Context

Anaemia is a persistent public health problem – most prevalent in low- and middle-income countries and in populations living in conditions of poverty and social exclusion. It is estimated that 40% of all children aged 6-59 months are impacted by anaemia,[1] which in severe cases can negatively affect mental, motor, and cognitive development. Children with severe anaemia are at increased risk of mortality and morbidity, and studies show that anaemia can account for up to 29% of childhood hospital admissions, and up to 10% of in-hospital mortality.[2] Children admitted to hospital with severe anaemia have a five times higher risk of death following discharge than children without anaemia, and a high risk of hospital readmission.[3] Progress toward global anaemia targets is slow.

Malaria is considered a main driver of childhood anaemia. Infants and children are amongst the most vulnerable to malaria transmission – of the 608,000 malaria deaths in 2022, 76% occurred in children under-5.[4] Similarly, progress towards the global malaria targets remains mostly slow, with millions continuing to miss out on the services they need to prevent, detect, and treat the disease.

In response to this health burden, WHO has highlighted malaria chemoprevention as a priority intervention to reduce anaemia prevalence,[5] and has included delivery of Post Discharge Malaria Chemoprevention (PDMC) in its malaria prevention guidelines since 2022.[6] PDMC is the administration of a full antimalarial treatment course at regular intervals to children who are discharged from hospital following a severe anaemia admission – regardless of malaria status – in settings with moderate-to-high malaria transmission. The purpose of PDMC is to prevent new malaria infections in vulnerable children after hospital discharge, a period when they are at highest risk of re-admission or death. The WHO recommendation is based on evidence that indicates that three months of PDMC is associated with a 77% reduction in mortality during the intervention period, and a 55% reduction in all-cause hospital readmissions six-months post-discharge.[7] Studies also show that PDMC strategies are less costly and more effective at increasing health-adjusted life expectancy than the standard of care.[8]

Although PDMC represents a potentially transformative intervention for highly vulnerable populations, country uptake has been slow, and key access barriers persist.

Despite the compelling evidence on the impact and cost-effectiveness of PDMC in trial settings, WHO has issued only a conditional recommendation due to numerous outstanding research gaps. Questions include optimal duration of the intervention in different geographical and transmission settings, impact in different risk groups, considerations related to drug selection, strategies for increasing patient adherence at-scale, feasibility of different delivery mechanisms, and cost of different approaches. Evidence that responds to these research gaps could inform planned implementation guidance from WHO.

Unlike other malaria chemoprevention strategies such as Seasonal Malaria Chemoprevention and Perennial Malaria Chemoprevention, there is no one existing platform that can be leveraged for PDMC delivery. Past pilots have utilized various delivery mechanisms (e.g. facility-based or community health workers) – but this has been largely left to the country programs to determine, and is not defined in the WHO recommendation. More guidance could help inform decisions on most effective delivery strategies within a local context.

There are questions on the most effective deployment approach for PDMC in the context of other malaria strategies, such as safety, feasibility and impact in parallel with other malaria chemoprevention interventions, as well as in the context of different case management approaches. Questions also exist on how to best optimize the strategy in the broader child health context – such as in combination with other anaemia-focused childhood interventions, in different age groups, and for hospital admissions beyond those for severe anaemia.

Demand and adoption barriers may also prevent scaled uptake of PDMC. In some cases, there are questions on cost and effectiveness in resource-constrained conditions given competing priorities. In addition to the general lack of awareness of PDMC, there is a need to ensure health system readiness – such as appropriate healthcare provider training, better resourcing for and linkages with community health workers, and supply chain requirements and drug availability. There are also barriers at the patient level, such as low adherence to dosing and caregiver hesitancy.

[1] Anaemia (who.int)

[2] Post-discharge morbidity and mortality in children admitted with severe anaemia and other health conditions in malaria-endemic settings in Africa: a systematic review and meta-analysis – PMC (nih.gov)

[3] Phiri KS, Calis JCJ, Faragher B, Nkhoma E, Ngoma K, Mangochi B, et al. Long term outcome of severe anaemia in Malawian children. PLoS One. 2008;3:e2903.

[4] World malaria report 2023. Geneva: World Health Organization; 2023. Licence: CC BY-NC-SA 3.0 IGO

[5] Accelerating anaemia reduction: a comprehensive framework for action. Geneva: World Health Organization; 2023. Licence: CC BY-NC-SA 3.0 IGO

[6] WHO guidelines for malaria, 16 October 2023. Geneva: World Health Organization; 2023 (WHO/UCN/GMP/ 2023.01 Rev.1). License: CC BY-NC-SA 3.0 IGO

[7] Phiri KS, Khairallah C, Kwambai TK, Bojang K, Dhabangi A, Opoka R, et al. Post-discharge malaria chemoprevention in children admitted with severe anaemia in malaria-endemic settings in Africa: a systematic review and individual patient data meta-analysis of randomised controlled trials. Lancet Global Health. 2023

[8] Economic evaluation of postdischarge malaria chemoprevention in preschool children treated for severe anaemia in Malawi, Kenya, and Uganda: A cost-effectiveness analysis – eClinicalMedicine (thelancet.com)

Call Scope

Under this Call, Unitaid is soliciting proposals for the following intervention, aimed at accelerating implementation and generating evidence to catalyse the adoption and scale-up of PDMC to address the burden of childhood anaemia and malaria:

Multi-country implementation of PDMC with robust evidence generation that responds to key knowledge gaps to inform future guidance and accelerate uptake. 

Projects should include implementation projects, delivered in diverse representative settings, to generate robust, transferable evidence on the impact, operationalization, and cost/cost-effectiveness of PDMC delivery – with a vision to informing national scale-up.

These strategies should be tailored to specific country contexts, including sub-national approaches and different delivery platforms (such as community health worker or facility-based delivery approaches). Projects will need to assess key barriers to PDMC delivery and implement activities that establish an enabling environment to support PDMC uptake – including supporting supply chains, human resources, national guideline updates, and pathways to scale.

Evidence generation through the projects should seek to respond to research needs identified by WHO and country implementers, such as, at-scale adherence using different delivery approaches, optimal coordination mechanisms, long-term impact, effectiveness of PDMC in different target groups (such as those presenting to hospital for causes other than severe anaemia) and for different intervention durations in different contexts, and cost of different delivery approaches.

Strategies should include assessment of PDMC feasibility in settings that are implementing other malaria prevention and strategies. Integration with other childhood health strategies, such as holistic management of severe anaemia of different causes, use of multiple micronutrient or iron supplementation, and nutritional or bacterial infection prevention interventions could also be considered.

Strong proposals will demonstrate early coordination with multi-disciplinary national programs, regional bodies, civil society, and global partners. Efforts should be made to secure buy-in and funding for transition to scale through the life of the project.

Proposal requirements

Proponents should clearly describe their overall project design with a Theory of Change, showing how it meets the objectives of the initiative and how the proposed activities form part of a coherent whole. Proposals should explicitly state what impact will be achieved within the project lifetime, as well as what, and how, lasting impact will be achieved.

The proponent should clearly demonstrate strong expertise in the intervention areas needed to undertake the project, including the implementation of large-scale multi-country projects of this nature, and robust evidence generation. Broad collaboration with relevant stakeholders will be vital to achieving the project objectives, including effective coordination mechanisms and well-articulated partnerships. Proponents should clarify the key stakeholders with whom they will engage, and how this will be achieved. It is important to include a country engagement model that outlines coordination and cooperation with countries in decision making around tailoring the design of elimination programs, monitoring introduction, and assessing impact. By actively involving government stakeholders in all phases of planning and implementation, projects will gain valuable insights into local contexts, policy frameworks, and stakeholder priorities. This collaboration will lead to more informed and effective project design, increased buy-in from government partners, and greater sustainability of project outcomes beyond the grant funding period.

Applicants should be clear about the underlying assumptions made in their proposed approach and should highlight any major risks or other factors that may affect the delivery of results. Finally, proposals are expected to outline a lean, concrete, and clear pathway to results and impact.

Additional information

Unitaid considers working with communities a critical part of generating demand and strongly encourages adopting inclusive approaches, and the early and continued meaningful engagement of communities towards improving the lives and health of the most vulnerable people. The role of affected communities and planned collaborations with other relevant groups including grassroots community organizations and Civil Society Organizations at all stages of a project/programme including ideation is essential, with this engagement a key determinant for success. Activities should be clearly budgeted in proposal submissions. Community-led approaches are important to consider and adequately fund and resource when designing, planning, implementing, and evaluating activities and programmes.

Unitaid will prioritize proposals from South-based lead implementers with experience in implementation and expertise in the technical and market intervention areas needed for the project. Additionally, Unitaid supports the meaningful inclusion of South-based sub-implementers, where feasible and relevant, in proposed project implementation consortia. Unitaid’s objective of progressively engaging an increased number of lead implementing partners from the global South does not preclude proposals that are led by or including partners from the global North. In all cases, we encourage coordination and collaboration across implementors and seek proposals with regional impact across key low- and middle-income countries’ markets and a clear path to global impact.

Unitaid is committed to climate and environmental action in its investments and expects its partners to make similar commitments. Proposals should clearly indicate: (i) Efforts that will be made to minimize carbon emissions from project activities; (ii) Potential opportunities to contribute to broader climate and/or environmental co-benefits, in synergy with core project objectives. More detailed guidance and definitions are provided in the proposal template.

Proposals should demonstrate value for money and measurable impact. Proposals should also include analysis of pathways to impact, scalability, and sustainability of key interventions.

Single-country interventions are out of scope for this Call for Proposals.

Process for proposal submission

When developing a proposal, please note the following resources:

• Answers to frequently asked questions relevant to proposal development (this document is regularly updated), please click here [PDF: 500 KB];

Applicants should be clear about the underlying assumptions made in their proposed approach and should highlight any major risks or other factors that may affect the delivery of results. Finally, proposals are expected to outline a lean, concrete, and clear pathway to results and impact.

After assessment of the proposals and endorsement by the Unitaid Board all applicants will be officially notified as to whether they will be invited to develop a full grant agreement for Unitaid funding.

Important dates

Submission and format of proposals

• Proposal form with scanned version of signed Front page template, [DOC: 300 KB]
• Annex 1: Log frame and GANTT chart template, [XLS: 278 KB]
• Annex 2: Budget details template, [XLS: 24 KB]
• Annex 3: Organizational details and CVs of key team members [no template]
• Annex 4: Country engagement support Letters [no template]
• Annex 5: Declaration of relevant interest template, [DOC: 21 KB]
• Annex 6: Applicable ethics, anti-discrimination and environmental policies template, [DOC: 21 KB]
• Annex 7: Declaration regarding tobacco entities template, [DOC: 24 KB]
• Annex 8: Anti-Terrorism Declaration template, [DOC: 30 KB]
• Annex 9: Audited financial statements for the past 3 years [no template]

If you have any questions about the application processes throughout any stage of the application review process, please send your queries to the Grant Application Manager:  proposalsUnitaid@who.int

You will find further guidance in the Unitaid proposal process document [PDF: 530 KB]. Additional guidance can be found in the following documents:

• Guidance on Impact Assessment [PDF: 160 KB]
• Financial Guidelines for Unitaid Grantees [PDF: 1,2 MB]
• Unitaid Results Framework [PDF: 1.3 MB]
• Unitaid Scalability Framework [PDF: 466 KB]