The global context for financing delivery innovations in fever case management and malaria treatment. Ramanan Laxminarayan

Transcription

1 The global context for financing delivery innovations in fever case management and malaria treatment Ramanan Laxminarayan

2 Changed environment 1. Greater challenges in continued funding for global health (including malaria)

3 Global Malaria-Control Funding Commitments, (US$ millions) Commitment (US$ millions) Year Source: Global Fund, World Bank, US-PMI

4 Global Malaria-Control Funding Commitments Over 7 Years by Donor ( ) Other donors World 7% Bank 8% USAID and PMI 15% Global fund 70% Total commitments between = approx. $4.6 billion Source: Roll Back Malaria, 2010

5 Number (millions) of ITNs, ACTs, and RDTs reported by national programs to have been distributed by year ( ) Numbers distributed (milions) ITNS 50 ACT courses 40 RDTS Year Source: World Malaria Report, 2009

6 Percentage of Febrile Children Under 5 Who received ACTs in 7 Countries (two recent years) Mozambique Tanzania Zambia Ghana Uganda Liberia Proportion of febrile children who received ACTs (%) 90.0 Sierra Leone Source: UNICEF global malaria databases

7 Changed environment 1. Greater challenges funding for global health (including malaria) 2. Less malaria in many countries as a result of recent investments

8 Malaria Deaths in 8 Countries 2004 and Reported Malaria Deaths CAF Ethiopia Gabon Kenya Madagascar Rwanda Senegal Zambia COUNTRY World Malaria Report

9 D Acremont et al, Malaria J 2010

10 Proportion of malaria among fevers in children under 5 Source: D Acremont V, Lengeler C, Genton B: Reduction in the proportion of fevers associated with Plasmodium falciparum parasitaemia in Africa: a systematic review. Malar J 2010, 9:240.

11 Guerra et al Plos Med 2008

12 Relationship between the percentage of febrile children with infection and infection prevalence among all children Okiro and Snow, Mal J, 2010

13 Relationship between the percentage of febrile children with infection and infection prevalence among children who did not report a fever Okiro and Snow, Mal J, 2010

14 Time for RDTs? Over million children aged less than five years live in areas where parasite prevalence is less than 40% representing 44.5% of children in P. falciparum malaria endemic countries in Africa.

15 Changed environment 1. Greater challenges funding for global health (including malaria) 2. Less malaria in many countries as a result of recent investments 3. AMFm experience showing the feasibility of using private sector supply chains

16 Median price ($) for an adult-equivalent treatment dose in the formal sector (tablet formulation only), by anti-malarial type in six 14 countries (June October 2011) Price (US $) 8 Ghana Kenya Nigeria Madagascar 6 Uganda Tanzania AMFm AL AMFm AS/AQ non-act SP non-amfm AL Antimalarial type Source: ACTWATCH. Health Action International. Retail Prices of ACTs co-paid by the AMFm and other antimalarial medicines: report of price-tracking surveys. Sept/Oct 2011

17 Median price ($) for an adult-equivalent treatment dose in the informal sector (tablet formulation only), by anti-malarial type in six countries (June October 2011) Price (US $) 2.5 Ghana Kenya 2 Nigeria 1.79 Uganda Tanzania 1.3 Madagascar AMFm AL AMFm AS/AQ non-act SP non-amfm AL Antimalarial type Source: ACTWATCH. Health Action International. Retail Prices of ACTs co-paid by the AMFm and other antimalarial medicines: report of price-tracking surveys. Sept/Oct 2011

18 AMFm Early Results: Reducing Prices, Increasing Affordability Median prices of AL 20/120mg (pack size 6x4) by country: AMFm vs. non-amfm, Sept 2011 AMFm Non-AMFm(OB) Non-AMFm(LPG) Price (US $) FORMAL INFORMAL FORMAL INFORMAL FORMAL INFORMAL FORMAL INFORMAL FORMAL INFORMAL FORMAL INFORMAL GHANA KENYA NIGERIA TANZANIA MADAGASCAR UGANDA OB = Originator Brand; LPG = Lowest-Price Generic Source: Health Action International. Retail Prices of ACTs co-paid by the AMFm and other antimalarial medicines: report of pricetracking surveys. Sept/Oct 2011

19 Unchanged

20 Role for Malaria RDTs? Benefits Reduce ACT use and costs Indicate appropriate treatment for patient Potentially lower likelihood of antimalarial resistance

21 Can we lower resistance without compromising on use?

22 Role for Malaria RDTs? Benefits Reduce ACT use and costs Indicate appropriate treatment for patient Potentially lower likelihood of antimalarial resistance Challenges Delivery and adherence to results The key is not in the technology, but in attitude and behavior change amongst clinical prescribers Whitty et al, 2010

23 Role for Malaria RDTs? Benefits Reduce ACT use and costs Indicate appropriate treatment for patient Potentially lower likelihood of antimalarial resistance Challenges Delivery and adherence to results Impact on antibiotic use

24 WHO Guidelines for the Treatment of Malaria, 2nd edition 2010 Prompt parasitological confirmation by microscopy or by RDTs is recommended in all patients suspected of malaria before treatment is started.

25 Etiologies of fever in 1005 Tanzanian children 1212 diagnoses Slide courtesy Valerie D Acremont

26 Bisoffi et al TMIH 2009

27 Ansah et al BMJ 2010

28 D Acremont et al Mal J 2011

29 Impact of mrdt introduction

30 Management of suspected malaria in Senegal public health services, Thiam et al Plos ONE 2011

31 Thiam et al Plos ONE 2011

32 But RDTs in informal private sector remain a challenge

33 Creating Incentives for Diagnosis Before Treatment Cost-effective Expansion Paths for RDT Use The Issue of RDT Negatives 33

34 Assumptions 1. Increased availability of and experience with treatment options for RDT negative cases will lead to increased provider/patient compliance with RDT results. 2. Technological progress will continue to offer better and easier-to-use RDT options for malaria and for other febrile illnesses 34

35 Which Expansion Paths Should Be Financed First? OR Which Direction of Expansion Yields the Greatest Health Gain per Unit of Available Resources? 35

36 Three Dimensions of Cost 1. Financial the things that money can buy 2. System capacity things money can t buy (in the short run) 3. Drug Resistance 36

37 Alternative Expansion Paths 100% Goal Low EIR environment Today 0% 0% 100% High EIR environment 37

38 Alternative Expansion Paths 100% Goal RDT use in the informal private sector Today 0% 0% 100% RDT use in public and formal private facilities 38

39 Alternative Expansion Paths 100% Goal Where treatment for NMFIs not available Today 0% 0% 100% Where treatment for NMFIs available 39

40 Four principles of RDT + drug incentives 1. RDT should be preferred to no-rdts by both retailer and consumer 2. Retailer should be indifferent between choice of treatment following RDT 3. Consumer should prefer the correct choice of drug following RDT 4. Financiers should be better off with RDTs alongside ACT financing relative to no-rdts

41 RDT should be preferred to no-rdts by both retailer and consumer Solution subsidize RDTs and make it profitable for retailers to sell them, and for consumers to buy them by subsidizing ACTs conditional on RDT results.

42 Retailer should be indifferent between choice of treatment following RDT Solution override provider preferences with consumer preferences

43 Consumer should prefer the correct choice of drug following RDT Solution make them financially better off with appropriate treatment.

44 Financiers should be better off with RDTs alongside ACT financing relative to nordts Solution ensure that cost of RDT subsidy is more than offset by benefit due to reduction in ACT needs

45 Broader Challenge Treatment strategy in world with less malaria but not malaria-free? Change in paradigm to management of management of febrile illness using RDTs as information tool

46 Pneumonia declines concurrent with a reduction in anti-microbial prescriptions 90 (% reduction 80 in pneumonia mortality) Significant reduction in pneumonia mortality following introduction of IMCI... (# of patients) Study result with 95% C.I Occurs in conjunction with prescribing 45 rationalization that lowers overall drug use on Standard consultation um 2 Al lp ne pp illi ia ns ea ni a sh Ta n za Ph Ba ng la de st an ki Pa In di a 0 Note: Number of drugs given in ICMI and standard consultations includes all formulations and different drugs, and also counts vitamins and supplements not strictly for pneumonia care Source: Black (Lancet Inf Dis 2003), Okeke (Lancet Infect Dis 2005) (# of different drugs given)

47 Broader Challenge RDTs through community health workers is possible in Asia and Latin America, but Africa? But real impact will require private sector involvement

48 Over 70% of antimalarials are bought in the private sector

49 Broader Challenge Incentives of patients and providers in private sector are key Need to define micro-financing architecture for RDTs and ACTs And identify macro-financing needs under various scenarios of ACT and RDT wholesale and retail prices