The recent scare concerning the magnitude of fake and poor quality malaria drugs in circulation has raised a number of questions about malaria drug supply management in endemic countries.Â The big question is who makes the decisions about what comes in and how it is used? Debates around public and private sector medicine use further complicates the debate.
In all cases there do seem to be national malaria treatment policies that specify the types of medicines appropriate for a ‘normal’ case of malaria, a case of severe malaria and cases of malaria in pregnancy.Â Within these policies are strong preferences for artenmisinin-based combination therapy (ACT) drugs. WHO has gone to the extent of examining malaria drug production and has published and regularly updated lists of ‘pre-qualified’ medicines from reliable pharmaceutical companies.Â This list usually guides the recommendations and purchases of major donors like the Global Fund and the US President’s Malaria Initiative.
Even with these various safeguards, the situation on the ground – and in the medicine shops and pharmacies – is quite variable. Lets look at two extremes.
Nigeria’s national case management guidelines do specify ACTs for first line malaria treatment.Â The main recommendation for treatment in uncomplicated cases is artemether-lumafantrine (AL) and as an alternative artesunate-amodiaquine (AA).Â Brand names are not specified, but for government and donor programs the choices do come from the WHO pre-qualified list.
Estimates vary, but roughly half of Nigerians get their malaria treatment in the private sector.Â There one still finds chloroquine and sulfadoxine-pyrimethamine products on sale.Â Over 100 different ACTs are registered with the National Agency for Food and Drug Administration and Control. It is not clear whether it has been possible to test the efficacy of all these different products. Let the consumer beware.
In Rwanda, not only does the Ministry of Health set malaria drug policy, it actually enforces it.Â Even in private pharmacies one can only buy the approved form of AL, Coartem.
Aside from the size of the two countries, what makes the difference? Political will to adhere to scientific evidence!
Closer to Rwanda, Edward Ojulu looks north and observes that, “Just across in neighboring Uganda, authorities say they suspect nearly 30% of the drugs imported into the country to be fake counterfeits. The tragedy is that the National Drug Authority, a Uganda Government agency that regulates manufacture, import and distribution of human drugs in the country, says it has neither the equipment nor the manpower to stop fake drugs from being sold to the people.”
Edward gets to the heart of the matter when he notes that, “Malaria is big business for pharmaceutical companies world-wide and counterfeiters also know this.” It takes a lot of political will to stand in the way of the profit motive. But that may be what is necessary to save the malaria drug supply and save lives.