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The$Politics$of$Malaria$Elimination: Strategic)Choices

Matthew'Lynch,'PhD Johns&Hopkins&University

The$material$in$this$video$is$subject$to$the$copyright$of$the$owners$of$the$material$and$is$being$provided$for$educational$purposes#under rules&of&fair&use&for&registered&students&in&this&course&only.&No&additional&copies&of&the&copyrighted&work&may&be&made&or&distributed.

What%Is%Malaria%and%Why%Should%I%Care?

The$Spatial$Distribution$of$P.#falciparum#Malaria—A"Disease"of" Poverty

Lifecycle(of( Plasmodium Parasite

Key$Points$on$ Transmission— 1"

► It#requires#an#Anopheles mosquito

► Anopheles mosquitoes)largely)bite)indoors,)at)night,)but)we’re) putting'selection'pressure'on'…'

► It#requires#time#and#temperature#in#mosquitoes

Key$Points$on$ Transmission— 2"

► It#requires#an#Anopheles mosquito

► Anopheles mosquitoes)largely)bite)indoors,)at)night,)but)we’re) putting'selection'pressure'on'…'

► It#requires#time#and#temperature#in#mosquitoes

► Requires(a(relatively(large(infected(human(population(to(infect( enough'mosquitoes'at'bite'#1

► Requires(a(lot(of(human!vector'contact'to'have'a'reasonable' probability*to*infect*humans*at*bite*#2

► If#mosquito#dies/is#killed#between#bite##1#and#bite##2,#no# transmission)happens

Control'Opportunity)Points—1"

► In#the#human:#treat#the#parasite,#eliminate#gametocytes#to#stop#infecting#mosquitoes

► In#the#mosquito:#vaccine#opportunity?

► In#the#puddle:#drain#or#manage#breeding#sites#to#reduce#mosquito#populations

► In#the#bedroom:#get#insecticides#into#bedrooms#to#kill#mosquitoes#either#on#nets#or# sprayed(on(walls

Control'Opportunity)Points—2"

► In#the#human:#treat#the#parasite,#eliminate#gametocytes#to#stop#infecting#mosquitoes

► In#the#mosquito:#vaccine#opportunity?

► In#the#puddle:#drain#or#manage#breeding#sites#to#reduce#mosquito#populations

► In#the#bedroom:#get#insecticides#into#bedrooms#to#kill#mosquitoes#either#on#nets#or# sprayed(on(walls

► No#single#intervention#alone#will#“solve”#the#problem

Priority'Roll' Back%Malaria% Partnership+ (RBM)&& Interventions— 1"

► Long!lasting(insecticidal(nets((LLINs) ► Catch!up:$universal$coverage$campaigns ► Keep!up:$continuous$distribution$systems

Priority'Roll' Back%Malaria% Partnership+ (RBM)&& Interventions— 2"

► Long!lasting(insecticidal(nets((LLINs) ► Catch!up:$universal$coverage$campaigns ► Keep!up:$continuous$distribution$systems

► Indoor&residual&wall&spray ► In#appropriate#settings

Priority'Roll' Back%Malaria% Partnership+ (RBM)&& Interventions— 3"

► Long!lasting(insecticidal(nets((LLINs) ► Catch!up:$universal$coverage$campaigns ► Keep!up:$continuous$distribution$systems

► Indoor&residual&wall&spray ► In#appropriate#settings

► Diagnosis(and(treatment ► Diagnosis:)RDTs)and)microscopy ► Artemisinin)combination)therapies)(ACTs)

Priority'Roll' Back%Malaria% Partnership+ (RBM)%% Interventions— 4"

► Long!lasting(insecticidal(nets((LLINs) ► Catch!up:$universal$coverage$campaigns ► Keep!up:$continuous$distribution$systems

► Indoor&residual&wall&spray ► In#appropriate#settings

► Diagnosis(and(treatment ► Diagnosis:)RDTs)and)microscopy ► Artemisinin)combination)therapies)(ACTs)

► Intermittent(preventive(therapy ► Treatment(dose(of(SP(as(early(as(possible(in(second(trimester(

(~13%weeks)%at%each%antenatal%visit%at%least%one%month%apart% in#moderate!high$transmission$settings$in$Africa

Politics

► Politics(is(“the(process(of(allocating(resources”

► It#happens,#whether#there’s#political#intent#or#not

► When%resources%are%limited,%priorities%must%be%set,%therefore: ► Deciding(who(gets(to(set(the(priorities(drives(most(political(actions ► Deciding(priorities(is(a(process,(with(many(factors(involved,(some(technical,(some(

financial,(some(emotional

History

► Global&Malaria&Elimination&Program&1955!1969 ► WHO$led$program,$based$on$one$technical$tool:$indoor$residual$spraying$with$DDT ► Financed(largely(by(one(donor:(USA ► Achieved(significant(successes(in(South(America,(Asia,(and(Europe ► Explicitly)excluded)Africa)due)to)logistic)challenges ► Its$“failure”$in$the$early$1970s$blocked$progress$on$global$malaria$control$for$about$30$

years

Resurging)Deaths)in)the)1990s

► After&abandoning&IRS/vector&control&in&1969,&major&tool&was&chloroquine&treatment,&and& focus&for&Africa&was&on&strengthening&access&to&treatment&through&health&facilities,&in&the& next%WHO%strategy%(1993)

► CQ#was#safe,#cheap,#effective#…#until#it#wasn’t

► In#1990s,#deaths#from#malaria#started#rising#rapidly,#as#parasite#resistance#spread#from#SE# Asia%across%the%world

Estimated)Malaria)Deaths)1980!2010

Source:"The$Lancet."DOI: http://dx.doi.org/10.1016/S0140!6736(12)60034!8

What’s'Being'Done'about'Malaria? What%Are%the%Key%Issues$and$Challenges?

Eventually,+a+Response—1"

► Roll$Back$Malaria$Partnership$created$in$1998$by$UNDP,$World$Bank,$UNICEF,$and$WHO

► USAID&begins&increasing&funding&around&2001

► Global&Fund&created&and&adds&malaria&to&the&Fund

Eventually,+a+Response—2"

► Roll$Back$Malaria$Partnership$created$in$1998$by$UNDP,$World$Bank,$UNICEF,$and$WHO

► USAID&begins&increasing&funding&around&2001

► Global&Fund&created&and&adds&malaria&to&the&Fund

► Advocacy(and(controversy ► Slow%shift%away%from%chloroquine to#more#effective#drugs

The$Lancet$Editorial,**2004

WHO,%the%Global%Fund,%and%medical%malpractice%in%malaria%treatment

Source:(Attaran,"Amir"et"al."(2004)."WHO,"the"Global"Fund,"and"medical"malpractice"in"malaria"treatment."The$Lancet, 363(9404),) 237$– 240;"http://dx.doi.org/10.1016/S0140!6736(03)15330!5

Technical)Consensus

► Changing'first!line%treatment%policies ► CQ’s%hold%on%the%medical%community:%“a%sentimental%attachment” ► The$cost$of$changing,$and$doubts$on$sustained$donor$support ► Negotiating)for)prices)and)sufficient)stocks)(WHO)and)Novartis) ► Creating)a)momentum)for)change)(Malawi’s)taking)the)heat)for)changing)early)to)SP)

Vector'Control' Debates

Building(Technical(Consensus:(Vector(Control—1"

► Early&family&fights: ► Sprayers(versus(nets ► Free$nets$versus$sustainable$supply$chains

Building(Technical(Consensus:(Vector(Control—2"

► Early&family&fights: ► Sprayers(versus(nets ► Free$nets$versus$sustainable$supply$chains

► Diagnosis(and(surveillance:

Building(Technical(Consensus:(Vector(Control—3"

► Early&family&fights: ► Sprayers(versus(nets ► Free$nets$versus$sustainable$supply$chains

► Diagnosis(and(surveillance:(test,(treat,(track

Building(Technical(Consensus:(Vector(Control—4"

► Early&family&fights: ► Sprayers(versus(nets ► Free$nets$versus$sustainable$supply$chains

► Diagnosis(and(surveillance:(test,(treat,(track

► Gates’'paradigm'change—coordinated*pressure*on*parasite*via*host*and*vector*reservoirs

► Moving'into'local'variations'and'increasing'complexity

Diagnosis(and(Surveillance—1"

► Conventional*wisdom*for*decades:*fever*=*malaria

► Burden'of'misdiagnosis'was/is'significant

► Resistance)to)change

► Slow%erosion%of%slide%microscopy’s%hold%on%therapeutic%diagnosis

Diagnosis(and(Surveillance—2"

► Conventional*wisdom*for*decades:*fever*=*malaria

► Burden'of'misdiagnosis'was/is'significant

► Resistance)to)change

► Slow%erosion%of%slide%microscopy’s%hold%on%therapeutic%diagnosis

► Reporting*diagnostic*results

► Compiling)and)communicating)surveillance)data)for$decision$making

Changing'Goals—1"

► Mortality)) ► “A#million#kids#are#dying” ► Focus&on&stopping&the&carnage ● Access%to%effective%treatment ● Replacing*clinical*diagnosis ● ITNs%for%vulnerable%populations%(pregnant%women%and%infants)

Changing'Goals—2"

► Realizing)the)importance)of)scale)and)centrality)of)transmission,)therefore)allocation)of) resources

Changing'Goals—3"

► Realizing)the)importance)of)scale)and)centrality)of)transmission,)therefore)allocation)of) resources

► Elimination

Changing'the'Goalposts

The$“e!word”&emerges,'Seattle,'2007

The$Attraction$of$Elimination

► Return'on'investment/allocation'of'resources ► The$US$recoups$its$1967$investment$of$$100$million$for$smallpox$eradication$about$

every%26%days%…%forever ► ROI$for$polio$elimination$in$the$US$is$450:1 ► ROI$is$lowest$right$before$elimination:$few$cases,$high$costs

Resurgence)following)Budget)Cuts

Source:"Cohen&et&al.$(2012).$Malaria$Journal.$http://dx.doi.org/10.1186/1475!2875!11!122

Resource( Availability

Source:"WHO$World$Malaria$Report.((2014).

Donor%Dependence%or%Domestic%Investment?—1"

► Who’s&needs&are&served&by&elimination?

► Is#it#donor#dependence,#or#simply#a#coldly#rational#investment#mix? ► Lowest'cost'is'to'be'the'last'country'to'eliminate ► Where%within%endemic%countries%does%the%burden%fall?

Donor%Dependence%or%Domestic%Investment?—2"

► Who’s&needs&are&served&by&elimination?

► Is#it#donor#dependence,#or#simply#a#coldly#rational#investment#mix? ► Lowest'cost'is'to'be'the'last'country'to'eliminate ► Where%within%endemic%countries%does%the%burden%fall?

► Political(systems:—does%democracy%facilitate%elimination?%Or%strong%business%elites?

Global&Response—Key$Issues$and$ Challenges

Work%of%the%RBM%Partnership

► Advocacy(to(raise(awareness,(particularly(at(global(institution(level

► Resource(mobilization

► Facilitating)coordinated)responses)with)articulated)global)priorities,)for)example ► Replacing*CQ*with*ACTs ► Increasing*access*to*ITNs*for*biologically*vulnerable*populations ► Promoting)treatment!seeking'behaviors

RBM$Redux—1"

► Reorganized+to+sharpen+focus+on+elimination,+increase+efficiency

► Change'in'hosting'from'WHO'to'UNOPS

► Board&no&longer&constituency!based,'now'action!oriented(rather(than(representative

RBM$Redux—2"

► Reorganized+to+sharpen+focus+on+elimination,+increase+efficiency

► Change'in'hosting'from'WHO'to'UNOPS

► Board&no&longer&constituency!based,'now'action!oriented(rather(than(representative

► Technical)working)groups)continue)as)info!sharing,)collaboration)fora)

► Partner'Committees'within'management'structure'for'core'partnership'roles

Current'Issues—1"

► Emerging(resistance ► Parasite(resistance(to(drugs ► Mosquito(resistance(to(insecticides

Current'Issues—2"

► Emerging(resistance ► Parasite(resistance(to(drugs ► Mosquito(resistance(to(insecticides

► Targeting)resources ► When%does%one%go%after%the%toughest%places? ► Balancing(consolidation(with(maintaining(forward(progress

Current'Issues—3"

► Emerging(resistance ► Parasite(resistance(to(drugs ► Mosquito(resistance(to(insecticides

► Targeting)resources ► When%does%one%go%after%the%toughest%places? ► Balancing(consolidation(with(maintaining(forward(progress

► Surveillance+and+localized+data ► Epidemiology+increasingly+complex+ ► Requires(significant(domestic(commitment

Current'Debates—1"

► Restructuring+RBM+for+elimination+

► Innovation(and(new(tools ► Gates’'role:'who'else'funds'new'ideas?'Is'this'a'dangerous'bottleneck? ► Private(sector(incentives(versus(public(goods

Current'Debates—2"

► Restructuring+RBM+for+elimination+

► Innovation(and(new(tools ► Gates’'role:'who'else'funds'new'ideas?'Is'this'a'dangerous'bottleneck? ► Private(sector(incentives(versus(public(goods

► Advocacy(as(a(central(function(of(partnership

► Maintaining'representation'from'beneficiaries'versus'efficiency'for'fast'results

Looking'Forward—1"

► New$tools?$Vaccine?

► Necessity(of(mobilizing(awareness(and(resources(from(subnational(levels(down(to( households

Looking'Forward—2"

► New$tools?$Vaccine?

► Necessity(of(mobilizing(awareness(and(resources(from(subnational(levels(down(to( households

► Riding&the&broader&development&wave—improved)housing,)electrification,)incomes

► Maintaining'political'priority ► When%to%tackle%the%tough%spots? ► Focusing)on)cases)averted)to)keep)the)funds)flowing

Tough& Questions—1"

► How$to$stimulate$endemic$country$domestic$investment$of$ resources,(human(and(financial?

► How$to$maintain$global$donor$interest$and$commitment?

► What’s'the'right'technical'mix'needed?'

► When%can%one%“graduate”%areas?%

► How$does$the$elimination$process$work,$biologically?$Is$there$a$ tipping&point?

Tough& Questions—2"

► How$to$stimulate$endemic$country$domestic$investment$of$ resources,(human(and(financial?

► How$to$maintain$global$donor$interest$and$commitment?

► What’s'the'right'technical'mix'needed?'

► When%can%one%“graduate”%areas?%

► How$does$the$elimination$process$work,$biologically?*Is#there#a# tipping&point?

► Is#economic#development#an#outcome,#or#an#input?