Archive for the ‘Affordable medicines’ Category
CONTAINMENT’s Moeun Chhean Nariddh follows Justice Police Officer Nuth Tith on his rounds in the Pailin market in North-West Cambodia.
It’s almost noon now in Cambodia’s Pailin province on the northwestern border with Thailand. Nuth Tith, a middle-aged health official, quickly changes his clothes and wears a new police uniform.
With a light blue shirt and dark blue trousers together with a sky blue cap, Nuth Tith looks no different from other police officers.
The only difference is that the sign on his shirt is a medical symbol instead of the normal Singha, or King of Lions, emblem used by other national police officers. Another thing is that he does not have a revolver in his belt and neither does he carry handcuffs.
Yet, he is not a normal policeman.
Trained as one of the five justice police officers in Pailin, Nuth Tith’s duty is to inspect pharmacies and drug stores to make sure that no counterfeit or substandard malaria drugs are on sale.
He is now ready to carry out his tasks.
After a ten-minute ride from the provincial hospital, he hops out of the car and rushes to a line of drug stores at a small market near Pailin.
“Do you have any malaria drugs left?” he asks Phat Sambo, a 28-year old drug seller at the front row.
“No!” she replies, laughing.
He searches the drug cabinet but finds no malaria drugs on sale.
“Now, put these flyers on the wall and don’t put any other pictures,” he advices and hands out a few anti-malaria drug flyers to Sambo.
Nuth Tith says the justice police officers would inspect the pharmacies and drug stores every three months as part of the efforts to stop the sale of malaria drugs and other fake and substandard medicines.
He explains that if the justice police find any counterfeit drugs, they will confiscate them. But he adds that a justice police officer has no power to arrest anyone found in possession of malaria drugs or other counterfeit and substandard medicines.
The drug inspector says that in the malaria containment project, funded by the Bill & Melinda Gates Foundation, drug sellers from Pailin and other remote areas had been invited to a workshop where they were trained by officers from the Ministry of Health and the National Centre for Parasitology, Entomology and Malaria Control or CNM. Tith says they received lectures on the dangers of artemisinin-resistant falciparum malaria spreading globally and were encouraged to help eradicate malaria altogether.
“I think it’s good to have justice police to make sure that no fake drugs that damage people’s health [are on sale],” says Phat Sambo.
Now, the drug inspector has got back into the car and moved to the pharmacies in Pailin market. He stops by a pharmacy run by 36-year-old Sor Pov, who’s been selling medicines for the past eight years.
When asked if she has received any patients who have come to buy malaria medicines, she replies that only about one in every 100 people have asked for malaria drugs at her store.
Duch Vanda, a 43-year-old vendor who sells medicines at a pharmacy next to Sor Pov’s, agrees that the number of people seeking malaria medicines has sharply declined.
“Now, almost nobody asks for malaria drugs,” he claims.
As instructed by the justice police, both Sor Pov and Duch Vanda say they would refer any malaria patients to get free treatment at the health centers around Pailin, if any customer asks to buy malaria medicines.
Sambo says the justice police officers have visited her store five times now since she started selling drugs two years ago.
“I think the anti-malaria campaign has been very successful, because there are no more malaria patients,” Sor Pov points out.
Drug inspector Nuth Tith then continues to the last pharmacy in the same row at Pailin market. But, he still cannot find any malaria or other fake drugs either.
Tith says that since he started his new drug inspection job three years ago, he has found less and less malaria drugs in the 25 pharmacies and drug stores he constantly inspects in Pailin.
After visiting the last pharmacy, Nuth Tith returns to the provincial hospital with a smile, proving that his work has been a success.
“[In the past] there were a lot of malaria drugs on sale,” he recalls. “Now, we hardly find any malaria medicines.”
Cambodian malaria experts and senior police officers have agreed that better cooperation and concerted efforts are needed to effectively combat malaria as well as curb the sale and smuggling of counterfeit and substandard drugs in Cambodia.
“The Ministry of Health has done a lot of work, but it would not be able to do anything without the cooperation of the police,” explained General Ben Rath, Vice Commissioner for Phnom Penh Municipal Police, during a workshop on “Strengthening Law Enforcement for Investigation of Counterfeit Medicines and Artemisinin Monotherapy”, which was held in Siemreap Province from November 10 to 12, 2010.
The National Centre for Parasitology, Entomology and Malaria Control or CNM that receives technical assistance from WHO, with support from the Global Fund and in cooperation with the Ministry of Interior organized the three-day training of trainers’ workshop for 55 senior police officers from 24 cities and provinces across the country. The workshop was to improve the investigative skills of the Cambodian senior police officers to identify and crackdown on fake and substandard malaria drugs that have been smuggled and sold in the country.
Dr. Kheng Sim, Vice-Director of Cambodia’s National Centre for Parasitology, Entomology and Malaria Control (CNM) speaks to CONTAINMENT on efforts to make vital anti-malarial drugs available to Cambodians at affordable prices.
Cambodia has been chosen for the Affordable Medicines Facility – Malaria (AMFm) Phase 1. The lessons learnt from AMFm’s Phase 1 will be used for Phase 2. Can you tell us how programs have been put in place, in Cambodia, to subsidize the cost of Artemisinin Combination Therapies (ACTs) and make them widely available for a lower cost, which should help eliminate the black market for counterfeit drugs.
Firstly I have to state that Cambodia’s application to AMFm was approved this year. CNM, together with other licensed importers, is now eligible to access ACTs at a greatly reduced price through subsidies from the Global Fund. When all parties agree on the ACT that is to be used nationally, one that also meets the requirement of the Global Fund quality standard, CNM and the private importers can procure these products at approximately 5% of the manufacturer’s sale price.
However the actual ACT co-payment is determined through negotiations between the Global Fund appointed agent and the manufacturer. Nonetheless due to the unique situation of emerging artemisinin resistance in Cambodia, there have been challenges to identify an appropriate ACT that is also eligible to be subsidized.
The Affordable Medicines Facility-Malaria (AMFm) is a mechanism to increase access to quality assured artemisinin-based combination therapy.
Universal access to effective malaria treatment is among the United Nations’ Millennium Development Goals. This also is among the goals of the Roll Back Malaria Partnership.
In spite of high-level commitments, political will and substantial increases in financing, the attainment of this goal has remained elusive in most malaria endemic countries, especially in relation to artemisinin-based combination therapy (ACT), the treatment recommended as first-line by the World Health Organization (WHO) for uncomplicated malaria caused by Plasmodium falciparum.
The Affordable Medicines Facility-malaria (AMFm) is a new financing mechanism to expand access to effective malaria treatment. A response to the dual challenge of poor access to quality-assured anti-malarial medicines and threats of parasite resistance to treatment, the AMFm combines price negotiations with a factory-gate buyer subsidy to reduce the price of ACT.
The AMFm will use price signals and a combination of public and private sector channels to achieve multiple public health objectives. These objectives include replacing older and increasingly ineffective anti-malarial medicines, such as chloroquine and sulphadoxine-pyrimethamine with ACT, displacing oral artemisinin monotherapies from the market, and prolonging the lifespan of ACT by reducing the likelihood of resistance to artemisinin.
The AMFm is hosted by the Global Fund to Fight AIDS, Tuberculosis and Malaria. The pilot phase of the programme, which includes Cambodia, Ghana, Kenya, Madagascar, Niger, Nigeria, the United Republic of Tanzania and Uganda, is scheduled to last from 2010 to 2012.
The AMFm is funded from multiple sources including a co-payment fund of US$216 million, financed by the Bill & Melinda Gates Foundation, the UK Government, and UNITAID. In addition, the Global Fund provides US$127 million to fund supporting interventions at the country level.
Enabling appropriate and rational use of ACT
To preserve the effectiveness of ACT over time, it is important that these life-saving medicines are used appropriately. A number of studies have shown that malaria case management, particularly in the retail sector, is unsatisfactory.
The private sector, in particular drug outlets, should be supported and capacitated to provide appropriate and rational management of malaria. Integrated approaches aimed at improving understanding and treatment of malaria can lead to tangible improvements in management of malaria. Building on lessons learned so far, the AMFm will work with countries and technical partners to build the skills of drug shop attendants using promising models, such as the Tanzania Accredited Drugs Dispensing Outlets (ADDOs).
Regulation can play an important role in enhancing access to ACT and improving the quality of care. A number of studies have reported that subsidizing ACT may need to be supported by effective regulatory policies for the intervention to be effective in crowding out less effective anti-malarials from the market. Countries in AMFm Phase 1 may use funds from the Global Fund to strengthen in-country regulatory systems.
Related to regulation is product quality. The AMFm will work with partners to adopt policies that assure product quality. For instance, AMFm uses the Global Fund’s quality assurance policy, which requires the procurement of WHO-prequalified products and those that have passed stringent quality assessment. Product branding serves to establish bonds among buyers, sellers and products. In many malaria-endemic countries there are various products available for the treatment of malaria. The availability of a wide range of products can makes it harder for buyers to distinguish quality-assured products from others. ACT under the AMFm will bear a distinct logo that will serve as an identifier and sales driver.
Finally, it is important to expand access to the parasitological confirmation of malaria, with a view to ensuring that only those who have malaria receive ACT as treatment. Most cases of presumptive treatment with ACT take place in the private sector. In the near- to medium-term, it is highly unlikely that effective public sector services will replace the private sector in most malaria-endemic countries.
Therefore, universal access to diagnostics requires the achievement of universal access to these technologies in the private sector. Given the new WHO’s normative guideline on the goal of universal access to diagnostics, it is important to identify the most suitable financing mechanisms for expanded access to diagnostics in the private sector, and to better understand the most feasible ways of expanding the use of diagnostics, particularly in the formal and informal private sectors.
The operations research elements of AMFm Phase 1 provide opportunities to learn how to increase coverage of diagnostics in the private sector in a way that can inform scaling up to universal access.
This is a condensed open-access article “The quest for universal access to effective malaria treatment: how can the AMFm contribute?” written by Lloyd Matowe and Olusoji Adeyi that was published in the Malaria Journal 2010, Vol 9, issue 274.