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Optimizing Investments in Malaria
Treatment and Diagnosis
Better targeting of antimalarials to people
who need them will maximize the impact
of interventions in the private sector.
Justin M. Cohen,1 Aaron M. Woolsey,1 Oliver J. Sabot,1 Peter W. Gething,2 Andrew J. Tatem,3
The Roll Back Malaria (RBM) Part- nership has set an ambitious target of achieving near zero deaths from
malaria by 2015 (1). Scale-up of insecti-
cide-treated nets, indoor residual spray-
ing of insecticide, and increased access to
treatment with artemisinin-based combina-
tion therapies (ACTs) over the past decade
have led to reductions in malaria incidence
of more than 50% in 43 countries, includ-
ing 8 in Africa (2). However, as an estimated
655,000 malaria deaths still occurred in 2010
(2), with the great majority in sub-Saharan
Africa, substantial challenges remain.
Prominent among these challenges is the
fact that the private sector is an important
source of treatment for suspected malaria in
many countries, but drugs available there are
primarily composed of affordable, yet often
ineffective, monotherapies (3, 4). ACTs,
the recommended first-line treatment for
malaria (5), are often prohibitively expen-
sive outside of the public sector (6), and
drug quality is often poor (7). Beginning in
*Author for correspondence. E-mail: jcohen@clinton-
1Clinton Health Access Initiative, Boston, MA 02127, USA.
2Spatial Ecology and Epidemiology Group, Department
of Zoology, University of Oxford, Oxford OX1 3PS, UK.
3Emerging Pathogens Institute and Department of Geogra-
phy, University of Florida, Gainesville, FL 32610, USA.
2009, the Affordable Medicines Facility for
Malaria (AMFm), a “factory-gate” subsidy
for ACTs, represented one prominent effort
to increase access to effective drugs even
in the private sector. The first phase of that
program ends this year, and initial evalua-
tion suggests that it was largely successful
in increasing availability and affordability of
ACTs in most, although not all, participat-
ing countries, particularly in the private sec-
tor (8). Regardless of whether the AMFm ini-
tiative continues, the RBM Partnership will
confront critical questions about the future
of overall diagnosis and treatment strategies,
especially regarding how to engage with the
These decisions will be made in the con-
text of a rapidly evolving epidemiologi-
cal and financial landscape. Malaria bur-
den varies greatly from country to country,
which leads to goals of elimination in Zan-
zibar (9) and Swaziland (10), even as inci-
dence rates have remained consistently high
in parts of West and Central Africa (11).
Resistance to artemisinin-based drugs has
been detected in Southeast Asia (12, 13).
Availability of the artemisinin monothera-
pies that may promote resistance in Africa
has been found to range widely, from vir-
tually absent in Madagascar to nearly half
of drug shops sampled in Nigeria (3). Tar-
geting resources properly and maximizing
their effectiveness has been rendered even
more crucial by the fact that international
donations for malaria control declined in
2012 for the first time in a decade (14).
Analysis of Private-Sector Antimalarial
Increased focus on private-sector antimalar-
ial markets through the work of groups like
ACTwatch (18) and evaluation activities sur-
rounding the AMFm (8) have begun to pro-
vide data that we have used to better under-
stand the volume of antimalarials distributed
through the private sector, the importance of
the private sector in treating febrile disease,
and the number of malaria infections reached