Sylvia Meek (Malaria Consortium), Mark Pearson, Linda Westberg,

Jody Tate & Kieh Christopherson Dunn

30 May 2014

An overview of antimalarial

commodity issues in the

Asia Pacific region

Based on a preliminary gap analysis

Contents

Executive summary .............................................................................................................................................. iii

1. Introduction .................................................................................................................................................. 1

Purpose of the report ....................................................................................................................................... 1

Background ....................................................................................................................................................... 1

2. What information is currently available on commodity and financing gaps for malaria in the Asia Pacific

region? .......................................................................................................................................................... 3

Methodology .................................................................................................................................................... 3

Findings from the analysis prepared for this paper .......................................................................................... 4

Findings from recent modelling exercises ........................................................................................................ 8

Findings from existing analyses based on national level data sets ................................................................ 11

3. Issues influencing access to quality antimalarial commodities .................................................................. 14

Access issues related to strategy .................................................................................................................... 15

Access issues related to the commodity user ................................................................................................ 16

Commodity issues affecting access ................................................................................................................ 17

Systems and access ......................................................................................................................................... 20

4. Conclusions and options for action ............................................................................................................ 23

Appendix 1: What key information do we need to identify commodity needs and funding gaps? ................... 27

Appendix 2: List of people consulted .................................................................................................................. 29

Appendix 3: Detailed Country Template............................................................................................................. 30

Appendix 4: Country Snapshots .......................................................................................................................... 34

Appendix 5: Overview of National Malaria Strategies ........................................................................................ 59

Appendix 6: Country Coverage Data Sources Used ............................................................................................ 65

Appendix 7: Concept Note submissions by TRP Windows under Global Fund New Funding Model ................. 68

References .......................................................................................................................................................... 69

i

*All references to currency refer to USD.

Acronyms

ADB Asian Development Bank

ACT Artemisinin-based combination therapy

ALMA African Leaders' Malaria Alliance

API Annual Parasitic Index

APLMA Asia-Pacific Leaders Malaria Alliance

AQMTF Access to Quality Medicine and Other Technologies Task Force

ASHA Accredited Social Health Activists

BCC Behaviour Change Communication

BMGF The Bill & Melinda Gates Foundation

CQ Chloroquine

DPR Korea Democratic People’s Republic of Korea

ERAR Emergency Response to Artemisinin Resistance

FDC Fixed Dose Combinations

GDP Gross Domestic Product

GMAP Global Malaria Action Plan

GMS Greater Mekong Subregion

HIV Human Immunodeficiency Virus

IPT Intermittent preventive treatment

IRS Indoor Residual Spray

ITN Insecticide-treated Mosquito Net

Lao PDR Lao People’s Democratic Republic

LLINs Long Lasting Insecticidal Nets

NVBDCP National Vector Borne Disease Control Program

MMW Mobile Malaria Worker

ii

NSP National Malaria Strategic Plan

PAR Populations at Risk of malaria

PNG Papua New Guinea

PQ Primaquine

RAI Global Fund’s Regional Artemisinin Initiative

RDT Rapid Diagnostic Test

SMC Seasonal Malaria Chemoprevention

SPR Slide Positivity Rate

TFM Transitional Funding Mechanism

USAID United States Agency for International Development

VHV Village Health Volunteer

VHW Village Health Worker

WB World Bank

WHO World Health Organisation

WMR WHO’s World Malaria Report 2013

WPRO Western Pacific Regional Office

iii

Executive summary

Reliable access to appropriate high quality antimalarial commodities is central to a successful malaria

control or elimination programme, and the achievement of targets. This includes Artemisinin-based

combination therapy (ACTs), long-lasting insecticidal nets (LLINS), rapid diagnostic tests (RDTs), personal

protective gear and vector control commodities.

In the short and medium term, as programs are scaled up commodities need to be available to enable

the necessary rapid expansion in coverage of key interventions. In the longer term, without predictable

access to necessary commodities, we will see resurgences in malaria incidence. An additional concern is

that the window of opportunity to eliminate Plasmodium falciparum malaria in areas with artemisinin

resistance will be lost if programmes do not maintain constant coverage with antimalarial commodities.

The consequences will be severe, particularly if resistance has the opportunity to spread to Africa.

This report is intended to inform deliberations on improving access to quality antimalarial commodities

at the second meeting of the Access to Quality Medicine and Other Technologies Task Force (AQMTF) to

be held in Manila, Philippines from 9 – 10 June 2014. It provides an overview of issues affecting access

to antimalarial commodities and services in malaria-affected Asia Pacific countries. It summarises what

information is needed and what information is available on the volume and cost of commodities needed

to meet the gap between current coverage and identified needs.

Financial and Commodity Gap Analysis

For those countries for which we have information on overall funding gaps for malaria, the gaps are

significant. Large amounts of additional funding are required to meet national malaria program

funding needs, including the financing of required commodities.

Understanding the financing and commodity needs in each country is essential to run an effective

malaria program. A comprehensive programmatic gap analysis outlines the requirements, available

funding, and gaps that exist in fully implementing a national malaria strategic plan. They are a powerful

tool for making the case for malaria funding.

Despite the importance of accurate and up to date information on financing and commodity gaps,

information from across the Asia Pacific region is patchy. Although there are national malaria strategic

plans which contain some information on overall financing gaps (Vanuatu, Cambodia, Nepal, Laos and

China) this is far from the norm and does not include detailed information on financing gaps for

commodities alone. The information which is available for these countries however points to large

overall future funding gaps. In China for example, between 2014 and 2016, there is an estimated $81.7

iv

million overall financing gap while for Cambodia between 2011 and 2025, the gap is estimated at $623.6

million.i

In addition to national malaria strategic plans, information on overall funding gaps is also available from

other sources for some countries. In 2012 the World Health Organization (WHO)’s Western Pacific

Regional Office undertook analysis for six countries in the Greater Mekong Subregion. This analysis

found that there were significant gaps: domestic funding covered less than 20% of needs and donor

support covered approximately 35% of needs (of which the Global Fund provided 80%). The outstanding

gap was $370 million, just under half of the estimated needs.

Modelling exercises have also produced some data, again on overall funding gaps rather than for

commodities specifically. Modelling carried out for the Malaria 2012 conference, for example, identified

an overall funding gap of $1.69 billion between 2013 and 2015 ($684 million excluding India and China)

based on a rapid scale up. Meanwhile, WHO have estimated a funding gap of $419 million for Cambodia,

Thailand, Vietnam and Myanmar through a separate modelling exercise.

Proposals under the Global Fund’s New Funding model will shed a lot of light on overall funding gaps in

the coming months. Sixteen countries in the region are due to submit before the end of 2014. An

example of a completed proposal is from Timor-Leste, which aims to address an outstanding financing

gap of $13.1m between 2015 and 2017; if approved the proposal will fully cover this gap.

This all points to the fact that currently there is no basis for estimating commodity funding gaps for

the region as a whole. The various data that are available are incomparable and incomplete. They

were compiled using different assumptions, covered different time periods, and used different data

sources and methodologies.

The information that we do have however all points to large overall funding needs (including

commodity needs) and overall funding gaps that are large in absolute terms. Given the size of these

funding gaps, it is reasonable to assume that the gaps for commodities are also significant. Some

countries may face greater challenges than others – due to their epidemiology, specific actions related

to preventing resistance, ability to fund activities domestically and / or recruit external donors. In

addition, there are inefficiencies in the current use of resources.

i This figure does not include funding commitments post 2015 so this gap could reduce if more funding is available.

v

Other factors influencing access to commodities

Access to antimalarial commodities is influenced by a complex range of factors beyond simply funding.

Additional funding alone cannot ensure adequate access to quality commodities without further efforts

to understand and address the most important of these factors. As countries move from malaria

control to elimination, their commodity needs change and understanding this is critical to improving

access. Key issues affecting access to antimalarial commodities can be classified into those relating to

strategy, the commodity users, the commodities themselves and health systems.

Strategy issues

As countries revise their strategies and move towards elimination, maintenance of consistently high

levels of access to commodities is essential. Fewer treatments are needed as malaria declines but more

diagnostic tests may be necessary. Despite the declining risk of infection, the decision of when to stop

providing access to preventive measures, particularly long-lasting insecticide treated nets (LLINs), is a

difficult one as premature cessation will risk reversal of progress.

Access to commodities in neighbouring countries is critical for protecting malaria eliminating countries

from re-introduction. This highlights the fact that commodity access is a regional concern as well as a

national one.

This regional aspect is also an important feature of the regional strategy to eliminate artemisinin

resistant Plasmodium falciparum in the Greater Mekong Subregion.

Commodity user issues

The key population groups at highest risk of malaria infection are unfortunately those with least access

to high quality health care and commodities. They include both mobile or migrant populations and

static populations living in geographically remote and inaccessible areas where the major malaria

vectors are prevalent. In Myanmar for example, those most at risk are migrant workers and individuals

living in villages in or near forests. Malaria among migrants is a region-wide challenge which demands a

regional solution. Many of these migrants are unregistered or illegal and actively avoid contact with

authorities of any kind. Because of population mobility antimalarial commodities are needed in malaria

endemic areas and in areas where people who have been infected by malaria may visit.

The most remote populations in several countries are marginalized further as many belong to minority

ethnic groups speaking different languages. Ethnic minority groups in Cambodia, for example, who

reside in remote forests are at high risk whilst also having little access to health infrastructure or

communications. In addition to LLINs, alternative protection measures are required to prevent outdoor

transmission of malaria. These are not currently widely available. Poorly designed antimalarial

vi

commodity distribution systems that do not take into account specific contextual and epidemiological

needs, or user preferences, can hinder access. The inaccessibility of many high risk groups in countries

such as Papua New Guinea, for example, is a major barrier to accessing antimalarial commodities.

Malaria will never be eliminated unless special efforts are made to help these populations overcome

barrier to access.

Commodity and commodity quality issues

Quality of commodities is critical in addition to availability. Poor quality commodities limit access to

effective malaria prevention, diagnosis and treatment. Although there is some (limited) encouraging

evidence of a decline in the prevalence of counterfeit drugs, much more surveillance for counterfeit

drugs is needed, together with dialogue with leaders in key source countries. Private sector providers

play an important role in supplying antimalarial commodities at the community level, though if they are

not strictly regulated they may provide access to poor quality or inappropriate commodities such as

untreated bed nets, artemisinin monotherapy and sub-therapeutic drugs. In India, for example, at least

50% of fever/malaria cases are treated in a largely unregulated private. In addition, poor engagement of

private sector providers has led to variations in the treatments provided and quality of care. Access to

diagnostics is limited in many cases by a lack of private sector involvement in malaria testing. This raises

the risk of presumptive treatment for malaria when a fever is presented without diagnosis being carried

out. It is important to incentivise private providers to diagnose even if this means they may not be able

to sell treatment. Acceptability of commodities and their presentation is also critical to effective access,

and needs to be assessed and promoted. In several countries of the Greater Mekong Subregion, for

example, there is a preference for more pliable polyester bed nets rather than those of polyethylene

which may be more durable and this is likely to affect utilisation.

Systems and access issues

Weak procurement and supply chains lead to stockouts across many countries of the region. This is

hampered by Global Fund procurement rules which in some cases have led to limited access. Other

systems-related barriers to access can include the number, distribution and quality of health workers. In

Solomon Islands for example, health workers are mainly concentrated in Honiara, leaving those in rural

areas less able to access health services and commodities. In some countries, such as in Indonesia,

decentralisation has resulted in a lack of specialist skills at the peripheral level, limiting access to

commodities. Similarly, integration of malaria control with other health services can lead to a loss of

malaria expertise, presenting a barrier to access. A major success has been engagement of community

health workers in countries such as Cambodia to extend access to remote and to mobile populations.

vii

Policy recommendations

On the basis of this rapid analysis some key options for policy recommendations are offered for

consideration, some of which require national level action and some of which require a regional

response:

Recommendation 1: Agree on the need to standardise the approach to estimating financing gaps for

commodities, and agree on a common approach that can be implemented and kept up to date.

Agreement on a common approach/methodology to estimate gaps, and on the assumptions which

underpin the estimates, should be a priority for the region. A common approach will ensure that the

region has information available to support planning on a regional scale, for example to enable funding

to be directed at countries otherwise unable to cover programme costs.

Because of the dominance of Global Fund among external sources of funds, there is scope for its gap

analysis approach to be a model which countries could adopt more widely, if it provides appropriate

information. Or, consideration could be given to the establishment of a regional real time system for

monitoring financial flows and gaps. This could be introduced initially in the Greater Mekong Subregion,

perhaps hosted by the WHO Emergency Response to Artemisinin Resistance (ERAR) Hub. This system

could ensure that resources are used strategically to ensure no key interventions remain unfunded

during this critical period of rapid scale up.

Recommendation 2: Ensure regional and country level funding needs can be met in a predictable and

sustainable way and any efficiencies are achieved. Development of sustainable funding models may

assist in meeting the outstanding financing gap as it is likely substantial external funding will be required

whilst countries gradually increase their domestic contributions. Countries may require external support

to develop such models. Efficient use of all resources, including from the private sector and civil society,

will assist in maximising the use of available funding. Continued efforts to harmonise all partners to

support country-led national malaria strategic plans will support the efficient use of available funding.

For example, on a regional level any countries which cannot use Global Fund systems for procurement

of ACTs could coordinate their commodity procurement enabling manufacturers to better plan

production and hopefully providing leverage for better prices.

Recommendation 3: Efforts to help countries cover their commodity financing gaps need to be

complemented by other efforts to ensure health systems are designed and implemented to ensure

equitable access. This will involve improvements not only to supply chains but particularly to human

resource issues. Successes achieved in several countries with malaria-specific community health

viii

workers should be replicated, giving careful consideration to issues of motivation and performance, and

encouraging opportunities for integration with access to care of other common illnesses.

Recommendation 4: Governments in the Asia-Pacific region need to engage with the private sector to

effectively control malaria. The private sector needs to be not only well regulated, with infringements

enforced, but the public sector needs to effectively engage in public private partnerships to improve the

quality of the care that is provided by the private sector while taking advantage of their role in working

with traditionally hard to reach populations. Options should be explored to train private sector providers

to be able to carry out malaria diagnosis themselves and be able to interpret the results and treat

accordingly. Where policy barriers exist to private sector providers carrying out diagnosis, effective

referral pathways between the public and private sectors should be explored. Collaboration with the

private sector may also involve supplying private sector outlets with high quality commodities at

subsidised prices.

Recommendation 5: Develop country-specific strategies based on regional lessons to improve access

to malaria care and commodities in these groups. Operational research could assist in gathering

needed knowledge on how best to provide these groups with access to needed commodities, including

for prevention.

Recommendation 6: Regional approaches are needed to engage major employers of migrant labour,

providing guidance on approaches to malaria control and recommending codes of practice.

Opportunities to promote corporate responsibility programmes could also be explored, alongside

engagement between national malaria control programmes and major employers of migrant labour.

Independent mobile and migrant workers also need to be able to access services and commodities,

requiring innovative deployment of commodities and behaviour change communication.

1

1. Introduction

Purpose of the report In recent years much attention has been paid to efforts to analyse the financial and programmatic gaps,

which need to be filled, if countries are to achieve their malaria control or elimination targets. Despite

this attention it has been surprisingly difficult to answer the question on what resources are needed for

commodities and what is available for a particular period of time in a particular country or region. This

question is, however, extremely important for national and international planning and resource

mobilisation. This report provides an overview of issues affecting access to antimalarial commodities

and services in malaria-affected Asia-Pacific countries. It summarises what information is needed and

what information is available on the volume and cost of commodities needed to meet the gap between

current coverage and identified needs.

The report is intended to inform deliberations on improving access to quality antimalarial commodities

at the second meeting of the AQMTF to be held in Manila, Philippines from 9 – 10 June.

Background

Without reliable and predictable access to necessary commodities, we shall see resurgences in malaria

incidence. In Asia there are several examples of resurgence linked to weakening of programme

implementation.1

Of additional concern is that the window of opportunity to eliminate Plasmodium falciparum malaria in

areas with artemisinin resistance will be lost if programmes do not maintain constant coverage with

antimalarial commodities. The consequences will be severe, especially if resistance has the opportunity

to spread to Africa.

Countries in the Asia Pacific region are making considerable efforts to combat malaria and this has

resulted in major progress. Malaria deaths in the region have declined from 55,900 in 2000 to 45,500 in

2012.2 There is, of course, huge variability in the scale of the problem from country to country related

to risk as well as to overall population size. Numbers of reported suspected plus confirmed cases in

2012 ranged from 82 in Bhutan, 93 in Sri Lanka, 2,718 in China to over one million in India and over two

million in Indonesia. The country snapshots for Cambodia, India, Indonesia, Myanmar, Papua New

Guinea and Solomon Islands illustrate the variability within the region (Appendix 4). Domestic

contributions to national malaria programmes have increased,2 as one might expect, given the growing

prosperity of the region. This has been supported by projects from the donor community – particularly

2

from the Global Fund but also from others including the Australian, United States and United Kingdom

governments and the Bill & Melinda Gates Foundation.

However, the large upfront costs of financing the rapid scale-up of key interventions (both prevention

and treatment) pose major challenges in most countries in the region, and these are particularly

pressing in ones that have weak fiscal capacity to meet costs themselves or have been unsuccessful in

attracting donor funding. The Global Fund, following recent funding challenges, expects to restore

support for malaria in the region to earlier levels in the period 2014-2016. It also plans to provide

support more effectively under its New Funding Model. 3 Nonetheless, significant funding gaps are likely

to remain. Recent analysis of the Mekong countries suggests that only around half of the estimated

financial needs from 2013 to 2016 are being met (WHO 2012 analysis).

A clear understanding of the needs in each country of the region is essential to run an effective

programme, and information on the extent to which funds are adequate for programme needs is

critical.

A comprehensive programmatic gap analysis outlines the complete programmatic requirement needed

to implement fully the strategic plan of a national malaria control programme. It identifies components

that are already funded, and highlights gaps for which funding is being sought. The gap analysis follows

an evidence-based approach to planning and programming based upon the targets and strategies

outlined in the national strategic plan. A gap analysis is a powerful tool for making the case for malaria

funding.

Despite the importance of good data on programmatic gaps, these data are not always readily available.

Some of the reasons why good gap analysis data are elusive include:

The wide range of epidemiological settings in the Asia Pacific region means that strategies are

tailored to individual countries, and blanket assumptions cannot be applied as they have been in

parts of Africa.

There is considerable variation in malaria risk within countries, which needs to be considered in

setting population coverage targets. Related to this, the populations at most risk tend to be the

most hard to reach, either due to geographical access or because of their mobile lifestyle. Costs

of protection for these population groups are high, and the strategies are often highly context-

specific.

Strategies in the region are dynamic, as more countries start to shift towards plans for malaria

elimination.

3

The rate of spending of allocated funds is less predictable than expected owing to a complex

range of factors, so that constant updates are needed. In addition, funding cycles differ among

countries, so the proportion of programme needs which are funded is not uniform among

countries.

Gaps in funding are not the only reason that commodities are not accessed by those who need

them. There is also a range of systemic challenges and barriers within the region, as discussed in

section 3.

Gap analysis data are more readily available in Africa, largely because mechanisms such as the

Harmonisation Working Group of Roll Back Malaria, and the African Leaders' Malaria Alliance (ALMA)

have provided intensive support to countries to undertake these gap analyses. The quantities of

antimalarial commodities needed in Africa are much greater than in other parts of the world, so require

adequate forecasting and drive production. There is much to learn from the experience of support

networks to avoid serious gaps in Africa, which could be adapted to Asia.

2. What information is currently available on commodity and financing

gaps for malaria in the Asia Pacific region?

Methodology

There is no single source of information that provides the current and future gaps in overall funding

for malaria, as a whole, nor on commodities in the Asia Pacific region. This analysis was undertaken to

identify what information is currently available and the results are presented below. Appendix 1

summarises the kinds of data that are required to identify common needs and funding gaps.

The methodology behind this analysis included a combination of qualitative and quantitative literature

review, using information from the following key sources:

WHO World Malaria Report 2013

National malaria strategic plans

Analysis prepared for the Malaria 2012 conferenceError! Bookmark not defined.

Analysis undertaken by the World Health Organization (WHO) on the countries in the Mekong

region

Global Fund grant applications, gap analyses and other relevant material

4

In addition, interviews were undertaken with key informants (see Appendix 2 for a list of those

consulted).

The information identified through the literature review and the interviews was fed in to a number of

templates which were used to sort, group and summarise findings. A detailed country template (see

Appendix 3) was completed, where data were available, for the 22 countries of the Asia Pacific region.ii

From these detailed templates an overview table has been produced for the purpose of this paper which

maps out the key findings and the significant gaps in the data (Table 1). For six countries, this analysis

was taken a stage further with country snapshots prepared (see Appendix 4) for Cambodia, India,

Indonesia, Myanmar, Papua New Guinea and Solomon Islands.

The findings collected through this process are presented below with supplemental information

gathered from the broader literature review. A summary of the data sources used for this analysis by

country is found in Appendix 6.

Findings from the analysis prepared for this paper This paper presents some findings on the size of the gap for financing of commodities for malaria. As

mentioned in the methodology above, we analysed national malaria strategic plans to gather

information on funding and commodity gaps. Strategic plans have the advantage of showing what

countries actually plan to do (as opposed to other modelling approaches which might set out more

idealistic visions of what is achievable). To date costed strategic plans have recently been carried out in

three countries in the region – Papua New Guinea, Solomon Islands, Vanuatu. Others are planned, or are

ongoing, and a number of existing, but often quite dated, plans are available. We analysed these plans

to assess the extent to which they clearly spell out funding or commodity gaps, recognising that the

countries for which current plans are available are not those with particularly high numbers of malaria

cases and are unlikely to be representative of the Asia-Pacific region as a whole. In all we reviewed 20

national strategies which contained information with various levels of detail. A list of the national

strategies reviewed and an assessment of the level of detailed information is in Appendix 5.

The plans are not always very useful in defining financing gaps – particularly financing gaps for specific

components such as commodities. It is possible that a country could have an overall funding gap but

that its commodity needs are met (the funding gap could relate only to other programmatic costs

associated with the malaria programme). As we could not find a single example of a national strategic

ii These have been defined as the countries in WHO’s Western Pacific and South East Asia regions with the addition

of Pakistan and Afghanistan.

5

plan which had specifically identified the financing gap for commodities the working assumption of

this analysis is that overall funding gaps are indicative, at least in part, of gaps in commodities. This is a

reasonable assumption given that commodity costs often account for a large share of total programme

costs although there is wide variation between countriesiii.

The recent strategic plans include fairly detailed breakdowns of financing needs and likely funding but

only provide estimates of the overall financing gap. The Solomon Islands’ plan was an exception as it

could not incorporate the Global Fund allocation which was not known at the time and could not

therefore identify a funding gap.

Coverage of older plans is mixed. Some contain no information on funding requirements or gaps at all

(Afghanistan, Bhutan). Most plans give a fairly detailed breakdown of needs but coverage of likely

funding sources and, therefore, funding gaps is very weak, for example Sri Lanka. Other countries do

identify overall funding gaps but the gap for individual inputs including commodities is not specified (e.g.

China). In other countries (e.g. Nepal) programme based gaps are given but these are too aggregated to

identify commodity needs and gaps.

The usefulness of strategic malaria plans is dictated by how recent and comprehensive they are. Figure 1

maps the strategic plans we looked at against these criteria and concludes that they are not sufficiently

comprehensive or recent to provide reliable estimates of the commodity funding gap.

The table below presents data where they exist on funding needs and/or gaps according to our

assessment of how useful the data are for our analysis.

iii In the Solomon Islands LLINS and IRS costs account for 16.8% of total costs over the plan period. In Cambodia health products

and equipment, pharmaceuticals and associated procurements costs account for 49.4% of total costs of $755m over the period to

2025. In China these categories amounted to only 6.3% of total costs of $777m between 2010 and 2015. In Nepal they accounted

71% of total costs of $68.6m over the plan period. They accounted for 19% of the $24m budget in Vanuatu.

6

Figure 1: National Malaria Strategic Plans: what do they tell us about commodity funding gaps?

Although data are only available in this format for a small number of countries; the data which are there

point to large gaps in overall funding for malaria which is likely to mean a large funding gap exists for

commodities which may affect access to key interventions. The table clearly shows that:

there are large data gaps

where data does exist they are often unreliable

where reliable data are available the gaps are clearly large

Table 1: Overall funding gaps for malaria as identified in national malaria strategic plans

2014 2015 2016 2017 2018 Age Comment on national malaria strategic plan content

Afghanistan No budget in the national plan

Bangladesh Plan not available for this analysis

Bhutan No need or budget info in national plan

Cambodia $623.6m (total funding needs 2011-2025, minus ‘total committed budget’ 2010-2015)

Funding gap is total need 2011-2025 minus committed budget 2010-2015. Post 2015 commitments would presumably reduce funding gap. Annual breakdown not provided.

China $ 32.4m $ 24.6m $ 24.7m A funding gap is available 2010-2015

DPR Korea Plan not available for this analysis

India $73.1m $67.2m $84.6m $99.6m Assumptions made from the “The financial gap for the national malaria control

program is estimated to be more than 50%”

Indonesia No budget in the national plan

Korea (ROK) An overall budget available up to 2011, no information on gaps

Lao PDR Rough indication of funding gap available for 2010-2011

Malaysia Plan not available for this analysis

Myanmar Plan not available for this analysis

Nepal

$23.0m (2011/12-2015/16) subject to Global Fund support – otherwise $39.9m

Financing Gap for 2011/12-2015/16 period; assumes Global Fund commits allocated $42,042,951

Pakistan Plan not available for this analysis

Philippines A detailed budget and funding gaps only noted for 2004-2008

PNG $42.1m $63.3m $59.3m $59.4m $61.3m Detailed budget prepared, but no details on how much is funded or whether there is a

gap.

Solomon Islands

$10.2m $12.7m $10.4m $10.2m

Incomplete gap analysis – awaiting announcement of Global Fund allocations

Sri Lanka Detailed budget, including for commodities, but no info on gaps or funding sources.

Thailand No details outlined

Timor Leste Plan not available for this analysis

Vanuatu $ 1.3m $ 2.1m $ 3.1m Funding gap provided for 2015-2017

Vietnam

Overall budget provided for 2012-15, but not clear whether resources are already

committed or gaps that need to be met.

Key Useful for the purposes of this analysis

Less useful for the purposes of this analysis

Not useful for the purposes of this analysis

No data

Findings from recent modelling exercises Data from different modelling exercises inevitably vary as different data sources and assumptions are

used. This is not to say any one is better than the other – they served different purposes – but to

highlight the wide range of assumptions and the need to come to some degree of consensus on them.

Key differences in the approaches relate to:

the stratification of risk groups;

assumptions about the effectiveness of interventions and whether they cover funding gaps (as

opposed to just needs) and;

how much contingency should be built into the costings.iv

Another issue to consider relates to the timing of funding, specifically the lag between the need for

funding and the services being provided/products being used. The Malaria 2012 costing model which is

described below, for example, estimated funding needs based on when coverage actually increased. In

practice, the real need and gaps would actually take place somewhat earlier to allow for the

procurement process.

Further guidance on underlying assumptions is provided in a document produced by the Roll Back Malaria Harmonization Working Group.4, v. A recent modelling exercise, carried out for the Malaria 2012 conference estimated an overall financing

gap for malaria in the Asia Pacific region (see Box 1).

iv The costing should not assume 100% efficiency. Costs are likely to be higher due to wastage but also due to

unpredictability of demand (e.g. the demand for ACTs depends on the results of RDTs). The WHO model 2012 adds in a 25% contingency to allow for this. This seems perfectly reasonable – more detailed analysis might shed further light on a more accurate figure – but it is important that the model highlights this. (The Malaria 2012 model did not allow for contingencies). v This includes, for example, in relation to LLINs:

one net per 1.8 at risk people

attrition rates (where country level data are not available) 8% of the distributed nets during the first year since distribution, 20% during the second year, and 50% during the third year. After three years, nets should no longer be considered viable

9

Box 1: Malaria 2012 - Background Paper: Challenges and opportunities for sustainable financing

A background paper which was prepared for the Malaria 2012 conference included a synthesised gap

analysis, based on a modelling exercise and drawing on the best available evidence at the time to estimate

commodity funding needs and requirements. The paper recognised that many of the underlying assumptions

were questionable – the key assumptions used were clearly set out in its Annexes. In particular, the approach

used global coverage targets rather than actual national targets (which often differ significantly). The analysis

identified financing needs by type of input (including commodities) but did not estimate a specific commodity

financing gap.

The paper suggested an overall funding gap of $1.69 billion between 2013 and 2015 ($684 million excluding

India and China) based on a rapid scale up involving universal use of mosquito nets in high risk malaria

populations and prompt and effective diagnosis and treatment of all malaria cases by the end of 2014 (see

Figure 2). It suggested that large up front investments would need to be complemented by sustained funding,

albeit at lower levels, to prevent resurgence which could otherwise result in avoidable deaths. It also called on

countries to develop sustainable financing models in which countries gradually increased their domestic

contributions – and its effectiveness - as external aid inevitably declined. It found that most countries could

cover their financing gaps in the medium term (by 2020) by allocating two or three per cent of their health

budgets to malaria but did recognise that some countries might face challenges in covering their funding gaps.

Figure 2: Modelled Funding Needs and Gaps in Asia Pacific if countries allocate 2-3% of health budget to malaria

Source: Pearson, M. (2013) Update of malaria 2012 figures with world malaria report 2013 data, Health

Resource Facility for Australia’s Aid Program

10

Several developments will have affected the funding gap estimates set out in the paper prepared for

Malaria 2012, often in opposing ways. The rapid scale up assumed in the modelling exercise has not

materialised – the up-front costs identified in the paper will still need to be incurred. They may be

higher than previously thought as it was assumed that the number of suspected cases in the region

would have declined by 10% from its 2011 levels by 2013. In practice, it has increased by around 10%

although with wide variation between countries (see Figure 3).

Figure 3: Change in suspected malaria cases from 2011 to 2013. (2011=100)

Source: Author’s calculations based on WHO World Malaria Report 2011 and 2013 data.

WHO has also developed a model to estimate malaria costs between 2013 and 2015 in Cambodia,

Thailand, Vietnam and Myanmar as part of efforts to address artemisinin resistance.vi The work is

currently on hold as the overall strategy is under review. Figures prepared to date indicate commodities

account for just under 40% of programme costs (varying from under 34% to over 45% between

countries). The work does not break down the financing gap for commodities. However, as shown in

Figure 4 even if all funds currently available were allocated to commodities, they would still fall short of

vi Data provided by WHO, due to be updated. Country specific data cannot be presented

11

needs by almost $50m. Overall, the funding gap for these countries for 2013-2015 is estimated at

$420m (needs of $604m compared to available funding of $185mvii) almost half of which is focused in

year 1 (2013) which seems to be due to rapid scale up costs, particularly the purchase of bednets (WHO

2012).

Figure 4: Funding Needs and Gaps: 4 Mekong Countries

Source: Unpublished data provided by WHO, 2012

Findings from existing analyses based on national level data sets Analysis commissioned by the WHO’s WPRO in early 20125, based largely on analysis of national plans in

six countries, identified funding needs for containment, control and elimination needs and identified

available or pending funding at the time for the period 2012 to 2016. The analysis found significant

funding gaps with domestic funding covering under 20% of needs, donor support covering around 35%

of needs (of which the Global Fund accounts for over 80%). This leaves an outstanding funding gap of

just under half of the estimated needs. Results are shown in Table 2.

vii

This excludes the $100m RAI grant

12

Table 2: Funding Needs and Gaps – WPRO Analysis of Six Countries

Cambodia

China

(Yunnan) Laos Myanmar Thailand Vietnam Total

Needs

Control,

Containment and

Elimination Needs

($m) 169.4 69.8 32.4 254.2 152.8 89.6 768.2

Funding

Domestic ($m) 17.5 56.7 2.4 5.5 20.5 23.0 125.6

Global Fund

(approved and

pending) ($m) 60.0 6.0 13.5 45.4 80.8 16.5 222.2

Three Diseases

Fund ($m) - - - 12.0 - - 12.0

BMGF ($m) - - - 7.5 - 0.2 7.7

PMI ($m) 5.7 - - 16.0 1.8 - 23.4

WHO ($m) 1.8 - 0.3 2.2 0.5 0.9 5.6

Gap ($m) 84.5 7.1 16.3 165.6 49.2 49.0 371.7

Gap as % of Total Needs 49.9 10.2 50.2 65.1 32.2 54.7 48.4

Source: Data provided by Sean Hewitt, WPRO consultant personal communication

Global Fund

The information which we have identified through our literature review and analysis can to some extent

be supplemented by information from the Global Fund. The Global Fund’s systems however have made

it extremely difficult to identify how grants were spent or how they were planned to be spent. Under

the recently implemented New Funding Model a new approach has been adopted, in which it should be

far easier to identify spending on particular categories such as commodities in the future. The New

Funding Model also requires countries to provide a Programmatic Gap table and a Financial Gap Analysis

and Counterpart Funding Table. To date, in the region, only Myanmar has had its New Funding Model

proposals approved. 16 more country proposals (and a regional proposal) are expected to be submitted

before the end of the year (see Appendix 7 for a list of countries and the month they are due to submit

their proposals). Earlier proposals however give some indication of funding gaps. Laos’ proposal under

13

the Transitional Funding Mechanism, for example, identified a gap of some $12.9m over the period 2012

to 2016.

These proposals should rapidly broaden our knowledge of overall funding gaps in the very near

future. Work is ongoing for many of these proposals. We were, however, able to access data from the

Timor Leste proposal which shows a gap of $13.1m between 2015-2017 which would be fully covered if

the proposal budget is approved by the Global Fund Board. We have also been able to access the

Regional Artemisinin Initiative (RAI) gap analysis which highlights that even if the total request from the

Global Fund was approved, there remain significant overall funding gaps, which increase over time and

total $241 million (see Figure 5).

Figure 5: Remaining gap by country and year assuming RAI support

Source: Funding gap analysis prepared for the RAI proposal under the Global Fund’s new funding model

Recent analysis of needs6 has been carried out in the context of the Global Fund replenishment using

updated data, revised unit costs for commodities and related coverage targets more specific to national

strategies (rather than simply assuming universal coverage of at risk groups). This significantly reduced

the overall needs compared to the modelled estimates carried out for the Global Malaria Action Plan

(which was updated for the background paper for Malaria 2012) largely due to reductions in India and

Indonesia. This analysis of needs was used as the basis for identifying Global Fund needs in preparation

for their New Funding Model.

14

Overall, the indicative allocation to the 22 Asia Pacific countries for malaria under the New Funding

Model is $567m of which $357m is already approved and $210m represents additional funding.

Compared to the previous three year period 2011 to 2013 the Asia Pacific region sees a 16% increase in

expected spending on malaria (28% if China and India are excluded) although there is considerable

variation between countries with Cambodia and Myanmar seeing large increases7,viii with Laos and PNG

seeing modest declines.

Summary

The findings of the analysis prepared for this paper and available existing analyses all point to large

overall funding gaps for malaria, which for some countries comprises over half of their funding need.

Some countries face greater gaps than others however due to specific contextual factors such as the

epidemiological landscape, their need to respond to resistance and their ability to utilise national

funding. Given that the gaps are so large and that commodities form a significant proportion of overall

funding needs we can assume that gaps for commodities are also large. This all points to the need for

countries to develop sustainable financing models to scale up activities in moving towards elimination.

Our analysis has also pointed to the lack of information currently available on commodity gaps and the

relative unreliability of what does exist. This is a reflection of the challenge of estimating commodity

gaps as they depend on many factors that are themselves subject to uncertainty. In addition, the

landscape is constantly changing meaning that gap analyses are just a snapshot in time and become

quickly outdated and different methods and assumptions are used to estimate gaps. A number of

exercises are currently ongoing and we expect that by the end of 2014, much more will be known about

overall funding gaps.

3. Issues influencing access to quality antimalarial commodities

Gaps in financing are not the only barrier to accessing antimalarial commodities in the Asia Pacific

region. There are also a range of issues which, at the national level, either limit or can enhance access by

those who need them.

In order to identify issues of greatest significance in influencing access to commodities the various

dimensions of access need to be considered. These can include availability, affordability, accessibility,

adequacy and acceptability. A study of access to malaria treatment in Tanzania led to development of

the framework in Figure 6. This illustrates the complexity of factors determining access and the many

viii

This is based on the assumption that RAI funding does not count against country indicative allocations

15

points where there could be barriers to access or opportunities to increase access. It also highlights that

solving a single barrier may not alone lead to better access, and an understanding of the causes of good

or bad access may guide strategies for improvement.

Figure 6: The ACCESS Framework

Source: Obrist et al. (2007)8

Key issues affecting access to antimalarial commodities can be classified into those relating to strategy,

the health commodity users, the commodities themselves and health systems.

Access issues related to strategy The malaria control strategies countries adopt are of great significance in influencing access to

antimalarial commodities in the Asia Pacific region. Several countries in the region are now committed

to malaria elimination, and the commodity needs for an elimination strategy are different from those in

standard malaria control programmes9.

In recent years several countries in the region have set long term goals for elimination, three (Malaysia,

Republic of Korea and Sri Lanka) have already entered the pre-elimination phase, 12 have set goals for

16

elimination, and six continue to scale up their control activities. Maintenance of consistently high levels

of access to commodities during elimination programmes is essential. Fewer treatments are needed as

malaria declines, but more diagnostic tests may be needed. Despite declining risk of infection, the

decision on when to stop providing access to preventive measures, mainly long-lasting insecticide

treated nets (LLINs), is a difficult one, as premature cessation will risk reversal of progress, yet the cost

of large-scale prevention relative to the number of lives saved at low transmission is high.

A challenge as countries reach very low levels of transmission is to decide where to maintain stocks of

antimalarial diagnosis and treatment commodities. Given the high population mobility in several

countries in the Asia Pacific, it is important to have drugs and diagnostics available even in non-endemic

areas, if people from endemic areas visit.

Finally, access to commodities in neighbouring countries is critical for protecting malaria eliminating

countries from re-introduction. Thus, commodity access is a regional concern as well as a national one.

This regional aspect is also an important feature of the regional strategy to eliminate artemisinin

resistant Plasmodium falciparum in the Greater Mekong Subregion.

Access issues related to the commodity user

Influence of geography on access

One of the most important barriers to access in several Asia Pacific countries reflects the epidemiology

of malaria in the region. Some of the highest risk populations live in very remote and inaccessible areas,

whether these are islands in the Pacific or mountains inhabited by ethnic minority populations in

Southeast Asia or tribal areas of India (see examples in Appendix 3). Other high risk groups are mobile

and migrant populations, including particularly migrant labour and security forces. Provision of health

care to such populations costs more per capita than for less remote populations, and there may be

cultural barriers between providers and users. Carefully designed programmes are needed to achieve

effective and equitable access. The paper on: “Ensuring access to malaria commodities for high-risk

populations” presented at the first AQMTF meeting in March 201410 discussed these populations in

detail. It made recommendations to sustain financing, ensure access irrespective of nationality, foster a

culture of corporate responsibility among employers of high-risk labour, show leadership in

multisectoral and multicountry responses and update Ministry of Defence strategies.

In order to maintain access at sufficiently high levels for elimination, strategies for distribution need

careful consideration. For instance, it is time to move away from a single strategy of blanket distribution

of long-lasting insecticidal nets (LLINs) in three-yearly mass campaigns to more continuous distribution

17

systems, which may vary according to local contexts, and which need to take into account

epidemiological stratification. Considerable work has been done to determine how different

distribution systems influence access, and which systems achieve greatest equity. Multiple channel

models including public and private sector appear to achieve highest coverage.

Prevention of outdoor malaria transmission is a particular focus in the region. Alternative personal

protection measures, complementary and in addition to LLINs, are recommended for further

exploration, including the use of topical repellents and other insecticide treated materials. The cost of

some of these tools may be higher than the cost of LLINs, but their deployment may be the only way to

ensure protection of key risk groups.

Acceptability and use Often the focus of efforts to improve access to commodities is on supply side issues, but the demand

side can be just as important. Issues include net preference, perceptions around the value of taking a

diagnostic test before a drug, and preferences for public or private sector health services. It is important

to give these issues sufficient attention in designing strategies to increase access, as their impact can be

substantial.

Access to LLINs varies in different countries in the region, and in several countries there is a thriving

market for mosquito nets, yet the markets tend to sell untreated nets and encouraging a shift to LLINs in

the private sector has not yet been successful in countries of the GMS. Issues of acceptability of nets of

different design have been highlighted by several countries of the GMS with a preference for nets of a

knitted polyester fabric which are more pliable than nets of woven polyethylene, which are claimed to

have greater durability, which can lead to cost savings. However, where utilisation is significantly

reduced, there is a need for careful weighing up of options based on good objective evidence.

Commodity issues affecting access

Cost and affordability

ACTs are substantially more costly than earlier first-line treatments, and a full course is beyond the

means of many of the poorest malaria patients. Most of the countries offer free diagnosis and

treatment for malaria in the public sector, but in the private sector, if not strictly regulated, there are

risks of underdosing to save money or taking only one of two components of a combination therapy if

not presented as a fixed dose combination. Fixed dose combinations (FDCs) are recommended as the

preferred ACT formulation wherever possible to improve patient adherence and discourage artemisinin

monotherapy. Considerable progress has been made in improving the accessibility of FDCs, especially as

more prequalified FDCs have become available. Other initiatives to ensure wide accessibility of

18

treatment whilst encouraging use of the correct first-line drugs have included the Affordable Medicines

Facility for malaria (AMFm), which provides a high level subsidy to manufacturers of approved drugs.

This was to have been piloted in Cambodia, but widespread drug resistance made it very difficult to

identify an appropriate approved product to subsidise.

Supply security

Because artemisinin is derived from a plant, which takes between ten and nineteen months to produce

any drug, there has been anxiety that global supply may fall short of demand, as programmes across the

world scale up their efforts.

Resistance

As resistance to artemisinin-based drugs increases, the choice of effective first-line antimalarials

becomes extremely difficult, and newer options tend to be even more costly, which may limit access.

New strategies need to be considered to ensure that patients will always have access to an efficacious

treatment. There is currently interest in looking for possible triple combinations, which could provide

better protection to the partner drug, but of course the additional drug would add to the cost. Given

the extremely limited options in the pipeline, such an investment would be worthwhile.

Quality of antimalarial commodities

Counterfeit and substandard drugs will kill people, so knowingly providing them needs to be seen as a

serious crime. Counterfeit drugs may have a major role in promoting expansion of drug resistance.

Southeast Asia and parts of Africa have had a major problem with counterfeit drugs for years, and a

study in 2012 reported that roughly a third of all antimalarial drugs being sold were falsified or

substandard11, and we do not seem to be making headway in tackling the problem.

A lot has been done to try and understand the extent of the problem and the sources of the counterfeit

drugs, even going as far as involving Interpol, but it is clearly not enough. As part of the drug resistance

containment efforts in Southeast Asia, Cambodia made major efforts to increase drug inspections and to

enforce the laws by training justice police and giving them more authority.

There are a number of steps which could help to eliminate the use of counterfeit and substandard

drugs:

Much more surveillance for counterfeit drugs – the number of surveys performed and

published is notably small

More serious dialogue with leaders in key source countries which include China, India and

possibly some countries in Africa

19

Much stronger regulation in countries and resources to enforce it

More support to the countries with the least ability to tackle the problem; e.g. Myanmar

Greatly increased effort to build local capacity to test drugs and take action.

These efforts should equally address those antimalarial drugs sold through the public and private

sectors.

Issues related to the availability and use of artemisinin monotherapy including causes and

consequences.

Until recently, there has been a major problem with use of artemisinin monotherapies, which is highly

dangerous in terms of encouraging selection pressure for resistance in artemisinin derivatives. For

instance, artemisinin monotherapies were found in 73% of pharmacies in a study in India12 , and in

Myanmar a large proportion of the market in 2011-12 was for artesunate monotherapy, mainly

originating from a single supplier.

Efforts to enforce a stop to their import are beginning to bear fruit, and demonstrate the importance of

political support. In Africa the ALMA scorecard includes an indicator on banning oral artemisinin

monotherapy, which is an idea that could be considered in Asia. Most countries have now imposed a

ban on the marketing of oral artemisinin monotherapy, but there are some issues around remaining

stocks and about export of monotherapies. In the Asia-Pacific, of countries needing to use ACTs seven

never registered oral artemisin derivative monotherapy, 12 have taken regulatory measures to

withdraw its marketing authorisation and only Timor Leste still allows its marketing for treatment of

uncomplicated malaria13.

Access to and quality of vector control commodities

Where nets are procured by the public sector or development partners, they are generally LLINs, so

quality is sound. Many nets are distributed however through the private sector, which is far more

responsive to issues of cost, and culture. LLINs are available through the private sector, but so are

untreated nets which are cheaper and may better meet cultural requirements such as colour, style,

smell and fabric. Untreated nets have some protective value but are not of the same quality as

LLINs. The private sector also sells insecticide treated nets (ITNs) which were treated when sold but

require regular retreatment which is inconvenient (and adds cost, distribution challenges, and potential

risk of toxic exposure) so ITNs are not ideal – eventually, they become untreated nets. Various

programmes to promote a switch to LLINs have been attempted, but more work is needed.

The WHO Pesticide Evaluation Scheme (WHOPES) makes recommendations on vector control tools such

as LLINs and insecticide compounds and formulations for indoor residual spraying (IRS) and other vector

20

control interventions. The need for timely introduction of new tools may require some strengthening of

the system. IRS may play an important role in some countries of the region, but evidence is lacking on

its effectiveness in several countries with outdoor resting vectors, where it is not recommended for

wide-scale application

Access to and quality of diagnostics

As there is now a global policy promoting universal access to parasitological diagnosis before treatment,

strategies for wide deployment of rapid diagnostic testing (RDTs) or lab services are needed, together

with efficient quality assurance systems. The region has several examples of competent use of RDTs by

community health workers, which should be promoted, but to date there is less experience with

sustainable strategies for promoting parasitological diagnosis in the private sector. In particular, it is

important to incentivise private providers to diagnose when this means they may not be able to sell

treatment.

In order to assure the quality of diagnosis with either RDTs or microscopy, quality assurance systems

need to be introduced and maintained. As the market for RDTs expands, there is a risk of substandard

products appearing. For RDTs, Cambodia and Philippines provide a lot of quality assurance testing. New

systems for testing quality at point of use are being developed using positive control wells.

A present challenge to the quality of RDTs is the recent rapid growth of their global market which has

depressed prices: in some places product quality has declined as manufacturers seek to cut

costs. Investment in strong quality assurance systems is essential. Guidance on selection of

appropriate tests needs to take into account quality and price (including the costs involved if a test with

different instructions is introduced).

A range of new diagnostic tools and uses are being considered by several countries in the region as part

of strategies for elimination and surveillance. For instance, tests for detection of very low levels of

parasites in the blood of asymptomatic populations may play a greater role, and molecular testing for

artemisinin resistance markers is now possible.

Systems and access

Procurement and supply chain management issues

In many countries stockouts of commodities are common. Despite efforts to improve systems for

supply chain management, it continues to be a challenge, and cannot be neglected.

As well as national level procurement challenges and barriers, which sometimes relate to lack of staff

motivation or training, some countries have had national supply crises, related to their full reliance on

21

Global Fund. The impact of funding commitments and procurement practices of the Global Fund and

other large procurers on the availability of commodities can be highly significant. In several countries in

Asia there have been some drug access issues related to Global Fund procurement criteria. As Global

Fund can only procure pre-qualified drugs, and some countries prefer drugs which are not on the list, a

few countries have elected to use domestic resources in order to purchase the drugs they want. This

presents a risk of reduced access to antimalarial commodities by fragmenting demand, potentially

leading to higher prices, worsening supply security and poor quality commodities.

The wide variety of drugs needed for different purposes poses a challenge for supply chain

management. Among the countries in the region a wide range of different artemisinin based

combinations (ACTs) have been selected as first line treatment of uncomplicated falciparum malaria.

The range of products needed increases the complexity of stock management with the risk of stockouts

becoming a barrier to access.

Health workforce considerations

It has been recognised that achieving Universal Health Coverage will only be possible in the Asia-Pacific

and elsewhere if several major improvements to health workforce policies are implemented.

A number of workforce issues influence access to antimalarial commodities. In some countries in the

region public sector workers have very low wages, and this translates into limited opening hours at

public health facilities as health workers seek to supplement their wages with income through private

sector practice. This in turn influences patients’ treatment seeking behaviour, and in countries such as

Cambodia about 65% of people seek care first in the private sector. Although not always the case, there

is a concern that private providers, especially small-scale non formal providers, are unlikely to follow

national treatment guidelines.

There are also issues of health workforce recruitment and retention which have an important impact on

limiting access to antimalarial commodities, especially in rural areas where needs are great. WHO

recommends that countries have 2.3 doctors, nurses and midwives per 1000 population but many

countries in the region fall well below this level. In 2012. Myanmar for example had a ratio of 1.6 per

1000 population while Laos had 1.1 per 100014 population across the country with levels in rural areas

likely to be much lower. This shortage in health workforce can have a huge impact on communities

being able to access antimalarial commodities. Issues of retention, quality, leadership and new

approaches involving the private sector are discussed further in a recent series of papers published in a

special issue of the WHO bulletin.15

22

Several countries in the region have developed some form of community health worker, such as the

village malaria workers in Cambodia, who now diagnose and treat almost 50% of confirmed malaria

cases in the country. Evaluations have shown that such community workers play a significant role in

improving access to quality treatment. In areas of artemisinin resistance, it is recognised that

community workers can play several critical roles, not only in diagnosis and treatment but also

surveillance and behaviour change communication.

An interesting decision facing countries, which are relying on community health workers to ensure

access of malaria services and commodities to the hardest to reach populations is whether or not to

expand the role of these community workers beyond malaria to include other common illnesses, such as

childhood diarrhoea and pneumonia. There are strong arguments for broadening their role since, as

malaria declines, their role becomes less clear to the community if they only deal with less than one case

a month, and their skills may decline. It is, of course, important to balance their tasks to avoid overload,

and decisions on appropriate packages of activities need to be country specific.

Broader Health Systems Considerations

Decentralisation of health service management has been introduced in several countries in the region.

Whilst this should be an opportunity to increase access to commodities and services, it is cited as a

barrier to effective malaria control in several cases (it is noted in the country snapshots for India,

Indonesia and Cambodia in Appendix 3). Some of the constraints relate to an unmet need to promote

informed decision-making and monitoring quality in a decentralised system. Special efforts are needed

to ensure that capacities to control malaria including through increasing access to antimalarial

commodities are developed at peripheral level, whilst maintaining a central core of specialist expertise

with clear modes of operation.

Most countries have undergone varying degrees of integration of malaria control both with other

vector-borne diseases and more broadly into general health services. Such decisions have been rational

in terms of both the declining burden of malaria relative to other health problems and the opportunities

for more efficient and affordable health service provision. However, they have led in several cases to

significant loss of the specialist expertise and commitment needed to control and eliminate malaria. This

can have a detrimental effect on access to antimalarial commodities as skills in areas including

antimalarial commodity specific procurement and supply chain management may be lost.

23

4. Conclusions and options for action

A major lesson learnt from reviewing available data was that extremely powerful data on financial and

commodity gaps could become available with a concerted and harmonized effort across the region.

Access to antimalarial commodities is influenced by a complex range of factors beyond simply funding.

More funding alone cannot ensure adequate access to quality commodities without further efforts to

understand and address the most important of these factors. The key issues affecting access to

antimalarial commodities relate to reaching marginalised groups, acceptability and use of commodities

and health systems issues.

Issue 1: We don’t know the exact funding gap for malaria commodities. The data are often

incomplete, incomparable or not up to date. The picture is patchy though it is improving. Currently

there is no basis for estimating current commodity funding gaps for the Asia and Pacific region as a

whole – this can only be done through detailed analysis at the country level following a standard

approach. Countries spend excessive time completing different proposals, gap analyses and monitoring

frameworks for different funders. A common approach will ensure that the region has information

available to support planning on a regional scale, for example directing funding at countries otherwise

unable to cover programme costs, regional procurement of commodities etc.

Any standard approach across the countries in the region to assessing needs and gaps must look at both

the short and the medium terms. In the short term the information will avoid ruptures in coverage and

allow effective planning, while in the medium to long term it will assure that progressive plans towards

elimination of artemisinin resistant malaria or all malaria can be followed without backsliding and

consequent resurgences. The medium to long term estimates could be the basis to promote more

predictable funding.

There are a number of ongoing exercises currently identifying financing gaps and much more will be

known by the end of 2014. However these exercises are not always following a standard approach.

Because of the dominance of Global Fund among external sources of funds, there is scope for its gap

analysis approach to be a model which countries could adopt more widely, if it provides appropriate

information.

Recommendation 1: Agree on the need to standardise the approach to estimating financing gaps for

commodities, and agree on a common approach that can be implemented and kept up to date.

Agreement on a common approach/methodology to estimate gaps, and on the assumptions which

underpin the estimates, should be a priority for the region. Consideration could be given to the

24

establishment of a regional real time system for monitoring financial flows and gaps. This could be

introduced initially in the Greater Mekong Subregion, perhaps hosted by the WHO Emergency Response

to Artemisinin Resistance (ERAR) Hub. This system could ensure that resources are used strategically to

ensure no key interventions remain unfunded during this critical period of rapid scale up. The

advantages of an online real-time database would be increased efficiency (no need to start from scratch

each time a new funding opportunity is identified) and transparency (internal and external funders

would be encouraged to share information on their investment plans and changes in timing).

For countries where ongoing work is not happening (e.g. because they are not submitting proposals

under the Global Fund’s New Funding Model or because they are category 4 countries which do not

have to complete programmatic and funding gap analyses) it could be beneficial for the region, perhaps

with external funding, to support those countries to undertake the work using an agreed common

approach. In this way a regional picture will emerge.

Issue 2: 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. Given the size of

these funding gaps and the fact that commodities account for a large share of overall funding needs – up

to half in some countries though this tends to decline in the elimination phase – it is reasonable to

assume that the gaps for commodities are also significant. Figures are available where countries have

recently developed national strategic plans, where recent Global Fund proposals have been approved or

where specific exercises have been carried out (largely in the context of artemisinin resistance efforts).

Some countries may face greater challenges than others – due to their epidemiology, specific actions

related to preventing resistance, ability to fund activities domestically and / or recruit external donors.

In addition, there are inefficiencies in the current use of resources.

Recommendation 2: Ensure regional and country level funding needs can be met in a predictable and

sustainable way and any efficiencies are achieved. Heavy up-front costs need to be met in the short

and medium term as programs are scaled up and commodities need to be available to enable the

needed rapid expansion in coverage of key interventions. In the longer term predictable funding is

needed to ensure gains made aren’t lost. Country development of sustainable funding models may

assist in meeting the outstanding financing gap as it is likely substantial external funding will be required

whilst countries gradually increase their domestic contributions. Countries may require external support

to develop such models.

Efficient use of all resources, including from the private sector and civil society alongside domestic and

external funding, will assist in maximising the use of available funding. National malaria strategic plans

25

are well placed to set out expected funding gaps and strategies for filling the gaps in a harmonised way.

Continued efforts to harmonise the processes of all partners to support country-led plans will support

the efficient use of available funding. For example, on a regional level any countries which cannot use

Global Fund systems for procurement of ACTs could coordinate their commodity procurement enabling

manufacturers to better plan production and hopefully providing leverage for better prices.

Issue 3: Ensuring access to malaria commodities to progress commitments to Universal Health

Coverage needs consideration of all health system barriers to access. We should not focus exclusively

on commodities nor on funding - supporting measures will also be needed.

Recommendation 3: Efforts to help countries cover their commodity financing gaps need to be

complemented by other efforts to ensure health systems are designed and implemented to ensure

equitable access. This will involve improvements not only to supply chains but particularly to human

resource issues. Successes achieved in several countries with malaria-specific community health

workers should be replicated, giving careful consideration to issues of motivation and performance, and

encouraging opportunities for integration with access to care of other common illnesses

Issue 4: Across most of the region, the private sector is already playing an important role in supplying

antimalarial commodities at the community level, especially for hard to reach and marginalised

communities which lack access to public services. Despite this, private sector providers may be

insufficiently regulated and of poor quality. This raises the risk of inappropriate treatment, for example

presumptive treatment for malaria when a fever is presented without diagnosis being carried out or the

use of artemsinin monotherapies (both of which are likely to increase the risk of artmisinin resistance).

In addition, poorly trained providers in the private sector may supply drug “cocktails” which contain a

variety of medicines, most of which are inappropriate for treating malaria, potentially putting patients at

risk and requiring them to spend more on treatment or may over/under treat patients. There is also a

need to promote greater availability and use of diagnostic tests in the private sector. In particular, it is

important to incentivise private providers to diagnose when this means they may not be able to sell

treatment.

Recommendation 4: Countries in the Asia-Pacific region need to engage with the private sector to

effectively control malaria. The private sector needs to be not only well regulated, with infringements

enforced but the public sector needs to effectively engage in public private partnerships to improve the

quality of the care that is provided by the private sector while taking advantage of their role in working

with traditionally hard to reach populations. Options should be explored to train private sector providers

to be able to carry out malaria diagnosis themselves and be able to interpret the results and treat

accordingly. Where policy barriers exist to private sector providers carrying out diagnosis, effective

26

referral pathways between the public and private sectors should be explored. Collaboration with the

private sector may also involve supplying private sector outlets with high quality commodities at

subsidised prices.

Issue 5: Hard to reach, remote, marginalised populations are the key groups at risk of malaria.

However these groups are geographically difficult to locate, provision of health care to such

populations costs more per capita than for less remote populations and there may be cultural barriers

between providers and users. Malaria will never be eliminated unless special efforts are made to help

these populations overcome barrier to access.

Recommendation 5: Develop country-specific strategies based on regional lessons to improve access

to malaria care and commodities in these groups. Operational research could assist in providing

needed knowledge on how best to provide these groups with access to needed commodities, including

for prevention.

Issue 6: Mobile and migrant populations are of particular concern because they could potentially

contribute to the spread of artemisinin resistant malaria parasites. This is a region-wide challenge

which demands a regional solution. Many of these migrants are unregistered or illegal and so actively

avoid contact with authorities of any kind. Because of population mobility, antimalarial commodities

are needed in malaria endemic areas and in areas where people who have been infected by malaria may

visit.

Recommendation 6: Regional approaches are needed to engage major employers of migrant labour,

providing guidance on approaches to malaria control and recommending codes of practice.

Opportunities to promote corporate responsibility programmes could also be explored, alongside

engagement between national malaria control programmes and major employers of migrant labour.

Independent mobile and migrant workers also need to be able to access services and commodities,

requiring innovative deployment of commodities and behaviour change communication.

Appendix 1: What key information do we need to identify commodity

needs and funding gaps?

In order to identify commodity needs and funding gaps, data are required, or assumptions need to be

made, on a range of variables. These are set out below and illustrated separately in Figure A1. It is

important to recognise that a financing gap depends on a large number of variables. Each variable is

subject to (often considerable) uncertainty and is often outside the control of countries themselves (e.g.

unit costs of commodities). This means that the estimate of the gap is subject to a great deal of

uncertainty. A gap analysis also represents a “snapshot” and may quickly become out of date.

In broad terms data are required on:

current population at risk

suspected malaria cases by type (mainly Plasmodium vixax and falciparum)

current coverage rates – for all interventions (prevention and treatment)

target coverage rates – for all interventions (and assumptions about the rate of scale up for each

intervention)

effectiveness of interventions – particularly the impact of prevention and treatment on the

number of cases

unit costs of interventions (and expected trends over time)

planned expenditures on commoditiesix

expected future funding sources for malaria commodities

There is no commonly agreed approach to using these data. Appendix 6 describes how some different

models have used different sources and assumptions to identify these data.

ix Strictly speaking we don’t really need to know current expenditures and funding sources. By definition current expenditure equals

current funding. In practice, such information is useful as a guide to future funding arrangements

28

Figure A1: Data and assumptions needed to identify commodity needs and gaps

Source: Author’s diagram

The two key information sources are:

national malaria strategic plans - these map out exactly what governments intend to do.

Although the plans do not always spell out explicitly the assumptions made they must still make

implicit assumptions to arrive at their funding estimates;

modelling exercises –these tend to rely more on global norms/targets rather than national

plans/targets and tend to spell out the assumptions used more explicitly. Again, more effort has

to date been made on models for an African setting.

29

Appendix 2: List of people consulted

Izaskun Gaviria (Global Fund RAI, Geneva)

Scott Filler (Global Fund Senior Malaria Advisor),

Atila Molnar (UNOPS Myanmar)

Charlotte Rasmussen (WHO HQ),

Melanie Renshaw (Co-chair Harmonisation Working Group, RBM)

Sean Hewitt (malaria control consultant, Vector Borne Disease Control Consulting Ltd)

30

Appendix 3: Detailed Country Template

Country Data: The following section shows detailed country data. This template was completed, as

much as possible for any countries where information was available. The colour key is as follows:

2012 data from World Malaria

Report 2013 (WMR)

Strategic Plan

Data that should needs to be filled

Not Necessary

Data Requirement 2013 2014 2015 2016 2017 2018

Population at Risk (high/low risk)

Expected Growth in PAR

Expected Suspected Cases

Prevention Approach

Treatment Approach

Current Coverage Rates

LLIN

IRS

IPT

Microscopy

RDT

ACTs

CQ + PQ

Other eg SMC

Target Coverage Rates

LLIN

IRS

IPT

Microscopy

Data Requirement 2013 2014 2015 2016 2017 2018

31

RDT

ACTs

CQ + PQ

Other eg SMC

Unit Cost of Commodity

LLIN

IRS

IPT

Microscopy

RDT

ACTs

CQ + PQ

Other eg SMC

Current Funding/Volumes

Government

LLIN

IRS

IPT

Microscopy

RDT

ACTs

CQ + PQ

Other eg SMC

Global Fund

LLIN

IRS

IPT

Microscopy

RDT

ACTs

CQ + PQ

Other eg SMC

32

Data Requirement 2013 2014 2015 2016 2017 2018

Other

LLIN

IRS

IPT

Microscopy

RDT

ACTs

CQ + PQ

Other eg SMC

Planned Funding/Volumes (by funder)

Government

LLIN

IRS

IPT

Microscopy

RDT

ACTs

CQ + PQ

Other eg SMC

Global Fund

LLIN

IRS

IPT

Microscopy

RDT

ACTs

CQ + PQ

Other eg SMC

33

Data Requirement 2013 2014 2015 2016 2017 2018

Other

LLIN

IRS

IPT

Microscopy

RDT

ACTs

CQ + PQ

Other eg SMC

Total Needs

Covered Privately

Funding Gap

LLIN

IRS

IPT

Microscopy

RDT

ACTs

CQ + PQ

Other eg SMC

34

Appendix 4: Country Snapshots

Country snapshot, India

Total population 1,236,686,732

Population at risk 272,071,081 (high risk), 828,580,110 (low risk) (2013)

Reported malaria cases and

deaths (trend data for last five

years if available- apparently

WHO has this data).

Presumed and confirmed malaria cases: 1,067,824

In patient malaria cases: No data

Malaria attributed deaths: 519

Estimated cases (2012): 19,000,000

Estimated deaths (2012): 28,000

Funding for malaria control by

source 2008-2012

Gov’t Global Fund (as reported by government)

WB PMI/USAID

Other bilat

WHO Other

2008 53,360,000 13,863,557 28,619,974 - -

- -

2009 60,222,222 9,184,373 9,480,000 - - - -

2010 91,551,356 13,179,273 10,265,300 - - - -

2011 99,525,920 6,496,121 30,898,403 - - - -

2012 47,240,020 7,863,868 16,696,978 - - - -

Total need and funding gap

Total need

2014: $146,257,902

2015: $134,547,588

2016: $169,290,828

2017: $199,278,828 (continued)

35

Total need and funding gap

Total gap

2014: $73,128,951

2015: $67,273,794

2016: $84,645,414

2017: $99,639,414 (Taken from National Malaria Strategic Plan)

Malaria goals and priority

interventions

The current strategic plan (2012 – 2017) has undergone a paradigm shift with the

introduction of new interventions for case management and vector control, namely

rapid diagnostic tests (RDT), artemisinin based combination therapy (ACT) and long

lasting insecticidal nets (LLINs).

National goals:

1. Screening all fever cases suspected for malaria (60% through quality microscopy and 40% by RDT)

2. Treating all P. falciparum cases with full course of effective ACT and primaquine and all P.vivax cases with three days chloroquine and 14 days primaquine

3. Equipping all health institutions (down to primary health care level) with microscopy facility and RDT for emergency use and injectable artemisinin derivatives, especially in high-risk areas

4. Strengthening all district and sub-district hospitals as per Indian Public Health Standards, with facilities for management of severe malaria cases in malaria endemic areas.

The impacts the plan is working towards are:

1. To bring down annual incidence of malaria to less than 1 case per 1000 population at national level by 2017.

2. At least a 50% reduction in mortality due to malaria by the year 2017, taking 2010 as baseline.

Intervention coverage 2012 % of population potentially protected by ITNs delivered: 6%

No. of people protected by IRS: 49,942,758

% IRS coverage: 18%

Any first-line treatment courses delivered (including ACT): 30,523,925

ACT treatment courses delivered: 3,147,400

% any antimalarial coverage: 100%

% ACT coverage: 100%

Outcome and impact of

interventions to date

Annual parasite incidence has consistently come down from 2.12 per thousand in 2001 to 1.1 in 2011 but confirmed deaths due to malaria have been fluctuating during this period between 1707 and 753.

Slide positivity rate (SPR) and slide falciparum rate have reduced over the years 2001-2011 with annual blood examination rate remaining within the range of 9.95% to 8.73%.

36

Outcome and impact of

interventions to date

(continued)

The annual case load, though steady around 2 million cases in the late nineties, has shown a declining trend since 2002.

The SPR has showed decline in India from 3.32 per 100 slides examined in 1995 to 1.20 per 100 in 2011 and. P. falciparum cases decreased from 1.14 million 1995 to 0.67 million in the same period.

P. falciparum proportion among all malaria cases increased gradually from 39% in 1995 to 50.7 % in 2011, which could indicate increasing resistance of P. falciparum to chloroquine.

Key affected populations Rural, tribal populations, scheduled castes and ethnic minorities with unique

socioeconomic characteristics and agriculture practices (including shifting

cultivation) and extensive forested and forest fringe areas are most affected.

80% of malaria cases in India are confined to about 20% of the population

residing in the high endemic areas which are in the eastern and north

eastern parts of the country.

Reported artemisinin

resistance

Reported as none in Strategic Plan for Malaria Control in India 2012-2017

Factors that may cause

inequity in access to

services for treatment and

prevention

In malaria affected areas there tends to be limited involvement of civil society, inappropriate treatment seeking behaviour and delayed recognition of danger signs and referral to appropriate health facility, infrastructure deficiencies, limited access to newer effective technologies like RDT, ACT, LLIN in addition to increasing drug resistance among parasites, insecticide resistance among vectors.

Malaria affected areas (in the Northeastern states of Arunachal Pradesh, Assam, Manipur, Meghalaya, Mizoram, Nagaland, Tripura) may also be hilly and forested, with difficult terrain and hence, fraught with problems of accessibility and public health system constraints.

One of the guiding principles of the Intensified Malaria Control Project—II [2010—2015] was ensuring equity in service provision.

Systems related constraints

at national, sub-national

and community levels

Inadequate human and financial resources

Inadequacies in public health infrastructure, and mushrooming private sector care providers

Inadequate regulatory frameworks and public private partnerships

Sub-optimal integration and coordination of public health programs

Lack of convergence with non-health public sector programs

Limited civil society participation

Shortage of health care services personnel and poor motivation

37

Proportion of patients using

private providers,

community health workers

and public facilities

It is estimated that at least 50% of malaria/fever cases seek care from the

private sector including formal and informal providers. 850,000 Accredited

Social Health Activists (ASHA) have been recruited at community level. It is

planned that there will be one ASHA for every 1000 population.

Commitment to

sustainability and

additionality

As a result of these constraints listed above, under the National Rural Health

Mission several health system strengthening initiatives are envisaged to

address them, many of which focus on the commitment to sustainability and

coordination:

Increasing public expenditure on health care from 0.9 percent of the GDP in 2005 to 2 - 3 percent of the GDP.

Giving flexibility in utilization of funds by providing untied funds at every level of the health infrastructure

Community owned decentralized health delivery system to address inadequate human resources.

Plans to hire health care services personnel and infrastructure improvement at all levels of the health system.

Increased participation by the Private sector/Civil society organizations.

Increasing participation and the ownership by the community.

Improved management capacity.

Integration of all vertical programs to ensure better coordination.

Sources: WMR 2013 Annex 6A

WMR 2013 Annex 6A

WMR 2013 Annex 3

Strategic Plan for Malaria Control in India 2012-2017

Round 9 Global Fund Malaria Proposal, June 2009

38

Country snapshot, Indonesia

Total population 246,864,191

Population at risk 41,966,912 (high risk), 108,620,245 (low risk)

Reported malaria cases and

deaths (trend data for last five

years if available- apparently

WHO has this data).

Presumed and confirmed malaria cases 2,051,425

In patient malaria cases: No data

Malaria attributed deaths 251

Estimated cases (2012): 5,600,000

Estimated deaths (2012): 9,400

Funding for malaria control by

source 2008-2012

Gov’t Global Fund (as reported by government)

WB PMI/USAID

Other bilat

WHO Other (UNICEF)

2008 2,135,753 13,199,217 - - - 406,000 2,800,000

2009 5,594,019 17,661,982 - - - 103,000 3,300,000

2010 5,787,267 31,659,696 - - 26,311 200,000 2,027,122

2011 - 40,573,846 - - - 222,222 3,111,111

2012 - 11,072,851 - - - 51,141 471,362

39

Total need and funding gap Financial gap (estimates from Global Fund Proposal):

Malaria goals and priority

interventions

Goal: Using a step wise basis, the creation of healthy community free from malaria

infections in 2030.

The program’s approach consists of prevention of transmission based on LLINs; diagnosis based on RDTs, with microscopy confirmation when available; treatment based on ACTs; and monitoring and surveillance through routine health information systems and special surveys.

Prevention and case management of malaria is integrated with maternal health and immunization programs, enabling synergies and efficiencies that enhance programme performance, reach the hard-to-reach population and expand access to vulnerable groups such as pregnant women, children under five and infants.

Intervention coverage 2012 % of population potentially protected by ITNs delivered: 26%

No. of people protected by IRS: 110,000

% IRS coverage: 0%

Any first-line treatment courses delivered (including ACT): 341,697

ACT treatment courses delivered: 341,697

% any antimalarial coverage: 13%

% ACT coverage: 24%

40

Outcome and impact of

interventions to date

Malaria deaths due to P. Falciparum declined by half from about 21,000 in 2000 to 11,000 in 2010.

Malaria incidence has declined, but many pockets of high incidence remain. Between 2002 and 2011, the number of malaria suspects with laboratory confirmation increased significantly from 1,440,302 to 2,321,678 and positive case finding increased from 273,793 to 475,508/year.

Artemisinin combination therapy (ACT) and long lasting insecticide treated nets (LLINs) were introduced in 2004/2005, with the number of laboratory confirmed cases treated with ACT reaching 378,994/year by 2011 and the number of LLINs distributed into targeted risk population increasing to 11,476,551 cumulative units in 2011.

Reporting of malaria cases from health centres also increased from 250 to 4,377 health centres per year.

Key affected populations Vulnerable groups such as pregnant women, children <5 and infants

Reported artemisinin

resistance

None reported

Factors that may cause

inequity in access to services

for treatment and prevention

Effective implementation in 33 provinces and 497 districts poses significant challenge in coordination, requiring better integration into the existing health services in reaching specific population.

In Eastern Indonesia and Sumatra, the coverage of LLINs and access to prompt malaria treatment is generally less favourable. The geography is exceptionally challenging for logistical systems and supply chains. To date, less than 1 million LLINs have been distributed in the last 10 years in Eastern Indonesia, to cover an at-risk population of 13 million. In Sumatera, 6 million LLINs have been distributed over the same period of time to cover 50 million people at risk.

Systems related constraints at

national, sub-national and

community levels

Shortages of skilled human resources: Due to high staff rotation as a consequence of decentralization and the establishment of new districts, requires continuous maintenance of human resources capacity.

Procurement and Supply Management: Despite significant progress in procurement and supply management for the remote and newly established districts, challenges remain in procurement forecasting, distribution and storage, inventory control, product quality monitoring, and logistics management information systems. These difficulties may lead to ineffective management of malaria drugs, lab supplies and LLINs and increased risks for stock outs.

Weak Reporting Systems: Routine reporting of malaria has not been carried out in a timely manner by all health centres, let alone the hospitals and private health care facilities. When data are available, its utilization is not yet optimal.

Proportion of patients using

private providers, community

health workers and public

facilities

No information available in the sources consulted

41

Commitment to sustainability

and additionality

Sustainable efforts to implement the malaria control programme would be

disrupted without continuous funding support. Funds from local and national

government for malaria control in Indonesia tend have increased in recent years,

but still fall far short of the amount needed for country-wide control. Contributions

from the private sector for malaria control exists in limited areas, but is poorly

documented.

Sources: WMR 2013 Annex 3 (contributions reported by countries)

WMR 2013 Annex 6A WMR 2013 Annex 4 Global Fund Indonesia TFM-Malaria Proposal Minister of health of the republic of Indonesia decree Number 293/menkes/sk/iv/2009 28 April 2009 Concerning Malaria Elimination in Indonesia

42

Country snapshot, Myanmar

Total population 52,797,319

Population at risk 19,535,008 (high risk), 12,143,383 (low risk), 31,678,391 (total)

Reported malaria cases and

deaths (trend data for last five

years if available)

Reported suspected cases in 2012: 1,,423,966

Reported presumed & confirmed cases in 2012: 408,586

Estimated cases in 2012: 1,400,000

Malaria attributed deaths in 2012: 403

Estimated deaths in 2012: 2,900

Malaria admissions and deaths

Funding for malaria control by

source 2008-2012

Gov’t Global Fund (as reported by government)

PMI/ USAID

Other bilat

WHO UNICEF Other

2008 314,000 - - 2,400,000 300,000 4,167,142 2,425,633

2009 375,000 - - 2,000,000 300,000 1,607,882 3,815,436

2010 2,250,000 - - 2,294,000 300,000 1,300,000 -

2011 1,259,002 5,900,000 - - - - -

2012 1,000,000 10,513,382 5,500,000 1,757,475 142,500 948,890 870,441

Total need and funding gap According to Concept Note for the Global Fund’s new funding model, Myanmar needs

$110m additional funding for the whole programme to reach 100% coverage of LLIN

in high risk populations by 2016 (however, this does not cover low risk areas,

suggesting that the gap is in fact bigger).

For LLINs between 2014 and 2016, Myanmar has requested 2,426,826 nets through

the Global Fund’s Regional Artemisinin Resistance Initiative. The actual gap in

available LLINs may in fact be larger than this.

43

Malaria goals and priority

interventions

The Goal of malaria control in Myanmar is to reduce malaria morbidity and mortality by at least 50 per cent by 2015 (baseline: 2007 data), and contribute towards socio-economic development and the Millennium Development Goals. Objectives

By 2015, at least 80% of the people in high and moderate risk villages in 284 malaria endemic townships (212 priority townships) are protected against malaria by using ITNs/LLINs complemented with another appropriate vector control methods, where applicable. In artemisinin resistance affected areas, the target coverage is 100% of total population at risk

By 2015, malaria cases in each township receive quality diagnosis and appropriate treatment in accordance with national guidelines preferably within 24 hours after appearance of symptoms.

By 2015, in 284 malaria endemic townships (270 priority townships) the communities at risk actively participate in planning and implementing malaria prevention and control interventions.

By 2015, the Township Health Department in 284 malaria endemic townships (270 priority townships) are capable of planning, implementing, monitoring and evaluating malaria prevention and control with management and technical support from higher levels.

Intervention coverage 2012 % of population protected by ITN – 35%

% IRS coverage – 0%

Any first-line treatment courses delivered (including ACT): 546 060

ACT treatment courses delivered: 546 060

% any antimalarial coverage – 78%

% ACT coverage – 100%

Outcome and impact of

interventions to date

Approximately, a 23% reduction in malaria morbidity was observed in 2011 compared to 2010, the lowest malaria morbidity in the last 5 years. The total number of malaria deaths in 2011 was 581 as compared to 3331 in 1999 and 1261 in 2007. While the number of malaria deaths is most likely underestimated, it is believed that the declining trend is a true picture of the malaria mortality in the country, as the reporting system has remained unchanged. The case fatality rate has been reduced by 50% (from 3.23% in 1999 to 1.6% in 2011), reflecting the impact of the scale up of case detection and treatment in the country. Coverage of key interventions has significantly increased. Coverage of ITN/LLIN (% household with at least one ITN/LLIN) increased from 19.9% in 2011 (prior to Global Fund Round 9 net distribution in Phase I) to some 74% by end of Phase I in 2012. However, the national malaria programme can only cover high-risk areas (Stratum

1a), leaving behind many townships at moderate and lower risk (stratum 1b, 1c). In

addition, new WHO guidelines suggesting a shorter life for LLINs will also mean a gap

in the LLIN coverage 1 to 2 years earlier than anticipated (e.g., in 2014 or 2015 all

LLINs distributed in 2011 will be expired and replacement of new LLIN is required).

This along with the need for scale up in an extended geographical coverage (from 226

townships in Phase I to 270 townships in Phase II as recommended by the Malaria

Technical Strategic Group), could mean a large gap in LLIN coverage.

44

Key affected populations Approximately 75% of population resides in malaria risk villages. Eighty out of the 284

malaria endemic townships already considered high risk of malaria.

Most malaria cases and deaths probably occur among people residing in villages near or in the forests, foothills. Forest, rubber and palm oil plantation, and mining-related malaria transmission persists in many parts of the country, particularly at its international borders. These people are usually national races living from subsistence agriculture supplemented by forest activities, such as cutting bamboo or rattan or production of charcoal. Generally, in villages located within 1-kilometer distance from the forest malaria transmission occurs in the village itself during part of the year, with all age-groups being at risk. In villages located at somewhat greater distance from the forest, the risk is usually confined to adult men, who enter the forest periodically for agriculture, forest produce gathering, hunting etc. Malaria database in 2011 indicated that male cases accounted for some 65% of total blood confirmed cases. The other major risk group is internal migrants, who are often induced by economic opportunities such as logging or mining in forested areas or road or dam construction etc.

Reported artemisinin

resistance

P. falciparum resistance to various antimalarial drugs has been observed in Myanmar.

In 2009-2010, early signs of P. falciparum resistance to artemisinin, characterized by

prolonged parasite clearance time were reported in at least 3 States/Regions (Mon,

Tanintharyi and Bago-East) and suspected evidence of artemisinin resistance was

reported in Kachin, Kayah and Kayin States.

Factors that may cause

inequity in access to services

for treatment and prevention

There are several population groups, which are poorly served by the health system and malaria services such as those living in remote border areas, migrant populations, forest workers and miners where malaria transmission is intense. Many of them are internal and external migrants who usually have limited access to malaria prevention and control. Major factors include distance from health facilities and poor awareness of malaria and its prevention.

Systems related constraints at

national, sub-national and

community levels

The health sector in Myanmar has long been underfunded, with public spending at levels under 1 percent of GDP. Total spending on health stands at 1.3 percent (2011) of GDP, or $2 per person per year. Out-of-pocket payments constitute about 85 percent of total spending on health, followed by public spending (around 10 percent) and external development assistance (around 5 percent). Overall development assistance is the second lowest per capita amongst low-income countries. This is further complicated by the internal conflict that caused extensive damage, these limited resources have translated to very low levels of basic services.

The physical barrier to access, given high transmission in forest settings. This includes long distance between residences of population at risk of malaria and health facilities and roads cut off during rainy seasons. A Malaria volunteer network was established in order to improve access of treatment and prevention to these hard-to- reach groups.

(continued)

45

Systems related constraints at

national, sub-national and

community levels

Health system challenges seriously undermine the capacity of the public sector in Myanmar to deliver basic health services. Shortage of essential drugs and supplies poses one of the main barriers to provision of basic services. The supply chain system is not well developed, and there are problems with storage and distribution of supplies, especially to facilities at township level and below. The health information system has many weaknesses and there are gaps in data from the community level and from hard-to-reach areas. Analysis and use of data at township level is limited. There are significant gaps in knowledge, and not much is known about health-seeking behaviour. A multiplicity of programs and projects, with separate planning, management and monitoring arrangements, contributes to inefficiencies and fragmentation in service delivery. Users have little influence on decisions about or delivery of health care. Much of the growing private sector is unregulated. Shortage of trained medical staff poses a particular challenge, one that is only exacerbated by low levels of remuneration, low morale and high turnover in rural areas. In-service training is mainly provided by projects and programs, and poorly coordinated. The heath infrastructure is poor, and many facilities require upgrading and refurbishment. Public hospitals lack many of the basic facilities and equipment. Transport is inadequate to ensure effective service delivery, supervision and monitoring, and referral for mothers and children who need emergency care

Proportion of patients using

private providers, community

health workers and public

facilities

Private out of pocket payments accounted for 73.4 per cent of national health expenditure in 2001-2002.

Commitment to sustainability

and additionality

Minimum threshold government contribution to disease programme In the Global Fund concept note, there is an assumption that 2011 level of government spending will be, at the minimum, maintained in subsequent years. Based on current levels of government spending, the counterpart financing share is 10% and meets the minimum threshold of 5% for low income countries.

Stable or increasing government contribution to disease programme Available data indicate that government health expenditures and malaria expenditures have significantly increased over time. With the prevailing government political and economic reform, it is likely that the Government contribution to malaria control programme will continue to increase.

(continued)

46

Commitment to sustainability

and additionality

Stable or increasing government contribution to health sector In an effort to address the funding crisis, the government has quadrupled the health budget for 2012-2013 from 92 billion kyat to 368 billion kyat. Until recently government spending was around 10% of the total health expenditure, and total health expenditure has been about 2% of GDP, one of the lowest in the world. As part of the planned health sector reforms, the country is aiming to attain universal coverage by increasing total health expenditure to around 4% -5% of the GDP through tax based financing and social health insurance and bringing down out-of-pocket expenditure to 30-40% of total health expenditure. Share of health in government budget, which was historically about 1%, has now increased to around 3%. Given that the economy is projected to grow at over 6%, resources are likely to be available for moving ahead with planned reforms of the health sector.

Sources: WMR 2013 Annex 3 (contributions reported by countries)

WMR 2013 Annex 6A WMR 2013 Annex 4 Global Fund Myanmar TFM-Malaria Proposal

47

Country snapshot, Solomon Islands

Total population 549,598

Population at risk 544,102 (high risk)

0 (low risk)

5,500 (Malaria-free)

Reported malaria cases and

deaths

Reported suspected cases in 2012: 249,520

Reported presumed & confirmed cases in 2012: 57,296

In-patient malaria cases: 1,050

Malaria attributed deaths: 18

Estimated cases (2012): 39,000

Estimated deaths (2012): 30

Funding for malaria control by

source 2008-2012

Gov’t

Global

Fund*

*as

reported

by gov’t

WB

PMI

/US

AID

Other

bilat WHO Other

2008 1,075,382 483,416 0 0 0 386,000 563681

2009 276,195 628,188 0 0 0 216,674 750189

2010 1,531,001 1,409,315 0 0 0 225,000 753085

2011 840,284 1,537,685 0 0 0 697,890 6,229,231

2012 269,486 1,696,290 0 0 0 706,000 5432362

48

Total need and funding gap Total need:

2015: $10,249,761

2016: $12,663,474

2017: $10,357,818

2018: $10,178,258

Financing gap has not yet been calculated, awaiting announcement of Global Fund

allocations. Total need taken from national malaria strategic plan.

Malaria goals and priority

interventions

Vision: Facilitate the sustained elimination of malaria in Solomon Islands by 2035

Goal: To reduce Annual Parasitic Index (API) from 44/1000 to <=25/1000 by 2020.

Priority Objectives:

To maintain high Long-lasting Insecticidal Net (LLIN) coverage, increase usage

and target supplementary Vector Control measures based on epidemiological

need.

To maximize access to and utilisation of early laboratory confirmed diagnosis

and appropriate treatment for malaria.

Achieve health systems related elimination criteria in pre-elimination provinces

and reach and maintain API <1/1,000 in provinces already designated for

elimination (Temotu and Isabel)

To maximize programme impact through partnership and improved programme

management.

Intervention coverage 2012 % of population potentially protected by ITNs delivered – 100%

No. of people protected by IRS: 131,752

% IRS coverage – 24%

Any first-line treatment courses delivered (including ACT): 190,255

ACT treatment courses delivered: 190,255

% any antimalarial coverage – 100%

% ACT coverage – 100%

Outcome and impact of

interventions to date

The Solomon Islands have achieved significant success in reducing malaria

incidence. Program activities outlined in the Malaria Action Plan 2008-14 aimed to

achieve 100% parasite-based diagnosis, introduce ACTs, expand IRS to high

transmission urban areas, achievement and maintenance of close to 100 per cent

population ownership of LLINs, and intensification of surveillance required to

identify cases at low levels of transmission.

Since 1997, incidence has been reduced by two-thirds, from 132 cases to 44 cases

per 1,000 people in 2012. APIs in the highest transmission provinces have been

reduced to <100 per 1,000 people and malaria-related mortality has been halved to

3.2/100,000 in this same period.

49

Key affected populations 99% of the population in the Solomon Islands is at high risk of Malaria. Malaria

transmission in Solomon Islands is quite variable with some areas classified as non-

endemic and others classified as hyperendemic. Where malaria occurs transmission

tends to be perennial and mildly seasonal with two peaks – April to September and

November to February. Transmission in most of the endemic islands occurs within 2

km of the coast except at the North Guadalcanal plains where transmission can

occur up to 10km inland. Endemicity varies considerably between provinces: Rennell

and Bellona province is currently considered non-endemic, Isabel and Temotu

provinces are considered to be low endemic, Central Islands, Choiseul, Malaita and

Western provinces are considered to be medium endemic and Honiara City Council,

Makira-Ulawa and Guadalcanal provinces are considered to be highly endemic.

Reported artemisinin

resistance

Not reported in Solomon Islands Malaria Strategic Plan 2015-2020

Factors that may cause

inequity in access to services

for treatment and prevention

There are regional inequalities in access across the provinces as well as access inequalities between the provinces and Honiara.

Some of the population live more than eight hours from a health facility and receive health care very infrequently.

Traditional beliefs about disease and low levels of education act as a barrier to care access and utilisation, particularly for women. Self-medication for a variety of illness if widespread and affects the rates at which formal health services are utilised.

Systems related constraints at

national, sub-national and

community levels

Poor distribution of health workers: Health workers in the Solomon Islands are concentrated in Honiara, leaving rural Solomon Islanders less able to access medical care.

Lack of specialised health workers: there are shortages in certain cadres such as medical specialists, laboratory scientists, pharmacists and other areas

Gaps in the health information system: In part because of weak communication infreastructure, indicator and commodity surveillance has been challenging.

Weak procurement and transport systems: There is a shortage of trained cadres for delivery of good quality services which has affected the quality and coverage of diagnosis and treatment of uncomplicated malaria. This is exacerbated by stock-outs of ACTs, RDTs and PQ because of difficulties in forecasting need.

Complicated financial system

Weak communication infrastructure

Proportion of patients using

private providers, community

health workers and public

facilities

Not reported in Solomon Islands Malaria Strategic Plan 2015-2020

50

Commitment to sustainability

and additionality

The NSP approach between 2015-2020 is to build a strong foundation that will

facilitate the sustained elimination of malaria in Solomon Islands by 2035. This NSP

describes how the NVBDCP will work at both a technical and a health system level to

ensure the short-term target of API reduction is met by 2020, and the longer term

vision of national malaria elimination can be realised.

Sources: WMR 2013 Annex 3 (contributions reported by countries)

WMR 2013 Annex 6A WMR 2013 Annex 4 Solomon Islands Malaria Control and Elimination Strategic Plan 2015-2020

51

Country snapshot, Cambodia

Total population 14,864,646

Population at risk 6,540,444 (high risk), 1,337,818 (low risk), 7,878,262 (total)

Reported malaria cases and

deaths

Reported suspected cases in 2012: 194,263 Reported presumed & confirmed cases in 2012: 45,553 Estimated cases in 2012: 160,000 Malaria attributed deaths in 2012: 45 Estimated deaths in 2012: 270

Funding for malaria control by

source 2008-2012

Gov’t Global Fund

WB

PMI/ USAID

Other bilat

WHO Other

2008 495,155 4,327,529 0 1,000,000 0 590,000

2009 1,019,923 5,334,038 0 1,000,000 0 650,000

2010 1,355,718 7,157,939 0 0 0 1,446,616

2011 3,127,120 39,422,203 0 0 0 380,347 60,000

2012 3,427,795 22,685,407 0 456,796 640,741 201,718

Total need and funding gap Total needs (2010-2025): $755,318,886

Funding gap: $623,578,643*

*Funding gap is simply the total funding need for 2011-2025 minus the committed

budget for 2011-2015. Presumably, additional commitments would be made post

2015 which would reduce the funding gap. Breakdown by year not provided. Taken

from National malaria strategic plan.

Malaria goals and priority

interventions

Goals:

Eliminate artemisinin resistant parasites of Plasmodium Falciparum malaria by 2015

Eliminate malaria with an initial focus on Plasmodium Falciparum and ensure zero deaths from malaria by 2020

Eliminate all forms of malaria in the Kingdom of Cambodia by 2025. (continued)

52

Malaria goals and priority

interventions

Strategic objectives:

To ensure universal access to early malaria diagnosis and treatment services with an emphasis on detection of all malaria cases (including among mobile/migrant populations) and ensure effective treatment including clearance of P. falciparum gametocytes and dormant liver stage of P. vivax.

To halt drug pressure for selection of artemisinin resistant malaria parasites by improving access to appropriate treatment and preventing use of monotherapies and substandard drugs in both public and private sectors.

To ensure universal access to preventive measures and specifically prevents transmission of artemisinin resistant malaria parasites among target populations (including mobile/migrant populations) by mosquito control, personal protection and environmental manipulation.

To ensure universal community awareness and behavior change among the population at risk and support the containment of artemisinin resistant parasites and eliminate all forms of malaria through comprehensive behavior change communication (BCC), community mobilization, and advocacy.

To provide effective management (including information systems and surveillance) and coordination to enable rapid and high quality implementation of the elimination strategy.

Intervention coverage 2012 % of population protected by ITN – 100%

% IRS coverage – 0%

Any first-line treatment courses delivered (including ACT): 422 024

ACT treatment courses delivered: 422 024

% any antimalarial coverage – 100%

% ACT coverage – 100%

Outcome and impact of

interventions to date

Cambodia has seen a significant decline in the number of malaria cases and deaths, particularly since 2000, due largely to improving access to effective malaria control interventions – in particular an effective and free LLIN distribution program, extensive use of Village Malaria Volunteers for prevention, diagnosis’s and treatment, provision of free diagnosis and treatment through the public sector and community based volunteers and subsidised diagnosis and treatment through the private sector, and improved surveillance, as well as more general favourable conditions, including peace, political stability, economic development including infrastructure, telecommunication and information, changes in occupational exposure, and environmental changes.

Key affected populations 53% of the population in Cambodia is at risk of malaria. The incidence has been significantly reduced, and key remaining affected populations are remote, mobile and/or migrant populations, particularly in border areas. Migrant workers include people working in the forest for extended periods such as gem miners, loggers, sandal wood collectors and soldiers who are at high risk of contracting malaria. Most are adult males; however some also appear to travel with their families.

(continued)

53

Key affected populations Mobile populations may choose to avoid seeking medical care or wait until they return to their homes before seeking care, which could increase the chances for further spread of artemisinin-resistant parasites. Ethnic minority groups living in remote forest villages where there is poor health infrastructure and communication are also a major risk group.

Reported artemisinin

resistance

There is evidence from the BMGF funded Artemisinin Resistance Confirmation, Characterization and Containment project and other studies that artemisinin resistant Plasmodium falciparum parasites are present on the Thai-Cambodian border.

Factors that may cause

inequity in access to services

for treatment and prevention

The populations most affected by malaria in Cambodia are remote and mobile populations who are often disadvantaged in other respects. While the current national strategy explicitly targets these populations, they remain difficult to reach, and there is a risk that the easier to reach will gain access to services for treatment and prevention, but the most remote or disadvantaged may continue to miss out.

Systems related constraints at

national, sub-national and

community levels

Weak public sector service delivery – Overall utilization of public health services is low which may reflect negative perceptions, but also is due to the passive nature of the system which is not designed to provide outreach to the more remote populations. Human resource issues include lack of motivation due to low wages, which leads health staff to split their time or move into the private sector. Quality of services is compromised as decentralization of supervision has been slow and treatment guidelines may not necessarily be strictly followed. Often laboratory services are weak or may not be available at all health centres for diagnosis.

Lack of synergy with the private sector - The majority of Cambodians (>65% of patients) seek health care via the private sector. There is a weak framework and enforcement of regulation of the private sector. This increases the risk that patients, especially the poor who are unable to pay for the more expensive quality drugs, receive sub-standard care, misdiagnosis, counterfeit pharmaceuticals, incorrect or incomplete treatment, monotherapy, and high burden of costs. In addition, little data are available on the number of patients diagnosed and treated for illnesses in the private sector.

Weak cross-border coordination and communication – Transmission across borders is a major issue for many communicable diseases in the region. The Thai-Cambodian border has a particularly high concentration of multi-drug resistant malaria parasites. A lack of coordination and communication with neighbouring countries contributes to weak surveillance and management of target populations. Unfortunately the National Health Strategy does not have a clear policy in dealing with cross-border health issues.

Gaps in the health information system Weak legislation and enforcement strategy for quality drugs – Counterfeit medicines, including those used in the treatment malaria are widespread, particularly in the private sector. Their unregulated use continue to contribute to the development and spread of drug resistance, including resistance to malaria medicines is widespread.

54

Proportion of patients using

private providers, community

health workers and public

facilities

In 2007, an estimated two thirds of respondents in a survey reported seeking

treatment for fever in the private sector.

Commitment to sustainability

and additionality

Through its Global Fund proposals, Cambodia has made a commitment to the

overall strengthening and further development of public, private and community-

based systems to ensure improved malaria service delivery and outcomes. Key

activities in this regard are:

Recruitment of new staff for the public, private and NGO sectors.

Expansion of VMWs and VHVs networks (with enhanced roles and responsibilities) and introduction of MMWs.

Provision of performance-based salary supplements, in line with the government MBPI rates, for public sector staff and realistic incentives for VHVs, VMWs and MMWs working in the containment area.

Needs-based training and supportive supervision, including for private sector providers.

Intensive monitoring of outcomes and impact with comprehensive feedback to implementers.

Upgrading disease surveillance systems

Sources: WMR 2013 Annex 3 (contributions reported by countries)

WMR 2013 Annex 6A WMR 2013 Annex 4 Global Fund Cambodia Round 9-Malaria Proposal National Strategy for Malaria Elimination in Cambodia 2011-2025

55

Country snapshot, Papua New Guinea

Total population 7,167,010

Population at risk 6,736,989 (high risk), 430,021 (low risk)

Reported malaria cases and

deaths (2012)

Presumed and confirmed malaria cases: 643,214

In patient malaria cases: 9,238

Malaria attributed deaths: 301

Estimated cases: 1,000,000

Estimated deaths: 2,800

Malaria admissions and deaths

Funding for malaria control by

source 2008-2012

Gov’t Global Fund (as reported by government)

WB PMI/USAID

Other bilat

WHO Other

2008 64,336 6,385,835 - - 75,000 300,000 -

2009 156 4,417,383 - - 75,000 300,000 -

2010 320,580 1,028,735 - - 75,000 - 3,260,803

2011 190,200 23,842,245 - - 75,000 - 8,968,127

2012 584,290 - - - 75,000 - -

Total need and funding gap 2012 2013

Need $43,180,960 $53,755,327

Funding $17,899,118 $21,881,539

Gap $25,281,842 $31,873,788

This was estimated using data on need and non-Global Fund funding from the

Global Fund round 8 proposal. Amount of Global Fund funding was estimated using

disbursed amounts listed in the grant performance report for that grant. These

figures together form the funding, the rest of the need being the gap.

56

Malaria goals and priority

interventions

Goal: a substantial and sustained reduction in malaria burden. To reduce annual parasite incidence to 84 per 1000 by 2015 and 71 per 1000 by 2018. Current efforts focused on intensification and aggressive malaria control.

Vector control: High coverage of LLINS for all at risk; intermittent preventive treatment in pregnancy; epidemic and emergency preparedness response consisting of improved surveillance, indoor residual spraying in response to outbreaks, delivery of emergency supplies and availability of technical and financial resources.

Diagnosis and case management to be strengthened through updated national treatment guidelines; use of rapid diagnostic tests (RDTs) and artemisinin combination therapy in health centres; improved microscopy quality assurance; strengthening RDT skills in public sector through; enforce ban on marketing/use of artemisinin monotherapy; ACT and RDT batch testing; improved management of severe malaria including improving referral systems; pilot new point of care tests for G6PD deficiency.

Epidemiology, surveillance, monitoring, evaluation and operational research.

Advocacy, information, education, communication and community mobilisation.

Strengthen programme management.

Expand public private partnerships for key malaria interventions.

Intervention coverage 2012 % of population potentially protected by ITNs delivered: 86%

No. of people protected by IRS: No data

% IRS coverage: No data

Any first-line treatment courses delivered (including ACT): No data

ACT treatment courses delivered: No data

% any antimalarial coverage: No data

% ACT coverage: No data

Outcome and impact of

interventions to date

Between 2009 and 2012 there was a 39% reduction in the number of reported malaria cases, a 50% reduction in reported malaria deaths and a 60% reduction in malaria admissions. Under a Global Fund round 8 grant, enough LLINs were distributed to cover 100% of the population at risk. Households with at least one LLIN increased from 65% to 82% between 2009 and 2011. Those sleeping under a LLIN increased from 33% to 49% during the same period.

Use of appropriate antimalarial treatment increased from 5% in 2009 to around 40% at the end of 2012.

Health centres and aid posts with ACTs has risen from 0% to 88% and 19% respectively between 2010 and 2012.

Presumptive treatment however is common and low levels of adherence to antimalarial guidelines

57

Key affected populations

Children under 5, pregnant women and those with HIV

Complex and diverse geography with malaria present in low and highland areas. Highland infections thought to be through increased mobility of people from the lowlands.

Perennial transmission in most lowland areas with only limited seasonality except for in drier areas along the south coast.

94% of PNG’s population is thought to live in areas which are highly malaria endemic. Even those living at high altitudes may have gardens at lower altitudes where they may sleep to protect their crops.

National and international staff tend to work on a fly in fly out basis in the mining and petroleum sectors. This heightens the risk of non-immune individuals being exposed to malaria. The immigration detention centre on Manus Island faces similar risks with those without immunity (immigrants, visiting officials etc) potentially facing risk of infection.

Reported artemisinin

resistance

None reported

Factors that may cause

inequity in access to services

for treatment and prevention

Uneven access to health care and essential drugs across PNG due to geography, finance, human resources and poor quality of care.

Harsh physical terrain which makes delivering and accessing health services difficult to deliver and access. Transport infrastructure is poorly developed with a limited road network that is poorly maintained.

PNG is home to some of the most isolated communities and is one of the least urbanised countries in the world. Many villages can only be reached on foot. In some places, planes are the only mode of transport.

Systems related constraints at

national, sub-national and

community levels

Although the health system is financed primarily through tax and donor funds, user fees are charged at health facility level (although these are being phased out).

Poor infrastructure limits access to health services.

Financing system at national/provincial level is not working well. Funds are not reaching their intended destination and facilities face inadequate funding for operating costs and medical supplies which inhibits improved service delivery quality.

Internal auditing and oversight of global fund grants is weak which undermines grant implementation. More stringent safeguards which are now in place have slowed implementation.

PNG faces critical human resource constraints. Out-migration of skilled workers is a challenge as has a moratorium on the hiring of new staff due to fiscal constraints. There are large geographical variations in workforce.

Procurement and distribution of drugs and supplies is a major challenge. Low availability and stock outs common for health facilities. Poor storage and lack of space is also a concern.

Laboratory services are understaffed, especially in rural areas, have inadequate space, dated equipment and poor physical infrastructure. quality assurance for microscopy is also inadequate.

58

Proportion of patients using

private providers, community

health workers and public

facilities

Relatively small private sector servicing mostly mining employees, in addition to private doctors (of which there are 80-100, mostly in Port Moresby) and traditional healers who provide nearly 5% of healthcare in rural areas (slightly less in urban areas).

Health centres tend to be staffed with a few community health workers (CHWs). In 2009 there were 4398 CHWs- one per 1500 population.

Commitment to sustainability

and ongoing national funding

No information available

Sources: WMR 2013 Annex 3 (contributions reported by countries)

WMR 2013 Annex 6A WMR 2013 Annex 4 Global Fund PNG Round 8-Malaria Proposal National Malaria Strategic Plan2014-2018

59

Appendix 5: Overview of National Malaria Strategies

Country Strategic plan Time period Commodity needs Financing gap for

commodities

Afghanistan National Malaria Strategic

Plan

2008-2013 Target coverage

rates are included,

but not volume of

commodities

required to meet

those targets.

No details – no budget.

Bangladesh Not available Plan not available for this analysis

Bhutan Bhutan National Malaria Control Strategy

2008-2013 No details No details – no budget

Cambodia National Strategy for Malaria Elimination in Cambodia

2011-2025 Gaps in volume of commodities not identified

Preliminary estimates of funding needs and gaps provided, broken down by cost category.

However, the funding gap is simply the total funding need for 2011-2025 minus the committed budget for 2011-2015. Presumably, additional commitments would be made post 2015 which would reduce the funding gap. Breakdown by year not provided.

China The People’s Republic of China - From Malaria Control to Elimination: A Revised National Malaria Strategy

2010-2015 Target coverage rates are included, but baseline figures are not included for vector control and case management.

Detailed budget is provided, broken down by cost category. There is a financial gap analysis for the budget as a whole, but not for commodities specifically.

60

Country Strategic plan Time period Commodity needs Financing gap for

commodities

DPR Korea National Malaria Control Strategy

2009-2013 Plan not available for this analysis

India Strategic Plan for Malaria Control in India

2012-2017 Needs assessment for commodities included in individual sections (RDTs, ACTs, LLINs)

Budget provided for programme as a whole, including breakdown for specific commodities. A breakdown of domestic vs. external funding is provided for 1997-2011. However, there is no breakdown of sources of funding for the current plan, or any financing gaps (for programme as a whole or commodities specifically). A more detailed breakdown of commodity needs is thought to be available in an annex to the Strategic Plan although it was not available for this analysis.

Indonesia Minister of Health of the Republic of Indonesia Decree - concerning malaria elimination

2009-2030 No details No details – no budget.

61

Country Strategic plan Time period Commodity needs Financing gap for

commodities

Lao PDR National Strategy for Malaria Control and Pre-Elimination

2011-2015 Quantification of commodity needs has been estimated for 2010-11

3 year budget (2011-13) is provided, broken down by activity and cost category. A rough malaria financing gap analysis is included, but it contains no data on national funding after 2011, and before then it considers the budget for communicable diseases (rather than just malaria). While the overall budget is broken down by cost category, the gap analysis is only for the programme as a whole (no details for commodities specifically)

Malaysia National Strategic Plan for Malaria Elimination

2010-2020 Plan not available for this analysis

Nepal National Malaria Control Strategic Plan: Nepal

2011-2016 Target coverage rates for 2016 for IRS and LLIN are outlined (numbers of households). Historical coverage rates are provided for IRS (2004-09) and LLINs (2006-10) in an annex, but gaps have not been calculated.

Financing gap analysis included for the budget as a whole, and broken down by programme objective. However, these objectives are quite broad and it is not possible to separate out commodities specifically.

Pakistan Pakistan National Strategic Plan for Malaria Control

2011-2015 Plan not available for this analysis

62

Country Strategic plan Time period Commodity needs Financing gap for

commodities

Philippines Malaria Medium Term Development Plan

2011-2016 There is mention of goal of universal access to prevention and treatment, but no specific targets, and no details on volume of commodities required for the implementation of the plan.

There is a detailed budget broken down by objective, strategies and performance indicators. A breakdown in sources of funding is provided for the previous period (2004-08) but not for the period of the plan. There is no indication of sources of funding for the budget, or anticipated gaps in financing (for budget as a whole or commodities specifically)

PNG National Malaria Strategic Plan

2014-2018 Detailed assessment of commodity needs (quantity) is provided in budget assumptions.

Very detailed budget prepared, including breakdown for commodities, but no details on how much of it is funded and if there is a financing gap.

Republic of Korea

Action Plan for Malaria Elimination

2010-2015 No quantification of commodities provided

An overall budget is provided for 2011-2010, but only for the programme as a whole, not broken down by cost category or activity; no budget for the duration of the plan, and no estimates for commodities specifically.

63

Country Strategic plan Time period Commodity needs Financing gap for commodities

Solomon Islands Solomon Islands Malaria Control and Elimination Strategic Plan

2015-2020 Detailed assessment of commodity needs are outlined, with quantities required for each commodity included in the budget.

Very detailed budget prepared. Table outlining financing gap has not been completed – the draft states it is awaiting announcement of Global Fund allocations

Sri Lanka Strategic Pan for Phased Elimination of Malaria

2008-2012 No details Detailed budget provided, including for commodities specifically, but no gap analysis or information on sources of funding.

Thailand National Strategic Plan for Malaria Control and Elimination in Thailand

2011-2016 No details No details

Timor Leste National Malaria Control Strategy

2010-2020 Plan not available for this analysis

Vanuatu National Malaria Strategic Plan (Draft)

2015-2020 Detailed assessment of commodity needs is provided

Financing gap analysis is provided for programme overall, but not for commodities specifically.

64

Country Strategic plan Time period Commodity needs Financing gap for commodities

Vietnam Strategy for Malaria Control and Elimination in Vietnam

2011-2020 No details. An overall budget is provided for 2012-15, including budget from the government and a separate line for ‘other resources’. However it is not clear whether these other resources are already committed or gaps that need to be met. The budget is for the malaria programme overall, with no details on commodities specifically.

65

Appendix 6: Country Coverage Data Sources Used

Key

Recentx

Dated information of limited

relevance

No recent information

Country Recent National Strategy

Global Fund: Financing Gap Analysis (available on the Global Fund website)

World Malaria Report 2013 Data

Covered in GMAP (GMAP follow on)

Additional Analyses (WHO/WPRO)

Comments

Mixed picture in terms of costing. None specify commodity financing gaps

Limited coverage. Identifies overall financing gap but not commodity gap

Useful background data for all countries

Good coverage. Outdated. Focus on global norms rather than country targets

Detailed information on financing needs and overall funding gap. Limited scope – focus on Mekong

Afghanistan 2008-2013 Round 8, 2008

Bangladesh Not available Round 9, 2009

Bhutan 2008-2013 TRM August 2012

Cambodia 2011-2025 Round 9, 2009*

Strategic Plan to Strengthen Malaria Control in the Greater Mekong Subregion: 2010-14; WHO Analysis; WPRO Analysis (in 2014)

China 2010-2015 Round 10 2010*

DPR Korea 2009-2013 Round 8, 2008

India 2012-2017 Round 9, 2009

Indonesia 2009-2030 TFM 2012*

x Forthcoming Global Fund proposals under the New Funding Model are listed in Appendix 7

66

Country Recent National Strategy

Global Fund: Financing Gap Analysis (available on the Global Fund website)

World Malaria Report 2013 Data

Covered in GMAP (GMAP follow on)

Additional Analyses (WHO/WPRO)

Lao PDR 2011-2015 TFM 2012*

Strategic Plan to Strengthen Malaria Control in the Greater Mekong Subregion: 2010-14; WHO Analysis (forthcoming); WPRO Analysis in 2014

Malaysia Not available

Myanmar Not available

Round 9, 2009*; New Funding Model early Concept Note 2013

Strategic Plan to Strengthen Malaria Control in the Greater Mekong Subregion: 2010-14; WHO Analysis

Nepal 2011-2016 Round 7, 2007

Pakistan Not available Round 10, 2010

Philippines 2011-2016 Round 2, 2006

PNG 2014-2018 Round 8, 2008 WPRO analysis (input to national strategy)

Solomon Islands

2015-2020 Round 5 (regional), 2007

WPRO analysis (input to national strategy)

Sri Lanka 2008-2012 Round 8, 2008

Thailand 2011-2016 Round 10 2010

Strategic Plan to Strengthen Malaria Control in the Greater Mekong Subregion: 2010-14; WHO Analysis

Timor Leste Not available Round 10 2010

67

Country Recent National Strategy

Global Fund: Financing Gap Analysis (available on the Global Fund website)

World Malaria Report 2013 Data

Covered in GMAP (GMAP follow on)

Additional Analyses (WHO/WPRO)

Vietnam 2011-2020 TFM August 2012*

Greater Mekong Strategic Plan 2010-14; WHO Analysis; WPRO Analysis (in 2014)

Vanuatu 2015-2020 Round 5, 2007 (regional)

Strategic Plan to Strengthen Malaria Control in the Greater Mekong Subregion: 2010-14; WHO Analysis; WPRO Analysis (in 2014)

*Funding gap analysis not available for this review

68

Appendix 7: Concept Note submissions by TRP Windows under Global

Fund New Funding Model

Expected Date of Submission

Country

June Indonesia Papua New Guinea Philippines Timor-Leste

July Bangladesh Korea Pakistan Solomon Islands Sri Lanka

September India Multi-country Western Pacific Nepal

November Afghanistan Bhutan Cambodia Lao PDR Viet Nam

Source: Global Fund PROGRESS UPDATE ON THE NEW FUNDING MODEL: MAY 2014

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