typically have higher fatalityrates than endemic malaria: an epidemic inEthiopia in 1958, for example, killed 150,000 of

One: The Challenge of Malaria

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the three million individuals infected – a 5 per centfatality rate.8 The World Health Organizationestimates malaria epidemics kill 110,000 peopleper year.9

In both endemic and epidemic regions, pregnantwomen are susceptible to the disease. In endemicregions, malaria during pregnancy mainly affectsthe foetus or newborn child. It can result inspontaneous abortion or neonatal death; morecommonly, it leads to low birth weight, which hasnegative impacts on health later in infancy andchildhood. Malaria causes 75,000 to 200,000infant deaths per year in endemic areas of Africa.10

In epidemic regions, where adults have not builtup immunity, pregnancy increases vulnerability tothe disease – WHO estimates that in these areas,pregnant women are two to three times morelikely to develop severe malaria than women whoare not pregnant.11 In Sub-Saharan Africa, malariacauses almost 4 per cent of maternal deaths.12

Malaria causes more harm in Africa than in anyother region (see map 2). It is the second highestcause of disease in the continent, causing 9 percent of deaths. In children below the age of five, itis responsible for 18 per cent of deaths.13

Although only 54 per cent of global malaria casesin 2004 occurred in Africa, the region accountedfor almost 90 per cent of malaria fatalities.14

A large proportion of care for malaria cases takesplace within households, but the disease alsoplaces a significant burden on health services. InAfrican countries with endemic malaria, itaccounts for over 25 per cent of outpatient visitsand over 20 per cent of hospital admissions.15

Malaria’s devastating impact on Africa is partlyattributable to the fact that the most efficienttransmitters of the disease – the Anophelesgambiae s.l. and An. funestus s.l. mosquitoes –are much more prevalent there than in any otherworld region. An. gambiae and An. funestus havelong lifespans, breed in peridomestic habitats andfocus their biting on people. In some parts ofAfrica where the disease is endemic, individualscan receive over 300 malaria-transmittingmosquito bites each year.16

The most deadly parasite – Plasmodiumfalciparum – is also most prevalent in Africa. Itcauses 35 per cent of malaria cases in Asia and18 per cent in the Americas. In Africa, it isresponsible for 93 per cent of cases.17 In recentyears, the parasite has developed resistance tochloroquine and sulfadoxine-pyrimethamine (SP),the most commonly used and most easilyavailable and affordable malaria treatments in theregion, contributing to an increase in morbidityand mortality in some areas (changing agriculturalpractices, deforestation, population movementsinto malarial areas and declining health systemshave also contributed to the increase). In the


Map 2 – Worlwide malaria prevalence, 2000

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• The costs of tools for prevention and treatmenthave proved beyond the financial means ofmany endemic-country governments, leading tocalls for more donor and private sectorintervention. Initiatives such as the Global Fundto Fight AIDS, Tuberculosis and Malaria havebegun to answer these calls.

Prevention

A combination of prevention and treatmentinterventions has been central to success infighting malaria in many regions.

Prevention efforts have ranged from altering theexternal environment to protection withinhouseholds. Draining or filling certain wetlands,pools of water and even puddles robs malarialmosquitoes of breeding sites and forces them outof populated areas. Spraying breeding sites withinsecticides (known as larviciding) helps rid urbanareas and refugee camps of mosquitoes.Improved weather forecasting helps in predictingepidemics, giving communities more time toprepare.

A more common use of insecticides involvesspraying the interiors of dwellings. The residue leftby the chemicals stops mosquitoes from enteringor kills them when they land on walls. Most sprayslast up to six months, although dichlorodiphenyltrichloroethane (DDT), which contributed greatly tomalaria eradication in southern Europe and theUnited States, lasts longer. DDT also helpedreduce malaria cases in South East Asia, butresistance to it has grown and, although somedispute that the amounts needed for indoorspraying are sufficient to cause damage, there areconcerns that it harms the environment. As aresult, its use is less common today.22 Pyrethroidinsecticides have replaced DDT as the standardindoor residual spray in many areas, althoughDDT-resistant mosquitoes are often also resistantto pyrethroids.

Insecticides are also used to treat bednets.Bednets have been used in malaria prevention forcenturies, but insecticide-treated nets (ITNs) havebeen adopted only recently. ITNs either killmosquitoes that land on the net or deter themfrom entering a dwelling (malaria-transmittingmosquitoes bite mainly at night). The latestgeneration of bednets (long-lasting insecticidalnets or LLINs) last over four years before theyneed to be replaced and, unlike earlier nets, they


period between 1990 and 1998, the number ofdeaths due to malaria in children below the age offive years in eastern and southern Africa wasdouble the number in the preceding eight years.18

Other regions are less hard hit by the disease,and the ratio of deaths to cases is much lower.19

Ten per cent of malaria deaths occur in Asia.South East Asia and some parts of Central Asiahave seen a resurgence in malaria incidence inthe past decade as eradication programmes havefaltered or vector or parasitic resistance to drugshas grown. Some Asian countries have achievedgreat success in the fight against malaria.Vietnam, for example, cut deaths by 97 per centand cases by 59 per cent between 1992 and1997 through an intensive control programme.20

In other areas, malaria incidence is very low. Thedisease was common in southern Europe until itseradication there in the 1940s and 1950s. In thesouthern United States, too, it was wiped out inthe last century. Today the main threat toEuropeans and North Americans is from travel tomalarious regions.

South America, Central America and theCaribbean have also greatly reduced the threat ofmalaria. There are fewer than four cases per1,000 people each year in these regions, andcases rarely prove fatal.21

How can malaria be prevented and treated?

• In the continued absence of a malaria vaccine,prevention of the disease centres on alteringthe external environment to remove breedingsites for mosquitoes and protecting dwellingsand individuals by killing mosquitoes.

• Indoor residual spraying with pesticides andinsecticide-treated bednets have been used togreat effect in many areas to reduce malaria.

• The World Health Organization recommendsintermittent preventive drug treatment forpregnant women and young infants, who areparticularly vulnerable to severe malaria.

• Artemisinin-based combination therapies arethe most effective malaria treatment, asresistance has rendered earlier drugs, such aschloroquine, ineffective.

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also withstand washing and do not require bi-annual retreatment. Unlike other forms ofprevention, such as indoor spraying, bednets areeasy for members of the public to use withoutexpert assistance.

ITNs are associated with sharp reductions inmortality. In five locations in Sub-Saharan Africa,they reduced child mortality by an average of 18per cent.23 One study in Tanzania found thatmortality was reduced by 27 per cent with ITNsand 19 per cent with untreated nets.24 Anotherfound that children who slept under bednets grewmore than unprotected children and were half aslikely to develop anaemia.25 According to a studyin Kenya, meanwhile, women protected by ITNsgave birth to fewer premature or low birth weightbabies than unprotected mothers.26

Insecticide-treated bednets protect more thanthose sleeping under them. Because they eitherkill mosquitoes or reduce the longevity of thosethat come into contact with the net, their effectextends over several hundred metres. If manypeople in a village use them, others will beprotected.27

ITNs are a central focus of international efforts tocontrol malaria; however, even at a cost of aroundUS$ 5 per net (or US$ 4 for untreated nets), thisadds up to a significant imposition on healthbudgets in some countries if provided by thepublic purse alone. The government of Malawi, forexample, spends about US$ 6 per year perperson on health, and the government of Angolaspends about US$ 16 per year per person. Bycontrast, the cost may not be prohibitive in othercountries, such as Botswana, where thecorresponding figure for health expenditures isUS$ 106.28

The World Health Organization estimates that 260million ITNs are needed to provide protection forall Africans at risk of malaria.29 In 2000, Africancountries committed to achieving ITN coverage for60 per cent of the highest risk groups andpregnant women by 2005. Only a few reached thetarget, with WHO reporting in 2003 that only 2 percent of African children sleep under ITNs andanother 15 per cent under untreated nets.30 Sofar, most of those using ITNs have been fromwealthy households. However, national subsidiesof delivery through public health systems in

countries like Ghana and Nigeria and distributionwith measles vaccinations in Togo have helped thepoor gain access in some areas.31 As discussedabove, even use that is limited to wealthymembers of a community can have beneficialeffects on others due to the protection ITNs offerto those in their vicinity.

Improved nutrition or prophylactic drugs can alsohelp prevent the worst effects of malaria.Micronutrient supplements have been found toprotect children against the disease, asstrengthened bodies and robust immune systemsare better able to withstand its impacts.32 Forpregnant women at high risk of severe malaria,WHO recommends intermittent use of antimalarialdrugs – normally sulfadoxine-pyrimethamine – asa preventive measure. The drug is given twiceduring pregnancy to women attending antenatalclinics.

Other prevention tools include mosquito coils torepel the insects and repellents sprayed on theskin, but their usefulness is limited. Coils are lesscost-effective than ITNs, and repellents arerelatively expensive and used mainly by tourists orbusiness people visiting malarial areas for shortperiods.33

The cost of prevention varies widely depending ongeographical circumstances, population density,and prevalence of infective mosquitoes, amongother factors. Different studies, moreover, finddifferent costs. Goodman et al (2000) found thatthe cost of ITNs per lost DALY averted wasbetween US$ 19 and US$ 85. For two rounds ofresidual spraying per year, it was US$ 32-58; andfor intermittent preventive treatment (IPT) forpregnant women it was US$ 4-29.34 Breman et al(2006) found an average cost per lost DALYaverted of US$ 11 for ITNs, US$ 11-34 for tworounds of residual spraying per year, and US$ 13for IPT for pregnant women.35

With many African governments spending lessthan US$ 10 per person per year on health care,such costs are likely to be prohibitive in endemicregions unless there is international or privatesector support. This is true even after taking intoaccount the fact that not everyone lives in amalarial area and that not all preventionexpenditures need to be made on an annualbasis.


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Most countries where malaria is endemic are poorand their health systems are weak. Public healthservices are not available to all sectors of thepopulation and governments lack the funds toundertake education campaigns to encouragefamilies to take care of their own health. Even theprovision of cheap interventions that have manybenefits, such as micronutrient supplements, hasproved beyond some governments, and many poorcountries lack the resources for more costlyprevention activities, such as draining wetlands.

With bednets, although the private sector is involvedin distribution through markets and pharmacies,coverage remains uneven, with the poor and peoplein remote rural areas finding it particularly hard toaccess or afford nets, or to re-treat those theyalready own. Indoor spraying and IPT for pregnantwomen requires specialist skills and humanresources that many malarial regions lack. Becauseeven the most cost-effective new malaria preventiontools add to the financial burden on public healthsystems, many governments remain unable to cope.As we discuss in Part Two of this report, this has ledto calls for businesses to become more involved inaddressing health problems.

Treatment

Treatment of malaria is also a form of prevention. Byreducing infectivity in those who have contracted thedisease, and thus making it less likely that humanswill pass the malaria parasite to uninfectedmosquitoes, treatment protects those who have notyet been infected.

Treatment is highly effective in curing malaria.However, it is often the case that malaria drugs aregiven for any fever, even if the symptoms are notconfirmed as malaria. Overuse of the drugs haspromoted resistance to them.36 Resistance to thetraditional malaria drug chloroquine has built up inmost malarial areas, contributing to the resurgenceof morbidity and mortality from the disease. Ineastern and southern Africa and more slowly inWest Africa, resistance to chloroquine’sreplacement, sulfadoxine-pyrimethamine, is alsospreading.

WHO currently recommends artemisinin-basedcombination therapies (ACT) as the preferred malariatreatment. Artemisinin, which is found in the shrubArtemisia annua, has been used in Chinese

traditional medicine for centuries to cure a rangeof illnesses. In the 1970s, scientists working forthe Chinese army discovered its effectiveness as amalaria drug. As resistance to chloroquine hasspread in recent years, more countries haveswitched to the drug. Used in combination withother drugs such as sulfadoxine-pyrimethamine toprevent resistance, it has proved highly effective inreducing malaria morbidity in countries such asVietnam and China.

Twenty-three African countries had incorporatedACT into malaria control programmes by 2004,but the cost of the drug has hampered efforts insome areas.37 At between US$ 0.75-2.75 pertreatment, ACT is currently ten to twenty timesmore expensive than older drugs such aschloroquine.38

As with prevention methods, providing treatmentto all who need it has proved beyond thecapabilities of many poor countries. Severalgovernments in regions hard-hit by malariapromote home treatment, training mothers toidentify and respond to symptoms and providingthem with pre-packaged treatment tools. In mostAfrican countries, out-of-pocket expenditure onmalaria exceeds government spending.39

How is the international community assistingin malaria prevention and treatment?

The World Health Organization has stated thatUS$ 3.2 billion per year is needed to financemalaria control worldwide. It suggests that $ 1.9billion of this should be spent in Africa.40 Of theglobal total, it recommends that 10 per cent bespent on long-life ITNs, 36 per cent onartemisinin-based combination therapy, 17 percent on rapid diagnostic tests for malaria, 17 percent on interventions such as IPT for pregnantwomen and epidemic control, and the remainderon improving health infrastructure and delivery andmonitoring systems.

Only a fraction of the target sum is currentlyavailable, according to WHO.41 “In most countrieswith a high malaria burden, the financial gapbetween what funds are needed and what areavailable remains large.”42 In Africa, 71 per cent oftotal public funding for malaria is provided throughgovernments. In Asia, they provide 80 per centand in the Americas, 96 per cent.43 WHO reportsthat government provision in many countries isinsufficient, and suggests that international donorsshould step in to boost the response.


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A number of international malaria control initiativeshave sprung up in recent years. The mostprominent is the Roll Back Malaria Partnership(RBM), which was launched in 1998 by WHO,UNICEF, the United Nations DevelopmentProgramme and the World Bank. RBM bringstogether governments of affected countries,donors, the private sector, non-governmentalorganizations and academic bodies to helpcountries draw up five-year plans to combatmalaria. It aims to halve malaria deaths by 2010,and again by 2015, by assisting countries inaccelerating access to treatment, increasing ITNcoverage, improving malaria control amongpregnant women and scaling up responses toepidemics.

Among RBM’s most important partners is theGlobal Fund to Fight AIDS, Tuberculosis andMalaria (GFATM). GFATM committed US$ 881million for malaria control in 2005-06 to helpcountries achieve the RBM targets. It has fundedprogrammes in Africa, Asia and the Americas.

Other programmes include the US President’sInitiative on Malaria, another RBM partner. Thisinitiative has pledged to increase funding formalaria control by US$ 1.2 billion in five years,thereby halving malaria deaths in its targetcountries within three years of implementation.Angola, Tanzania and Uganda are its initial targets,but it aims to expand into fifteen or more hard-hitcountries. The World Bank, meanwhile, hasincreased its investment in malaria through itsBooster Programme for Malaria Control, andUNICEF’s accelerated Child Survival andDevelopment programme has helped increasebednet provision and cut child mortality in elevencountries in West Africa.44

Work on a malaria vaccine involves a number ofinternational agencies, many of them partners ofthe GAVI Alliance (formerly the Global Alliance forVaccines and Immunization). Spending on thedevelopment of a malaria vaccine has increased inrecent years, but malaria is comparativelyneglected in terms of research, accounting for justUS$ 100 million of the global biomedical researchtotal of US$ 56 billion.45 Among the mostimportant partners of the GAVI Alliance are thePATH Malaria Vaccine Initiative, the World Bank,UNICEF, the Bill and Melinda Gates Foundationand the International Finance Facility forImmunization (which aims to boost funding forvaccine development by borrowing against futureaid flows to pay for increased currentinvestments).

Some governments have worked with these andother international agencies to successfully tacklemalaria, but others have seen a worsening in itsimpact in recent decades. The latter are now thefocus of international malaria reduction efforts.Within these efforts, Roll Back Malaria views theprivate sector as an important partner inaddressing the disease, and in the next section ofthe report, we consider the case for businessinvolvement.


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A second channel through which health affectseconomies is its impact on labour productivity.Healthier workers, like healthier schoolchildren,attend work more often and are more energeticand mentally agile when at work. If workers’communities are healthier, moreover, they needless time off to look after sick relatives. A one-yearincrease in life expectancy is thought to boostlabour productivity by as much as 4 per cent.48

Good health also boosts economies by promotingsaving and investment. People who expect to livelonger have a greater incentive to save forretirement, and their saving increases the fundsavailable for investment in the economy. Foreconomies to grow, investment – which promotesjob creation, higher incomes, and improvedtechnology – is essential. Those companiesconsidering investments are more likely to take theplunge if they are not threatened by the effects ofpoor health. Foreign investors, too, may be morelikely to invest in healthy workforces. Recentevidence indicates that overall population health isa significant determinant of a nation’s ability toattract foreign investment.49

The fourth channel through which health affectseconomies relates to demography. As a country’shealth improves, more infants survive to childhoodand then adulthood. As parents perceive that theirchildren are more likely to reach adulthood, theyalso eventually realize they need fewer children toattain their desired family size. Birth rates fall asparents concentrate their resources in fewerchildren, thus improving the educational andhealth prospects of these children. In the lagbetween health improvements increasing survivaland birth rates falling, a “boom” generation ofchildren is created, which is larger than both itspreceding and succeeding generations. As thisboom generation reaches adulthood and swellsthe size of the workforce compared to the non-working age population, it has the potential, if thepolicy environment allows, to contributesignificantly to the economy. It has been estimatedthat this “demographic dividend” was responsiblefor one-third of East Asia’s rapid growth between1965 and 1990.50

Health and wealth

• Health problems affect businesses by theirindirect impact on economies and their directimpact on operations.

• Health affects economies by boosting ordamaging a child’s education; strengthening orweakening labour productivity; influencingdecisions on savings and investment andaltering a country’s demographic structure.Research has demonstrated significant impactsin each of these areas.

• Health can affect businesses through its impacton workforces, customers, and corporatereputation. Actions that promote good healthcan help companies create new businessopportunities and protect themselves frompotential negative effects.

Macro-economic impacts

Health problems affect businesses in two ways:first, by damaging the overall environment in whichbusinesses operate, and second, through directeffects on firms’ workforces, supply chains,customer bases or reputations.

There is growing literature on the importance ofhealth to economies. Healthy populations are seenas an important engine of economic growth, whilehealth shocks can cause great economic damage,as recent scares over SARS, mad cow disease,and foot and mouth disease show. HIV/AIDS,moreover, is thought to be hindering many Africancountries’ prospects of escaping poverty.46

Good health affects economies in four main ways.First, good health improves children’s’ education.Healthy children are able to attend schoolregularly. They are also more capable of learningwhen in class than peers with poor health.Vaccines, for example, have been shown to havestrong effects on cognitive abilities: a recent studyof children in the Philippines showed thatimmunized children score higher in language andIQ tests taken several years after receiving basicvaccines than children who have not beenimmunized.47 Improved cognitive abilities inchildren, in turn, are associated with higherearnings – and therefore potentially strongereconomies – in adulthood.

Two: Why malaria matters for businesses

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Direct effects on business

Beyond altering the macro-economic environment,health may affect businesses more directly. Themost immediate effect of a health problem likemalaria is its impact on the workforce. Employeeswho fall sick are less able to work effectively andmore liable to take time off to recover. If workers’family members fall ill, workers may have to taketime off to care for them. Staff morale, too, maybe affected by illness among colleagues andfamily members, and this is likely to be magnifiedif illness leads to death. Death due to disease alsopresents companies with increased costs as theyrecruit and train replacement workers.

The effect on communities is not limited to itsimpact on staff attendance and morale. Ifcustomers are hard hit by an illness, they mayhave to divert resources towards healthcare. Thisdiversion can benefit some businesses, such asthose developing healthcare products or funeralservices, but it damages others as overallconsumption declines.

The impact of health on corporate reputation isanother consideration for some firms. Corporatesocial responsibility has become a buzzword inthe modern economy. With activists,governments, consumers and sometimesshareholders pressuring companies to behave in asocially responsible manner, many businesseshave invested in either cleaning up their act (forexample, by not polluting the environment or notemploying children) or engaging in activities thatpromote societal improvements (for example,corporate philanthropy or sponsorship of healthprogrammes). In the health sector, pharmaceuticalcompanies have been pressed to cut drug pricesfor developing countries for diseases such asHIV/AIDS and many firms have engaged in public-private partnerships on public health. Such actionscan strengthen brands and enhance the loyalty ofworkers and customers.

These three motivations – workforce health,reputation and, to some extent, the customerbase – can lead to action by businesses thateither averts negative impacts of health problemsor creates positive health outcomes. Firmsworking to avert negative impacts are inspired bythe need to protect themselves from problemssuch as litigation, bad publicity, or the effects ofdisease on workers and customers. Firms workingto create positive impacts are more likely to be

spurred by a desire to capitalize on new businessopportunities. Strengthening a brand through aproactive stance on social issues may be animportant motivation for such firms. In addition,firms may seek opportunities to build relationshipswith policy-makers or other businesses involved insimilar activities.

The effects of malaria on economies andbusinesses

• There are few robust findings on the economicimpacts of malaria. Research on its effects ondemography, savings and investment or healthsystem costs is limited.

• Malaria’s effects on attendance at work andland use can translate into significant impactson productivity. The disease also has negativeeffects on schooling and cognitive abilities.

• Countries including Greece, Spain, Italy andJamaica have experienced rapid economicgrowth after eradicating malaria.

• According to a study by Gallup and Sachs,economies with high malaria prevalence grew1.3 percentage points less per year than othersbetween 1965 and 1990.

• Businesses have been known to be negativelyaffected by malaria, from the construction ofthe Panama Canal to more recent largeconstruction projects in Africa.

• A survey of firms in Ghana found that nearlyone-third of business leaders believed thedisease was having strong impacts onproductivity.

Data limitations

Measuring the impact of malaria on economies iscomplicated by inadequate data on malariamorbidity and mortality. In the most affected areas,official health monitoring systems are weak andpost-mortem reports often attribute all deathspreceded by fevers to malaria despite theexistence of other diseases with similar symptomssuch as pneumonia.51

An extensive review of the academic literatureconducted by Goodman and co-authors in 2000found that, “the weakness of the literatureavailable on the economic impact of malaria is


15

clearly evident. No studies can be highlighted asmodels of good methodology.” “Excessive effort,”the authors continue, “has been devoted toindirect studies that use often very weak data onearnings and days lost to make gross andpotentially misleading estimates.” 52

Of the major channels from health to wealthdiscussed above, no robust studies assess thedemographic impact of malaria, although it ispossible that high infant and child mortality due tothe disease will keep fertility high and preventheavily affected countries from enjoying ademographic dividend.

In terms of the effect on savings and investment,Gallup and Sachs (2001) found circumstantialevidence showing that the eradication of malaria insouthern Europe in the 1940s and 1950s spurredeconomic growth via a large increase in foreigninvestment and tourism to the region.53 Again,further literature on the subject is limited.

The effect on productivity

A few studies discuss how malaria influences theother channels from health to wealth, includingproductivity.

In areas where malaria is endemic, pregnantwomen and children are most at risk from thedisease. Neither group is likely to be highlyproductive in work, but both need care and willeventually either return to or begin working. Theimmediate economic effect of malaria amongthese groups is likely to be most strongly felt byhealth systems, which expend resources ontreatment and by families who take time off workand draw down savings to pay for care. Themonthly cost of malaria prevention in Sub-SaharanAfrica ranges from US$ 0.05-2.10 per person. Thecost of treatment ranges from US$ 0.41-3.88 perperson per month – a significant burden on poorhouseholds suffering frequent malaria episodes.54

A study in Rwanda calculated that 19 per cent ofthe country’s health budget was consumed bymalaria treatment in public health facilities.55 Andan epidemic in a district in Zimbabwe in 1996 and1997 was found to increase the cost of malariacontrol to the Ministry of Health by US$290,000.56

Absenteeism from work is a more directcontributor to increased business costs resultingfrom the disease. Adults who fall sick from malariahave been found to miss between one and fivedays of work per malaria episode. They miss asimilar period when caring for sick children.57

WHO has calculated even larger effects,estimating that a malaria episode costs anequivalent of ten working days in terms of lostlabour.58

Foster and Leighton (1993) estimated the value ofmalaria-related lost production to be between 2and 6 per cent of Kenya’s gross domestic product(GDP) and between 1 and 5 per cent of Nigeria’sGDP.59 They found that different sectors feltdifferent impacts. In Kenya, agriculture washardest hit, with total production 13 per cent lowerthan it would have been without malaria. InNigeria, the service sector bore the brunt oflosses, losing 8 per cent of production. Accordingto the authors, the difference in effects amongsectors reflects the different proportions of womenworking in each. Most of the agricultural workforcein Kenya is female; in Nigeria, the service sectorhas a high concentration of women.

Studies that consider absenteeism as the maineconomic impact of malaria rarely take account ofthe surplus of labour in many malarial countries. Ifhealthy individuals fill in for sick workers, outputmay remain stable. In Sudan, for example, familymembers compensated for 62 per cent of workinghours lost to malaria and schistosomiasis;however, as it was often children that filled in fortheir sick parents, schooling may have suffered.60

Productivity effects need not only include changesin worker productivity. Changes in land use mayalso have an effect. Previously unfarmed areas ofCorsica, Italy, Greece and Nepal, for example,became highly productive agriculturally as a resultof the eradication of malaria.61

Notwithstanding the above studies, there remainproblems with the literature on malaria’s economicimpacts in terms of lost productivity. No robuststudies assess the effect of malaria on workers’performance while at work, for example. Gallupand Sachs, meanwhile, (2001) opined that thedisease’s impacts on productivity “cannot beassessed with the current state of research.”62

Goodman et al (2000) agreed, adding that moststudies neglect the effect of household copingstrategies and the impact of malaria on aspects ofproductivity such as willingness to invest.63 Thereis much scope for further research in this area.


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The effect on schooling

A handful of studies have found that malaria canimpede a child’s schooling, with potential long-term harm to economies. The effect worksprimarily through absenteeism and damage tocognitive abilities.

According to Holding and Kitsao-Wekulo (2004),malaria accounts for 15 per cent of health-relatedabsenteeism from school in some areas.64 InKenya, a focus group-based study found thatprimary school students miss an average of 20school days per year because of the disease. Thisamounts to over 10 per cent of total school days.Secondary school children miss eight school daysper year.65

Malaria’s effect on learning abilities is alsoimportant. Cerebral malaria kills over 100,000children in Africa each year.66 Of children whosurvive, between 10 and 15 per cent are left withsome neurological damage, including behaviouralproblems, language difficulties and epilepsy. In astudy in Zimbabwe, malaria was found to accountfor 16 per cent of seizures in children, and a studyin Kenya found it caused 31 per cent ofseizures.67 Epileptic seizures can weaken cognitiveabilities in children and impair their ability to benefitfrom schooling.68

Protecting children against malaria can helpreduce its negative impacts on schooling. Arandomized study in Sri Lanka showed thatchildren who were given chloroquine as aprophylactic had improved language andmathematics scores compared to those whoreceived a placebo.69 The prophylactic made nodifference to attendance. A controlled study inGambia showed that absenteeism due to feverwas higher among children unprotected by ITNsthan among protected children.70

Overall economic impacts

Estimates of the overall impact of malaria oneconomies vary. In the last century, Greece, Spain,Italy and Portugal grew faster than the average forthe rest of Western Europe after the eradication ofmalaria. Jamaica and Taiwan also saw increasedgrowth and grew quickly relative to their regions

after wiping out the disease in the late 1950s andearly 1960s. Mauritius, on the other hand, did notexperience a similar effect after malariaeradication.71

A study comparing incomes in the US, Brazil,Colombia and Mexico before and after the malariaeradication campaigns in the 20th Century foundthat those born after eradication had higherincomes in adulthood than the preceding cohort,and that this change is temporally linked to thecampaigns rather than a pre-existing trend inincome growth.72

In a widely cited study by Gallup and Sachs(2001), the economies of countries with asignificant malaria burden were calculated to havegrown 1.3 percentage points less per year thanothers between 1965 and 1990, after takingaccount of other factors such as tropical location,colonial history, economic policy, life expectancyand initial wealth.73 The study also found that areduction in malaria cases of 10 per cent per yearwas associated with increased growth of 0.3 percent.

Many studies have focused on Africa. A study byShepard et al analyzed four countries and showedthat malaria cost Sub-Saharan Africa 0.6 per centof its GDP.74 In Zambia, it was estimated that animproved malaria control programme would boostthe national economy by 1.8 per cent of GDP.75

And McCarthy, Wold and Wu (2000) found thatalthough malaria was associated with reducedgrowth, its impact differed greatly amongcountries, with the strongest effects felt in Sub-Saharan Africa.76

The economic impact of malaria isdisproportionately felt by the poor. Many poorpeople live in environmentally vulnerable areas andare less able to afford protection and treatmentthan wealthier groups. A study in Tanzania foundthat mortality resulting from acute fever among thepoorest children was 39 per cent higher thanamong the wealthiest children.77 A study inZambia found similar effects.78 Moreover, drawingdown savings or selling off limited assets to payfor treatment may make it more difficult to escapepoverty. In northern Ghana, malaria care wasfound to take up 1 per cent of wealthy families’income, but it consumed 34 per cent of that ofpoor households.79

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The effects of malaria on businesses

As with research on the effect of malaria oneconomies, research into its impact on businessesis patchy. Spielman et al (2002) cite the historicalexample of the construction of the Panama Canal,where a French team had to abandon the projectbecause of the high toll of malaria and yellowfever. The canal could only be built after scientificadvances related to vector control and quinine-based treatment allowed an American-financedgroup to combat the threat of disease.80

A further historical example is the case of theCreole Petroleum Corporation, which in 1946began a DDT house-spraying programme inVenezuela in collaboration with the country’sgovernment. The programme cut workforcemalaria cases for the corporation from 362 in1946 to 91 a year later.81

More recent evidence of the impacts on theprivate sector is found in a survey of businessleaders in 119 firms in Ghana. The survey, a partof the World Economic Forum’s AfricaCompetitiveness Report 2000-2001, foundsignificant reported impacts on businessoperations.82 30 per cent of those surveyedreported that malaria had a strong impact onproductivity, with 35 per cent perceiving noimpact. 63 per cent of firms reported that thedisease caused absenteeism among employees,and many believed the removal of malaria wouldimprove certain aspects of operations. Inparticular:

• 72 per cent of firms surveyed believed malariaeradication would increase efficiency andproduction

• 46 per cent believed it would reduce operatingexpenses

• 45 per cent believed it would increase sales

• 39 per cent believed it would create widermarketing opportunities

• 30 per cent believed it would have little or noeffect

The reports of some individual firms alsodemonstrate effects on business. The constructionof BHP’s Mozal smelter in Mozambique was badlyhit by malaria. The company suffered 6,000malaria cases in two years. Absenteeism, illness,and medical costs reportedly led to companylosses of $ 2.7 million.83 Exxon Mobil reports thatits workplace malaria programme in Chad andCameroon, which included employees,contractors, and the community, saved it US$ 8.9million (for a US$ 3 million investment) inproductivity gains. This figure does not includehealthcare cost savings.84

Unfortunately, there is no research showing thedifferent impacts of malaria on businesses inendemic and epidemic regions. In the latter, theeffects of the disease on workers are likely to beperiodic but severe, with the unpredictability ofepidemics making it hard for firms to developmanagement strategies. It seems likely that thenature of impacts differs, and this would appear aworthwhile avenue for future research.


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Business concern

• 22 per cent of business leaders who respondedto the World Economic Forum’s ExecutiveOpinion Survey in 2004 believe malaria isaffecting their business. 10 per cent reportserious current impacts.

• In countries with at least some malaria, 40 percent of respondent firms in EOS 2005 predictimpacts on their business within the next fiveyears. The corresponding figure in EOS 2004 is34 per cent.

• Based on EOS 2004, businesses in Sub-Saharan Africa are most likely to perceiveeffects, with 39 per cent reporting seriouscurrent impacts and 72 per cent reporting atleast some impact. This is followed by Southand South East Asia (where 30 per cent ofrespondents report impacts) and then by theCaribbean and East Asia.

• Firms in areas with high malaria prevalence andlow incomes report the most severe currenteffects.

• Firms based in countries where malaria is bothendemic and epidemic are significantly moreconcerned about its impacts than those incountries with endemic malaria only. This maybe because epidemics hit adults harder thanendemic malaria or because epidemicsintroduce an element of unpredictability tobusiness operations that firms are less able toprepare for, or both.

• The future toll of the disease is thought likely tobe similar to its current impact. However,concern over future effects increased slightlybetween the 2004 and 2005 surveys.

• Firms that believe their countries are generallywell governed are less concerned than othersabout the future impacts of malaria. Aresponsible private sector is also associatedwith reduced concern. It appears thatbusinesses believe both they and theirgovernments have a role to play in malariacontrol.

• Worldwide, HIV/AIDS and tuberculosis causeslightly more concern to businesses thanmalaria. However, business concern over futuremalaria impacts is higher in countries with atleast some malaria than is business concernover future TB impacts among countries with atleast some TB (that is, all countries).

The survey

This section of the report discusses data from theWorld Economic Forum’s annual ExecutiveOpinion Survey (EOS), which forms part of itsGlobal Competitiveness Report. The EOS pollsover 8,000 business leaders worldwide about theirviews on a range of issues that influence thecompetitive environment. The firms surveyedcome from over 100 countries (see Table 1).

For the purposes of our analysis, we dividedrespondents into groups according to the regionin which they are based, national income of theircountry and malaria prevalence in their country(Tables 2 and 3).85 The largest group of firms(between 46 and 48 per cent of the sample ineach of the three years) is that of countries withno reported malaria cases. Between 27 and 31per cent are based in countries with 1 to 99malaria cases per 100,000 people. The smallestproportion comes from higher prevalence settings;between 5 and 8 per cent of firms surveyed arebased in the countries hardest hit by malaria,where there are 5,000 or more reported cases per100,000 people.

In each of the past three years, the EOS includedquestions about the effects of HIV/AIDS,tuberculosis and malaria on the businessenvironment. In 2003, respondents were askedone question about the perceived current andfuture impacts of malaria on their companies. In2004, they were asked separate questions aboutcurrent and future impacts, and in 2005, theywere only asked about future impacts.86

In this assessment of the survey results, we firstlook at the responses of the overall sample beforemoving on to different regions, prevalence groupsand income categories.

Three: Business concerns over malaria:the Executive Opinion Survey

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How serious are the perceived currentimpacts of malaria?

The latest year in which firms were asked aboutthe current effects of malaria was 2004.87 In thatyear, 22 per cent of respondents worldwidereported that the disease was affecting theirbusiness to some extent. 10 per cent reportedserious impacts, and 76 per cent minimal impacts(see Map 3 and Table 4).

Not surprisingly, firms in Sub-Saharan Africareported by far the most serious impacts (seeFigure 1). In this region, 72 per cent of thosesurveyed observed some current effect frommalaria, with 39 per cent reporting that theseeffects were serious. In some of the hardest hitAfrican countries – including Angola, the Gambia,Malawi, Mozambique and Zambia (each of whichhas over 5,000 malaria cases per 100,000population per year – at least eight of every tenfirms reported impacts on their business. Even inChad, Mali, Tanzania and Uganda, where thedisease is less rife, a similarly high proportion offirms perceived impacts.

A significant minority of firms in South and SouthEast Asia are also concerned about malaria. 30per cent of respondent firms in this regionreported some impact on their operations, with 6per cent perceiving serious impacts. In theCaribbean and East Asia, 19 per cent and 17 percent respectively reported impacts. In all otherregions 12 per cent of firms or less believe thedisease is affecting them.

Figure 1 – Reported current impacts ofmalaria on firms, 2004


Map 3 – Reported current impacts of malaria, 2004

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As one might expect, concern rises with malariaprevalence. As Figure 2 shows, firms in thehardest hit settings are much more likely to reporteffects of the disease than those in malaria-freeregions.

Figure 2 – Reported current impacts, 2004, bymalaria prevalence group

Concern is also greater in low-income countries.66 per cent of firms in low-income countriesbelieve malaria is affecting operations, comparedto just 3 per cent in high-income settings. 35 percent in the former group report serious impacts; inall other income groups 4 per cent of respondentsor fewer believe they are hard hit by malaria.

Is the disease thought likely to hit harder infuture?

In the 2004 survey, a comparison of perceivedcurrent impacts and concern for future impactsreveals only slight differences. 22 per cent of firmsreport current impacts and 21 per cent believe thedisease will affect them in the next five years (seeMap 4 and Table 5). The proportion expectingserious future impacts (8 per cent) is slightly lowerthan the proportion reporting serious currenteffects (10 per cent).

When these perceptions are considered by region,the biggest difference between current and futureconcern is seen in Sub-Saharan Africa. 72 percent of African firms believe malaria is currentlyaffecting them and 68 per cent expect futureimpacts. 39 per cent believe current impacts areserious, compared to 31 per cent predicting thatfuture impacts will be similarly grave. As withcurrent concern, however, firms in Sub-SaharanAfrica are by far the ones that are most concernedabout the future effects of malaria, even aftercontrolling for income, malaria prevalence, industrygroup and firm size (for a full description ofregression analyses that assess future concernafter controlling for key variables, see Appendix 1).

This finding corresponds to the reported impactsby malaria prevalence. Most of those countriesthat are hard hit by malaria are in Sub-SaharanAfrica, and, as with that region, businesses in


Map 4 – Predicted future impacts of malaria, 2004

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heavily affected countries expect future impacts tobe less severe than reported current effects. AsFigure 3 shows, businesses in the hardest hitsettings think serious impacts in particular arelikely to be less widespread in the future.88

Figure 3 – Serious current impacts versus seriousfuture concern, by malaria prevalence group

When looked at by income group, future concernis very similar to current concern in all incomecategories bar the lowest. In the low-incomecountries, the proportion of firms seriouslyconcerned about future impacts is 28 per cent, 7percentage points lower than the proportionreporting current effects. Future concern tends tofall as per capita income rises, even aftercontrolling for malaria prevalence, geographicregion, industry group and firm size.

Compared to diseases such as HIV/AIDS, whoseeffect on societies and businesses may becumulative as more and more people becomeinfected, malaria’s impacts are more likely toremain stable over time. In endemic areas inparticular, incidence waxes and wanes slightly, butits overall predictability gives businesses time toadjust and adopt coping strategies. Even incountries hit by periodic epidemics, it is difficult topredict that the disease’s future effects onbusinesses will increase. That future concerns areno greater than current reported impacts istherefore not surprising.

In the 2005 Executive Opinion Survey, reportedfuture concern over malaria increased slightly fromthe previous year (Table 6). As Figure 4 shows, 26per cent of firms in the 2005 survey expected thedisease to affect them in the next five years,compared to 21 per cent in 2004. Seriousconcern, however, remained more or less stable ataround 9 per cent. This finding holds even aftertaking into account differences in the countriesincluded in the survey, malaria prevalence rates,

and income per capita over the two years (seeAppendix 2 for an explanation of the methodologyused for the year-on-year comparisons).

Figure 4 – Future concern over malaria,2004 versus 2005

At a regional level, the largest year-on-yearincreases in concern occurred in South and SouthEast Asia and in Latin America. In the former, theoverall proportion of firms concerned grew from 25to 37 per cent and serious concern doubled from 5to 10 per cent. In Latin America, the proportionexpecting impacts increased from 11 to 22 percent. The North Africa and Middle East region andthe Caribbean region also saw significant increasesin future concern, while Sub-Saharan Africa saw asmaller increase (Figure 5).

Figure 5 – Future concern 2004 versus 2005 byregion


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Future concern also spread in areas with highmalaria prevalence. In countries with 100 or moremalaria cases per 100,000 people, the proportionexpecting the disease to affect them in the nextfive years rose sharply between 2004 and 2005(Figure 6). It may be that health systems in thesecountries are weakening or that surveyed firms ingeneral were for some reason more pessimisticabout infectious disease in 2005 than 2004(concern over HIV/AIDS and TB also increasedyear on year). Many factors might have influencedconcern, including increased attention from globalleaders and the media; however, the data do notallow us to draw conclusions.

Figure 6 – Future concern 2004 versus 2005 bymalaria prevalence group

Looking at the year-on-year results by nationalincome group shows small increases in futureconcern in high-income and upper middle-incomecountries and a slightly larger increase in lowermiddle-income settings. In low-income countries,future concern fell marginally over the two years.

Does future concern vary in differentindustries or firms of different sizes?

We conducted regression analyses to determinewhether firms in different sectors reported differinglevels of concern over malaria. After takingaccount of location, income, malaria prevalenceand firm size, we found little variation in eithercurrent or future concern.

With firm size too, after controlling for location,income, malaria prevalence and industry group,we found little difference in current or futureconcern. However, in the 2005 survey, firms withover 10,000 employees were found to have lowerlevels of concern than firms with fewer than 5,000employees, after taking account of the abovevariables (see Appendix 1 for details of regressionanalyses).

The importance of governance

We also conducted a number of analyses aimedat exploring whether significant variation in futureconcern could be accounted for by other aspectsof the social, economic and political environment,as perceived by the survey respondents.

Our main descriptive findings, based on both the2005 and 2004 surveys, are that businessconcern over the future impact of malaria tends tobe less when countries are perceived as generallywell governed. If a country’s economic prospectsover the next year are perceived with optimismand if governments are seen to be effective interms of providing for public goods, developingand maintaining a strong infrastructure andreducing poverty and inequality, businesses tendto be less pessimistic about the future effects ofmalaria. A free media is also associated withreduced business concern, perhaps becausegovernment health programmes can be moreeasily held up to scrutiny in such an environment.

The relationship between business and societyalso has an effect on private sector concern overmalaria. Where labour relations are cooperative,and where corporate codes of conduct and otheraspects of corporate social responsibility are thenorm, concern is reduced. Businesses appear tobelieve malaria control is the responsibility ofsociety as a whole. Effective and fair governments,a free media and a private sector where corporatecodes of conduct and other aspects of corporatesocial responsibility are frequent are all seen tohave an influence on how malaria will affectbusinesses. Firms do not appear to believeaddressing the disease is the task of governmentsalone.

Concern, endemicity and epidemics

It is interesting to ask whether business concernabout malaria varies depending on whethermalaria in a country is endemic (meaning that it isconstantly present in a country) or whether thecountry has areas in which it is epidemic (meaningthat the disease flares up from time to time).89

Quite plausibly, businesses in areas where malariais endemic, but not epidemic, would have lessconcern about malaria, for several reasons. First,endemicity confers a certain level of immunity onadults, so workers are less likely to be affected.Second, in endemic areas, businesses are used to


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malaria, so they have, perhaps, already adjustedbusiness practices in response to the constantthreat of malaria. Finally, periodic malariaepidemics bring uncertainty to a business: it isunclear when one will occur, and if one occurs inan area where few people have immunity, workersmay be severely affected.90

To answer this question, we calculated thepercentage of businesses that have “someconcern” about malaria and found the following:

Figure 7 – Concern where malaria is epidemic andendemic, versus endemic only

Businesses are significantly more concernedabout malaria when it is both epidemic andendemic in a country than when it is onlyendemic. However, examination of the survey datain conjunction with prevalence data shows thatmalaria prevalence is also significantly higher (notsurprisingly) in countries in which the disease isboth endemic and epidemic, than where it is onlyendemic. It would be possible, therefore, that thedifference in business concern could be dueentirely to greater malarial prevalence in the priorset of countries. Regression analyses of the dataallow us to answer this further question:prevalence does increase business concern, butcontrolling for malarial prevalence (in addition toincome per capita), businesses are moreconcerned about malaria in countries where it isboth epidemic and endemic than where it is onlyendemic.

Malaria, HIV/AIDS and tuberculosis

Executive Opinion Survey respondents were alsoasked about the impact of HIV/AIDS andtuberculosis on their operations. In 2004, thesediseases were perceived as having a greatercurrent impact on firms than malaria. 30 per centof respondents reported that HIV/AIDS wasaffecting them and 24 per cent perceived impactsfrom TB. As we have seen, 22 per cent believedmalaria was having an impact. The proportion offirms expecting future impacts of HIV/AIDS andTB was also higher in both 2004 and 2005 (seeFigure 8 and Table 7), as was the proportionexpecting those impacts to be serious. The year-on-year increase in future concern, too, wasslightly more marked for HIV/AIDS and TB.

Figure 8 – Current and future concern over theimpacts of HIV/AIDS, TB and malaria, 2004

If we narrow our analysis for malaria down tocountries with at least some reported cases ofmalaria (that is, 1 or more case per 100,000population), perceptions of the disease becomemore significant relative to HIV/AIDS and TB.91 Inthese countries, 40 per cent of respondentbusinesses in 2005 believe malaria will affect themin the next five years. 14 per cent expect seriousimpacts (see figure 9 and table 8). This comparesto 46 per cent of firms worldwide expectingimpacts from HIV/AIDS and 33 per cent expectingimpacts from TB (table 9).


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Figure 9 – Future concern over malaria incountries with malaria, versus future concernworldwide over HIV/AIDS and TB, 2005

Respondents were more concerned about thebusiness impacts of malaria in areas that are hardhit by HIV/AIDS.92 This may reflect a weak overallhealth environment in these settings, and weakhealth systems. It may also be related to theincreased vulnerability to malaria of people whoseimmune systems are compromised by HIV/AIDS.

Given that HIV/AIDS kills over 3 million people peryear, many of them adults of prime working age; itis not surprising that the latter is perceived to takea higher toll on business than malaria. Indeed, onemight perhaps expect a bigger difference.


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What can businesses do?

• Many of the resources needed for malariacontrol match core business skills andcapabilities.

• Companies in many different sectors, includingbut not limited to healthcare, have the potentialto assist prevention and treatmentprogrammes.

• Business associations can help firms bydeveloping guidelines of good practice.

• Several major businesses have taken action onmalaria, with benefits including developing newbusiness contacts, promoting worker andcustomer loyalty and protecting workforcesand, to some extent, markets.

Parts Two and Three of this report outline whysome businesses might benefit from involvementin malaria prevention and treatment. We haveseen that many businesses believe that thedisease is either currently affecting their operationsor likely to affect them in future, and that both theyand their governments can play a part in malariacontrol. The potential impacts on employees,reputations and, to some extent, customers maymotivate firms to act. In this section, we discusswhat businesses can do to combat malaria andhighlight the actions some companies have taken.

Many of the requirements of successful malariacontrol match the skills and capabilities of theprivate sector. Devising strategies, developing newtechnologies, distributing and marketing productsand financing programmes or campaigns are allimportant aspects of malaria control efforts andalso a part of the private sector’s day-to-dayactivities. Businesses also have close relationshipswith employees and their families, and often withsuppliers and customers, so they are well placedto assist with health education campaigns. Thatmany firms in malarial areas already haveworkplace HIV/AIDS or other health educationprogrammes also leaves them well positioned todevelop new programmes.

Most firms currently involved in malaria control arethose that either manufacture or deliver preventionand treatment tools as a core part of theirbusiness. Pharmaceutical companies develop andsell drugs and mosquito repellents, for example,and a variety of firms have helped develop

pesticides and insecticide-treated bednets. Theprivate sector is also heavily involved in vaccineresearch, and pharmaceutical companies are keypartners in the Malaria Vaccine Initiative and otherinternational vaccine-promoting agencies.

A recent report by the World Economic Forum listspossible roles in malaria control for firms working inparticular sectors.93 For example:

• Firms working in the health sector can developnew drugs, cheaper and more efficient diagnosticmalaria tests, and vaccines, and can also work tostrengthen medical infrastructure and training

• Construction and engineering firms can buildmosquito-proof structures, and promote vectorcontrol by draining or filling in breeding sites

• Energy companies can make dam reservoirs safeagainst malaria

• Firms working in the food, beverage and retailsectors can use their strong distribution networksto deliver malaria prevention and treatment tools

• Information technology businesses can work withgovernments to develop surveillance systems totrack the disease and predict outbreaks and canalso work to strengthen health managementsystems

• Media and entertainment firms can promoteawareness of malaria and educate consumersabout prevention and treatment

• Financial services firms can help the poor copebetter with malaria by developing micro-creditprogrammes that are linked to the provision ofinformation about health insurance or itspurchase

• Logistics and transport firms can deploy theirservices in delivering malaria commodities

Roles in malaria control are not limited to firms inthese sectors. For example, all firms in vulnerableareas can educate employees and their familiesabout prevention and treatment or train community-based volunteers to educate. They can also provideor facilitate the administering of drugs anddistribution of bednets. In addition, firms can assistgovernments in building up more robust malariadatabases by collecting data on the disease’sincidence among employees and the surroundingcommunities. Firms in non-malarial regions,meanwhile, can protect workers who travel toendemic or epidemic zones.

Four: Business action on malaria

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Business associations may also play a role. Bydistributing good practice guidelines to firms andacting as an information resource, theseassociations can help firms that lack the resourcesto create malaria programmes themselves. Theycan also encourage manufacturers of drugs andITNs to provide more comprehensive informationabout the disease to consumers, and to combatthe problem of counterfeit drug sales, which isprevalent in many developing countries.

What is business doing?

Private sector involvement in malaria controlincludes some action by firms for which malariacontrol is a core business activity and some forfirms wishing to protect employees andcommunities.

Action on malaria as a core business activity

For Sumitomo Chemical Company, a Japanesefirm, malaria control is a core business activity.The company developed an insecticide-treatedbednet, the ‘Olyset net’, which lasts for at leastfive years without re-treatment and withstandswashing.94 In 2001, the World Health Organizationapproved the net, and in order to increasedistribution of the nets and reduce their cost,Sumitomo Chemical agreed to transfer thetechnology used in making the nets to the largestnet manufacturer in Africa, A to Z Textile Mills.With financial and technical assistance from arange of other organizations, production rose from300,000 nets in 2004 to 3 million a year later. 95per cent of those nets produced in 2004 weresold to high-risk populations in 25 countries.

Pharmaceutical firms have also acted to assistmalaria control in developing countries. ICI,Aventis and Bayer, for example, have alldistributed insecticides at low cost in thedeveloping world.95 Similarly, Novartis haspartnered with WHO to provide its artemisinin-based Coartem drug to poor countries at afraction of its cost in the industrialized world.96

Action to protect employees andcommunities

Some firms have engaged in malaria controlbecause of the toll it takes on employees andcommunities.

As noted earlier, BHP Billiton’s construction of itsMozal aluminium smelter in southern Mozambiquewas seriously threatened by malaria.97 The totalcost of malaria to the company was estimated atalmost US$ 2.7 million. It therefore joined theLubombo Spatial Development Initiative (LSDI), apublic-private partnership that aims to improve thehealth and economic strength of the region.Malaria control is a key part of the LSDIprogramme. LSDI introduced indoor residualspraying to southern Mozambique, developed acomputerized tracking system to track the effectof malaria control, and promotes early treatmentwith ACTs. BHP Billiton helped fund theprogramme and loaned its project-managementskills to the indoor-spraying campaign. Its costshave come down as a result of joining andcontributing to LSDI and it has been able to builda second smelter.

In a similar example, the oil firm ExxonMobil foundthat malaria would increase the costs ofconstructing an oil pipeline from Chad toCameroon.98 A survey of employees andcontractors revealed a case incidence of 1,750malaria cases per 1,000 workers per year. In theabsence of an effective malaria control effort,construction would take over 4 days longer thanplanned and cost an extra US$ 4 million. Thesemotivations spurred ExxonMobil to invest in acomprehensive malaria control programme aimedat employees, contractors, and the widercommunity. The company required contractors tooffer prevention and treatment services to theirworkers, and worked with NGOs to provide suchservices to communities. Programme monitoringshows that the project saved ExxonMobil US$ 3.8million in project delay costs, as malaria incidencewas reduced by 70 per cent compared to the pre-programme survey. The number of additionaldays’ work, moreover, was sharply reduced.

Several mining firms have also become involved inmalaria control. In Zambia, Konkola Copper Minesreacted to very high malaria incidence in theirsurrounding communities by launching aprevention campaign based on householdspraying.99 Malaria incidence during theprogramme’s first five months was 57 per centlower than in the same period the previous year,and cost savings have been estimated at US$177,500.


27

In Indonesia, the mining company FreeportMcMoRan’s malaria control programme includeddraining swamps, larviciding and indoorspraying.100 The campaign dramatically cut malariacases around the mine and the company has alsoinvested in prevention activities in a wider area.

In the above examples, companies used theirskills and resources to create new businessopportunities and enhance customer andemployee loyalty, or to avert negative impacts byprotecting workers and communities. Each of theinterventions had measurable benefits both for thecompanies involved and for the populations ofhard hit regions. The actions of these and othercompanies that have already taken up the gauntletprovide guidelines for firms wishing to begin orstep up malaria control activities, as discussed inPart Five.


28

Conclusions

A significant minority of business leadersworldwide are concerned that malaria is eitherimpacting their operations currently or will affectthem in the near future. In countries where thedisease poses a threat to populations, two inevery five firms that responded to the ExecutiveOpinion Survey expect impacts from the diseasein the next five years. This concern increasedslightly between 2004 and 2005.

Firms in poor countries and in countries ravagedby other infectious diseases such as HIV/AIDS arethe firms most concerned about malaria. In thesesettings, it appears governments have beenunable to reduce its toll on societies andbusinesses. Firms appear to believe that tacklingthe disease effectively requires a combination ofpublic and private sector activity – effectivegovernments and socially responsible businessesare both associated with reduced concern overmalaria.

The private sector, with its skills in strategicplanning, technology development, productdistribution and marketing, can make an importantcontribution to malaria control. The examples ofsome companies, moreover, show that action canaffect the bottom line as well as boostrelationships with employees, customers andother organizations.

Recommendations101

Given business concerns over malaria, and takinginto account the factors that have influenced thesuccess of company malaria programmes, thosefirms wishing to engage in or step up malariaactivities may benefit from the followingconsiderations:

• Businesses should first identify a need foraction on malaria. For many firms worldwide,this will be limited to protecting workers whotravel to malarial regions. In some countrieswhere malaria is widespread, governmenthealth programmes are coping effectively withthe problem. In others, the public sector needsbusiness support. Firms conducting a carefulassessment of the problem and its impacts onthem and the countries in which they operatewill be best placed to develop an appropriateand effective response.

• Firms engaging in malaria control activitiesshould seek partners to assist their efforts.Many of those companies that have takensuccessful action to combat malaria haveenlisted the support of governments, non-governmental organizations and otherbusinesses. Business skills are well matched tothose required for malaria control, but bytapping into the specialist knowledge andresources of other organizations, partneredactions are more likely to effectively address theproblem. Business associations may also havean important role to play in providinginformation and training to companies.

• In most circumstances, programmes shouldbegin in the workplace. As the survey ofbusinesses in Ghana showed, the mostimmediate business impacts of malaria arelikely to be felt by workers, who are also theeasiest for companies to reach withprogrammes. Protecting employees’ familiesmay also provide direct benefits to firms interms of reduced absenteeism and improvedworkforce morale.

• Firms should be careful to define the coverageof programmes. The workplace is likely to bethe initial focus of malaria programmes, butsome programmes will then expand intocommunities. Managing expectations amongboth workers and communities is important forprotecting corporate reputations and forprogramme planning.

• Some of the firms’ programmes reviewedabove benefited by encouraging suppliers andcontractors to protect their workers againstmalaria. In the case of ExxonMobil, thecompany required contractors to join malariaprogrammes. Given that such measures arelikely to increase contractors’ costs (at least inthe short term, before the benefits accrue),companies should look to assist suppliers andcontractors by sharing policies and materials.

• Finally, rigorous evaluation of programmes willhelp firms to ensure programmes’ continuedsuccess and cost-effectiveness. This includesmonitoring coverage of prevention andtreatment methods among target audiencesand measuring programmes’ impact on health.Assessing financial impact relative to cost tellscompanies whether they are getting the mostout of their investment in a programme.Because malaria is a durable disease that canresurge if control programmes are neglected,assessing impacts over the long term will helpfirms keep engaged in the problem.

Five: Conclusions and recommendations

29

Descriptive multiple regression analyses wereconducted, focusing on 2 key variables:

• Future concern about the impact of malaria –2005

• Future concern about the impact of malaria —2004

Ordered logits — statistical tools appropriate tothe nature of the data — were fit to the differentdependent variables. Robust standard errors wereestimated. All computations were done using thestatistical software package STATA.

All regressions included the following controls:

• Per capita income in 2002 (or, if not available,per capita income in 2001 with a dichotomousvariable indicating that the data refer to 2001;these data come from the World Bank’s WorldDevelopment Indicators)

• Malaria prevalence category for the country(these data come from the WHO, defined asper the attached league tables)

• Geographic region dummies (grouped as perthe attached league tables)

• Industry group categories from the GlobalBusiness Survey (GBS)

• Firm size categories (from the GBS)

The baseline regression analyses for 2005 and2004 reveal the following:

• There is a good deal of regularity in the data:the patterns are sensible and reveal multipleindependent covariates of future concern aboutmalaria in terms of its impact on the company.

• Future concern about malaria tends to fall withper capita income, controlling for malariaprevalence, geographic region, industry groupand firm size.

• Future concern about the business impact ofmalaria tends to rise with the country’s malariaprevalence, controlling for income, geographicregion, industry group and firm size. Businessleaders in countries with malaria prevalencegreater than 100 cases of malaria per 100,000population tend to have much greater concernthan their counterparts in countries with malariaprevalence less than 100.

• There are significant differences acrossgeographic regions in future concern, even aftercontrolling for income, malaria prevalence,industry group and firm size. Business leadersin Sub-Saharan Africa have the greatestconcern about the future impact of malaria ontheir businesses, followed by business leadersin East Asia.

• There is little variation in current or futureconcern across industry groups, controlling forcountry, income, malaria prevalence and firmsize.

• There is little variation in current or futureconcern across firm size categories, controllingfor country, income, malaria prevalence andindustry group. However, in the 2005 GBS,large firms (i.e., those with more than 10,000employees) have lower levels of future concernthan firms with less than 5000 employees,other things equal.

Appendix 1: Notes on multiple regressionanalyses

30

Identical questions were asked about the futureimpact of malaria in the 2005 and the 2004 surveys.In the 2005 (2004) survey, Question 7.15A (7.21A)asks “How serious do you consider the future impactof malaria on your company in the next 5 years?”The objective of the shift-share analyses is to makemeaningful comparisons of average responses in2004 and 2005 to the question about the futurebusiness impact of malaria.

The per cent of respondents expressing someconcern about the future impact of malaria on theirbusiness increased from 22.1 to 26.6 per cent from2004 to 2005. Is this notable increase an artefact ofchanges in the set of countries included in the GBSsample and in the distribution of survey responsescoming from different countries, or does it reflect agenuine increase in concern among similarly situatedbusiness leaders? A simple sample-wide comparisoncould be biased by changes in the list of countriessampled from year to year (some countries areadded and some are dropped). It could also bebiased by a lack of representation of the GBS samplewithin countries or by changes in representation overtime.

Tables 10, 11 and 12 provide the results of threeshift-share analyses. We conducted one set ofanalyses from the perspective of malaria prevalencein 2000 (as reported by WHO), another from theperspective of country income per capita and a thirdfrom the perspective of geographic region.

The virtue of the shift-share analysis is that itevaluates every respondent on the basis of themalaria prevalence of the country (or the per capitaincome of the country, or the geographic region inwhich it is located) from which they come. This is thesense in which respondents are said to be “similarlysituated” in 2004 and 2005.

The shift-share analysis proceeds from theobservation that the overall level of concern can beexpressed as a weighted-average of the levels ofconcern within malaria prevalence categories, withinincome groups or within geographic regions. Theweights are the proportions of respondents in thoseprevalence categories, income groups or geographicregions. Thus, we decompose the changes in theproportion indicating some concern into two parts:

1.Changes in the distribution of respondents indifferent prevalence categories (or income groupsor geographic regions)

2.Changes in the degree of concern withinprevalence categories (or within income groupsor geographic regions)

We do this by estimating the proportion ofrespondents that would have expressed someconcern in 2005 if the proportions of respondentsin the different prevalence categories, incomegroups or geographic regions had beenunchanged from 2004. Insofar as the 2005estimate of the proportion expressing concern ishigher than the 2004 figure, we find that we canattribute at least some of the rise to increases inconcern within prevalence categories, incomegroups or geographic regions (depending on theanalysis). Because the estimate for 2005 isconstructed under the assumption that theproportions of respondents in the differentprevalence categories, income categories orgeographic regions are unchanged, we can besure the year-to-year change in overall concern isnot due to changes in sample composition.

Based on all three shift-share analyses, thebottom line is quite clear: the year-to-year increasein malaria concern from 2004 to 2005 was duesubstantially to changes in levels of some concernwithin prevalence categories (or income groups orgeographic regions) – not to changes in samplecomposition. Indeed, the proportion of GBSrespondents expressing some concern increasedfrom 2004 to 2005 in every prevalence category,income group (with the exception of low-income)and geographic region (with the exception ofOceania).

We repeated this analysis for serious futureconcern. This statistic increased more modestlyfrom 8.5 per cent of respondents in 2004 to 9.5per cent of respondents in 2005. These shift-shareanalyses (by malaria prevalence group, incomegroup and geographic region) generally confirmthat this increase is not due to changes in samplecomposition; rather, it is due to changes in levelsof future concern among respondents who arecomparable in terms of the malaria prevalence oftheir country, the income of their country, or thegeographic region within which their country islocated.

All of the results cited here are based on non-missing responses for the variables in question.

Appendix 2: Notes on shift-share analyses of year-on-year changes in concern over future malaria impacts

31

1 Breman J, A Mills, R Snow, R Steketee, N White, KMendis and others (2006): Conquering Malaria. InDisease Control Priorities in Developing Countries, 2nded., ed. DT Jamison, JG Breman, AR Measham, GAlleyne, M Claeson, DB Evans and others. OxfordUniversity Press, New York: 413; Disease ControlPriorities Project (2006): Malaria. Available atwww.dcp2.org; WHO (2005): World Malaria Report 2005.WHO, Geneva.

2 Breman et al (2006) op cit: 415

3 Centers for Disease Control and Prevention (nd): TheHistory of Malaria, An Ancient Disease. Available atwww.cdc.government/malaria/history/index.htm.

4 Carter R and K Mendis (2002): Evolutionary andHistorical Aspects of the Burden of Malaria. ClinicalMicrobiology Reviews 15 (4), October.

5 Breman et al (2006) op cit: 413.

6 Breman JG, MS Alilio, A Mills (2004): Conquering theIntolerable Burden of Malaria: What’s New, What’sNeeded: A Summary. American Journal of TropicalMedicine and Hygiene 71 (Suppl. 2): 1-15.

7 Roll Back Malaria (2006): What is Malaria? RBMInfosheet.

8 WHO, UNICEF (2003): Africa Malaria Report 2003.Geneva.

9 Ibid.

10 Steketee RW et al (2001): The burden of malaria inpregnancy in malaria-endemic areas. American Journal ofTropical Medicine and Hygiene 64 (1,2 S): 28-35.

11 WHO, UNICEF (2003) op cit.

12 Disease Control Priorities Project (2006): Malaria.Available at www.dcp2.org .


14 Global Fund to Fight AIDS, Tuberculosis and Malaria(2006): Malaria. GFATM Disease Report, available athttp://www.theglobalfund.org/en/files/about/replenishment/disease_report_malaria_en.pdf.



17 ibid.


19 WHO (2005): World Malaria Report 2005. WHO,Geneva.

20 WHO (2005). “Promise for Progress,” Roll Back MalariaPartnership. Geneva. Available athttp://rbm.who.int/cmc_upload/0/000/015/146/p4p.pdf

21 ibid.

22 WHO (2000): WHO Expert Committee on Malaria.Twentieth Report. Geneva, WHO Technical Report Series,No. 892.

23 Lengeler C (2004): Insecticide-Treated Bed Nets andCurtains for Preventing Malaria. Cochrane DatabaseSystematic Reviews (2) CD000363.

24 Armstrong-Schellenberg, JR, S Abdulla, R Nathan, OMukasa, TJ Marchant, N Kikumbih and others (2001):Effect of Large-Scale Social Marketing of Insecticide-Treated Nets on Child Survival in Rural Tanzania. Lancet357: 1241–47.

25 Schiff C, W Checkley, P Winch, J Premji, J Minjas, PLubega (1996): Changes in weight gain and anaemiaattributable to malaria in Tanzanian children living underholoendemic conditions. Transactions of the RoyalSociety of Tropical Medicine and hygiene 90(3): 262-265.

26 Kuile et al (2003): Permethrin-treated bednets reducemalaria in pregnancy in an area of intense perennialmalaria transmission in western Kenya. American Journalof Tropical Medicine and Hygiene.

27 Curtis CF: The mass effect of widespread use ofinsecticide-treated bednets in a community. CMH PolicyMemorandum. Cited in Commission on Macroeconomicsand Health (2001): Macroeconomics and Health:Investing in Health for Economic Development. WorldHealth Organization. Geneva.

28 All figures are calculated from World Bank, WorldDevelopment Indicators, 2005.


30 ibid.

31 ibid.

32 Caulfield L, SA Richard, and R Black (2004):Undernutrition as an underlying cause of malariamorbidity and mortality. American Journal of TropicalMedicine and Hygiene 71 (Suppl. 2): 55-63.

33 Lacarin, CJ and Reed, RA (1999), Emergency VectorControl Using Chemicals. WEDC, Loughborough, UK.

34 Goodman C, P Coleman, and A Mills (2000): EconomicAnalysis of Malaria Control in Sub-Saharan Africa. GlobalForum for Health Research, Geneva.

35 Breman et al (2006): op cit.

Endnotes

32

36 World Economic Forum (2006): Harnessing PrivateSector Capabilities to Meet Public Needs: The Potentialof Partnerships to Advance Progress on Hunger, Malariaand Basic Education. WEF, Geneva. January.

37 WHO (2005) op cit.

38 ibid.

39 ibid.

40 ibid.

41 ibid.

42 ibid.

43 ibid.

44 UNICEF (2005): Accelerating Child Survival andDevelopment: Results-Based Approach in High Under 5Mortality Areas. UNICEF, May.

45 GAVI Alliance (2006): Disease Information: Malaria.Available at:http://www.vaccinealliance.org/General_Information/Immunization_informa/Diseases_Vaccines/malaria_3.php.

46 Commission on Macroeconomics and Health (2001):Macroeconomics and Health: Investing in Health forEconomic Development.

47 Bloom DE, D Canning, and M Weston (2005): TheValue of Vaccination. World Economics 6 (3): 15-39.

48 Bloom DE, Canning D, Sevilla J (2004): The Effect ofHealth on Economic Growth: A Production FunctionApproach. World Development 32 (1): 1.

49 Alsan M, DE Bloom, and D Canning (2006): The Effectof Population Health on Foreign Direct Investment Inflowsto Low- and Middle-Income Countries. WorldDevelopment 34 (4). April.

50 Bloom DE, and J Williamson (1998): DemographicTransitions and Economic Miracles in Emerging Asia.World Bank Economic Review.

51 Mills A and S Shilcutt (2004): Copenhagen ConsensusChallenge Paper on Communicable Diseases.Copenhagen Consensus, February.

52 Goodman CA, P Coleman and A Mills (2000):Economic analysis of malaria control in sub-SaharanAfrica. Report prepared for the Global Forum for HealthResearch, Strategic Research Series, Geneva.

53 Gallup JL and JD Sachs (2001): The Economic Burdenof Malaria. American Journal of Tropical Medicine andHygiene, Special Supplement, June.

54 Chima R, C Goodman, and A Mills (2003): The

Economic Impact of Malaria in Africa: A Critical Review ofthe Evidence. Health Policy 63 (1): 17–36.

55 Kirigia JM, RW Snow, J Fox-Rushby, and A Mills(1998): The cost of treating paediatric malaria admissionsand the potential impact of insecticide treated mosquitonets on hospital expenditure. Tropical Medicine and

International Health 3: 145-150; Ettling MB, and DSShepard (1991): Economic cost of malaria in Rwanda.Tropical Medicine and Parasitology 42 (3): 214-8.

56 Worrall E, and C Hongoro, unpublished data cited in EWorrall, A Rietveld, C Delacollette (2004): The Burden ofMalaria Epidemics and Cost-Effectiveness of Interventionsin Epidemic Situations in Africa. American Journal ofTropical Medicine and Hygiene 71(Suppl 2): 136–140.


58 WHO (1998): Malaria. Fact Sheet No. 94. WHO,Geneva.

59 Foster R and C Leighton (1993): Economic Impacts ofMalaria in Kenya and Nigeria. Research Paper 6, HealthFinancing and Sustainability Project, Agency forInternational Development, USA.

60 Nur ET (1993): The impact of malaria on labour useand efficiency in the Sudan. Social Science and Medicine37 (9): 1115-9; Nur ET and A Mahran (1988): The effectof health on agricultural labour supply: a theoretical andempirical investigation. In AN Herrin and PL Rosenfield,eds. Economics, Health and Tropical Diseases. Universityof the Philippines, School of Economics, Manila.

61 Gallup and Sachs (2001) ibid.

62 ibid.

63 Goodman et al (2000) op cit.

64 Holding PA, and PK Kitsao-Wekulo (2004): Describingthe Burden of Malaria on Child Development: WhatShould We Be Measuring and How Should We BeMeasuring It? American Journal of TropicalMedicine and Hygiene 71 (Suppl. 2): 71–79.

65 Foster and Leighton (1993) op cit.


67 Axton JH, and SL Siebert (1982): Aetiology ofconvulsions in Zimbabwe children three months to eightyears old. Central African Journal of Medicine 28 (10):246-9; Waruiru CM, CR Newton, D Forster, et al (1996):Epileptic seizures and malaria in Kenyan children.Transactions of the Royal Society of Tropical Medicineand Hygiene 90(2): 152-5.

68 Boyle CA, P Decoufle, M Yeargin Allsopp (1994):Prevalence and health impact of developmentaldisabilities in US children. Paediatrics 93 (3): 399-403.

Endnotes

33

Endnotes

83 World Economic Forum, Global Health Initiative, BHPMalaria Private Sector Intervention Case Example. WorldEconomic Forum, Geneva.

84 World Economic Forum, Global Health Initiative, ExxonMobil Malaria Private Sector Intervention Case Example.World Economic Forum, Geneva.

85 The regions discussed are the Caribbean, East Asia,Eastern Europe and Central Asia, Latin America, NorthAfrica and the Middle East, Oceania, North America,South and South East Asia, Sub-Saharan Africa, andWestern Europe. Income groups include low-income,low-middle income, upper-middle income and high-income countries, as defined by the World Bank in its2004 World Development Report. Low-income countriesare defined as those that had gross national income (GNI)per capita of US$ 735 or less in 2003; lower middle-income as those with GNI per capita between US$ 736and US$ 2,935; upper middle-income as those with GNIper capita between US$ 2,936 and US$ 9,075; and high-income as those with GNI per capita of US$ 9,076 andabove. Malaria prevalence groups are based on datafrom the United Nations Statistics Division’s MillenniumIndicators. Data are from 2000 from all countries exceptAlgeria, Benin, Cameroon, Chad, Ethiopia, Haiti, Mali,Mauritius and Tanzania, where data are from an earlieryear. By prevalence, we refer to the number of malariacases (in terms of episodes of illness) per year per100,000 people.

86 The exact questions asked were: (2003) How seriousdo you consider the current and future impact of malariaon your company?; (2004) How serious do you considerthe current impact of malaria on your company? Howserious do you consider the future impact of malaria onyour company in the next five years?; (2005) How seriousdo you consider the future impact of malaria on yourcompany in the next five years? For further details on thedesign and sample coverage of the World EconomicForum’s Executive Opinion Surveys see Bloom DE, LRBloom, D Steven and M Weston (2005): Business andHIV/AIDS: Commitment and Action? World EconomicForum, Global Health Initiative, Geneva (esp. Appendix 1,p. 30) and Bloom DE, LR Bloom, D Steven and MWeston (2006): Business and HIV/AIDS: Commitmentand Action? World Economic Forum, Global HealthInitiative, Geneva.

87 The questions on malaria include seven-point Likertscales. The World Economic Forum practice is fornumbers 1 to 3 on the scale to signify agreement with theleft-hand proposition, 5 to 7 to equal agreement with theright-hand proposition, and 4 to be neutral. For thequestions on malaria, 1 means extremely serious impactand 7 means not a problem, or no impact at all. Logically,any answer other than 7 implies at least some impact –although this contradicts World Economic Foruminstructions to treat 4 as neutral. The data are thereforedifficult to interpret, and we decided to set threestandards: 1-2 as a serious impact, 1-5 for some impact,and 6-7 for minimal impact. This does not result innumbers that sum neatly to 100 per cent, but it appearsto be the best possible interpretation in other regards.

69 Fernando D, R Wickremasinghe, KN Mendis, and ARWickremasinghe (2003): Cognitive Performance at SchoolEntry of Children Living in Malaria-Endemic Areas of SriLanka. Transactions of the Royal Society of TropicalMedicine and Hygiene 97 (3): 161–65.

70 Aikins MKS (1995): Cost-effectiveness analysis ofinsecticide-impregnated mosquito nets (bednets) used asa malaria control measure: a study from the Gambia. PhDThesis, Department of Public Health and Policy, LondonSchool of Hygiene and Tropical Medicine, University ofLondon.

71 Gallup JL, and JD Sachs (2001): The EconomicBurden of Malaria. American Journal of Tropical Medicineand Hygiene 64 (Suppl. 1): 85–96.

72 Hoyt Bleakley (2006): Malaria in the Americas: ARetrospective Analysis of Childhood Exposure.Forthcoming.

73 Gallup and Sachs (2001) op cit.

74 Shepard DS, MB Ettling, U Brinkmann, R Sauerborn(1991): The economic cost of malaria in Africa. TropicalMedicine and Parasitology 42 (3): 199-203.

75 Masiye F and C Rehnberg (2005): The economic valueof an improved malaria treatment programme in Zambia:results from a contingent valuation survey. Malaria Journal4: 60.

76 McCarthy FD, H Wolf, and Y Wu (2000): The GrowthCosts of Malaria. NBER Working Paper 7541,NationalBureau of Economic Research, Cambridge, MA.

77 Mwageni et al (2002): Household wealth ranking andrisks of malaria mortality in rural Tanzania. In Third MIMPan-African Conference on Malaria, Arusha, Tanzania.

78 Roll Back Malaria (2001): Report on the Zambia RollBack Malaria baseline study undertaken in 10 sentineldistricts, July to August 2001. RBM National Secretariat,Zambia.

79 Akazili J (2002): Costs to households of seekingmalaria care in the Kassena-Nankana District of NorthernGhana. In: Third MIM Pan-African Conference on Malaria,Arusha, Tanzania.

80 Spielman A, S Weerasuriya, P Malaney, A Kiszewski, DWillis, R Pollack, A Teklehaimanot (2002): Industrial Anti-Malaria Policies. Global Health Initiative, World EconomicForum, Geneva.

81 ibid.

82 Oppong Y (2001): Public health and profitability:Perceptions and responses of business community inGhana to HIV/AIDS and Malaria. African Economic Policy,discussion paper number 78. Center for Population andDevelopment Studies: Harvard School of Public Health.

34

88 Again, future concern is higher in countries with highmalaria prevalence even after controlling for key variablessuch as income, geographic region, industry group andfirm size.

89The countries for which we attempted to answer thisquestion are those in the survey that had either endemicmalaria or that had both endemic and epidemic areas.The list of countries with endemic malaria is from WHO.The list of countries with epidemic malaria is fromAnthony Kiszewski, Harvard School of Public Health.From these two lists, we constructed a list of countries inwhich malaria is endemic but not epidemic: Algeria,Argentina, Armenia, Azerbaijan, Benin, China, Costa Rica,Dominican Republic, East Timor, Egypt, El Salvador, theGambia, Georgia, Ghana, Guatemala, Guyana, Honduras,India, Kyrgyz Republic, Malaysia, Mexico, Morocco,Nicaragua, Nigeria, Panama, Paraguay, South Korea,Tajikistan, Turkey and Venezuela. We also constructed alist of countries where it is both endemic and epidemic:Angola, Bangladesh, Bolivia, Botswana, Brazil,Cambodia, Cameroon, Chad, Colombia, Ecuador,Ethiopia, Indonesia, Kenya, Madagascar, Malawi, Mali,Mozambique, Namibia, Pakistan, Peru, Philippines, SouthAfrica, Sri Lanka, Tanzania, Thailand, Uganda, Vietnam,Zambia and Zimbabwe.

90 It is also worth noting that relative rates of infectionamong indigenous and expatriate workers vary betweenendemic and epidemic regions. In endemic regions, forexample, infections tend to be asymptomatic amongadult, long-term residents. By contrast, expatriates are atelevated risk of infection in endemic regions and tend tosuffer severe illness when infected. Insofar as expatriatesare able to rely on chemoprophylaxis in epidemicsettings, their risk of infection is correspondingly reduced.

91 The latter are presumed to exist in every country, so wecompare malaria concern in malarial countries withHIV/AIDS and TB concern worldwide.

92 Bloom DE, LR Bloom, D Steven and M Weston (2005):Business and HIV/AIDS: Commitment and Action? WorldEconomic Forum, Global Health Initiative, Geneva.

93 World Economic Forum (2006): Harnessing PrivateSector Capabilities to Meet Public Needs: The Potentialof Partnerships to Advance Progress on Hunger, Malariaand Basic Education. World Economic Forum, January,Geneva.

94 World Economic Forum, Global Health Initiative (2005):Building a public-private partnership to transfer thetechnology of a life-saving malaria prevention tool inAfrica. Public-Private Partnership Case Example, WorldEconomic Forum, Geneva.

95 Spielman et al (2002) op cit: 8

96 ibid: 11

97 World Economic Forum (2006) op cit.

98 World Economic Forum, Global Health Initiative (2006):Using malaria control strategically to improve workers’health and prevent project delay. Private SectorIntervention Case Example, World Economic Forum,Geneva.

99 Spielman et al (2002) op cit. 16

100 ibid: 17-18

101 See World Economic Forum, Global Health Initiative(2006): Guidelines for Employer-Based Malaria ControlProgrammes. World Economic Forum.

Endnotes

Survey Tables

36

Table 1 - Classification of respondents in Executive Opinion Surveys 2003 - 2005

(1) (2) (3) (4) (5) (6) (7) (8)

37


(1) (2) (3) (4) (5) (6) (7) (8)

38


NOTES:

(1) Malaria estimates are based on years prior to 2000(2) These countries were not included in the UNAIDS listing of countries (within each regional grouping); they were

classified based on their geographical proximity to other countries that were listed.(3) Taiwan’s population is the 2002 population estimate; the 2005 population was not provided in the UN source

document

(1) (2) (3) (4) (5) (6) (7) (8)

39

Table 2 - Classification of respondents by income group and region:Executive Opinion Surveys 2003-2005

(1) (2) (3) (4) (5)

40

Table 3 - Classification of respondents by malaria prevalence:Executive Opinion Surveys 2003-2005

(1) (2) (3) (4) (5) (6) (7) (8)

41


(1) (2) (3) (4) (5) (6) (7) (8)

42


(1) (2) (3) (4) (5) (6) (7) (8)

NOTES:

(1) Malaria estimates are based on years prior to 2000(2) These countries were not included in the UNAIDS listing of countries (within each regional grouping); they were

classified based on their geographical proximity to other countries that were listed.(3) Taiwan’s population is the 2002 population estimate; the 2005 population was not provided in the UN source

document

43

Table 4 - How serious do you consider the current impact of malaria on your company (2004)?

(1) (2) (3) (4) (5) (6)

44

Table 4 - How serious do you consider the current impact of malaria on your company (2004)?

NOTES:

Column 3 represents the percentage of firms that provided responses of 1 or 2 to question 7.20AColumn 4 represents the percentage of firms that provided responses of 1, 2, 3, 4 or 5 to question 7.20AColumn 5 represents the percentage of firms that provided responses of 6 or 7 to question 7.20AColumn 6 represents the percentage of firms that did not respond to question 7.20A

(1) (2) (3) (4) (5) (6)

45

Table 5 - How serious do you consider the future impact of malaria on your company inthe next five years (2004)?

(1) (2) (3) (4) (5) (6)

46

Table 5 - How serious do you consider the future impact of malaria on your company inthe next five years (2004)?

(1) (2) (3) (4) (5) (6)

NOTES:


47

Table 6 - How serious do you consider the future impact of malaria on your company in the next fiveyears (2005)?

(1) (2) (3) (4) (5) (6)

48

Table 6 - How serious do you consider the future impact of malaria on your company in the next fiveyears (2004)?

(1) (2) (3) (4) (5) (6)

NOTES:


Table 8 - Concern over future business impacts of malaria incountries with at least some malaria, 2005

49

Table 7 - Overview of future worldwide business concern over malaria TB,and HIV/AIDS, 2004 and 2005

NOTES:


(1) (2) (3) (4) (5) (6)

50

Table 9 - Overview of future concern - malaria (firms in countries with some malaria)vs HIV/AIDS and TB (firms worldwide), 2004-2005

NB: Restricted to firms that responded to the question about the expected future business impact of malaria.

51

Table 10 - Shift share analysis: malaria future concern by income group

NOTES:

Question 7.15A in the 2005 EOS, and Question 7.21A in the 2004 EOS, ask the same question of respondents:”How serious do you consider the future impact of Malaria on your company in the next five years?”

52

Table 11 - Shift share analysis: malaria future concern by region

NOTES:


53

Table 12 - Shift share analysis: malaria future concern by prevalence group

NOTES:


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Incorporated as a foundation in 1971, and basedin Geneva, Switzerland, the World EconomicForum is impartial and not-for-profit; it is tied tono political, partisan or national interests.(www.weforum.org)

Business and Malaria: A Neglected Threat? · 4 Summary and key findings Introduction Malaria is a serious threat to humanity. Centuries of effort to mitigate its impact have borne

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