Sometimes, when Good Ideas Die, Kids Die (from Malaria)

The Affordable Medicines Facility – Malaria (AMFm), an innovative subsidy program designed to increase access to life saving malaria medications in poor countries, died last week.

I would argue that malaria is the most important health issue in the world. This ancient disease kills the young, debilitates the living, and universally strikes the weakest of the weak and the poorest of the poor. Malaria’s complex biology doesn’t lend itself to the easy creation of vaccines, and its deep relationship with poverty makes it nearly impossible to eradicate. The only way to successfully eradicate malaria will be to eradicate poverty itself, not an easy task.

We have been able to create drugs which successfully treat malaria, but the parasite quickly finds and exploits weaknesses in the drugs. After time, the drugs become utterly useless. Right now, our last hope is medical cocktail based on artemisinin, a ancient plant grown in China, Artemisinin Combination Therapies (ACTs). The drugs are effective, and the cocktail based nature of the drug means that the parasite has difficulty developing a resistance to it.

Despite ACTs being effective, most people in parts of the world where malaria is most common have no access to it. ACTs are expensive, delivery difficult and developing country health systems poor and ineffective. In the public sector, stockouts are common making them an unreliable source. Distance from facilities is also a barrier. In Sub-Saharan Africa, for example, most people (often the poorest) live too far away from a facility to justify the trip.

This is where the AMFm comes in. The AMFm takes money from the Global Fund to Fight TB, Malaria and HIV and pays it directly to manufacturers for ACTs. Private wholesalers in participating countries are then able to procure ACTs at low prices. Wholesalers then pass this discount on to small private drug retailers, who are able to sell ACTs at a price equivalent to less effective (and cheap) anti-malarial medications. As private drug retailers exist just about everywhere, cheap ACTs become widely available to the poorest and most remote of populations at a price they can afford. The private sector, with profit as a motivator will maintain consistent stocks and older, ineffective medications are crowded out of the market.

At least, this was the hope. A meeting of the Global Fund last week effectively killed the AMFm.

The program was first proposed in 2002, has been piloted in 8 countries (7 in Africa and 1 in South East Asia), and has been under review for the past few years. Full disclosure, I was a part of a review of the AMFm as part of a a group affiliated with the UM Business School.

We found that under the AMFm, availability of ACTs increased, stocks were more consistent and prices fell. Our results agreed with other evaluations. Granted, problems in equity of access still existed, but, given the challenges of drug delivery in Sub-Saharan African countries, the AMFm was a rounding success, and potentially a more effective method of increasing access to meds than strategies which exclusively rely on the public sector.

The AMFm, despite all the indications that the program was going to bring (and has brought) life saving meds to populations that would normally go without, faced intense criticism. The critics most notably came from within the United States. The Presidents Malaria Initiative (PMI), a program started under George W. Bush to fight malaria was the most vocal. Some critics worried about diversion to non-AMFm countries. The same critic, with almost no data, (right wingers) even claimed that the AMFm supported organized crime.

PMI claims that the AMFm haphazardly doled out ACTs to people who did not need them, wasting resources and potentially inducing parasite resistance to the drug, rendering it ineffective. They claim that the AMFm undermined the public sector’s ability to provide services. They claim that ACTs under the AMFm disproportionately went to areas which had low levels of malaria transmission, such as the nearly malaria-free island of Zanzibar. The problem isn’t that these claims are false. They are all based on an independent evaluation of the AMFm sponsored by the Global Fund. The problem is in how the results were spun.

The reality, that PMI (and others) seem to ignore, is that nothing is perfect in Sub-Saharan African countries. In a world where the extent of poverty and human suffering is so great, a less than perfect result might be better than anything that was there before. Even if people are being misdiagnosed, the truth is that a number of people who do have the disease and did not have access before, now have access to drugs. Even if the public sector is being crowded out, the truth is that public sector health delivery in SSA is frought with problems. In survey after survey, people state that the private sector is their first choice for medical treatment. Bolstering health delivery through the private sector is an obvious solution.

In the end, the AMFm was held to a standard that was impossible to reach. I can think of no program in the past decade which has been held to this level of scrutiny. The AMFm, in this regard, was doomed to fail from the start.

Malaria metrics are often elusive. Information on malaria mortality exists, but only for people who show up and die at a formal facility. Estimates of infection prevalence exist, but asymptomatic cases and the difficulty of reaching remote and very poor populations reduces confidence. We know that malaria cases are down everywhere, but determining the exact causes of this decline are difficult. it is admittedly difficult to know how many kids the AFMm saved. We do know, however, that untreated symptomatic malaria in children is dangerous and that drugs are hard to get.

The odd thing to me, is that PMI, being a American group started by a free-market Republican would disparage an effort to bolster private sector health delivery. In essence, PMI is suggesting that a top down, government centered form of health delivery is optimal, which is entirely backwards from the stated philosophy of the Republican Party. Domestically, we know the attitude to be quite different. Personally, I think this smacks of paternalism. Private sector health care in the US is lauded, but Africans can’t be trusted with the same models.

I admit, before I became involved with this project, I was also skeptical of private health care delivery in developing countries. While regulation and certification programs are key to optimizing efficiency and insuring that standards of effective delivery are met, the results of the AMFm evaluations indicate that the private sector can be very effective. Really, it took me going to these areas and visiting these shops to realize how effective it can be. I wonder if the administrators of PMI ever took the time to visit.

Improving access to medications saves lives. Now that the AMFm is dead, I worry that kids will die, simply because a few people didn’t take the time to put their feet on the ground.


About Pete Larson

Assistant Professor of Epidemiology at the Nagasaki University Institute for Tropical Medicine

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