The Business of Malaria

By Alia McKee, Kaylin Fabian and Karen Sommer Shalett

Despite recent progress, the Democratic Republic of Congo remains the second most malaria-affected country in the world, with upwards of 10 million cases reported each year. Population Services International (PSI) and its partner network member Association de Santé Familiale (ASF) want to ensure that all Congolese have access to better diagnostics and care by creating a thriving business for treating malaria.

“We are making the market smart,” says deputy project director Katie MacDonald. “This is a systems-level change.”

The drugs commonly used to treat malaria in Congo aren’t artemisinin-based combination therapies (ACTs), the best medication for malaria. And people with fever using ACTs without testing may not have malaria and should be treated for something else all together. To reverse these trends, PSI/ ASF, with support from DfID, are creating a market for quality ACTs. Medications are pre-qualified by the WHO and marketed with a stylized Greenleaf logo. The product line is subsidized so drug manufacturers, importers and pharmacists have incentives to drive its use.

ASF generates demand for the brand with TV ads, billboards, radio spots and door-to-door promotion, and advocates to allow malaria testing in private pharmacies and for lower duties on ACTs to ensure that low prices outlive subsidies. To transform the market and give consumers access to quality medication, all market players must make the supply chain work. Here’s a look at who those players are and why they believe the effort will succeed.

The Manufacturers

A rapid diagnostic test (RDT) manufacturer and five ACT manufacturers are branding their products with the Global Fund’s Greenleaf symbol and shipping to importers in Kinshasa.

“Sustainable profits are required for new product development, for registration in new territories and for increasing manufacturing capacities,” says Business Development Director Vijay Agarwal at Macleods Pharmaceuticals Ltd., which manufactures the Lumiter ACT. “We expect this venture to be profitable.”

Rachel Hinder, a malaria specialist at Novartis Pharma AG, which manufactures the Coartem ACT, agrees. “The ultimate goal of the ACT access program in the DRC is to create a sustainable market for quality assured ACTs, gradually removing donor funding,” she says. “We expect it to become profitable within five years.”

The Importer

Kareem Pabani owns Pharmex, a 20-year old drug importer and wholesaler in Kinshasa that distributes to over 5,000 pharmacies in the city. In 2014, he was identified by ACT manufacturers to import WHO-qualified anti-malarials. “Why we’re doing this is simple,” he says. “Malaria is Congo’s biggest problem. It’s not new. It’s not a lot of up front investment for us considering the possible return.”

Defeat Malaria, PSI Green Leave Project DRC, Importer Kareem Pabani

Kareem Pabani at Pharmex. Photo Credit: Benjamin Schilling

Even so, ASF subsidized Kareem’s wholesale purchase, letting him sell the drugs at a reduced price so that his customers — pharmacists — will stock the quality product long enough for their consumers to see its value. The partnership with ASF helps lower marketing costs, and the Congolese trust ASF. “They are never substandard and their seal of approval gives confidence,” Kareem says.

Still, it takes six to eight months to get medicines from the manufacturers to importers and pharmacies. Competitors with substandard products have complicated ASF’s efforts. But Kareem and leaders at PSI/ASF have high hopes for the long-term success of the project because they see the wholesale demand for the products.

Pharmacists

Faustin doesn’t want a boss. The pharmacist got into the field so he could make a good living without reporting to anyone. “In Congo, it’s best to be independent,” he says.

His pharmacy, in a bustling part of Kinshasa, brings in long lines of people for consultation and medications. His office, located up a steep green spiral staircase, provides some respite from the activity below. “Most people who come into the pharmacy come because they have a fever,” he says. “That’s the primary ailment I see.”

But fever might not actually be caused by malaria. Faustin requires a test for anyone seeking malaria medications. “If they need the medicine, then I’ll give it. But I won’t hand out malaria treatment without doing a test first.”

Faustin prepares medication in his pharmacy.

Faustin prepares medication in his pharmacy. Photo Credit: Benjamin Schilling

He sells a WHO-approved test, provided by ASF, that detects malaria antibodies in blood samples. Faustin heard about the project through a former schoolmate and staff member of ASF. “I knew them before primarily because they give out mosquito nets,” he says. “But they are now helping me with other things like training.”

In order to get the product, Faustin orders supplies through an ASF-approved importer, like Kareem. Faustin buys the product less expensively than he would otherwise and passes the savings on to patients.

Ambassadors

They walk the streets of Kinshasa in pairs. Green shirts. Big smiles. Open hearts.

“This isn’t health work,” Christian says. “It’s love work.”

He’s one of two ASF-trained “ambassadors” standing outside of a door in a concrete fence. They knock. An older gentleman opens the door. He’s seen them around and he lets them in with a handshake and a warm greeting. “Our role is to spread the word, door to door, to encourage people to stop taking poor quality malaria medications without guidance,” Christian says. “They first need to go to a pharmacy or clinic to find out if they have malaria. If they do, they need to buy a drug that has this sign.”

Greenleaf ambassadors Christian and Thethia make a home visit.

Greenleaf ambassadors Christian and Thethia make a home visit. Photo Credit: Benjamin Schilling

He points to his green shirt with the huge Greenleaf logo, a simple way for Congolese people to identify quality medicines easily. If it has the Greenleaf, it’s a go.

Because manufacturers pass subsidies down the supply chain, the logo also signals that the medicines are more affordable than inferior competitors.

Why isn’t it free? By charging a price, they encourage manufacturers and importers to enter and compete in a crowded market.

But profits only come if there’s demand.

That’s where Christian and his partner Thethia come in. They are part of a largescale campaign that includes TV ads, billboards, radio spots and door-to-door promotion in which they see 100 people each day. “We visit families, old people, everyone,” says Thethia. “We were given communications training and training on how Greenleaf works.”

The work is challenging. “Most people think the price is right,” says Christian. “But the malaria tests and the medicines need to be in every pharmacy. And right now, they aren’t. It can be frustrating for someone who has talked with us and can’t find the medications.”

ASF is combating this challenge by unblocking supply channels so customers can find the medications they are hearing so much about.

The Beneficiaries

Beatrice, a mother of four, gets an early start each day. After her husband leaves for work and the children are off to school, she goes to market to sell beignets. In the early afternoon, she returns to cook dinner.

When Beatrice or her husband, a local van driver, are sick they need to rebound quickly. “If I can’t work or my husband can’t work, it paralyzes the family,” she says.

Beatrice. Photo Credit: Chris Khonde

Beatrice. Photo Credit: Chris Khonde

When anyone in the family is sick everyone worries about the cost of proper care. Recently, Beatrice herself had a fever. She’d heard ads for Greenleaf products. “I wasn’t completely sure about it though so I went and asked the pharmacist,” she says.

Her pharmacist tested her with an RDT. She was positive for malaria so he treated her with a GreenLeaf ACT. The cost: about $2 for the test and medication. “Sometimes at the clinic have to pay $9 or $10 for the consultation and the medications,” she says.

Now Beatrice is prepared for the next time one of her children has a fever. She can get her child diagnosed in her neighborhood and get the right medication. “If the test is negative, then we get referred to the hospital where the doctor can do more tests to figure out what is wrong,” she says. “This saves time and money and helps the family get back to work and regular life.”

Photo Credit: Patrick Settle 

This article is part of an ongoing conversation about #MakingMarketsWork in Impact Magazine No. 22 “Are We Thinking Big Enough” issue. Join in the conversation with @PSIImpact.

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