Industry Briefing: World diseases: Can the private sector cure malaria?
Published on the The Economist Intelligence Unit website Viewswire
Despite critics, a malaria subsidy targeting the private sector is set to roll out this year
Efforts to control malaria have received a surge of financial support over the past year, lending an air of an excitement in the field. Researchers now openly discuss the possibility of eradication, a taboo topic since the 1960s. By most accounts, stakeholders are standing at a crossroads - take the right path, and one of humankind’s deadliest foes might finally be defeated.
At this critical juncture, practitioners are working out improved ways to get malaria drugs to those who need them, the bulk of whom live in sub-Saharan Africa. Although effective anti-malarials have existed for decades, scant public health facilities, unaffordable prices, and inappropriate administration of treatments through private sector channels have increased resistance to old first-line drugs such as chloroquine and sulfadoxine-pyrimethamine (SP).
This summer, a global subsidy for ACTs—combination therapies that provide near sure-fire cures and have yet to develop evidence of resistance in Africa—is finally set to launch after nearly five years of discussion. The Affordable Medicines Facility-malaria (AMFm), spearheaded by the World Bank, will attempt to lower ACT prices to increase uptake in areas where prohibitive prices prevent poor populations from accessing effective anti-malarials.
The programme - supported by a wide range of organizations under the management of the Global Fund to Fight AIDS, Tuberculosis, and Malaria - will subsidise the wholesale price of ACTs to bring prices down across the distribution chain, starting with eleven countries in a two year pilot. In particular, the plan focuses on bringing down prices in the private sector, where roughly half of sub-Saharan Africans buy medicines.
Several pilot programmes that have released results over the last several months have shown that private sector subsidies of ACTs can dramatically increase uptake of the drugs. Nonetheless, the AMFm is not without detractors. Some advocates worry the subsidy will not bring prices low enough for the poorest patients, while siphoning resources from other malaria control efforts and the public sector.
The recent focus on private sector distribution stems from problems in the public sector distribution chains in countries where malaria is endemic. Most public health systems in Africa have difficulty keeping treatments up-to-date and in stock at all health facilities; in many countries, public health centres are so geographically spread that many simply cannot access them.
"It’s almost like an ingrained mindset in Africa at this point. Why waste your time going to the public health centre? Even if it is free, it’s not there," George Jagoe, Executive Vice-President of Global Access for MMV, told the Economist Intelligence Unit. "The real new frontier that has been discussed and now is finally coalescing, is how do you make these quality drugs affordable when Africans themselves are paying out of pocket?" he adds.
To answer this question, MMV and the Ministry of Health Uganda launched the Consortium for ACTs Private Sector Subsidy (CAPSS) in Uganda in October 2008. The pilot project brings ACT prices in private sector shops in four districts down from USD$6-9 to USD$0.12-0.50, trains shop employees to properly distribute the drugs, and encourages people to buy them through a public awareness campaign symbolised by a green leaf found on packages and in the windows of participating pharmacies.
While the pilot is still too young to yield comprehensive results, Jagoe said preliminary findings show up to a 40% increase in the uptake of ACTs in some areas in the first two months of the programme.
These results are in line with findings from a subsidy pilot project begun by the Clinton Foundation in 2007 in Tanzania, where up to half the population obtains treatment from private sector outlets. According to Clinton Foundation results from April 2008, prices dropped from USD$10 to 50 cents or less in subsidised districts, increasing the uptake of ACTs and decreasing purchases of other medicines. The authors noted that overall ACT access appeared to increase in both the private and public channels as a result of the subsidy, but cautioned against broad application of the findings.
Despite preliminary evidence from pilot projects, several stakeholders have criticised the AMFm mechanism. Sir Richard Feachem, former head of the Global Fund, warned that the subsidy risks leaving behind vulnerable populations, and could even lead to resistance and innovation stifling, the Financial Times reported in April 2007. Later that year, he told The Economist newspaper that the AMFm might work provided safeguards are put in place to guard against counterfeit pills infiltrating the system.
Earlier this month, Oxfam published a briefing paper (Blind Optimism) warning against the growing international focus on private-sector healthcare delivery in the developing world. In it, the organisation said the AMFm plan does not yet elaborate how private health providers will safely dispense treatments; providers may over- and under-prescribe medications leading to problems of resistance. The group also criticised the AMFm for not explaining how those who cannot afford to buy treatments, whether subsidised or not, will access them.
Finally, "The malaria subsidy if applied only through the private sector risks setting a damaging precedent of further diverting international donor attention away from addressing the problems of the public sector," Oxfam wrote in the report.
Tido von Schoen-Angerer, Director of the Campaign for Access to Essential Medicines at Médecins Sans Frontières, which supports the AMFm, told the Economist Intelligence Unit that the subsidy could have a positive impact "if done well."
"We want to make ACTs more available and cheaper...but at the same time we do need to have the main focus on expanding access through the public sector as much as possible," von Schoen-Angerer said, adding that confirming the malaria diagnosis with rapid tests could be an important component in properly administering malaria drugs.
Jagoe of MMV said the public sector will continue to remain the predominant delivery channel through at least 2012, even as the AMFm scales up in 2010 to provide an estimated 49 million subsidised treatments through the private sector.
"The public sector footprint across Africa will take decades to build up," Jagoe said, but "we can’t ignore that all hands need to be on deck to make sure the public sector can improve and do what it needs to do."