The Malaria Contract

The problem

Malaria is the oldest killer in the world and the one the world knows how to beat. Since 2000, by the World Health Organization's count, the global effort has averted about 2.2 billion cases and 12.7 million deaths, with bed nets, spraying, drugs and, since 2023, vaccines. It has not finished the job. In 2024 there were an estimated 282 million cases and 610,000 deaths, up from 598,000 the year before; 95 percent of both were in Africa, and most of the dead were children under five. The world spent $3.9 billion on malaria control in 2024, against a target the WHO puts at more than $9 billion, and the gap is the reason the deaths rose.

The United States was the largest single funder. The President's Malaria Initiative, created in 2005, worked in thirty countries with most of the world's cases, and together with American contributions to the Global Fund disbursed $15.6 billion between 2003 and 2023. An analysis by Oxford Economics estimated that every dollar returned $5.80 in economic gains to the countries where it was spent, more than $90 billion in all, through children who lived and workers who did not lose a month a year to fever. In 2025 the initiative was dissolved with the agency that ran it, and the funds were paused, cut and partly restored in a sequence that left clinics without drugs for months.

The programme's design was also its weakness. It paid for inputs: nets purchased, doses shipped, houses sprayed, staff trained. Inputs are easy to count and easy to cut, and they do not by themselves say whether a child lived. № 053 argued that where a goal has a verifiable finish line, the government should pay for the result rather than the attempt. Malaria has the most verifiable finish line in global health: a case is a blood test, a death is a death, and both are counted.

The proposal

The Malaria Contract: a standing, statutory American commitment of $3 billion a year to malaria, paid not for inputs but for results, per verified case prevented and per death averted against a published baseline, to any government, company or organisation that delivers them in a partner country. The results are verified by independent surveillance the Contract funds first. The commitment cannot be paused or cancelled by executive action. The vaccine, where it works, is paid for on the same terms.

How it would work

1. The surveillance first. A results contract is only as good as the count, and the count in most malaria-endemic countries is an estimate. The Contract's first spending is on surveillance: sentinel sites, rapid tests reported by phone, death registration, and the statistical infrastructure to turn them into a baseline per district. The Famine Guarantee of № 063 funds the warning before the food; the Contract funds the count before the payment.

1. The price. A published payment per case prevented and per death averted, set per district against the baseline: on the order of $10 per case and $5,000 per death, calibrated so that the cheapest effective interventions are profitable to deliver and the ineffective ones are not. The prices are reviewed every three years against what delivery actually costs, in public.

1. Who is paid. Any deliverer: a national malaria programme, a district health office, a nonprofit, a company. The Contract does not care who hangs the net, sprays the wall or administers the vaccine. It pays whoever the surveillance shows reduced the count, and it pays after, not before. Deliverers who need working capital borrow against the contract, which the guarantees of № 111 can cover.

1. The vaccine. The malaria vaccines approved since 2021 reduce deaths in young children substantially where delivered fully; delivery is the constraint. The Contract pays per child fully vaccinated in a high-burden district, verified, at a price that makes the last mile profitable. The Cold Chain of № 120 is the last mile.

1. Statutory and standing. $3 billion a year, appropriated as a standing commitment on the model of № 063's famine response, with a statutory bar on pausing or rescinding it by executive action. The 2025 shutdown left clinics without drugs; the Contract is written so that the next shutdown cannot.

1. Published. Each year, by country and district: the baseline, the cases and deaths, the payments made and to whom, and the cost per death averted. The Contract's claim is that results-based payment buys more lives per dollar than input-based aid; the page is where the claim is tested, and if it fails, this catalog's rule is to say so.

The numbers

The deaths. 610,000 in 2024; 282 million cases; 95 percent in Africa.

The gap. $3.9 billion spent, $9 billion needed. The Contract's $3 billion is roughly the pre-2025 American level restored and made permanent, and it closes a third of the gap.

The price of a life. If the Contract's payments average $5,000 per death averted and the surveillance is honest, $3 billion buys on the order of several hundred thousand deaths averted a year, which is the order of magnitude of the disease. The pre-2025 programmes achieved comparable results per dollar; the Contract's bet is that paying for the result rather than the net improves on them.

The return. $5.80 per dollar by the Oxford Economics estimate, in the economies of the countries where the disease is fought. A country that wants to be followed for what it does has few better uses of $3 billion.

The honest objections

"Paying per result invites fraud in the count." The strongest objection, and the reason item 1 spends first on surveillance that the deliverers do not control. A results contract with a self-reported count is a fraud contract; one with independent sentinel sites, phone-reported tests and death registration is a contract the count can support. Where the count cannot be trusted, the Contract pays for inputs until it can, and says so.

"Malaria control needs steady inputs, and results payments are volatile." Deliverers need working capital and predictability, and item 3 lets them borrow against a standing contract with published prices. A national programme that knows it will be paid $5,000 per death averted for the next decade can plan better than one that knows its next grant depends on a budget in Washington, which is the arrangement that collapsed in 2025.

"Three billion dollars a year for foreign disease control." For the disease that kills more children than any other, at a return of nearly six to one, in the countries that this catalog has argued are the century's partners. The Contract is the Open Hand at its most literal, and its most cheaply justified.

"The vaccine's efficacy is modest and it will absorb the money." The vaccines reduce severe malaria and death in young children by a meaningful fraction where delivered fully, and the Contract pays for them per child fully vaccinated in high-burden districts only, at a price set against their measured effect. A vaccine that does not reduce the count does not earn the payment, which is the discipline that input-based aid never had.

"Results-based aid has been tried and the evidence is mixed." It has, in health, with mixed results, mostly because the results were not independently counted. Malaria's count is the most tractable in global health, and the Contract funds it first. If the page in item 6 shows the model failing, the Contract reverts to inputs, in public, and the catalog will have learned something worth $3 billion.

Sources

• World Health Organization, World Malaria Report 2024, cases, deaths, regional distribution, and investment against the target
• Kaiser Family Foundation, The Trump Administration's Foreign Aid Review: Status of the President's Malaria Initiative (2025)
• Malaria No More and Oxford Economics, The Economic Impact of U.S. Malaria Investments (2024), on disbursements 2003–2023 and returns
• World Bank and Global Fund, results-based financing partnership for maternal and child health, including malaria services
• WHO, recommendations on the RTS,S and R21 malaria vaccines, 2021 and 2023
• Proposals № 053 (The Prize Fund); № 059 (The Hospital Fleet); № 063 (The Famine Guarantee); № 111 (The Six Hundred Million); № 120 (The Cold Chain, forthcoming)