Malaria has been and remains a global challenge. Tremendous progress has been made in the last ten years in reducing morbidity and mortality caused by malaria . From 2000 to 2009, there has been an estimated 17% global reduction of malaria incidence, from 225 million cases of malaria in 2000  to 216 million in 2010 . Deaths attributed to malaria have declined by 32% between 2004 and 2010 . Today, many countries are striving for malaria elimination - the interruption of transmission of all Plasmodium parasites within their borders . This substantial progress has been made possible because of major improvements in global funding for malaria control and elimination over the last decade. The region of sub-Saharan Africa is a good example of this trend. In 34 countries of this region, there was a 66-fold increase in the amount of official development assistance (ODA) disbursed for malaria control, from $9.8 million in 2002 to $651.7 million in 2008 . This increased funding has led to the scale-up of improved treatment through artemisinin-combination malaria therapy (ACT), improvements in diagnosis and increased coverage of vector control tools such as long-lasting insecticide treated nets (LLIN) and indoor residual spraying (IRS).
Amidst this progress, however, a number of challenges remain, including the relative neglect of cross-border and regional initiatives in malaria control and elimination. Border regions are often overlooked and hinder the goal of malaria elimination. Frequent human and vector border movements, a blurring of responsibility of individual countries in these regions, and relatively poorer access to health care and preventative measures, in particular for mobile populations, leave space for reservoirs of infection that can lead to continued low level transmission of malaria and vulnerability to malaria outbreaks and epidemics.
Such problems are experienced in a number of continents. In southern Africa, movements across the Angola-Namibia, Zimbabwe-South Africa and Mozambique-Swaziland borders create challenges for successful malaria elimination. In Swaziland, 90% of imported cases of malaria across two years (2005–2007) came from Mozambique , from groups such as truckers, informal traders and sugar plantation workers . In the northern South African province of Mpumalanga, from 2001 to 2009, 48% of the cases were acquired from Mozambique . In Latin America, cross-border movement of people between Argentina, Paraguay and Brazil is essentially preventing both Argentina and Paraguay from declaring themselves free from malaria. It is estimated that 50 to 70% of all reported cases in Argentina are linked to migration, in particular movement across the border from Bolivia [9, 10]; this migration is fueled by economic growth on the Argentina side and a porous border between countries . Similarly, cross-border population movement in the Greater Mekong Subregion of South East Asia impedes efforts to prevent the spread of drug-resistant malaria. An example of this challenge is in Yunnan Province of China, where in 2009 98.8% of total malaria cases and 75.0% of P. falciparum malaria cases were found to be imported from neighbouring countries . Across the border in Myanmar there is poor access to malaria control interventions which is contributing to the continuing transmission in this area.
Given these persistent challenges along and across borders around the globe, one solution is to create a multi-country regional initiative. These initiatives can accelerate progress towards malaria elimination by increasing the scale and quality of malaria control activities. There are many examples where countries direct large amounts of internal and external resources toward combatting imported malaria: Suriname targets gold mining groups from Brazil, public hospitals in Bhutan treat people from Assam, and China implements control measures along the Yunnan Province-Myanmar border in order to prevent, diagnose and treat malaria in migrants [13–15]. All of these activities are currently or have been supported by the Global Fund in addition to national resources. These expenditures potentially could have higher impact if conducted as multi-country initiatives in that the funding and supervision could take place in all affected countries. Surveillance systems and methods of inter-country communication could be built to benefit both countries and vector control methods, insecticides, and timing of activities could be harmonized, increasing the potential for reduction in transmission and reducing the potential of insecticide resistance. Research could inform better identification of migration trends and targeting of the populations. Through these activities, regional collaborations can increase the quality and scale of interventions in a highly-endemic neighbour while at the same time reducing risk of importation and potentially the cost of malaria control in the low-endemic country.
In this way, multi-country initiatives can add value to prevention and control of infectious disease, in particular across porous borders. This value can be seen in various current experiences. Due to the combined effort of the Lubumbo Spatial Development Initiative (LSDI) of Mozambique, South Africa, and Swaziland, funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) malaria prevalence in targeted areas has been reduced by more than 90% [6, 16]. The Amazonian Malaria Initiative (AMI), funded by USAID, consists of national ministries of health and technical partners of seven countries is similarly on the path towards successful malaria eradication . In the Middle East, Saudi Arabia, Kuwait, Oman, United Arab Emirates, Bahrain, and Qatar have combined efforts to donate $17 million (USD) towards malaria elimination interventions along the Yemen border to support regional efforts for malaria control and elimination .
While regional and cross-border programmes are recognized as being important for the control and eventual elimination of malaria, they do not always receive the required political or financial support. This may be because border areas are susceptible to political instability or conflict; and because it can be difficult to broker fair, acceptable, and sustainable agreements amongst different countries to co-fund or co-manage cross-border programmes. For example, despite it success thus far, LSDI currently does not have long-term funding support beyond 2012. Likewise, the Yemen-Saudi cross-border malaria control programme is threatened by political instability.
For these reasons, the role of the Global Fund in supporting regional or cross-border malaria control efforts is important. The Global Fund is an international financing agency established to support HIV, tuberculosis and malaria programmes in mainly low and middle-income countries. For the past ten years, countries have submitted funding proposals to the Global Fund during periodic ‘rounds’ of funding which occurred approximately once every year. These proposals are reviewed by a Technical Review Panel (TRP) consisting of up to 42 experts that makes a recommendation to the Global Fund Board about whether the proposal should be funded. The Global Fund also allows countries to develop and submit multi-country proposals so as to enable economies of scale and learning across countries, as well as cross-border work. Multi-country proposals can be of two types: a group of small island nations too small to make individual applications or a group of contiguous countries who come together for a regional or cross-border collective effort.
While the Global Fund is not the only source of funding available for these multi-country projects, its contributions to overall malaria programme financing in low- and middle-income countries has been estimated to be 45%, well above that of other donors, whether multi or unilateral . Thus the GF plays a significant role in determining which multi-country projects get funded overall. For this reason, this review concentrates on the Global Fund’s role in financing multi-country initiatives. Given the importance of regional and cross-border initiatives in the future of malaria control, this review aimed to achieve a better understanding of the Global Fund’s support for such initiatives in terms of: 1) the Global Fund’s policies and practices for funding multi-country proposals; 2) temporal trends in the submission and funding of multi-country proposals to the Global Fund; and 3) the factors and variables associated with successful proposals.