Part III: Regional Strategies
Introduction to Malaria in the Region
Malaria is present in 20 countries or territories in South Asia, Eastern Asia, Southeast Asia and in the Western Pacific.
South Asia (5): Bangladesh, Bhutan, India, Nepal and Sri Lanka
Eastern Asia (3): China, DPR Korea and Republic of Korea
Southeast Asia (9): Cambodia, Democratic Republic of Timor-Leste, Indonesia, Lao People’s Democratic Republic, Malaysia, Myanmar, the Philippines, Thailand and Viet Nam
Pacific (3): Papua New Guinea, Solomon Islands and Vanuatu
Population at risk. More than ~2.2 billion people are at risk of malaria in Asia-Pacific, which represents ~67% of the world population at risk of malaria. Six of the 10 countries worldwide with the largest populations at risk are located in the Asia-Pacific region (India, China, Indonesia, Bangladesh, Viet Nam and the Philippines).World Malaria Report 2008. Geneva, World Health Organization, 2008.
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Malaria transmission. Of the total population at risk, ~77% live in areas of low transmissionWhere reported case incidence is <1 per 1000 population per year. while the remaining ~23% live in areas of moderate to high transmission. In India, Indonesia, Myanmar, Viet Nam and Bangladesh, ~91% of the population at risk lives in areas of high transmission of both P. vivax and P. falciparum. Frequent epidemics occur in these countries and are often caused by large seasonal weather events. DPR Korea, Indonesia, Myanmar, Nepal, Viet Nam, the Philippines, Papua New Guinea and India (in Rajasthan and Gujarat) have all experienced epidemics in recent years.
P. vivax is endemic in all 20 countries. P. falciparum is found in all countries except DPR Korea and Republic of Korea. The proportion of P. falciparum malaria has decreased steadily since the late 1970s in Southeast Asia. Myanmar, parts of Papua New Guinea, Indonesia, Vanuatu, Democratic Republic of Timor-Leste, the Solomon Islands, Cambodia, Lao People’s Democratic Republic, and some states of India continue to suffer from high transmission of P. falciparum malaria.
There are at least six different species of mosquito vectors that contribute to malaria transmission. The mosquitoes can be both indoor- and outdoor-biting, depending on the time of day. Different types of vector control interventions must be employed simultaneously in the region.
Malaria burden. Asia-Pacific had an estimated 134 million cases in 2002 (26% of worldwide cases) and 105,000 deaths in 2000 (9.4% of worldwide deaths).Breman JG et al. Conquering Malaria. In: Jamison DT, Breman JG et al, eds. Disease Control Priorities in Developing Countries
Conquering Malaria. Oxford University Press and the World Bank; 2006. p 415.
Click for source India bears the highest share of cases with ~45% of estimated cases in the region. Five countries (India, Myanmar, Bangladesh, Indonesia and Papua New Guinea) account for approximately ~93% of the death toll in the region (see Figure III.12).
Figure III.12: Malaria cases and deathsin Asia-Pacific
Note: Countries with negligible burden are not shown (Sri Lanka)
Source: World Malaria Report 2008. Geneva, World Health Organization, 2008
Adapted Approaches and Current Levels of Coverage
Malarious countries in Asia-Pacific are very large with sizeable populations at risk, which hide extreme variations within each country in terms of transmission settings, strengths of health systems and levels of burden (e.g. Indonesia has its highest burden area in the easternmost provinces; Thailand has a large proportion of its burden concentrated in border areas). Within the same country, some areas can be malaria free, while others are in the control stage or the elimination stage, requiring a stratified and targeted approach for each country (see section on Challenges). In the remainder of this chapter, countries will be classified in the control stage unless an elimination program is being conducted nationwide.
Sri Lanka, Malaysia and DPR Korea are in the pre-elimination stage, and the Republic of Korea is in the elimination stage.Country elimination status is based on the WHO World Malaria Report 2008. The country classification is not fixed, and countries' status can change depending on the effectiveness of malaria programs and resulting incidence. Please check with a country's Malaria Control Program for the most up-to-date classification.
Click for source All 16 other countries are currently in the control stage according to WHO. Some of these countries, such as the Philippines, Indonesia, Vanuatu, China, Viet Nam and the Solomon Islands have "malaria-free" projects in some areas but are classified in the control stage overall. Figure III.8 presents the country categorization in the region.
Figure III.13: Country categorization in Asia-Pacific
Source: World Malaria Report 2008. Geneva, World Health Organization, 2008
Almost all of the 16 countries in the region in the control stage are implementing the two main vector control measures (LLINs / ITNs and IRS) depending on the setting and case management with microscopic diagnosis and appropriate treatment. The role of IPTp in high-burden areas of Asia-Pacific needs to be clarified (See section on High transmission of P. falciparum below).
Approaches for the 4 countries in pre-elimination or elimination (Malaysia, DPR Korea, Republic of Korea, and Sri Lanka) are detailed in Part II – Chapter 3: Elimination and Eradication: Achieving Zero Transmission and rely mainly on active case detection and management of active foci. DPR Korea, Republic of Korea and Sri Lanka have almost solely P. vivax transmission. Due to the liver stage infection, interruption of P. vivax transmission is difficult to achieve and requires strong adherence to a program of radical cure (14-days of primaquine). Some countries are using innovative malaria treatments: since 2002 DPR Korea has employed mass prophylaxis of primaquine against P. vivax in targeted populations.
Locally adapted approaches to malaria control and elimination. Choosing the appropriate tools requires a deep understanding of local epidemiology, geography and socioeconomic conditions. This section summarizes the appropriate interventions for various settings in Asia-Pacific.
Vector control strategies. The use of at least one of the two core vector control interventions (IRS, LLINs / ITNs) is recommended. The appropriateness of one or the other depends on the epidemiological profile, acceptance by the population, adapted structures to deliver the intervention and other factors outlined in WHO recommendations.Malaria vector control and personal protection. Geneva, World Health Organization, 2006.
Click for source The choice needs to be determined by countries. Additionally, larval control and environmental management measures (e.g. management of salinity in aquaculture and coastal lagoons, rice field draining) can work well in Asia-Pacific as has been illustrated by Indonesia and the Solomon Islands.
P. vivax and mixed transmissions settings. Parasitological confirmation is essential in areas where both P. vivax and P. falciparum occur. Microscopy is recommended as RDTs currently available for non-falciparum infections have low sensitivity and high cost.Guidelines for the Treatment of Malaria. Geneva, World Health Organization, 2006.
Click for source To treat both the blood stage and the liver stage infections, chloroquine combined with 14-days treatment with primaquine is recommended against P. vivax malariaGuidelines for the Treatment of Malaria. Geneva, World Health Organization, 2006.
Click for source in places where there is no proven resistance to chloroquine. Radical cure with primaquine is contraindicated for pregnant women. In regions where both parasite species coexist, mixed infections are commonPrice et al. Vivax Malaria: neglected and not benign. American Journal of Tropical Medicine and Hygiene, 2007, 77.
Click for source and require ACTs completed by primaquine.Treatment of mixed infections in Guidelines for the treatment of malaria. Geneva, World Health Organization, 2006.
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High transmission of P. falciparum. Some countries in Asia-Pacific have high transmission of P. falciparum malaria (e.g. Papua New Guinea, Myanmar, parts of Indonesia, Bangladesh, Solomon Islands, Democratic Republic of Timor-Leste, and some states of India). The use of parasitological diagnosis is recommended for all populations at riskWith the exceptions mentioned in Guidelines for the treatment of malaria. Geneva, World Health Organization, 2006.
Click for source and ACTs are the recommended first-line treatment against P. falciparum malaria. Further research needs to clarify the management of malaria in pregnancy in high transmission settings in this region and especially the appropriateness of IPTp. Trials are underway in Papua New Guinea and the Solomon Islands.
Current intervention coverage. Many interventions have been used in the region with varying degrees of success. These are described below.
LLINs / ITNs. Coverage with LLINs has been historically low in the region since countries used them only for small scale projects. However, tremendous efforts are underway to scale-up their use.In 2005, a Regional Framework for Scaling-Up the use of Insecticide-treated nets was published by WHO-SEARO office and LLINs are
one of the main priorities of the SEARO Revised Malaria Control Strategy 2006-2010.
Click for source Countries such as Bangladesh, Bhutan, Viet Nam, Cambodia, the Solomon Islands, Vanuatu and Papua New Guinea have used insecticide-treated nets for several years. Today all 16 countries in the control stage count LLINs / ITNs as part of their national malaria control strategy. The high up-front cost of LLINs (which are effective for 3-5 years) relative to ITNs (which are effective for approximately 1 year per treatment) is still a barrier to scale-up efforts in Asia-Pacific. In 2006, ~8.6 million LLINs / ITNs were in circulation.GMAP estimates based on data from WHO World Malaria Report 2008 and the Roll Back Malaria Commodity database, 2008. See Appendix 3. Assumptions behind Current Burden, Coverage and Funding Estimates.
Click for source However, these figures likely understate the number of effective nets because they do not count ITNs that have been retreated. For example, in Viet Nam alone, more than 5 million nets are treated annually.
IRS. IRS has historically been the main tool used for vector control, especially in high transmission settings and for the management of epidemics.Currently the Western Pacific Region policy on spraying is: that a) IRS is the best method for interrupting malaria transmission,
but should only be considered where good quality spraying can be done and where high levels of coverage can be attained; b) DDT
remainsthe best choice for IRS, but due to problems with acceptance and other issues like agricultural exports, alternatives like
lambda-cyhalothrin, alpha-cypermethrin or delta-methrin are available which are equally effective; and c) generally two or more
cycles of spraying per year are recommended but where two properly timed rounds with high coverage are not possible because
of logistics or other problems, then every effort should be made to carry out one complete round with high levels of coverage
just prior to the beginning of the main transmission season, using a long-lasting residual insecticide. Source: WHO-WPRO, internal
In the mid-1990s, China, Malaysia, the Philippines and Viet Nam replaced DDT and organo-phosphates with other insecticides. Today, IRS is performed without DDT in all control countries except India. Successful IRS programs have been conducted routinely in India, Thailand, Malaysia and Sri Lanka. In Indonesia, Solomon Islands, Viet Nam, Papua New Guinea and the Philippines, IRS is principally used to contain epidemics. Approximately 16 million households (or ~81 million people) in Asia-Pacific are covered by IRS.GMAP estimates based on data from WHO World Malaria Report 2008. See Appendix 3. Assumptions behind Current Burden, Coverage and Funding Estimates.
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Other vector control measures. Countries in Asia-Pacific have a strong history of environmental management. It was used in the early 20th century for vector control. Although IRS became the main vector control intervention in the region after the 1950s, environmental management (such as draining of rice fields, modification in water salinity, blocked river mouths and coastal lagoons) continued to be used in several countries such as Indonesia, India and the Solomon Islands, where the participation of local communities is a key to success in reducing vector breeding sites.Lindsay et al. Environmental Management for Malaria Control in the East Asia and Pacific (EAP) Region. HNP discussion paper,
Washington, D.C., World Bank, 2004.
Click for source Though larvivorous fish are often used, the evidence base for their effectiveness is weak.W Hawley, UNICEF, personal communication, 2008. In forest malaria settings, such as the Greater Mekong sub-region, personal protection is required for temporary exposure (e.g. for forest workers, loggers, miners, rubber plantation workers and swidden field cultivation). Personal protection measures include insecticide/long-lasting insecticidal hammock nets, long-lasting insecticidal hammocks, insecticide-treated clothing or veils, insecticide-treated blankets and repellents.
Diagnostics (Microscopy and RDTs). Parasitological diagnosis is essential in Asia-Pacific countries to confirm parasitaemia as transmission is rarely high and malaria constitutes a minority of fevers, and to distinguish between treatment for P. falciparum and P. vivax. All countries have functional microscopy capabilities but overall coverage is limited. Some countries such as Thailand,Malaria Rapid Diagnosis, Making it work. WHO - Western Pacific Regional Office, 2003.
Click for source Bhutan or Sri Lanka have good microscopy and in the Philippines, Solomon Islands or Viet Nam, microscopy is available down to the community level. RDTs have been integrated into routine practice in several countries (e.g. Cambodia, Indonesia, Sri Lanka and Thailand) but their use is still limited. Approximately 122 million parasitological diagnoses were reported in 2006, ~88% from India alone. Only ~407 thousand RDTs were used in 2006.GMAP estimates based on data from WHO World Malaria Report 2008. See Appendix 3. Assumptions behind Current Burden, Coverage and Funding Estimates.
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Anti-malarial treatment. P. vivax cases are treated with chloroquine and primaquine in most countries. The exception are Vanuatu and Solomon Islands, where cases are treated with ACTs and primaquine and Cambodia and Papua New Guinea where currently primaquine is not widely used due to G6PD deficiency. Currently, treatment of confirmed, uncomplicated P. falciparum cases are treated with ACTs in most countries. Countries have different policies for treating unconfirmed cases. An estimated 10 million treatment courses were distributed in 2006.GMAP estimates based on data from WHO World Malaria Report 2008 and the Roll Back Malaria Commodity database, 2008. See Appendix 3. Assumptions behind Current Burden, Coverage and Funding Estimates.
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Recommended Regional Approach to Control and Eliminate Malaria
Targets, approaches and priorities must be tailored to the region.
Targets. The target for 2010 is to reduce malaria mortality and morbidity by 50%, which means Asia-Pacific will have less than 67 million cases and 52,500 deaths in 2010. By 2015, the objective is to have less than 33 million cases and to reach near zero mortality for all preventable deaths.Preventable death is defined as deaths from malaria that can be prevented with rapid treatment with effective medication. Nonpreventable deaths represent an extremely low mortality rate for the most severe malaria cases and occur even with the best available and most rapid treatment. Beyond 2015, the objective is to maintain near zero mortality for all preventable deaths and further reduce morbidity.
To reach universal coverage with appropriate interventions by 2010 in Asia-Pacific (see Figure III.14):
- ~349 million LLINs need to be in circulation in 2010;
- ~120 million households need to be sprayed with insecticides;
- ~780 million diagnostics are needed to confirm suspected malaria fever cases, either by microscopy or RDTs; and
- ~24 million first-line treatments are needed for both P. falciparum and P. vivax infections.
Figure III.14: Scale-up in interventionsfrom 2006 to 2010 in Asia-Pacific
a) Because of 3-year life span, each year approximately 1/3 of the old nets will need to be replaced
b) Actual use is likely not all directed to confirmed malaria cases today
Source: Need based on GMAP costing model; actual based on analysis of World Malaria Report 2008. Geneva, World Health Organization, 2008 and Roll Back Malaria Commodities database
Approaches to main challenges in the region. Challenges faced by countries in their malaria control efforts are varied. However, some common trends unique to malaria in Asia-Pacific are described below.
Respect in-country variations. There are large variations in epidemiology and malaria burden within Asia-Pacific countries. Large countries such as China, Indonesia, or India have regions in very different situations, some bearing most of the malaria burden, others almost or totally malaria free. Stratified approaches are required to adapt the strategy to local needs. In the Philippines, for example, programs are highly decentralized and the establishment of Provincial Investment Plans for Health (PIHP) has enabled the development of detailed workplans at the local level.
Build managerial capacity. Capacity building is required at the national, regional and local level. In many countries, malaria control programs lack sufficient human resources to successfully run their programs. This is due to a variety of factors: high attrition rates of skilled staff, difficulty filling positions, competing demands with other programs and the unwillingness of health providers to be stationed in remote areas. In particular, countries report a dearth of technical experts (e.g. entomologists and M&E specialists), staff for the delivery of interventions (e.g. nurses and skilled IRS teams) and laboratory workers in health facilities to conduct microscopy. There is a strong need to increase trainings for new staff, especially in areas where there is a high demand (e.g. Bhutan, Nepal, Democratic Republic of Timor-Leste). The training network ACTMalaria (Asian Collaborative Training Network for Malaria) has been established in 11 countries in the region to provide collaborative training and improve communications on malaria affecting common borders. In addition, the rapid decentralization of malaria control in some countries has led to a greater need for skills (especially program management) at the regional and local level.
Monitor, prevent, and contain anti-malarial drug resistance. Asia-Pacific countries report the highest rates of anti-malarial drug resistance in the world. Chloroquine and sulphadoxin-pyrimethamine resistance by P. falciparum are reported from almost all countries (averaging ~40% for CQ and between 20% and 40% for SP).World Malaria Report 2005. Geneva, World Health Organization, 2005.
Click for source Chloroquine-resistant P. vivax is found in Indonesia, Papua New Guinea and India. Multi-drug resistant P. falciparum, which includes decreased sensitivity to artemisinin (called artemisinin-tolerant), is found at the Cambodia-Thailand border, and in northeastern Myanmar bordering Thailand. A major effort is underway to contain artemisinin-tolerant malaria in this area. The potential expansion of artemisinin-tolerant P. falciparum to other parts of Asia and Africa is a global threat. The rapid strengthening of monitoring systems for drug resistance is therefore critical in the Asia-Pacific region. To avoid resistance to ACTs, the rational use of anti-malarial drugs should be enforced and the quality ensured. Sub-regional surveillance networks exist in the Greater Mekong sub-region and the Pacific that foster collaboration between countries in monitoring malaria drug resistance.
Monitor insecticide resistance. Insecticide resistance is also a major issue in several countries in Asia-Pacific. In India, resistance to almost all types of insecticides has been reported. In the Greater Mekong sub-region, insecticide resistance was reported from several countries.Van Bortel et al. The insecticide resistance status of malaria vectors in the Mekong region. Malaria Journal, June 2008.
Click for source Resistance that occurs even in non-endemic areas needs to be monitored because of the risk of vector migration to endemic regions. Sri Lanka has adopted the rotational use of insecticides for indoor residual spraying to delay the emergence of resistance to insecticides. Insecticide resistance monitoring, quality assurance of products, resistance management strategies, and overarching Integrated Vector Management approach are needed to manage insecticide resistance.
Improve quality of anti-malarial treatments and other commodities. Due to the high cost of effective anti-malarial drugs such as ACTs and the strong manufacturing capabilities of companies in the region, fake and substandard drugs are prevalent, especially in the Greater Mekong sub-region. In 2001, studies showed that more than 30% of artesunate collected from international borders of Mekong countries was fake.Newton P et al. The Lancet, 2001. Regular monitoring of the quality of anti-malarial medicines in the Mekong Region since then has
led to a successful cooperation with INTERPOL to stop the production and the distribution of counterfeit artesunate.
Click for source The issue of poor quality drugs is even more complicated in countries where most of the drugs are obtained from the private sector or from drug peddlers. Therefore, national programs (in Cambodia, Lao People’s Democratic Republic and Myanmar) are cooperating with the formal and informal private sector (Public-Private Mix for Malaria Control). Similarly, concerns have been raised on the quality of LLINs and insecticides used for IRS and RDTs, particularly when districts have their own procurement mechanisms. Greater quality control and regional cooperation should be encouraged on this issue for all interventions.
Strengthen control and elimination efforts against P. vivax. The transmission of P. vivax is widespread in the Asia-Pacific region. P. vivax has a unique biology (generation of hypnozoites in the liver stage) that leads to a large prevalence of asymptomatic cases among semi-immune populations. It also responds differently to anti-malarial treatments than P. falciparum. The cure for liver stage infection, 14-days of primaquine, poses challenges as patients often do not adhere to treatment for the entire period. To date, P. vivax research has been poorly funded, resulting in few new tools and approaches for controlling P. vivax. Basic and operational research on P. vivax needs to be expanded and strong behavioral change communication (BCC) programs are required to ensure adherence to primaquine treatments. In addition, regional cooperation networks could be created to share practices on the control of P. vivax malaria. An Asian Vivax Network was founded in 2005 to conduct research on P. vivax but still lacks funding to become operational.
Focus on forest malaria and migrant populations. In parts of Asia-Pacific (e.g. in the Greater Mekong sub-region) forest malaria is common. Some mosquito vectors (e.g. Anopheles dirus) bite and rest outdoors. These forested areas may contain difficult-to-access trans-border areas. Hence, a significant part of the malaria burden is borne by isolated ethnic groups or new settlers who reside close to the forest and mobile/migrant forest workers (e.g. for logging, mining, plantation work and swidden field cultivation). It is challenging to provide interventions to the resident populations in these areas because they are hard to reach and because traditional vector control interventions (LLINs / ITNs, IRS) are not always effective in these settings. Innovations in personal protection (e.g. insecticide-treated blankets, hammocks or hammock nets) are being tested but the continued development and availability of new tools is crucial.
In Pacific island countries, migration and inter-island travel creates a transient reservoir of infective and infectious carriers (mostly asymptomatic) who serve as a constant source of transmission. In the Solomon Islands, active case detection through periodic mass screening, treatment and follow-up of all positive cases has been a major factor in reducing transmission between the capital city and smaller townships over the past 10 years. This approach will be introduced as part of the malaria elimination strategy in island groups of the Solomon Islands and Vanuatu.
Operational research and regional collaborations with other initiatives (e.g. labor, migration, HIV/AIDS) focused on these populations may be successful in developing comprehensive approaches that include malaria. In order to reach these isolated populations, integration with other health services (such as immunization) and cooperation with other sectors and agencies (such as rural development, military and border police) needs to be strengthened. In addition, community health management could be promoted, with the establishment of networks of community heath workers.
Maintain long term malaria funding and political support. Maintaining funding and political support for malaria control efforts, especially in areas where successful control has lowered the burden and led countries in the pre-elimination stage, is critical. Increased national funding will hedge countries from drops in donor support. In-country and international advocacy efforts are required to maintain political and financial support.
Strategic priorities. Success in malaria control and elimination is essential in all countries. However, some countries are especially important to achieving the RBM targets, both in the short and the medium / long term. (Figure III.15)
Figure III.15: Distribution of malaria deathsin Asia-Pacific
Source: World Malaria Report 2008. Geneva, World Health Organization, 2008
To reach the 2010 targets, several types of countries must receive focused attention:
- High contribution to global deaths. Of the 35 countries that account globally for ~98% of malaria deaths, 5 are located in the Asia-Pacific region. These 5 countries (India, Myanmar, Bangladesh, Indonesia and Papua New Guinea) account for approximately ~93% of the death toll in the region. India alone accounts for ~38% of regional mortality. It is critically important to support these countries to achieve the 2010 targets in the region.
- High burden relative to population size. Countries such as Democratic Republic of Timor-Leste or the Solomon Islands have few deaths due to smaller populations but are high burden countries when the number of deaths is considered relative to their populations.
- Emergence of artemisinin resistance. The Greater Mekong sub-region is of global importance because emerging artemisinin tolerance has the potential to spread around the world. WHO is coordinating and technically supporting research and containment efforts in affected countries, particularly through its sub-regional WHO Mekong Malaria Program.For more information, see the WHO website.
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Success in malaria control in these countries will be critical to achieving regional targets in Asia-Pacific as well as the global targets of burden reduction. Therefore, in addition to the general support provided to all countries in the control stage, the RBM Partnership will coordinate targeted technical assistance to these countries to increase the speed with which they can achieve universal coverage to meet the 2010 targets.
In terms of priorities beyond 2010, all countries which will have reached universal coverage need to be encouraged in maintaining these efforts while entering the sustained control stage. It is essential that control measures are sustainable in all countries to avoid resurgence of malaria transmission and subsequent upsurge in malaria mortality and morbidity. The 4 countries in the elimination stage need to be encouraged to bring local transmission to zero and then prevent the reintroduction of malaria.
International coordination. Support provided by RBM partners should address the challenges faced by the countries in Asia-Pacific as outlined above. To complement existing sub-regional networks such as the WHO Mekong Malaria Programme, the Pacific Malaria Initiative and the Asian Vivax Network, the RBM Partnership could play a valuable role by encouraging increased coordination between countries and partners in the region and by providing opportunities to share best practices. The RBM Partnership may want to establish two Sub-Regional Network nodes (e.g. linked to the WHO Regional Offices for South-East Asia - SEARO and the Western Pacific - WPRO) in Asia-Pacific to strengthen ties within the region. In addition, technical networks could be created and/or strengthened, such as networks on the management of P. vivax malaria and on monitoring the quality of insecticides, LLINs and RDTs.
Capacity building. Most malarious countries in Asia-Pacific require capacity building at the national, regional and local level. Trainings need to be designed and disseminated to increase management skills (program or financial management) as well as technical knowledge of experts (entomologists, M&E specialists etc.). In addition, a certification program for intervention providers (e.g. spraying teams for IRS) could be established to ensure the quality in the delivery of interventions. The Asian Collaborative Training Network on Malaria (ACTMalaria) has over 10 years of experience in addressing these needs and is an exemplary training network for other regions.
Targeted assistance to high priority countries. In addition to the general support provided to countries in the control stage (See Part II: Chapters 2 and 3), the high priority countries need targeted technical assistance and increased capacity to successfully scale-up interventions by 2010 and achieve universal coverage.
In particular, technical assistance from RBM partners is needed for:
- Planning and developing funding proposals
- Accelerating disbursements from major donors
- Identifying and rapidly resolving procurement and supply chain bottlenecks
- Improving national forecasts of commodities
- Designing and implementing communication and behavior change programs
- Strengthening monitoring and evaluation systems
To ensure sustainability of successful control programs, technical assistance should be complemented by increased capacity at the country level and targeted training programs. In particular, in-country experts are required in a number of key activities, such as program and financial management, procurement and supply chain management, in-country communication and monitoring and evaluation. Providing these experts to the highest burden countries will increase their chances of success. These country-based technical experts would work in a network with coordinators at the sub-regional and global level.
Funding Requirements: US$ 2.8 billion gap for 2010
In 2007, approximately US$ 217 million was disbursed against malaria in Asia-Pacific, out of which 66% came from national budgets. (See Figure III.16) After national disbursements, the Global Fund is the main donor in the region (31% of regional disbursements in 2007). The remaining disbursements in 2007 came from other international donors. The Global Fund has awarded grants to 15 countries in the region and a multi-country grant in the Western Pacific for Vanuatu and the Solomon Islands, with a total commitment of US$ 479 million in the first 7 rounds. In addition, the World Bank approved in July 2008 over US$ 500 million, approximately US$ 200 million of which may go to malaria, for a project to support India’s efforts against malaria and other diseases.US$ 121 million for malaria specific activities, US$ 52 million for management and policy strengthening (including significant inputs for malaria), and US$ 37 million not yet allocated which could also be used for malaria. Other donors include USAID, AusAID and The Asian Development Bank.
Figure III.16: Gap in malaria fundingin Asia-Pacific
Note: See appendices on methodologies to estimate costing needs and current funding
Source: GMAP costing model (WHO, GFATM, World Bank, PMI)
Compared to 2007 investment levels, there is a funding shortfall of US$ 2.8 billion to reach the 2010 targets. Approximately US$ 2.7 billion is needed in 2009 and US$ 3 billion in 2010 to scale-up preventive and curative interventions in Asia-Pacific to reach universal coverage targets (see Table III.4). Preventive costs are approximately two thirds of these costs in 2010, case management costs are approximately 20% of the costs, and the remaining costs are malaria control program costs. Declines through 2015 are due to lower treatment costs due to preventive efforts and countries shifting from control to elimination.
Table III.4: Summary of annual costs in Asia-Pacific
|Cost category (US$ millions)||2009||2010||2015||2020||2025|
|Chloroquine and primaquine||3||3||1||0||0|
|Severe case management||3||3||1||0||0|
|Case management cost||400||577||198||9||5|
|Community health workers||28||29||34||35||13|
|M&E and OR||73||91||91||91||129|
|Infrastructure / inst. strengthening||51||76||68||71||27|
|Total control & elimination cost||2,721||3,008||2,459||2,301||839|
Note: Diagnostic costs are covered both by RDTs in case management and by microscopy in infrastructure / institutional strengthening
Source(s): GMAP costing model; Johns B. and Kiszewski A. et al