Points of Agreement

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Points of Agreement

• Artemisinins should be the mainstay of first-line
  treatment in the short-to-medium term, at least
• First-line treatment for uncomplicated malaria
  should rely on fixed-dose combinations
  (coformulations) henceforth
• Subsidies are needed to maintain current levels
  of access (to CQ)
• No new organizations should be created to
  administer an antimalarial subsidy, if this can
  be avoided.

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Short- vs. Medium/Long Term Issues

• Short Stimulating ACT production, including
  quality issues, financing, prioritizing uses,
  etc.
• Medium/Long Establishing architecture of
  subsidization

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Goals of an Antimalarial Subsidy

• Saving Lives Widespread access by lowering
  price to consumer to CQ levels (10
  cents/treatment course)
• Buying Time Maintain drug effectiveness as long
  as possible by preventing the emergence of
  resistance using economic incentives
  coformulations vs. monotherapy

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Estimating the Size of the SubsidyBased on ACTs
(1)

• Immediate goal ACTs into the hands of those who
  would have access to chloroquine
• Challenge poor or absent data on numbers of
  treated episodes (some non-malaria, accepted)
• Best guess 200-400 million treated episodes in
  Africa, 100 million elsewhere annually

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Estimating the Size of the SubsidyBased on ACTs
(2)

• 300-500 million treatment courses needed per year
• Cost
• About US1 per course of treatment wholesale,
  after competition, economies of scale kick in (2
  years?)
• TOTAL SUBSIDY US300-500 million/yr

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Drug Resistance andTransmission Intensity

• Drug resistance is more likely to
• emerge in low-transmission areas
• AND
• spread more quickly in low-transmission areas
• Borne out by experience with CQ and other drugs.
  Hence the importance of combinations over
  monotherapy in Asia, S. America.

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Financial Architecture of a Global Subsidy

• High in distribution chain, i.e., above the
  country level
• Accessible to all public and private sector
  distributors in all endemic countries, regardless
  of income levels

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Advantages of High-LevelGlobal Subsidy

• Utilizes existing channels with least disruption
  market based
• With adequate supplies, minimizes price gouging,
  smuggling, counterfeiting
• Provides leverage with manufacturers to limit
  monotherapy production

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Potential Difficulties With Lower-Level
(Country-Specific) Subsidy

• Difficult to include certain (particularly
  private sector) drug flows without creating new
  structures/relationships
• Requires specific plan for every malaria-endemic
  country
• Requires good estimates of country level
  consumption, rather than allowing demand to
  dictate supplies

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Beyond ACTs and the Global Subsidy

• Widespread access to ACTs can halt the erosion of
  past gains against malaria, but more is needed to
  make real progress. Even greater access to ACTs
  and other effective drugs, anti-mosquito measures
  (insecticide-treated nets, house spraying,
  environmental measures), and eventually vaccines
  all will be needed to gain ground on malaria in
  the most heavily endemic places.