Commentary

Learning all the lessons: Expanding access to

malaria diagnosis and treatment
Tido von Schoen-Angerer
Department of Pediatrics, Hospital of Fribourg HFR, Case Postale, Fribourg 1708,
Switzerland.
E-mail: tido.von.schoenangerer@gmail.com
Abstract An independent evaluation of the Affordable Medicine Facility for
malaria (AMFm) pilot phase has hailed it as a success, but important limitations and
unanswered questions remain. In 2012, the board of the Global Fund decided to
integrate the AMFminto country grants by 2014. This means that countries nowneed
to determine how much of available grant resources to spend on expanding access
through the public sector and how much, if any, on subsidizing drugs in the private,
for-profit sector. The assumption of the AMFmhas assumed that improving delivery of
artemisinin-based combination therapy through the private sector would be more
efficient than further expanding access through the public sector and community health
workers. But, the advantage of expanding and improving service delivery through the
public sector and community health workers is that treatments can be effectively linked
with diagnosis and that diagnosis and treatment can be offered for free.
Journal of Public Health Policy advance online publication, 28 March 2013;
doi:10.1057/jphp.2013.15
Keywords: malaria; ACT; AMFm; subsidy; community health worker; RDT
Around 40 per cent of people worldwide seek malaria treatment from
the private, for-profit sector.
1
When the Affordable Medicine Facility for
malaria (AMFm) was designed around 10 years ago, its founders
sought to target private retailers to boost access to affordable malaria
treatment.
2
Therein lies the unproven assumption of the AMFm, that
improving delivery of artemisinin-based combination therapy (ACTs)
through the private sector would be more efficient than further expand-
ing access through the public sector and community health workers.
When the AMFm was finally launched in 2010, it worked to reduce
prices of ACTs in two ways: by negotiating price reductions with
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www.palgrave-journals.com/jphp/
manufacturers and asking them to extend public sector prices to the
private sector, and by subsidizing the medicines at the time of procure-
ment from factories.
3
In 2010, Ghana was the first among the seven pilot countries to begin
implementation of the AMFm, and it has achieved significant price
reductions and increased availability of quality-assured ACT in the
private, for-profit health sector. In this issue of JPHP, Keziah Malm and
collaborators describe the process of implementing the AMFmin Ghana.
The authors provide valuable lessons on the coordination, including the
benefits of collaboration with relevant stakeholders through a Coordi-
nating Committee, the importance of setting a recommended retail price,
and of conducting an awareness raising campaign, training, monitoring,
and evaluation. Interestingly, to get the private sector engaged, the
implementers found they first had to explain how the private sector
could maintain profitability.
An independent evaluation of the AMFm pilot phase, published in
September 2012, hailed the AMFm pilot phase as a success and showed
that end-user prices were reduced and availability increased in five out of
seven countries.
3
However, important limitations exist, and unanswered
questions remain.
Although increased availability was found in both urban and rural
areas, there are no data on accessibility for the poorest and most remote
populations.
Median prices paid per adult treatment in the private sector in early
2012, all lower than before, varied significantly from US$0.58 in Kenya
to $1.13 in Ghana, $1.48 in Nigeria, and $1.96 in Uganda. These prices,
despite, the reductions obtained, can exclude poor people. As the drugs
were heavily subsidized by donors in procurement from the factories,
local sellers marked them up as much as $1.83 per treatment in Uganda.
By contrast, all pilot countries, except Ghana, were providing ACT for
free in the public sector.
4
The greatest unknown concerns the public health impact of the
AMFm. The independent evaluation did not measure how many of the
more than 230 million subsidized ACT treatments reached patients with
malaria and how many were taken for other ailments.
With the pilot phase now over, there has been (again) serious debate if
the AMFm is the right approach and what should be the way forward.
2,5
In November 2012, the board of the Global Fund to Fight AIDS,
Tuberculosis, and Malaria wisely decided that the AMFmwould be fully
Schoen-Angerer
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integrated into country grants by 2014. This leaves countries to deter-
mine how much of available grant resources to spend on expanding
access through the public sector and how much, if any, on subsidizing
drugs in the private, for-profit sector.
Countries are being asked, then, how best to expand access to
diagnosis and treatment. The response may well be different in
different contexts, but countries should consider that the malaria
situation has changed significantly since the AMFm was designed 10
years ago:
K First, malaria incidence has declined in sub-Saharan Africa. The
chances that a child with fever does not have malaria, but another
potentially life-threatening infection have increased.
6
Since 2010, the
World Health Organization has therefore recommended malaria
treatment for all age groups be based on parasitological testing by
microscopy or a rapid diagnostic test (RDT). Use of parasitological
testing in the public sector has increased to 77 per cent of suspected
cases worldwide.
1
Use of RDT at the community level has proven
efficient but remains limited; in the private, informal sector (for
example, drug stores), RDTuse is extremely limited as the ability and
incentives to provide tests are usually lacking. To date, there are still
no clear strategies or plans on howto link the AMFmwith diagnostics
in the private, informal sector.
K Second, artemisinin resistance has appeared in South East Asia, with
fear for its spread to other regions. The AMFm aimed to crowd out
artemisinin mono-therapy and poor quality ACT, as both can lead to
development of resistance; in practice, mono-therapy availability
was already low in most AMFm countries.
4
Widespread, indiscri-
minate use of ACT, as it is still possible through the AMFm,
could, however, lead to the development of resistance in its own
right, when consumers fail to complete treatment. An intervention
study in Uganda found that adherence to ACT obtained over-the-
counter from well-trained private outlets was moderate at 65.8 per
cent,
7
emphasizing the need for clear instructions to go with any
ACT sale.
Clearly, the AMFm does not provide a magic bullet for improving
access to quality malaria treatment. The advantage of expanding and
improving service delivery through the public sector and community
Commentary
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health workers is that treatments can be effectively linked with diagnosis
and that diagnosis and treatment can be offered for free. Studies have
shown that community health workers perform best in ability to use
RDTs and to adhere to the test results.
8
This approach should now be
prioritized. Where the subsidy is to be discontinued, the private sector
need not be ignored and RDT use should be further increased. The
Global Fund should work with manufacturers to secure the AMFmprice
discounts in the private sector for all countries regardless of subsidy.
Acknowledgement
I am grateful to James Arkinstall for helpful comments on the manu-
script.
About the Author
Tido von Schoen-Angerer, MD, MSc, is an Attending Pediatrician
at the Department of Pediatrics, Hospital of Fribourg HFR, Fribourg,
Switzerland. He serves as the alternate NGO Board Member to the
UNITAID board (one of the three main funders of Phase 1 of the AMFm).
References
1. World Health Organization. (2012) World Malaria Report 2012. Geneva: WHO, http://
www.who.int/malaria/publications/world_malaria_report_2012/wmr2012_no_profiles.pdf,
accessed 24 February 2013.
2. Arrow, K.J. et al (2012) The Affordable Medicines Facility Malaria: Killing it slowly. Lancet
380(9857): 18891890.
3. Tougher, S. et al (2012) Effect of the Affordable Medicines Facility Malaria (AMFm) on the
availability, price, and market share of quality-assured artemisinin-based combination therapies
in seven countries: A before-and-after analysis of outlet survey data. Lancet 380(9857): 1916
1926.
4. Arnold, F. et al (2012) Final Report of the Independent Evaluation of AMFmPhase 1. Submitted
to the Global Fund to Fight AIDS, Tuberculosis and Malaria, September, http://www.theglo-
balfund.org/en/amfm/independentevaluation/, accessed 25 February 2012.
5. Kamal-Yanni, M. (2012) Salt, Sugar, and Malaria Pills: How the Affordable Medicine Facility
Malaria Endangers Public Health. Oxfam Briefing Paper 163, http://www.oxfam.org/sites/
www.oxfam.org/files/bp163-affordable-medicine-facility-malaria-241012-en.pdf, accessed
25 February 2013.
6. DAcremont, V., Lengeler, C., Genton, B. (2009) Reduction in the proportion of fevers associated
with Plasmodium falciparum parasitaemia in Africa: a systematic review. Malaria Journal
22(9): 240, doi:10.1186/1475-2875-9-240.
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7. Cohen, J.L., Yavuz, E., Morris, A., Arkedis, J. and Sabot, O. (2012) Do patients adhere to over-
the-counter artemisinin combination therapy for malaria? Evidence from an intervention study
in Uganda. Malaria Journal 11: 83, doi: 10.1186/1475-2875-11-83.
8. Kamal-Yanni, M., Potet, J. and Saunders, P. (2012) Scaling-up malaria treatment: Areviewof the
performance of different providers. Malaria Journal 11: 414, doi: 10.1186/1475-2875-11-414.
Commentary
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