Priorities in Financing the Control of Malaria in the

Asia-Pacific

Prabhat Jha

Prabhat.jha@utoronto.ca

Conclusions• Fight artemisinin and insecticide resistance

– Regulation for counterfeit and sub-standard drugs– Double spending on regional anti-resistance efforts to $400 M

• Engage the private sector– Asian Affordable Medicine Facility-malaria for quality-assured

ACT and RDTs• Sustainable finance

– Raise more revenue: domestic spending inc. tobacco tax– Spend better: strengthen national programs, enable results-

based financing, change health aid – Regional Malaria/Infectious Disease Fund

BackgroundDiverse epidemiological scenarios in region

– Most countries report declines in malaria cases over last 10 years

– Control to elimination

Common needs(1) protect current tools of control, most importantly

artemisinin-based combination therapies (ACT); (2) engage the private sector, where most people continue

to purchase malaria treatments; and (3) achieve sustainable finance in the region at the domestic

and developmental assistance levels.

Past resurgence of malaria

1. Fight ResistanceDouble spending to about $400 M

– Currently $180 M or about 4% of total required malaria investment in region between 2012-15 or 0.5% of total to eliminate malaria in 19 countries by 2030• Insurance against global risks

– R&D spending for new drugs is about 5-10% of total spending

– Strengthen regulation against counterfeit and sub-standard drugs

– Pilot elimination strategies

2. Engage Private Sector

Asian Affordable Medicine Facility-malaria– Negotiated price reductions with private pharma to

sell quality-assured ACTs– High-level subsidy “factory gate”– Support countries in regulation and quality

assurance– Focus on ACT and RDTs– Various models all of which would with GFATM on

new internal AMFm

Malaria incidence and drug consumption in India

-100000

0

100000

200000

300000

400000

500000

600000

700000

CQ (Kg)

SP(Kg)

Malaria cases (x 10)

Pf cases (x 10)

AMFm: getting ACTs affordably available worldwide & so, much more widely used

-Allows better treatment in public and private clinics of all types (including faith-based & other NGO clinics, dispensaries, shops etc)-Avoids mono-therapy (less rapidly effective & risks resistance emerging to artesunate)-Avoids counterfeiting (cf. aspirin) -Will eventually allow near-home treatment (which could greatly reduce child and adult mortality)

Source: Laxminaryanan et al, Lancet 2010

AMFm: Affordable Medicines Facility-malaria $250M pilot phase hosted by GF in Geneva

AMFm, 2013→ Procure ~300M complete courses of high-quality artesunate combination therapy (ACT) per year for $300M, but sell at only ~$0.05 per complete course through all major wholesale outlets in all countries.

Retail price then undercuts/compares with the cheapest available poor products (eg SP, CQ, poor-quality artesunate monotherapy, counterfeits).

Governments, NGOs and clinics that want to provide antimalarials free of charge can buy them in bulk at low cost and do so with little corruption.

$250M pilot phase, 2010-2012, now running well throughout 8 countries (including Cambodia, Ghana, Madagascar, Nigeria, Tanzania, Uganda): spot surveys in 60 random outlets/country show low-cost ACT is on sale.

GF board vote in late 2012 for/against full worldwide AMFm scale-up; if implemented, AMFm will save lives, undermine smuggling/counterfeiting and prevent/substantially delay emergence of resistance to artesunate.

AMFm: Median Prices of AL 20/120 mg (pack size 6x4) by country: AMFm vs non AMFm (OB- Other

Brands and LPG – Lowest Priced Generic)

In the November 2011 HAI survey of AMFm antimalarial availability in 360 outlets distributed throughout six African pilot-phase countries, AMFm ACTs were found available at low price in 83% of the outlets (informal ones 72%, formal ones 94%).

AMFM objections• Inappropriate use by non-malaria patients

– 60% of malaria contacts in public sector in Asia have microbiological diagnosis

• Use by adults– Adult malaria/fever deaths common- eg rural India

• Subsidy is captured by rich– Subsidy was pro-poor in Africa– No major rent seeking by private pharma (and indeed

reduces monotherapies and decreases artemisinin resistance)

*

WHO indirect estimates of Indian malaria mortality rates

Study-attributed Indian malaria mortality rates

Age-specific all-India malaria-attributed death rates estimated from the present study, and those estimated

indirectly for WHO * No. of study deaths per age class (in red)

Indian malaria mortality rates in 2005 were high in early childhood and in middle age

0

10

20

30

40

50

60

70

80D

eath

rate

per

100

000

Age range

0 − 4 5 − 14 15 − 29 30 − 44 45 − 59 60 − 69

591

349

388319

500

538

Malaria deaths occurred where the most dangerous type (Plasmodium falciparum) of

malaria parasite occurs

CGHR.ORG

Death rates from malaria in Mozambique: national mortality

surveyCummulative probability of death: 20%

0.02.04.06.08.0

10.012.014.016.0

0-4 5-14y 15-24 25-49 50+

Age

Cru

de r

ate

per

1000

3A. Sustainable finance

Current spending $0.3B; need is $1.5B/year:• Wide variation in per capita spending and reliance on donor

support• Most donor support for IRS/nets and other key inputs• GFATM resources slowing

Raise more revenue: • 2% of health budgets is target• Malaria control yields at least 2X benefits than costs• Consider tobacco tax: 200% higher tax=$24 B in just 5 countries

3B. Sustainable financeMore malaria control for the money:

• Strengthen national programs to be less input-driven approaches, more evidence-based spending

• Result-based financing (but complex to manage)• Big investments in surveillance/monitoring (esp. to aid elimination)

Change malaria donor assistance: • Fund what governments will not fund easily (regional or global

public goods)• Regional cooperation and Regional Fund

Conclusions• Fight artemisinin and insecticide resistance

– Regulation for counterfeit and sub-standard drugs– Double spending on regional anti-resistance efforts to $400 M

• Engage the private sector– Asian Affordable Medicine Facility-malaria for quality-assured

ACT and RDTs• Sustainable finance

– Raise more revenue: domestic spending inc. tobacco tax– Spend better: strengthen national programs, enable results-

based financing, change health aid – Regional Malaria/Infectious Disease Fund

• Background slides

MILLION DEATH STUDY IN INDIA: (1) visit 1 M homes with a recent death & ask standard questions and get a narrative; (2) use non-medical surveyors (electronic entry + GPS) & central double coding by 500 doctors; (3) study all diseases, work with census dept; (4) keep costs <$1 per home

“For sanitary purposes it is indispensable to know the relative mortality in small and, as far as possible, well-defined tracts to ascertain the death rates in each of these communities; to see how far this arises from preventable causes; and to apply the remedies” Sanitary Commissioner of India, 1869

Malaria deaths before age 70 in the study

• 90% (2422/2685) were in rural areas

• 86% (2315/2685) did not occur at a health facility

All India, 2005

Age rangeDeaths

(thousands)Death rate per 100 000 (lakh)

<1 months 0 44

1-59 months 55

5-14 years 29 12

15-29 years 25 8

30-44 years 22 10

45-59 years 37 27

60-69 years 37 75

Subtotal, ages 0-69 years (lower, upper bounds)

205(125, 277)

18

70 + 71 236

Malaria-attributed deaths: estimated national totals, by age

120 thousand at ages 15-69

* Malaria death rates, India 2005, standardised to population aged 0-69

~100

Half of the malaria deaths were in a few high-malaria states in eastern India

Risk of a newborn Indian dying from malaria before

age 70 (at current rates, in the absence of other

disease)

• About 2% overall in India• Over 12% in Orissa

Geographical variation in absolute numbers of malaria deaths in the different populations studied

by the MDS and NVBDCP

State MDS malaria-attributed deaths

before age 70, 2001-03

NVDCP slide-positive, clinically-confirmed

malaria deaths, 2000-05

No.% No. %

Orissa823

31% 2102 37%

Northeast468

17% 1023 18%

Chhattisgarh131

5% 109 2%

Jharkhand118

4% 152 3%

Madhya Pradesh217

8% 262 5%

All other states928

35% 1999 35%

All India268

5

100% 5647 100%

Malaria deaths did not occur in states where dengue or meningitis or typhoid * were common (1)

* These diseases can be confused with malaria

Malaria deaths did not occur in states where dengue or meningitis or typhoid * were common (2)

* These diseases can be confused with malaria

Malaria was a minority cause of rural, unattended fever deaths

in 2005 (1.3M <age 70)Cause Orissa All INDIA

Pneumonia % 14 28

Other infection % 12 20

Tuberculosis % 15 17 Diarrhoea % 13 16 Malaria % 43 11

Unknown fever % 2 7

All causes (in 000s) 74 1,323

Indian Malaria Program (NVDCP): 2006-2009

average• People tested for malaria: 100 M in

public hospitals/clinics• No. positive for malaria: 1.6 M

– 0.8 M P. falciparum

• No. of deaths: 1304

Thus, with a successful treatment program, establishing a reliable death rate among UNTREATED population is difficult, if not impossible.

NVBDCPMalaria testing in public

hospitals2006 2007 2008 2009

People tested for malaria (millions)

107 95 97 103

Cases positive for malaria (and PF) in millions

1.8

(0.8)

1.5

(0.7)

1.5

(0.8)

1.6

(0.8)

No. of deaths 1707 1311 1055 1144

Rectal artesunate and child survival in

Africa/Asia

Source: Gomes et al, Lancet 2009