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

1.Funding and commodity gaps are large. We cannot achieve malaria control and elimination unless we fill them 2.We need better gap information for planning and advocacy. Consider a regional real-time system to monitor financial flows and gaps 3.There are many systems barriers to access Build on successes with community health workers Better engage with private labour project owners to protect migrant workers. 4.Artemisinin resistant malaria will not be eliminated unless today’s strategies are inclusive of marginalised high risk populations. Key Messages

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

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

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

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

Strategies Users Commodities Systems Issues influencing access to antimalarial commodities

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

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

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

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

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

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

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

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

Thank you