When you might as well be taking just ‘a spoon full of sugar’
Author: Jasson UrbachDate: 9 May 2008
In many parts across the world malaria continues to be a serious public health concern. It affects over 100 countries and approximately 40 per cent of the world's population. It causes between 300 and 500 million infections and approximately 1 million deaths each year. It is estimated that malaria claims a child’s life every thirty seconds and this in spite of the fact that the disease is entirely preventable and curable.


At the eighth World Health Assembly meeting in 1955 it was resolved to begin a worldwide eradication campaign of malaria. Despite the fact that the campaign was eventually abandoned and considered a failure, it registered resounding successes in wiping out malaria from large regions across the globe. The successful application of insecticides on the inside walls of houses, coupled with the effectiveness of antimalarial treatments such as chloroquine formed the cornerstones of the programme.


However, due to the nature of the malaria parasite, which is constantly evolving to try and outsmart the human race, our ability to successfully control the parasite hangs in a precarious balance. Chloroquine, along with many other monotherapy antimalarial drugs has been rendered completely resistant for a number of years now and although the WHO  was slow to adapt it eventually changed it’s policy regarding the production of monotherapy antimalarial drugs. In January 2006 the WHO appealed to pharmaceutical manufacturers to cease production of these drugs.


As a result of the wide-scale resistance, scientists developed new antimalarial drugs called artemisinin based combination therapies (ACT’s) derived from the Artemisia annua plant to stay one step ahead of the parasite. But due to the unscrupulous behaviour of some pharmaceutical manufacturers that are producing fake or substandard drugs that raise the probability of resistance building up we could potentially lose a very valuable tool in the fight against malaria.


Africa Fighting Malaria (AFM) along with Amir Attaran from the University of Ottawa in Canada released a report this week published in the highly influential Public Library of Science journal PLoS ONE. The report entitled Antimalarial Drug Quality in the Most Severely Malarious Parts of Africa – A Six Country Study reports on the tests AFM conducted to check the efficacy of drugs collected in six malaria endemic African countries namely: Ghana, Nigeria, Tanzania, Rwanda, Kenya and Uganda.


In the analysis, over 200 samples of antimalarial treatments were collected and tested to see if they met international standards and the results were alarming. Overall 35 per cent of the samples were substandard and failed the test. This means that one in three patients are unlikely to be cured by the proclaimed antimalarial treatments purchased. Furthermore, it was found that 33 per cent of the treatments tested were artemisinin monotherapy drugs (42 per cent of these failed the test). 78 per cent of the monotherapy drugs collected were manufactured after the appeal from the WHO to stop monotherapy production.


Sub-standard drugs as opposed to outright fakes (where there is no attempt whatsoever to include the active ingredient) are of particular concern because in addition to affecting the patients’ health, they also increase the probability of the malaria parasites building up resistance to good quality drugs.
This has the potential of rendering an entire class of drugs useless and thus has serious long-term implications for our ability to fight the disease.


Given the precarious nature of the situation it is in many instances unfortunate that large multilateral donors are actively supporting and encouraging the domestic production of antimalarial drugs. First impressions may find the local production of drugs appealing, since it has the potential to decrease transportation costs, provide local jobs, increase expertise and cut dependence on foreign suppliers. However, apart from the potential for the production of fake or substandard drugs, local manufacturers may not be as efficient in production as other established manufacturers that are already supplying the market on a no-profit and no-loss basis.


Furthermore, in order to support inefficient and sub-standard home industries, a government may protect local manufacturers from foreign competition by imposing high tariffs on imported pharmaceuticals. At the same time, the government may offer tax incentives and subsidies to local companies. These constrict the supply of imported drugs, which are often of superior quality, without necessarily increasing local supply appreciably.


Despite the international donor communities’ best intentions in wanting to increase access to medicines in developing countries through the development of local manufacturing facilities they should be cautious in their prescriptions, particularly if the wider policy environment in these economies is not conducive to the development of local facilities. Taxes and tariffs on pharmaceutical drugs and devices must be eliminated as a matter of urgency and strict regulatory standards must be adopted in order to clamp down on the production of fake and substandard drugs. 

Author: Jasson Urbach is an economist with the Health Policy Unit (a division of the Free Market Foundation) and a director of the health advocacy group Africa Fighting Malaria. This article may be republished without prior consent but with acknowledgement to the author. The views expressed in the article are the author's and are not necessarily shared by the members of the Foundation.


Note: Africa Fighting Malaria’s journal article: Antimalarial Drug Quality in the Most Severely Malarious Parts of Africa – A Six Country Study can be downloaded online from PLoS One journal or by clicking here.