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3. 22 Bill & Melinda Gates Foundation Malaria Forum  A meeting of grantees, partners, leaders, scientists and advocates  Space constraints limited number of participants – 250 total  Timing dictated by opportunity of leadership schedules and review after $1 B grant investments in malaria  Goals: »Review progress »Share challenges and successes »Think creatively how to solve problems  Themes »Collaboration »Innovation »Impact

4. 33 MALARIA FORUM AGENDA  Plenary discussions with malaria leadership; breakout sessions on cross-cutting topics  Side meetings with country delegations; AMFm  Keynote speeches by Bill and Melinda Gates  Leadership Summit

5. 44 State of the malaria world…  Compared to a decade ago, malaria is more visible as a global health problem »GFATM, World Bank Booster Program, US President’s Malaria Initiative – total of $3.6B has been committed for malaria control and in the process of being rolled out to over 70 countries  New tools have been globally recommended – uptake is beginning, but challenges remain »ACTs (Artemisinin combination therapies) being deployed in >40 countries; prices for adults in the public sector have dropped from $2.40 to $1 »Over 70M nets were procured in 2006, three quarters of which were long lasting nets (LLIN) »Barriers to distribution, uptake and compliance are still significant, but are beginning to be addressed, including: distribution / logistic difficulties, demand forecasting, and access in the private sector  Resistance is threatening the new tools »SP resistance emerged rapidly over the past 5 years in East Africa »Artemisinin (ACT) resistance has been tentatively described in Asia »Resistance to pyrethroids on bednets has been documented in East and West Africa  Research and development of new anti-malarials drugs, vector tools and vaccines shows promise, but much work remains »Advancing pipelines of drugs, vaccines and vector control tools that are intended to address significant gaps in current toolkit, overcome resistance, and improve efficacy and efficiency, uptake, cost and compliance of existing interventions  Few examples of demonstrable national impact on disease morbidity and mortality »Need stable level of utilization for 2 years to assess impact on disease rates »Focus has been on the effective scale up of current tools; assessment of impact available in near future »Early example of single intervention: WHO claims widespread distribution of free nets in Kenya led to 44% reduction in child mortality from 2003-2007 (to be validated)  Malaria is regaining lost foothold in disease control, but that only points to the need for a more comprehensive, longer term strategy

6. 55 Prevent infection severe disease and death Prevent illness / treat infected persons Prevent transmission/ reduce parasite population Reduce vector population / prevent parasite asexual maturation 1 Prevent human contact 2 3 4 Breaking the malaria transmission cycle through multi-pronged attack is key to sustainable control Drugs Vaccine IPT Vector control Drugs  Stable transmission requires parasite to complete life cycle »Multiple points (1-5) where transmission can be interrupted  Parasite resilience, imperfect tools and implementation / compliance issues mean multiple intervention points required to break transmission cycle »When delivered in combination, imperfect tools can have significant health impact  If the transmission cycle isn’t broken, will need to pay for control in perpetuity »If parasite reservoirs are not eliminated, incidence will rebound rapidly if control measures are scaled down 5 100% efficacy of an intervention and perfect 100% implementation at any phase would break the transmission cycle. This is not possible with any of the current tools, nor is it possible with any of the tools in the foreseeable future. Therefore effective control requires a multi-pronged approach

7. 66 Cost ($M) Funding less than 80% coverage for implementation lessens impact and delays timeline to sustainable control Note: Hypothetical need model assuming 80%/60% coverage possible in all malaria endemic countries. Deaths figures assume a case fatality rate of 0.26%. See funding model appendix for further details of scenario assumptionsSource: Global Fund; Akhavan (2005); Malaria R&D Alliance (2005); Expert interviews; BCG analysis “80%” scenario: 80% coverage with current and future tools R&D Implementation Ongoing support Cases Higher implementation spend today leads to faster decline in implementation cost, cases, and deaths Totals ('08-'40) Cost = $164 B Cases = 6.2 B Cost per case averted = $17 Deaths = 16M “Abuja” scenario: 60% coverage with current and future tools Cost ($M) Cases (M) R&D Implementation Ongoing support Cases Cost, cases, and deaths decline more slowly due to lower coverage and therefore slower shrinking of malaria-endemic areas Totals ('08-'40) Cost = $126 B Cases = 11.3 B Cost per case averted = $28 Deaths = 30M Cases (M)

8. 77 80% coverage at today's cost LLIN IRS IPT ACT Ongoing support Meeting global needs requires annual spend of $500-800M for R&D and ~$7B for implementation To meet global needs for tool development... Information needs  Control and scale up: resistance monitoring, market data collection, mapping, disease burden quantification, performance evaluation studies  Effectiveness: of individual and combined interventions, cost effectiveness Vector control  3 novel active ingredient (AI) classes in next 10 years; 1 in subsequent decades  2-3 new formulations every 2 years Drugs  Therapeutic: 2 combinations, 4 line extensions in 10 years; declining need over time  Preventive: 1 combination, 1 monotherapy, 4 line extensions in 10 years; declining need over time Vaccines  Completion of RTS,S development  Discovery and development of series of improved second generation and combination vaccines R&D for tools Implementation To meet “80%” global coverage targets today Ongoing support  Includes environmental management, training, human resources, disease and resistance surveillance ACT  80% coverage of entire population who become ill (with both public and private channels) IPT  IPTp in perennial and seasonal endemic areas, 1 treatment in second and third trimester of pregnancy  IPTi/c: IPTi in perennial areas, 3 courses/yr or IPTc in seasonal areas, 3 courses/yr Vector control  80% coverage with either LLINs or IRS in perennial endemic and seasonal endemic areas where vector is indoor biting and/or resting; ratio between LLIN and IRS varies according to vector behavior, setting  LLIN: 2 net per household, (last 3-5 years) IRS: 2 sprays/yr (perennial), 1 spray/yr (seasonal)...need ~$500-800M annually for R&D $M Vector control Preventive drugs Vaccine Therapeutic drugs Information needs... need ~$7B annually for implementation Cost will decrease over time as the number of cases decreases and cheaper tools become available 80% coverage at today's cost LLIN IRS IPT ACT Ongoing support LLIN IRS IPT $6,920 M $1266M $2751M $580M $836M $1,486M LLIN IRS IPT ACT Ongoing support

9. 88 What is needed by the global community to control malaria? R&D for tools Advocacy Implementation  Three types of innovation required across all the categories of tools (vector control, vaccine, drugs and diagnostics) »Innovation to fill gaps in current arsenal (e.g. vaccine) »Innovation to manage resistance (e.g. new classes of insecticides and drugs) »Innovation to improve uptake and compliance (e.g. one dose cure, affordable accurate point-of-care diagnostic )  Improved biological understanding of the parasite, vector and host response to enable development of better tools  Enhanced management and on-the-ground support for critical components such as demand estimates, logistics, and effective supply chains  Systems in place to measure impact, resistance and adjust programs  Clear data and guidelines to inform choice of most effective and cost efficient intervention packages in a particular epidemiological setting  Adequate financial and human resources  Sustained and increased national and global funding, as well as political will to meet goals »Continuation of current PMI, World Bank funding »Estimated $3-7B per year required to achieve impact at 80% uptake with current tools and meet R&D needs; Current global spend ~$2B per year is well short of this »Political will at the national level to sustain commitment to controlling disease  Global plan for malaria that is owned by the community  Streamlined regulatory and policy processes to ensure rapid translation of innovation into impact  An even broader and more vocal constituency for malaria

10. 99 Key points arising from Malaria Forum…  Collaboration – key to success in control but also discovery and development – and we need to use new approaches to improving this.  Innovation - needed to overcome resistance merely to maintain the status quo. BUT targeting a long term goal of eradication challenges and changes the R&D agenda. NOT just a vaccine.  Impact - the true outcome of all these efforts must be measured in impact against the disease. The degree of desired impact became a major focus of discussion.

11. 10 Key points arising from Malaria Forum…  Focus on malaria does not displace other global priorities (polio, MDGs)  Innovation is key across Discovery, Development and Delivery – to manage resistance, but to reach more ambitious goals  Costs of sustained control somewhere between $3-6 B per year – and costs of continued impact of malaria at least $12B/year – need better data  Importance of other tools and communities, such as modeling and mapping, which can strengthen how programs are implemented – climate rather than weather maps  Need to communicate commitment to a vision, rationale and strategy as part of single, global business plan  Long term strategy further emphasizes the need for credible success in scaling up malaria control in the near term

12. 11 Next steps  Communicate discussions and outputs of forum Forum Report – to be distributed tomorrow Broad access to videos (Kaiser Foundation website) and access to videos for those to whom webstreaming is a challenge  Need to collaborate, combine intellect and resources to develop, implement and monitor a comprehensive and adaptive plan  We must be willing to innovate, knowing that some things will fail, but we will overcome barriers  Bill & Melinda Gates Foundation commits to the creation of a long term common vision, and to collaborate as a member of the RBM community