Millions of malaria drugs and dollars down the drain

The Affordable Medicines Facility for malaria (AMFm, previously introduced here) may go down as one of the largest failures in public health history. Subsidizing effective antimalarials (namely artemisinin-combination therapies) for sale through private vendors (largely the wide-spread pharmacy/drug kiosk) is an untested idea for increasing access – yet is backed by more than $225 million in funding at a time when the successful Global Fund is struggling to finance existing commitments.

First, are decreased private sector costs even passed on to buyers? It’s hard to say in any systematic way, especially past the small trial projects. Daily Nation media from Kenya reports that the first batches to hit drug stands all over the country are going for 1.25  to 6 times the recommended price of Sh40 (US$0.50). Expect similar reports from other countries.

Second, even if the strategy works to lower drug costs in pharmacies – will it have much public health benefit? Access issues will likely persist in rural areas, where the treatments are most needed, as pharmacies are concentrated in urban areas anyways. Among those with access, the majority of people with fever will not actually have malaria and that proportion is declining as control efforts are strengthened. The resultant overuse of drugs will be enormous, other etiologies of fever may go untreated, and increased drug pressure could quicken the spread of resistance. Adherence to the full course of drugs, which are dispensed without much counseling, may be poor. Coupling a system of diagnosis with the subsidized drugs  seems near impossible, and not doing so is irresponsible.

Finally, let’s remember this is not about providing a quality medical service and does nothing to strengthen a country’s health system. The essential strategy of AFMm is to enable people to continue to “self-medicate but now with better drugs”. It is a desperation move, a stop gap at best.

Pro-market groups, such as the Clinton and Gates foundations, who pushed AFMm are showing no signs of stopping – they’ve learned one trick (and not even well) and want to try it out everywhere. In an Indian editorial, Clinton Foundation blindly promotes the idea in a country where it possibly makes the least sense (in India less than 2% of fevers are due to malaria in most areas and the government is making large investments in improving primary care). While the private sector has a role to play in improving malaria care, we should not invest money or energy in risky and unproven approaches towards this end.

PS: Medecins Sans Frontieres commentary about quality concerns with AFMm


3 Responses to “Millions of malaria drugs and dollars down the drain”

  1. 1 thadk November 29, 2010 at 3:04 am

    Even besides the discount-sharing concerns you’ve raised, anecdotes I’d heard in Tanzania suggested that “affordable” state-associated malaria medicines were often assumed inferior to expensive, private (even fake) stuff. I’m not completely familiar with the program but it rang a little false by being distant from dispensary realities in TZ.

  2. 2 How to make a billion dollars March 14, 2011 at 7:37 pm

    Decreased private sector costs will be passed on to buyers as pharmacists compete to outdo each other, just as in every other retail market. The hope is that eventually the savings will trickle down to the rural areas. The plan might not be perfect, but it offers an improvement. I mean, honestly, what do you expect for a measly $200m when you’re tackling one of the most widspread diseases there is? Short of forcing the manufacturers to sell it at cost (which isn’t an option), this is the best way to address the problem in the short term.

  3. 3 naman March 15, 2011 at 12:06 pm

    Thanks – but even if the prices come down, 1) are the drugs getting to the people who need them (most pharmacies are urban and most patients are rural) and 2) among the people who take the drug how many have malaria as the cause of their fever?

    You’re right it’s not perfect, but an improvement over what? Doing nothing is not the appropriate comparison, rather the costs should be compared to other alternate strategies – for example, a community health worker system that provides testing and treatment as a public service.

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