Big news in the international development world last week: the Global Fund announced it would no longer fund the $225 million Affordable Medicines Facility-malaria (AMFm) project. This is a significant decision, both because it will have an immediate human impact and for what it signals to future initiatives.
The debate has been vigorous and a perfect way to glean a lot of insight in a short time about a complicated topic – especially for someone like me, who knew relatively little coming in. I had a number of questions coming into the research, so you may too; this will be necessarily high-level but hopefully still useful.
What is malaria and what is its impact?
Overview. Malaria is a parasitic infection that afflicted 216 million people in 2010, according to estimates by the World Health Organization (WHO), causing approximately 655,000 deaths. It’s transmitted to humans by female Anopholes mosquitoes, and isn’t contagious (as a blood-borne illness, though, it can be contracted through needle sharing and passed from mother-to-baby). The vast majority of cases are found in sub-Saharan Africa and East Asia.
Symptoms. Common symptoms include fever, chills, muscle aches, tiredness, and paroxysms (spasms or seizure – yes, I had to look it up too). As you’d expect, achy, tired people that occasionally have seizures are not very productive; studies have made the case that malaria causes poverty – the “malarial trap” as a symptom – and reduces per capita income by half, though others have advised caution in making a direct link. There are many, many confounding variables, but it seems fair to contend that malaria causes at least some of the per capita difference between non-malarial countries and malaria-infected countries (in 1995, $8,268 and $1,526 respectively); another estimate puts the productivity loss in Africa at $12 billion per year.
Prevention. There isn’t an effective vaccine for malaria, yet; progress is being made – achingly slowly – on a vaccine known as RTS, that gave one-third of babies protection against malaria. Travelers can use a variety of compounds as malarial prophylactics, many of which come with significant side effects (mefloquine is associated with night terrors and depression; doxycycline can cause “thin skin”). Insecticide-impregnated bed nets (IIBNs) are used widely to prevent infection at night.
Treatment. The treatment of malaria has evolved over the years, as the parasite becomes resistant to more and more compounds. Initially, quinine (as in the bitter ingredient you drink in your gin and tonics) was effective – and still is – but came with nasty side effects (cinchonism, which causes blurred vision, hearing loss, vertigo, diarrhea, and sometimes even death).
Chloroquinine was next, and it was fantastic – until the parasite developed a resistance to it; then came artemisinin, which was originally administered solo (known as Artemisinin Monothreapy, or AMT), until it became clear malarial parasites were developing resistance to that, too. Now, a derivative of artemisinin is administered in conjunction with other compounds (known as Artemsisin Combination Therapy, or ACT). This is AMT’s slightly younger, more expensive, and more effective cousin.
What is AMFm?
AMFm is a program that began operations in July 2010 in eight countries (Cambodia, Ghana, Kenya, Madagascar, Niger, Nigeria, Tanzania, and Uganda) with the goal of providing heavily subsidized ACT in the public and private sectors. It did so by negotiating lower prices from ACT manufacturers, providing subsidies, and requiring parity between public and private sector prices.
The Global Fund and other partners believed that lowering prices of ACT to below AMT prices would allow sellers to discontinue selling AMTs (which are much cheaper than unsubsidized ACT). Functionally, this meant that ACTshould have been available at many private-sector drugstores and markets, at a price that most could afford, obviating the need to stock AMT.
Sounds like a good idea – why cut its funding?
The program isn’t without its critics. Oxfam came out with a scathing report highlighting what it feels are the components of AMFm that “poses a risk to public health and could skew investment away from effective solutions.” Chief among its complaints:
- Selling ACTs at any price will exclude the poorest/worst off
- AMFm is built on the private sector, but the private sector isn’t capable of properly diagnosing and treating malaria
- Malaria drugs could be used to treat non-malarial fevers, putting people in danger, and AMFm can increase resistance to malaria drugs
- AMFm distorted the market for ACTs, leading to gluts and drug deserts: “The total number of ACT treatments purchased by AMFm for the eight pilots was 155,812,358, nearly five times the estimated number of malaria cases in 2010 in those countries. The global ACT crisis forced the AMFm secretariat to enforce rationing mechanisms…”
- AMFm barely crowded out AMTs: “this was because the availability of AMT was already low due to governments’ banning its importation and sale…”
Other researchers estimated that up to 400 million doses of AMFm-subsidized ACT went to those without malaria (the graphic below presents the percent of people receiving treatment who tested positive for malaria, so the darker red, the better; it comes from here).
Why de-fund it – couldn’t the program just be improved?
Yes – at least according to Kenneth Arrow (a pre-eminent health scholar at Stanford who was an early proponent of AMFm). If the issue is improper diagnosis, then a re-tooled AMFm program could incent rapid diagnosis testing too. If the issue is that ACT is still too expensive for the worst off, there could be additional subsidies to make the therapy free in certain cases.
As Arrow puts it, “The risk is that efforts to develop and implement “the perfect” will end up killing “the good” in the process;” the benefits were well-known and the risks understood, so the program could be re-designed to mitigate risks.
So – now what?
Technically, AMFm will continue for a one-year transitional period, and countries can still use the subsidies – provided they come from their regular health budget.
To some, the larger concern is that this decision will act as a signal to other groups to discontinue work with the private sector. It’s hard to discern whether this concern is warranted – public-private partnerships are kind of the rage right now. My guess – based on what little I know – is that this may give future initiatives pause, but only to double-check that they’ve mitigated as much risk as possible.