By Eunice Menka - Ghana

The Malaria Consortium has observed with dismay that in spite of the recent ban on the sale of artemisinin monotherapies in Cambodia, ensuring compliance and enforcement of this policy will remain a challenge in view of the complex factors responsible for drug resistance.

There are factors like lack of compliance with recommended therapy, use of counterfeit and substandard drugs, self treatment, mobile and migrant populations and, of course, monotherapies.

But while the global malaria community is trying to come to terms with this disturbing development, Ghana’s leading malaria campaigner, Dr Constance Bart-Plange has thrown down the gauntlet by demanding that persons involved in the production and sale of monotherapies be criminalised.

The Manager of the National Malaria Control Programme (NMCP) did not mince words when she scolded the Food and Drugs Board for its leniency with companies producing and selling monotherapies in Ghana.

Speaking at the launch of the Global Plan for Artemisinin Resistance (GPARC) at a meeting in Accra recently, Dr Bart-Plange pointed out that although the ban on monotherapies, including chloroquine, has been in force in Ghana since 2006, those drugs are still being peddled with impunity.

The meeting, which brought together stakeholders including the Ghana Health Service, Food and Drugs Board, health reporters and Non-governmental organizations, was in response to reported resistance to artemisinin-based combination therapies (ACT) along the Thai-Cambodia border in South- East Asia.

The call for the criminalization is however not that simple nor is it just a simple mathematical solution of additions and subtractions. Talk of ignorance, poverty and other factors, which come into play when tackling malaria!  

The disease, unlike others, is unfortunately a disease of the community and its management has everything to do with the community where it must first begin.

Victor Asamoah works at his father’s chemical shop at the busy Nungua community in Ghana’s capital, Accra.

He usually has to work from morning till as late as 12pm at the shop sited close to the Nungua Traditional Authority (NTA) a meeting place for Nungua chiefs and their subjects. 

The noisy area, far from the affluent parts of Accra, is a market place of shops, small buinesses and a transport yard where food vendors, commercial drivers and other business people work late into the night, surrounded by a swarm of mosquitoes.

One can count as many as three licensed chemical shops, all within a few minutes walk from the NTA building, where vendors dispense drugs to the busy community.

Asamoah’s shop is well-stocked with varieties of anti-malarials, which he knows only by brand names.

Responding to enquiries on types of stocks they have at the shop, Asamoah takes time to form his thoughts and pours out a lists of names - Alaxin, Lonart, Coaterm and Malafan.

Asamoah is unable to tell the difference between mono-therapies such as Alaxin and ACTs like Lonart. His assessment of the efficacy of a drug is simply based on price differences; good drugs cost more, he thinks.

According to him, a client is served based on what he or she can afford.

 “Malafan which is not efficacious costs about half a dollar while better ones like Lonart cost around 3 US dollars. We usually add a bit of Paracetamol, and if you add Lonart, you pay even more,’ he explains. 

 Asamoah is among thousands of chemical sellers playing a critical role at the community level. They are the foot soldiers in health care delivery but do not have the benefit of requisite training. Their services, though mundane, are vital because they serve as the main non-formal outlets, representing first-line health providers for diseases like malaria.

It is therefore good news that the National Malaria Control Programme (NMCP targeted these chemical sellers to train them in the proper diagnosis and treatment of malaria using ACTs.

             A pharmacist dispensing drugs

Kwame Dzudzorli Gakpey, Commincations Officer of the NMCP, told the African Media and Malaria Research Network (AMMREN) that the Pharmaceutical Society of Ghana has trained all private pharmacists in Ghana while the Ghana Social Marketing Foundation, GSMF, is also training thousands of licensed chemical sellers across the country.

According to the AMFm implementation schedule of the NMCP,  nine importers have brought in a total of 2.2 million doses of ACTs and distributed them to retailers across the country. 

It also showed that 30 leading importers and manufactures of anti-malarials companies have so far signed contracts with the Global Fund to do business with manufactures as first line co-buyers and to import co-paid ACTs in Ghana.

For many community dwellers it is cheaper and convenient to seek treatment for malaria or any other disease at chemical shops. The shops are not only ubiquitous and accessible but are also vital in helping clients avoid long hospital queues and over-stretched facilities.

It is great news that Ghana has signed-up to the Affordable Medicine Facility-malaria (AMFm) initiative,  spearhead by the Global Fund to provide ACTs at cheaper prices. And Ghana was the first country in the sub-region to receive a consignment of co-paid. The country has been a beneficiary of the AMFm since August 2010 to make ACTs affordable to all.

Pharmacies in Accra are selling them, with an adult package costing about a US dollar.The facility will increase the provision of affordable ACTS through the public and private sectors to help reduce inappropriate and costly treatment.

Dr Bart-Plange has meanwhile, condemned pharmacies who are charging about five times the recommended price for ACT drugs. She urged the media to encourage patients and victims to report such profiteering chemists to the police and the Food and Drugs Board (FDB) for prosecution.

The NMCP Manager also has a bone to pick with doctors who prescribe malaria drugs just upon a visual examination or statements of patients. Her advice to patients and their families is to confront such doctors who prescribe malaria drugs without first confirming the symptoms through diagnosis.

The success of AMFm is expected to kill off interest and demand for mono-therapies which are losing their efficacy.

The NMCP is not only concerned about ACTs , but is also dissuading doctors from the practice of presumptive diagnosis of malaria within communities.  It has therefore begun a programme targeting pharmacists and privately-owned pharmacy shops.

Under the programme, some 2,000 pharmacists are encouraged to use rapid diagnostic test (RDT) kits as comfirmatory tests for malaria before putting a client on anti-malarials.

The good news is that some private pharmacies have bought into the idea of testing on their premises and have written letters to the NMCP for a permission to dispense the  kits.