Case Studies of successful industry involvement in malaria control programmes
Private companies have increasingly been playing an important role in malaria control in the region through a number of engagement modalities such as:
- Engaging in advocacy and lobbying.
- Multi-company coalitions to support national programmes with a private sector focus.
- Financial support to malaria programmes.
- Implementation of high quality malaria treatment and control services, both within and outside the fence. The latter can have a particularly profound impact where companies are working in remote populated areas beyond the reach of national health services.
Donors, governments and regional bodies are increasingly recognizing the important role that the private sector has been playing and could increasingly play in making good quality malaria interventions more accessible.
In 2012 the Australia Department for International Development convened a conference to consider the role of the private sector in malaria control in the Asia-Pacific region. A number of useful issue papers were prepared for this meeting.
Case studies of successful private involvement in malaria control collated by Montrose International are summarised here:
Elimination of Taxes and Tariffs, Papua New Guinea
In 2011, the Malaria Taxes and Tariffs Advocacy Project (M-TAP) reported that only six countries worldwide had completely removed tariffs on products used to fight the disease despite agreement to do so ten years ago. Dropping taxes and tariffs can play a key role in cutting costs because the vast majority of medicines and other products used to fight malaria are imported. These are: LLINs, ACTs, RDTs, insecticides for indoor spraying, and insecticide spray pumps.
M-TAP, which has been gathering evidence from nearly 80 malarious countries over the two year project, found that taxes and tariffs on anti-malarial products provide only minimal revenues, and these gains are often offset by health costs and lost productivity from preventable malaria illnesses. In Cambodia, M-TAP found that non-tariff barriers present more obstacles for importation than existing taxes and tariffs, for example, in issues of procurement and supply management. Private sector providers continue to play a critical role in supplying access to malaria treatment and prevention despite the huge increase in donor commitments over the past five years, so removal of taxes and tariffs are another way to ensure that cost does not pose a significant barrier to access
Affordable Medicines Facility for Malaria (AMFM), Cambodia
Despite efforts to assure quality of care in the provision of ACTs, an alarming resistance to artesunate (an active derivative of artemisinin) was documented in western Cambodia. The poorly regulated private sector, where approximately 70 per cent of fever-sufferers seek treatment, is believed to have contributed to this resistance development by dispensing artemisinin based monotherapies (AMTs) and sub-therapeutic doses of artemisinin.
The government reconsidered its use of the private sector in its battle against malaria. International support programs offered new opportunities to test market-based incentives that compel the private sector to provide optimal malaria care. The AMFm, hosted and managed by the Global Fund, invited Cambodia (and six other countries) to participate in its plan to flood their markets with highly subsidised formulations of ACTs that are so inexpensive that private sector providers can sell them as profitably as AMTs and other ineffective treatments. The AMFm program required participating countries to partner with the private sector for the distribution of ACTs.
The AMFm enables private importers to pay up to 80 per cent less than they did in 2008-2009. It pays most of this reduced price (a ‘buyer co-payment’) directly to the manufacturers to further lower the cost to eligible first-line buyers of ACTs. Unfortunately, low cost ACTs procured through AMFm arrived late in country and so it was not possible to show impact in the ACTwatch evaluations in Cambodia.
Net Bundling Strategy, Cambodia
A bundling strategy was devised as an interim measure to address the issue of high demand for untreated nets. The strategy aimed to make use of the huge cost efficiencies of using the existing private sector net retail channels to supply long-lasting insecticide treatment kits bundled with untreated nets. This was possible because Cambodia has relatively few net importers and a highly centralised retail distribution system, with one major wholesale market as the hub through which most products flow out to provincial markets.
Population Services International (PSI) was identified as the partner to work with to implement the strategy due to their significant experience of working in the private sector. PSI approached and gained buy-in from the existing net traders (importers and wholesalers) operating in Phnom Penh. Conventional nets were bundled at the top of the supply chain where possible. A mass communications strategy encouraged buying a bundled net and dipping the net in the insecticide. The evaluation found 72 per cent of outlets were selling bundled nets (according to PSI MAP Survey data).
It was learnt that it is not efficient to segment the retail market and limit it to cater only to the high transmission areas of the country without incurring huge cost inefficiencies; therefore the program was designed to bundle all nets, reaching all areas of the country. It was considered that as there is migration around the country, nets would be assured to reach migrant populations via this method before they moved to the at-risk areas.
Social Franchising – Sun Quality Health (PSI) Myanmar
Launched in Myanmar in 2001, the social franchise network consists of a first tier of private licensed General Practitioners (GPs) called Sun Quality Health (SQH). SQH clinics offer services in malaria and also reproductive health, TB, pneumonia, diarrhoea, and HIV including STIs. In 2008 a Sun Primary Health (SPH) channel was launched to reach poor and vulnerable rural communities within a 3 hour radius of the SQH clinic. SPH are a second tier of the network and are trained in a range of health areas for which they sell subsidised products. Currently SPH is being scaled up. Payment sources are 99 per cent out-of-pocket expenditure and 1 per cent free. Malaria disability adjusted life years (DALYs) averted in 2010 were 18,523 rising to 46,567 in 2011. This significant increase was attributable to the SPH community health workers.
Private Provider Alliances, the Myanmar Medical Association
The Myanmar Medical Association (MMA) is the only professional body of medically qualified doctors in Myanmar, with over 8,000 members and a total of 74 branches throughout the country. In 2009 MMA was funded to implement the Quality Diagnosis and Standard Treatment of Malaria by Private General Medical Practitioners (QDSTM) Project.
MMA’s QDSTM project aims to provide quality assured diagnosis and treatment of malaria by the private medical GPs in selected townships. It is a continuation of a Three Diseases Fund project that empowered 173 GPs in 46 townships and provided quality assured diagnosis and treatment of malaria. Two fixed clinics extend the services to the village level through setting up mobile teams and trained volunteers. The mobile teams and volunteers provide health education and case management of malaria. The volunteers are provided with essential medicines and RDTs to manage malaria in between the visits of mobile teams. The mobile team visits one/two villages per week and also supervises the activities of trained volunteers. The implementation is regularly supervised and provides feedback to MMA technical staff, central supervisors and the WHO malaria unit.
In year 3 and 4, the project will further expand to 14 new project townships and train 50 more GPs to deliver malaria case management in accordance with the National Malaria Treatment Guidelines. In addition, the project management, in consultation with WHO, will open fixed and mobile clinics in two remote townships (Kachin and Rakhine) where malaria is highly endemic and access to health services is very limited. The project will focus on strengthening in-house capacities; ensuring participating GPs follow the QDSTM Project Standard Operating Procedures; and improving monitoring and evaluation.
Exxonmobil, Papua New Guinea
ExxonMobil is implementing ‘inside’ and ‘outside’ the fence initiatives at its operations in PNG. Inside the fence, the Malaria Control Programme covers both employees and contractors working in malaria-prone areas. It includes awareness campaigns, mosquito bite prevention tools, and anti-malarial medication, and promotes early diagnosis and treatment to fight malaria. Outside the fence, ExxonMobil, through its Malaria Initiative, has collaborated with the Rotarians Against Malaria Program on logistics, planning and bed net distribution. Plans are under development for enhanced malaria diagnostics at relevant community clinics. More than 1,000 community members have been tested for malaria and were treated if positive. ExxonMobil is also working with the Medicines for Malaria Venture to fund clinical trials of new antimalarial medicines in PNG.
Newcrest Mining Ltd., Gosowong, Indonesia
Newcrest Mining Ltd is implementing an ‘inside the fence’ employee protection malaria control program at the Gosowong gold mine in Indonesia. Education, counselling, prevention, risk-control and treatment programs are available to all workers and treatment is also provided to workers’ families. Employees are given safety inductions to learn about the dangers of malaria and can obtain further information from or report cases of malaria to the safety officer, malaria control officer or site doctor. Prevention and risk-control methods include reporting of potential malaria hazards, fogging, IRS, and sanitation. Malaria cases are treated at the site clinic or the local hospital where employees are covered by health insurance.
Newmont, Batu Hijau, Indonesia
Since 1996, Newmont has been contracting International SOS to operate an integrated broad-based health service at its Batu Hijau mine. The program involves prevention and treatment activities both inside and outside the fence including larviciding, screening of military personnel for malaria before entering the control zone, distribution of mosquito nets, space spraying, training of community members on diagnosis of malaria, capacity building of government health workers, screening and treatment of children in surrounding villages, case management in the site clinic and first aid posts and medical evacuation if necessary. Malaria prevalence reduced in community school children from 47.3 per cent in 1999 to 1.5 per cent in 2007. In addition, the malaria incidence rate in the mine workforce dropped from 53 per 1,000 employees in 1998 to 5 per 1,000 in 2007.
Shell, Palawan, Philippines
In 1999, the Pilipinas Shell Foundation launched the Movement Against Malaria social investment program. The foundation worked with the provincial government and the Department of Health to set up 344 malaria village laboratories in the Palawan province, with trained local staff to detect the malaria parasite in blood smears. The program provides leaflets and holds village meetings to raise awareness of malaria prevention. It encourages people to sleep under mosquito nets, clear breeding areas and keep themselves covered in the evening. In 2006, the program received a US$14 million five-year grant from Global Fund to expand to four more provinces. Another grant in 2010 provided US$31.4 million and increased the total number of provinces covered to 40. The program has reduced malaria deaths by nearly 97 per cent from 99 deaths a year in 1999 to three in 2011.
Oil Search, Southern Highlands Province, Papua New Guinea
Since 1998, Oil Search has been implementing the Marasin Stoa program, a village malaria treatment initiative at its Hides gas field project area in the Southern Highlands Province. The program entails training a community member, usually a woman, in basic malaria diagnosis using a Rapid Diagnostic Kit and supplying pre-packaged (dosage for weight category) malaria medication. The village treatment providers also collect malaria blood slides from each case for laboratory analysis in the Oil Search laboratory in order. The treatment providers charge a nominal fee and can sell additional ‘over the counter’ health products to supplement their income. This ensures sustainability of the program and addresses other social development issues such as poverty and gender equity. The program has seen a steady decline in the incidence and prevalence of malaria in all affected communities. Direct management has been taken over by a local church health service provider, with technical support provided by the Oil Search Health Foundation. The National Department of Health (NDOH) has endorsed the program and the model is being trialled in other parts of the country. Additionally, Oil Search has been appointed the new principal recipient (PR) of funding from the Global Fund replacing the NDOH as PR.
mhealth Management Information Systems, Philippines, Indonesia
EpiSurveyor is a free mobile phone- and web-based data collection system. It is used for the collection of information regarding clinic supervision, vaccination coverage or outbreak response, and it helps to identify and manage important public health issues including HIV/AIDS, malaria, and measles. As of April 2012, EpiSurveyor, based in Kenya, has nearly 8,000 users in more than 170 countries worldwide including the Philippines and Indonesia, making it the most widely used mHealth software. Partners include: Datadyne, United Nations Foundation, Vodafone Foundation, and Knight Foundation.
Sources of technical support and advice