Category Archives: Private Sector

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.

Private Sector and Malaria – Many Roles, Many Benefits

progress-and-impact-business-investing-in-malaria-control.jpgThe latest edition in the Roll Back Malaria Progress and Impact Series is “Business investing in malaria control: economic returns and a healthy workforce for Africa. “The report provides an overview of the direct and indirect economic costs of malaria and looks closely at activities by three businesses in Zambia to tackle the malaria problem.

These companies were “able to scale up malaria control quickly and have seen a rapid return on investment. Malaria-related spending at three company clinics in Zambia decreased by more than 75%, and a very conservative estimate showed that the companies gained an annualized rate of return of 28%.” These experiences provided “Strong models … for businesses to take leadership roles in controlling malaria, protecting their workers and their families, strengthening their businesses, and extending programmes into communities.”

In fact there are several different and complimentary business roles for participation in rolling back malaria as seen below …

  • Manufacturers of preventive and treatment commodities
  • Wholesalers and retailers of malaria prevention and treatment commodities
  • Private health service providers: Formal orthodox, Informal, Indigenous
  • Private companies and industries based in endemic areas that aim to prevent and treat malaria among their employees and surrounding communities
  • Private companies and industries that provide donations to or organize malaria programs whether they are based in endemic areas or not
  • Sales of non-malaria products with a proportion/donation to malaria programming, like PRODUCT RED
  • Private companies that donate to malaria programming through their Foundations

The RBM website that features the Progress and Impact Series on Business involvement provides 16 downloadable case studies on the different models outlined above. Several diverse examples follow:

  • The Azalaï Hotels Group in West Africa, an active participant in the United Against Malaria (UAM) campaign, implements programmes to protect its employees with nets and hotel guests against malaria.
  • The ExxonMobil Malaria Initiative protects employees, supports malaria research and enables NGOs to carry out innovative community malaria control efforts
  • The MTN telecommunications group uses its technology and communication platforms to educate communities through radio, television, SMS, billboards and fliers.
  • The Sumitomo Chemical Company not only produces long lasting insecticide-treated nets but has provided technical assistance toward the establishment of the A to Z Textile Mills, based in Arusha and Kisongo, Tanzania, to ensure locally produced net supplies.

Although not featured by RBM, AngloGold Ashanti in Ghana has maintained an indoor residual spraying from for all structures in Obuasi District for five years now. Cases of malaria illness have steadily reduced at the district hospital.  This protects employees, their families and the wider community.

The impact of individual business efforts may affect a community or a region and vary widely from place to place. In order for greater impact to be felt, national malaria control programs need to identify all potential and actual business partners and bring them into national partnership forums so that collectively the private sector impact on malaria will be most strongly felt.

Chronic diseases – as if malaria were not enough

Two news stories today remind us that low and middle income countries (LIMCs) not only continue to suffer from infectious diseases like malaria, but that they are also burdened with chronic health problems arising from ‘western lifestyle’ behaviors like smoking and over-eating.

The New York Times describes efforts of cigarette companies, not only to promote use of tobacco products, but also to intimidate through lawsuits LMICs who try to control tobacco advertising and sales. Specifically …

Companies like Philip Morris International and British American Tobacco are contesting limits on ads in Britain, bigger health warnings in South America and higher cigarette taxes in the Philippines and Mexico. They are also spending billions on lobbying and marketing campaigns in Africa and Asia, and in one case provided undisclosed financing for TV commercials in Australia.

A Lancet article reported in the BBC documents how adult obesity in Brazil, Mexico and South Africa are above the average for Organization for Economic Co-operation and Development (OECD) countries. Recommendations to reverse these trends include “media campaigns promoting healthier lifestyles, taxes and subsidies to improve diets, tighter government regulation of food labeling and restrictions on food advertising.”

We have here an intersection among the public, the private and the personal. Although individuals can make personal choices and public health organizations can provide health education, the private sector can use their disproportionately enormous financial resources to advertise unhealthy behaviors and threaten in court those who oppose their efforts against health. Statements by agencies like the World Health Organization (WHO) may have a relatively smaller effect here.

The balance seems completely different when it comes to malaria. All partners appear to promoting the same healthy agenda – use of Long Lasting Insecticide-treated Nets and prompt treatment with appropriate antimalarial drugs to name a two key behaviors. The role of WHO is stronger in determining what are appropriate malaria commodities including its pre-qualification of medicines and the WHOPES evaluation scheme for reviewing insecticides.

These WHO processes influence the bulk of purchases for major international donors and national malaria control programs. This is not to say that “unqualified”, substandard or counterfeit malaria drugs don’t make it into the markets of developing countries, but the legal framework is more likely to work against such unhealthy schemes.

Hopefully the malaria partnership that promotes healthy behaviors will continue, resulting in reduced mortality among vulnerable groups such as young children.  It would be a shame for these efforts to reduce infant and child mortality were overshadowed by forces that threaten the lifespan in later years from obesity and tobacco induced cancers and coronary problems.

The Private Sector and Malaria

The East African today noted that, “Every African business in malaria endemic areas knows all about high absenteeism during the malaria season.” This opinion article goes further to state that, “Health spending cripples African consumers and governments, the tax base struggles to expand and foreign investment is discouraged by high rates of illness among workers,” referring to HIV, TB and malaria.

ghana-net-voucher-poster-sm.JPGThe solution according to the East African is, “For the African private sector to maximise these returns, awareness must be raised of effective practices in engaging health, and the benefits of partnership towards this end … Using established multilaterals like the Global Fund is an effective way for the private sector to engage health goals while maintaining business focus.”

While these are good sentiments, in reality of private or non-governmental contributions to the Global Fund have been minimal. Currently private pledges to date account for 4.4% of the total pledges ($29,928,488,771) to the Global Fund and a slightly higher 5.0% of the total paid ($18,146,056,176). One donor, the Bill and Melinda Gates Foundation, provided around three-quarters of this support.

The next largest private sources are the Product Red Campaign, which has paid 17.4% of the total private contribution, UNITAID (4.3%) and the Chevron Corporation (3.3%). These Global Fund contributions do not measure the total private contribution of global disease control, which includes, according to the Global Fund

  • Marketing campaigns and financial contributions
  • Pro bono services and core competency partnerships
  • Support for advocacy and governance, globally and locally
  • In-country co-investments and operational contributions

The private sector is an identified constituency of the Roll Back Malaria Partners Forum. According to RBM the contributions of the private sector are as follows:

  • First, the private sector possesses a breadth of expertise and implementation skills – including delivering products and programmes in the developing world.
  • Second, the private sector has a particularly important role to play in ensuring the supply and efficient distribution of drugs, diagnostics, LLIN’s and other interventions against malaria.
  • Finally, the private sector can bring the “business mindset” to the RBM Partnership, with its emphasis on good management practices and tangible results.

Clearly such contributions are not limited to financial ones and address in kind provision of expertise.The list also does not clearly identify individual focused efforts such as the Obuasi IRS program of AngloGold Ashanti, ITN donations from the telecommunications company MTN, or support from corporations like ExxonMobil to bilateral programs like the US President’s Malaria Initiative.

But back to the East African … are these contributions commensurate with economic benefits that can accrue from the major internationally and bilaterally funded efforts to control malaria? The answer probably comes down to the country level.  Private sector partners need to participate actively in each national RBM partnership forum so that their presence, expertise and of course financial help, can be felt.

PS:

Two news stories in the Washington Post shed further light on the issue. The first shows the need for increased private giving because foreign aid may be in doubt … “even the administration’s ability to provide direct climate assistance to poor nations over the next two years is in doubt because a looming budget battle with Republicans could freeze U.S. foreign aid at this year’s levels, or even cut it.”

The second highlights private sector philanthropy in other countries. “As India’s wealth continues to expand, a growing number of millionaires here are finding ways to do more for the poor, especially as cash-strapped foreign donors, including the United States, curtail aid.” Major religions in India may play a role in encouraging charity. “Indian billionaires give more than billionaires in China but less than those in developed countries, including the United States.”

Diversions – bumps in the road to malaria elimination

During visits to private pharmacies in 11 African cities from late 2007 to early 2010 Bate and colleagues purchased 894 samples of antimalarial medicines. Overall 6.5% of these medicines had evidence of being diverted from the public health system. This was only 4.2% of the older malaria therapies, but 27.8% of the 151 ACTs had come from the public sector.

global-fund-coartem-found-at-pharmacy-in-angola2.jpgThe ACT diversion problem was most noticeable in Nairobi, Lagos, Kampala, Luanda and Dar es Salaam.  The photo here shows ACTs we found in a small pharmacy shop down the street from a clinic in the suburbs of Luanda in 2008. Informal discussions in Luanda with donors also revealed major problems of theft from the ports. Specifically, the Boston Globe reported that, “According to an audit last year by the US President’s Malaria Initiative, about $640,000 worth of medicines sent to Angola vanished from airports and the government’s medicines warehouse.”

The authors are the first to admit that the study design is not perfect and that their sample size could have been larger, but the key issue is that they have actually documented the ‘leakage’ of these donated medicines from the people who need them. This moves the problem beyond the anecdotal level.

Medicines are not the only area where the diversion makes malaria commodities take a detour. Nets disappear, too.

Last year’s universal LLIN distribution in Kano State, Nigeria experienced some challenges in terms of reaching people and their retaining nets.  The goal was two nets per household, but a report by donors after the distribution found that 28% of households surveyed got only one. Seven percent of nets that reached households were also ‘lost’. So far there have been no mechanisms like the study by Bates and colleagues to trace nets into the private sector or elsewhere.

The main issue we see is that health systems need to be strengthened and public education needs to be improved – in this was diversions will be less likely and the public can serve as a watchdog for any malpractices and take an active role in rolling back malaria in their communities.

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ps –

08 Sep 2010 17:37:32 GMT

Source: Reuters