Affordable Medicines Facility-malaria Research Articles

Do Price Subsidies on Artemisinin Combination Therapy for Malaria Increase Household Use?: Evidence from a Repeated Cross-Sectional Study in Remote Regions of Tanzania

BackgroundThe Affordable Medicines Facility-malaria (AMFm) is a pilot program that uses price subsidies to increase access to Artemisinin Combination Therapies (ACTs), currently the most effective malaria treatment. Recent evidence suggests that availability and affordability of ACTs in retail sector drug shops (where many people treat malaria) has increased under the AMFm, but it is unclear whether household level ACT use has increased.Methods and FindingsHousehold surveys were conducted in two remote regions of Tanzania (Mtwara and Rukwa) in three waves: March 2011, December 2011 and March 2012, corresponding to 3, 13 and 16 months into the AMFm implementation respectively. Information about suspected malaria episodes including treatment location and medications taken was collected. Respondents were also asked about antimalarial preferences and perceptions about the availability of these medications. Significant increases in ACT use, preference and perceived availability were found between Rounds 1 and 3 though not for all measures between Rounds 1 and 2. ACT use among suspected malaria episodes was 51.1% in March 2011 and increased by 10.9 percentage points by Round 3 (p = .017). The greatest increase was among retail sector patients, where ACT use increased from 31% in Round 1 to 49% in Round 2 (p = .037) and to 61% (p<.0001) by Round 3. The fraction of suspected malaria episodes treated in the retail sector increased from 30.2% in Round 1 to 46.7% in Round 3 (p = .0009), mostly due to a decrease in patients who sought no treatment at all. No significant changes in public sector treatment seeking were found.ConclusionsThe AMFm has led to significant increases in ACT use for suspected malaria, especially in the retail sector. No evidence is found supporting the concerns that the AMFm would crowd out public sector treatment or neglect patients in remote areas and from low SES groups.

Access to subsidized ACT and malaria treatment--evidence from the first year of the AMFm program in six districts in Uganda

To determine the effect of the Affordable Medicines Facility for malaria (AMFm) launched in April 2011 in Uganda on the use of Artemisinin Combination Therapies (ACTs) for malaria treatment. 2398 households across six districts in Eastern Uganda were monitored through monthly survey visits from April 2011 to April 2012. During each visit, health seeking modules were completed for any morbidity episode reported by the household. Additional surveys were conducted with 114 licensed drug shops in the same districts in April 2011 and April 2012. Changes in drug shops' stocking and pricing of ACTs, as well as changes in households' treatment behaviour and drug usage were analysed. The fraction of licensed drug shops reporting that an ACT was one of their top five bestselling antimalarial drugs increased from 32% to 84% (Δ=0.517, 95% Confidence Intervals (CI) [0.407, 0.628], P<0.001). The fraction of children under the age of 5 with fevers getting an ACT increased from 37% to 47% (Δ=0.103, 95% CI [0.070, 0.136], P<0.001), and the fraction of ACT treatments among patients getting any antimalarial increased from 51% to 65% (Δ=0.145, 95% CI [0.121, 0.169], P<0.001). The observed changes were particularly large among poorer households, and were smallest for households from the highest wealth quintile. The study results suggest that, during its first year of implementation in Uganda, the AMFm achieved its main objective of increasing the availability and use of ACTs. Estimates of the impact of the AMFm on ACT use for children under 5 imply that the program should be considered highly cost-effective under current World Health Organization (WHO) guidelines. The overall results look promising, but larger and longer term studies will be needed to assess the health impact and cost-effectiveness of the program.

Antimalarial use and the associated factors in rural nigeria following implementation of affordable medicines facility-malaria (amfm) price subsidy

Purpose: This study was set out to find out the pattern of antimalarial drug use in a Nigerian rural community following the aggressive price subsidy of Artemisinin Combination Therapy(ACT) recently embarked upon by Roll Back Malaria partners through Affordable Medicines Facility-malaria (AMFm).Methods: Questioners were administered to 310 adult members of the community with the most recent malaria episodes so as to find out about the drugs used and some of the factors associated with the choice of the drug.Result: Although the overall use of ACT (13.55%) in this community was about 4 times higher than what it used to be, Chloroquine 123(39.62%) and sulphadozine/pyrimathamine 120(38.71%) were the mostly used antimalarial agents. Choice of drug used was significantly associated with perception of efficacy and price among other factors. Respondents liked the price of ACT (33.3%) most, CQ was the drug most liked in terms of efficacy (44.2%) while SP was the drug most liked in terms of lack of side effect (38.9%), taste (61.6%) and convenience (35.7%).( P= 0.001)Conclusion: In addition to sustaining the current price control, there is a need to continuously monitor and effectively regulate the quality of the ACTs in circulation so as to gain the confidence of both the prescribers and the end users regarding efficacy and adherence to ACTs. This will help to safeguard the huge investment in ACT subsidy by the Roll Back Malaria partners.Key words: ACT, Subsidy, Affordable Medicines Facility-malaria

Artemisinin-based combination therapy availability and use in the private sector of five AMFm phase 1 countries

BackgroundIn 2009, the Global Fund to Fight AIDS, Tuberculosis and Malaria established the Affordable Medicines Facility-malaria (AMFm) in order to increase access to quality-assured artemisinin combination therapy (QAACT). AMFm Phase 1, which includes nine pilot programmes in eight countries, was launched in 2009. The objective of this study was to assess anti-malarial stock and purchase patterns at private outlets in five AMFm Phase 1 countries in regard to three of the core AMFm goals: increase the affordability of QAACT, increase the availability of QAACT, and crowd out artemisinin monotherapies and other substandard therapies.MethodsThe study was conducted between April and May 2012 and included interviews with personnel in 598 private pharmaceutical outlets in Ghana, Kenya, Nigeria, Tanzania, and Uganda. Questionnaires were administered at private retail outlets and the data were analyzed to assess within- and between-country differences in QAACT price, availability, and popularity.ResultsAMFm medications were less expensive than their non-AMFm counterparts, yet prices for both types were above country-specific suggested retail prices. Market penetration of AMFm QAACT in both urban and rural areas was high, although stock-outs of both AMFm and non-AMFm products were more common in rural compared with urban outlets in Ghana and Kenya (p = 0.0013). Government recommendation was the most significant factor influencing anti-malarial stock choices in urban (41.5%) and rural (31.9%) outlets. The three top-selling anti-malarials reported for both urban and rural areas in each country were, with the exception of rural Uganda and urban Nigeria, combination therapies.ConclusionsResults from this study indicate that the AMFm has not fully achieved its affordability and crowd-out objectives. Still, the final purchase price of AMFm QAACT was substantially lower than non-AMFm equivalents. Moreover, for both urban and rural areas, AMFm QAACT availability was found to be high, and the various forms of QAACT were the best-selling products among all anti-malarials. These findings suggest a continued need for initiatives like the AMFm that improve the affordability and accessibility of QAACT. Similar programmes may be especially effective if employed in combination with rapid diagnostic testing to ensure the appropriate use of these products.

The affordable medicines facility-malaria—A success in peril

The Affordable Medicines Facility-malaria (AMFm) has put into place a bold financing plan for artemisinin-combination therapy in a pilot phase in seven countries covering half the population at risk of malaria in Africa. A report of the AMFm independent evaluation, conducted by ICF International and the London School of Hygiene and Tropical Medicine, describes the success of the programme in the pilot sites: Ghana, Kenya, Madagascar, Niger, Nigeria, Tanzania (mainland and Zanzibar) and Uganda, comparing availability and affordability of high-quality artemisinin-combination therapies before and after AMFm launched. Proof of concept was achieved: AMFm increased availability and kept prices low, meeting its initial, ambitious benchmarks in most settings. Despite this overwhelming success, opposition to the programme and dwindling resources for malaria control conspire to cripple or kill AMFm.

Effect of the Affordable Medicines Facility—malaria (AMFm) on the availability, price, and market share of quality-assured artemisinin-based combination therapies in seven countries: a before-and-after analysis of outlet survey data

Malaria is one of the greatest causes of mortality worldwide. Use of the most effective treatments for malaria remains inadequate for those in need, and there is concern over the emergence of resistance to these treatments. In 2010, the Global Fund launched the Affordable Medicines Facility--malaria (AMFm), a series of national-scale pilot programmes designed to increase the access and use of quality-assured artemisinin based combination therapies (QAACTs) and reduce that of artemisinin monotherapies for treatment of malaria. AMFm involves manufacturer price negotiations, subsidies on the manufacturer price of each treatment purchased, and supporting interventions such as communications campaigns. We present findings on the effect of AMFm on QAACT price, availability, and market share, 6-15 months after the delivery of subsidised ACTs in Ghana, Kenya, Madagascar, Niger, Nigeria, Uganda, and Tanzania (including Zanzibar). We did nationally representative baseline and endpoint surveys of public and private sector outlets that stock antimalarial treatments. QAACTs were identified on the basis of the Global Fund's quality assurance policy. Changes in availability, price, and market share were assessed against specified success benchmarks for 1 year of AMFm implementation. Key informant interviews and document reviews recorded contextual factors and the implementation process. In all pilots except Niger and Madagascar, there were large increases in QAACT availability (25·8-51·9 percentage points), and market share (15·9-40·3 percentage points), driven mainly by changes in the private for-profit sector. Large falls in median price for QAACTs per adult equivalent dose were seen in the private for-profit sector in six pilots, ranging from US$1·28 to $4·82. The market share of oral artemisinin monotherapies decreased in Nigeria and Zanzibar, the two pilots where it was more than 5% at baseline. Subsidies combined with supporting interventions can be effective in rapidly improving availability, price, and market share of QAACTs, particularly in the private for-profit sector. Decisions about the future of AMFm should also consider the effect on use in vulnerable populations, access to malaria diagnostics, and cost-effectiveness. The Global Fund to Fight AIDS, Tuberculosis and Malaria, and the Bill & Melinda Gates Foundation.

The Affordable Medicines Facility—malaria: killing it slowly

In 2002, we served on a committee for the Institute of Medicine of the US National Academy of Sciences that was asked to recommend measures for getting new and effective, but relatively expensive, artemisinin-based antimalarials to poor populations. 1 Arrow KJ Panosian CB Gelband H Saving lives, buying time: economics of malaria drugs in an age of resistance. Institute of Medicine, Washington DC2004 Google Scholar People were still buying chloroquine because it was cheap and available, but it was becoming less effective because of parasite resistance, and malaria mortality was increasing. 2 Trape JF The public health impact of chloroquine resistance in Africa. Am J Trop Med Hyg. 2001; 64: 12-17 Crossref PubMed Scopus (405) Google Scholar At that time, artemisinin derivatives were highly effective but no other drugs in the pipeline were expected to be as good. Effect of the Affordable Medicines Facility—malaria (AMFm) on the availability, price, and market share of quality-assured artemisinin-based combination therapies in seven countries: a before-and-after analysis of outlet survey dataSubsidies combined with supporting interventions can be effective in rapidly improving availability, price, and market share of QAACTs, particularly in the private for-profit sector. Decisions about the future of AMFm should also consider the effect on use in vulnerable populations, access to malaria diagnostics, and cost-effectiveness. Full-Text PDF

The affordable medicines facility - malaria in Ghana: baseline and endline survey findings

The Affordable Medicines Facility - malaria (AMFm), hosted by the Global Fund to Fight AIDS, Tuberculosis and Malaria, is a financing mechanism which subsidizes quality-assured Artemisinin-based Combination Therapies (ACTs) for distribution to the public and private sectors, complemented by supporting interventions to promote rational drug use. AMFm has been in operation since mid-2010 in eight national-scale operational pilots in Ghana, Kenya, Madagascar, Niger, Nigeria, Tanzania mainland, Uganda and Zanzibar. By March 2012, over 220 million co-paid ACT treatment doses had been ordered. The Independent Evaluation (IE) of AMFm Phase 1 was commissioned by the Global Fund to assess the impact of AMFm on availability, price, market share and use of quality-assured ACTs in all the operational pilots as part of evidence gathering needed to inform decisions regarding the future of the AMFm. The assessment is based on a pre- and post-test design with detailed documentation of the implementation process and context, treating each pilot independently. In each pilot, a nationally representative survey of outlets stocking antimalarial medicines was conducted at the baseline (2009/10) and the endline (2011). In Ghana, the IE was carried out by a team comprising collaborators from the Komfo Anokye Teaching Hospital, Drugs for Neglected Diseases initiative, ICF International and London School of Hygiene and Tropical Medicine. As part of the IE, national level baseline and endline outlet surveys were conducted in Ghana involving the collection and analysis of primary data to answer three questions related to the availability, affordability and market share of quality-assured ACTs using a cluster sampling approach. In-depth key informant interviews were also conducted to provide the necessary context information to help in the interpretation of the survey results. In Ghana, 1,241 and 1,093 outlets were enumerated for the baseline and endline outlet surveys respectively. For the baseline survey, 57.3% (CI: 50.5-64) of outlets with any antimalarials in stock at the time of the survey visit carried artemisinin monotherapies, while only 30.7% (CI: 26.1-35.8) of interviewed outlets had quality-assured ACTs in stock at the time of the survey visit. At baseline, the median cost to patients of one adult equivalent treatment dose of quality-assured ACTs was US$ 3.42 (IQR: 2.4-7.53) for 1,092 products. Detailed results on changes in quality-assured ACT availability, price and market share over a 14-month period between baseline and endline surveys in Ghana will be presented.

Trends in availability and prices of subsidized ACT over the first year of the AMFm: evidence from remote regions of Tanzania

BackgroundThe Affordable Medicines Facility for malaria (AMFm) is a pilot supra-national subsidy program that aims to increase access and affordability of artemisinin combination therapy (ACT) in public sector clinics and private retail shops. It is unclear to what extent the AMFm model will translate into wide scale availability and price reductions in ACT, particularly for rural, remote areas where disparities in access to medicines often exist. This study is the first to rigorously examine the availability and price of subsidized ACT during the first year of the AMFm, measured through retail audits in remote regions of Tanzania.MethodsPeriodic retail audits of Accredited Drug Dispensing Outlets (ADDOs) were conducted in two remote regions of Tanzania (Mtwara and Rukwa). Temporal and spatial variation in ACT availability and pricing were explored. A composite measure of ADDO remoteness, using variables, such as distance to suppliers and towns, altitude and population density, was used to explore whether ACT availability and price vary systematically with remoteness.ResultsBetween February 2011 and January 2012, the fraction of ADDOs stocking AMFm-ACT increased from 25% to 88% in Mtwara and from 3% to 62% in Rukwa. Availability was widespread, though diffusion throughout the region was achieved more quickly in Mtwara. No significant relationship was found between ACT availability and remoteness. Adult doses of AMFm-ACT were much more widely available than any other age/weight band. Average prices fell from 1529 TZS (1.03 USD) to 1272 TZS (0.81 USD) over the study period, with prices in Rukwa higher than Mtwara. The government recommended retail price for AMFm- ACT is 1,000 TZS ($0.64 USD). The median retail ACT price in the final round of data collection was 1,000 TZS.ConclusionsThe AMFm led to large increases in availability of low priced ACT in Tanzania, with no significant variation in availability based on remoteness. Availability did remain lower and prices remained higher in Rukwa, which is a more remote region overall. Low availability of child and adolescent ACT doses could be due in part to lower quantities of non-adult packs imported into Tanzania. Future research will explore whether increased availability and affordability persists and whether it translates into higher ACT use in Tanzania.

Subsidizing artemisinin-based combination therapies: a preliminary investigation of the Affordable Medicines Facility - malaria.

The Affordable Medicines Facility - malaria (AMFm) is a subsidy mechanism to lower the price of, and hence increase access to, the best antimalarial medicines, artemisinin-based combination therapies (ACTs). While the AMFm stipulates that only quality-approved products are eligible for subsidy, it is not known whether those products, when actually supplied, are of good quality and comport with established pharmacopeial guidance on formulation and content of active ingredients. This study aimed to assess price and quality of AMFm ACTs, to compare AMFm ACTs with non-AMFm ACTs and artemisinin monotherapies, and to assess whether AMFm ACTs have been pilfered and diverted to a nearby country. In all, 140 artemisinin-based antimalarial drugs were acquired from 37 pharmacies in Lagos, Nigeria, and Accra, Ghana. An additional ten samples of AMFm ACTs were collected from Lomé, Togo (not participating in the AMFm). Samples were analyzed using high-performance liquid chromatography. The AMFm ACTs were lower in price than many of the other drugs collected, but by less than anticipated or stipulated by the participating governments of Nigeria and Ghana. The quality of the AMFm ACTs was not universally good: overall, 7.7% had too little active pharmaceutical ingredient (API) and none had too much - these results are not likely to be as a result of random chance. AMFm ACTs were also found to have been diverted, both to pharmacies in Lagos not participating in the AMFm and to a foreign city (Lomé) where the AMFm is not operational. The AMFm is at best imperfectly displacing undesirable monotherapies, some portion of which are replaced by ACTs lacking sufficient API, which are often sold at prices exceeding government authorization. ACTs sold at a lower price with low-dose API, potentially extrapolated to approximately 100 million treatments ordered under the AMFm for Nigeria and Ghana, represent a possible concern to public health and the promotion of drug resistance.

Piloting the Affordable Medicines Facility-malaria: what will success look like?

The Affordable Medicines Facility-malaria is an innovative financing mechanism, managed by the Global Fund to Fight AIDS, Tuberculosis and Malaria. This initiative aims to increase the use of artemisinin-based combination therapies for treating malaria. A pilot is underway in eight countries to determine whether the mechanism reduces the consumer price of these drugs and increases their availability in public and private outlets, their market share and their use. To evaluate the pilot, an analysis was done to estimate predetermined "benchmarks" of success at 1 and 2 years. The analysis used a mixed-methods approach, triangulating data from a literature review with information from 33 interviews with experts. A sensitivity analysis and other methods were used to verify the results. Benchmarks used to determine success include an increase in availability of artemisinin-based combination therapies of 40 percentage points from baseline, and an increase in their use of 10-15 percentage points from baseline at year 2. These benchmarks were based on evidence that national public health programmes aimed at increasing the use of a specific health commodity in developing countries have generally achieved only modest changes in use within a 2-year time frame. Evaluation should also take individual country contexts into account.

Monitoring fever treatment behaviour and equitable access to effective medicines in the context of initiatives to improve ACT access: baseline results and implications for programming in six African countries

BackgroundAccess to artemisinin-based combination therapy (ACT) remains limited in high malaria-burden countries, and there are concerns that the poorest people are particularly disadvantaged. This paper presents new evidence on household treatment-seeking behaviour in six African countries. These data provide a baseline for monitoring interventions to increase ACT coverage, such as the Affordable Medicines Facility for malaria (AMFm).MethodsNationally representative household surveys were conducted in Benin, the Democratic Republic of Congo (DRC), Madagascar, Nigeria, Uganda and Zambia between 2008 and 2010. Caregivers responded to questions about management of recent fevers in children under five. Treatment indicators were tabulated across countries, and differences in case management provided by the public versus private sector were examined using chi-square tests. Logistic regression was used to test for association between socioeconomic status and 1) malaria blood testing, and 2) ACT treatment.ResultsFever treatment with an ACT is low in Benin (10%), the DRC (5%), Madagascar (3%) and Nigeria (5%), but higher in Uganda (21%) and Zambia (21%). The wealthiest children are significantly more likely to receive ACT compared to the poorest children in Benin (OR = 2.68, 95% CI = 1.12-6.42); the DRC (OR = 2.18, 95% CI = 1.12-4.24); Madagascar (OR = 5.37, 95% CI = 1.58-18.24); and Nigeria (OR = 6.59, 95% CI = 2.73-15.89). Most caregivers seek treatment outside of the home, and private sector outlets are commonly the sole external source of treatment (except in Zambia). However, children treated in the public sector are significantly more likely to receive ACT treatment than those treated in the private sector (except in Madagascar). Nonetheless, levels of testing and ACT treatment in the public sector are low. Few caregivers name the national first-line drug as most effective for treating malaria in Madagascar (2%), the DRC (2%), Nigeria (4%) and Benin (10%). Awareness is higher in Zambia (49%) and Uganda (33%).ConclusionsLevels of effective fever treatment are low and inequitable in many contexts. The private sector is frequently accessed however case management practices are relatively poor in comparison with the public sector. Supporting interventions to inform caregiver demand for ACT and to improve provider behaviour in both the public and private sectors are needed to achieve maximum gains in the context of improved access to effective treatment.

Got ACTs? Availability, price, market share and provider knowledge of anti-malarial medicines in public and private sector outlets in six malaria-endemic countries

BackgroundArtemisinin-based combination therapy (ACT) is the first-line malaria treatment throughout most of the malaria-endemic world. Data on ACT availability, price and market share are needed to provide a firm evidence base from which to assess the current situation concerning quality-assured ACT supply. This paper presents supply side data from ACTwatch outlet surveys in Benin, the Democratic Republic of Congo (DRC), Madagascar, Nigeria, Uganda and Zambia.MethodsBetween March 2009 and June 2010, nationally representative surveys of outlets providing anti-malarials to consumers were conducted. A census of all outlets with the potential to provide anti-malarials was conducted in clusters sampled randomly.Results28,263 outlets were censused, 51,158 anti-malarials were audited, and 9,118 providers interviewed. The proportion of public health facilities with at least one first-line quality-assured ACT in stock ranged between 43% and 85%. Among private sector outlets stocking at least one anti-malarial, non-artemisinin therapies, such as chloroquine and sulphadoxine-pyrimethamine, were widely available (> 95% of outlets) as compared to first-line quality-assured ACT (< 25%). In the public/not-for-profit sector, first-line quality-assured ACT was available for free in all countries except Benin and the DRC (US$1.29 [Inter Quartile Range (IQR): $1.29-$1.29] and $0.52[IQR: $0.00-$1.29] per adult equivalent dose respectively). In the private sector, first-line quality-assured ACT was 5-24 times more expensive than non-artemisinin therapies. The exception was Madagascar where, due to national social marketing of subsidized ACT, the price of first-line quality-assured ACT ($0.14 [IQR: $0.10, $0.57]) was significantly lower than the most popular treatment (chloroquine, $0.36 [IQR: $0.36, $0.36]). Quality-assured ACT accounted for less than 25% of total anti-malarial volumes; private-sector quality-assured ACT volumes represented less than 6% of the total market share. Most anti-malarials were distributed through the private sector, but often comprised non-artemisinin therapies, and in the DRC and Nigeria, oral artemisinin monotherapies. Provider knowledge of the first-line treatment was significantly lower in the private sector than in the public/not-for-profit sector.ConclusionsThese standardized, nationally representative results demonstrate the typically low availability, low market share and high prices of ACT, in the private sector where most anti-malarials are accessed, with some exceptions. The results confirm that there is substantial room to improve availability and affordability of ACT treatment in the surveyed countries. The data will also be useful for monitoring the impact of interventions such as the Affordable Medicines Facility for malaria.

A path to an optimal future for the Affordable Medicines Facility – malaria

In 2004, the Institute of Medicine (IOM) proposed a simple solution to a pressing global problem (Arrow et al. 2004). The price of artemisinin-based combination therapies (ACTs), the most effective malaria treatment in many countries, would be subsidized at the factory-gate to make them as affordable as ubiquitous, sub-optimal monotherapies such as chloroquine. This would, the IOM theorized, lead to widespread crowding out of the less effective drugs through both public and private channels, thereby improving immediate health outcomes and delaying the development of devastating resistance to artemisinin. The subsequent process to translate that theory into a corresponding global initiative, however, was complex and lengthy, with 3 years of debate. Sceptics of the subsidy argued that it would not have the necessary impact because middlemen would capture excessive profits, poorer patients would not access the drugs through private shops regardless of price, and most ACTs would be purchased by individuals without malaria and would be wasted (Oxfam International 2009; Kamal-Yanni 2010). Proponents countered that market forces would ensure affordable pricing and broad supply, and that the problems of ensuring the equity and targeting of ACTs were not unique to the private sector and had not hampered major investments in distribution of drugs in the public sector (Roll Back Malaria Partnership 2007). After significant negotiation and compromise, the Affordable Medicines Facility-malaria (AMFm), as the subsidy concept is now known, opened its doors in July 2010. One of the most important compromises was that the AMFm would not begin as a global initiative, but would rather be ‘piloted’ at national-scale in selected malaria-endemic countries with an extensive evaluation of that initial phase. The Board of the Global Fund to Fight AIDS, Tuberculosis and Malaria, which hosts the AMFm, eventually set December 2012 as the target date to review the evaluation and determine whether to continue, accelerate, expand or terminate the facility. Despite this process, the debate that defined the formation of the AMFm continues, with both sides using issues such as the scope of the evaluation and anecdotes and early results on the uptake of subsidized drugs as fuel to advance their positions (Esipisu 2011; AMFm Ad Hoc Committee 2010). The evaluation is looked to as the means to definitively resolve the debate, but the restricted timeline (see below) and the nature of the national-scale, global-level intervention defy clear answers—the results will undoubtedly present a mixed and nuanced picture that will require careful interpretation. As a result, if the current dynamics continue, the dialogue at the review will mirror those during the initial design process despite years of work and hundreds of millions of dollars spent. We accordingly propose here a means of redefining that debate prior to the completion of the pilot phase to ensure the decisions on the future of the mechanism are as productive as possible. In short, we argue that the dialogue should be redirected from the question of ‘if’ the AMFm should continue, to ones of ‘how, when and where’ it should be used. Rather than an initiative that is applied universally and that warrants unique scrutiny—and fierce argument—the AMFm should be considered part of the toolkit of interventions that can be used to control malaria. And as is now best practice in global health, malaria-endemic countries themselves should lead decisions on how and when to use that intervention to fit local needs and context.

The Global Fund's Malaria Medicine Subsidy: A Nice Idea with Nasty Implications

Phase 1 of the Affordable Medicines Facility for malaria (AMFm) is a $225 million initiative that was launched in 2010 in an effort to increase access to safe and effective artemisinin-based combination therapies (ACTs) by dramatically lowering their price with a global subsidy. The AMFm also seeks to drive out oral artemisinin monotherapies as their continued use threatens the entire class of drugs due to drug resistance.

Socially-marketed rapid diagnostic tests and ACT in the private sector: ten years of experience in Cambodia

Whilst some populations have recently experienced dramatic declines in malaria, the majority of those most at risk of Plasmodium falciparum malaria still lack access to effective treatment with artemisinin combination therapy (ACT) and others are already facing parasites resistant to artemisinins.In this context, there is a crucial need to improve both access to and targeting of ACT through greater availability of good quality ACT and parasitological diagnosis. This is an issue of increasing urgency notably in the private commercial sector, which, in many countries, plays an important role in the provision of malaria treatment. The Affordable Medicines Facility for malaria (AMFm) is a recent initiative that aims to increase the provision of affordable ACT in public, private and NGO sectors through a manufacturer-level subsidy. However, to date, there is little documented experience in the programmatic implementation of subsidized ACT in the private sector. Cambodia is in the unique position of having more than 10 years of experience not only in implementing subsidized ACT, but also rapid diagnostic tests (RDT) as part of a nationwide social marketing programme. The programme includes behaviour change communication and the training of private providers as well as the sale and distribution of Malarine, the recommended ACT, and Malacheck, the RDT. This paper describes and evaluates this experience by drawing on the results of household and provider surveys conducted since the start of the programme.The available evidence suggests that providers' and consumers' awareness of Malarine increased rapidly, but that of Malacheck much less so. In addition, improvements in ACT and RDT availability and uptake were relatively slow, particularly in more remote areas.The lack of standardization in the survey methods and the gaps in the data highlight the importance of establishing a clear system for monitoring and evaluation for similar initiatives. Despite these limitations, a number of important lessons can still be learnt. These include the importance of a comprehensive communications strategy and of a sustained and reliable supply of products, with attention to the geographical reach of both. Other important challenges relate to the difficulty in incentivising providers and consumers not only to choose the recommended drug, but to precede this with a confirmatory blood test and ensure that providers adhere to the test results and patients to the treatment regime. In Cambodia, this is particularly complicated due to problems inherent to the drug itself and the emergence of artemisinin resistance.

The quest for universal access to effective malaria treatment: how can the AMFm contribute?

Access to quality assured artemisinin-based combination therapy (ACT) has remained very low in most malaria endemic countries. A number of reasons, including unaffordable prices, have contributed to the low accessibility to these life-saving medicines. The Affordable Medicines Facility-Malaria (AMFm) is a mechanism to increase access to quality assured ACT. The AMFm will use price signals and a combination of public and private sector channels to achieve multiple public health objectives: replacing older and increasingly ineffective anti-malarial medicines, such as chloroquine and sulphadoxine-pyrimethamine with ACT, displacing oral artemisinin monotherapies from the market, and prolonging the lifespan of ACT by reducing the likelihood of resistance to artemisinin.Access to medicines frameworks paint a broad picture of dimensions of access to medicines and juxtapose components that enhance or hinder access to medicines. Access requires various activities--funding, institutions, interventions, and thinking--from public and private actors at global, national, and local levels. This paper examines, within access to medicines frameworks, the role of the AMFm across and within each dimension and discusses how the AMFm can help to solve access bottlenecks.

Nicholas White—winner of 2010 Gairdner Global Health Award

Nicholas White—winner of 2010 Gairdner Global Health Award

Innovating for impact: The Affordable Medicines Facility-malaria (AMFm)

Innovating for impact: The Affordable Medicines Facility-malaria (AMFm)

Focusing on quality patient care in the new global subsidy for malaria medicines.

Tido von Schoen-Angerer and colleagues discuss the new Affordable Medicines Facility for malaria (AMFm), which subsidizes and facilitates access to artemisinin-based combination therapy, and what mechanisms are needed to ensure it stays focused on quality patient care.