The Global Malaria Response: Extending The Reach Of Primary Health Care, Expanding Coverage Towards UHC

Extending the reach of primary health care systems to provide malaria services to those in the most hard-to-reach places has become part and parcel to the global malaria response, and according to experts, is paving the way for the expansion of other essential health services – and moving the world closer towards realising universal health coverage (UHC).

This progress, driven by the innovation of effective and easy-to-use drugs and diagnostics, and strategic partnerships that integrate the efforts of governments, local health systems, international organisations and global donors, cannot slow down, experts caution, or malaria will come back.

That is why the global malaria community is calling on all stakeholders to “step up the fight,” with increased financing for malaria control and elimination, as part of an integrated health agenda that strengthens primary health care systems and drives innovation to leave no one behind.

One of the children to receive the world’s first malaria vaccine in Ghana in April 2019. Photo: WHO/Fanjan Combrink

“The interesting dynamics that malaria may offer, is that malaria may always challenge the need of thinking beyond just strengthening the health system, and may look at alternative ways of reaching and providing services which by itself can sometimes precede or be a pathfinder for where the health system needs to move,” Andrea Bosman, WHO lead for Malaria Prevention, Diagnostics and Treatment, told Health Policy Watch.

“There is still a massive need to expand a platform with community health workers which can serve not only malaria, but other public health programs, especially malnutrition, pneumonia, and diarrhoea,” he said.

The malaria response is delivered by primary health care systems, and is therefore closely linked to the overall strength and performance of these systems. “Malaria is a bellwether that tells you how good your primary care delivery systems are working. If you can’t take care of malaria, you’re probably not doing a good job [in other areas],” George Jagoe, Executive Vice President of Access & Product Management at Medicines for Malaria Venture (MMV), told Health Policy Watch.

The recent certification of Algeria and Argentina as malaria-free demonstrates that malaria elimination is on the horizon for many countries; but the sobering reality detailed in WHO’s World Malaria Report 2018 – that overall global progress has stalled between 2015-2017, and that malaria cases are on the rise in the ten highest burden African countries – underscores that, as Jagoe said, “this is no time to take our foot off the gas.”

“Malaria,” he said, “is there to remind us that either we’re on top of the game – not just the malaria game, but the whole delivery game – or it will come back.”

The ten highest burden countries in Africa include: Burkina Faso, Cameroon, Democratic Republic of the Congo, Ghana, Mali, Mozambique, Niger, Nigeria, Uganda and United Republic of Tanzania. Source: WHO World Malaria Report 2018

In the lead-up to the replenishment of The Global Fund to Fight Aids, Tuberculosis and Malaria later this year, Peter Sands, the Global Fund’s Executive Director, made the case in a video for increased investment to the tune of US$14 billion over the next 3 years, which he described as the “minimum” of what is actually needed, calling on governments to also increase health sector budget allocations to at least the 15 percent set by the 2001 Abuja Declaration.

Sands also reiterated the Global Fund’s commitment to a more integrated health agenda. “Beating the three big epidemics is not just about disease-specific interventions. It requires building stronger and more resilient health systems,” he said.

According to the Roll Back Malaria (RBM) Partnership to End Malaria’s AIM – Action and Investment to Defeat Malaria 2016-2030 report, investment in malaria today could actually reap huge financial rewards in the future, by reducing the burden of the disease on health systems to reinvest in other health priorities, and by stimulating growth of national economies due to a healthier workforce.

This September, world leaders will gather at the United Nations General Assembly High-Level Meeting on Universal Health Coverage in New York, to set goals and make commitments for UHC that will be put in writing, in the form of a political declaration on UHC currently under negotiation by member states.

The initial draft of the declaration sets the tone, recognising “that primary health care is the most inclusive, effective and efficient approach to enhance people’s physical and mental health, as well as social well-being,” and calling on countries to implement the “most effective, high impact, people-centred, gender-responsive and evidence-based interventions to meet the health needs of all.”

Reflective of the global paradigm shift that has come to identify primary care as the vehicle for UHC, driving forward an integrated primary health care agenda within the global malaria response is, according to WHO’s Bosman, not just rhetoric, but a platform for action.

The WHO and the RBM Partnership have catalyzed a new country-led approach to accelerate reductions in malaria cases and deaths globally, which is detailed in the video below.

Solving the Problem of Malaria Isn’t Rocket Science, It’s Primary Health Care

As the original “poster child” for neglected tropical diseases, malaria affects the poorest populations, and results in an enormous burden, especially for poor countries. Malaria “can be the cause of up to 50% of hospital visits and admissions, and can account for 40% of public health spending in high-transmission settings,” according to the RBM Partnership’s AIM report.

Detecting and responding to malaria, however, is “not rocket science,” Jagoe of MMV said. “I don’t mean to trivialise it, but malaria is not a hard disease to detect and to treat if you do it on a timely basis.” It’s something “you can do with very limited training and very limited education,” so “if we’re not doing well on malaria,” he said, “then it means that other things are probably broken.”

Strengthening and extending the reach of primary health care systems has therefore become a core component of the global malaria response – without effective primary care systems, effective malaria prevention and treatment programmes that leave no one behind would just not be possible.

“Like it or not, you can look around the world at different funded programmes and you’ll see that they are heavily branded and vertically designed around a specific disease,” Jagoe said. “At the end of the day, if those programs are doing their jobs well, they absolutely have to be so firmly aligned with larger efforts to be improving overall healthcare delivery.”

As a partnership-driven organisation, Jagoe explained that MMV needs to really be asking the “hard questions” around whether or not “the funding streams, the delivery partners, and the approaches that we’re trying to align ourselves with are really enmeshed with overall approaches for improved primary health care.”

One such MMV partnership that exemplifies this integrated approach is the MAMaZ against Malaria pilot project in rural Zambia, which shows that when you combine a high-functioning primary health care system with a steady supply of effective antimalarial drugs and a rapid transport system connecting rural areas with health centres, you can reduce severe malaria fatality by 96 percent.

Severe malaria results when uncomplicated malaria is left untreated, and is particularly dangerous for children and pregnant women. According to WHO, severe malaria is responsible for 285,000 deaths in children under five each year.

To achieve this dramatic 96 percent reduction in malaria deaths, MMV worked with the National Malaria Elimination Centre in Zambia, local health system partners, and TransAid as well as other international partners. The project provided training to community health workers, a steady supply of rectal artesunate specifically designed as a pre-referral treatment for severe malaria in children, and a rural transportation system using bicycle ambulances to ensure rapid follow-up treatment at a health centre within six hours of the initial dose.

Jagoe said that this project demonstrates that integrated primary health care approaches to malaria prevention and treatment work, and that it isn’t rocket science – it just took some “thinking outside of silos.” He added that according to this approach, other countries would need to come up with their own solutions, according to their specific realities and contexts.

Rabbecca Chisenga, an Emergency Transport System (ETS) rider and Community Health Volunteer (CHV) in the village of Mupola, Serenje, Zambia. Photo: MMV

Malaria: a Pathfinder for Innovating Health Systems

According to the WHO malaria global technical strategy, the “first priority for all countries where transmission rates of malaria are high or moderate is to ensure maximal reduction of morbidity and mortality through sustained provision of universal access to quality-assured and appropriate vector control measures, diagnostics and antimalarial medicines, together with the implementation of all WHO-recommended preventive therapies that are appropriate for that epidemiological setting.”

While protecting the most vulnerable to prevent mortality is the first priority, Bosman of WHO noted that in order to truly do this, you “have to cover the whole population, including the adult males – everybody should get access to long-lasting insecticide-treated nets in sufficient numbers to cover all household members, so that also the most vulnerable will be protected.”

“Working in malaria in general, we’re aware that this is ultimately a disease that hits people at some of the farthest-out settings,” Jagoe said. “We call them primary care settings, but sometimes there’s not even a proper primary care delivery system there.”

Bosman explained that when you extend malaria prevention and treatment services into communities, you are able “to go beyond what the health services have been able to provide.”

“So malaria, by providing some new interventions in a way opens up new dynamics in the health system, in the regulatory areas, in the policy areas, which are then used for other [diseases], like extending testing for HIV.”

“This is the interesting dynamic of malaria,” Bosman said. “It depends on and contributes to strengthening of the health system, but can go beyond, and by innovation then stimulates new ideas and openings in the health systems, which certainly are useful for other public health programmes as well.”

An example of this “usefulness” is the integration of chemoprevention of malaria in pregnancy with antenatal care services. The seasonal chemoprevention of children under five delivered at the community level, he said, could also incorporate and support “other interventions requiring periodic outreach of the community in the village, such as mass treatment for neglected tropical disease, TB [tuberculosis] outreach for children and malnutrition screening and referral.”

Many of the activities required for an effective malaria prevention and control program, he added, also “require the strengthening of the laboratory services, which then can also serve [to provide] better lab diagnosis for other diseases.”

In areas where there is no lab, the malaria response has “deployed on a large scale rapid diagnostic tests, which can be used by community health workers just with half a day of training, extending malaria testing to guide treatment in [remote] places.”

Thinking outside of silos, Bosman emphasised, also requires working more closely with the private sector, which includes local drug shops, where in some places the majority of people seek treatment. “For the private sector, in the past we have introduced subsidies for medicines – providing quality medicines at a reduced price for the private sector.”

But more recently, Bosman said that accreditation schemes are increasingly being promoted so that drug shops can get “training, accreditation, and some level of supervision and support.” Through accreditation, “the clients see where to go to get the quality treatment.”

A child receiving injectable artesunate treatment for severe malaria at a health centre. Photo: MMV/Ben Moldenhauer

Aggressively Affordable Malaria Drugs, Interventions for the “Lowest Common Denominator”

Medicines for Malaria Venture, a leading product development partnership (PDP) that facilitates the research, development and delivery of innovative and effective antimalaria drugs, has a number of drug candidates in the pipeline, as well as a number that have already been approved and are in use around the world.

This, however, was not always the case. MMV was originally founded to address the lack of drugs in the R&D pipeline. “In 1999 the pipeline for new antimalarials was virtually empty. The possibility of profit in antimalarial drug development was considered too low to attract pharmaceutical investment,” while malaria “was killing 1-2 million people a year – most of them children under 5 and pregnant women from the poorest regions of the world.”

MMV has now filled this gap, and according to Bosman of the WHO, MMV’s “drug development programme is fully aligned with what is needed” in terms of WHO recommendations.

Jagoe explained that because “MMV’s funding remains donor-driven,” this allows MMV “to do drug development without a profit motive, and frankly without a profit requirement. If we’re financing a large part of drug development, then the pharma companies are not under the same duress to have to fund that program through future profits, and that’s why we help de-risk, and help remove the need for a heavy profit motive in developing these malaria medicines.”

This lack of profit motive in the development of drugs for malaria is essential because in order for these drugs to be accessible in some of the poorest areas, they need to be “aggressively affordable,” according to Jagoe.

“Affordability of medicines is at the very core of access. So, we don’t even start on a journey of drug development if we haven’t asked ourselves and our pharma partners really hard questions about affordability,” he said.

This is part of what he described as developing drugs for the “lowest common denominator,” which are drugs that are not only affordable, but are highly effective and easy to use in the most challenging of circumstances.

“The overarching principle for any drug we’re working on,” he said, “is ensuring that it truly is adapted to effective use by the countries and the health workers that are going to be grappling with a malaria case and need an efficacious, easy-to-use treatment that they’ve been well-trained on, and they can teach parents and caregivers how to use.”

“A decade of discovery and development of new antimalarial medicines has led to a renewed focus on malaria elimination and eradication. Changes in the way new antimalarial drugs are discovered and developed have led to a dramatic increase in the number and diversity of new molecules presently in pre-clinical and early clinical development. The twin challenges faced can be summarized by multi-drug resistant malaria from the Greater Mekong Sub-region, and the need to provide simplified medicines.” – MMV

Financing the Malaria Response: Striking the Balance Between International & Domestic Requires a More “Nuanced” Approach

In the year of both the Global Fund’s replenishment and the UN High-Level Meeting on UHC, when it comes to questions of health financing, all eyes are on countries to increase domestic allocations for health to at least the 15 percent set by the Abuja Declaration.

In this current context, “malaria is on the increase [in high burden countries], and the level of overall funding is levelling off, and certainly domestic funding is being reduced,” WHO’s Bosman noted.

At this critical moment, to ensure that the fight against malaria is not set back, Jagoe of MMV said that according to the WHO, “we need to go from under 3 billion dollars to closer to 6 billion dollars a year spent globally for malaria programs alone.”

“The international donor community is not going to be able to come up with that,” he said. “We’re out right now, in the Global Fund community, trying to get replenishment before the end of 2019, but knowing that it still will fall short. How will we go about finding other sources of funding?”

Bosman explained that the funding landscape can be fickle, moving to follow shifting priorities, but if you focus on “the burden of child mortality as a way of prioritising areas of intervention… especially in Africa, where the malaria burden is the highest… this could be a good way of ensuring that international funding is having an impact and having the greatest buy in terms of public health.”

When it comes to greatest buys, a recent study published in The Lancet Infectious Diseases that tracked malaria spending from 2000-2016 suggests that “[m]ajor up-front investments in new technologies—such as malaria vaccines, new drugs, or gene drive—have the potential to dramatically reduce the resources required to combat malaria in the future, particularly if coordinated financing mechanisms can make these technologies affordable.”

However, the question comes down to what is sustainable. At a Global Fund panel event last month in Geneva, Peter Sands of the Global Fund said that “we have to respect the fact that health ministers face very difficult trade-offs,” while adding frankly that “most low income countries are not spending enough money on health… not meeting the Abuja declaration of 15 percent.”

The Lancet study observes that “low levels of public financing suggest [that] raising additional public revenues might be an opportunity for more malaria financing,” however the “mechanisms used to mobilise additional funds are not immediately apparent,” it says.

“But how to then elicit more allocations of domestic funding is a complex exercise altogether,” Bosman conceded, as many governments don’t even have budget lines for certain diseases if there is external funding. “We have seen this for many years that when the Global Fund was providing good financial support, paradoxically then the government funds would be reduced to support other public health programmes for which there is no existing international funding mechanism.”

He added that the Global Fund has since put in place mechanisms to negotiate what is required from governments in terms of matching funds, and according to the Global Fund this is now equivalent to 15-30 percent of the allocated grant.

“The fight against malaria is one of the biggest public health successes of the 21st century… However, after many years of breathtaking progress, malaria is on the rise… This is a fight we can win, if we build and maintain unwavering commitment,” says the Global Fund. Photo: The Global Fund/Jonas Gratzer

“It is complex,” Jagoe underlined, as “historically, since we have been in many of these countries working off a donor-driven financing model, it’s hard, because we’re talking about decades in some cases of a model that has been used, and that now needs to be re-engineered.”

To add to the complexity, he posed the question: “How much can a national budget go to health care, when under austerity programs due to debt servicing?” adding that there are a lot of “macro forces” putting pressure on how far governments can go in terms of budget allocations.

It’s not just about international and domestic, he said. “It has to be nuanced and multifaceted.”

In addition to calls for increased domestic health funding, the Ministers of Health of the Non-Aligned Movement of 120 developing countries issued a statement on UHC urging “donor countries to honor their commitments to allocate 0.7% of their gross domestic product for official development assistance… to support international cooperation programs in health and strengthen national health systems.”

According the RBM Partnership’s AIM report, “[m]alaria prevention and treatment are among the most cost-effective public health interventions.” While costs of achieving 2030 malaria goals are high at US$101.8 billion, with an additional US$673 million needed each year to fund malaria R&D, “the benefits will be even greater – more than 10 million lives will be saved and over US$4 trillion of additional economic output generated.”

Bosman agreed that especially in high burden countries, malaria is a “best buy.” He noted that “a rapid diagnostic test could be like 20 cents of a dollar. A long-lasting net, which may last you 2 years, is around 2.5 dollars. If you look at a treatment for malaria with an ACT, a combination therapy with artemisinin, for an adult you are down to 70 cents, so it’s less than a dollar. So for preventing death due to malaria, these investments are extremely cost effective.”

On the other hand, he explained that as a country moves towards elimination and malaria cases become more sporadic, while still requiring significant resources to prevent resurgence, “that’s the most difficult moment for malaria elimination – to keep the focus, to keep the momentum and the investments.” It is at this point that malaria-free certification comes in, he said. It’s a political incentive to stay the course, and permanently eliminate the disease in the country.

Image Credits: WHO/Fanjan Combrink, WHO, MMV, Ben Moldenhauer / MMV, Source: MMV, The Global Fund.

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