Global high-level subsidy for ACT procurementto facilitate low-cost commercial, & other, distribution

(allowing effective, affordable home treatment or healthcare facility treatment of suspected malaria)

Richard Peto

Clinical Trial Service Unit &

Epidemiological Studies Unit (CTSU),

University of Oxford, UK

Annual malaria deaths, M=million (from Global Burden of Disease, 2006)

1.2 M worldwide

1.1 M Africa

1.0 M Africa, age <5

~0.8 M Africa, age <5, rural

~2/3 malaria deaths are children aged <5 in rural Africa, most with health clinics not conveniently available (& hence, no reliable diagnosis/injections locally)

Need indoor residual spraying of houses, sleeping under bed-nets and use of drugs, either in clinics or for home treatment

• If one main aim is to use DRUGS to reduce global MORTALITY from malaria substantially,

• then one key need is effective, affordable near-home treatment of children with suspected (but unconfirmed) severe malaria in African villages and hamlets.

Malaria home treatment requirement: artesunate combination treatment (ACT)

Oral ACT drug packs need to be affordably available and widely used by non-medical people (eg, mothers) on children in endemic areas with suspected acute malaria who can still swallow

Malaria home treatment requirement: artesunate combination treatment (ACT)

Antimalarials should be tried sooner rather than later for near-home treatment, so if they do not seem to help there is still time for other strategies, including referral.

NB A policy of restricting treatment to healthcare facilities would probably cause far more deaths than it prevents.

• Rectal artesunate (single dose):– Some absorption within 10 minutes;– Blood parasite count halved within hours;– Acceptable (in rural Ghana and Tanzania);– Non-medical villagers who cannot inject drugs

can still get effective artesunate blood levels quickly into children who cannot swallow.

– Even as drugs change, a strategy of “rectal then oral” may remain appropriate for some sick children in African villages.

Recommendations from the 2004 IoM report, Economics of Malaria Drugs in an Age of Resistance

1. Subsidise procurement of good-quality, appropriately packaged ACT, ensuring strong competition between prospective suppliers

2. Distribute it into private and public sectors, including wholly commercial ones, as inexpensively as chloroquine or SP used to enter these distribution chains (losing money)

3. Point of sale prices would then be about double the cost, but should still be low enough to undercut even poor quality mono-therapy, and to make drug counterfeiting unlikely.

Ideal might be a low-cost (but not zero-cost) complete course of three oral ACT pills (daily for 3 days),

in a condom-like pack that is easy to open and use (even in the dark!) and that, once opened, cannot be re-sealed.

Dose should be safe & effective for kids of 5-25 kg (no dosing by weight), and cost to user should be only about 10-20c, not 1$ (production cost) or a few $$ (unsubsidised retail cost).

Low-cost, high-quality ACT that saturates all global markets consistently & reliably

• Avoids hoarding, clinic surcharges etc

• Undercuts monotherapy, preventing drug resistance emerging

• Helps avoid drug counterfeiting

• Much wider rural outreach than healthcare facilities

• Complements bednets, vector control, IMCI, better healthcare facilities &c

Malaria needs are special

• Global procurement & low-cost market saturation is a new economic strategy

• Uses market forces both for efficient procurement and for efficient distribution

• Not appropriate for other major diseases such as TB or HIV/AIDS

• Home use of ORT has halved diarrhoeal deaths in children; can affordable home ACT prevent a few hundred thousand child deaths a year for a few hundred million dollars a year??