Plan Tries to Lower Malaria Drug Cost

Donald G. McNeil Jr. | 17 Apr 2009
New York Times
A new campaign to save lives and prevent drug resistance by driving the price of the best malaria medicine down to as little as 20 cents was announced Friday by international health agencies and European governments.

The subsidy program, unveiled in Norway, will have an initial budget of $225 million and will be run by a new partnership called the Affordable Medicines Facility for Malaria, or AMFm.

Malaria experts hailed the program as one of the most important recent advances in fighting malaria, which kills one million people a year, 90 percent of them children. Awa-Marie Coll-Seck, executive director of one of the groups involved, the Roll Back Malaria Partnership, called it "a triumph of international cooperation."

But the United States, the world's biggest donor to the war on malaria, is not supporting it yet.

The goal of the medicines facility is to pressure the few drug companies that now make artemisinin combination drugs to lower their wholesale private-sector price to $1 per treatment from $4, and then to use donor funds to subsidize 95 cents of that dollar so the drugs cost only a nickel. The hope is that when the drugs are sold at retail in villages in Africa and Asia, the marked-up price will still be low enough to drive out cheap but less effective alternatives.

"For a poor farmer in Cameroon or a poor market woman in Ghana, the difference between 20 cents and $8 is huge," said Olusoji Adeyi, who led the World Bank task force that drew up the plan.

The program is a joint effort by the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Roll Back Malaria partnership, the governments of Norway, Britain and the Netherlands, and the Unitaid partnership of 30 countries raising money through airline ticket fees.

Heavily subsidizing the private malaria medicine market was first proposed in 2004 by a committee of the Institute of Medicine of the American Academy of Sciences, led by Kenneth Arrow, a winner of the Nobel Prize in economics. The Bill and Melinda Gates Foundation and the Clinton Foundation backed the plan.

The United States has declined to put any money in yet. Dr. Bernard Nahlen, deputy coordinator of the President's Malaria Initiative, said in an interview Thursday that he wanted more studies proving that subsidies would work before investing hundreds of millions of dollars.

"I sometimes joke that this is the biggest faith-based initiative in the world of malaria," he said. "I'm perfectly willing to be convinced, but sometimes the advocacy gets out ahead of the evidence."

Mr. Adeyi said Thursday that "a few pilot studies" had convinced the plan's backers it would work; Dr. Nahlen dismissed those as "two highly controlled Clinton Foundation studies in two districts in Tanzania."

The law Congress passed last year authorizing another $48 billion for AIDS, tuberculosis and malaria specifically forbids donations to the AMFm until the head of malaria activities for the government — Dr. Nahlen at the moment — has "compelling evidence of success from pilot programs."

Early plans were for the program to start with $1.9 billion in donor funds, so the $225 million kickoff is being treated as a pilot project to be rolled out in 11 countries: Cambodia and 10 countries in Africa.

It will be re-evaluated after two years.

At the base of the dispute are a few details that make fighting malaria different from fighting AIDS or tuberculosis.

Those diseases kill slowly, and drugs for them are handed out at public health clinics.

But cerebral malaria can kill a child in 24 hours, so antimalaria drugs must be sold everywhere, ideally within walking distance of even the remotest village. Many brands are stocked by pharmacies and even in small huts whose owners sell soap, matches and cooking oil.

The World Health Organization now endorses first-line treatment only with cocktails of two drugs. One of the drugs is artemisinin, a derivative of artemisia annua or sweet wormwood, which was developed as an antimalarial by the Chinese in the 1970s — originally on the orders of Mao Zedong to help the North Vietnamese in their fight with the United States.

The backers of the subsidy hope to crowd two different sets of cheaper drugs out of the market: old drugs like chloroquine and Fansidar, because resistance to them is common, as well as artemisinin monotherapy, because taking the drug when it is not in a multidrug cocktail greatly increases the chance that the parasite will develop resistance.

Only three companies — Novartis, Sanofi-Aventis and Ajanta, an Indian generics company — now make cocktails of two drugs in one pill that have been accepted by the W.H.O. Several other drugs by several other companies are expected to qualify soon.

Doctors Without Borders, the medical charity that treats patients all over the world, endorsed the subsidy plan for the combination pill but also said it "jeopardized the future" of artemisinin by permitting subsidies for blister packs that allow people to take only the artemisinin and avoid the bitter companion drugs sold with it.

Drug companies usually sell artemisinin combination therapy at $1 to governments but $4 to private wholesalers. By the time it reaches village level, it may cost 10 to 40 times as much as old drugs — which may reduce fever the way aspirin does but not kill parasites.

Complicating matters further is the lack of diagnosis. In malarial areas, fearful parents give malaria drugs whenever a child spikes a fever, but some studies show that up to 90 percent of fevers are not malaria. In those situations, subsidies are costly and wasteful.

Dr. Nahlen endorsed programs like those in Ethiopia, in which 30,000 village health workers are taught to use rapid test kits. But those are not widely available in Africa yet.