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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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One Response to “Saving a program that saves lives: A rejoinder”

  1. Ditto from me. Über-jaded, twisted, and not funny at all.

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