To increase production, the Swiss drug giant headed to the fields where artemisinin was grown, investing in new contracts
with growers in China and East Africa. As the supply increased, the price of artemisinin dropped from $1,000 per kilogram
to $300, according to Paul Herrling, head of corporate research for Novartis. Between 2004 and 2006, Novartis scaled up production
from 4 million treatment courses to between 50 and 60 million.
"The money didn't flow as quickly as expected due to the various bureaucracies that hadn't been geared up," says Renshaw.
"But because Novartis took a risk, we don't have a global shortage of ACTs in 2007."
Today, Coartem represents 85 percent of the global public-sector market for ACTs, according to Andrea Bosman, MD, a WHO medical
officer. But Novartis reports that it is capable of doubling its output. Recently the company cut Coartem's public-sector
price from $2.40 per dose to $1, and expected to see a substantial increase. Volume, however, didn't budge. "No orders came
in," says Klaus Leisinger, President and CEO of the Novartis Foundation for Sustainable Development. "We had to sit on the
product and worry that it would expire."
A Global Fund scheme for bed nets encourages sustainability: Coupons are distributed to new mothers to redeem in village shops,
which order the nets from local manufacturers. and sustainable adoption .
This was a sign that the battle against malaria was entering a new phase. Supply and price were no longer the only issues.
Now the challenge was access: to take drugs, as Leisinger says, "five miles beyond the tarmac road" and into the villages
for the people who need them most.
Local Access and Vocal Resistance
Outside the capital city of Kampala, Uganda, is a slum called Kabalagala, where some 16,000 people live in grinding poverty
without running water or proper sanitation. In the dry season, it is hot and dusty. But when the rain comes, the dust turns
to mud, roads become impassable, and the children grow sick with malaria.
Uganda's government guidelines mandate Coartem as first-line treatment for malaria. But that makes little difference in Kabalagala,
where most patients have to settle for what they can find in the local drug shops and kiosks.
"The malaria drugs range from $2 to $30 per treatment—and of course the most expensive are the best ones," says Paddy Luzige,
a pastor in Kabalagala's New Life Church, which provides care to orphans and street kids. "Nowadays you need to combine two
or three types, but still you can be sick—and you have to watch out for all the fakes from China and India."
Many public hospitals across Africa stock Coartem. But access to these hospitals is limited for people who live in remote
villages. "If you really want to have an impact, then you have to have drugs at the kiosks in villages, and people there need
to explain how to take the medications," says Klaus Leisinger. "That's a huge education challenge, and only experience will
show what we can achieve."
Historically, once malaria drugs enter local shops, drug resistance develops quickly. That's partly due to poor compliance
and partly due to substandard drugs. Researchers in Ifakara, Tanzania, for example, found that every fourth tablet in village
shops had an insufficient concentration of active substance, while every eighth was a counterfeit or contained only traces
of active drug.