Quality of programming is improving – more cost-effective but higher absolute cost

Achieving sustainable coverage – particularly the last mile – has challenges

Co-dependence of RSSH and malaria brings opportunities and challenges

Financial gaps faced by all malaria partners

• Subnational tailoring and some regional approaches can drive progress
• Identified drug or insecticide resistance need for better, more expensive commodities.
• Identified substandard programme quality need for expansions in delivery models.
  • Better understanding of malaria tools coverage and lifespan affects commodity needs and operational plans.
  • Extending or scaling-up innovative malaria tools such as SMC, malaria vaccines, etc
• Evidence-based data through increased siurveillance tailored to local context and  targeting the most in needs.
• High costs of elimination strategies .

• Achieving and maintaining coverage of effective tools to the most in need is hindered by the challenge of reaching the last mile, and product durability.
• Reaching vulnerable populations the last mile continues to be challenging for malaria with health systems often weakest at these points but innovative approaches are seeing some success.
• Costs per person reached increase at the last mile.

• A strengthened health system particularly at community and primary public health care level supports sustainability of quality malaria services.
• Investing in malaria is investing in strengthening health systems, given malaria’s huge contribution to the public health burden in many places. Malaria programming in the last mile can particularly be an entry point to community system strengthening; challenging financing trade-offs can arise.

• Economic climate limits government capacity to maintain/increase malaria funding
• Difficulty of other financers to support gaps given similar resource challenges and widespread increased costs
• President’s Malaria Initiative/Against Malaria Foundation unable to access GF negotiated dual-AI ITNs containing pyrethroid plus chlorfenapyr (CFP) ITN prices - due to special contracting terms. Ongoing conversations with manufacturers to extend pricing to partners.
• Recognized gap in malaria funding, with the 2022 World Malaria Report reporting $3.8 billion for 2021 alone.

Explore all funding

✓ Work with countries and partners on advocacy plans and work globally in resource mobilization.

✓ Explore innovative financing mechanisms under the leadership of malaria endemic countries.

✓ Prioritize conversations with the private sector and explore joint areas of concern e.g. climate change.

✓Explore COVID-19 Response Mechanism (C19RM) reprogramming opportunities where relevant.

Optimizing investments

 ✓ Sub-national tailoring of malaria interventions as per the country national malaria strategies to supporting both optimization and prioritization decisions

✓ Examine potential for efficiencies during grant making by changing product specifications, delivery models or scope of ‘supportive’ activities (such as support supervision) – but risk/benefit critical to assess.

✓Alternative financing approaches can bring efficiencies and will be further explored.

Address unit costs

✓Working with partners under the NextGen MarketShaping SI has seen a successful start with the Revolving Fund lowering CFP nets prices; there is potential for a co-financing model for specific artemisinin-based combination therapies (ACTs).

✓Move towards standardization in ITNs - important value for money opportunities, but implementation/change management challenges.

Prioritize highest impact investments

✓WHO GMP prioritization document across interventions.

✓Work with national programs, WHO and other partners to consider relative cost effectiveness and prioritize highest impact interventions as per Malaria strategic plans, includes consideration of omitting lower risk geographies/populations at greater scales than previously

Diversify ACT portfolios

✓With partners, support countries to consider Multiple First Line (MFT) strategies to delay emergence and spread of resistance.

✓ W1/W2: positive examples of countries including MFT plans, especially in countries reporting partial resistance – but insufficient in scope, particularly in countries where there is an opportunity to avoid emergence, due to large part to funding decision trade-offs, as well as needs for TA and operational support.

Support surveillance for informed decision-making

✓Support and align across partners, Therapeutic Efficacy Surveys (TES) and HRP2/3 gene deletion surveys and strong data sharing, to inform appropriate introduction of health products.

✓TES and HRP2/3 gene deletion studies budgeted and prioritized.

Address critical barriers through market shaping

✓Market barriers to scale-up AS-PY and DP, AS-AQ being considered to reduce pressure on AL*. ✓NextGen Market Shaping SI likely to include ACT co-financing, a short-term solution to reduce price gap – increase affordability, drive up demand but funding is far off the need.

✓With partners, ensuring country readiness in terms of resistance mitigation strategies and framework for introduction of diversified ACTs.

Scale up coverage of effective vector control

✓Scale up to better nets has been accelerating since GC6 but the opportunity for impact from greater shift is not yet being fully embraced - (acceleration may increase through grant-making).

✓ Sub-national tailoring of malaria vector control as per the country national malaria strategies to supporting both optimization and prioritization targeting the most in need.

✓Support national decision-making around balancing coverage and tool choice.

✓Aspiration for better nets is high, challenges are around financial gaps.

✓Innovations in downstream efforts to more successful and efficiently reach coverage and usage targets, including in last mile: digitization, value stream mapping, activity-based contracting, alternative deployment modalities.

Address critical market barriers to most effective tools

✓With partners, under NextGen Market Shaping SI, lower pricing has been achieved for CFP Dual AI nets using the Revolving Facility and an innovative operating model with a smaller number of standard net specifications.

✓This has enabled an increase in expected volumes of these most effective nets, and will require ongoing discussions with countries to transition to the standard net specifications.

✓Need for more nuanced decision-making for countries around value for money.

Support surveillance to enable informed decision-making

✓Recommend maintaining entomological surveillance to support decision-making and performance monitoring. ✓Strong support from other partners: PMI and BMGF. ✓Continued challenges on appropriate scope and scale and maintaining priority against other needs.

Short term

Longer term

• SNT will allow countries to appropriately prioritize as per their Malaria strategic plan
• Essential case management needs, at GC6 scope and scale, are likely to be covered for the full 3 years.
• Existing mitigation measures will go some way to reducing gaps, enabling scale up of the most effective tools, and appropriate strong malaria programming.
  • For example: malaria gap in Nigeria moving from $332 million to $90 million.
• However, even short-term challenges remain:
  • GC6 scope and scale may not be maintained everywhere
  • Limits to additional operational efficiencies that can be found
  • Full coverage of most effective prevention tools (new nets and expanded/extended SMC) will not be achieved – a missed opportunity
  • National prioritization decisions mean some populations in need may remain uncovered with vector control; elimination activities are underfunded, and vivax responses are limited.

• Coverage – of most effective tools and full scope programmes – will need to ramp up to truly reinvigorate progress and enable countries to proactively address resistance.
• Better and additional tools and interventions are on the horizon and will come at higher cost – better understanding or relative cost effectiveness to inform evidence-based prioritization and sub national tailoring, will be key.
• Limited programming in lower burden areas could bring future problems - further exacerbated by climate instability and population movement
• To revive spending power at levels to revive impact:
  • Full scoping of financial need, tailored advocacy plans (as supported by partners) and strong high-level support is needed
  • Financing efficiencies need to be further explored
  • Innovative financing approaches, including co-financing, are critical.

Short term

Longer term

• Strategies to mitigate are not being employed at speed to make a large difference in GC7 – the partnership is responding - progress will come but will take time.
• Budgets are insufficient for adequate diversification and inclusion of alternative diagnostics, even if demand were strong.
• NextGen Market Shaping SI (~ $8-10 million for malaria ACTs) has limited ability for large impact – it is useful for short term support but insufficient even for priority countries.

• Lack of consistent surveillance methodologies is hindering the comparability needed to better inform national treatment policies and regional responses, cross partner work is needed.
• Diagnostics: appropriate product options are limited and no product is yet ready to be supported by market shaping. Support to innovation pipeline, especially in endemic countries, is an important longer-term goal.
• Partner-wide market-shaping approaches to drive increased diversification and price reductions will take time and require advocacy and strong coordination.

Short term

Longer term

• Mitigating actions will speed the scale up of the most effective tools, though not fully.
• Better pricing for newer nets comes with challenges to consider value for money decisions on net specifications.
• Gaps in coverage resulting from prioritization choices may risk upsurges.
• Residual transmission and inability to push coverage to highest levels (last mile challenges) won’t be address with current tools, distribution, and funding approaches.
• An. Stephensi remains under-addressed.

• The urgent and continued need for new tools in the vector control space:
  • CFP dual ai nets: risk of rise of CFP resistance as the second insecticide (pyrethroid) is not protecting the need
  • Need for dual NEW active ITNs (combination therapy approach) to mitigate resistance
  • Need for newer tools beyond ITNs to address residual transmission and potential stephensi-driven urban transmission – work on this is limited due to lack of SI.
• Challenges on how to ensure a diverse market base of manufacturers who remain committed to innovation, as this innovation will be needed in the medium to long term.