Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Is advocacy an option for achieving increased access to ACT in Africa?
- Mukosha B Chitah (30 September 2005)
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Need for strategic approach to Malaria resistance
- David Kieghe (5 October 2005)
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Premunition in malaria: let’s look forward to it
- Dr. Rajesh Chauhan, Dr. Akhilesh Kumar Singh, MD; Dr. Parul (Chauhan) Kushwah, MBBS, MISMCD. (10 October 2005)
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Is ACT cost really a barrier to implementation?
- Catherine M Royce (22 November 2005)
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Mukosha B Chitah, Health Economist Central Board of Health, Lusaka, Zambia
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Sir, I would like to add one more issue - pharmaceutical firms - to the issues your excellent editorial, 'Antimalarial Treatment with Artemisinin Combination Therapy in Africa', succintly raises and summarises in terms of the major issues that countries such as mine, Zambia, are grappling with. This is with respect to both specifically and generally accessing proven or technologically advanced drug remedies necessary for life saving conditions for illnesses with major burden and public health priorities such as malaria. As pointed out there are challenges within the public and private sectors when dealing with ACT. This issue has yet to be resolved in Zambia's case. The central issue as you righly point is cost. Firstly, dependency on donor financing led to protracted discussions on the likely "cost- ineffectiveness" of switiching to ACT in Zambia. From spending, on average, US 10 Cents for chloroquine, we now had to spend somewhere in the range of US$1.6 - 2.4 for a course of ACT. The cost factor was so critical that it permeated right through the health system and health workers became relatively conscious about the cost to the extent that there was a preference, as observed in a related article, for SP to be prescribed rather than ACT, even when ACT is in stock. Yet, the shelf life does not render the current ACT to delays in consumption. Even when some form of subsidy is available, there there is secondly, the question of the exclusion or inclusion of the private sector. The private sector is reluctant to stock a drug whose cost is so high that it is almost restrictive - for the simple reason that montherapy drugs available are much cheaper and so the profit element is realisable in the oppotune time frame. Demand generated by malaria for antimalarials imply that the private sector is able to turnover much more rapidly less costlier medications. In this case, there is the aspect of the availability of the drug in the public sector, free of cost and also the tenfold pricing in the private sector. Donors are reluctant to pay for ACTs. Yet commitment to addressing conditions that can be controlled or managed appear to be contracted by this very measure or attitude. An issue not discussed, most surprisingly in your editorial are the pharmaceutical companies themselves. Again, elements of contraditory behaviour cannot avoided to be seen. The usual argument by the pharmaceuticals on why prices remain high for their products or why some products for certain conditions is the issue of research and development investment. Yet information available demonstrates that this cost is not as high as argued. In any event given that the product research and development has already taken place, as in the case of ACT, is there any other justifiable reason for the donor reluctance as well as to the pharmaceutical reluctance to ensure that the pricing is brought down to the levels where a public and private health care system spending about a combined total of per capita 15-25 per annum will afford? Should this be an issue for concerted advocacy or should reason prevail? To take the matter further, we are currently, in Zambia,working on attempting to demonstrate that improvement or changes in health practioner/provider practices, specifically through appropriate diagnosis and rational drug use, the costs attributable to ACT can be minimised and benefits attributable to ACT can be maximised through the ill-health and death prevented or successfully treated. The result, hopefully is significant increase in the well being of the population and budgetary gains in resource terms through the savings incurred. Of course at the outset, there appear to be issues with this effort, given the cost of developing laboratory capacity as well as the cost of Rapid Diagnostic Test Kits where microscopy is not available. However, if the results are demonstrable of a positive link, we hope this may form part of the body of evidence which you say is lamentably lacking for informed policy decision making. Mukosha Bona Chitah,
Health Economist,
Central Board of Health,
Ndeke House,
Haille Selassie Avenue,
Longacres,
Lusaka,
Zambia
Competing interests: None declared |
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David Kieghe, Medical Doctor MMSL, UBA House, 57 Marina, Lagos Nigeria
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I want to say "thank you" to those who have put together this paper. I guess it touches on all issues and challenges the use of ACT regimes poses in coping with the huge (and increasingly so) burden of malaria all over the world but particularly in endemic territories most often some of the poorest. My worry is that resistance is an on going thing and thus an on going fight. The factors that fuel resistance are still quite rife and in some cases conditions are getting worse. Some of these factors have got to do with attitudes and behaviours in a complex mix with problems of ignorance, poverty and illiteracy. As it has been with many monotherapies that were hitherto quite effective in the treatment of malaria these combinations may soon encounter resistance and widespread too if the very factors fuelling resistance are not addressed. Then we will begin to look at other treatment alternatives which may again be more expensive in an unending vicious circle. The resultant collateral damages in costs against benefits to society and business could be quite huge considering that malaria is only one such of the many infectious diseases bringing about great human suffering. I would rather want a total strategic approach that looks at the issues in malaria as part of the "whole" global challenges that the world must together respond. This has been the attitude of the world against Tsunami and Katrina in recent times. The world is a big brotherhood with lots of interdependencies and interconnectivities and with ernomous capacity to cope together in adversity. This is how malaria and other diseases in the category should be seen in my view if we are to win this fight against one of human's big tragedy! As it continues along with other diseases to make poor communities even poorer, developmental gains may be lost and instead of making progress Sub-Saharan Africa and other such places will stagnate or even retrogress (if not already). This spells potential danger and an indictment to humanity. We will need to look seriously at sustainable policies along lines of strategic partnerships in keeping with set measurable and realisable goals. The "millenium development goals" must have as part of it enforceable strategies that ensures good/responsible/accountable leadership at all levels around the world particularly in Africa. This is the proactive flip side that I consider will make the difference. David Competing interests: None declared |
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Dr. Rajesh Chauhan, Consultant, Family Medicine & Communicable Diseases. 309/9 A.V. Colony, Sikandra, Agra – 282007. India., Dr. Akhilesh Kumar Singh, MD; Dr. Parul (Chauhan) Kushwah, MBBS, MISMCD.
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Premunition in malaria: let’s look forward to it. Malaria has persisted since ages, and ostensibly would endure to inflict mankind till the doom’s day. Although never sitting idle, mankind (and malariologists) have been trying for different ways and means to stop this menace or at least circumvent it. However, this fastidious parasite seems equally determined to stay put and enjoy its pleasures, so readily available. Although miniscule by size, this parasite is so well determined and adaptable at that so as to withstand all armamentarium that is employed (or will be employed) against its very existence. We must search for reasons why in other parts of the world, where P. Falciparum malaria is endemic, the morbidity and mortality rates are not as high as that in Africa. The state of Assam and other Northeastern regions of India are P. Falciparum endemic regions. Similar is the case of Southeast Asian region. In comparison to these areas, the morbidity and mortality rates that are experienced in Africa are certainly quite high. The reason is probably related to the indigenous people having gained immunity to malaria to specific species prevalent in their areas, whereas the people of Africa have failed to gain the requisite immunity. Malaria immunity is not so easy to acquire. In its own natural way, it is always preceded by premonitions, repeated sub-clinical illnesses and/or a frank illness. Once acquired, immunity keeps rejuvenating with every subsequent exposure. Are we hindering the process of acquisition of active malarial immunity in Africa? In Africa the state of art and latest technologies available for diagnosing malaria along with equally best brains and experience is being put to use to solve the malaria problem. A chance of malaria being missed or ill managed in Africa on a regular basis is therefore somewhat remote. Probably malaria is being picked up rather too early, without giving sufficient time or opportunity for the antibodies to start developing. Many of the war veterans of the Vietnam War, and of the II World War, may be harboring antibodies against malaria, and most of them without their actually knowing about having suffered from malaria. Rather than being too proactive for the population living in malaria endemic areas of malaria in Africa, expectant waiting period should be incorporated as adjuvant to the modalities of management, instead of going in for the kill immediately. Active management can always be rapidly initiated as and when required. This will provide chance to an individual to start gaining minor amounts of active immunity in malaria endemic areas and can help them in dealing with malaria. Secondly, the tendency of indigenous population within endemic malarial regions to continue taking anti-malarial prophylactic drugs should be curbed, as it not only denies malarial immunity from developing, but also adds on to the problem of drug resistance and the drugs taken can also lead to deleterious effects. If the drug prophylaxis is withdrawn, at worst the incidence of malaria would rise and a few breakthrough cases may be seen, which can be easily managed with active surveillance and therapy. This exactly was the experience with the population from an organized sector, which in 1990 had been taking anti-malarial prophylaxis at Vadodara, Gujarat (India). Prophylaxis was instituted following heavy floods and since malaria incidence was expected to rise. Following discontinuation of prophylaxis, malaria incidence did rise and many break- through malaria cases were registered, increasing the burden but managed without fatality or serious complications. Malaria is rather invincible, and will remain such, unless an all-out concerted global effort is undertaken with zest. This may not be possible under prevailing circumstances and the state of funding. ‘When unable to beat an enemy, its best to make friends’. Let us consider this saying in relation to malaria and look forward to its friendly premunitions. With regards. Competing interests: None declared |
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Catherine M Royce, clinical researcher Drugs for neglected diseases initiative,(DNDi) 1 Place St gervais, geneva 1201 Switzerland
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Dear Sir, I would like to challenge the 'cost is a barrier' theory for non-implementation of ACTs in Africa.The cost of currently available ACTs may be more than a dollar for an adult course, but given that most cases of malaria in Africa are in small children the cost for a course for them is only one quarter of the adult cost, ie 60 cents. Additionally WHO has a donation programme in place for governments to access free supplies for public use. It might be worth informing health workers of this and that most parents, including very poor ones, will afford 60 cents for a treatment that works more than 95% of the time if they can't get access to a hospital where free treatmnet is available. Cost savings of avoiding re-treatment of failures should also be emphasised. In the next couple of years several new ACTs will become available, including 2 from DNDi. Thus we have a unique opportunity to change the whole market from a variety of montherapies with variable results to a choice of ACT all of which are highly effective. Shouldn't we be focusing on making this happen and exert a real effect on the malaria burden or are we going to let this opportunity go by? Yours sincerely, Competing interests: Formerly International Clinical Team Leader for Co-artem at Novartis 1994-97 |
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