Malaria in the Asia Pacific

Before going further into guidance on this it may be useful to review the pros and cons of working outside the fence on malaria control.

Pros

• Mosquitoes, and the malaria they carry are not limited to within the fence.
Lowering malaria transmission at the community scale will reduce the risk of malaria in the company’s workforce (click here for the information on community-wide transmission and the importance of a buffer zone thereby having economic benefits for the company through reduced work time lost, improved productivity, lower healthcare costs etc. (click here for more information on the impact of malaria on businesses.
• This is a high impact option for a corporate social responsibility programme.
• It may be an ethical responsibility if companies are working in a local area where malaria is a high priority problem and where their activities risk increasing transmission (click here for more information on the potential for businesses to affect malaria transmission.

Cons

• Designing and implementing an effective community-wide malaria control strategy requires specialised skills in entomology, malaria vector control, case management, community health promotion and communication.
• Costs:
  Malaria commodity costs can be considerable (WHO, 2012 and Wafula et al., 2010)
  
  • LLINs cost around $2.7 - $4 per net if bought in bulk, often more if bought in smaller quantities.
  • ACTs cost around $1.3 - $1.4 for an adult treatment course (for the most commonly procured brand which is an artemether-lumefantrine combination).
  • RDTs cost around $0.7 for a multi-species test.
  • IRS costs vary considerable in relation to economies of scale. Where more than 1 million people are protected, as in large national programmes, costs per person protected will be lower; but in smaller programmes, such as those likely to be supported by private companies, costs can be around $5.5 per person protected.
  Expanding services beyond employees to employees’ families or to whole communities can therefore have important cost implications.
  
  These issues are reviewed again as you work through the following steps in designing a malaria control programme.

NEXT

This section will give you a step by step guide to planning a malaria control programme for local communities

NEXT

Step 1: Screening and Scoping

The purpose of this phase is to assess how important it is that a malaria management programme is put in place, and to collate the data to support this.

These initial steps will collate available data or expert opinion on:

• Disease burden by location. Sources may include high level estimates of burden by location such as those available through the following mapping applications:
  Global Malaria Mapper
  CDC Malaria Map Application showing the worldwide distribution of malaria with information by country.
• Data on workforce malaria cases should also feed into development of a complete picture of the known and potential scale of the malaria problem relevant to the company.
• Travel practices of the local and international work force that may bring them in and out of malarious zones even if some sites are non-malarious.
• The likelihood of the company worsening malaria transmission.

Assessment of these findings will allow the company to consider whether it has a responsibility to address malaria as a problem and/or whether there are significant benefits to the company in designing a malaria management programme. Benefits may arise from meeting health and safety responsibilities. For example, there may be financial benefits in implementing a malaria management program through a decrease in the number of employee sick days or increased social capital through supporting malaria control in wider communities, potentially through capacity building within local institutions.

If the scoping finds that malaria is not currently a major concern for the company, then the company may still consider getting involved in advocacy work or malaria business coalitions given its presence in the region.

The subsequent steps refer to progressive activities companies may undertake once they have determined that malaria is likely to have an impact on their business activities, or vice versa, and a substantive programme may be needed to address this.


NEXT

Step 2: Establishing Commitment and Support

A vital component of a successful control programme is robust commitment from senior managers to the programme. This commitment is important for:

• Ensuring sufficient funds are made available or robust support is given to advocating for external funds.
• Ensuring senior managers support field managers in progressing with required changes to working sites or operations.
• Ensuring senior managers support field managers in requiring certain practices to be followed by staff, e.g. use of personal protection measures.
• Ensuring senior managers support processes for expanding beyond site control programmes to engage with national and sub national programmes and stakeholders.

Data from Step 1 will support the process of establishing commitment at senior levels.


NEXT

Step 3: Situation Analysis of Epidemiology and Context

A company malaria management programme will include aspects on protecting and informing travelling staff as well as location specific control programmes.

Location specific control programmes must first and foremost be grounded on a detailed and accurate understanding of the epidemiological context. Required activities include:

• Vector surveys: These will address the following questions:
  • What are the dominant malaria vector species?
  • What are their behaviours?
  • What is the insecticide resistance profile?
  Answering these questions will require specialist entomological surveys.
• Epidemiological profiling: This will address the following questions:
  • What is the transmission profile? Is malaria stable or unstable?
  • Who are the most affected groups (where caseloads or infection rates are highest)?
  • What phase of control effort is the country in? Control or moving towards elimination?
  • What malaria species are present?
  • What is the range of transmission relevant to the site of interest? i.e. is transmission localized in specific company assets of interest, or are nearby communities involved in the transmission?

Epidemiological profiling requires access to very high quality and localised data and it is likely that this type of data will only be available if dedicated malaria prevalence surveys are carried out. Such surveys involve a representative sample of the population group of interest providing blood samples for testing. These surveys must be designed by a malaria surveillance specialist with appropriate skills to ensure the results are robust and that ethical requirements are attended to.

• Malaria related knowledge, attitudes, practices and behaviours surveys should be conducted and targeted at the relevant group (either the workforce or the local communities) who may be included in a control programme. A researcher with expertise on malaria and qualitative research should be responsible for this survey.
• Health system surveys should include health facility surveys as well as a broader assessment of the capacity (resources, infrastructure, equipment, personnel and systems) of the health system in the area of interest. These will inform planners about opportunities for linking and supporting the local health system, with potential for more sustainable programme impacts. The health system survey should be conducted by an expert in health systems, and malaria.
• Geo-spatial mapping: overlaying malaria prevalence information with meteorological and land cover information can give a useful visual understanding of the areas targeted in the control programmes and the variation within them. Specialist software and skills are required.
• Workforce reviews to determine high risk groups: combining information from the epidemiology in specific locations and the practices of different employees, the company should identify who are the highest risk groups in the work force. This may include those who travel locally or internationally between malarious and non-malarious areas and security guards or other night shift workers who work in malarious sites.
• Stakeholder analyses should define which groups are relevant to potential malaria control activities, their level of interest, level of support and the potential roles they could play as supporters, funders or implementing partners.

Next

Step 4: Policy and Goal Development

As part of ensuring senior commitment, companies should plan on developing a malaria policy for the company. Guidance on company malaria policy development is available as part of the World Economic Forum’s malaria guidance document.

The goal will likely specify the desire to reduce the malaria burden within employee or local populations, reduce the financial impact of malaria on the business, or support sustainable effective community-wide malaria control as part of a social responsibility component.

For country specific community-wide programmes, goals should align with national malaria goals where possible.


NEXT

Step 5: Option Appraisal

Here different technical and operational options need to be assessed for appropriateness and cost-effectiveness. Options to be considered include:

• Scope: Whether to implement company and location specific control programmes or to expand into community-wide, ‘outside the fence’ control programmes.
• Partnership approach: Whether to plan a programme that will be delivered using the companies own health, safety and environmental personnel, to partner with the local health system, or to partner with other implementing organisations.
  
  Some options for scope and partnership approach can be reviewed below to prompt discussions:
  Protecting employees without community-wide programmes
  Building a community wide malaria control programme: advantages, disadvantages and options.
  
• You will need to access detailed information on the appropriate approaches for your setting and it may involve getting expert epidemiological or entomological advice. You can click here to access more information on appropriate approaches by sub-region

Examples of successful industry malaria control programmes What would you like to do now?

Examples of successful industry malaria control programmes

Case Studies Sources of technical support and advice

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.


NEXT

Sources of technical support and advice

How malaria consortium can help
How Montrose can help

NEXT

What would you like to do now

Get guidance on another issue Find out more about malaria Find out where to access more information Find out how to access advice and assistance