Burden of malaria and other infectious
diseases in the Asia-Pacific
Ravi P. Rannan-Eliya
Institute for Health Policy
Sri Lanka
Disease Burden
1
Disease burden in DALYs – Developed vs.
developing regions (2010)
2
Composition of disease burden – Developed
vs. developing regions (2010)
3
Distribution of disease burden in South-East
Asia (2010)
4
Distribution of disease burden in South-East
Asia (2010)
5
Malaria burden in Asia-Pacific
6
Status of malaria control and elimination,
Asia-Pacific 2013
7
Malaria cases and deaths, Asia-Pacific 2012
• 2.2 billion at risk, 32 million cases, 48,000 deaths (2012)
– 8% of global deaths, but 67% of global population at risk
– Including most of the largest country burdens – India, China,
Bangladesh, Viet Nam
8
Artemisinin resistance, Greater Mekong
Global hotspot for
artemisinin in SE Asia
• Linked to weak health
systems, high degree of
reliance on private/informal
provision, high levels of
prevalence
• Continued production of
artemisinin monotherapies,
esp. in India
• Major risk to global malaria
eradication
9
Economic impact of malaria and other
diseases
10
Impact of malaria on households and
nations
Prior to HIV/AIDS, malaria had the largest economic and social
impact of any infectious disease in Asia-Pacific.
Effects include:
• Families
– Direct impact on ability to work and function
– Direct costs of medical treatment frequently impoverished
– Indirect costs of looking after sick patients
• Nations
– Prevented settlement and use of affected agricultural land, e.g,
Cambodia, Sri Lanka
– Barrier to foreign investment and tourism
• Best estimates of net impact:
– Reduces GDP growth by 1-2% in affected countries
11
Health financing and expenditures on
malaria and infectious diseases
12
Sources of financing in health systems,
Asia-Pacific countries 2010
13
Financing levels by source of funding, by
income level within Asia-Pacific 2012
Grouping
Per capita
health
expenditure
(USD)
Public health
expenditure
(% of GDP)
Private health
expenditure
(% of GDP)
Total health
expenditure
(% of GDP)
External
financing (%
of total health
expenditure)
71
1.6
3.6
5.0
14.1
Lower middleincome
countries
166
2.3
2.2
4.5
11.5
Upper middleincome
countries
514
2.7
1.7
4.4
0.6
3,228
5.8
2.9
8.3
0.0
Asia-Pacific
Low-income
countries
High income
countries
•
•
•
Poorest countries with highest malaria burden have least capacity to finance
healthcare, in particular to raise public funds
Private financing (% GDP) does not grow with GDP per capita
External financing significant in poor countries, but fungibility is substantial
14
Distribution of out-of-pocket/private spending
by income levels in high burden countries
15
How much is spent on specific diseases?
• Short answer = We usually don’t know
• WHO, GFATM and others collect data on specific diseases, but
data only reliable for external financing
– Efforts uncoordinated, duplicative, inconsistent
– Typically fails to cover spending by government and private
sources for treatment within general health services
– Significant burden created for countries from multiple,
uncoordinated expenditure reporting requirements, with little benefit
– Domestic financing may be 100-300% more than reported for many
countries, e.g., malaria in Bangladesh, Solomon Islands
• For malaria and many other diseases, unreported domestic
spending is likely to be significant
– Potential to use increased awareness of current spending levels to
increase domestic financing
16
Progress towards disease expenditure
tracking
2011-14
• Agreement by international agencies to use health accounts as
basis for tracking disease expenditures
• Decision by GFATM to support countries to use health accounts
(disease accounts) to track and report spending
Asia-Pacific
• Significant national capacities to produce health accounts, but
only few have disease accounts currently – Bangladesh, Sri
Lanka, Thailand
• Efforts by OECD and regional networks to share expertise, but
underfunded
• Potential new initiative by GFATM to give partial support to
some countries
17
Bangladesh Disease Accounts
MOHFW Facility Expenditure Per Capita by Age and Condition (Tk)
25
20
15
10
5
0
0
1-4
5-9
10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90-94 95+
Acute respiratory infections
Benign neoplasms
Cardiovascular disease
Chronic respiratory diseases
Diseases of the digestive system
Congenital anomalies
Endocrine & metabolic disorders
Diabetes mellitus
Genitourinary diseases
III-defined conditions & other contacts
Infectious & parasitic diseases
Injuries
Malignant neoplasms
Maternal conditions
Mental disorders
Musculoskeletal disorders
Neonatal causes
Nervous system and sense organ disorders
Nutritional deficiencies
Oral health
Other anaemias and blood/immune disorders
Skin diseases
Unspecified abnormal clinical & laboratory
18
Conclusions
19
Prospects for increasing financing for target
diseases in high burden countries
• High burden countries = Poorest countries
– Least able to mobilize new funding
– Case for regional and global solidarity
• Private financing dominant, but difficult to capture and mostly
serves non-poor
– High burden countries have weak capacity to organize financing or
to regulate private providers
– General global consensus that out-of-pocket spending must be
reduced because of link to impoverishment and barriers to access
• External financing important for many countries, but additionality
is not 100%
– Some crowding out today of domestic funding
– But governments generally underestimate their actual financial
costs
20
Conclusions
• Disease and economic burden justify attention to malaria in
Asia-Pacific after HIV/AIDS, TB.
• Cost-effectiveness of available interventions, economic impacts
and potential losses from malaria resurgence justify prioritization
of spending today at regional level
• Highest burden countries least able to finance efforts, but
growing incomes in Asia-Pacific and large size of countries
points to increasing domestic mobilization in those that can
afford, and increased reliance on domestic public financing
• Issue of fungibility of aid and challenge of maintaining domestic
financing commitments in elimination countries suggests
potential for using external and new funding to incentivize
greater domestic government spending efforts
21