E-DRUG: Cost is killing patients: subsidising effective antimalarials
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Comment in The Lancet
The Lancet Vol 374 October 10, 2009, pp 1224-25
Ambrose Talisuna, Penny Grewal, John Bosco Rwakimari, Susan Mukasa, George Jagoe, Jaya Banerji
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National and global efforts to treat malaria have focused largely on provision of effective antimalarial treatment, mainly through public health services. The private sector (although a key source of antimalarials in most countries) has been mostly ignored in the effort to find solutions to the issues of accessibility, availability, and affordability of effective drugs.1 The cost of artemisinin-based combination treatments (ACTs), the only truly effective antimalarials,2 is far beyond the reach of the average family in Africa, let alone poorer populations. The Affordable Medicines Facility for malaria (AMFm), an initiative of the Global Fund to Fight AIDS, Tuberculosis and Malaria, offers a radical solution,3 the possibility for countries to procure heavily subsidised ACTs that will reduce the price for patients so it is similar to that of chloroquine. On July 1, 2009, 11 countries submitted a first round of proposals to the AMFm.4 In November, 2009, they will know whether their proposal has been successful.
Is the solution suggested by the AMFm workable and relevant? As with all innovative ideas, the AMFm has to contend with scepticism. Is the Global Fund falling prey to mission creep (namely, expansion of a project beyond its original goals)?5 Is this a good use of resources? Will the AMFm work?6 Where is the evidence? Evidence is available from two pilot studies in Tanzania and Uganda in 2007-08 and 2008-09, respectively.1,7,8 Both studies have informed the design of the AMFm. Let us take the example of Uganda.
Malaria is one of the major causes of death in Uganda, and one of the main reasons for this mortality is the exorbitant price of non-effective antimalarials and ACTs in the private sector, which is the first port of call for more than 60% of Ugandans.1 The AMFm solution will greatly reduce the price of ACTs both to governments and in the private sector.3,9 The pilot study in Uganda, led by the Ministry of Health and Medicines for Malaria Venture, showed that availability of subsidised ACTs led to rapid growth of stocks of these drugs.1 Drug shops seemed to charge reasonable markups. Supportive interventions such as communication and training was essential to ensure accessibility and uptake of ACTs. Affordability of drugs rose in the private sector with a concomitant increase in uptake by children younger than 5 years (figure). Even more heartening, augmented ACT uptake eroded the market share of ineffective antimalarials such as chloroquine.
(Figure Antimalarials purchased for children younger than 5 years in Uganda}
In Uganda, although the much-reduced price increased affordability in licensed drug shops in the four study districts, unlicensed shops were more accessible and widely used. All countries that participate in the AMFm have to show a willingness to also implement systems to remove barriers to ACT availability. Ugandan researchers are looking into ways to upgrade unlicensed shops and are considering granting over-the-counter status to ACTs, even though this step is not mandatory.
Advances in malaria prevention have affected the burden of the disease for the better, but we cannot lay down arms and claim a victory against malaria.10 Although worth celebrating, these successes cannot hide the fact that close to a million people (mostly young children) continue to die every year and more than 250 million individuals are infected annually,11 of whom only 3% have access to ACTs. We have to find a way to get effective drugs to these vulnerable children whose futures hang in the balance.
The AMFm is attempting to find that elusive solution. By hosting and managing this initiative the Global Fund is not subjecting itself to mission creep: AMFm funds for subsidising ACTs are not part of the larger Global Fund bursary but have been specially allocated from the UK Government and UNITAID.4 The AMFm is based on a robust idea and will be rigorously evaluated at every step. How else should responsible innovation take place?
1 Medicines for Malaria Venture. Understanding the antimalarials market: Uganda 2007-an overview of the supply side. Nov 6, 2008. http://www.mmv.org/article.php3?id_article=536 (accessed Aug 20, 2009).
2 WHO. The use of antimalarial drugs: report of a WHO informal consultation. Nov 13-17, 2000. http://www.who.int/malaria/cmc_upload/0/000/014/923/use_of_antimalarials.pdf (accessed Aug 20, 2009).
3 Arrow KJ, Panosian CB, Gelband H. Saving lives, buying time: economics of malaria drugs in an age of resistance. 2004. http://www.nap.edu/openbook.php?isbn=0309092183 (accessed Aug 12, 2009).
4 The Global Fund to Fight AIDS, Tuberculosis, and Malaria. Affordable Medicines Facility-malaria: frequently asked questions. July 29, 2009. www.theglobalfund.org/documents/amfm/AMFmFAQs_en.pdf (accessed Aug 20, 2009).
5 Bate R, Hess K. Affordable Medicines Facility for malaria. Lancet Infect Dis 2009; 9: 396-97.
6 Moon S, Pérez Casas C, Kindermans J-M, de Smet M, von Schoen-Angerer T. Focusing on quality patient care in the new global subsidy for malaria medicines. PLoS Med 2009; 6: e1000106.
7 Sabot O, Yeung S, Pagnoni F, et al. Distribution of artemisinin-based combination therapies through private-sector channels: lessons from four country case studies. January, 2009. http://www.rff.org/RFF/Documents/RFF-DP-08-43_FINAL.pdf (accessed Aug 20, 2009).
8 Samarasekera U. Drug subsidy could help Tanzania tackle malaria. Lancet 2008; 371: 1403-06.
9 The Global Fund to Fight AIDS, Tuberculosis, and Malaria. Report of the Affordable Medicines Facility-malaria ad hoc committee. Nov 7-8, 2008. http://www.theglobalfund.org/documents/board/18/GF-B18-07_ReportAMFmAdHocCommittee.pdf (accessed Aug 20, 2009).
10 Roll Back Malaria. Introduction to the Global Malaria Action Plan. 2008. http://www.rollbackmalaria.org/gmap/1-1.html (accessed Aug 20, 2009).
11 WHO. World malaria report 2008. 2008. http://apps.who.int/malaria/wmr2008/malaria2008.pdf (accessed Aug 20, 2009).
AT: Member of the Global Fund Technical Review Panel
PG: Member of the former AMFm Task Force of the Roll Back Malaria Partnership
Ambrose Talisuna, Penny Grewal, John Bosco Rwakimari, Susan Mukasa, George Jagoe, *Jaya Banerji
Medicines for Malaria Venture, 1215 Geneva 15, Switzerland (AT, PG, GJ, JB); Ministry of Health, Kampala, Uganda (JBR); and Program for Accessible Health, Communication, and Education, Kampala, Uganda (SM)
banerjij@mmv.org