it, and vice versa. It is much more unlikely that the parasite will develop resistance to both at the same time if the mode of antimicrobial action is different. Widespread use of artemisinin monotherapy—that is, using artemisinin alone—is the biggest threat to the long-term viability of this family of compounds. Artemisinin and another antimalarial can be taken together (in combination) in two ways: as two separate tablets taken at the same time—referred to in this report as a blister pack—or as two drugs in one pill—a coformulation or “fixed-dose combination” referred to here as an ACT. To encourage the use of combination treatment over monotherapy, it is clearly preferable to have both drugs in a single tablet. When two pills must be taken, people often will take just one—in this case, the artemisinin.

Fifty-six countries have adopted ACTs as the first-line or second-line treatment for uncomplicated malaria, and a majority have a general policy in favor of ACTs. And yet only a fraction of the people needing or receiving treatment in Africa will have access to an ACT. ACTs have been effective wherever they have been tried, including highly endemic areas in Africa. However, the supply of ACTs is currently far lower than the need, and the cost is over 20 times that of chloroquine, the most common treatment drug. The side effects of both chloroquine and ACTs are minimal.

The current production situation is evolving. Only one ACT (Coartem) is currently recognized internationally through precertification by WHO, but several others are being manufactured and sold mainly in Asia. Large purchases in Africa—most, if not all, of which employ financing from the Global Fund for AIDS, Tuberculosis and Malaria (Global Fund)—are limited to Coartem or to blister pack combinations, which are also available from a few manufacturers that produce precertified artesunate. Within two years, additional manufacturers are likely to be producing different ACTs.

Nigeria has adopted Coartem as the first-line treatment for uncomplicated malaria, but most people in Nigeria, like those in the rest of Africa, are still using the older, cheaper drugs. Coartem sells for a wholesale price of $2.40 per adult course and about $20 retail in the pharmacy. A blister pack artesunate-amodiaquine combination is sold in Nigeria for $6–$7 per adult course under the brand name Artequin or Artekan.

About 100 million cases of malaria occur each year in Nigeria. However, the market for ACTs is generally calculated on the basis of the “real demand,” which takes into account not just need based on malaria incidence, but also national policies and the funding available for purchase by consumers, government, or donor agencies. That figure is about 10 million courses per year, or about a tenth of the estimated medical need. Although the distribution of ACTs has been plagued by shortages since the WHO recommendation on use of ACTs, today the global production capacity is