Making Antimalarial Agents Available in Africa
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- Early release article - NEJM
The New England Journal of Medicine of 7th July 2005 has re-
leased an article "Making Antimalarial Agents Available in Af-
rica" by K.J.Arrow, H .Gelband and D.T Jamisonby as "early re-
lease article". The article can be accessed from www.nejm.org as
Adobe PDF file (2 pp. 100 kB) at:
http://content.nejm.org/cgi/reprint/NEJMp058168v1.pdf
The authors suggest how artemisinin based combinations such as
artemether-lumefantrine can be made available at an affordable
cost to third world countries. They suggest a subsidy at the
"higher level of the distribution channel". These subsidies at
higher level would enable an international agency to buy it and
resell it at the subsidized cost to various governments and mar-
kets. These would alleviate the need to create another distribu-
tion system. The drugs would enter the markets in the same way
as other drugs such as chloroquine enter the market.
I was impressed with the article and the fact that NEJM pub-
lished it. The NEJM in the past usually concentrated on health
issues affecting the developed world however over the last few
years it is publishing health issues affecting the developing
countries and making articles available to health workers in de-
veloping countries.
ACT therapy presently costs around US$ 2 - US$ 5 per patient at
both the retail and wholesale. This is beyond reach of most Sub-
Saharan countries. The authors suggest the subsidy so that the
patients can buy it at a much lower and affordable cost. The
subsidy at the higher level of the distribution channel would
make it easier for the manufactures to plan production since
there is a world wide shortage of Arteminisis annua, the plant
from which artemether is derived.
This seems practical and much more easier than use of vouchers
or reimbursements to hospitals or governments. This would work
like targeted food subsidies. There would be no need for social
marketing; let the ACT be distributed by the markets.
The idea is to make sure that the patients get a full course of
ACT. ACT could be sold through shops and would be accessible to
those in rural areas which are far away from hospitals and clin-
ics. Dr V Marsh had trained shop keepers in Kilifi District on
how to dispense chloroquine tablets and it was quite successful.
Making ACT available at the village shops would be realistic
since one of the aims of the malaria control programs is to make
sure that children get anti-malarials within 8 hours of a fever
in malaria endemic regions.
One issue about subsidies means that even those who can afford
it will be able to get it at a cheaper price. In a way it is
true, however when one considers the fact that about 56% of peo-
ple in Sub-Saharan Africa live below the poverty line and these
are the ones who are the most vulnerable, it really does not
matter if those who can afford pay less. It is unlikely that
those who can afford the drugs will consume more of the drugs
because they are cheap, drugs are not like food - you do not
consume more drugs because they are cheap. It is like the TB or
the immunization programs in Kenya, all patients are entitled to
get free TB drugs and immunizations. Early treatment of malaria
has positive benefit since early treatment reduces morbidity,
mortality and reduces time taken off by the parents from work
when they are looking after the sick children.
The other issue which is attractive about procuring by an agency
from a manufacturer is that it will ensure quality compliance.
About 40% of anti-malarials in Kenya were found to be sub-
standard.
The most important issue is about who is going to fund it. The
US government initiative on malaria could fund these. However,
it time to do something now. As the Roll Back Malaria programme
has admitted, there are more children dying of malaria then was
estimated. The Global Funds which were supposed to help Kenya
get ACT into the country has failed, ACT drugs are not available
in Kenya's public health sector despite the fact that arte-
mether-lumefantrine (Coartem) is the recommended first line
drug.
Dr S K Sharif
Kenya
mailto:sksharif@ikenya.com