The Controversy Of The Global Malaria Program

A group of 29 researchers, led by a team from the London School of Hygiene and Tropical Medicine, who evaluated a global malaria treatment subsidy – AMFm – reported in The Lancet that it has had a considerable impact in a brief space of time.

They acknowledged, however, that the program has been “highly controversial”.

Oxfam, a major charity organization, last week described the Affordable Medicines Facility-Malaria as a “dangerous distraction from effective public health measures”. It says that a program which was designed as a “silver bullet” to combat malaria may, in fact, be putting lives at risk.

Oxfam claims that the medications are being distributed by unqualified shopkeepers and hawkers, and not qualified health workers. Oxfam published a study titled “Salt, Sugar and Malaria pills”.

The 29 researchers in this Lancet report say the scheme reduced the price of medications and led to more treatment for malaria. A large number of American experts say that the scheme should include data on outcomes.

Malaria is one of the major killers globally. Estimates for malaria mortality in May 2012 were doubled to 1.2 million deaths annually. For those who need it the most, the use of the best treatments for malaria continues to be inadequate. Experts are becoming concerned about the emergence of resistant malaria – malaria for which current treatments do not work. Some are becoming resistant to the most powerful anti-malarial drugs.

The Affordable Medicines Facility-malaria (AMFm) was launched by the Global Fund in 2010. It consists of a series of pilot programs that are applied nationally in each country, and is aimed at providing access to more people, including the use of quality-assured QAACTs (quality-assured artemisinin based combination therapies), and reduce artemisinin-alone therapies for treating malaria.

AMFm consists of the following :

• Price negotiations with manufacturers
• For each treatment bought, subsidies on the manufacturer price
• Supporting interventions, including communications campaigns

The researchers focused on the effect of AMFm on QAACT price, availability and market share from 6 to 15 months after subsidized ACTs (artemisinin based combination therapies) were delivered in Tanzania, Uganda, Nigeria, Niger, Madagascar, Kenya and Ghana.

The authors gathered data from each country on nationally representative baseline and endpoint surveys of private and public sector outlets that kept stocks of antimalarial treatments. They used the Global Fund’s quality assurance policy to identify QAACTs, while fluctuations in availability, price and market share were determined against specific efficacy benchmarks 12 months after AMFm started.

Below are some highlights of their findings:

• There were large increases in QAACT availability in all pilot schemes, except for Niger and Madagascar
• Market shares rose from 15.9 to 40.3 percentage points, mainly due to changes in the private-for-profit sector
• Large price cuts for QAACTs per adult equivalent dose occurred in the private for-profit sector in six of the pilots. Price falls ranged from $1.28 to $4.82
• Oral artemisinin monotherapy market share dropped in Nigeria and Zanzibar, the two countries where market share was over 5% at the beginning of the project

The authors concluded:

“Subsidies combined with supporting interventions can be effective in rapidly improving availability, price, and market share of QAACTs, particularly in the private for-profit sector. Decisions about the future of AMFm should also consider the effect on use in vulnerable populations, access to malaria diagnostics, and cost-effectiveness.”