“We abandoned chloroquine when it failed to cure one in four patients and was available everywhere,”…..“We now have a drug that cures 100% of patients but is not available in one in four clinics.”

That is a quote taken from a recent Editorial by the Editors of the PLoS Medicine journal who are calling for what they call a “third wave” in malaria treatment advocacy.

According to the authors of this editorial, the first wave of malaria activism brought to global attention the disparity between the burden of malaria and the amount of money spent on the disease by the international community. Successes during this period include the establishment of the Global Fund and other major new fund raising mechanisms for the disease.

The second wave highlighted the fact that although money was rushing it, much of it was not being spent on the most efficacious malaria treatments, namely ACTs. We have now seen the establishment of the Affordable Medicines Facility for Malaria (AMFm) and much more attention to this issue globally.
Now the big problem, they argue, is that despite the fact that there is money available for treatments and commitment to spend them on the best drugs, the medicines are still not always making it to the patients who need them, largely due to stock-outs of medicines in facilities. They see this as perhaps the biggest barrier to expanded treatment coverage.

This finding should not be terribly surprising, big global solutions tend to start at the top and only when they realize that things are not working do they look one level down to see why the solution did not work (parallels can be drawn with HIV and health human resources). But how is this nitty gritty operational problem going to be solved? It will all depend on health systems, and solutions are likely country specific, but will need to be resolved if global targets are to be met.

A friend of mine, Jeremie Gallien, a brilliant operations researchers at MIT, who normally devotes his energy to figuring out how to get parcels from warehouses to people’s doors or how to get the latest fashions on store shelves as fast as possible, is now working on this problem in Zambia, and I can’t wait to find out what he has learned.

I know that there are lots of other really smart folks out there also working on this important problem, it is just too bad we always have to start at the wrong end of a problem to identify the most important barriers or to foresee them in advance. Perhaps an operations researcher would have said that all along!

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3 Responses to “The third wave of malaria activism – stopping stock-outs”

  1. Jack says:

    What does it mean if they have no supply?

    Here in Orissa, India, only public doctors (who are well-qualified) benefit from these types of programs. If they do receive the drugs, they regularly funnel them to their private side practices. (Maybe this isn't a problem)

    Most patients go to less-qualified private health providers. These are targeted by drug companies and have access to a surprising number of medicines. Unfortunately, private providers generally don't know what they are doing and dispense the wrong ones.

    I look forward to seeing what Jeremie Gallien comes up with. I suspect that the solutions Wave Three requires will be more locally-specific and require cooperation from local authorities to an even greater extent than Waves 1/2.

  2. Brian Hanley says:

    The developing/redeveloping nations (Russia, Eastern Europe, Central Asia) I worked in (not doing public health) sold medications by the dose/pill in the bazaar. One could also buy them at pharmacies, but bazaar was how the less well off got their medicine. Consequently, there were textbook evolution of resistance conditions set up. (See Ewald, Paul.) Not surprisingly resistance rapidly appeared.

    Others have documented that efficacy of medications can be restored by careful government control of supplies to prevent misuse. (Mostly with TB in Eastern Europe.)

    Many of the poor, if they receive medication will go to the bazaar and sell much or all of it. I believe that families can support themselves with an infectious disease version of the old beggar's trick of deliberately burning an infant to give disfiguring scars. (I am rather suspicious of the Tbilisi tale of Irakli in Garret's "Betrayal of Trust" for instance.) Think of this as Munchausen's for profit and survival.

    Similarly, if you are an official receiving medications in the third world, (particularly HIV medications) it is awfully tempting to sell a large amount into the gray market for resale on the streets of San Francisco, New York, London, etcetera. It is awfully tempting for a Westerner when they realize that they can make $100,000 on a couple of suitcases, and penalties are a slap on the wrist.

    I have also had to ask myself what the truly ethical position is for the poor who profit from selling medications. Is it actually right for us to expect a mother to give herself or her child all of her medication but risk of experience starvation or being forced onto the streets? This problem is multidimensional and not a straight line.

  3. Antaryami says:

    I differ with Jack. Doctors in orissa usually do not funnel govt.supplies to private practice. It is other people (non medicos) involved in distribution chain with lower moral. however with all said and done the old drug like quinine still works wonderfully, nobody knows how. Similary penicillin in rheumatic heart diseses still works.the resistance depends on organism more than anything else.
    Dr Antaryami maharana.M.D.Pharmacology

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