Context

Infants and children are highly vulnerable to malaria transmission, as they have not yet developed protective immunity against the malaria parasite. Of the 435,000 malaria deaths in 2017, 61% occurred in children under 5. The greatest risk of hospitalization and mortality within this group is in the first 2-years of life. Malaria infection can also cause or worsen anaemia, which can be life-threatening to infants and children.

Intermittent Preventive Treatment in infants (IPTi) is the administration of preventive antimalarial drugs to infants to provide personal protection against malaria transmission. Under current WHO guidelines, the drug sulfadoxine-pyrimethamine (SP) is delivered to infants at approximately 10 weeks, 14 weeks, and 9 months of age during routine immunization services. IPTi is safe, cost-effective, well accepted by health workers and communities, and has been found to reduce clinical malaria by 30%, and episodes of anemia by 21%.

Despite the WHO recommendation to administer IPTi in areas of moderate-to-high transmission since 2010, there has been very little uptake to date. Although IPTi access barriers are country-specific, there are several key challenges that contribute to low uptake generally.

Firstly, as IPTi is a malaria intervention deployed through routine immunization services, it can ‘fall through the cracks’ between malaria and immunization programs. As a result, responsibility and ownership is ambiguous at a policy level, and IPTi is deprioritised at the delivery level.

Further, while the Expanded Programme on Immunization (EPI) is the preferred IPTi delivery platform, it is an imperfect fit for full protection in the first year of life and beyond. While the current IPTi schedule offers significant health impact in the first year of life, concerns over gaps in protection (between the second and third dose, and following the third dose) may have limited adoption to date. Further, additional doses of IPTi may extend the benefits of the current schedule. Opportunities exist to explore expansions of the existing IPTi schedule, both within the EPI through additional contacts, and through the use of complementary platforms.

WHO’s 2010 IPTi policy recommends implementation in areas of sub-Saharan Africa where the level of parasite resistance is low, defined as prevalence of a specific (PfDHPS 540) resistance-causing gene mutations of 50% or less in the malaria parasite. However, there is a lack of evidence to determine whether IPTi would be effective at resistance levels higher than 50%. This recommendation was made before the ongoing effectiveness of another drug-based malaria preventive strategy (Intermittent Preventive Treatment in Pregnancy), even at high levels of resistance, was demonstrated. Moreover, to determine eligibility for IPTi, country programmes need to conduct studies to determine levels of parasite resistance to SP, which can act as an additional barrier to implementation.

There are also a number of demand and adoption barriers that prevent uptake of IPTi by healthcare providers and caregivers. For example, caregivers may be reluctant to provide medication to healthy infants. This may be compounded by caregiver and provider perceptions of SP as a ‘failed drug’, due to parasite resistance that make SP ineffective as malarial treatment, despite proven efficacy as a prophylaxis.

On the supply side, a key barrier has been a lack of quality-assured SP in the strengths and dosage form suitable for use in infants.

In October 2019, WHO held a Technical Consultation to Review the Role of Drugs in Malaria Prevention for People Living in Endemic Settings. Participants encouraged increased IPTi scale-up, and reiterated that IPTi should be pursued with a sense of urgency. There was agreement that a more flexible approach to IPTi implementation could engender adoption by countries. It was therefore recommended that adaptations of the current IPTi recommendations be tested through pilot implementation with robust evaluation to assess impact, operational feasibility and cost effectiveness.

As described in Unitaid’s Malaria Disease Narrative 2019, accelerated adoption and scale-up of malaria chemoprevention, including IPTi, represents a near-term opportunity that would support efforts to reignite progress in high-burden countries.

Call scope

Under this Call, Unitaid is soliciting proposals for the following interventions, aimed at accelerating the adoption and scale-up of IPTi in moderate-to-high transmission settings:

Implementation pilots for IPTi delivery to catalyse country uptake and inform future policy and guidelines. 

Projects can include:

• Proof-of-concept pilots that demonstrate the impact, operational feasibility and cost-effectiveness of at-scale IPTi delivery
• Evaluation of modifications to the current IPTi schedule, particularly those that leverage additional vaccination contacts at ages where the risk of severe malaria disease and death are highest, potentially expanding IPTi coverage into the second year of life
• Delivery of IPTi through alternative platforms that complement the existing EPI schedule which could help fill coverage gaps, such as nutrition or weigh-in visits, antenatal care contacts (when pregnant women present with infants), community delivery under the Integrated Community Case Management platform, or other opportunities
• Sub-national approaches to IPTi implementation, particularly in countries that are implementing Seasonal Malaria Chemoprevention, but also have regions with less seasonal malaria transmission where children do not currently benefit from chemoprevention but could benefit from IPTi
• Testing of IPTi in areas of medium-to-high malaria transmission, where levels of parasite resistance are above the WHO recommended threshold of 50% (e.g. in certain regions of East Africa), to determine the resistance thresholds under which IPTi remains effective

Proposals can address one or more of the items above. Proposals should demonstrate plans for close engagement with national immunization programmes. Proposals should also recognize that challenges related to the adoption of IPTi can be closely related, and should therefore reflect the proponent’s ability to coordinate closely with other actors in this space.

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) click here [PDF: 560 KB];

Proposals should clearly demonstrate the use of innovative and sustainable approaches to accelerating uptake of IPTi. Unitaid notes that this call may share some common elements or activities with other recent calls or ongoing Unitaid grants, and welcomes approaches that outline a coherent, integrated approach.

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.

Successful applicants should plan to be available for a face-to-face kick-off meeting with Unitaid, in Geneva, between 29 June-2 July 2020 (exact date tbc). In addition, successful applicants should plan to have sufficient human resources available to advance a first draft of the project plan by mid-2020.

Important dates

Please note, a proposal is considered submitted only once you receive an e-mail message of confirmation of receipt from Unitaid.

Please note that the confirmation of receipt is not an automated message and will be sent to you within one working day following the deadline. If for any reason you have not received the confirmation of receipt within one working day, please reach out to proposalsUnitaid@who.int.

Please note that our email system accepts messages up to 8 MB in size. For submissions exceeding this size, please consider splitting your submission in several messages.

Submission and format of proposals

Proposals, including all annexes, should be submitted electronically to proposalsUnitaid@who.int. A full proposal consists of the following documents:

• Proposal form with scanned version of signed Front page template, [DOC: 170 KB]
• Annex 1: Log frame template, [XLS: 50 KB]
• Annex 2: Timeline GANTT chart template, [XLS: 35 KB]
• Annex 3: Budget details template, [XLS: 23 KB]
• Annex 4: Organizational details and CVs of key team members [no template]
• Annex 5: Country engagement support Letters [no template]
• Annex 6: Declaration of relevant interest template, [DOC: 21 KB]
• Annex 7: Applicable ethics, anti-discrimination and environmental policies template, [DOC: 21 KB]
• Annex 8: Declaration regarding tobacco entities template, [DOC: 25 KB]
• Annex 9: Anti-Terrorism Declaration template, [DOC: 30 KB]
• Annex 10: Audited financial statements for the past 3 years [no template]
• Guidance on Impact Assessment [PDF: 160 KB]
• Financial Guidelines for Unitaid Grantees [PDF: 1,2 MB]

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].

Webinar on this Call for Proposals:

• Play recording in English (62 min)