President's Malaria Initiative's 'mystery' solved

Roger Bate | 27 Sep 2012
American Enterprise Institute The Center for Global Development (CGD) recently ran a post describing the reticence within the U.S. Government, and more specifically the President's Malaria Initiative (PMI), to support a malaria subsidy scheme known as the Affordable Medicines Facility - Malaria (AMFm). The piece characterized the U.S. position as a 'mystery' whose nefarious underpinnings must be attributable to some hidden agenda or interest group.

PMI recently underwent an external evaluation and passed with flying colors — it is a highly respected program that has been a game-changer in driving down malaria mortality in Africa and elsewhere. So how does CGD arrive at the conclusion that PMI leadership is driven by motives other than simply wanting to save more lives?
It is arrogant and blinkered to characterize the U.S. government's stance as a "mystery." Why isn't the willingness of the U.K. government and the Department for International Development to fund AMFm considered equally enigmatic?

The evidence that it would work was scant; the "consulting process" to discuss possible flaws was not a process at all, but a method by which advocates could simply ignore opposition and ensure it continued to receive tens of millions of dollars. The advocacy — or rather PR — for AMFm was aggressive to say the least, overpowering any solid scientific evidence that would have supported the subsidy. The mystery — if there is one — is why so many malaria advocacy groups kept silent. Perhaps that isn't a mystery either — the large sums of money these groups were paid to do PR work speak for themselves.

CGD calls on Admiral Ziemer to be transparent about the U.S. government's decision to fund AMFm in the future, stating that the fate of the subsidy rests on his decision. Yet PMI alone among the largest malaria control programs has been outspoken and completely open from the beginning about why they oppose it. If the other actors had been as publicly critical of AMFm as they have been in private, we wouldn't be in this mess. But since the Gates Foundation supported the initiative and many aid groups, including CGD, are supported by Gates, criticism was at best limited.

Furthermore, CGD assumes that AMFm is working well. However, as I've documented, the quality of the drugs has probably suffered. The program has also undermined public sector delivery of the best malaria drugs, and has even led respected academic researchers to remove themselves from independent critiques of the subsidy as a result of pressure from the malaria community. And the best malaria drugs are routinely diverted.

AMFm is an interesting experiment. I was supportive of its use of the private sector and I appreciate that what opposition there has been of AMFm has come from knee-jerk reactionaries who dislike any involvement from "private" actors in health. But the AMFm was pushed along by a malaria community that does not welcome dissent. It never addressed some of the harder questions - how many products would be stolen and diverted, what impact would this have on criminal networks, how might intermediaries always game systems to their advantage and not those of patients, how manufacturing incentives to sustain drug quality might be undermined etc.

The result has been a partial success in increasing access to artemisinin-based combination therapies (ACTs) in some locations (which is all independent reviewers looked at), but it has also encouraged criminal networks operating in the trade of stolen drugs, while undermining public sector distribution. And as much as I like the private sector, ineffective over-treatment is bound to occur at private clinics because many believe it is cheaper to treat malaria than to test for it.

A case for AMFm can be made, but the case against it remains stronger. PMI's apparent crime is to have taken a stand against the rest of the lemming-like malaria community. What a shame that the normally excellent CGD would not at least encourage a well-rounded discussion.

http://www.aei-ideas.org/2012/09/presidents-malaria-initiatives-mystery-solved/