Overview of anti-malaria commodity issues based on preliminary gap analysis

1. Overview of anti-malaria commodity issues based on preliminary gap analysis Sylvia Meek (Malaria Consortium), Mark Pearson, Linda Westberg, Jody Tate & Kieh Christopherson Dunn June 2014

2. Key Messages • Funding and commodity gaps are large. • We cannot achieve malaria control and elimination unless we fill them • We need better gap information for planning and advocacy. • Consider a regional real-time system to monitor financial flows and gaps • There are many systems barriers to access • Build on successes with community health workers • Better engage with private labour project owners to protect migrant workers. • Artemisinin resistant malaria will not be eliminated unless today’s strategies are inclusive of marginalised high risk populations.

3. Information from modelling exercises gives a higher estimate than national plans • WHO (August 2012) model: • Cambodia, Myanmar, Thailand, Vietnam (2013-15) • Needs $604m, Available $185m. Gap $419 million • WHO Western Pacific (early 2012) plan analysis: • Cambodia, China, Laos, Myanmar, Thailand, Vietnam (2012- 2016) • Needs $768m. Available $396m. Gap $372 million • Malaria 2012 meeting background paper model: • Asia-Pacific Region (2013-15) • Gap $1.69 billion ($684m. excluding India & China)

4. Why are good gap analysis data so elusive? • Wide range of epidemiological settings • Blanket assumptions for multiple countries not possible • Variation in malaria risk within countries affects coverage targets • And those at highest risk are often remote or mobile  costs of delivery are higher • Strategies in region are dynamic • More countries re-orienting to elimination • Rates of spending not predictable • Not only funding but also systems issues influence access

5. Recommendation 1: Common approach to estimate funding gaps • Development partners and governments agree to a common approach to estimating financing gaps for commodities that can be implemented efficiently and kept up to date • Consider establishing a real-time online system to monitor financial flows and gaps (initially in Greater Mekong and hosted by ERAR?) • Saving time and effort, information ready when needed, encouraging transparency • APLMA to hold governments and funders to account for maintaining and sharing accurate information • by monitoring the completeness of gap analysis data • by collating new data at end of 2014 Issue: exact gap for malaria commodities is not known. Data are often incomplete, incomparable or not up to date

6. Recommendation 2: Advocate for sustainable funds • APLMA advocates and acts to ensure that the large and variable regional and country funding needs are met in a sustainable way. • Develop sustainable financing models (review existing models in region) • Request external funding while levels of domestic funding increase • Ensure efficient use of resources from private sector and civil society as well as government. Issue: The information we have for some countries on overall funding needs (including commodity needs) and on overall funding gaps show that the gaps are large in absolute terms

7. Issues influencing access to antimalarial commodities • Strategies • Users • Commodities • Systems

8. How Strategies Influence Access • Elimination strategies need consistently high commodity access • Fewer treatments are needed as malaria declines, but more diagnostic tests • Decision to stop prevention, when risk declines, is difficult • Premature cessation may lead to reversal of progress • Access to commodities in neighbouring countries important to prevent malaria re-introduction • Regional aspect also important for eliminating artemisinin resistant malaria

9. User issues • Populations at highest risk often have lowest access • Mobile and migrant populations • Static populations in hard-to-reach areas • Often marginalised ethnic minorities – language and cultural barriers • Occupational risk from working or sleeping outdoors at night (e.g. rubber tappers, miners, security forces) • Need alternative protection measures – not widely available. • User preferences, understanding and knowledge of where to find commodities affect access

10. Commodity-specific issues affecting access • Quality is critical • Need for more surveillance of counterfeit drugs • Some private providers selling untreated nets, sub-therapeutic doses of drugs etc. • Use of diagnostics limited in private sector • Acceptability affected by presentation, other characteristics

11. Systems and Access • Weak procurement and supply stockouts • Global Fund systems have sometimes hampered access • Health workers number, distribution and quality affecting access • Decentralisation and integration can  lack of specialist skills where needed - if not planned well • A positive finding: community health workers are extending access to remote and mobile populations. • Broadening the role of volunteer malaria workers (within reason) may be a benefit, as it increases community appreciation and provides more skills refreshment

12. Recommendation 3: Design health systems to ensure equitable access • In addition to making continued efforts to cover their commodity financing gaps, APLMA should work to ensure national health systems provide equitable access to commodities. • APLMA to review successful initiatives to assess which may suit high-risk groups • Tax-funded user fee exemptions (Malaysia) • Free health care and accessible services (Sri Lanka) Issue : Health systems barriers to access are impeding progress to Universal Health Coverage

13. Recommendation 4: Governments engage with the private sector to better control malaria. Issue: Private sector already plays an important role in supplying anti-malaria commodities - especially for hard to reach and marginalised communities which lack access to public services • Governments need to engage with the private sector to effectively control malaria • APLMA could play a key role in promoting intersectoral collaborations • APLMA could consider implications of Trans-Pacific Partnership – to enhance, not to limit access to affordable generics?

14. Recommendation 5: Access for hard-to-reach Issue: Hard to reach, remote, marginalised populations are the key groups at risk of malaria but geographically difficult to locate. The provision of health care to such populations costs more per capita than for less remote populations • Develop country-specific strategies based on regional lessons to improve access to malaria care and commodities in these groups • APLMA to offer high level promotion of strategies to minimise discrimination of marginalised groups • Bring issues to MOH planning • Share best practices among countries

15. Recommendation 6: Access for mobile and migrant populations • Regional approaches are needed to engage major employers of migrant labour, providing guidance on approaches to malaria control and recommending codes of practice • APLMA could explore needs for guidance/legislation on appropriate malaria care of migrant labour Issue: Mobile and migrant populations are of particular concern because they could potentially contribute to the spread of artemisinin resistant malaria parasites.

16. Thank you