Priorities in Financing the Control of Malaria in the Asia-Pacific

1. Priorities in Financing the Control of Malaria in the Asia-Pacific Prabhat Jha Prabhat.jha@utoronto.ca

2. 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

3. Background Diverse 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.

6. Past resurgence of malaria

7. 1. Fight Resistance Double 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

13. 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

14. Malaria incidence and drug consumption in India

15. 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)

16. Source: Laxminaryanan et al, Lancet 2010

17. 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.

18. 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)

19. 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%).

20. 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)

21. Indian malaria mortality rates in 2005 were high in early childhood and in middle age * Study-attributed Indian malaria mortality rates WHO indirect estimates of 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)

22. Malaria deaths occurred where the most dangerous type (Plasmodium falciparum) of malaria parasite occurs

23. Death rates from malaria in Mozambique: national mortality survey CGHR.ORG

24. 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

28. 3B. Sustainable finance More 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

30. 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

31. Background slides

32. “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 MILLION DEATH STUDY IN INDIA: (1) visit 1 M homes with a recent death & ask standard questions and get a narrative; (2) usenon-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

33. 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

34. Malaria-attributed deaths: estimated national totals, by age 120 thousand at ages 15-69

35. Half of the malaria deaths were in a few high-malaria states in eastern India ~100 * Malaria death rates, India 2005, standardised to population aged 0-69

36. 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

37. Geographical variation in absolute numbers of malaria deaths in the different populations studied by the MDS and NVBDCP

38. Malaria deaths did not occur in states where dengue or meningitis or typhoid * were common (1) * These diseases can be confused with malaria

39. Malaria deaths did not occur in states where dengue or meningitis or typhoid * were common (2) * These diseases can be confused with malaria

40. Malaria was a minority cause of rural, unattended fever deaths in 2005 (1.3M <age 70)

41. 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.

42. NVBDCPMalaria testing in public hospitals

43. Rectal artesunate and child survival in Africa/Asia Source: Gomes et al, Lancet 2009