What is the cost and who will pay?
13 February 2002
(summary of a paper by Jean-Marie Kindermans) "As doctors, we want to use effective treatments. We cannot continue prescribing a first-line malaria treatment - such as Fansidar® - which we know is not going to cure the patient." Christophe Fournier, Programme Director for Burundi, MSF Paris Malaria: a few facts Every year, there are an estimated 300 to 500 million cases of malaria in more than 90 countries worldwide. Ninety percent of cases occur in Africa. Of the four species of malaria parasites, Plasmodium falciparum is responsible for most deaths - 1.5 to 2 million a year, 90% of which are African children. Malaria remains the first cause of death for children under five in Africa - children are more vulnerable to the disease than adults because their immunity is less developed. Malaria not only cuts lives short but has a huge socio-economic impact: patients are often bedridden and incapable of carrying out normal daily activities, therefore suffer considerable loss of income and place a heavy burden on their families, the health system and society as a whole. Treatment Malaria treatment protocols include both first-line and second-line treatment. Patients with uncomplicated malaria are treated with first-line drugs. Patients with severe malaria and those who don't respond to first-line treatment are treated with second-line drugs. Resistance to anti-malarial drugs In Africa, national treatment protocols have traditionally mandated use of one anti-malarial drug, either chloroquine or Fansidar® as first-line treatment. But in recent years, resistance to these drugs has increased dramatically. Experts now strongly recommend changing protocols to include a combination of drugs. By hitting different biochemical targets of the parasite, drug combinations are more effective and allow for shorter treatment courses. As importantly, they protect each individual drug from resistance. It is widely agreed that the best current treatment solution is to use artemisinin-containing combinations. Artemisinin derivatives - which are extracted from a Chinese plant - have attributes that make them especially effective: they are fast-acting, highly potent and complementary to other classes of treatment. To date, no resistance to artemisinin-containing combinations has been reported. National treatment protocols Despite all the evidence in favour of artemisinin-containing combinations, many governments are changing their malaria treatment protocols from chloroquine to another drug used on its own (= in "monotherapy"), or to a combination of drugs that doesn't include artemisinin derivatives. For example, several countries in the East African Network for Monitoring Antimalarial Treatment (EANMAT) have recently switched from chloroquine to Fansidar® monotherapy for first-line treatment of malaria. Considering the high levels of resistance to Fansidar® in East Africa (e.g. up to 60% or more in parts of Burundi and Uganda), this short-sighted policy is likely to lead to continued increases in morbidity and mortality as well as a rapid rise in resistance to Fansidar®. Effectiveness versus cost Ministries of health are aware of the drawbacks of Fansidar® monotherapy and are planning to introduce combinations. But most are not planning to use the more effective artemisinin derivatives. It's a question of cost: using a combination of amodiaquine and Fansidar® may be less effective and more likely to increase resistance rates, but treating one adult costs just US$0.25. Using the more effective combination of amodiaquine and artesunate (an artemisinin derivative) costs US$1.30. CoartemÃ?® (artemether/lumefantrine) has the further advantage of being easy to use, because the combination has been developed as a one-pill co-formulation - but it costs US$2.40 per adult dose. Rwanda has 1.2 million cases of malaria every year and is about to change its national treatment protocol. It has been estimated that it would cost the country an extra US$945,000 to introduce artemisinin-containing combinations rather than a less effective combination. For Burundi, with 2 million cases of malaria a year, the switch would cost an extra US$1.6 million. For Burundi, Kenya, Rwanda, Tanzania and Uganda combined, the cost would be US$19 million. Historical experience shows that the prices of artemisinin-containing combinations are likely to decrease over time as more producers are validated and competition is encouraged. We estimate that the price of the amodiaquine artesunate combination will decrease from US$1.30 to US$0.60 by 2004. In this case, the supplementary cost of using the most effective treatment would come down to US$6.3 million for the five countries combined. Longer term savings can be achieved by using artemisinin combinations MSF believes that the only way to prevent the widespread use of sub-optimal, ineffective treatment and further malaria epidemics is to find resources to fund the use of more effective drugs. The increase in cost today will be repaid many times over in years to come. Using effective treatment saves lives, reduces the number and length of medical consultations and hospital stays, and avoids the expense of ineffective treatment. People return more quickly to their families and workplace, thus reducing the enormous socio-economic burden of the disease. International aid will be needed Malaria is one of three priority diseases that the international community has committed to fight. UN secretary general Kofi Annan has estimated US$8 billion a year will be needed for the Global Fund, but so far only $1.9 billion has been pledged and even this amount is to be spread over a three year period. Providing the cash to change national malaria treatment protocols in East Africa in a sustainable manner is a worthwhile investment and a pragmatic step in combating one of the leading killers in Africa today. Action must be taken now to avoid the needless deaths that will be caused by using treatment that no longer works. Conclusions/recommendations: 1. When considering changing national treatment protocols, it is essential that financial considerations do not lead to sub-optimal medical choices. Effective drugs that can save lives are available and must be included in national protocols. Other "transition" strategies are short-sighted and merely postpone the necessary switch to more effective treatment. They will also lead to increased incidence of disease and drug resistance. The so-called "transition" strategy proposed by several countries may in fact remain in place for longer than expected, as protocol change is a difficult, expensive process which cannot be repeated every few years. It will also be more expensive in the long-term when it becomes essential to switch to more expensive drugs such as quinine, mefloquine or co-artemether. 2. Developing countries should not be forced to cope with the financial burden of improving malaria treatment on their own. Malaria is a growing worldwide crisis and international aid should be forthcoming to help implement practical solutions. International leaders must follow up on their political rhetoric and make available promised resources. There is great urgency in the case of malaria, and moderate investment can concretely improve treatment and save lives - it is a chance to transform words into actions. Furthermore, considering that international aid covers a significant proportion of the health budget of some developing countries, donors have an ethical responsibility to ensure that interventions are medically appropriate. WHO should work proactively to support the ministries of health in developing countries to adopt effective malaria protocols. 3. Antimalarials produced in Asia should be made available in Africa as soon as possible. UN organisations have a role to play: WHO should expand the existing AIDS drug pre-qualification system to malaria and UNICEF can directly support procurement and distribution. 4. In the long term, a considerable increase in research and development for malaria treatment is also necessary. Medicines for Malaria Venture (MMV) and other research initiatives should be actively supported.