Dr Char Meng Chuor CNM Director Email: mengchuor@gmail

Dr Char Meng ChuorCNM Director

Email: [email protected]

Regional Malaria Financing Task Force (RFMTF) MeetingHong Kong, 12 May, 2014

Benefits to National Malaria Programs from Regional Support:

The Cambodia case

Country background malaria epidemiologic status• 181,135 Spkm • 14,7 million inhabitants • 22.9% live below poverty line• 3.1 million household with

Malaria mortality/100,000:2000: 5.2 2010: 1.72011: 0.66 < (MDG (2015:0.78)2013: 0.08

Forest cover map 57%

Malaria Map

Reported Malaria Case treated by Public health facilities per 1000:2000: 11.0 2010: 4.22011: 4.0 = MDG (2015:4.0)2013: 1.5

Group specific incidence rate: in creased risk among male adult

71% has forest or hunting activities

71% has forest or hunting activities

Three major challenges arePf. Resistance

not just a treat to

Cambodia but = Global treat

Pf. Resistancenot just a treat to

Cambodia but = Global treat

Vivax in G6Pd liverVivax in

G6Pd liver

Core issue: Migrant & or

MobileNot just victim but also carry Pf./Vx

more effective than mosquito

Core issue: Migrant & or

MobileNot just victim but also carry Pf./Vx

more effective than mosquito

Hot spot resistance: We know it is in NW but not sure about the rest of the country

Government leading processIntegration of malaria program integrated to the health system in the context of government

decentralization policies

Government resource share to health and malaria program

Gov. expenditure on health has increased 4-fold over the last 10 years. Its % share of health budget is already among the highest in the world

Externally assisted projects: Money “actual” amount, building networks, outcome…

Reduction in malaria prevalence Research projects (AFRIMS, BMGF, CHAI, ITM, MC, MSF, NIH, MORU, NAMRU2, UBS, US-CDC, WHO) were vital for CNM policy decision).

A 3-fold decrease in prev every 3 yrs in the W region, mostly ARCE provinces compared to a less than 2-fold decrease in the E region

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Four pillars on private Sector (Medical and selected non-medical sectors)

1. Regulation: Ban on monotherapy, anti-malaria drug registration licensed to CNM only2. social marketing of RDT/ACT and insecticides (PSI)3. Non-medical-sector: Mosquito net loans, taxi drivers….4. Private health providers (MoU) on supplies, training, diagnostic and treatment, report

and referring severe case to public health facilities

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Challenges with additional government financing for malaria program ?

• Health expenditure share of Government Expenditure was 12%: among the highest compared to other low/middle income countries

• Annual Operational Plan 2014: Of US$384 million total budget CDC get US$64.7 million including malaria (US$21.9 million) while Non-CDC get US$2.65 only. Number of death related with non-CDC is much higher than other diseases (Incl. external aids)

Competing priorities within Government and within heath sector

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Challenges with externally assisted projects

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Challenges with externally assisted projects

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Lessons learned

"Cambodia’s effort to eliminate eventually point the way toward a goal that’s shared by many of us in the global health |...| A lot more work needs to be done in the years to come. But I left Cambodia thinking that if we can be successful there, it will be a giant step toward the long-term goal of wiping out malaria everywhere."

Overall, key factors of successes : •High-level political will and support; •Universal bed net coverage (1 net per person in all malaria risk areas); •Community-based Early Diagnosis and Treatment (Village Malaria Workers); •Health Facilities well stocked with diagnostics and drugs.

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Interventions Control phase e.g. Pre-elimination/elimination e.g.Prevention and BCC:

• Relies on net distribution campaign

• IRS based on available resource

- Campaign + & continuous net coverage and regular monitoring/supervision of appropriate net use

- Systematic IRS and repellent distribution and use monitoring

Diagnosis and treatment

Passive case detection and treatmentNo Primaquine

- Aggressive/active case detection (ACD) and systematic DOT

- Primaquine deployment and use- Special screening among prioritized vulnerable groups

(e.g. Pregnant women)- Explore feasibility of targeted MDA

Surveillance system

Pilot surveillance on malaria cases

- Systematic surveillance of all individual detected cases and comprehensive response

- Surveillance on local malaria vectors “Foci transmission”

We are making consensus on what exactly additional programmatic activities in pre-elimination and how these will be managed with flexible funding modality. See sample matrix below

Financing ++ As available and as possible mobilization and unpredictable

++++ Confirmed funding from relevant and specific stakeholders with very flexible approach

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WHAT ACTIVITIES SHOULD BE ADDRESSED REGIONALLY

• Explore support to South-South partnership arrangement in CDC and pharmaceutical markets e.g. MBDS, incentivize private sector to keep prices of commodities down and to promote/offer vector control services and diagnosis before treatment…

• Support of expansion of monitoring: Regular tracking of molecular markers (K13) to support policy decision (Drug policy…), Joint ACT Watch…

• Intervention on migrant workers mobility and expand the coverage and access to malaria prevention & treatment, where possible linkage with K13.

• Iincentivise the private sector and keep prices of commodities down and to promote vector control services and diagnosis before treatment;

• Resource mobilisation for the regions based on a credible financial gap analysis and exploring how to raise resources;

• Advocacy or participation in harmonization of various regional initiative in fight against malaria in collaboration with SEARO & WPRO;

• Possibly, a reserve fund for rescue supplies in case of stock-out;

"Resistance to artemisinin […] has now emerged or spread across Southeast Asia. Radical measures in Southeast Asia will be necessary to prevent resistance to artemisinins and their partner drugs spreading to the Indian sub-continent and then to Africa“ (MORU. Article Submitted for publication 5 April 2014).

Whether or not this quotation is accepted by all, I would to suggest:

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WHAT ISSUES SHOULD A REGIONAL FINANCING TASK FORCE EXAMINE TO ASSIST CAMBODIA NATIONAL PROGRAM

• Funding support to re-estimation of Financial Needs and Identification of Financial Gaps, and in resources mobilization for the pre-elimination phase (2015-2020) of the National Strategic Plan for Elimination of Cambodia 2015-2025;

• Pilot local elimination in selected district to complement with the existing initiative (AFRIMS/BMGF, URC/PMI, MORU)

• Ensure close involvement in the already established joint partnership working group led by CNM, involving members from all development partners including government and non-government sector

• Pilot model of joint programmatic intervention based on VMWs network: Malaria, Dengue, NTD, MCH, HIV…)

• Continue support to Dengue, NTDs and other public health treat such as AF…• Support to Independently assesse all key interventions to ensure effective prioritisation and

maximize cost • Support to intervention on private sector both medical and non-medical.• Support to pharmaceutical management based at Department of Food and Drug (MOH)

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Thanks for your attention!