Public Release: 

Ineffective monotherapies common in high-burden malarious countries

Unprecedented data from ACTwatch unveils low accessibility of ACTs

Powell Tate

(November 2, 2009; Nairobi) ACTwatch, a research project led by PSI, in collaboration with the London School of Hygiene and Tropical Medicine, released evidence today that indicates that artemisinin combination therapy, the most effective medicines for treating malaria, continue to have a significantly low presence on the market among populations considered to be most at risk.

Announcing the results at the 5th Multilateral Initiative on Malaria (MIM) Pan-African Malaria Conference in Nairobi, Dr. Kathryn O'Connell presented on the current state of the antimalarial market across 6 sub-Saharan African countries and Cambodia. Data on availability, pricing and volumes for 23,000 antimalarials, sourced from 20,000 outlets, revealed a diverse market structure across countries. The majority of malaria endemic countries changed malaria treatment policies more than three years ago in the face of widespread drug resistance to monotherapies, adopting extremely effective artemisinin combination therapy; however, years later, the availability of these more effective medicines has been shown to be as low as 20% in public sector health facilities. Even in the private sector, where the majority of patients seek treatment, availability is still relatively low compared to cheaper, but less effective, drugs.

"These data confirm that access to ACTs is restricted by their high price. A full course of an adult treatment of ACT can be up to 65 times the minimum daily wage. This provides an overpowering incentive for a consumer to make the wrong antimalarial choice," says Dr. Desmond Chavasse, Vice President of Malaria Control and Child Survival at PSI.

Worryingly, in most countries, ACTs currently make up only 5󈝻% of the total volume of antimalarials on the market, with ineffective monotherapies dominating the market share. More disturbing still, despite a call by the World Health Organisation to ban artemisinin monotherapies, these continue to permeate private sector markets in key countries such as Nigeria and the Democratic Republic of Congo, which together account for 30% of the total malaria-related disease burden in sub-Saharan Africa. In the Nigerian context this is particularly important as approximately 95% of all antimalarials are delivered through the private sector.

With most people accessing antimalarial medication through the private sector, price becomes a critically important barrier affecting demand and utilisation of the more expensive but also most effective treatments. Artemisinin combination therapies can be over twenty times more expensive than ineffective therapies such as chloroquine; for example, some artemisinin combination therapies cost as much as $11 in the private sector, while ineffective antimalarials typically cost a mere $0.30 cents.

ACTwatch data from Cambodia, a country that has implemented a subsidy with the support of PSI, reveals that the most effective antimalarials are sold at around $1.20, which although still expensive compared to ineffective monotherapy sold for $0.20 cents, is a marked improvement compared to other countries. In fact, 60% of all antimalarials provided to patients in Cambodia are now the more effective artemisinin combination therapies.

"The operation of the distribution chain has a major influence on which antimalarials are available to retailers, and their price and quality," says Dr. Kara Hanson of the London School of Hygiene & Tropical Medicine. "Influencing practices of providers near the top of the chain may be the most cost-effective way to change outcomes in this market."

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Funded by a $10 million grant to PSI from the Bill & Melinda Gates Foundation, ACTwatch is providing the critical information necessary to make evidence-based policy decisions around the issue of increasing access to ACTs. The project will serve as a thermometer for the success of global interventions aimed at reducing the price and increasing the availability of the most effective antimalarials, including global financing mechanisms such as the Affordable Medicines Facility for malaria (AMFm).

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