Guidelines

1
Global malaria situation and WHO Global Malaria
Programme (GMP) new direction on malaria control
and research Sixth Intercountry Meeting of
National Malaria Programme Managers Cairo, Egypt,
36 July 2006 Dr Arata Kochi, Director Global
Malaria Programme
2
Structure of the presentation

• Global malaria epidemiology
• Current malaria control situation in Africa and
  in other regions
• Challenges
• Proposed WHO new direction
• Proposed WHO specific products
• Proposed process to produce these products

3
Global malaria situation rough estimates

• 3.2 billion at risk of malaria
• 350500 million incident cases annually
• more than 1 million malaria deaths annually

4
Who suffers from malaria?

• In Africa
• children under the age of 5 years old (80 of
  malaria-related deaths)
• pregnant women
• Outside of Africa
• all age groups are at risk of malaria
• however, mainly concentrated among the
  marginalized populations
• In emergencies
• malaria is one of the most important disease in
  refugees
• Travellers from rich northern countries
• reported malaria cases are larger than TB in
  France, UK, Netherlands, Switzerland...

5
Direct and indirect costs of malaria

• Average loss of 1.3 of annual economic growth on
  countries with intense transmission
• Malaria contributes to poverty through
• private and non-private medical care costs
• reduced productivity of malaria sufferers and
  caretakers
• human capital effects on cognitive development
  and education levels
• demographics fertility decisions and dependency
  ratio
• discouraging foreign direct investment, trade and
  tourism
• inhibiting the movement of labour

6
Trends in malaria deaths
Asia
3.0
China
Central S. America
N. America Europe
2.0
annual deaths (in millions)
WORLD
1.0
AFRICA
0.1
1900
1930
1950
1970
1990
2000
(after R.Carter,1999)
7
Global malaria situation regional burden

• Regional distribution of malaria cases by WHO
  Regions

Source WHO Provisional Estimates 2004
8
Abuja 2000 targets for Africa

• Abuja coverage targets by 2005, from the African
  Summit on RBM
• At least 60 of those suffering from malaria
  should be able to access and use correct,
  affordable and appropriate treatment within 24
  hours of the onset of symptoms
• At least 60 of those at risk of malaria,
  particularly pregnant women and children under 5
  years of age, should benefit from suitable
  personal and community protective measures such
  ITNs
• At least 60 of all pregnant women who are at
  risk of malaria, especially those in their first
  pregnancies, should receive IPT
• At least 15 of government budget is allocated to
  health sector (African Union, 2003)

9
Targets and strategies in other Regions

• EMRO
• prevent reintroduction of malaria in malaria-free
  countries
• eliminate malaria where eradication is feasible
  and sustainable
• create functional health systems that manage
  effective malaria programmes in order to reduce
  mortality in countries with low-to-moderate
  transmission
• halve malaria burden in countries with high
  transmission
• EURO
• prevent or reduce mortality and the related
  economic loss by strengthening health services
  and mobilizing communities
• WPRO, AMRO, SEARO
• halve the number of deaths related to malaria by
  2010

10
Malaria in Africa where are we now?

• Only Eritrea has achieved the Abudja targets
• A number of southern and central African
  countries started progressing due to Global Fund
  money and WHOs technical assistance
• Other countries are far short from the Abuja
  targets
• Weak monitoring and evaluation system

11
Malaria out of Africa where are we now?

• Clear success stories
• Viet Nam, Sri Lanka, Arabian peninsula
• Morrocco, Tajikistan, Armenia
• Mexico, Guyana, etc.
• Not much progress (Indonesia, Pakistan, PNG,
  etc.)
• Data mainly based on Health Information System,
  weak ME systems and few community-based surveys

12
Emerging environment

• New tools ACT, LLIN, RDT, etc.
• Increasing visibility and money
• increase in research money US 300400
  million/year (Gates Foundation, NIH, other
  funds...)
• GFATM
• Bilateral (Japan, Italy, USA...)
• World Bank the Malaria Booster Program

13
Cumulative disbursements for malaria control (WHO
and Global Fund)
400,000,000
GF disbursment for malaria
300,000,000
US
200,000,000
100,000,000
WHO expenditure
1999
2000
2001
2002
2003
2004
2005
14
Challenges (1)

• Interventions "WHAT" should be done is clear,
  but not "HOW"
• To what extent are these strategies being
  implemented?
• weak MIS in "strategy"
• How robust is the epidemiological relationship
  between coverage targets and goals?
• Given the rising resistance (parasites to
  medicines, and mosquitoes to insecticides) how
  efficacious are the current strategies in the
  medium term?

15
Challenges (2)

• Does the current priority RD agenda address
  these challenges? Are RD results quickly
  utilized for policy implementation? Where is the
  intellectual centre of gravity? The example of
  Lapdap
• developed as a collaboration between TDR, GSK and
  Liverpool University
• registered by the UK in 2003 for use in Africa (
  contraindication for patients with known G-6PD
  deficiency)
• in the face of SP resistance, problematic
  efficacy
• While rapidly increasing funding, do we have
  enough capacity for technical assistance and can
  countries absorb the money?
• How strong is the political commitment of African
  countries and other malaria endemic countries?

16
Challenges (3)

• Do we have management capacity at country level
  to perform well?
• vertical vs. integrated, decentralization, etc.
• How is malaria among travellers addressed?
• awareness of its importance in rich countries?
• effective policy, implementation, surveillance?
• Do we have enough production capacity for
• key commodities (e.g. ACTs, LLINs)?
• effective supply chain management systems?
• how to rectify the market failure?

17
Challenges (4)

• How effective is the current human resource
  development strategy for malaria?
• in malaria endemic countries
• internationally
• How is the global malaria community
  functioning?
• inward looking?
• fighting each other?
• cannot be bold and innovative?
• do we have "activists and what are the messages?

18
New direction for WHO Malaria control and
research (1)

• Strong WHO/HQ leadership and a united WHO/GMP (HQ
  RO CO)
• From African to global approach, but Africa is
  still the highest priority
• Highly endemic epidemic elimination malaria
  among travellers
• Multisectoral, but strong health sector
  leadership
• Simple and practical policy, and apply best
  available tools
• Develop clear strategies focussing on how?
  case-management with ACTs, ITN, IRS
• Effective, practical ME system
• improve HIS for performance monitoring
• improve community health facilities surveys on
  coverage impact evaluation
• Provide support to strengthen malaria programme
  management at country level

19
New direction for WHO Malaria control and
research (2)

• Develop the critical mass of technical expertise
  through cascade-style training
• Opportunistic but strategic alliance between
  technical expertise, money and politics for
  country operations
• Place competent staff in charge of implementing
  support in countries
• Research ask right question, step ahead of
  parasites and mosquitoes, set priority research
  agenda and franchise research activities, fund
  a selected and innovative needs-driven research
  to support implementation, intellectual centre
  of gravity in GMP
• Partnerships
• focused on country level, specific partners on
  specific issues to reduce transaction costs

20
Structure of the WHO Global Malaria Programme
(GMP)
21
GMP products related to normative activities,
20062007 (1)

• Disease burden estimates and modelling
• 2 African countries, India, Brazil (2006)
• 4 to 6 other countries (2007)
• revised global estimates (2007)
• develop malaria control models
• Minimum indicators for performance monitoring
  through improved health information management
  system
• case-management, ITN, IRS...
• Community and health facility surveys for
  effective coverage and impact
• survey methodologies development (2006)
• 4 surveys (2 in Africa and 2 outside Africa)

22
GMP products related to normative activities,
20062007 (2)

• Cost analysis
• cost analysis handbook development (2006)
• National Malaria Control Programme cost analysis
  (for 6 to 8 countries)
• National Malaria Control Programme management
  analysis
• development of minimum human resource needs and
  basic structure
• GMP country data base
• epidemiology, policy, programme management
  structure, performance, resource flow tracking,
  etc.
• GMP brochure, success stories, GMP annual report

23
GMP products related to normative activities,
20062007 (3)

• Case management strategy development
• treatment guidelines for vivax malaria
• case-management manual
• training modules
• regional and sub-regional quality assurance of
  malaria microscopy system
• prequalification and quality assurance of RDTs
• Global drug resistance surveillance
• ITN strategy development
• ITN manual
• training modules

24
GMP products related to normative activities,
20062007 (4)

• IRS strategy development
• IRS position paper
• IRS manual
• training modules
• Global insecticide resistance surveillance
• Malaria epidemic prevention/control and
  emergency
• guidelines development
• 4 subregional emergency stock pile centres
• Urban malaria analysis and guidelines development
• Malaria elimination guidelines
• Malaria control/prevention guidelines for Europe,
  North America, Japan

25
GMP products related to normative activities,
20062007 (5)

• Market size forecasting (ACTs, LLINs, RDTs)
• Improve WHOPES, WHO prequalification for drugs
  and RDTs
• Enforcement of artemisinin monotherapy ban
• ACT pharmacovigilance surveys
• ACT procurement

26
GMP products related to technical support,
20062007 (1)

• FOR ALL COUNTRIES
• Policy guidelines, strategies
• WHO malaria training by 3 training modules (to
  teach how)
• Support to regional and sub-regional training
  courses (to teach why) (Ethiopia, Oman, Iran,
  India, Thailand, Philippines, Burkina Faso, etc.)
• National Programme Managers meetings in all
  regions

27
GMP products related to technical support,
20062007 (2)

• INTENSIFIED TECHNICAL SUPPORT
• Criteria
• availability of national technical leadership
• availability of funds (national, GF, WB,
  bilaterals, etc.)
• but GMP will also brokerage/facilitate for
  external funding
• Approaches
• assessment of epidemiological situation, and
  history and performance of malaria control
  programme
• operational research and cost analysis are also
  included
• programme reviews

28
GMP products related to technical support,
20062007 (3)

• Focused support
• case management 20 countries
• ITN 20 countries
• IRS 10 countries
• malaria elimination 8 countries
• urban malaria 23 countries

29
How to manage the process

• Internally
• annual GMP staff meeting (Nov. 2006 Nov. 2007)
• GMP single workplan/budget and quarterly review
  system
• GMP human resources development plan
• Externally
• proposed GMP strategic advisory committee
• proposed GMP technical and research advisory
  committee working groups
• WHO EB and WHA