SECTION III:
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I. FINANCING II. COMMODITIES AND SERVICE DELIVERY |
GLOBAL FINANCING, COMMODITIES AND SERVICE DELIVERY
II. COMMODITIES AND SERVICE DELIVERY
1. Net sales and (re-)treatments
By 2003, around 18 million mosquito nets had been sold or distributed in Africa: 8 million in East Africa, over 5 million in West Africa, close to 4 million in Southern Africa and close to 1 million in Central Africa. Around 13 million nets had been (re-)treated with insecticide, of which close to half were in East Africa (Fig. 43). Data totalled from 16 countries in Asia show that around 8 million nets had been distributed or sold and that over 65 million existing nets had been (re-)treated by 2003 (Fig. 44).
Figure 43. Cumulative number of mosquito nets sold or distributed and (re-)treated in Africa according to country reports, 1999–2003  |
Figure 44. Cumulative number of mosquito nets distributed, sold or (re-)treated by region according to country reports, 1999–2003  |
2. Insecticides used for vector control
Reports to WHO from countries on quantities of insecticides used for malaria control, including ITN production and (re-)treatment, and on numbers of units, houses or rooms, sprayed with insecticides give some indication of the extent of vector control. Of all regions, South-East Asia reports by far the largest volume of insecticide usage for IRS (Fig. 45); in contrast, the reported number of units sprayed is greatest in Africa (Fig. 46). This difference indicates that reporting on units sprayed is not complete from all Asian countries; or it might be explained by different regions using different definitions of units sprayed: houses or rooms. Countries in South- East Asia reported a non-negligible amount of insecticide usage for larviciding. Some American countries reported on the use of insecticides for IRS and space spraying, but none reported on units sprayed. The lack of a standardized approach for reporting on IRS makes it difficult to compare countries and regions and to track trends over time.
Figure 45. Annual insecticide usage for malaria control, by kilogramme of active ingredient, vector control strategy and world region, averaged over 2000–2002  Note: reported usage of IRS in Asia was 1 970 000 kilogrammes. |
The reported number of households or units using IRS by region and by year increased between 2000 and 2003, especially in East Africa and South-East Asia (Fig. 47). This suggests that IRS activity is being intensified, even though the reporting by countries was not complete, especially in the earlier years.
Figure 46. Units sprayed with residual insecticide by region, averaged over 2000–2003 
Data reported to WHO. |
Figure 47. Reported use of indoor residual spraying by region, 2000–2003  |
3. Drug supplies
For ACTs, production and financing presents a major challenge to meet the estimated global demand for 120 million adult treatment courses in 2005 (64). An increasing number of countries adopted ACTs as their national policy and have started procuring artemether–lumefantrine (Fig. 48), with most procurements in dosages for young children (Fig. 49).
In 2004, a shortage arose of artemether–lumefantrine. Novartis Pharma AG, the manufacturer of Coartem®, has secured sufficient artemisinin derivatives for 30 million treatment courses in 2005; however, over half of this will be produced during the last 3 months of the year, which means that the drug combination will only become available after the high transmission season in many malarious areas. Scaling up the cultivation of A. annua is under way in China and Viet Nam. With support from USAID, WHO and other RBM partners, the possibility of large-scale production of artemisinin in Africa is being explored. Pilot cultivation schemes in Kenya and United Republic of Tanzania are encouraging.
For antimalarial drugs other than Coartem®, global production and supply are currently not being monitored. Some countries record and report volumes of drugs procured, but these data were not available in standardized format and in sufficient completeness to permit analyses for this report.
Figure 48. Number of countries procuring artemether–lumefantrine (Coartem®), by region, 2001–2004  Source: WHO. No procurement data are available for other ACTs. |
Figure 49. Procurement of artemether–lumefantrine, by category of intended patients’ weight, 2001–2004  Source: (64). |
4. Development of new drugs, diagnostics, insecticides and vaccines
Effective insecticides and drugs to prevent and treat malaria exist, but the rapid development of resistance of Plasmodium to most available antimalarial drugs and of Anopheles mosquitoes to insecticides means that currently effective tools are likely to be less effective in the future. Therefore, continuing to deliver prompt and effective prevention and treatment for malaria depends on the ongoing discovery, development and implementation of new tools.
The funding and management of the discovery, development and registration of next generations of safe, effective and affordable antimalarial drugs—including new ACTs—is being coordinated by the Medicines for Malaria Venture, which brings together public, private and philanthropic sector partners (65). Its priority is to develop drugs with low intrinsic “cost of goods”, in part by focusing on simple process chemistry and in part by manufacturing in countries such as China, India and the Republic of Korea, which are relatively competitive and where production costs are less. As of October 2004, the Medicines for Malaria Venture had 21 drug discovery and development projects for malaria in its portfolio. The organization estimates that it requires US$ 200 million to develop one new fixed-dose ACT. The continual development of new antimalarials for populations at endemic risk, including special groups such as children and pregnant women, at the rate dictated by the development of drug resistance will cost at least US$ 30 million per year, possibly more after 2006 when more projects move into the expensive phases of clinical development.
For diagnosis of malaria, a considerable array of rapid diagnostic tests has become commercially available since their introduction in 1994. Rapid diagnostic tests are used increasingly in all malaria-endemic regions, particularly as a replacement to symptom-based (presumptive) diagnosis and often in the context of adopting a costly ACT as first-line malaria treatment. In Thailand, rapid diagnostic tests have been used experimentally for many years; in Botswana, Cambodia, South Africa and parts of Mozambique and Swaziland, they are now used routinely for confirmation of suspected malaria cases. In 2004, several new tests have become available, in particular tests for detecting non-falciparum malaria. There remain limitations in sensitivity and suitability of rapid tests for use in remote tropical environments, but more stable tests are under development. A planned WHO prequalification scheme will assist in purchasing good-quality tests (66).
Although no effective malaria vaccine is currently available for prevention of malarial disease, prospects for vaccine development improved with the completion of the genetic blueprints of the Anopheles mosquito and of P. falciparum in October 2002. In 2004, a Phase II trial with the pre-erythrocytic vaccine RTS, S/AS02A demonstrated a 30% reduction in total clinical episodes of malaria and 58% reduction in severe clinical episodes in young children in the short term in Mozambique. This suggests that the development of an effective vaccine against malaria is feasible (67). The Malaria Vaccine Initiative currently supports 10 vaccine projects globally, 2 of which have clinical trials under way in Africa (68).
