Malaria Treatment in Africa

07 May 2008
Africa Fighting Malaria
Drug resistance due to parasite mutation was a key driver of malaria's resurgence in sub-Saharan Africa in the 1990s. Southeast Asian countries demonstrated the efficacy of a new but expensive treatment and, together with a Swiss pharmaceutical company, developed the first fixed-dose artemisinin-based combination therapy (ACT) for malaria. Few countries claimed they could afford to adopt this drug as a first line treatment. Advocates, malaria scientists and United States Congress ultimately exposed the folly of continuing to fund outdated drugs like chloroquine and sulfadoxine-pyrimethamine (SP), and donor agencies moved to meet the huge need for ACTs.

The results have been a mixture of success and systemic failure. The United States Government, World Bank and the Global Fund to Fight AIDS, TB and Malaria have substantially increased malaria control funding and through the World Health Organisation (WHO) and Roll Back Malaria Partnership (RBM) provided technical assistance to help countries change treatment guidelines to ACTs and devise strategies to finance them. As of September 2007, ACTs are listed as first-line treatments for uncomplicated malaria in every national treatment policy in sub-Saharan Africa where they are needed. The Global Fund is helping to deliver 264 million ACTs, backed by an unprecedented $471 million allocation for malaria control (42% of total allocations) in its most recent round of grants (Round 7). Largely as a result of these efforts, some African countries are reporting localized declines in malaria cases and deaths.

Yet the rising demand for artemisinin has increased incentives for producers to market artemisinin as a monotherapy. The WHO has explicitly recommended against this practice, as widespread exposure could accelerate parasite resistance to artemisinin. No new class of antimalarial treatment is expected to enter the market for at least a decade, so all foreseeable malaria treatment strategies depend on the integrity of this drug. Recent evidence from Southeast Asia suggests that artemisinin may be losing effectiveness against malaria. If this is attributable to parasite resistance, Africa may not be far behind.

Unfortunately, public health systems on the African continent remain weak and underdeveloped. Most people still seek treatment from the private sector, where substandard and artemisinin monotherapy drugs abound. Africa Fighting Malaria (AFM) has confirmed this in a recent study of private sector antimalarial drug quality in six African countries - Ghana, Kenya, Nigeria, Rwanda, Tanzania and Uganda. Antimalarial monotherapy tablets, including artemisinin, were widely available in urban and peri-urban pharmacies, with 35 percent of all treatments failing basic content testing.

This comes as no surprise. Only 20 percent of the WHO's 191 member states currently have well-developed drug regulation. Post-market surveillance of the private sector in low-income countries is practically non-existent, and national drug registries are infrequently updated or publicized. Africa has only six WHO-registered national pharmacovigilance systems to detect substandard drugs. Though the agency has made efforts to scale these up and develop new sites, resistance monitoring networks remain severely limited.

In the absence of strong national regulatory and pharmacovigilance systems, consistent leadership among donor agencies providing ACTs is critical - and sorely lacking. The Global Fund has adopted a stand-alone policy of procuring drugs not tested by competent agencies. This is intended to increase competition and spur price reductions, but it may result in the distribution of unsafe drugs. Such practice is forbidden in developed countries. The Executive Director of RBM has voiced concerns about the quality of these drugs, but the Global Fund is reticent to leave nascent copy drug companies in the lurch.

An outgrowth of the trend toward generics and copy drugs is "local production" of pharmaceuticals. Some donors aggressively advocate this concept even as they acknowledge safety risks and substantial opportunity costs. Tremendous investment of limited resources will be required to turn African factories into viable, internationally-accredited production facilities. Further, localized producers have an inclination and incentive to protect their output by lobbying for tariffs and other protective measures, which threaten to increase costs and impede access to quality drugs. Ideological support for local production destructively conflates industrial and public health policy, and provides copy drug companies little incentive to improve quality.

The latter point is most concerning as donor agencies roll out new treatment solutions like the Affordable Medicines Facility - malaria (AMFm). If approved, this initiative will adopt the commendable goal of subsidizing ACTs for private and public sector distribution. Unfortunately it plans to compromise on drug quality standards in line with the Global Fund. Without a commensurate strengthening of national regulation, postmarket surveillance and pharmacovigilance to pace the inevitable development of artemisinin resistance, such policies could result in setbacks for malaria control and public health.

Substandard drugs continue to circulate in Africa, causing an estimated 200,000 avoidable deaths from malaria alone each year. Structural reforms are elusive. Malaria endemic countries remain hugely dependent on donors, who too often reward policy failures with new aid initiatives. Eight years ago, African governments pledged to remove taxes and tariffs on malaria control technologies, and devote at least 15 percent of their national budgets to improving health care. Most are failing to live up to these commitments. Unless Africa takes its own health care more seriously, the present gains against malaria should not be expected to last.

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