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 qualityassured 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
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.
Past resurgence of malaria
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 substandard 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
700000
CQ (Kg)
SP(Kg)
Malaria cases (x 10)
Pf cases (x 10)
600000
500000
400000
300000
200000
100000
20
00
19
98
19
96
19
94
19
92
19
90
19
87
19
85
19
79
19
77
19
75
-100000
19
73
19
60
0
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)
Indian malaria mortality rates in 2005 were
high in early childhood and in middle age
80
538
Death rate per 100 000
70
60
50
*591
40
30
500
Study-attributed
Indian malaria
mortality rates
20
349
10
319
388
WHO indirect estimates of
Indian malaria mortality rates
0
0−4
5 − 14
15 − 29
30 − 44
45 − 59
60 − 69
Age range
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)
Malaria deaths occurred where the most dangerous
type (Plasmodium falciparum) of malaria parasite
occurs
Death rates from malaria in
Mozambique: national mortality survey
Crude rate per 1000
Cummulative probability of death: 20%
16.0
14.0
12.0
10.0
8.0
6.0
4.0
2.0
0.0
0-4
5-14y
15-24
Age
CGHR.ORG
25-49
50+
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 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
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 qualityassured 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
“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) 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
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
Malaria-attributed deaths:
estimated national totals, by age
All India, 2005
Age range
<1 months
Deaths (thousands)
Death rate per
100 000 (lakh)
0
44
1-59 months
55
5-14 years
29
15-29 years
25
30-44 years
22
45-59 years
37
60-69 years
37
75
205
(125, 277)
18
71
236
Subtotal, ages 0-69
years (lower, upper
bounds)
70 +
12
120
thousand at
ages 15-69
8
10
27
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
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 malariaattributed deaths
before age 70,
2001-03
NVDCP slide-positive,
clinically-confirmed
malaria deaths,
2000-05
No.
%
No.
%
Orissa
823
31%
2102
37%
Northeast
468
17%
1023
18%
Chhattisgarh
131
5%
109
2%
Jharkhand
118
4%
152
3%
Madhya Pradesh
217
8%
262
5%
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 %
Other infection %
Tuberculosis %
Diarrhoea %
Malaria %
Unknown fever %
14
12
15
13
43
2
28
20
17
16
11
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.
NVBDCP
Malaria testing in public hospitals
2006
2007
2008
2009
People tested for
malaria (millions)
107
95
97
103
Cases positive for
malaria (and PF)
in millions
No. of deaths
1.8
(0.8)
1.5
(0.7)
1.5
(0.8)
1.6
(0.8)
1707
1311
1055
1144
Rectal artesunate and child
survival in Africa/Asia
Source: Gomes et al, Lancet 2009