Impact update – UNDP’s work on malaria in Iran

22 Jul 2014

   

*Zone definition: Zone A-HR (High Risk): Cleared-up areas which are suffering from intensive population movement from/to malaria affected areas, so the possibility of reintroduction of malaria transmission exists and assessed at high level. Zone A-LR (Low Risk): Cleared-up areas which are suffering from low level of population movement from/to malaria affected areas, so the possibility of reintroduction of malaria transmission exists at low level. Zone B: Endemic areas with local malaria transmission. Free from Malaria: Cleared-up areas with no local transmission where risk of re-introduction of malaria is rare.

Once a public health hazard across the country, malaria is now mainly contained in 3 southeastern provinces of Sistan-Baluchistan, Hormuzgan and Kerman.

As a national strategic policy, Iran has planned for, and is on track towards eliminating falciparum malaria by 2016 and all cases of malaria by 2025.

Between 2000 and 2013, the total number of local malaria cases has dropped from about 20,000 to about 500 due to the effective interventions including the initiatives carried out under the GFATM project.

While early elimination of falciparum has been achieved in some target areas, Iran remains concerned about the risk of reintroduction of the disease from neighbouring countries (mainly Pakistan) given the huge number of people crossing the border every day. To reduce this risk, Iran needs to establish inter-country dialogue and disease control initiatives with Pakistan and other neighbouring countries. Based on the discussions with the Global Fund, it is expected that the new malaria grants for Pakistan will place a focus on the cross-border issues.


Face to face community education on personal protection and using bed net for prevention of malaria

ACHIEVEMENTS FOR MALARIA

In line with the national plans and priorities, the Global Fund project on malaria in Iran, for which UNDP Iran is Principal Recipient, has helped Iran to achieve the following:

  • 284 (out of 457, 62 per cent) of laboratories showing adequate performance among all laboratories that received external quality assurance;
  • 100% of reported malaria cases are laboratory confirmed (by RDTs or blood smear examination).
  • 3,3835 diagnosis and treatment service providers of public and private sectors (Physician, PHC staff) and rural community volunteers were retrained for malaria case finding, Case management and using RDT (Rapid Diagnostic Test).

BACKGROUND

The Health System in Iran

The Constitution of the Islamic Republic of Iran stipulates that every Iranian has a right to enjoy the highest attainable level of health. The health system is overseen by the Ministry of Health, Treatment and Medical Education (MoH) that is responsible for designing and implementing the national health policy.

At subnational level, the health policy is implemented by medical universities in provinces. University chancellors are in charge of public health care facilities as well as medical education and report to the Minister.

Public health care and services are provided through a network that starts at primary care centres in villages and goes through secondary and tertiary level hospitals in larger cities. Such public services are provided either for free or at subsidized rates in public facilities. The structure of the public health sector.

The private sector is well developed, present in all parts of the country and playing a significant role in providing care and treatment.

The non-governmental organizations active in the area of health are focused in special fields like cancer, diabetes, thalassemia and the like.

Iran is currently restructuring its public healthcare system towards a new national health structure based on a ‘family physician’ system which will act as a guardian to ensure prevention and care for the public. It is hoped that this approach will also help alleviate the financial burden on citizens with regard to the high (60% on average) out-of-pocket costs for most Iranians.

History to the Global Fund’s Work in Iran

The first Global Fund grant allocated to Iran took shape in 2005 in the area of HIV under the 2nd financing round of the Fund with a provision – as is the case in many countries – to apply the Global Fund Additional Safeguard Policy (ASP). As per the ASP, no national entity may be assigned the role of Principal Recipient (PR) of the Global Fund grants. UNDP has been given this mandate.

Country Coordinating Mechanism (CCM), a standing team of national stakeholders and international parties, oversees the partnership with GFATM.

The grants have grown over time to constitute a sizable portfolio of three projects.

In its PR capacity, UNDP works with a number of national Sub-Recipients (SRs) and Sub-Sub-Recipents (SSRs) as listed in below table:

Disease Area

SRs

SSRs

HIV/AIDS

Centre for Disease Control (CDC-MoH)

Prisons Org.

Min. of Education

Medical universities

Welfare Org

Tuberculosis

CDC-MoH

Prisons Org.

WHO

Medical universities in 7 target provinces

Malaria

CDC-MoH

WHO

Medical universities in target provinces

 

Budget

Since the inception of Iran’s partnership with the Global Fund, approximately US$ 91 million has been allocated to Iran.

Currently, Iran has four ongoing projects – one project in each disease area plus a small grant to support the activities of the Country Coordinating Mechanism.

Challenges and Lesson

In the areas of TB and Malaria, Iran receives and responds to a significant level of disease burden from neighboring countries.

Given the current budgetary crisis and inflation, the primary healthcare funding issues are a challenge.

Extending the coverage of insurance system to all citizens and reducing out-of-pocket expenses are other urgent challenges. Government is aiming to reduce these from 60 to 30%.

The geopolitical situation has placed a significant burden on the country’s access to local markets of medicine and health supplies/equipment. UNDP and other UN agencies have tries to assist to some extent.

The ASP will require an international agency to serve as PR. The situation does not allow for the transfer of the role to national entities.

End-project transitioning and integration of the project achievements and services into national policies and implementation mechanisms is a challenge.

Future of the Projects

The Global Fund eligibility criteria focus on 2 indicators: national income (World Bank data) and burden of disease (WHO data).

Iran is an upper middle income country with low disease burden of TB and malaria. The country will not be eligible to receive funding in those two areas.

The TB project was concluded in March 2014. A Sustainability and Transition Plan has been developed under the TB project and officially endorsed by the Government.

The current malaria project will come to an end in 2016. A similar approach has been embedded into the malaria project plans.

Under the HIV, where Iran is considered to suffer a medium level of disease burden, the country will be eligible to receive an additional level of funding for the period of 2015-2017. A proposal is being developed to be submitted to the Fund in August.

Post-project Prospects

Over the years and thanks to its engagement with the Global Fund projects, UNDP has developed a high level of partnership and trust with the public health authorities and stakeholders. This is something to build on given the direct link between health and development in the country. To that end, the CO has established its Health and Development Cluster and aims to continue the partnership with national counterparts through mobilizing resources from within the national public health sector and bilaterals. The latter remains to be influenced by the geopolitical aspects of the country’s engagement with the international community.
22july2014malariastructurePublic Health System Structure

Cumulative List of GFATM-funded Projects

Grant

Grant amount (total signed)-USD

SRs

Start date

Program End date

Last Grant Rating

R2 - HIV Phase 1

5,698,000

Center for Disease Control; Prisons Org; Ministry of Education

1-May-05

30-Apr-07

A1

R2 - HIV Phase 2

10,224,855

1-Aug-07

30-Apr-10

Total

15,922,855

 

 

R8 - HIV Phase 1

9,295,097

Center for Disease Control; Prisons Org; Ministry of Education

1-Apr-10

30-Sep-12

A1

R8 - HIV Phase 2

19,599,212

1-Apr-12

31-Mar-15

Total

28,894,309

 

 

 

 

R7 - TB Phase 1

12,652,286

Center for Disease Control; Prisons Org; WHO

1-Oct-08

30-Sep-10

A1

R7 - TB Phase 2

6,305,126

1-Jan-11

31-Mar-14

Total

18,957,412

 

 

R7 - Malaria Phase 1

5,615,598

Center for Disease Control; WHO

1-Oct-08

30-Sep-10

Consolidated with R10

R7 - Malaria Phase 2

1,281,814

1-Jan-11

30-Sep-11

Total

6,897,412

 

 

SSF (R10&7)- Consolidated - Malaria Phase 1

13,241,610

Center for Disease Control; WHO

1-Oct-11

31-Mar-14

A2

R10- Consolidated - Malaria Phase 2 (incremental)

7,297,374

1-Apr-14

30-Sep-16

Total

20,538,984

 

 

CCM - Basic funding - 1

46,207

CCM

1-Aug-10

31-Jul-11

 

CCM - Basic funding - 2

33,846

CCM

1-Nov-11

31-Oct-12

 

CCM - Basic funding - 3

37,663

CCM

1-Nov-12

31-Oct-13

 

CCM - Funding - 4

134,973

CCM

1-Nov-13

31-Oct-15

 

Total

252,689

 

 

Total

91,463,661