New study describes perils of delivering anti-malarial drugs through private sector

November 8, 2012

GAINESVILLE, Fla. — Getting high-quality anti-malarial drugs to people in places like Zanzibar and Mozambique is a tricky business.

A 2009 program, called the Affordable Medicines Facility-malaria, or AMFm, tried to do it by giving subsidies directly to drug manufacturers, but critics are now saying that the program has promoted dangerous misuse of these expensive medications. A new study co-authored by a University of Florida researcher, however, suggests that misuse is a bigger problem in some areas than others, and that an AMFm-like approach could still have value in some regions.

The study is published in the Nov. 2 edition of the journal Science.

“It’s a bit silly to talk about the private sector market for anti-malarials in Africa in general terms because there is so much variation in malaria prevalence, availability of health services, finances and culture within the region,” said Justin Cohen, senior technical adviser for the Clinton Health Access Initiative and lead author of the study.

A “one-size-fits-all” approach to working with the private sector in Africa will inevitably be an ill fit for some places, he said.

In many African countries, more people have access to privately run health facilities or drug stores than to public health institutions, so using them as a means to get better quality medicines to people in outlying areas is an attractive strategy. However, the decentralized nature of the private sector has also made it difficult to assess how many drugs are being purchased and how the drugs are being used.

“Part of the problem has been that we’ve never had good information for how big the private sector market is for anti-malarials in sub-Saharan Africa,” Cohen said.

Andrew Tatem, associate professor of geography at UF’s Emerging Pathogens Institute, was able to help in that regard.

Tatem combined population data from a project he runs called AfriPop with sub-Saharan household survey information to estimate the number of people buying anti-malarials from private sector markets. The team then combined the results with data from the Malaria Atlas Project to see how demand for medication stacked up against known rates of malaria infection.

“We found that in some regions, as few as 5 percent of the people taking anti-malarials likely had malaria.” Tatem said.

Malaria is often assumed to be the culprit when children run a fever in sub-Saharan Africa. When that happens, parents will often treat it with anti-malarials the way that Americans might treat flu symptoms with a cold medicine.

Taking the drugs when they are not needed wastes money, and it could possibly cause drug-resistant strains of malaria to develop. Cohen said that AMFm critics aren’t wrong when they say that programs should be providing more diagnostic tests along with these medications. The study notes that while 655 million people purchased anti-malarial medications, only about 50 million rapid diagnostic tests were delivered globally in 2010.

However, Cohen said that increasing access to affordable drugs even in the absence of diagnosis may be a good short-term strategy in places like Nigeria where infection rates are high.

“Ultimately, everyone should receive effective diagnosis and the appropriate treatment for the true cause of their illness,” Cohen said. “But in the short term, if most people in an area have malaria, we can do a lot of good by increasing accessibility to higher quality malaria drugs.”

Testing everyone who needs it will be expensive and resources are currently limited. According to the study, donations for malaria control declined in 2012 for the first time in a decade.

“It’s great to talk in the abstract about how things should be ideally,” Cohen said. “But in the end, you have to get going and do your best with what you have.”