ATM | 06 June 20081 |

MMV Access Symposium 2008 Accra, Ghana

Expanding Reach of ACTs in the Private Sector: Dialogue with Countries

ATM | 06 June 20082 |

The State of ACT Access in AFRO Countries

Dr Nathan Bakayita, WHO AFRODr Jackson Sillah, WHO/IST West Africa

Dr Felicia Owusu-Antwi, WHO Country Office, Ghana

Accra, Ghana, 2 June 2008.

ATM | 06 June 20083 |

Outline of presentation

• Introduction – Global overview of malaria treatment policy change and implementation

• Impact of implementing ACT treatment policies • ACT procurements • Appropriate treatment coverage in AFRO• Challenges of implementing ACT treatment

policies• Conclusions and recommendations

ATM | 06 June 20084 |

Global Status of ACT Implementation

Countries which need ACT policy

Countries which adopted ACT Countries Deploying ACTs Countries with ACTs at Community level

Update: Update: May 2008May 2008

ATM | 06 June 20085 |

76 countries have adopted ACTsContinent Countries Drug Line

Burundi, Cameroon, Congo, Côte d'Ivoire, Democratic Republic of Congo, Eq. Guinea, Gabon, Ghana, Guinea, Liberia, Madagascar, Eritrea, Mali, Mauritania, Senegal,

Sao Tomé & Principe (ST&P), Sierra Leone, Sudan (S), Tchad, Zanzibar

AS + AQ 1st

Angola, Benin, Botswana, Burkina Faso, Central African Republic, Comoros, Ethiopia,Gambia, Guinea Bissau, Kenya, Malawi, Mozambique, Namibia, Niger, Nigeria, Rwanda,

Uganda, S. Africa, Tanzania, Togo, Zambia, Zimbabwe

AL 1st

Côte d'Ivoire, Djibouti, Gabon, Sudan (N), ST&P, Zanzibar AL 2nd

AFRICA

Djibouti, Somalia, Sudan (N) AS + SP 1st

Cambodia, Malaysia, Thailand AS + MQ 1st

Bangladesh, Bhutan, Laos, Myanmar, Philippines, PNG, Solomon Islands, Sri Lanka,Vanuatu,

AL 1st

Indonesia AS + AQ 1st

Afghanistan, India, Iran, Pakistan, Saudi Arabia, Tajikistan, Yemen AS + SP 1st

Viet Nam, China DP 1st

ASIA

Iran, Papua New Guinea, Saudi Arabia AL 2nd

Ecuador, Peru AS + SP 1st

Bolivia, Colombia, Peru, Venezuela AS + MQ 1st

SOUTHAMERICA

Brazil, Colombia, Guyana, Suriname AL 1st

58 are deploying ACTs

58 are deploying ACTs

Updated May 2008

AQ=amodiaquine; AL=artemether/lumefantrine; AS=artesunate; DP=dihydroartemisinin/piperaquine; MQ=mefloquine; SP=sulfadoxine/pyrimethamine;

ATM | 06 June 20086 |

ACT adoption and implementation in AFROSource: WHO Reports.

20

3436

40 41

0 14 4

11

19

25

7

1 3

36

0

5

10

15

20

25

30

35

40

45

20012002

20032004

20052006

20072008

Y

Num

ber O

f Cou

ntrie

s

• Implementation

• Adoption

ATM | 06 June 20087 |

WHAT HAS BEEN THE IMPACT OF POLICY CHANGE

TO ACTS?

ATM | 06 June 20088 |

Malaria Notifications in KwaZulu Natal before (2000) and after (2001 – 2002) effective residual spraying w DDT and deployment of artemether-lumefantrine

0

1000

2000

3000

4000

5000

6000

7000

Jan Mar May July Sep Nov

Artemether-lumefantrine implemented in January 2001

2000

2001

2002

ATM | 06 June 20089 |

ATM | 06 June 200810 |

Proportion of confirmed malaria cases: ZanzibarSource: NMCP Zanzibar Report October 2007.

0.6%

40.7%

0

20000

40000

60000

80000

100000

120000

2003 2004 2005 2006 2007

# B

lood

slid

es

0.0%5.0%10.0%15.0%20.0%25.0%30.0%35.0%40.0%45.0%

% p

ositi

ve s

lides

BS Grand Total BS positive Grand Total Positivity Rate

ATM | 06 June 200811 |

WHAT VOLUMES OF ACTSHAVE BEEN SUPPLIED?

ATM | 06 June 200812 |

ACT ProcurementsSource: Andrea Bosman GMP/WHO (personal communication) 140508

• Procurements– 2006 : 82.7 million doses– 2007 : 97 million doses

• Forecasts for Coartem®– 2008: 107 million doses– 2009: 113 million doses

• Funding for ACTs from GFATM

ATM | 06 June 200813 |

Adoption and deployment of ACTs procurement and forecast

0.5 0.6 2.1 5

31.3

82.7

97

140

0

20

40

60

80

100

120

140

2001 2002 2003 2004 2005 2006 2007 20080

10

20

30

40

50

60

70

80

ACT procured No countries: ACT 1st line No countries deploying

Mill

ions

of A

CT

trea

tmen

tco

urse

s

Cum

ulat

ive

num

bero

f cou

ntrie

s

Forecast

ATM | 06 June 200814 |

WHO ARE THE DRUGS REACHING? AND HOW?

ATM | 06 June 200815 |

Proportion of children under five with fever who used any antimalarial in 2005-2007Source DHS, MICS and MIS 2005-2007

0 1 0 2 0 3 0 4 0 5 0 6 0 7 0

Z i m b a b w eR w a n d a

M a l a w iS a o T o m e a n d P r i n c i p e

S e n e g a lA n g o l a

B u r u n d iN i g e r

C ô t e d ' I v o i r eG u i n e a

G u i n e a - B i s s a uB u r k i n a F a s o

T o g oC o n g o

S i e r r a L e o n eB e n i n

C e n t r a l A f r i c a n R e p u b l i cC a m e r o o n

T a n z a n i aZ a m b i aG h a n a

U g a n d aG a m b i a

%

ATM | 06 June 200816 |

Proportion of children with fever who used any antimalarial vs. ACT in relation to the year ACT policy was adopted in selected countries

Country Used Any

Antimalarial % Used ACT % SOURCE Year ACT Policy AdoptedAngola 29 2 MIS (2007) AL (2006)

Burundi 30 3 MICS (2006) AS+AQ (2003)

Cameroon 58 3 MICS (2006) AS+AQ (2004)

Central African Republic 57 3 MICS (2006) AL

Cote d'Ivoire 36 3 MICS (2006) AS+AQ (2003)

Gambia 63 <1 MICS (2006) AL (2005)

Ghana 61 4 MICS (2006) AS+AQ (2004)

Malawi 24 <1 MICS (2006) AL (2007)

Rwanda 19 5 MIS (2007) AL (2005)

Sao Tome and Principe 25 6 MICS (2006) AS+AQ (2004)

Sierra Leone 52 1 MICS (2006) AS+AQ (2004)

Togo 48 1 MICS (2006) AL

Uganda 62 1 DHS (2006) AL(2004)

Zambia 58 13 MIS(2006) AL (2002)

Source : DHS, MICS and MIS (2006-2007)

ATM | 06 June 200817 |

Use of any antimalarials and ACTs by children with a malaria episode in UgandaSource: Adapted from Uganda MOH-MMV household survey, 2007.

38.9

24.428.9

20.1

46.5

31.5

0

10

20

30

40

50

Kamuli (N=711) Pallisa (578) Soroti (545)

%

24 hrs from onset of fever 48 hrs from onset of fever

Any antimalarial: Less than 30% ACT: Less than 4%

3.2 3.8 3.55.5 6.6 5.1

0

10

20

30

40

50

Kamuli (N=711) Pallisa (N=578) Soroti (N=545)%

Within 24 hours Within 48 hours

Source: MoH-MMV household surveys

ATM | 06 June 200818 |

Source of antimalarials for under 5s by socio-economic quintiles (e.g Uganda)Source Uganda MOH-MMV Household Surveys, 2007.

0% 20% 40% 60% 80% 100%

Lowest quintile(n=111)

Second quintile(n=165)

Middle quintile(n=89)

Fourth quintile(n=181)

Highest quintile(n=159)

Govt healthfacility

CMD

Private disp. /clinic

Drug shop

Pharmacy

Other

ATM | 06 June 200819 |

WHAT ARE THE CHALLENGES?

ATM | 06 June 200820 |

Challenges at Country Level

• Limited capacity of NDRA to register appropriate ACTs, enforce withdrawal of monotherapies, etc

• Weak procurement and supply chain management system (monitoring stock levels, quantification and re –ordering mechanisms, drug distribution systems)

• Limited capacity of central medical stores and NMCPs to handle bulkier medications with short shelf-life, multiple course-of-therapy packs (per different age-groups; paediatric formulation) and relatively higher volume of goods.

• Synchronisation of policy-change activities • Funding uncertainities.. dependance on donor agencies (e.g GF)

ATM | 06 June 200821 |

Challenges at Country Level

• Poor diagnostics and declining malaria transmission in some countries leading to wastage.

• Presence of counterfeit medications and low quality ACTs in the market.

• Weak surveillance, monitoring and evaluation systems

• Getting affordable ACTs into the private sector and at community level

• Price regulation in the public and private sectors

ATM | 06 June 200822 |

Challenges at Global/Regional Levels

• Compliance of ACT manufacturers with international quality standards as set by WHO pre-qualification programme

• Forecasting and quantification of demand for Artemisinin and ACTs

• Impending ACT shortage 2009-2010 (expected API reduction in the market due to low price of Artemisinin in 2007 – 2008 with consequent farmers withdrawal, and several API producers run bankrupt).

• Continue marketing of Oral Artesunate monotherapy in some countries.

ATM | 06 June 200823 |

Summary conclusions• Most countries have adopted ACTs and have begun

implementation.• Scaling up use of ACTs reduces malaria morbidity

and mortality. • Coverage of ACTs for children under 5 yrs old is still

very low. • Majority of patients still seek care from the private

sector.

ATM | 06 June 200824 |

• There is need to urgently address issues limiting access to ACTs.

• Countries need to put in place measures that are appropriate to their country context to ensure broader coverage of ACTs.

• All possible channels including the private sector should be used to increase access to ACTs.

Recommendations

ATM | 06 June 200825 |

THANK YOU FOR YOURKIND ATTENTION

Meda mo ase pii !!!!!!.