AMFm Subsidy Plan Seeks to Cut Malaria Drug Cost
See the MSF response to AMFm's announcement.
By DONALD G. McNEIL Jr., New York Times
A new campaign to save lives and prevent drug resistance by driving the price of the best malaria medicine down to as little as 20 cents was announced Friday by international health agencies and European governments.
The subsidy program, unveiled in Norway, will have an initial budget of $225 million and will be run by a new partnership called the Affordable Medicines Facility for Malaria.
Malaria experts hailed the program as one of the most important recent advances in fighting the disease, which kills one million people a year, 90 percent of them children. Awa Coll-Seck, executive director of the Roll Back Malaria Partnership, called it "a triumph of international cooperation."
But the United States, the world's biggest donor to the war on malaria, is not supporting it yet.
The goal of the program is to press the few drug companies that now make artemisinin combination drugs to lower their private-sector price to $1 per treatment from $4, and then use donor funds to pay 95 cents of that dollar so the drugs cost only a nickel wholesale. The hope is that when the drugs are sold at retail in villages in Africa and Asia, the marked-up price will still be low enough to drive out inexpensive but less effective alternatives.
"For a poor farmer in Cameroon or a poor market woman in Ghana, the difference between 20 cents and $8 is huge," said Olusoji Adeyi, who led the World Bank task force that drew up the plan.
The program is a joint effort by the Global Fund to Fight AIDS, Tuberculosis and Malaria; the Roll Back Malaria Partnership; the governments of Norway, Britain and the Netherlands; and the Unitaid partnership of 30 countries raising money through airline ticket fees.
Heavily subsidizing the private malaria medicine market was first proposed in 2004 by a committee of the Institute of Medicine of the American Academy of Sciences led by Kenneth Arrow, a winner of the Nobel Prize in economics. The Bill and Melinda Gates Foundation and the Clinton Foundation backed the plan.
The United States has declined to put any money in yet. Dr. Bernard Nahlen, deputy coordinator of the President's Malaria Initiative, said that he wanted more studies proving that subsidies would work before hundreds of millions of dollars were invested in them.
"I sometimes joke that this is the biggest faith-based initiative in the world of malaria," he said. "I'm perfectly willing to be convinced, but sometimes the advocacy gets out ahead of the evidence."
Mr. Adeyi of the World Bank task force said that "a few pilot studies" had convinced the plan's backers that it would work, but Dr. Nahlen dismissed those as "two highly controlled Clinton Foundation studies in two districts in Tanzania."
The law that Congress passed last year authorizing $48 billion for AIDS, tuberculosis and malaria specifically forbids donations to the Affordable Medicines program until the head of malaria activities for the government has "compelling evidence of success from pilot programs."
The program will be rolled out in Cambodia and 10 African countries, and re-evaluated after two years.
At the base of the dispute are a few details that make fighting malaria different from fighting AIDS or tuberculosis. Those diseases kill slowly, and drugs for them are handed out at public health clinics.
But cerebral malaria can kill a child in 24 hours, so antimalaria drugs must be sold everywhere, ideally within walking distance of even the remotest village. Many brands are stocked by pharmacies and even in small huts whose owners sell soap, matches and cooking oil.
The World Health Organization now endorses first-line treatment only with cocktails of artemisinin and at least one other drug. Artemisinin, a derivative of artemisia annua or sweet wormwood, was developed by the Chinese in the 1970s - originally on the orders of Mao to help the North Vietnamese.
The intent of the subsidy is to crowd out of the market older drugs like chloroquine and Fansidar, to which resistance is common, as well as artemisinin monotherapy, because taking any drug by itself greatly increases the chance that the parasite will develop resistance.
Only three companies - Novartis, Sanofi-Aventis and Ajanta, an Indian generics company - now make cocktails of two drugs in one pill that have been accepted by the World Health Organization. Several other drugs made by other companies are expected to qualify soon.
Drug companies usually sell artemisinin combination therapy at $1 to governments but $4 to private wholesalers. By the time it reaches village level, it may cost 10 to 40 times as much as chloroquine, which reduces fever the way that aspirin does but does not kill parasites.
Complicating matters further is the lack of diagnosis before treatment. Fearful parents often buy malaria drugs whenever a child spikes a fever, but some studies show that up to 90 percent of fevers are not malaria. In those situations, subsidies are costly and wasteful.
Dr. Nahlen endorsed programs like those in Ethiopia, in which 30,000 village health workers are taught to use rapid test kits. But those are not widely available in Africa yet.