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Misdiagnosing malaria: experiences of the AMFm scheme in Ghana

A few months ago Oxfam published a critical report on the Affordable medicines facility for malaria (AMFm), calling it a ‘dangerous distraction’ from more effective ways of providing treatment. Our problem with the scheme is that it relies on unqualified shopkeepers to diagnose and distribute drugs, rather than trained health workers. This means there’s a huge danger of people being misdiagnosed, given there are many other causes of fever, not just malaria.

Oxfam spoke to people in Ghana, to see what their experiences were. Christiana’s story highlights how harmful selling someone the wrong medicines can be. 

Christiana Donyinaa is 43 and makes a living selling cosmetics. A few months ago her youngest daughter, Gloria (age 12), became ill with a fever. Christiana went to a shopkeeper and described Gloria’s symptoms and was told her daughter had malaria. The shopkeeper sold her malaria drugs.  

“I gave Gloria the medicine and she felt better after a few days. The following week, schools were on vacation so she decided to visit her older sister, who lives in Accra. As soon as she got to Accra she felt sick again. Her sister took her to the hospital and she was diagnosed with typhoid fever.  She was admitted to hospital for several weeks.   

I got very worried because school had resumed and she was still in the hospital.  The doctor said Gloria had been suffering from typhoid for a very long time, but because we didn’t take her to the hospital, we didn’t realise it early enough.   
 
When I was told that she was sick, I was very concerned and quickly jumped on a bus to Accra.  When I got there her condition was serious and I stayed with her in the hospital for more than two weeks.”   

Gloria’s condition became quite serious, she found it difficult to breathe and couldn’t eat anything without being sick. Because Christiana was at her daughter’s bedside, she was unable to earn any money over those few weeks. She also spent all the money she needed to run her business on medical expenses. In the end Gloria spent several months off school recovering and has now fallen behind with her studies.

“Gloria’s sickness has affected her a lot. She wants to be a Nurse in future but her illness has set her back a bit.”
  
Christiana believes that malaria medication should only be prescribed and distributed by trained health workers and not through shopkeepers.

“The advice I have for the government and NGOs is that the malaria drug is very good, if you have malaria.  But they should not give it to the drug peddlers; they should give it only to clinics. Some of the drug peddlers have these medicines in their pockets. They sell it to you when you tell them you have a headache, they will just give you the medicines without any diagnosis.  This is very dangerous the drug peddlers don’t know what illness people have.

I will advise every parent that when their child is sick they should take them to a doctor. Because if I had taken Gloria to the hospital from the onset when she was sick I don’t think both of us would have suffered as we have done.”

Oxfam is warning against any further funding for the AMFm scheme and for money to be used to invest in the training and salaries of community health workers instead, who are proven to save lives.

Sarah Dransfield is the Essential Services Press Officer at Oxfam GB

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Saving a program that saves lives: A rejoinder

In November 13th edition of the New York Times, Professor Kenneth Arrow (a  Professor of Economics at Stanford University)  published an article in which he reiterated the rationale for establishing the Affordable Medicines Facility – malaria (AMFm), and asked for the Global Fund to modify and scale it up. 

The AMFm model was conceived by a team of researchers led by Professor Arrow.  The idea was to establish a global subsidy which would reduce the price of Artemisinin-based Combination Therapy (ACT) – an effective malaria treatment. The AMFm model also sought to make ACT affordable and available and as well as drive out artemisinin monotherapy (AMT), a cause of Malaria drug resistance. In 2010, the AMFm model was piloted by the Global Fund to expand access to ACT through delivery at local shops. 

Our main argument against the implementation of the AMFm model is that using shops to sell malaria treatment is dangerous to public health.  Shopkeepers may wrongly diagnose malaria and consequently provide the wrong treatment.  In many low income countries shopkeepers who sell medicines lack the needed skills to diagnose and administer malaria treatment correctly. Particularly, shopkeepers often struggle to appropriately deal with negative malaria test. The usual outcome of shop treatment is that a patient is taken to the hospital late in their illness, potentially putting their life at risk and causing their family unnecessary financial and emotional distress.

Professor Arrow’s article also asserts that “diagnosis makes sense only if treatments that follow are both affordable and accessible”. This obviously carries some truth, however,   it is also important that people who provide treatment are able to diagnose and prescribe properly.  The effective and indeed efficient treatment of malaria therefore requires using trained health workers. Although the article seems to suggest that public health service systems in low income countries, particularly in rural areas are unable to deliver on this, there is mounting evidence that Community Health Workers (CHWs) can be effective at providing healthcare in rural and remote areas. For example, Zambia and Ethiopia are two countries that have made remarkable progress at controlling malaria with strong emphasis on public sector facilities and the use of trained CHWs to administer malaria treatments. Recent evidence from Uganda confirms the ability of CHWs to diagnose and treat both malaria and pneumonia. Also,   studies have shown higher utilization of CHWs in remote areas and small villages, and by poor people.

CHWs have many advantages for providing healthcare in remote and rural areas.  As members of the community, they have insights into local beliefs and culture and can therefore provide appropriate and acceptable care.  Their presence in local communities typically reduces transportation costs and allows for wider reach of rural and remote population. Finally, CHWs training also equips them to provide referral services so that patients who have non-malarial fevers can get the right treatment from an appropriate healthcare provider.
 
However, continuing and building on the successes of CHWs require greater investment to provide them with the needed training and support. It is not too expensive to provide such training and support.  For example, our calculation shows that the AMFm subsidy could have trained 1.7 million CHWs in Africa.  Therefore, there is a great need to build public health systems, particularly at decentralized levels in order to provide much needed supervision and referral services for primary providers.

Finally, we question the relevance of the AMFm model for controlling malaria. As of 2004 when the AMFm model was first put forward,   the malaria landscape was already changing. This process of change has continued, and the current realities eight years on are strikingly different.  This means that approaches that seemed good at controlling malaria then, are not necessarily relevant today. The following landmark changes are worth nothing: 
1.  The WHO issued guidelines in 2010 that treatment of malaria has to be based on correct diagnosis. Since then Rapid Diagnostic Tests (RDTs) have been increasingly available and are used by health workers in many countries.
2. The incidence of malaria is decreasing in most countries and therefore the likelihood that a child with fever has pneumonia or other diseases is high. A recent study (i)   in Tanzania puts malaria as a cause of only 10% of children’s fever. Applying AMFm means that 90% of the children with fever will get medicines they do not need and thus delay diagnosis of killer diseases. Parents will pay precious money for useless drugs.
3. There is mounting evidence that shows that other providers are more effective than informal shops. Community health workers (CHWs) are able to diagnose and treat malaria and pneumonia more effectively. 
4. The AMFm evaluation showed a great difference in implementation between and within countries and therefore the idea of a global model that fits all is not valid. 
5. The evaluation showed that AMFm had no effect on monotherapy because governments’ regulations had already done the job of decreasing monotherapy in the market.

Our above arguments show that modification and scale up, as proposed by Professor Arrow, require a careful consideration. The recent decision by the Global Fund to modify the AMFm to allow countries to decide on how best to tackle malaria is welcomed. However, to focus on shopkeepers as the vehicle for malaria treatment is dangerous and short-sighted. It is important to support solutions that are proven to effectively control malaria and other causes of fever, like investing in community health workers.

Reference

(i)  Valerie D’Acremont, Mary Kilowoko, Ester Kyungu, Sister Philipina, Willy Sangu, Judith Kahama-Maro, Christian Lengeler, Blaise Genton ( Forthcoming),  Etiology of fever in children from urban and rural Tanzania

Mohga Kamal-Yanni works for Oxfam as a Senior Health & HIV Policy Advisor

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Oxfam warns malaria subsidy is too risky to continue

A girl receiving treatment from a community health worker in Port-au-PrinceLast week in our new report ‘Salt Sugar and Malaria Pills’, Oxfam is calling for an end to a global malaria scheme; the Affordable Medicines Facility – malaria (AMFm).

Despite great successes in fighting malaria, many poor people continue to die of this treatable disease.  The majority of those dying in Africa are children. In fact in 2010, 86 per cent of malaria deaths were children under five.  So why are we not supportive of a scheme that aims to reduce the price of life saving medicines?

As you may expect – and hope – we have some very good reasons based on the evidence.

It is true that the AMFm has succeeded in reducing the price of ACT – the ‘good’ malaria drug – and increasing the number of medicines available in the countries where the subsidy operated. You don’t need a PHD in economics to understand that a subsidy will achieve these things. But that doesn’t mean the subsidy is helping the poorest families to get the treatment they need, and doesn’t take into account the public health risk of treating malaria in this way.

Firstly, there is no evidence that the poorest and most vulnerable have benefited. The AMFm’s own evaluation of the pilot phase, which has seen the subsidy rolled out in 7 territories, failed to measure this.  They don’t know who bought the medicines.  What we do know is that when medicines have even a low price, the poorest families cannot afford them.  Ordinary people have spent over 105 million USD buying these subsidised medicines in the pilot countries. This level of out of pocket payment is not what will allow the poorest people, living below the poverty line, to get the medicines they need.

But there is a far more fundamental flaw in the AMFm.  The scheme has mainly incentivised increased sales through small-scale private providers.  Which doesn’t sound like a problem, until you realise this doesn’t mean chemists or private doctors. It means shops.  The AMFm has put the majority of medicines in the hands of shopkeepers who don’t have any medical training, and can’t give medical advice to families or properly diagnose malaria.  Given that an estimated 60% of fevers are not malaria, distributing medicines in this way runs a real risk of wrong treatment for the majority.

We are not idealists either. We know that public health infrastructure in many countries cannot always provide a well trained doctor on the doorstep of the poorest people.  This is why our report also proposes a pragmatic solution that will have a far better chance of success than the AMFm.  Community health workers are based in communities, and can be trained to diagnose and treat malaria and non-malarial fevers.  When Ethiopia invested in 30,000 community health workers, they saw malarial deaths fall by half in just 3 years.  And the amount that has been spent so far on the AMFm could have trained and paid the first year’s salaries of 390,000 community health workers in sub-saharan Africa.  This is the opportunity cost of the AMFm that the Global Fund Board must bear in mind.

So ask yourself this. If there is a 2 in 3 chance your daughter who woke up this morning with a fever, doesn’t have malaria, but another life threatening disease, would you really take her to a shopkeeper without any medical training but with a financial incentive to sell you malaria pills? Or would you prefer to have a trained health worker in your community, who can diagnose and treat pneumonia and other diseases?

A child in Tanzania has the right to safe treatment, just like our own children do. The AMFm puts lives at risk in the poorest countries, and poses a dangerous distraction away from more effective interventions that can save the lives of the poorest and most vulnerable.

This is why we are urging the Global Fund who will meet in early November, to base their decisions on the evidence. To put an end to the AMFm, and free up the resources to invest in what we know works.

Emma Seery is Oxfam’s Head of Public Services and Development Finance team

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Une subvention pour lutter contre le paludisme qui, selon Oxfam, comporte trop de risques

Une subvention pour lutter contre le paludisme qui, selon Oxfam, comporte trop de risques

La semaine passée, dans notre dernier rapport “Des anti-paludéens à l’épicerie”, Oxfam suggérait que l’on mette fin à un projet mondial contre le paludisme Fonds pour des médicaments antipaludéens à des prix abordables (AMFm).

Malgré une avancée notable dans la lutte contre le paludisme, un nombre important de personnes indigentes meurent encore de cette maladie pourtant curable. La majorité des victimes en Afrique sont des enfants. De fait, en 2010, 86 pour cent  des personnes décédées des suites du paludisme avaient moins de cinq ans. Alors pourquoi ne sommes-nous pas en faveur d’un projet qui vise à réduire le prix de médicaments qui sauvent des vies?

Oxfam a de très  bonnes raisons d’exiger l’arrêt de ce mécanisme à la lumières de plusieurs  faits.

Il est vrai que le AMFm a réussi à faire baisser le prix des ACT – les meilleurs traitements antipaludéens à l’heure actuelle– et à augmenter la quantité de médicaments disponibles dans des pays où la subvention a été attribuée. Nul besoin d’un doctorat en économie pour comprendre qu’une subvention permette d’atteindre ces objectifs. Mais cela ne signifie pas pour autant que cette aide rend l’accès aux médicaments plus aisé pour les familles les plus démunies ni qu’elle prend en compte les risques de santé publique en traitant le paludisme de cette façon.

Tout d’abord, il n’existe aucune preuve que les plus pauvres et les plus vulnérables aient bénéficié de cette aide. La propre évaluation de l’AMFm lors de la phase pilote, durant laquelle la subvention a été déployée sur 7 territoires, n’a pu le mesurer et ils ne savent pas qui a acheté les médicaments. Mais ce que nous savons, c’est que même lorsque les prix sont bas, les familles les plus pauvres ne peuvent se permettre une telle dépense. Les gens ordinaires ont déboursé plus de 105 million USD pour ces médicaments subventionnés dans les pays pilotes. Pour autant, ce système de contribution personnelle ne permet pas aux plus nécessiteux, vivant en dessous du seuil de pauvreté, d’obtenir les médicaments dont ils ont besoin.

Ensuite, il existe un autre défaut encore plus fondamental dans l’AMFm. Le programme a essentiellement renforcé la hausse des ventes de petits prestataires privés. Ce qui ne semble pas poser problème, jusqu’à ce qu’on réalise que cela ne correspond pas forcément à des pharmaciens ou des médecins privés. Non, cela concerne plutôt des magasins. L’AMFm a mis la grande majorité des médicaments entre les mains de petits commerçants qui n’ont aucune formation médicale et ne peuvent donner aucun conseil à des familles, ni diagnostiquer correctement le paludisme. Dans la mesure où l’on estime que 60% des fièvres ne sont pas liées au paludisme, distribuer des médicaments de cette manière comporte un risque réel de distribuer des traitements inappropriés dans la majorité des cas.

Nous ne sommes pas idéalistes pour autant. Nous savons que les infrastructures de santé publiques dans de nombreux pays ne peuvent pas toujours fournir des médecins bien formés au plus près des plus démunis. C’est pourquoi notre rapport propose également une solution pragmatique qui aura bien plus de chance de réussir que l’AMFm. Les travailleurs de santé locaux basés dans les communautés qui peuvent être formés pour diagnostiquer et soigner le paludisme et des fièvres autres que paludéennes. Lorsque l’Éthiopie avait investi dans 30,000 travailleurs de santé locaux, les décès dus au paludisme avaient diminué de moitié en 3 ans. Or, le montant jusqu’à présent dépensé pour l’AMFm aurait pu servir à la formation et au salaire de travailleurs de santé locaux en Afrique sub-saharienne. Ceci est le coût d’opportunité engendré par l’AMFm que le Conseil du Fonds Global doit avoir à l’esprit.

Il faut se poser les questions suivantes : s’il y a deux chances sur trois que votre fille qui s’est levée ce matin avec de la fièvre, n’ait pas le paludisme mais une autre maladie qui mettrait sa vie en danger, l’amèneriez-vous vraiment chez un commerçant sans formation médicale mais financièrement incité à vous vendre des comprimés anti-paludéens? Ou préfèreriez-vous avoir un travailleur de santé formé dans votre communauté, qui pourrait diagnostiquer et traiter une pneumonie ou d’autres maladies ?

Un enfant en Tanzanie a le droit à un traitement sûr, au même titre que  le votre. L’AMFm met des vies en danger dans les pays les plus pauvres et risque de détourner l’intérêt général au détriment d’interventions efficaces qui peuvent sauver la vie des plus pauvres et des plus vulnérables.

C’est pourquoi nous invitons le Fonds mondial qui se réunit début novembre à prendre leurs décisions à la lumière de ces faits. Mettre fin à l’AMFm et libérer les ressources pour les investir dans ce qui, nous le savons, fonctionne.

Emma Seery, responsable de l’équipe Fonds de développement et Services publics à Oxfam

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Malaria, aid and shopkeepers: saving lives or playing with fire?

On World Malaria Day there is much to celebrate. Today’s UK Guardian cites malaria control as ‘one of the most notable achievements of international aid’. Dramatic reductions in malaria deaths from Ethiopia to Zambia have been attributed to large scale free prevention, diagnosis and treatment via trained health workers. But the Global Fund for HIV, TB and Malaria, one of the major vehicles responsible for delivering these approaches and capable of further scale up, now faces a severe financial crisis. Meanwhile some donors are making the choice to invest more precious aid resources into a different unproven and risky scheme – the Affordable Medicine Facility for malaria (AMFm).

Recently the UK and Canadian governments as well as UNITAID decided to inject more funding into AMFm which actively promotes the sale of the only effective treatment left for malaria (Artemisinin Combination Therapy or ACT) via unqualified shopkeepers. Not only does this go against WHO guidelines that say malaria must be diagnosed, it also risks lives because:

  • Paying for treatment excludes poor people. Inability to pay for a full course renders patients vulnerable to buying an incomplete course of treatment or going without treatment altogether
  • Using unqualified shopkeepers to deliver medicines creates a real danger of widespread misdiagnosis and mistreatment. If shopkeepers treat all fevers as malaria other killer diseases are missed and the already alarming detection of drug resistance to malaria treatment grows
  • Even when shopkeepers have access to Rapid Diagnostic Tests (RDTs), poor people cannot afford to pay for the test and there is no provision to treat people who test negative for malaria

Last year, uncontrolled ordering by AMFm buyers also threatened to destabilise the market for Artemisinin Combination Therapy (ACTs) and led to a funding gap in the AMFm of $120m. For example, buyers in Zanzibar, a country where malaria has almost been eliminated, have ordered over 240,000 treatments when the number of malaria cases is around 10,000 per year. These cases of unnecessary over-ordering constitute a massive waste of aid.

The AMFm experiment presents a great risk of repeating the sad story of chloroquine – an effective drug rendered useless in Africa because of resistance. Despite being cheap, poor people could not afford a full treatment course allowing resistance to develop. A few years ago the first cases of resistance to ACTs were identified along the Thai-Cambodia border – where resistance to chloroquine first emerged. Alarmingly, recent research has found more cases of ACT resistance on the Thai-Burmese border.

The threat of growing resistance to ACT cannot be taken lightly and containing it must be a global priority if the world is to avoid losing the battle against the malaria parasite. As well as specific measures in the regions affected, that means using aid to scale up proven approaches of diagnosing and treating patients free of charge via trained community health workers or primary health care units. Instead, with donor support, UNITAID (the international drug purchasing facility) has made the recent decision to invest $34 million over 3 years in the sale of RDTs by shopkeepers. The decision could result in RDTs flooding the private-sector market without prescribers being qualified to use the tests, without the drugs necessarily there to accompany them, and without addressing the treatment of those who test negative for malaria.

Supporting the AMFm is not only a risk to public health it is also a waste of precious resources. With donors including the UK government ever more focussed on ‘results’ it makes sense to rethink support for the AMFm and instead focus limited aid resources on scaling up evidence-based approaches that have already worked to save so many lives. That means fully financing the Global Fund to deliver free malaria prevention, diagnosis and treatment by trained health workers.

This blog was co-authored by Dr Mohga Kamal-Yanni, Senior Health and HIV Policy Advisor for Oxfam GB

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Global Health Check is edited by Anna Marriott, Health Policy Advisor for Oxfam GB, and welcomes contributions from different authors. If you would like to write an article for this site or if you have any queries please contact: amarriott@oxfam.org.uk.