quine prescribed to outpatients was administered by injection rather than orally (Ofori-Adjei and Arhinful, 1996).

• Poor quality drugs are common in retail pharmacies in Africa and Asia, due both to lack of quality control in manufacture and to degradation during storage (Shakoor et al., 1997; Maponga and Ondari, 2003).

• Counterfeit drugs are an enormous problem in tropical countries. Fake antimalarials have been a particular problem recently in Southeast Asia. For example, until a recent publicity campaign, more than half of the antimalarial drugs available in the private sector in Cambodia were fake. Widespread counterfeiting of artesunate has led to erroneous reports of resistance (Newton et al., 2001).

When patients buy their own drugs through shops or drug sellers, they may use their own judgment about how much to take (or how much they can afford to buy), and they also may get information from the sellers which may or may not be accurate. As an example of what takes place:

• In a survey in Kenya, only 4 percent of children given store-bought chloroquine got an adequate dose, and only half of those children received this dose over the recommended 3-day period (Marsh et al., 1999).

• In the same survey, aspirin was widely used and 22 percent of children received potentially toxic doses (Marsh et al., 1999).

Patients factor in what they know from past experience and general community knowledge when they decide on malaria treatment. In one rural area in Tanzania, the most common reason people gave for not using government services was the poor drug supply. At the same time, people report that public clinic staff are often rude and insensitive, and there are long waiting times to be seen. The facilities themselves often are in poor condition, discouraging people from coming (Gilson et al., 1994).

Costs are sometimes unpredictable in public facilities. Providers may add on charges for drugs that ought to be covered by the consultation fee. If there are no drugs in the clinic, the patient may have to pay for the consultation, and then be told to purchase the drugs privately.

Private clinics and other outlets have their problems too. While staff attitudes may be better and waiting times shorter, private facilities may not have as wide a range of equipment or trained staff as in the public sector (Silva et al., 1997; Mutizwa-Mangiza, 1997). And patients are aware they are paying higher prices for private services, which may make them skeptical about the motivations of private providers, balancing the welfare of patients against their own profits (Silva et al., 1997; Smithson et al., 1997).

Front Matter (R1-R20)

Executive Summary (1-16)

Part 1: A Response to the Current Crisis1 Malaria Today (17-60)

2 The Cost and Cost-Effectiveness of Antimalarial Drugs (61-78)

3 The Case for a Global Subsidy of Antimalarial Drugs (79-111)

4 An International System for Procuring Anitmalarial Drugs (112-122)

Part 2: Malaria Basics5 A Brief History of Malaria (123-135)

6 The Parasite, the Mosquito, and the Disease (136-167)

7 The Human and Economic Burden of Malaria (168-196)

8 Malaria Control (197-251)

9 Antimalarial Drugs and Drug Resistance (252-298)

Part 3: Advancing Toward Better Malaria Control10 Research and Development for New Antimalarial Drugs (299-311)

11 Maximizing the Effective Use of Antimalarial Drugs (312-328)

Acronyms and Abbreviations (329-333)

Glossary (334-346)

Index (347-364)