MALARIA: Ghana: Household cost in treating fevers in the Dangme West District, Ghana

Bill Brieger : 07 Dec 2011

Is malaria treatment affordable in a rural district of Ghana? - a poster presentation at the American Society of Tropical Medicine and Hygiene annual meeting.
Alexander A. Nartey, Patricia Akweongo, Christine Clerk, Elizabeth Awini, Jonas Akpakli, Margaret Gyapong: Dodowa Health Research Centre, Accra, GhanaAlthough Ghana has instituted a national health insurance scheme (NHIS) as a measure to lessen the burden of health care cost to households, majority of people continue to pay cash directly to seek care, a study has revealed.



The study which was conducted in Dangme West District from October 2009 to August 2011 under the INDEPTH Effectiveness and Safety Studies of Antimalarials in Africa (INESS) platform was to assess household cost in treating fevers and the socio-economic burden of fever/malaria to households in the district. Malaria ranks first on the top ten list of most important diseases within the district.



The study showed that 78.9 per cent of the 511 people interviewed from pre-selected households paid out of their own pockets for the treatment of fever while the remaining 21.1 per cent used their health insurance. The majority of the people had health insurance cover but paid directly for care because they claimed it took too long for them to be attended to at the hospital if they presented their health insurance card. Additionally, some of the respondents paid out of their pockets because they preferred the private clinics where they received prompt care for their fevers.



The study also showed that 79.5 per cent of the respondents sought care outside home by visiting a drug store or health facility. An average of ¢5.00 ($3.3 USD) was spent before seeking care at the health facility and direct average cost per visit to health facility was ¢11.5 ($7.8 USD).



The average number of days lost due to malaria was six days while reduction of productivity due to malaria accounted for 28 per cent. About 1.6 per cent of the patients borrowed money to access health care.
It is evident that a household spends substantial amount on drugs, transport and food for an episode of fever within the district. Out-of-pocket payment is very high and places a high burden on household income. A household may spend an average of 12 working days of the daily minimum wage for the treatment of a fever episode.
The study, therefore, recommended that there is the need to investigate why individuals who are insured with the NHIS have to pay to get prompt treatment at NHIS accredited health facilities. Additionally, home based management of fever should be rolled out in rural communities to help reduce household burden of treating fevers.
http://www.malariafreefuture.org/blog/?p=1345

MALARIA: Tanzania: Yes, Reduce Prices of Malaria Drugs

The Citizen (Dar es Salaam) : 14 July 2011

Researchers have come up with the shocking revelation that nearly a million people die from malaria worldwide each year because they cannot afford the most effective treatment and instead often buy old drugs to which the malaria parasite has become resistant.
A study of six high-risk nations by Populations Services International Malaria shows that Artemisinin combination therapy, or ACT, drugs made by firms such as Novartis and Sanofi-Aventis can cost as much as 65 times the daily minimum wage in some African countries.
ACTs can cost up to $11 (Sh15,000) to patients buying over the counter, while older to less effective drugs cost just 30 US cents (Sh500). This explains why malaria is still a major killer in developing countries, including Tanzania, despite the proven efficacy of ACTs in treating the disease.
In Tanzania, prices of ACTs dispensed at public dispensaries and hospitals are subsidised by up to 90 per cent, but the drugs are sometimes not readily available at such facilities due to various reasons. In such a situation, patients are left to choose between facing the consequences of the disease and buying the drugs at private pharmacies for anything between Sh10,000 and Sh15,000 per dose.
According to official estimates, half of Tanzania's population lives on less than a dollar (Sh1,300) a day, and it's easy to see why malaria remains a major problem in the country. The irony here is that the most effective malaria treatment is still out of the reach of the vast majority of Tanzanians.
This is why we fully support the $225 million (Sh293 billion) Affordable Medicines Facility for malaria (AMFm) subsidy scheme launched in April by the Global Fund to fight Aids, Tuberculosis and Malaria, and which aims to drastically cut the price of ACTs in poorer nations.
It is hoped that the scheme will slash ACT prices to about 20 to 50 US (Sh260 to Sh650), and it's heartening to note that Tanzania is among 11 countries to which the plan is being offered, others being Benin, Cambodia, Ghana, Kenya, Madagascar, Uganda, Nigeria, Rwanda, Senegal and Niger.
http://allafrica.com/stories/201107170101.html

MALARIA: Kenya: The cost of "affordable" medication

Isaiah Esipisu : 19 May 2011
Nairobi — On the streets of Nairobi, James Odhiambo goes from one pharmacy to the next in search of anti-malarial drugs marked with the Global Fund's logo of a green leaf. He is looking for this specific brand because he understands that it is more than ten times cheaper than the same drug produced by different manufacturers.
He finally buys it from Nila Pharmacies along Accra Road - the sixth outlet he has visited this morning.
"My brother was yesterday evening diagnosed with malaria at a private clinic in Dandora suburb upon his arrival from a two week holiday in the lakeside city of Kisumu. That is why I have come to town to search for drugs," says Odhiambo holding a prescription from the Samaritan Health Clinic - where his brother was diagnosed.
However, Odhiambo says his brother could not buy anti-malarial drugs from the clinic where he was tested because the available drugs were expensive costing 400 Kenyan Shillings (KES) (five dollars). This is the average price of anti-malaria drugs in Kenya.
"We have always seen these subsidised drugs being advertised all over in the media. We were not going to waste the entire 400 KES - equivalent to two days' wages - on a similar dose," said Odhiambo, who works as a casual labourer in the city.
The drugs Odhiambo is referring to are subsidised through the Affordable Medicines Facility - malaria (AMFm). All drugs manufactured under the scheme have the logo of a green leaf. It is managed by the Global Fund with support from the United Nations, the UK Department for International Development and related donors.
Kenya was one of the very first countries in Africa to implement the scheme in August 2010, where a dose for an adult was supposed to retail at 40 KES or 50 cents, and a dose for children under the age of five would cost 10 KES.
However, many pharmacies across the country took advantage of the subsidy to maximise profits. "Two months ago, we requested our reporters from different parts of the country, including rural areas, to check on retailing prices of the subsidised anti-malarial drugs. As a result, we discovered that pharmacists sold them at varying prices ranging from 80 KES (one dollar), to 240 KES (three dollars)," says Gatonye Gathura, the chief science reporter at the Nation Media Group in Kenya.
A pharmacist at a private pharmacy in Buruburu Estates in Nairobi told IPS that she had to inflate the price simply because if she sold the drugs at the recommended retail price, it would not make any economic sense to her - considering her costs of transporting it from the distributors, and other inputs.
According to Harley's Ltd, the distributor of one of the brands recommended for subsidy, a dose for an adult should be sold to retailers for 26 KES (over 25 cents) to be sold to consumers at the recommended price of 40 KES (50 cents).
But like many other pharmacists, Linda Atieno's pharmacy did not stock the subsidised drugs. "If I sold a dose of unsubsidised Coartem drugs for example, I make a profit of up to 200 KES (over two dollars). This compares poorly with the profit I would make from a dose of the subsidised version of Coartem - which is 14 KES," she says.
In order to reduce instances where pharmacists are inflating the cost of the subsidised drugs, the Kenyan government has embarked on awareness campaigns through the media to inform Kenyans of the availability of the drugs, and the recommended prices per dose.
According to Dr John Logedi, the deputy program manager at the Division of Malaria Control, the awareness campaign will help consumers make an informed choice and enable them to seek outlets that sell the drugs at the right price.
Technically, the government of Kenya does not have control over drugs sold in pharmacies in the private sector because the pharmaceutical market in the country is based on 'a willing seller, willing buyer' concept.
So far, the subsidised drugs in Kenya are distributed through both the public and the private sector.
However, despite difficulties in searching for pharmacies that stock the subsidised drugs and sells them at the correct prices, Odhiambo admits that the subsidy program is a great relief to many people with a meagre income like his. "Most of us cannot afford the unsubsidised drugs that cost up to 600 KES (over seven dollars). The subsidy is therefore good news to most of us," he said.
In marginalised rural areas such as Turkana, private pharmacies are yet to begin stocking the subsidised drugs, despite the launch of the programme several months ago. "We have the subsidised drugs in public health centres within Turkana Central. But not in private pharmacies," said Dr Gilchrist Lokoel, the Turkana Central Medical Officer of Health at the Lodwar District Hospital.
Phase one of AMFm is already under implementation in nine pilots in eight countries. They include Cambodia, Ghana, Kenya, Madagascar, Niger, Nigeria, Tanzania (mainland and Zanzibar) and Uganda.
http://allafrica.com/stories/printable/201105210027.html

MALARIA: INTERNATIONAL INITIATIVE SLASHES COST OF ANTI-MALARIA DRUGS IN SEVERAL AFRICAN COUNTRIES

GENEVA – An international initiative to put affordable and effective anti-malaria drugs within reach of people in often remote communities in Africa is making rapid progress. In four implementing countries, Ghana, Kenya, Madagascar and Nigeria life-saving malaria treatment can now be bought in private stores and pharmacies for as little as 50 U.S. cents. Before the launch of the program, these treatments cost up to 20 times as much. The only way most people in Africa could get effective malaria drugs for free was by travelling long distances to reach public health clinics. The Affordable Medicines Facility – malaria (AMFm) gets key financial support from UNITAID, the United Kingdom and the Bill & Melinda Gates Foundation, technical support from members of the Roll Back Malaria (RBM) Partnership and it is hosted by the Global Fund. The initiative which began last year is being piloted in eight countries -- Ghana, Kenya, Madagascar, Niger, Nigeria, Tanzania (including Zanzibar), Uganda and Cambodia – to enable lessons to be learnt before a potential global rollout. Early results are now visible in the four countries that began implementing earlier.
AMFm aims to make anti-malarial drugs, known as artemisinin-based combination therapies (ACTs), available as widely and cheaply as possible. About 225 million people fall ill with malaria every year and 780,000 die from the disease.
Although the World Health Organisation specifically recommends ACTs as first-line treatment for Plasmodium falciparum malaria, the most deadly form of the disease, the drug accounts for only about one in five of all treatments taken for malaria and until recently it has only been available for free or at low cost in public health facilities.
Most people buy anti-malaria treatments in private shops and pharmacies where ACTs were not available at an affordable price before the launch of AMFm. These shops sell older, cheap medicines such as chloroquine and sulfadoxine-pyrimethamine which are no longer effective because the Plasmodium falciparum is increasingly resistant to them.
The objective of the AMFm program is to drive out these ineffective therapies by bringing down ACT treatment costs drastically and making the drugs more accessible for millions of people.
"We are making further progress in fighting malaria in Africa by providing affordable treatment to millions of people through the Affordable Medicines Facility for malaria" said Prof. Michel Kazatchkine, Executive Director of the Global Fund. "The Affordable Medicines Facility - malaria is a major step forward. It uses innovative financing methods to save lives by providing affordable and effective medicines to more people in need through the public, NGO and private sectors". Working with Roll Back Malaria partners, AMFm is bringing life-saving treatments to millions of people.
The innovation works like this: the Global Fund first negotiates a discounted price for ACTs with drug manufacturers and then pays most of the reduced price on behalf of importers from the private, NGO and public sectors, leading to an average sales price of less than 10 cents. The reduced prices allow private wholesalers to sell the ACTs to retailers at a profit. Pharmacies and stores in turn sell the drugs to patients and caregivers with an additional mark-up, while keeping the retail price affordable.
As of early April 2011, the Global Fund has approved AMFm payments for over 75 million courses of ACT treatment. Early findings show that the AMFm is working, with dramatic falls in over-the-counter drug prices in several African countries.
A formal price survey in Kenya showed that most retailers were selling subsidized ACTs at or slightly more than the recommended local price, equivalent to about 50 U.S. cents. This is about one-twentieth the price of unsubsidised ACTs.
In Ghana informal price checks show that subsidised ACTs are selling in shops in parts of the capital, Accra, at prices ranging from 60 US cents to US$ 1.20, down from US$ 9 per adult treatment before the AMFm.
In Madagascar informal price checks in early 2011 showed that the private sector retail price of AMFm co-paid ACTs was about US$ 0.40 equivalent per adult treatment in the capital city of Antananarivo, and about US$ 0.50 outside the city. Before AMFm, ACTs recommended by the World Health Organization sold for US$ 8.51-9.36 per adult treatment in the private sector.
In Nigeria, where AMFm was introduced in March 2011, ACTs that are not co-paid by the AMFm cost about 1,000 – 1,500 Naira (US$ 6.70 – 9.50) per adult treatment. The Society for Family Health (SFH), a not-for-profit NGO started distribution of AMFm co-paid ACTs in Nigeria in March 2011. Thanks to the vastly reduced purchase price of co-paid ACTs under AMFm, SFH will sell a full course of treatment for children aged under five years in private health facilities and outlets at US$ 0.20. The adult course of treatment is expected to sell for US$ 0.80.
In the eight countries where the AMFm is being implemented, governments are supporting the initiative with public awareness campaigns and training for ACT providers.

For more information on the AMFm, see http://www.theglobalfund.org/en/amfm/?lang=en

TUBERCULOSIS: Viet Nam: More patients resistant to tuberculosis drugs

HCM CITY — Doctors warn that the number of tuberculosis patients resistant to drugs is on the increase in HCM City.
Director of the Pham Ngoc Thach Hospital for Tuberculosis and Lung Diseases Nguyen Huy Dung said the number of TB patients in the city had doubled from 8,000 to 15,000 in the past 10 years.
On average, the number of patients increases by about 2 per cent a year. Most patients are between 25-54 years old.
Hospital statistics show that TB patients and thousands more with lung and bronchial diseases are making life a burden for the medical sector.
Dung said that every year, about 14,000-15,000 more patients attended TB control programmes in the city. About 8,000 were new patients.
Last year, more than half of the 100,000 people – or nearly 1 per cent of the city's population – who went to the TB hospital for health checks were found to have various levels of the disease. About 1,100 of them were resistant to drugs, including about 200 patients who cannot be treated with them.
There are a total of about 700 chronic tuberculosis patients who are resistant to most drugs. Only about 50 per cent can be cured.
Phan Thuong Dat, a doctor of the hospital, said that treating these patients was as difficult as treating patients 50 years ago when there were few antibiotics.
Dung said the main reason for the increased number of TB patients resistant to drugs was the low awareness.
After treatment for two months many patients refused to take more drugs because they were feeling healthier, but the correct treatment period is about eight months.
Another reason for the increase in TB patients was the cost of treatment was nearly VND10 million (US$500) in eight months, so many patients could not afford a complete course.
"Patients joining the national tuberculosis control and prevention programme are exempted from paying for the five main drugs, but they still have to buy a number of restorative and other drugs," said Dung.
"Besides, doctors at private hospitals write prescriptions for tuberculosis patients although they do not specialise in the disease," he said.
Dung said that this year the medical sector would join hands with municipal police to supervise the work of private hospitals.
http://vietnamnews.vnagency.com.vn/Social-Isssues/208120/More-patients-resistant-to-tuberculosis-drugs-.html

POVERTY: Drug costs would push millions more into poverty

Kate Kelland
Sep 1, 2010
Tens of millions of people in low and middle income countries would be pushed below the poverty line by buying common but vital medicines which are already unaffordable to hundreds of millions more, a study has found.
Laurens Niens' team at Erasmus University Rotterdam analyzed the number of people who would be pushed below an income level of $1.25 or $2 a day -- poverty indicators used by the World Bank -- by paying for four important, widely used medicines.
The Dutch researchers whose work was published in the Public Library of Science (PLoS) Medicine journal on Tuesday said their findings showed that greater effort is needed to encourage the use of cheaper generic drugs in poor countries and to ensure more medicines are made available through the public sector.
The drugs studied were a salbutamol inhaler, used for the management of asthma, glibenclamide, a common diabetes drug, atenolol, which belongs to a drug class commonly known as beta-blockers and is used to treat high blood pressure, and amoxicillin, a broad spectrum antibiotic.
Using data from the World Bank and the World Health Organization, the researchers generated "impoverishment rates" for these medicines in 16 low- and middle-income countries.
The results of their study -- available here show the much greater impoverishing effect of branded drugs which are sometimes the only option available in countries where public sector provision is often patchy.
In Yemen, for example, where seven percent of people live on less than $1.25 a day, buying branded glibenclamide -- sold as Daonil by Sanofi-Aventis -- would impoverish another 22 percent, but buying the cheapest generic equivalent would only push another 3 percent below the poverty line.
In Nigeria, amoxicillin is already unaffordable to the 56 percent of the population who live on less than $1.25 per day. A further 23 percent of Nigerians would be pushed into poverty by having to buy branded version Amoxil, made by GlaxoSmithKline, while only another 12 percent would be impoverished by buying the cheapest generic version.
http://www.reuters.com/article/idUSTRE67U5G120100901?feedType=RSS&feedName=healthNews

MALARIA: Practical problems of therapy

According to Professor Chris Whitty, Head of Research at the Department for International Development (DfID), almost every death by malaria is avoidable. We have drugs that work and that are affordable. Yet there are still substantial numbers of deaths due to malaria. Why?
In a talk at the London School of Hygiene and Tropical Medicine (LSHTM) last Friday, Whitty highlighted one of them: deaths occur because people simply cannot get anti-malarial drugs.
“Those who need malaria drugs and those that are given malaria drugs are not the same group,” he said. The reasons for this are complicated, but the top three are:
Many malaria patients do not seek care.
Of those who do, most do not seek care from the formal healthcare sector.
Cost.
Earlier I wrote that the drugs are affordable. But ‘affordable’ is a relative term. ACTs are relatively cheap if you live in Thailand and only get malaria once every so often. In parts of Africa, however, ACTs cost over $1.50 a course and people tend to suffer 3-5 bouts of malaria a year. That’s a lot of money considering the average person lives on $0.64 a day. And people have different ideas of what they are willing to pay for things, even medicines. Research has shown that the value consumers put on antimalarial drugs is less than their true market value.
Prices are coming down, but slowly and Whitty believes they are unlikely to fall enough. Again, there are many reasons for this. Growth of the plant from which artemisinin is derived requires land, something that is expensive to come by. It also costs a lot to extract and process. Moreover, it’s a risky business – the market is immature and with researchers developing synthetic artemisinin many companies are unwilling to take the risk of investing in the current process. Furthermore, the shelf life of artemisinin is short, raising significant problems with stock control and wastage.
Then there is the problem of distribution. The poorest patients will always go to the closest point for care. This will almost always be local retailers – even if they have to pay for them, it’s still cheaper than travelling to a hospital. And when I write ‘local retailers’, this isn’t necessarily a proper pharmacist, but often a general supply store. Worse still, most of the working anti-malarial drugs won’t even appear in such retailers.
Then there’s drug efficacy. This depends on several factors: whether the patient attends a doctor, the accuracy of diagnosis, prescription of the drug, the patient taking the drug course correctly. By the end of this, the efficacy of any drug is likely to be only 16 per cent in a population. This drops to 5 per cent if formal healthcare services aren’t involved at all (i.e. if people are buying their drugs directly from the local shop).
The problem, said Whitty, is not the lack of effective anti-malarial drugs, but getting them to the right people at the right time. Public health professionals are looking at a number of different ways to do this, including community involvement (giving the drugs to the community to distribute themselves when needed), subsidising drugs to reduce the price to get them into local retailers, and focusing on improving the formal healthcare sector.
None of these are particularly easy, given the complexity of healthcare in many countries. There’s also the risk of over-treatment (and with it, drug resistance). Flooding the market with anti-malarial drugs also doesn’t guarantee that the people you reach are necessarily those with malaria.
Improving diagnosis
What we need alongside better drugs and better access to drugs, is better diagnosis. According to a 2007 study just a quarter of the cases that look like malaria are actually malaria. Two 2004 studies published in the Lancet and BMJ found that more than 50 per cent of those treated for malaria don’t even have the disease, and that mortality is almost twice as high for those that have been misdiagnosed for malaria.
According to Dr David Bell, a researcher from the World Health Organization (WHO), over half of all malaria cases are diagnosed on the basis of symptoms alone, contrary to the WHO’s recommendation that use microscopy for confirmation.
The trouble is, while microscopy is reliable, it’s neither quick nor easy to do without the right equipment and personnel. So, scientists have been working to develop an alternative: rapid diagnostic tests (RDTs) that can diagnose malaria from a blood drop using labelled antibodies. The result is an accurate diagnosis, but one as quick and simple to use as a home pregnancy test.
RDTs are now being rolled out all over the world. In Senegal a 2007 study found that the level of malaria reported had dropped by a third, and in India, they have helped save over a 1.5 million doses of artemisinin-combination therapy (ACT). Researchers are also working to make better RDTs with improved sensitivity, the capacity to detect different malaria strains and suitability for use in the tropics.
With a variety of RDTs, of varying quality, currently on the market Bell emphasised the importance of training healthcare workers in how to use them correctly. “You can’t just throw things out to the community and expect them to work.” Manufacturers must consider proper training manuals as being as important as the actual product itself, he said.
This will help to ensure that the tests are being used properly, which will help with the other challenge of convincing people that RDTs really work and that a null result really does mean they don’t have malaria. Microscopy diagnosis still accompanies the use of RDTs for this reason.
There are still a lot of problems for the malaria research community to solve. But improved diagnosis, better treatments and better treatment strategies are helping us win the fight against the disease. According to the World Health Organisation’s 2009 Malaria report, over one third of the 108 countries where malaria is endemic documented reductions in malaria cases of more than 50 per cent in 2008 compared to 2000. In countries that have achieved high coverage with bednets and drug treatment programmes, recorded cases and deaths due to malaria have fallen by 50 per cent.
There’s still much to do, but researchers are starting to think about the next challenges in malaria on the horizon. “We have the tools to identify and manage malaria as a common disease,” said Bell, “Now we need tools and strategies to manage it as a rare disease”.
http://wellcometrust.wordpress.com/2010/04/30/counting-malaria-out-the-drugs-do-work-getting-them-is-the-problem/

MALARIA: Uganda, drug corruption

Prime Minister Apolo Nsibambi and Health Minister Stephen Mallinga were named among senior government officials who got excess consignments of drugs meant for malaria control, court heard yesterday.
While testifying before the Anti-Corruption Court, Dr John Bosco Rwakimari, the former National Malaria Control Programme manager, said Prof Nsibambi, Dr Mallinga and his junior in charge of General Duties, Dr Richard Nduhura would request for whatever quantities of drugs and would be given.
"They would request for any amount of drugs they wanted and I would give them. They were adequate-enough doses for them," Dr Rwakimari said.
Without mentioning names, Dr Rwakimari added that other top Health ministry officials also benefited from getting excess consignments of drugs without question.
He told court that health officials were required to request for only 10 doses, but Prof Nsibambi, Dr Malinga and Dr Nduhura would get even more than 20 doses.
Revealing more rot in the malaria drug scam, Mr Pontiano Jjumba, an assistant director of Health Service Delivery Monitoring Unit in the ministry, told court that Dr Richard Ndyomugyenyi, the programme manager of Malaria Control Programme, his deputy Dr Myers Lugemwa and administrative manager Martin Shibeki, got drugs without signing for them.
The trio are facing trial before the Anti-Corruption Court over alleged misappropriation of malaria drugs worth over Shs2 billion.

http://allafrica.com/stories/201005050297.html

MALARIA: Kenya will subsidise drug cost

The government will subsidize recommended malaria drugs by June this year.
The initiative, which is the result of a grant agreement between the government and the Global Fund will see a dramatic drop in the price of the drugs from a high of Ksh 600 million to an average cost of Ksh 20 million.
Public Health and Sanitation Minister Beth Mugo was quick to reassure the public that all malaria drugs bought by the government for public health facilities through the initiative were of the highest quality.
http://www.kbc.co.ke/story.asp?ID=63572