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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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2 Responses to “Oxfam warns malaria subsidy is too risky to continue”

  1. Sara Bennett says:

    Your advocacy for dropping the AMFm scheme rests upon the idea of channelling anti-malarials through community health workers instead. While on paper this seems like a good solution, in practice, in many countries in Sub-Saharan Africa governments are struggling to pay CHWs salaries and/or CHWs are working without a salary. In contexts where CHW salaries are hard to come by, the CHW may end up behaving very much like a shop keeper – selling drugs to make a living. In advocating for an end to AMFm please don’t neglect the bigger picture and the need for developing sustainable long term financing mechanisms for CHW salaries and support.

  2. Mohga says:

    Hi sara
    First apologies for late reply
    You raised an important point about sustained financing of CHWs and indeed of health system. As you know Oxfam campaigns for increased public financing for health sector especially PHC including CHWs.

    AMFm (just like user fees) has been an ideological “easy” solution: let people pay for their care because they pay anyway! Apart from it being dangerous, it is not a “value for money” mechanism for using donors funding to achieve effective and sustained public health outcomes. Donors could have put the money in funding CHWs just like they do in Ethiopia.

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