ACCRA, Ghana — Eating overripe mangoes, excessive heat, and arduous labor used to be some of the myths concerning the causes of malaria in Ghana’s Ashanti region. “I used to believe I fell ill because I worked for too many hours under the sun,” said Dina Serwa, a mother of five from the gold mining district of Obuasi.
That was before the rollout of indoor residual spraying, or IRS, in 2006, which is based on the seasonal application of long-lasting insecticides to the walls of homes to kill malaria-carrying mosquitos.
“By 2012, malaria cases in the Obuasi district had fallen by 75 percent,” and awareness on disease prevention had significantly increased, said Samuel Asiedu, director of AngloGold Ashanti’s malaria program, AGAMal. This initiative of the world’s third-largest gold producer is supported by The Global Fund to Fight AIDS, Tuberculosis and Malaria. Asiedu also leads IRS implementation across the Ashanti, Upper West, and Upper East regions, in a public-private partnership with Ghana’s National Malaria Control Programme.
IRS, alongside insecticide-treated nets, is one of the prime tools in the global fight against malaria. However, IRS coverage has fallen by around 40 percent over the last few years due to the resistance of anopheles mosquitoes to older products and the steep cost of new formulations.
Dwindling donor funds has Ghana turning to PPPs to help fight malaria. Devex sits down with Keziah Malm, manager of the country's National Malaria Control Programme, to find out how they are engaging corporate Ghana in malaria control.
In Obuasi, “mosquitoes had lost susceptibility to all available insecticides for IRS,” noted NMCP director Keziah Malm. In 2017 alone, she said, the country of 28 million people registered 4.8 million confirmed malaria cases.
But late last year came a breakthrough, when the World Health Organization made its first recommendation for an innovative insecticide in 40 years. It prequalified Sumishield 50WG, deeming it "acceptable for procurement by the U.N. and other international agencies and countries.”
Since April, Ghana Health Service has introduced the new insecticide as part of a pilot scheme which runs until June, expecting it to benefit 400,000 households this year in the framework of the $65.1 million, next generation NgenIRS project. Funded by Unitaid, the project aims to create a sustainable market for new, third-generation insecticides at affordable prices between 2016-2020 — but until now, there has been only one such insecticide available.
“This is the largest Sumishield 50WG pilot so far, and the first one in West Africa,” Unitaid Technical Manager Alexandra Cameron told Devex.
At the launch of the initiative in Accra in May, Ghana’s Deputy Minister of Health Tina Mensah pointed out that the development means they “can now implement WHO’s Global Plan for Insecticide Resistance Management in Malaria Vectors,” launched in 2012.
Rotating insecticides is one of the key strategies to manage resistance, but this wasn’t previously possible with just one third-generation insecticide available — Actellic 300CS, an agrochemical compound which had been reformulated for use in global health and launched in 2016 with the support of NgenIRS.
Last year, the project supported the procurement of some 4 million bottles of Actellic 300CS, protecting an estimated 52.2 million people across Africa, according to the Innovative Vector Control Consortium.
Sumishield 50WG is the second new-generation compound to enter the market. Unlike previous alternatives, this nonpyrethroid insecticide has a completely new mode of action and lasts for nine months.
“I like it because it does not smell and it kills all bugs, not only mosquitoes,” said Esther Oppong, who is pregnant with her second child, after having her house sprayed in the rural village of Domeabra.
The queen mother of the Andasi Ondwase community, Wana Fwantemaa Adam II, agreed: “Now I can sleep at peace; I know that mosquitoes do not have a chance in my home.”
Overcoming market barriers
Developing new chemical compounds has not been the only obstacle to rolling out third-generation insecticides, however — market barriers have also played a role. These include limited demand and competition; market instability; high prices; and the lack of a strong evidence base on cost effectiveness. The innovative, market-shaping approach of the NgenIRS project is designed to overcome this, according to Director David McGuire.
Also innovative, he said, is the multistakeholder partnership that has powered the development and launch of third-generation insecticides — one that brings together actors from the private, public, and nonprofit arenas in pursuit of better health, and more economical outcomes. NgenIRS is led by the Unitaid-funded IVCC, which liaises with the industry to facilitate the development and launch of new products. NMCP then authorizes the use of new insecticides, while implementation of IRS in Ghana is done by two groups: The U.S. President’s Malaria Initiative VectorLink Project, and AGAmal.
NgenIRS aims to lower the price of existing insecticides for IRS and to increase their availability, while getting other new products on the market to support resistance management.
To this end, it estimates the price a given product should have once the market is fully mature — for example, when there is sufficient demand and multiple competing products. “Unitaid then offers a co-payment equivalent to the difference between the current and the target price, meaning that African countries and their implementing partners can procure third-generation insecticides at reduced price,” McGuire explained.
NgenIRS has also developed a forecasting methodology that helps establish volume guarantees with manufacturers — Syngenta and Sumitomo Chemical — in exchange for annual volume discounts, a strategy that reduces the co-payment per unit.
In 2017, various countries that were not participating in the co-payment mechanism were also able to procure Actellic 300CS at reduced prices, representing around 50 percent of the overall procurement volumes and coverage — an unexpected collateral impact that McGuire said “could absolutely be the case” again this year with the new product.
Last year, the downward trend in the use of IRS in Africa turned around for the first time since 2012.
“We hope that in the next couple of years, we will get it back to where it was, or even better,” McGuire told Devex. “Especially since the WHO is evaluating two additional products that could potentially enter the market before the project ends, one of them this year.”
Engaging the industry, sustainably
As a product development partnership, IVCC has been working hand in hand with the insecticide industry for over a decade. After searching 4.5 million chemical compounds, its agrochemical partners identified nine types of novel active ingredients with potential for vector control use.
“Developing new products takes a huge amount of time and resources, and we need a return on investment, so Unitaid’s co-payment is a big help,” Atsuko Hirooka, executive officer at Sumitomo Chemical, told Devex in Accra.
“We are very good at developing new tools, but PPPs help us overcome market barriers such as limited demand and price,” she said. That is precisely Unitaid’s role, added Cameron: Investing in developing and unlocking markets to enable the mass introduction of innovations in global health.
One of the challenges in vector control innovation is keeping industry partners fully engaged over the long term, despite the uncertainty inherent in product development and launches.
“These [vector control] products are not that profitable,” said McGuire. “We have had some experiences where partners have dropped out because they did not think they could make it from a business perspective.”
However, companies “are starting to realize that their core business is actually related to malaria” because only healthy farmers that can work will invest in agrochemicals.
So much so that, for the first time, chief executive officers of each of the insecticide manufacturers have committed to co-investing and sharing technical resources to further malaria elimination goals. The agreement, announced earlier this year, “is a ground-breaking step forward, because in the past we had not really worked at the CEO level,” he said.
Ghana is increasingly turning to public-private partnerships to mobilize domestic resources for the health sector. NMCP often presents its PPP with AGAMal as offering a model for the private sector to engage in the fight against malaria in Ghana and elsewhere, NMCP’s Malm told Devex. The partnership has allowed the country to mobilize Global Fund money through joint grant applications from the government and AGAmal for IRS implementation campaigns, and has also reduced the impact of malaria in operational areas and beyond, Malm said.
“It is not so common for the Global Fund to be working with private companies on the ground, so this is a really innovative model,” noted Cameron from Unitaid. AGAMal’s Asiedu confirmed they are reaching out to other mining companies who could potentially replicate the approach.
For Anglo Gold Ashanti, AGAMal’s parent company, the business case for the malaria control program was compelling. Its 2004 “Report to Society” stated that the disease remained “the most significant public health threat” to its operations in Ghana, Tanzania, Guinea, and Mali.
At that time, the company lost on average three days per worker to malaria, amounting to roughly a third of the mine’s workforce, and faced medical treatment costs averaging $55,500 every month.
Nowadays, the private hospital in Obuasi records around 110 confirmed malaria cases per month, down from over 6,000 at the outset of the IRS program, according to its director, Richard Cromwell.
For Asiedu, there are three keys to a successful PPP in malaria prevention: “Operating within the national policy framework, ongoing communication, and transparency,” for example, by keeping and sharing a digital database on the progress of IRS operations.
Reflecting on the way forward, McGuire made two points: First, no country has ever been able to beat malaria without using IRS; and second, more resources are needed to scale this intervention up to reach global elimination goals.
“Both on the donor side, and even more importantly on the domestic side, countries need to understand the importance of eliminating malaria and the value of IRS in achieving that,” he said.