fees for health care is regressive, and restricts access to medical services, often leading to inappropriate treatment or no treatment at all. This is particularly so in the cases of a catastrophic illness such as malaria. Although a household may have been able to cover the costs of an occasional minor illness, the sudden onset of a life-threatening disease may stretch family finances past the breaking point or, indeed, come at a time when no money is available at all. Charging fees at such a time is unlikely to improve the allocation of resources.

It is true that fees can play a useful role if they derive directly from the locality in which they are collected, and if they are used for locally provided services, for example, the supplementation of nurses’ and doctors’ wages. Fees have proved successful in some Indian States, but only where procedures exempt the very poorest from having to pay. Fees play a relatively small part in overall contributions to health costs, and the increased costs of new drugs to combat malaria would not seem the desirable peg on which to hang an initiative to expand the use of user fees while at the same time ensuring widespread access to improved treatments.

Insurance programs, other types of taxes (e.g., carbon taxes, “Tobin taxes” related to currency conversion), and such things as lotteries also are potential sources of revenue for governments, but they are not promising as ways to raise monies that could consistently and reliably fund ACT subsidies.

Most African countries are unlikely to be able to contribute large amounts directly to a global antimalarial subsidy, but they should be able to mobilize external resources to contribute to such a subsidy. This report does not attempt to prescribe how much countries should contribute either directly or through external sources, but it does recognize that such contributions will have to make up some portion of the total.

An initial feature of the proposed global antimalarial subsidy is that ACTs be available at subsidized prices to all legitimate consumers. We have discussed the limited resources likely to flow directly from African countries in support of a subsidy. We recognize that Asian countries with endemic malaria will be the other major block of consumers, although the