How Medicine Quality and Management Shape the Fight Against Malaria
Artemisinin and its derivatives are the fastest-acting antimalarial drugs we have. In ACTs, artemisinin's role is to rapidly reduce the number of parasites during the first three days of treatment, while a partner drug eliminates the remaining parasites to complete the cure4 . This powerful one-two punch has made ACTs the World Health Organization's recommended first-line treatment for uncomplicated P. falciparum malaria worldwide4 .
The specter of artemisinin resistance first emerged in the Greater Mekong Subregion in Southeast Asia, characterized by delayed clearance of parasites from the bloodstream after treatment4 . We now understand this partial resistance is associated with mutations in the PfKelch13 (K13) gene4 . The concerning development is that confirmed cases have now appeared in several African countries, including Eritrea, Rwanda, Uganda, and the United Republic of Tanzania4 7 .
But what if the drugs themselves—their quality and how they're managed—might be silently contributing to this problem?
In the early 2010s, alarming signals emerged from Guyana and Suriname in South America. Studies suggested diminishing efficacy of artemisinin derivatives, based on the persistence of parasites in patients' blood by day three of treatment1 . This prompted scientists to investigate whether medicine quality and pharmaceutical management practices might be contributing factors.
Problems were more prevalent in the private and informal sectors than in public health facilities—particularly concerning since the populations at greatest risk often lived in hard-to-reach areas with scarce public health services1 .
Patient receives medicine with insufficient active ingredient
Inadequate drug concentration in bloodstream
Enough drug to pressure parasites but not enough to kill all
Naturally resistant mutant parasites survive and multiply1
Faced with concerning signals from the Guiana Shield region, researchers undertook a crucial study in 2014 to definitively assess whether artemisinin resistance was emerging in Guyana8 .
50 patients with confirmed P. falciparum malaria
7-day artesunate monotherapy (4 mg/kg daily)
Blood smears every 8 hours for 7 days + genetic analysis
Monitoring artemisinin efficacy and detecting resistance requires sophisticated tools and methods. Here are the essential components of the scientist's toolkit:
| Tool | Function | Application in Resistance Monitoring |
|---|---|---|
| Therapeutic Efficacy Studies (TES) | Gold standard for monitoring drug efficacy in patients | Assesses day 3 parasite clearance and treatment failure rates4 8 |
| Parasite Genotyping | Distinguishes recrudescence from new infections | Uses polymorphic loci (MSP1, MSP2, GLURP) to confirm treatment failures2 |
| PfK13 Propeller Sequencing | Identifies molecular markers of artemisinin resistance | Detects mutations associated with delayed parasite clearance2 4 |
| Pfmdri Copy Number Assay | Quantifies gene amplification | Helps understand partner drug resistance in ACTs2 |
| WHO Parasite Clearance Estimator | Standardized analysis of parasite clearance dynamics | Calculates parasite clearance half-life (t1/2) from serial parasite counts8 |
The emergence of artemisinin partial resistance in Africa has triggered a coordinated global response. In May 2025, health leaders from malaria-endemic African countries and global partners convened at the World Health Assembly to intensify action against this growing threat7 .
"Antimalarial drug resistance is a threat to every community on this continent. It demands a shared response, rooted in science, solidarity and speed."
Strengthening systems to map resistance presence and monitor drug efficacy7
Moving away from over-reliance on single ACTs and developing next-generation therapies7
A country-driven, community-led partnership to revitalize malaria control efforts7
The evidence suggests that medicine quality and pharmaceutical management indeed play crucial roles in the complex dynamics of artemisinin resistance. While the 2014 study in Guyana provided reassurance that full-blown resistance had not yet taken hold, the identified substandard medicines, drug stock-outs, and inappropriate availability of monotherapies created risk factors that could drive resistance development1 .
The global health community has learned valuable lessons from the Guyana-Suriname experience and the more recent emergence of resistance in Africa. Strong pharmaceutical systems, quality-assured medicines, and appropriate use of combination therapies are essential pillars in preserving the efficacy of our most powerful antimalarial weapons.
"Data needs to be shared in a timely way so that researchers share it with policymakers – and then policymakers are able to use that data to make decisions."
The fight against malaria continues, but with robust pharmaceutical quality management as part of a comprehensive strategy, we can work to ensure that artemisinin remains the powerful tool that has saved millions of lives.
References to be added manually in this section.