Affordable Medicines Facility for malaria

Roger Bate & Kimberly Hess | 23 Jun 2009
The Lancet Infectious Diseases
The Global Fund to Fight AIDS, Tuberculosis and Malaria recently approved an innovative initiative called the Affordable Medicines Facility for malaria (AMFm), to increase access to artemisinin-based combination therapies (ACTs) for the treatment of malaria.[1] The AMFm emerged from proposals in 2004 by the Institute of Medicine.[2] However, since the publication of this report much has changed in malaria control and treatment programmes. The AMFm risks imposing substantial opportunity costs and diverting key agencies away from their core functions and activities in which they have a comparative advantage.

The AMFm is expected to subsidise, at a worldwide level, ACTs in the public and private sectors and to saturate the market, thereby driving all monotherapy tablets and inappropriate or poor quality antimalarial drugs out of the market. This goal is important, because exposure to artemisinin monotherapy tablets and substandard drugs has the potential to accelerate parasite resistance to artemisinin, the current best hope for treatment of Plasmodium falciparum, with no new class of drugs likely for at least a decade.

Most highly endemic malarial countries have limited public health infrastructure and most people buy malaria treatments from private pharmacies and shops. For this reason, it is sensible and commendable to work with private sector shops to deliver ACTs in the absence of a robust public health system. However, since the release of the Institute of Medicine's report, much has changed in treatment and control of malaria. Although there is still an urgent need to improve access to treatment, much more is being done to control malaria with increased donor funding through the distribution of insecticide-treated bednets and indoor residual spraying of insecticides. Diagnosis and treatment of malaria is improving in many countries through strengthening of the formal health sector (public and private), as well as expanding the public health sector into communities most affected by malaria through the training and support of community health workers.

As a publicly funded initiative, the AMFm will impose opportunity costs. Irrespective of the origins of the funds, public agencies should strive to ensure funds are spent in the best possible way, on the basis of evidence and careful measurement. Although the Global Fund board approved phase one of the AMFm in 11 countries—estimated to cost US$330 million—at its November 2008 board meeting,[3] it simultaneously announced a delayed submission date for round-nine proposals and a reduction in funding for all approved round-eight proposals.[1]

That the Global Fund board and major donors are prepared to restrict the core functions of the Global Fund, while funding the untested and relatively costly AMFm shows an openness to move the Global Fund away from its core function as a financing mechanism. This could lead to mission creep and a parallel system with earmarks established by donors rather than allowing malarial countries to decide the best use of public funds.

There are also other concerns. All countries participating in the AMFm would need to make ACTs available over-the-counter. Many countries are attempting to improve diagnosis and treatment and the rational use of medicines. In this context, encouraging the purchase of ACTs without confirmed diagnosis would be contradictory and probably counterproductive. Treatment outcomes could be worsened if, as is possible, the AMFm procures medicines not registered with a stringent regulatory authority or granted WHO prequalification, as currently happens with allocations of some Global Fund grants. Pressure from business interests to buy locally produced medicines might exacerbate this problem.

Proponents of the AMFm have cited data from four pilot ACT subsidies as evidence that a worldwide ACT subsidy would be successful. However, a report compiled by the Clinton Foundation and others[4] of the lessons learned from these country case studies offers no conclusive evidence that the AMFm will achieve its goals and would therefore caution against such enthusiasm.

There are always costs of both action and inaction; however, before a costly scheme is funded, better evidence of its effectiveness should be established. As the Global Fund delays new funding rounds and cuts back on its core functions, it risks wasting public funds pursuing a scheme that might have been appropriate 4 years ago, but which could undermine malaria control and treatment programmes and impose considerable opportunity costs today.

The Lancet Infectious Diseases, Volume 9, Issue 7, Pages 396 - 397, July 2009

1 The Global Fund to Fight AIDS, Tuberculosis and Malaria. Final decision points for the eighteenth board meeting. (accessed Feb 5, 2009).
2 Arrow KJ, Panosian CB, Gelband H. Saving lives, buying time: economics of malaria drugs in an age of resistance. Washington, DC: The National Academies Press, 2004.
3 The Global Fund to Fight AIDS, Tuberculosis and Malaria. Report of the affordable medicines facility—malaria ad hoc committee. (accessed Feb 5, 2009).
4 Sabot O, Yeung S, Pagnoni F, et al. Distribution of artemisinin-based combination therapies through private sector channels: lessons from four country case studies. (accessed Feb 5, 2009).