Category Archives: Private Sector

Patent Medicine Vending: vendors’ perspectives on business and health

Patent medicine vendors (PMVs) , also known as medicine shop owners, are a major source of malaria medicines. This qualitative examination of how PMVs perceive their business was conducted by Kabiru Salami, Bill Brieger and Stephen Kodish.

DSCN3873 Pharmacies see many malaria patients, but do they keep malaria records 2Access to high-quality, affordable medicines is a global concern but manifests in distinctly local ways. In Nigeria, patent medicine vendors (PMVs) are a major source of medicines.  Criticism of PMVs focuses on drug quality, dispensing practices, and their lack of formal health care training.

This qualitative investigation approached PMVs as small business people and sought their business perspectives in comparison with views of other small business owners in Igbo-Ora, Nigeria.  This study utilized an iterative approach to data collection among 51 entrepreneurs.

In-depth interviews about participants’ businesses were collected from PMVs (16), Food (7), Clothing (7), Provisions (9), Motor Parts (n7), and others (n5). A codebook containing 27 themes was inductively developed from emergent data and combined into broader themes for interpretation using Atlas.ti v7.1.

Accounts from participants reveal differences between PMVs and other businesses including amount of education necessary to learn the trade, as well as the level of professionalism and cleanliness required to operate successfully. Unlike other groups, PMVs routinely are asked for highly technical information at point of purchase.

PMVs work largely under strong trade associations due to more controls imposed by regulatory agencies. Although selling medicine is a small-scale enterprise, the purveyors of the trade see their work differently from other small business people. Their business model is based on having adequate knowledge about their products and maintaining standards. PMVs can increase human resources for health because they want to improve both their work and business prospects.

Invest in the Future: How Corporations Can Impact Malaria

The word “invest” in the new World Malaria Day theme encourages us to focus our attention on the role of the corporate community.

A recent study completed on behalf of the Roll Back Malaria partnership by Malaria No more and McKinsey and Company, reviewed the potential impact of future business investment on malaria control.  They found that, “According to the McKinsey report, if business were to invest approximately $10.9 billion over 5 years, we’d be able to achieve full coverage of prevention and treatment measures in the most affected African countries.”

chw-akwa-ibom-nigeria-trained-with-corporate-support-demonstrated-malaria-testing-at-community-event-sm.jpgExxonMobil, has contributed broadly to malaria control programs and research both from the headquarters level as well as through its national affiliates.  ExxonMobil Foundation, the company’s philanthropic arm, has committed $110 million worldwide since 2000 to its Malaria Initiative.  For example, with ExxonMobil Foundation support, Jhpiego conducted proof of concept interventions in Akwa Ibom State, Nigeria that showed how community directed interventions (CDI – the foundation approach for onchocerciasis control in Africa) could be adapted to increasing coverage of insecticide treated nets, intermittent preventive treatment for pregnant women and community case management for malaria, diarrhea and pneumonia.

Corporate contributions do not have to be direct financing. Corporations have certain skills and mechanisms that can be applied to public health challenges. In a press release The Coca-Cola Company and the Global Fund to Fight AIDS, Tuberculosis and Malaria “announced they will expand a project leveraging the Company’s expansive global distribution system and core business expertise to help government and non-governmental organizations deliver critical medicines to remote parts of the world, beginning in rural Africa.” This has been dubbed “Project Last Mile.”

AngloGold Ashanti in Ghana provides another model of corporate involvement.  Starting in 2005, AngloGold began indoor residual spraying (IRS) of all houses in Obuasi District.  Within a few years there was a noticeable drop of 74% in malaria cases in the district health facilities.   Bringing its experience managing a large program in Obuasi, AngloGold as “AngloGold Ashanti Malaria Control Limited,” has become the Principal Recipient of a Global Fund grant in Ghana to conduct IRS in 40 districts.

Corporate involvement in social programs generally and malaria control specifically is obviously not completely without controversy, especially in countries where corporations need to interact with governments that have questionable human rights records.

What is of importance in considering corporate investment in malaria control may not necessarily be the scale of investment, but its quality.  Corporate activities can demonstrate good management practices that should be adopted by other major players in the malaria control arena. Corporate supported projects may provide proof of new concepts that can be taken to scale by national malaria control programs to increase their coverage.  Finally corporate contributions set an example and serve as an advocacy point to encourage national governments to fulfill their own obligations to their citizens.

A longer version of this article will appear in the March 2013 edition of Africa Health.

Revisiting the AMFm Controversy

Paul Kartchner contributes this guest blog via the SBFPHC Policy Advocacy Blog.For years, a major obstacle to controlling malaria in developing countries has been the high cost of effective medications. Yet in recent years a coalition of public health agencies and organizations are targeting this problem by subsidizing the most effective medications. Called the Affordable Medicines Facility – malaria (AMFm), the project hopes to make these medications more available and affordable to hospitals, physicians, and local pharmacies in developing countries.

amfm-2010-04-23_malaria-shipment-abuja-novartis.jpgPhoto shows Workers load AFMm medications in Abuja, Nigeria (courtesy Novartis International AG)

Yet even though the project has been found to increase the supply of medications, criticisms have been raised regarding the program’s long-term benefits. A recent report by Oxfam, an international aid group, claims that although these medications are now broadly available, they are not being used appropriately to treat patients with malaria. They also claim that many patients that do need these medications, including women and children, still do not have access to them.

Another aid group, Doctors without Borders/Médecins Sans Frontières (MSF), claims that a project like AMFm cannot be successful if it is not carefully integrated into a larger strategy to combat malaria. Instead MSF recommends a plan whereby not only the medication but also treatment by knowledgeable providers is subsidized.

These criticisms raise important questions about the nature of complex global diseases such as malaria. Focusing efforts and resources on a particular aspect of a problem without considering the larger context may not only fail to improve the situation, but potentially make it worse.

Corporations weigh in on solving the malaria challenge

The Corporate Alliance on Malaria in Africa announces a Member Meeting that will take place on December 3, 2012 from 10 am – 4 pm in Houston, Texas. They have shared their invitation with us to let interested colleagues know how to take part.

The Corporate Alliance on Malaria in Africa (CAMA) is a unique coalition of companies that share a vision to reduce the incidence of malaria by promoting private sector cooperation in sub-Saharan Africa. Founded by Marathon Oil in 2007, CAMA serves as a platform for private sector collaboration with country governments and other major stakeholders in the global response against malaria.

CAMA’s three principal objectives include –

  1. building country-level capacity for effective malaria control and its eventual elimination;
  2. providing a forum to exchange knowledge and current best practices in malaria control; and
  3. facilitating the establishment of effective multi-sector partnerships to increase the scale and impact of malaria control interventions.

GBCHealth is the implementing partner and secretariat of CAMA.A special Member Meeting will be held Monday, December 3, 2012, in Houston, Texas, to discuss the accomplishments of the past year and to develop the CAMA engagement strategy for 2013. As CAMA transitions into a fully integrated GBCHealth flagship initiative, this CAMA member meeting will be open to all current and prospective GBCHealth members interested in contributing to global malaria efforts.

The meeting will cover the importance of social and behavioral change programs for controlling malaria at the country level and provide a great networking opportunity for companies to meet key malaria stakeholders from academia, business and non-profits.

RSVP by clicking this link.

Healthy workers can be malaria champions in their communities

Emmanuel Fiagby of the VOICES for a Malaria-Free Future in Ghana shares a recent workshop of the Ghana Revenue Authority at Kpetoe, Volta Region, Ghana. Below are his experiences.

slide1.JPGThe Ghana Revenue Authority has made a giant stride in the implementation of its Employee Wellbeing Program (EWP) by initiating a program which will result in the development and implementation of a Malaria Control Strategy and Program of Action for the Authority. A total of 45 officials of the GRA mostly EWP Focal Persons participated in the program.

Launching the program at the Customs Excise and Preventive Services (CEPS) Academy here, the Commissioner General of the  GRA Mr. George Blankson stated that the GRA has since its establishment shown tremendous commitment towards the welfare, health and wellbeing of its staff who are its most valued asset and therefore finds the theme for its Malaria Control strategy development exercise, “Turning Revenue Makers in to Malaria champions; a true demonstration of corporate social responsibility,” an apt reflection of what the GRA stands for.

Mr. Blankson emphasized that, the aim of the GRA in setting up its EWP of which malaria is becoming a key component is to set the pace as a leading healthy workplace in Ghana where staff and management work together to protect and promote the health, safety and wellbeing of its over 7,000 staff and almost 30,000 community members on a sustainable basis. “Today we stand at the threshold of expanding the frontiers of the Employee Wellbeing Program (EWP) to encompass malaria control programs for our staff and the wider community which GRA serves. I am extremely certain that this effort will lead to the total obliteration of the 25% absenteeism of our workforce attributed to malaria and the random deaths this disease wrecks on our institution,” the Commissioner General reiterated. He called on all officers selected to lead the malaria program and noted that by becoming champions for malaria control, they will be “contributing to sustaining a stronger workforce, a stronger community and therefore a more productive and taxpaying community.”

slide1.JPGIn her key note remarks, Dr. Kezia Malm, Deputy Manager of the National Malaria Control Program (NMCP) stressed that Ghana has made tremendous progress in the fight against malaria and it’s only through the collaborative efforts of parastatal institutions such as the GRA and others that the country would be able to sustain the gains. “Our journey to eliminating malaria can only end successfully if the support of every sector of our development effort – the public sector, private sector, NGOs, and the donor community is sustained,” she concluded.

The two day GRA Malaria Control Strategy development and action plan development program was organized by the Johns Hopkins University Center for Communication Programs Voices Project in collaboration with the Ghana Revenue Authority and the National Malaria Control Program. In setting the stage for the program, the Country Director of the Voices for a Malaria-free Future Project, Mr. Emmanuel Fiagbey pointed out that the GRA, a non-health institution becoming a champion for malaria control should be an effort worth emulating by other powerful parastatal institutions. “That the ‘Revenue Makers’ our tax officials have become malaria advocates and mentors for their colleagues should not only result in preserving the health of the GRA Workforce against malaria, it must also lead to speedy action on malaria commodities and their documentation that come to the tables of the tax officials in the course of their work,” Mr. Fiagbey emphasized.

slide1.JPGThe Ghana Revenue Authority is a major parastatal institution in Ghana made up of the Customs Excise and Preventive Service, the Internal Revenue Service and the VAT Service. Fifteen senior officers of the Authority including Mr. K. E. Enyimayew the Deputy Commissioner HR, Deputy Directors of the three arms of the Authority, Service Commanders/Commissioners and the Director of the CEPS Academy also participated in the opening activities of the program.

Malaria is often a major cause of absenteeism – either for the sick worker or the worker who has to stay home with a sick child or relative.  The GRA sets a great example how malaria training for members of the workforce can improve occupational, family and community health.

AMFm – the importance of training malaria medicine providers

When the Affordable Medicines Facility malaria (AMFm) was conceptualized, designers clearly identified several ‘supportive mechanisms’ that would be needed at the country level. In particular guidance called for “RESPONSIBLE INTRODUCTION: IN-COUNTRY SUPPORTING INTERVENTIONS” [1] in five key areas:

  • National policy and regulatory preparedness
  • Wholesaler incentives and pricing/margin-control mechanisms
  • Public education and awareness (IEC)
  • Provider training
  • National monitoring and quality preparedness (resistance monitoring, pharmacovigilance, and quality surveillance)

dscn7970-ghana-shop-amfm.jpgThe planners envisioned the need to, “Train health professionals and private wholesalers/retailers to promote safe and effective use of ACTs, including diagnosis, prescription, and treatment,” since many of these would be in the private and/or informal sector without the benefit of more orthodox health training or recent updated in-service training. Such training could also reinforce other supportive interventions such as consumer education and adherence to recommended pricing levels.

AMFm was designed as a two-year ‘pilot’ to determine subsidized antimalarials could get into the market – both private and public – in such a was as not only to increase overall supply of quality medicines, but also drive out more expensive and inappropriate drugs. As the project comes to a close at the end of this year, many people are looking to see if it would make a difference.

Earlier this year Yamey, Schäferhoff and Montagu [2] raised the question – what would AMFm’s success look like.  Would the subsidized quality drugs really ‘crowd out’ the costlier share of the market?  In the process they too addressed the importance of supportive interventions, noting that, “In addition to the price subsidy, the AMFm involves supportive interventions aimed at boosting ACT use, including in-country branding and associated awareness campaigns for sellers and patients, training for ACT providers and greater access to rapid diagnostic tests for malaria.”

dscn7972-ghana-amfm-meds.jpgNow a preliminary report has come out looking at the outcome issues of Artemisinin-based Combination Therapy (ACT) availability, affordability, use and market share. [3]  A key finding so far has been that, “It is notable that the major benchmarks for success for the upstream indicators of availability, price and market share of quality-assured ACTs have been met or exceeded in 6 of 8 pilot countries, particularly in light of the short implementation period.”

The Advisory group was concerned that, “the evaluated implementation period in each pilot was less than 12 months for assessing the full combined effect of the three components of the model: (i) manufacturer negotiations; (ii) buyer co-payment; and (iii) supporting interventions,” but were excited that even with such drawbacks, progress was evident.

They focused their definition of the ‘supporting interventions’ on consumer education and awareness (IEC/BCC) and provider training and observed that these were, “integral to assuring success of the program objectives of increasing availability and market share and decreasing price” of quality ACTs. They found that “Pilots with higher achievement had the following characteristics: longer period of co-paid ACTs in-country with simultaneous implementation of key supporting interventions (i.e., IEC/BCC and provider training) …”

The initial model for AMFm envisioned that almost 20% of the grant should be devoted to these supportive interventions, and the pay-off seems to be confirmed. The training component will become even more crucial as malaria rapid diagnostic tests (RDTs) become a more common part of provider skill sets, especially those in the private sector.

Not every health management problem can be solved by training and education, but the AMFm experience seems to show that these are crucial components in a comprehensive program to increase access to affordable quality medicines.  Whether the actual structure of AMFm continues past this year or not, we need to take the lessons and apply them in guaranteeing that those in need receive appropriate and affordable malaria medicines at the closest point of care.
[1] Technical Design for the Affordable Medicines Facility-malaria. November 2007. Prepared with guidance from the AMFm Task Force of the Roll Back Malaria Partnership.

[2] Yamey G, Schäferhoff M & Montagu D. Piloting the Affordable Medicines Facility-malaria: what will success look like? Bull World Health Organ 2012;90:452–460.

[3] Expert Advisory Group on the Affordable Medicines Facility-malaria (AMFm) Review of the AMFm Phase 1 Independent Evaluation Preliminary Report Friday 22 June 2012, Geneva

Malaria in Pregnancy – analyzing processes, involving new partners

Malaria in Pregnancy: A Solvable Problem—Bringing the Maternal Health and Malaria Communities Together – a meeting in Istanbul organized by the Maternal Health Task Force, Harvard University.

Take Away Messages from Day 2 Presentations. Report by James Kisia, Kenya Red Cross.

Jayne Webster of the London School of Hygiene and Tropical Medicine as the Malaria in Pregnancy Consortium shared a tool that helps identify and address barriers to the delivery of malaria in pregnancy services.  She referred to the tool as “An innovative ‘soft’ technology, a decision-making tool to improve the effectiveness of the delivery of IPTp and ITNs.” The tool is still under development, but key components were presented.

dscn1612b.jpgJayne noted that there are still research questions to answer on how to effectively implement interventions, but while we are waiting for these questions to be answered there are improvements in data collection, collation and use to be made and used for decision making.

Jayne said that we must use the wealth of knowledge we already have to start to take action and make improvements! She took us through the work in progress of a decision tool for use by health managers to assess country and/or sub-national barriers and priority actions required for effective scale-up of the IPTp and ITNs. The tool will eventually be available on the Malaria in Pregnancy Consortium website.

Nancy Nachbar of Abt Associates presented her experiences on Malaria in Pregnancy: The role of the private sector. She said we must talk about the complete health system. If we fail to consider the private sector, we are not considering the whole system!

Half of care for fever or Diarrhea is happening in the private sector- and much of this is happening in the informal sector. Those who are poorer are utilizing the informal sector for treatment seeking. Unfortunately we lack similar utilization data for antenatal care.

Nancy discussed challenges to private sector participation from the public sector perspective as well as from the private sector perspective. She also discussed opportunities for improving private sector participation in MiP prevention. Nancy incited and excited us to think about way out ideas. One creative idea: Could tithing be used as a funding source for malaria in pregnancy?

A key factor to tie these presentations together is the need to develop tools to assess and guide not only the public sector, but also private health care providers on malaria services to pregnant women.

Not so affordable medicines for malaria

The two-year trial balloon of the Affordable Medicines Facility, malaria (AMFm) is well underway in its eight pilot countries trying to make quality ACTs available cheaply, but it seems some people are trying to let the air out of the balloon.  In particular, one suspects that aspects of the way AMFm might be managed in some settings goes against the business-minded nature of private sector proprietors of malaria drugs.

dscn9876a.jpgGhana was one of the first to get started. Ghana’s news source, Joy Online, led on this topic with a finding that, “A survey conducted by the Pharmacy Council from March to May this year, has revealed that some private pharmacy shops in five regions have been selling anti-malarial drugs for more than 200 per cent of the approved price.”

Early indications in December 2010 were that shops were keeping to the recommended price of 1-2 Cedis (0.60-1.20 USD) for adult doses.  The recent survey found prices as high as 4-5 Cedis.

The goal of the low prices was to ‘crowd out’ unapproved or non-recommended ACTs and other malaria medicines by offering WHO prequalified ACTs at subsidized prices similar to those of chloroquine or sulphadoxine-pyrimethamine, the former first line medicines. This would have had the added benefit of encouraging people to buy ACTs instead of the old medicines for which parasite resistance has developed. Ghana Business News explained that, “Despite the availability of the Artemisinin-based combination therapies (ACTs) in the country chloroquine continues to be the second most used medicine in the treatment of malaria.”

Obviously in Ghana, other forces are at work. For example Joy Online reported …

  • some shop keepers were buying through unauthorized sources that added extra cost the procurement process
  • many shops were still selling unapproved medicines such as chloroquine and artesunate monotherapies that were as cheap to the customer as the AMFm ACTs, but which gave the seller a larger profit
  • there is no legally binding way to ensure shop keepers adhere to the recommended price

Maybe the market is to large and diverse for price controls on one product to work, especially voluntary ones.

On the other hand, the ‘high end’ prices found in the survey are still lower that the pre-AMFm market prices of up to 9 USD in Ghana. The experiment continues and given the large role that private informal providers play in reaching global and national malaria treatment targets, we will all be watching the results closely.

A goldmine of private sector assistance against malaria

Guest Posting by Emmanuel Fiagbey, Voices, Ghana, August 4, 2011: Sefwi Etwebo, Western Region of Ghana

Chirano Gold Mines Ltd. just launched a $5.6 million Integrated Malaria Control Program and joined the United Against Malaria Partnership. Private sector involvement in malaria control has received a big boost in Ghana with the launching of a $5.6 million malaria control program by the Chirano Gold Mines Ltd, a Kinross Company. Over 600 people including chiefs, queen mothers, government officials, mine workers and the people of the Sefwi Wiawso and Bibiani Anhwiaso Bekwai District attended the lively durbar which marked the occasion.

chirano-goldmines-local-chiefs-at-launching-sm.jpgA section of the chiefs and community members who attended the launching are pictured to the right.

“Malaria is a killer, it is the largest cause of death in the Sefwi area. With this effort directed at improving prevention and treatment, this insidious malaria cycle can be reduced and broken. Reducing the impact of this disease on our workforce, the surrounding communities and the socio-economic structure is our goal.” So says Mr. John Seaward, General Manager of the Chirano Gold Mines, speaking at the launch ceremony.

Developed and modeled on the highly successful integrated malaria control program of Anglo Gold Ashanti, the Chirano Gold Mines program extends over 13 communities within and outside the operational area of the Chirano Mines.

The first phase of the program which began in September, 2008 as a Mosquito Abatement Project with a major focus on larval control and environmental management grew into a fully integrated program in May 2009 and the results so far are astounding. At the Chirano Mines Clinic, the incidence of malaria has reduced from 912 treated cases per 1000 in 2008 to 210 cases per 1000 people this year 2011 amounting to a reduction of 77% in four years.

chirano-general-manager-sm.jpgThe General Manager (photo at left) hinted that after a successful implementation of the first phase of the project (2008-2011) and sustaining the level of achievement being made, the interventions will be intensified and extended to cover 50% of the communities in the two districts through 2016.  Implementation activities would therefore focus on vector control measures such as IRS, targeted larviciding and the distribution of LLINs supported with engagement of community leaders and people in prevention and treatment community education activities.

A representative of the Manager of the National Malaria Control Program, James Frimpong commended the efforts of Chirano Gold Mines in supplementing the country’s efforts at working towards eliminating malaria from Ghana. He promised the NMCP’s continued support for the Chirano Gold Mines Integrated Malaria Control Program. Also present at the event was the World Health Organisation Malaria Program Adviser Dr. Felicia Owusu-Antwi.

The UAM partnership was not left out of this event. Mr. Emmanuel Fiagbey, Country Director of the JHU CCP Voices project presented a UAM Ball and 10 copies each of the UAM Malaria-Safe Playbook and CDs of the Black Stars Malaria Cheer song to the General Manager, Mr. John Seaward and invited Chirano Mines to the fold of the UAM partnership. “The UAM Black Stars Cheer Song will not only provide messages on prevention and treatment but also help in mobilizing community members to actively participate in the program’s community level educational activities,” Mr. Fiagbey stressed. The UAM Malaria Safe Plabook provides guidance to Private Sector companies on ways in which they could sustain their malaria control activities applying the four pillars of Education, Protection, Visibility and Advocacy.

In his response Mr. Seaward who was moved by the presentation remarked, “I am humbled by the fact that the Ghana Black Stars are also part of the campaign against malaria”. “We at Chirano Mines are pleased that our efforts are being recognized and are ready to work with all others to ensure the malaria cycle is broken. Malaria can be eliminated and Ghana can be malaria free,” he declared.

Other partners on the Chirano Gold Mines Integrated Malaria Control Program include the Vector Control Consult Ltd (Principal Implementer), the Noguchi Memorial Institute of Medical Research, the District Assemblies of Sefwi Wiawso and Bibiani Anhwiaso-Bekwai and their District Health Management Teams and the Ghana Education Service.

Buying malaria medicines in Sokoto

Ideally these days in Nigeria one should be able to get supplies of the recommended artemisinin-based combination therapy (ACT) drugs in public outlets throughout the country. Major malaria partners/donors in Nigeria include the Global Fund to fight  AIDs, TB and Malaria (GFATM), the US President’s Malaria Initiative (PMI), the SuNMaP project of the UK’s Department for International Develoment (DfID) and the World Bank’s Malaria Booster Program.

question.JPGIn reality one finds shortages of medicines that drive consumers and patients to medicine shops in search of whatever is available, and importantly, affordable.  The pictures herein detail what we bought in two patent medicine shops, one urban and one rural, in Sokoto State.

First, even though testing of chloroquine (CQ) for the past 10 years has shown it lacks efficacy, and in fact only ACTs are recommended first-line treatment, we found CQ in both tablet form as well as syrup for children.  Of equal concern is the sale of syrups, which in and of themselves are unstable in the environment.

That said, each of the CQ medicines was duly registered by the National Agency for Food and Drug Administration and Control (NAFDAC). This demonstrates a lack of communication between NAFDAC, one arm of the Federal Ministry of Health, and the National Malaria Control Program, another arm of the same ministry.

The ‘questionable’ products also include Artesunate, a monotherapy drug. It has only artesunate, not a combination, a situation deplored by the World Health Organizations, who explains that use of monotherapy leads down the road to resistance, and we have little in the pipeline to replace the artemisinin derivatives.  This product is registered by NAFDAC, who had promised to not renew licenses for such drugs, and in addition this packet is set to expire in a few months.
sp.JPGWe found numerous brands of sulfadoxine-pyrimethamine (SP).  According to national malaria drug and treatment policies, SP should also not be used for first-line treatment due to increasing parasite resistance. SP should therefore be reserved only for use as Intermittent Preventive Treatment in pregnant women (IPTp).  This use is clearly stated on the Melofan packet, though we are not sure that the NMCP has given permission for such labeling. The key reason for this is that SP for IPTp should not be taken as self-treatment, but integrated into a comprehensive antenatal care program.

Finally we did find ACTs.  The card showing Coartem (artemether-lumefantrine – AL) was the only one of the four different age-specific Coartem packagings seen in the shops.  Supposedly this Coartem was being made available in shops at subsidized rates through the Affordable Medicines Facility malaria (AMFm) administered through GFATM.  Normally drugs for this program have different packaging than seen here, which is the normal format for medicines supplied for the public sector from donor programs.

We bought this Coartem pack for $1.33, which was more than the going price for AMFm drugs. The shopkeeper said she also previously had some artesunate-amodiaquine (AA), another ACT in stock, but this had sold out.
act.JPGAlso seen in the ACT picture is an empty carton of AL provided through private wholesalers as part of the AMFm program as evidenced by the small green leaf logo.  The medicine seller with this empty box informed us that he bought many of these cartons and shared with fellow medicine dealers. Unfortunately they did not pay him back and he has been unable to order more. He was excited that these were purchased from the wholesaler for only 50 Naira (about 33 US Cents) compared to proces of several dollars under normal commercial arrangements. Not shown was a bottle of AL suspension that could be reconstituted with water for child use.

We have been rolling back malaria since at least 1998. Nigeria changed its malaria drug policy to ACTs in 2005. Based on the Abuja Declaration of 2000, we should be seeing near universal coverage of malaria illness episodes with ACT drugs by now. There are not gaps in the system – there are wide crevasses.