Mike Egboh and Garba Safiyanu: Scaling down the cost of malaria treatment in Nigeria

Malaria is a deadly disease which kills at least 300,000 Nigerian children every year. The contribution of Malaria to the high mortality rate amongst children is of grave global concern. The Nigeria Demographic and Health Survey (NDHS) 2008 study report shows that malaria is endemic throughout the country. Data from the study results indicates that malaria accounts for nearly 110 million clinically diagnosed cases per year, 60 percent of outpatient visits, and 30 percent hospitalisations’.

It also contributes up to 11 percent maternal mortality. Almost all the population in the country is at risk. In addition to the direct health impact of malaria, there are also severe social and economic burdens on communities and the country as a whole, with 134 million naira (that’s about $1 billion) lost to malaria annually in form of treatment costs, prevention and loss of productivity (NDHS 2008).

Malaria is a parasitic infection spread by the female anopheles mosquito. It is caused by four different species of the plasmodium parasite, the most dangerous of which is the plasmodium falciparium, commonly found in Sub-Saharan Africa. Apart from being the most virulent of the plasmodium species, Plasmodium falciparium has also developed resistance to the conventional anti-malarial treatment such as Chloroquine and sulphadoxine –pyrimethamine also known as mono-therapies – which are older malaria medicines grown less effective due to the development of resistant strains.

The resistance of the plasmodium falciparium species to conventional drugs is a major factor that has led to difficulty in control of the malaria epidemic. In view of this, the World Health Organisation recommended Artemisinin-based Combination Therapies (ACTs) for the treatment of uncomplicated malaria caused by Plasmodium falciparum. It has been shown to be effective both in sub-Saharan Africa and in areas with multi-drug resistance. Artemisinin-based compounds are used in combination with other classes of antimalarial to form ACTs and this combination therapy is considered best for malaria management. The benefits of ACTs are their high efficacy, fast action and the reduced likelihood of resistance.

In 2005, the Artemisinin-based Combination Therapies (ACTs) for the treatment of malaria was endorsed by Nigeria’s Federal Ministry of Health. This was meant to improve effectiveness of malaria treatment and reduce the morbidity and mortality associated with this disease.  However, at a cost of N1,500 ((£6-00) – many times the cost of chloroquine and other conventional drugs used for mono-therapy, ACTs are largely unaffordable especially for the poor who are most affected by the killer disease. Consequently, many people in the rural areas of the country have continued to die in large numbers from   malaria despite the effectiveness and availability of the combination therapy.

In Nigeria, more than 70 per cent of the population live below the poverty line and the major impediment to accessing effective anti-malarial treatment is its high cost. Many poor and rural people end up seeking for traditional remedies for malaria treatment where the ACTs are not affordable. During a visit to the Mambilla Plateau in North East Nigeria a few years ago, I found chloroquine supplies that had expired two years earlier still displayed on a local dispensary shelves. The first step towards ensuring access of ACTs to the poor is to reduce the cost and make it affordable by the poor.

Following the need to provide hope for millions of poor Nigerians to gain access to the most effective combination treatment for malaria at a fraction of its current cost, the United Kingdom Department for International Development (DFID) funded Partnership for Transforming Health Systems (PATHS2) in collaboration with Clinton Health Access Initiative (CHAI) brought together Nigeria’s Federal and the five project State Ministries of Health including Pharmaceutical Manufacturing companies in Nigeria through the Affordable Medicines Facility for malaria (AMFm) initiative. The AMFm is an innovative financing mechanism to expand access to affordable ACTs. — It is hosted and managed by the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund), with key financial support provided by UNITAID, DfID and the Bill & Melinda Gates Foundation, and with exclusive right given to CHAI to ensure availability of ACTs. In order to ensure the availability of this effective drug at facilities in the PATHS2 supported States, a clever partnership was formed with CHAI. This led to a roundtable dialogue between the Public and Private sector actors in Lagos.

At the ground breaking roundtable meeting between key Government Agencies and Private manufacturers facilitated by PATHS2 in Lagos, Nigeria, an agreement was reached on how to make ACTs available and affordable to the poor, make manufacturers  WHO pre-certified for quality control and the roles and responsibilities of each stakeholder.  At the end of the meeting, a compact was signed between the five PATHS2 supported States Ministries of Health and the pharmaceutical manufacturers. PATHS2, in collaboration with the Clinton Health Access Initiative (CHAI), will provide life-saving anti-malaria treatments to health facilities based largely in rural communities in the five Nigerian states of Lagos, Kaduna, Jigawa, Enugu and Kano. A course of treatment will be provided for as low as 60 Naira (approximately 25 pence in Sterling), in comparison to previous costs of nearly 20 times as much, making the drugs affordable to even the poorest Nigerians, many of whom still subsist on less than US$1 a day.

Through the AMFm initiative, International manufacturers of ACTs will receive a subsidy directly almost to the tune of 95% which in turn will be passed on by a Nigerian pharmaceutical company as the First Line Buyer of ACTs. Acting as second line buyers, PATHS2 will distribute ACTs through primary health centres in the five Nigerian states in which it currently supports. These states have a total population of approximately 37 million, representing about 22% of the population of Nigeria as a whole.

PATHS2 is thus supporting the unprecedented and significant reduction in prices of ACTs by bringing First Line Buyers and PATHS2 states together to discuss their requirement and supporting the signing of annual contracts between the states and First Line Buyers. The First Line Buyer is a pharmaceutical company in Nigeria who buys directly from WHO certified manufacturers outside the country. In Nigeria, there is currently no domestic manufacturer of AMFm drugs. With this effort, there will be improved availability of quality ACTs drugs at an affordable price.

The Pharmaceutical company supported under AMFm will sell Artemisinin/ Lumefantrin (Pack of 24) for just 50 Naira to PATHS2 States health facilities and patients will get it for about 60 Naira, compared to its previous cost, which was as much as 1,500 Naira (£6-00). This pricing makes it the cheapest price available anywhere in the country.

This ground breaking agreement facilitated by PATHS2 between the state governments and pharmaceutical manufacturers will revolutionise the treatment of malaria in Nigeria. People in the rural communities in the five states will have access to quality and affordable ACTs drugs. It will have a significant long term positive impact on health care service delivery as it will strengthen the treatment of malaria and save tens of thousands of lives, particularly women and children who are the most vulnerable to malaria. Subsidised ACTs are expected to come on stream in PATHS2 supported public health facilities within the next one month or two months.

In order to sustain the funding and availability of ACTs in health facilities where care is received, there is need for improved partnership among the government, donors and the private sector. Pooling resources through partnerships is one way to expand services. When successfully implemented, PATHS2 proposes to present the model to the National Council on Health for adoption by other States to ensure full scale national implementation and possible dramatic control of Malaria.

PATHS2 hopes that the model it has successfully negotiated will be rolled out nationally, making the WHO’s drug treatment of choice for malaria affordable to the entire population of Nigeria. Working closely with government of Nigeria and other development partners, Ukaid-PATHS2 is committed to helping halve malaria deaths in Nigeria by 2015.

Mike Egboh, National Programme Manager, PATHS2 and Garba Safiyanu, Director, Service Delivery, PATHS2.