Focusing on Quality Patient Care in the New Global Subsidy for Malaria Medicines

Suerie Moon et al | 21 Jul 2009
PloS Medicine
Almost 40 years ago, Chinese scientists rediscovered the near-miraculous potency of artemisinin derivatives against malaria. Today, we are approaching a decade since the World Health Organization (WHO) recommended that artemisinin-based combination therapies (ACTs) replace older antimalarials rendered ineffective by resistance [1]. Yet the global malaria community—researchers, governments, international organizations, funding agencies, nongovernmental organizations, and activists—has collectively failed to provide widespread access to this treatment and to minimize the threat of resistance. The evidence is sobering:

-Although nearly all endemic countries have adopted ACTs as first-line therapy for Plasmodium falciparum malaria, access on the ground remains dangerously low. In recent household surveys from 18 African countries, on average only 3% of febrile children under five years received an ACT, while only 38% had access to other antimalarials. African children comprise 85% of global malaria deaths [2].

-The parasite is demonstrating decreased sensitivity to artemisinin in Cambodia, where use of artesunate monotherapy and substandard artemisinin-based drugs remains common [3]-[5]. If artemisinin-resistant strains of P. falciparum emerge and spread, they would weaken the last effective antimalarial we have.

Therefore, the Affordable Medicines Facility-malaria or AMFm (see Box 1) is a welcome step toward improving access to this lifesaving treatment. Funding commitments from UNITAID and the UK Department for International Development, along with the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) decision to host the facility, have launched an ambitious global subsidy on ACTs into operation. By lowering the price of ACTs, the AMFm may broaden access in the public sector. However, since many governments already receive GFATM support to purchase ACTs for public use, the AMFm's most dramatic impact is likely to be on prices in the private sector. (The term "private sector" here refers to for-profit entities and can denote a wide range of drug outlets, from small rural kiosks to regulated urban pharmacies and private clinics.) Approximately half of suspected malaria patients seek care outside the public sector in the WHO African and Western Pacific regions, and up to 78% in the Southeast Asian region [2].

ACT prices have significantly decreased in recent years, mainly due to competition (see Figure 1); however, they are still costlier than most antimalarials. ACT production incorporates a relatively expensive extraction, purification, and derivatization process, the cost of the companion drug (e.g., amodiaquine), and the cost of co-formulation for fixed-dose combinations (FDCs). Thus, a subsidy is warranted to bring ACT prices down to the level of other antimalarials, at least until semi-synthetic artemisinin production is available at adequate volume and low cost, which is not expected before 2012 [6].

The AMFm is both promising and ambitious. However, as the first major global initiative of its kind, its precise impact and consequences are still unknown. As the AMFm prepares for its first phase of implementation, it is critical to recognize areas that require further attention, where additional research is urgently needed, and how countries can best take advantage of the opportunities it may offer.

In the first section we propose policies to improve patient care. We then briefly suggest measures that could improve AMFm implementation. Finally, we discuss the implications of our analysis for calibrating support for the public and private sectors.

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