Interview conducted by April Cashin-Garbutt, BA Hons (Cantab)
Please could you give a brief introduction to antimalarial drugs?
Artemisinin-based combination therapies (ACTs) are the currently recommended drugs for treating malaria. However, they are expensive, which limits their affordability. This means that people with malaria are likely to buy cheaper, less effective antimalarials such as chloroquine and sulphadoxine-pyrimethamine; or to simply buy painkillers and antipyretics.
How many people that are in need of antimalarial drugs currently do not have access to them?
We reviewed recent data on the share of children receiving an antimalarial who received an ACT and found that in 12 of the 16 countries for which this indicator was available, fewer than 60% of antimalarial drugs used by febrile children were ACTs.
Where is this unmet need?
WHO estimates that across the world there are 3.3 billion people at risk of malaria. In 2010, there were 216 million malaria cases, of which 80% were in Sub-Saharan Africa. There were 655,000 deaths in 2010, of which more than 90% were in Sub-Saharan Africa and the vast majority of deaths occurred in children under 5 years of age.
What are the main reasons people do not have access to antimalarial drugs?
Cost is a major barrier to accessing ACTs. Availability is another problem: between 40 and 60% of people who have a fever and are trying to get malaria drugs use the private sector. But because demand for ACTs is limited, most private sector outlets don’t stock them, and if they do, they are very expensive.
Availability of ACTs in the public sector is much better, but there are also problems with access to the public sector. People may have to travel long distances to get to a public sector clinic; even if there are no charges for services in the clinic, there may be costs associated with getting there, i.e. transport costs. The opening hours are also often inconvenient. And public sector facilities are often out of stock of ACTs, so having travelled to a clinic, patients may be directed to pharmacies or drug shops to buy their drugs
Our data show that although availability of ACTs in the public sector was much higher than the private sector, still as many as 1 in 5 public health facilities did not have any ACTs in stock at all.
Please could you outline the new international scheme to provide antimalarial drugs at subsidised prices?
The new scheme is called the Affordable Medicines Facility-malaria (AMFm). It has three components:
Price negotiations with the manufacturers of quality assured ACT – this brings the price down to the price that is charged to large public sector purchasers.
A subsidy for public, private and non-profit buyers of quality assured ACTs that is administered at the top of global supply chain (a “copayment”).
A set of interventions to ensure effective scale-up, including training of providers; regulation; interventions to increase public awareness and education; and use of a special logo which indicates that the copaid ACT is a subsidized, quality-assured drug.
Do you think the AMFm will save lives?
Where it was fully implemented, AMFm dramatically increased the availability of quality assured ACTs, reduced prices, and led to an increase in the share of ACTs in total antimalarial sales. These changes were observed after only a few months of operation, and such improvements in affordability and accessibility have the potential to save lives. By September 2012, over 250 million subsidized treatments had been ordered. The changes in ACT availability and market share were much less marked in Madagascar and Niger.
Why do you think the AMFm didn’t really work in Niger and Madagascar?
There are both immediate and underlying factors. The immediate reason for slower uptake in Niger and Madagascar is that the for-profit buyers in these countries bought far fewer numbers of the subsidized drugs. In the strongest performers, Ghana and Kenya, first line buyers bought around 1 treatment per person at risk of malaria. In contrast, in Madagascar and Niger, buyers purchased 1 treatment for every 10-12 people.
However, we also need to look at why the buyers didn’t take up the subsidy to the same level. In both places, there was much less implementation of the “supporting interventions”, particularly mass communication campaigns to promote the subsidized drugs. We have argued that in order for AMFm to work you need both the subsidy on the drugs and the supporting interventions.
Both countries had much more difficult social and economic contexts. In Madagascar there had been a coup in 2008, the effects of which are still being felt in terms of difficult economic and political circumstances. In Niger there were floods and difficult transport conditions.
Finally, the structure of the for-profit antimalarial sector is quite different in those two countries than it is in the other countries where AMFm was implemented. General shops play a much greater role in distribution of antimalarials, and in Niger there are also a lot of mobile vendors. These types of outlets are outside of the formal drug distribution chain and probably had fewer opportunities to procure subsidised ACTs.
What do you think of the international scheme as a whole? Are there any ways it could be improved?
Our evaluation showed that AMFm can have a dramatic effect on availability and affordability of quality assured antimalarials. These effects were more marked in the private for-profit sector than in the public sector. This is partly because changing the financing mechanism for the public sector doesn’t alter the fundamental problems of securing drug supply.
Going forward, we need to take notice of the changing epidemiology of malaria. There needs to be more attention to making sure that subsidised drugs are targeted to people that actually have malaria parasites, by expanding the use of malaria diagnostics.
Is AMFm likely to be continued in the future?
In November 2012 the Global Fund board decided to integrate the Affordable Medicines Facility - malaria (AMFm) into core Global Fund grant management and financial processes, following an orderly transition period in 2013. There will no longer be a separate fund with external donor contributions to cover co-payments for antimalarial procurement. Under the new, integrated model, eligible countries will be able to allocate funding from their core Global Fund grants and determine how the money should be spent, including supporting programmes to expand access to malaria diagnosis and treatment through the private sector.
What do you think the future holds with regards to access to antimalarial drugs?
It will be important to get the right balance between increasing access to antimalarials, and improving the way antimalarials are targeted to people with the parasites. There has got to be a much stronger coupling of the access to treatments with the access to diagnostics. That is already happening in the public sector with increased use of rapid diagnostic tests. But there are many groups looking at how to make diagnostics available in private outlets as well.
Where can readers find more information?
They can find our research paper here:
For more information on the London School of Hygiene and Tropical Medicine please visit: http://www.lshtm.ac.uk/
About Kara Hanson
Kara Hanson is a health economist with nearly 25 years’ experience working in international health.
She is currently a Professor of Health System Economics at the London School of Hygiene & Tropical Medicine.
She studied economics and political science, development economics, and did her doctorate in health economics at Harvard University. She started her career as a health planner in the Ministry of Health, Swaziland, where she first learned about the importance of health systems as the basis for for delivering priority health interventions.
Her research interests are in the economics of malaria, the role of the private sector in health systems, and health care financing.