Free and Public

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


BRICS reshaping global health and development; pregnant women and children to get free health care in Nigeria, Indian government provides free generic drugs; Kenyan NHIF to include outpatient services, Sweden appoints first Global Health Ambassador while Spain cuts health aid budget; links I liked…..

Because imitation is the best form of flattery, here’s my version of Duncan Green’s ‘From Poverty to Power’ “links I liked”:

A report on the contribution of the BRICS countries (Brazil, Russia, India, China and South Africa) on global health and development notes their overseas development aid has grown 10 times faster than the traditional G7 donors in the past 5 years. Despite their own domestic development problems, the BRICS are increasingly becoming a significant global force for financing development in poorer countries.

In recognition of the importance of government subsidies for achieving universal coverage, the federal government of Nigeria is to start paying the premium contributions of pregnant women and children under 5 years under the country’s National Health Insurance system.

The India government is rolling out a pilot scheme for a universal health package.  The pilot will provide access to free generic drugs in at least one district in every State in the country.  This move is expected to provide a huge relief to millions of poor people in India who spend a larger share of their meager income on medicine.

The Kenyan government plans to add outpatient services to the NHIF benefit package.  Strangely, this move is aimed at reducing fraud and cost rather than improving access.  Questions remain if current capacity of health service can support such expansion, and whether this will make any real improvements in access for the people given its objectives. In a related development, the NHIF has adopted capitation payment system, and has also   raised contribution rates (premiums) paid by scheme members.

The Swedish government has appointed an Ambassador (Dr. Anders Nordström) to champion its work on helping poorer countries achieve MDG goals 4, 5 and 6 (child mortality, maternal health, and HIVAIDS and malaria.  The appointment is in recognition of the importance global health on Swedish overseas development agenda and the need to strengthen efforts at achieving the health related MDGs as the deadline looms very large.

Meanwhile the Spanish government is to cut about 10% of its budget for health as part of broader measures to reduce the country’s budget deficit.



Global Health Check was created by Anna Marriott and is currently edited by Mohga Kamal-Yanni