ACTs, manufacturers will not have the incentive to scale up production, and prices will not drop. In addition to competition driving prices down (i.e., companies being willing to accept lower profits per dose with higher volumes), technological improvements in the process could bring down the actual production costs, which would be passed along to purchasers in a competitive environment.
The real price breakthrough will likely occur only when a fully synthetic artemisinin is developed, eliminating the growing and extraction process. The Medicines for Malaria Venture (MMV) has such a compound under development, which they predict could be available in 5-6 years. The ultimate price is not known, but it should be significantly less expensive than current artemisinins (assuming no premium for exclusivity). If the synthetic product is better than, or at least as effective as the extracted ones, the market would change dramatically. A global subsidy might still be needed, but it could be less than what is needed now.
A per-course price of US$1 can be taken as a reasonable upper limit for the wholesale cost of ACTs purchased in large quantities (e.g., 1 million or more courses) within 1 to 2 years. Prices of US$1 and less have already been offered to MSF by several companies, assuming that no major problems are encountered in scaling up, and producers can meet quality standards (no major problems are foreseen for either issue).4 Using our estimate of 300-500 million episodes treated each year, the math is simple: US$300-500 million per year. This quantum jump in the global cost of antimalarials is, in all likelihood, a one-time phenomenon, for the following two key reasons.
First, the volume of antimalarials needed is not expected to increase significantly—assuming that treatment and other control measures remain at least at current levels. If treatment coverage could be expanded, more treatments might be required, but such changes are likely to be incremental and small in relation to the current treatment volume. Currently, treatment failures account for some number of treatments, and these should be reduced with effective drugs, balancing out some of the incremental increases. In the lower transmission areas at least, if used optimally, ACTs have the potential to decrease malaria transmission, and therefore the volume of drugs required, as has occurred in KwaZulu Natal, South Africa, as part of an integrated control program.
The second reason is, as already stated, future drugs are likely to be