A new international scheme providing lifesaving antimalarial drugs at cheap subsidised prices has rapidly transformed access to effective artemisinin combination therapies (ACTs) in seven African countries accounting for a quarter of the world’s malaria cases, and could save millions of lives. The first independent evaluation of the Affordable Medicines Facility-malaria (AMFm) programme is published Online First in The Lancet.
“Africa is home to 80% of malaria cases, yet most of the population do not have access to affordable ACTs”, explains Kara Hanson from The London School of Hygiene and Tropical Medicine, UK, one of the lead authors. “Access is restricted by unreliable public health facility supply, high prices, and limited availability in the private sector where most people go to buy medicines. Cheaper, less effective antimalarials currently dominate the market. Worryingly, artemisinin monotherapies are also widely available in some countries, and use of these medicines can encourage development of resistance to ACTs.”
The study evaluated eight national AMFm pilot programmes in Ghana, Kenya, Madagascar, Niger, Nigeria, Tanzania (including Zanzibar), and Uganda. Changes in availability, price, and market share were assessed in each country using nationally representative surveys of public and private sector outlets that stock antimalarial drugs before, and 6–15 months after, the introduction of subsidised quality-assured ACTs (QAACTs) and supporting interventions (e.g. communication campaigns).
Between August, 2010, and the end of 2011, over 155 million doses of QAACTs were subsidised by AMFm. QAACT availability more than doubled in five countries and market share more than doubled in four. The effect of AMFm was more limited in Niger and Madagascar, where AMFm ACT orders were lower.
AMFm had a particularly dramatic effect on the private sector where QAACT market share increased in all pilots, with the increase exceeding 30 percentage points in five of these. What is more, private for-profit QAACT prices fell substantially (by up to 80%) in six countries, with the decrease ranging from US$1.28 to $4.82 per dose.
The market share of artemisinin monotherapies also experienced large declines in Nigeria and Zanzibar, the two countries where their presence on the market was highest at the start of the programme.
Although AMFm had less impact on public health facility ACT supply, the authors point out that there were substantial delays in ordering drugs and implementing the full programme in some countries.
“But not all of the changes observed can be attributed to AMFm”, caution the authors. “There was some evidence from two countries that prices had already begun to fall before AMFm started and the market share of ACTs had started to increase, although most of this increase occurred in the public sector.”
According to Hanson, “It is clear that tapping into the private sector distribution chain can have a major influence on which antimalarial treatments are available and their price and quality in just a few months, but more information is needed about whether the subsidised drugs are reaching those most in need and on how diagnostics can be scaled up in the public and private sectors.”
Writing in a linked Comment, some of the world’s most eminent scientists warn that despite the programme’s success its future could be under threat, “In November, 2012, the Board of the Global Fund will vote to either continue AMFm in a modified form after December, 2013, or terminate the programme. There is a strong push from donors (though not from countries) to integrate AMFm into the regular Global Fund model, whereby countries would choose how much of their country budget envelopes, which are already committed to other priorities supporting the public sector, to reallocate to AMFm. We believe that this approach will create instability in artemisinin demand, lower the number of ACT manufacturers, increase ACT prices, and abandon the millions who depend on AMFm-subsidised ACTs.”
Worse still they say, “With the world’s largest global health funder [the US President’s Malaria Initiative (PMI)] expressing unremitting opposition, even after the positive independent evaluation, 13 the programme’s future is uncertain. PMI has yet to suggest an alternative that would come close to the access afforded by AMFm in the private sector.”
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