As part of Oxfam’s work collecting evidence on the role of the public and private sector in scaling up access to health care in poor countries we have been closely following the developments of the recently launched Affordable Medicines Facility -malaria (AMFm) (http://www.theglobalfund.org/en/amfm/). Backed by the UK government, the World Bank and the Bill and Melinda Gates Foundation, AMFm will subsidize the cost of malaria treatment.
Oxfam applauds the overall goal of the AMFm to reduce prices of Artemisinin Combination Therapies (ACTs). However, we have expressed serious concerns about the initiative because of its objective to use largely unregulated shops to deliver the last effective treatment available for malaria. The sale of drugs through shops risks misdiagnosis and mistreatment. This means that lives could be put at risk, and it means that families could go without food to pay for malaria treatment for a child who is actually dying of pneumonia.
Not only does misdiagnosis risk lives, it also increases the threat of drug resistance.
The AMFm aims to target poor people but charging poor people for drugs also risks drug resistant strains of malaria developing and spreading. The world has already lost chloroquine, which was a very effective and cheap drug, partly because poor people could not buy a full course of treatment from shops. We now risk repeating the same story through the AMFm. Already there is worrying evidence of resistance to ACTs in Cambodia and large-scale distribution of ACTs through unqualified shopkeepers has been blamed (http://news.bbc.co.uk/1/hi/world/asia-pacific/8072742.stm).
Charging for drugs also runs counter to the AMFm’s objective to expand overall access to effective malaria treatment. Poor people cannot afford treatment, subsidized or not. Recent research by Médecins Sans Frontiéres in Africa found that numbers of people diagnosed and treated for malaria significantly increase only when services are provided free of charge (http://www.msf.org/source/medical/malaria/2008/MSF_malaria_2008.pdf).
Without treatment cerebral malaria can kill a child in just 24 hours. Urgently expanding access to effective malaria treatment to all children is a global responsibility. Given this urgency Oxfam questions why more is not being done to learn from and invest in the proven large scale successes of expanding access to effective prevention and ACTs through the public sector. This includes recruiting and training large numbers of community based health workers to distribute bed nets and to safely diagnose and treat patients free of charge, in addition to indoor spraying. For instance, this approach has reduced malaria deaths by a staggering 66% in Zambia over the last 6 years and halved malaria deaths in Ethiopia in just 3 years (http://www.who.int/mediacentre/news/releases/2009/malaria_deaths_zambia_20090423/en/index.html
http://www.theglobalfund.org/en/savinglives/ethiopia/ma1/).
Unfortunately although the AMFm initiative is open to supporting public sector distribution, it remains weighted in favour of commercial sales of ACTs. A requirement for successful country applicants to the AMFm is a focus on increasing accessibility to ACTs through the private sector. Does this mean that malaria endemic countries, who lack the capacity to safeguard ACT delivered by shops, and who choose instead to focus on scaling up to universal access through the public sector, will be denied support from the AMFm?
The AMFm is still going ahead without evidence to support the approach it will take, and despite the fact that this approach is in some respects contrary to the evidence. Oxfam agrees with Dr. Bernard Nahlen, the deputy co-ordinator of the US President’s Malaria Initiative, that the AFMm constitutes ‘the biggest faith-based initiative in the world of malaria’ (http://www.nytimes.com/2009/04/18/world/18malaria.html). We’d like to see more interventions based on the evidence of what works.
Oxfam.
Note: Nahlen quoted in the New York Times article: “I sometimes joke that this is the biggest faith-based initiative in the world of malaria,” he said. “I’m perfectly willing to be convinced, but sometimes the advocacy gets out ahead of the evidence.”
The NYT report that he likes programmes such as those in Ethiopia, in which 30,000 village health workers are taught to use rapid test kits.
NYT explains in the text that as much as 90% of cases are misdiagnosed, and are not, in fact malaria).
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