Rwanda: Malaria - Great Idea, Bad Scheme

Roger Bate | 01 Nov 2008
New Times (Kigali)
A new global subsidy to give malaria patients the best treatment may divert money from simpler campaigns and could undermine drug quality--but it looks set to be rubber-stamped by donors without proper assessment.

The fact that malaria kills an African child every thirty seconds has prompted the new Affordable Medicines Facility for Malaria (AMFm), which will cost around $2bn over five years and could save lives. Major donors such as the USA and Germany fear it could plunder existing funds but there is no sign they will veto it.

There is a powerful need for a cheap, effective malaria treatment. Currently the not-for-profit price for the best medicine is around one dollar for one treatment--still too expensive for millions in malarial countries.

Chloroquine is only ten cents a treatment so is still widely used, even though it is often ineffective due to the malaria parasite's acquired resistance. Drug resistance is inevitable and contributed to the worldwide rise in malaria from the 1970s onwards. But it can be prevented.

Given resistance to drugs like chloroquine, a combination of two drugs, with different modes of action, dramatically reduces the chance of parasites developing resistance to either.

As there are no new medicines on the horizon, it is important that the effectiveness of artemisinin, the newest drug, is preserved as long as possible. One way is to take artemisinin mono-therapies off the market.

The World Health Organisation demanded this and failed. The AMFm aims to drive them from the market by making the Artemisinin Combination Therapies (ACT) cheaper--a great idea, in principle.

But in rural Africa, the availability of prevention and treatment is poor, regardless of price. Public dispensaries are rare and most people get their medicines from private shops and travelling traders.

The AMFm would provide subsidised medicines through wholesalers to this rural private market, reaching far more people than any scheme working just with the public sector.

Yet rural markets in Africa are not sufficiently understood. While a limited AMFm pilot scheme in Tanzania has demonstrated that delivery of ACTs could increase, it is far from certain that it is cost-effective.

The largest anti-malaria donor is The Global Fund to Fight AIDS, Tuberculosis and Malaria, which plans to run the AMFm. But the Fund is a champion of local drug production even when that means promoting untested medicines for the poor and even against the technical advice of its own analysts.

Locally-produced drugs are often more expensive than imports (for example in Ghana) and of questionable quality. The Global Fund requires only that the drugs come from factories that show Good Manufacturing Practices (GMP), meaning a company that makes decent aspirin is acceptable for complex anti-malaria drugs.

In February 2007 the Fund admitted that half the drugs purchased under one programme did not comply with its weak Quality Assurance Policy.

To allow untested medicines that would never be allowed in any industrialised country to be foisted on Africans is wrong, encouraging harm and drug resistance. Yet the populist notion of stimulating local production seems to have trumped patients' safety.

Poor infrastructure and a lack of health staff remain the greatest barriers to drug access and there is no single solution. AMFm is not necessarily that solution either: its US$2bn could probably save many more lives in existing preventative efforts such as indoor insecticide spraying or treated mosquito nets.

Supporters of the AMFm present the scheme as a fait accompli: "Put up or shut up" was how Julian Schweitzer, a senior World Bank official, recently responded at a meeting to those questioning its wisdom.

The final decision on the AMFm will be taken at a meeting in India on 7 to 8 November of the Global Fund's Board, which includes NGOs, the private sector and recipient and donor governments.

The big donors, such as the USA, Germany and Japan, and sceptical Board members are being aggressively lobbied to change their position. But there is still no evidence that AMFm will cut infant mortality and general sickness or that it will be cost-effective or maintain quality control.

Until its fans can prove it is the best use of the money, donors should not fund the AMFm and recipients should reject it in favour of proven methods.