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Artemisinin-based combination therapy: an illustration of the global pharmaceutical drug market in Asia and Africa

Final Report Summary - GLOBALMED (Artemisinin-based combination therapy: an illustration ofthe global pharmaceutical drug market in Asia and Africa)

Pharmaceutical markets in the Global South were profoundly disrupted during the post-colonial period by the construction and growth of an industry in emerging countries, particularly in India; by the creation of global donor markets in the early 2000s; and by the emergence of local production centers in Africa. These changes have created a hierarchy in pharmaceutical markets, objectified by standards and intellectual property, and subjectified in the imaginaries of consumption that mix colonial and post-colonial legacies, the recent dominance of Asian medicines, and the ascendency of global health. These upheavals are scrutinized through unprecedented analysis in this research programme. Using the recommended artemisinin-based combination therapies to treat malaria as a salient example, the health, economic, and political consequences are analyzed more broadly in three West African countries—Benin, Côte d’Ivoire, and Ghana— by drawing comparisons between anglophone and francophone models and with a Southeast Asian country—Cambodia. This research, conducted over five years, mobilizes in-depth field studies that are primarily qualitative but also quantitative, conducted jointly at various levels of pharmaceutical systems: production; importation; State and supra-State regulation; distribution; prescription; and, lastly, consumer usage, which often occurs as a last resort in response to an autonomy that is both elected and endured.

For each of the study countries, the results of the program share a comprehensive understanding of the issues that drive medicine markets in the Global South today. Our detailed analysis primarily focus on comparing the existing pharmaceutical systems in Benin and Ghana. It will first highlight the influence of the countries’ colonial and post-colonial history on their models for State regulation, production, and distribution. The issues of promoting local production and the monopoly of the pharmacist appear to be important levers for States. Beginning with the currently recommended first-line malaria treatments—artemisinin-based combination therapies (ACTs)—the results explore the determining role that transnational actors (bilateral and multilateral aid agencies, United Nations agencies, private foundations, public-private partnerships, etc.) play in influencing local pharmaceutical markets. Facing but as well playing with them, pharmaceutical firms from Europe, Asia and Africa develop strategies to increase their market shares. It is from the hierarchy of this medicines offer that health care professionals and individuals manage this major epidemic. ACTs provide a case study illustrating the pharmaceutical markets’ current trends in the South. Next, taking a broader perspective on the entire pharmaceutical supply in the study countries, the “pharmaceuticalization” of societies are analyzed by looking at the biomedical health system, representatives of pharmaceutical companies, actors in private distribution, and consumer practices. We also highlight the linkages between these various levels of social realities. Finally, our research contextualize the inherent dualities of medicines between public health requirements and economic interests, and between the pipe dream of care and the imaginaries of consumption.
The research programme conclude by appealing to policy makers and public health actors to improve existing pharmaceutical systems and strengthen the sovereignty of the States and regions under consideration. We construct an appeal to return to the idea of “essential”—in the sense of “essential medicines”—when structuring all pharmaceutical systems in the South. The principles of the concept, ones that favor governing medicines through public health and cost-saving criteria and that include pharmacy in a community-based health system at hospitals, are far removed from the vertical global health programs and massive disease-specific pharmaceuticalization. In terms of production, we advocate that regulation and local production be regionalized to scale, especially in West Africa, including the creation of regional standards and alternatives to WHO standards, as seen in Brazil. We also take a position on the issue of the industrialization of “traditional” medicines which currently need to be thought. In terms of prescribing, we highlight the importance of strengthening health systems horizontally and backing them with a universal health coverage system. Lastly, in terms of distribution, we emphasize the importance of thinking about the differentiated application of the pharmaceutical monopoly based on distribution steps: the need to strengthen it during the wholesale distribution step and to make it more flexible for retail distribution. Thus the results of our research opens avenues for reflection, based on a comparative analysis of the advantages and disadvantages of the pharmaceutical systems studied.