Time for a “Third Wave” of Malaria Activism to Tackle the Drug Stock-out Crisis

‘‘Probably no other disease in human history has been associated with social and political activism to the extent that the HIV epidemic has,’’ says the AIDS Activism Web site [1]. Such activism played a huge role in reducing the costs of antiretroviral drugs in developing countries [2]. Five years ago, one of us (GY) argued that similar activism was needed to raise awareness of shortfalls in global efforts to control malaria [3]. We believe there are now signs of an evolving ‘‘malaria activism,’’ which has resulted in two major successes. The first wave of malaria activism highlighted the disparity between the massive burden of disease and the tiny amount of international development assistance dedicated to its control [4,5]. This assistance amounted to just US$100 million in 2000, yet the World Health Organization (WHO) Commission on Macroeconomics and Health estimated that global malaria control would cost US$1.5–US$2.5 billion annually worldwide [5]. Advocacy by researchers, nongovernmental organizations, journalists, and editors helped motivate donors to increase their malaria commitments [5–7]. By 2007, according to a study by Bob Snow (KEMRI-Wellcome Trust, Kenya) and colleagues, international financing of malaria control had increased to around US$1 billion (40% came from the Global Fund to Fight AIDS, Tuberculosis, and Malaria) [7]. Although this upward trend in funding was a victory for ‘‘malaria activists,’’ there is still no room for complacency, since the study found insufficient funding to fully scale up malaria control worldwide. Commenting on the study, Anthony Kiszewski (Bentley University, USA) argued that while underfunding continues, the fashionable talk of eliminating malaria seems ‘‘quixotic at best’’ [8]. The second wave of malaria activism focused on exposing an inconvenient truth. A substantial proportion of the additional malaria funds was being spent on monotherapies (chloroquine, sulfadoxine-pyrimethamine), often ineffective in Africa because of parasite resistance [9,10], rather than more efficacious artemisinin-based combination therapy (ACT). Activism by academics, journalists, and newspaper editors scored a further success: in 2004 the Global Fund reprogrammed its financing to spend more on ACT, while the United Nations (UN) health agencies pledged to discontinue support for the use of ineffective monotherapies [11,12]. Since then, ACT has been scaled up across Africa [13]. These are big victories. But one benchmark of successful ACT scale-up is whether the drugs are available at the point of care [14]. One of us (GY) has just returned from a health reporting fellowship in East Africa [15], where he found that ACT ‘‘stock-outs’’ (shortages) were common. This observation is backed by empirical evidence from many African countries [14,16,17]. For example, in 2008, two years after Kenya introduced artemether-lumefantrine (AL) as first-line treatment for uncomplicated malaria, Beth Kangwana (KEMRI-Wellcome Trust, Kenya) and colleagues surveyed government health facilities to assess AL availability [14]. The drug comes in four different weight-specific blister packs. A quarter of the surveyed facilities had none of the four packs. So it’s time for a ‘‘third wave’’ of malaria activism to raise awareness of this ACT stock-out crisis. Interviewed at the KEMRI-Wellcome Trust Research Centre in Nairobi, Bob Snow, coauthor of the Kenyan survey [14], said the current situation is two steps forward, three steps back. ‘‘We abandoned chloroquine when it failed to cure one in four patients and was available everywhere,’’ he said. ‘‘We now have a drug that cures 100% of patients but is not available in one in four clinics.’’ Snow said that the stock-out crisis results from ‘‘inadequate ordering, distribution, and supply—it’s a health systems issue.’’ Chloroquine cost pennies and was being given presumptively to any child with fever. Supplying ACT to the right patient at the right time is more complex. The drug is expensive (around US$6–10 per treatment). Because it comes in four weight-specific packs, countries are essentially managing the supply of four drugs, not one. And there is growing pressure for public sector health facilities to abandon presumptive treatment and use a rapid diagnostic test (RDT) before prescribing ACT [18]. So the central medical supplies agency of each country is in effect managing the flow of five products.