Malaria kills more African kids than any other disease. April 25 marks Africa Malaria Day to raise public awareness of malaria, commemorate lives lost, and gauge progress against the disease. Many African countries are developing indoor residual spraying programs, some with DDT, a highly effective and safe insecticide proven to reduce the burden of malaria. Insecticide-treated mosquito net distribution, however, continues to dominate efforts. Our analysis shows that slow approvals for new net technologies have limited competition and wasted public funds for malaria control. Qualified, cost-effective alternatives exist and competition should be encouraged.
Hung properly and used every night, nets can protect people from mosquitoes that carry malaria. Long-lasting insecticidal nets (LNs) are expected to remain effective for several years. The Roll Back Malaria Partnership (RBM) and its constituent foreign donors adopted LNs as a priority intervention against malaria, and in 2004 urged various companies to develop new LNs. To establish guidelines for safety and efficacy, the World Health Organization Pesticide Evaluation Scheme (WHOPES) reviews and recommends new LN technologies. Though WHOPES is not a regulatory body, successful companies aggressively market its recommendation. It has become a 'gold standard' because donors almost exclusively purchase WHOPES-recommended LNs.
Between 2001 and 2006, only two products received WHOPES recommendation, giving two companies an effective duopoly. Between 2004 and 2006, Vestergaard-Frandsen and Sumitomo Chemical were awarded the vast majority of government contracts for net distribution. Sumitomo, a chemicals company, sold about 30 million Olysets® through its Corporate Social Responsibility program, and Vestergaard, a textiles company whose primary business is selling public health products, sold over 100 million PermaNets®. Vestergaard currently manufactures 75 percent of all available LNs and maintains 60 percent of global production capacity, and 95 percent of its business comes from taxpayer-funded government contracts.
Due to limited test center capacity and infrequent meetings new net reviews takes over two years on average. During this time LN developers pay for WHOPES testing and other independent evaluations and production costs, but cannot compete for contracts specifying WHOPES recommendation. As a result, WHOPES delays in approving new net technologies have unintentionally restricted competition, limited product options and kept prices and distribution costs high.
The President's Malaria Initiative (PMI), run by the US government, recently bucked the system. In January 2007 it signed a contract with a non-WHOPES approved LN producer, Tana Netting, to deliver its Dawa Plus® net to districts in Uganda for $4.93. This cost is on average about 50 percent lower than UNICEF charges to procure and deliver PermaNets® and Olysets®. Independent studies confirm that Dawa Plus® nets are safe and effective, and so the PMI should be commended for encouraging competition. New private initiatives like Malaria No More have skillfully raised funds for LNs but opted to buy only WHOPES recommended LNs through UNICEF, costing them on average $8 per net delivered. This is a waste. They should instead follow the PMI and source qualified new products.
They should not, however, expect existing suppliers to appreciate competition. Insiders have told us that Mikkel Vestergaard-Frandsen, the company's eponymous CEO, flew to Washington, D.C. to protest the PMI's contract with Tana Netting and convince senior personnel to choose PermaNet® instead. His efforts that day failed, but his tactics have long paid off. Since WHOPES recommended PermaNet® in 2004, governments without regulatory capacity for LNs have increasingly specified "WHOPES recommendation" in their tenders. This is understandable, but many have incomprehensibly outlined the precise specifications for PermaNets®. This amounts to an African government asking net manufacturers, "Who among you can provide the best PermaNet®?" One supposedly competitive public tender published in the Kenyan Daily Nation in April 2006 explicitly specified "PermaNet 2®, Polyester net treated with deltamethrin". Competitors protested and the tender was republished but the contract inevitably went to Vestergaard.
Open competition is the best remedy for high prices and limited choice, as is evident in the provision of anti-malarial treatments. Malaria treatment guidelines call for new Artemesinin-based Combination Therapies (ACTs) and there are now an increasing number of manufacturers bringing new products to the market at lower cost. For several years, the Swiss-based drug company Novartis dominated the market with its ACT, Coartem®. However the company never enforced its patent and provides Coartem® at zero profit through the WHO and has its accounts independently audited to prove this. Given the lack of competition in the LN market, the incumbents could take a leaf out of Novartis' book and open themselves up for an independent audit. This would help the taxpayers around the world to better understand how their money is being spent in the fight against malaria.
Tens of millions of dollars have been invested in developing safe and effective alternative LNs, including by US taxpayers. NetMark, a USAID partnership for commercial net development, provided seed funding to new producers, but has been frustrated by the World Bank, Global Fund, Red Cross and other RBM Partners' adoption of policies to only buy WHOPES-recommended LNs. Kept out of contracts and unable to sell nets, some companies are likely to shut down this year, threatening jobs in low-income countries and potentially denying African children new LNs. The WHO and the RBM Partners have urged these companies on since 2004, and they must act now to let them compete.
Richard Tren is the Director and Philip Coticelli is the Research and Communications Manager for Africa Fighting Malaria. Coticelli is the author of "WHOPES and Its Impact on Long-lasting Insecticidal Net Availability".