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.

Short- vs. Medium/Long Term Issues

• Short: Stimulating ACT production, including quality issues, financing, prioritizing uses, etc.

• Medium/Long: Establishing architecture of subsidization

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

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

Estimating the Size of the SubsidyBased on ACTs (2)

300-500 million treatment courses needed per year

Cost

About US$1 per course of treatment wholesale, after competition, economies of scale kick in (2 years?)

TOTAL SUBSIDY: US$300-500 million/yr

Drug Resistance andTransmission Intensity

Drug resistance is more likely to:

• emerge in low-transmission areasAND

• 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.

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

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

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

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.