[Ip-health] Cost is killing patients: subsidising effective antimalarials - Comment in The Lancet

[Jaya Banerji]

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The Lancet Vol 374 October 10, 2009, pp 1224-25

<Cost is killing patients: subsidising effective antimalarials>

Ambrose Talisuna, Penny Grewal, John Bosco Rwakimari, Susan Mukasa, George =
Jagoe, Jaya Banerji



National and global efforts to treat malaria have focused largely on provis=
ion of effective antimalarial treatment, mainly through public health servi=
ces. The private sector (although a key source of antimalarials in most cou=
ntries) has been mostly ignored in the effort to find solutions to the issu=
es of accessibility, availability, and affordability of effective drugs.1 T=
he cost of artemisinin-based combination treatments (ACTs), the only truly =
effective antimalarials,2 is far beyond the reach of the average family in =
Africa, let alone poorer populations. The Affordable Medicines Facility for=
 malaria (AMFm), an initiative of the Global Fund to Fight AIDS, Tuberculos=
is and Malaria, offers a radical solution,3 the possibility for countries t=
o procure heavily subsidised ACTs that will reduce the price for patients s=
o it is similar to that of chloroquine. On July 1, 2009, 11 countries submi=
tted a first round of proposals to the AMFm.4 In November, 2009, they will =
know whether their proposal has been successful.

Is the solution suggested by the AMFm workable and relevant? As with all in=
novative ideas, the AMFm has to contend with scepticism. Is the Global Fund=
 falling prey to mission creep (namely, expansion of a project beyond its o=
riginal goals)?5 Is this a good use of resources? Will the AMFm work?6 Wher=
e is the evidence? Evidence is available from two pilot studies in Tanzania=
 and Uganda in 2007-08 and 2008-09, respectively.1,7,8 Both studies have in=
formed the design of the AMFm. Let us take the example of Uganda.

Malaria is one of the major causes of death in Uganda, and one of the main =
reasons for this mortality is the exorbitant price of non-effective antimal=
arials and ACTs in the private sector, which is the first port of call for =
more than 60% of Ugandans.1 The AMFm solution will greatly reduce the price=
 of ACTs both to governments and in the private sector.3,9 The pilot study =
in Uganda, led by the Ministry of Health and Medicines for Malaria Venture,=
 showed that availability of subsidised ACTs led to rapid growth of stocks =
of these drugs.1 Drug shops seemed to charge reasonable markups. Supportive=
 interventions such as communication and training was essential to ensure a=
ccessibility and uptake of ACTs. Affordability of drugs rose in the private=
 sector with a concomitant increase in uptake by children younger than 5 ye=
ars (figure). Even more heartening, augmented ACT uptake eroded the market =
share of ineffective antimalarials such as chloroquine.



Figure Antimalarials purchased for children younger than 5 years in Uganda



In Uganda, although the much-reduced price increased affordability in licen=
sed drug shops in the four study districts, unlicensed shops were more acce=
ssible and widely used. All countries that participate in the AMFm have to =
show a willingness to also implement systems to remove barriers to ACT avai=
lability. Ugandan researchers are looking into ways to upgrade unlicensed s=
hops and are considering granting over-the-counter status to ACTs, even tho=
ugh this step is not mandatory.

Advances in malaria prevention have affected the burden of the disease for =
the better, but we cannot lay down arms and claim a victory against malaria=
.10 Although worth celebrating, these successes cannot hide the fact that c=
lose to a million people (mostly young children) continue to die every year=
 and more than 250 million individuals are infected annually,11 of whom onl=
y 3% have access to ACTs. We have to find a way to get effective drugs to t=
hese vulnerable children whose futures hang in the balance.

The AMFm is attempting to find that elusive solution. By hosting and managi=
ng this initiative the Global Fund is not subjecting itself to mission cree=
p: AMFm funds for subsidising ACTs are not part of the larger Global Fund b=
ursary but have been specially allocated from the UK Government and UNITAID=
.4 The AMFm is based on a robust idea and will be rigorously evaluated at e=
very step. How else should responsible innovation take place?



Ambrose Talisuna, Penny Grewal, John Bosco Rwakimari, Susan Mukasa, George =
Jagoe, *Jaya Banerji

Medicines for Malaria Venture, 1215 Geneva 15, Switzerland (AT, PG, GJ, JB)=
; Ministry of Health, Kampala, Uganda (JBR); and Program for Accessible Hea=
lth, Communication, and Education, Kampala, Uganda (SM)

banerjij@mmv.org



We declare that we have no conflicts of interest.

AT: Member of the Global Fund Technical Review Panel

PG: Member of the former AMFm Task Force of the Roll Back Malaria Partnersh=
ip

1          Medicines for Malaria Venture. Understanding the antimalarials m=
arket: Uganda 2007-an overview of the supply side. Nov 6, 2008. http://www.=
mmv.org/article.php3?id_article=3D536 (accessed Aug 20, 2009).

2          WHO. The use of antimalarial drugs: report of a WHO informal con=
sultation. Nov 13-17, 2000. http://www.who.int/malaria/cmc_upload/0/000/014=
/923/use_of_antimalarials.pdf (accessed Aug 20, 2009).

3          Arrow KJ, Panosian CB, Gelband H. Saving lives, buying time: eco=
nomics of malaria drugs in an age of resistance. 2004. http://www.nap.edu/o=
penbook.php?isbn=3D0309092183 (accessed Aug 12, 2009).

4          The Global Fund to Fight AIDS, Tuberculosis, and Malaria. Afford=
able Medicines Facility-malaria: frequently asked questions. July 29, 2009.=
 www.theglobalfund.org/documents/amfm/AMFmFAQs_en.pdf (accessed Aug 20, 200=
9).

5          Bate R, Hess K. Affordable Medicines Facility for malaria. Lance=
t Infect Dis 2009; 9: 396-97.

6          Moon S, P=E9rez Casas C, Kindermans J-M, de Smet M, von Schoen-A=
ngerer T. Focusing on quality patient care in the new global subsidy for ma=
laria medicines. PLoS Med 2009; 6: e1000106.

7          Sabot O, Yeung S, Pagnoni F, et al. Distribution of artemisinin-=
based combination therapies through private-sector channels: lessons from f=
our country case studies. January, 2009. http://www.rff.org/RFF/Documents/R=
FF-DP-08-43_FINAL.pdf (accessed Aug 20, 2009).

8          Samarasekera U. Drug subsidy could help Tanzania tackle malaria.=
 Lancet 2008; 371: 1403-06.

9          The Global Fund to Fight AIDS, Tuberculosis, and Malaria. Report=
 of the Affordable Medicines Facility-malaria ad hoc committee. Nov 7-8, 20=
08. http://www.theglobalfund.org/documents/board/18/GF-B18-07_ReportAMFmAdH=
ocCommittee.pdf (accessed Aug 20, 2009).

10        Roll Back Malaria. Introduction to the Global Malaria Action Plan=
. 2008. http://www.rollbackmalaria.org/gmap/1-1.html (accessed Aug 20, 2009=
).

11        WHO. World malaria report 2008. 2008. http://apps.who.int/malaria=
/wmr2008/malaria2008.pdf (accessed Aug 20, 2009).