SAVING LIVES, BUYING TIME

Economics of Malaria Drugs in an Age of Resistance

Committee on the Economics of Antimalarial Drugs

Board on Global Health

Kenneth J. Arrow, Claire B. Panosian, and Hellen Gelband, Editors

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
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Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance SAVING LIVES, BUYING TIME Economics of Malaria Drugs in an Age of Resistance Committee on the Economics of Antimalarial Drugs Board on Global Health Kenneth J. Arrow, Claire B. Panosian, and Hellen Gelband, Editors INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. HRN-A-00-00-00012-00 between the National Academy of Sciences and the U.S. Agency for International Development (USAID) and the Bill and Melinda Gates Foundation. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the views of the organizations or agencies that provided support for this project. Library of Congress Cataloging-in-Publication Data Saving lives, buying time : economics of malaria drugs in an age of resistance / Committee on the Economics of Antimalarial Drugs, Board on Global Health ; Kenneth J. Arrow, Claire Panosian, and Hellen Gelband, editors. p. ; cm. Includes bibliographical references and index. ISBN 0-309-09218-3 (hardcover) 1. Antimalarials—Economic aspects. 2. Pharmaceutical policy. 3. Drug resistance in microorganisms. [DNLM: 1. Malaria—drug therapy. 2. Antimalarials—economics. 3. Antimalarials—therapeutic use. 4. Drug Costs. 5. Drug Resistance. WC 770 S267 2004] I. Arrow, Kenneth Joseph, 1921- II. Panosian, Claire. III. Gelband, Hellen. IV. Institute of Medicine (U.S.) Committee on the Economics of Antimalarial Drugs. RC159.A5S28 2004 616.9’362061—dc22 2004017959 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2004 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Cover photograph by Claire B. Panosian. Mkuranga, Tanzania, November 2002. Family and neighbors of Amina Selemani, including her daughter and newborn grandchild. Another grandchild, Zulfa Mshamu (not shown) received ACT treatment for malaria through a clinical research trial co-sponsored by the Ifakara Health Research and Development Centre and the U.S. Centers for Disease Control and Prevention.

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Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Adviser to the Nation to Improve Health

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Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance COMMITTEE ON THE ECONOMICS OF ANTIMALARIAL DRUGS KENNETH J. ARROW, (Chair), Professor Emeritus, Department of Economics, Stanford University, Stanford, CA PATRICIA M. DANZON, Professor, Health Care Systems Department, The Wharton School, Philadelphia, PA BRIAN M. GREENWOOD, Professor, Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK JEAN-MARIE KINDERMANS, Médecins Sans Frontières, Brussels, Belgium RAMANAN LAXMINARAYAN, Fellow, Resources for the Future, Washington, DC ANNE J. MILLS, Professor, Health Policy Unit, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK HASSAN MSHINDA, Director, Ifakara Health Research and Development Centre, Ifakara, Tanzania GERMANO MWABU, Associate Professor, Department of Economics, University of Nairobi, Nairobi, Kenya RICHARD PETO, Professor and Co-director, Clinical Trial Service Unit, Oxford University, Oxford, UK ROBERT G. RIDLEY, Coordinator, Product Research and Development, Special Programme for Research and Training in Tropical Diseases, World Health Organization, Geneva, Switzerland NICHOLAS J. WHITE, Professor, Wellcome Trust Research Laboratories, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand PETER B. BLOLAND (Consultant), Chief, Malaria Case Management Activity, Malaria Epidemiology Branch, Centers for Disease Control and Prevention, Atlanta, GA DEAN T. JAMISON (Liaison from the Board on Global Health), Professor of Public Health and of Education, University of California, Los Angeles, CA Staff PATRICK KELLEY, Board Director HELLEN GELBAND, Study Director CLAIRE B. PANOSIAN, Senior Consultant HARRIET N. BANDA, Senior Project Assistant (from August 2003) JASON PELLMAR, Research Assistant (until August 2003)

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Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance BOARD ON GLOBAL HEALTH DEAN T. JAMISON, (Chair), Professor of Public Health and of Education, University of California, Los Angeles, CA YVES BERGEVIN, Department of Child and Adolescent Health, World Health Organization, Geneva, Switzerland DONALD M. BERWICK, (IOM Council Liaison), Clinical Professor of Pediatrics and Health Care Policy, Harvard Medical School, and President and CEO, Institute of Healthcare Improvement, Boston, MA JO IVEY BUFFORD, Professor, Robert F. Wagner Graduate School of Public Service, New York University, New York, NY DAVID R. CHALLONER, (IOM Foreign Secretary), Vice President for Health Affairs, Emeritus, University of Florida, Gainesville, FL SUE GOLDIE, Associate Professor, Harvard School of Public Health, Boston, MA RICHARD GUERRANT, Professor, Department of Infectious Diseases and Director, The Center for Global Health, University of Virginia School of Medicine, Charlotesville, VA MARGARET HAMBURG, Vice President for Biological Programs, Nuclear Threat Initiative, Washington, DC GERALD KEUSCH, Assistant Provost for Global Health, Medical Center, and Associate Dean for Global Health, Boston University School of Public Health, Boston, MA JEFF KOPLAN, Vice President for Academic Health Affairs, Emory University, Atlanta, GA ADEL A. F. MAHMOUD, President, Merck Vaccines, Whitehouse Station, NJ MICHAEL MERSON, Professor and Dean, School of Public Health, Yale University, New Haven, CT MAMPHELA A. RAMPHELE, Managing Director, The World Bank, Washington, DC MARK L. ROSENBERG, Executive Director, The Task Force for Child Survival and Development, Emory University, Atlanta, GA PHILLIP RUSSELL, Professor Emeritus, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD JAIME SEPÚLVEDA AMOR, Director, Instituto Nacional de Salud Pública, Cuernavaca, Morelos, México

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Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the NRC’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Umberto d’Alessandro, Prince Leopold Institute of Tropical Medicine, Belgium Scott Barrett, The Johns Hopkins University Mohamud Daya, Oregon Health and Science University Peter Heller, International Monetary Fund Tran Tinh Hien, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam Alison Keith, Consultant, Health Economist, Springdale, UT T.K. Mutabingwa, Gates Malaria Partnership & National Institute for Medical Research, Muheza, Tanzania François Nosten, Shoklo Malaria Research Unit Hospital for Tropical Diseases, Bangkok, Thailand

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Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance Jeffrey D. Sachs, Columbia University Terrie E. Taylor, Michigan State University Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final version of the report before its release. The review of this report was overseen by Robert E. Black, The Johns Hopkins University and Charles Phelps, University of Rochester. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures, and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance Preface Let me use this preface to share some of my own learning experience over the course of this study. At first blush, recommending appropriate therapy for malaria, as for other diseases, might seem a matter for medicine, pharmacology, and other branches of biology. Indeed, as this report will show, while biological and pharmacological details are of utmost importance, malaria policy also requires the best economic understanding we can muster. Anyone conscientiously engaged in practical policy making is painfully aware of the limitations of our understanding of the economic system. In the course of developing this report, I also became increasingly aware of our limited understanding of natural systems, a fact of life that my biological and medical colleagues on our committee candidly acknowledged. Economics is the study of the allocation of scarce resources among competing ends. It is not surprising, therefore, that economic considerations should loom large in health policy, including the provision of effective pharmaceuticals. Today, the richer countries of the world are devoting an ever-growing proportion of resources to health care. In the United States, how to finance therapeutic drugs for the elderly is an ongoing political debate. If countries in which scarcity is least felt must still devote major attention to medical economics, how much more is this likely to be true of those countries, especially in Africa, where per capita incomes are 5 percent or less of the U.S. level? It was clear before this IOM Committee met that the existing antimalarial drug supply was starting to fail. For more than 40 years, the system

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Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance had been largely based on a single agent—chloroquine—which was at one time very effective and remarkably cheap. Even in the poorest countries, at 10 cents per retail course, most people can still afford it. Moreover, the drug is familiar to the populace, and has been used—both within and outside of organized health care systems—well enough to prevent many malaria deaths and suppress (if not completely cure) acute attacks of the disease. For lack of an affordable alternative, chloroquine remains the most frequently used antimalarial in Africa. Chloroquine is distributed mainly through private economic channels, eventually reaching consumers via the local stores and drug sellers that are ubiquitous in poor countries. The private sector has, in this case, filled a niche left open by public and private health care systems that are neither sufficiently accessible nor affordable to serve much of the population—particularly, the rural poor. Over time, however, resistance to chloroquine emerged worldwide, first leading to treatment failures in Southeast Asia, then to treatment failures in large parts of east Africa. It is now believed that chloroquine will be useless against most life-threatening falciparum malaria infections in fairly short order. In the meantime, replacement drugs have been introduced, but they too have quickly lost ground. The main exception is a family of antimalarials derived from sweet wormwood (Artemisia annua). Over the last 25 years, artemisinin derivatives have proved highly effective in Thailand, Vietnam, and other Asian countries while no artemisinin resistance has surfaced. Partnering artemisinins with a second drug confers even greater protection against the development of drug-resistant mutants. Two-or three-drug treatments—now commonly called artemisinin combination therapy, or ACT—also offer therapeutic advantages over single antimalarial drugs. In short, the occurrence of a medical difficulty is offset by an opportunity. An economist does not expect a free lunch, as the cliché goes, and this lunch is not free. In fact, it is relatively, though not absolutely, expensive. At present, ACTs cost about US$2 a treatment, roughly twenty times the price of chloroquine. By any reasonable standards, their cost per individual course is not large and will decline even further with competition and economies of scale. As best we can estimate, the total drug cost of ACTs for worldwide treatment of falciparum malaria is likely to be about $500 million a year—barely noticeable on the scale of the budget of any major developed country. Nevertheless, this is an unmanageable cost for countries with per capita incomes of $2,000 a year or less. Subsidies are needed. Having said this, multiple economic issues arise. What is the justification for subsidies targeted to specific kinds of expenditures? Why is there not a whole series of new antimalarial drugs coming on line (as there is, for example, for HIV/AIDS or depression)? How do we measure the benefits of curing a case of malaria against the increased costs of treatment? If we

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Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance agree on the necessity of subsidies, how can we maintain an efficient system of distribution? We discuss all of these issues in one way or another in the report, but I will make a few brief comments here. ACTs (compared with monotherapies) serve to avoid the emergence of resistance worldwide. This equals, in economists’ jargon, the avoidance of negative externalities, or the creation of global and intertemporal public goods. Preventing or delaying the emergence of resistance will save lives in future generations. Even if artemisinin resistance eventually emerges, slowing down its appearance increases the chance that high-risk individuals will have access to new and improved drugs when that time arrives. The historical slowness in producing new antimalarials reflects the way in which new drugs are developed in a market system. Research, development, and testing of drugs engender a large upfront cost. In a private enterprise system, the incentive to make this expenditure is the monopoly mark-up over the relatively low manufacturing costs, a monopoly conferred by intellectual property rights. This incentive, however, depends on the economic strength of the market. When a large market exists in rich countries, drugs are developed. When the market mainly consists of poor people, however, the incentive is weak and drug development usually founders. In fact, the original development of artemisinins did exemplify an alternative path to pharmaceutical innovation. The first artemisinins were developed by Chinese medical researchers who claimed no intellectual property rights. Not even fame, the scientist’s alternative motivation to money, was involved; the original paper was published under the name of a collective. However, today, if artemisinin production is to expand and ACTs are to become the global norm, the international community must take the initiative and fuel a series of actions to ensure this outcome. Economic evaluation of a new antimalarial treatment requires an analysis of its respective costs and benefits, or at least a comparison of its reduction of malaria morbidity and mortality vis-à-vis other therapies. In the case of ACTs, the costs were so low and the relative efficacy so high that inquiring into the benefits in greater detail was hardly worthwhile. Perhaps the knottiest issue we faced was how an ACT subsidy might be administered. It was hard to conceive that subsidizing ACTs at a local level, say through vouchers, would be compatible with a market-driven distribution system. Although public health systems have succeeded in distributing antimalarials in Thailand and Vietnam, the consensus of our experts was that such systems would not work equally well in Africa. We want to disturb the existing market system as little as possible. Therefore, we urge that the subsidies enter at a high international level. Another lesson of medical economics is the importance of recognizing

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Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance the specific character of the disease under consideration. The policy challenges that arise in treating malaria are simply very different from those attached to other major infectious scourges. For example, speed of treatment is much more important in malaria than in TB or HIV/AIDS, and reliance on sophisticated diagnosis necessarily reduced. Malaria’s distinctive mode of transmission (via mosquitoes) suggests additional environmental control measures. High mosquito breeding rates and the special “homophilia” of the major vector species in Africa also carry important policy implications. In the course of the study, I learned that the challenge of controlling malaria involves far more than identifying and treating individual victims one at a time. Malaria exists as an entire ecology for which real control requires a complement of measures, chief among them, effective antimalarial drugs. Our charge was the study of the economics of drugs; we could not have done justice to other antimalarial measures. But I came away with the clear understanding that interventions such as insecticide-treated bednets and other, broad environmental strategies offer great potential for synergy when effective drug therapies are available. Finally, this report consciously refrains from the frequent recommendation by committees such as ours for more research. Nonetheless, it must be said that resources devoted to gathering malaria data are grossly inadequate. For one thing, we were not able to determine clearly the number of malaria deaths worldwide, where the error may be 25 percent either way. Such an elementary fact as the current number of treatments taken per year (a very important figure when estimating the cost of changing the drug of choice) seems not to be known within a factor of three. One could go on, but these examples are illustrative. The information gaps and vast uncertainties made this committee’s task more difficult, but not impossible. The scientists, physicians, and economists who compose the committee are unanimous about the correctness of the solutions proposed in our recommendations. We need not—and cannot—wait for better information to meet the current crisis. Kenneth J. Arrow, Ph.D., Chairman Professor Emeritus, Department of Economics, Stanford University

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Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance Acknowledgments The committee gratefully acknowledges the contributions of many individuals who provided information and insights for the study. Those listed below assisted in particular ways—participating in workshops, helping to arrange field visits, providing unpublished materials or data, or simply being available for consultations on salient topics. Salim Abdulla, Ifakara Health Research and Development Centre Irene Agyepong, Ghana Health Service David Alnwick, Roll Back Malaria, WHO Lawrence Barat, The World Bank Joel Breman, U.S. National Institutes of Health Denis Broun, Management Sciences for Health Dennis Carroll, USAID Yann Derriennic, Abt Associates Mary Ettling, USAID David Evans, WHO Catherine Goodman, London School of Hygiene and Tropical Medicine William Haddad, Biogenerics, Inc. Ian Hastings, Liverpool School of Tropical Medicine and Hygiene Carolyn Hicks, University of Oxford Gerald Keusch, Boston University School of Public Health Rashid Khatib, Ifakara Health Research and Development Centre

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Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance Patience Kuruneri, Roll Back Malaria Partnership Jo Lines, London School of Hygiene and Tropical Medicine Francesca Little, University of Capetown Ellis McKenzie, U.S. National Institutes of Health Kamini Mendis, Roll Back Malaria, WHO Wilbur K. Milhous, WRAIR Dr. Abdulnoor Mulokozi, Ifakara Health Research and Development Centre Vinand Nantulya, The Global Fund to Fight AIDS, Tuberculosis and Malaria Ok Pannenborg, The World Bank Christopher Plowe, University of Maryland School of Medicine Wirichada Pongtavornpinyo, Mahidol University Magda Robalo, WHO-AFRO A. Ebrahim Samba, WHO-Afro Allan Saul, U.S. National Institutes of Health Thomas E. Wellems, U.S. National Institutes of Health Shunmay Yeung, Mahidol University

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Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance PROJECT CONSULTANTS AND COMMISSIONED AUTHORS Karen Barnes, Division of Pharmacology, University of Cape Town, South Africa Paul Coleman, London School of Hygiene and Tropical Medicine, London, England Don De Savigny, Swiss Tropical Institute, Basel, Switzerland; Tanzania Essential Health Interventions Project (TEHIP), and International Development Research Centre (IDRC), Canada David Durrheim, James Cook University, Australia Edward Elmendorf, The World Bank, Washington, DC Catherine Goodman, London School of Hygiene and Tropical Medicine, London, England Patricia Graves, Independent Consultant in International Health, Fort Collins, Colorado Jean-Marc Guimier, Management Sciences for Health, Arlington, Virginia Steven Hoffman, Sanaria, Gaithersburg, Maryland John Horton, Department of Pharmacology and Therapeutics, Liverpool University, England, and WHO/TDR, Geneva, Switzerland Barbara Jemelkova, Resources for the Future, Inc., Washington, DC Harun Kasale, International Development Research Centre (IDRC), Canada, and Ministry of Health, Tanzania Ramadhan Madabida, Tanzania Pharmaceuticals Industries Limited Honrati Masanja, International Development Research Centre (IDRC), Canada, and Ifakara Health Research and Development Centre, Tanzania Charles Mayombana, Ifakara Health Research and Development Centre, Tanzania Conrad Mbuya, International Development Research Centre (IDRC), Canada, and Ministry of Health, Tanzania Di McIntyre, Health Economics Unit, University of Cape Town, Cape Town, South Africa Abdulatif Minhaj, Rufiji Demographic Surveillance System, Tanzania Yahya Mkilindi, Rufiji Demographic Surveillance System, Tanzania Devota Momburi, Rufiji Demographic Surveillance System, Tanzania Chantal Morel, London School of Hygiene and Tropical Medicine, England Charlotte Muheki, Health Economics Unit, University of Cape Town, Cape Town, South Africa Eleuther Mwangeni, Rufiji Demographic Surveillance System, Tanzania Clive Ondari, World Health Organization, Geneva, Switzerland Graham Reid, Tanzania Essential Health Interventions Project (TEHIP), and International Development Research Centre (IDRC), Canada

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Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance Sam Shillcutt, Health Economics Research Centre, University of Oxford, Oxford, England Rima Shretta, Management Sciences for Health, Arlington, Virginia Robert Snow, The Wellcome Trust / KEMRI Collaborative Programme, Nairobi, Kenya, and Centre for Tropical Medicine, University of Oxford, John Radcliffe Hospital, Oxford, England Alan Tait, Consultant, Sandwich, Kent, England Jean-Francois Trape, IRD, Dakar, Senegal David Ubben, Medicines for Malaria Venture, Geneva, Switzerland Holly Anne Williams, Malaria Epidemiology Branch, Centers for Disease Control and Prevention, Atlanta, Georgia Virginia Wiseman, London School of Hygiene and Tropical Medicine, London, England

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Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance Contents EXECUTIVE SUMMARY   1 PART 1 A RESPONSE TO THE CURRENT CRISIS     1   MALARIA TODAY   19 2   THE COST AND COST-EFFECTIVENESS OF ANTIMALARIAL DRUGS   61 3   THE CASE FOR A GLOBAL SUBSIDY OF ANTIMALARIAL DRUGS   79 4   AN INTERNATIONAL SYSTEM FOR PROCURING ANTIMALARIAL DRUGS   112 PART 2 MALARIA BASICS     5   A BRIEF HISTORY OF MALARIA   125 6   THE PARASITE, THE MOSQUITO, AND THE DISEASE   136 7   THE HUMAN AND ECONOMIC BURDEN OF MALARIA   168 8   MALARIA CONTROL   197 9   ANTIMALARIAL DRUGS AND DRUG RESISTANCE   252

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Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance PART 3 ADVANCING TOWARD BETTER MALARIA CONTROL     10   RESEARCH AND DEVELOPMENT FOR NEW ANTIMALARIAL DRUGS   301 11   MAXIMIZING THE EFFECTIVE USE OF ANTIMALARIAL DRUGS   312 ACRONYMS AND ABBREVIATIONS   329 GLOSSARY   334 INDEX   347

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Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance SAVING LIVES, BUYING TIME Economics of Malaria Drugs in an Age of Resistance

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