Free and Public

Success for free public health care in the epicentre of drug resistant malaria

Women cycling back to their village, Cambodia. Credit: Jim Holmes/Oxfam(This article was written in July 2010 by Anna Marriott for Oxfam and is reproduced here for Global Health Check)

Oxfam has raised significant concerns in recent years about the Affordable Medicines Facility for malaria (AMFm) because of its approach using largely unregulated shops to deliver the last effective treatment available for malaria. While the overall objective of AMFm to reduce the price of Artemisinin Combination Therapies (ACTs) is to be applauded, the sale of drugs through untrained shopkeepers, risks misdiagnosis and mistreatment. This could lead to lives lost and growing resistance. The question is whether aid money could be better spent.

In defence of the AMFm some commentators argue that it is about getting the correct treatment to the places large numbers of people already go for their medicines – local shops and market stalls. Oxfam argues that this approach miss those who lack access to medicines altogether (public or private), it also ignores that there are viable and effective alternatives to settling for this unsatisfactory and dangerous status quo.

The press release announcing the official start of the pilot phase of AMFm was released on 14 July 2010.  This came just a week after the Government of Cambodia, together with the World Health Organisation (WHO), released promising news on their efforts to tackle the alarming growth of Artemisinin resistant malaria along the Thai-Cambodia border.   What is of note is that the approach taken by the Cambodian government and the WHO directly contradicts that promoted through the AMFm. What can we learn from their early success?

Growing Artemisinin resistance in Cambodia and efforts taken to tackle

The alarming evidence of growing resistance to Artemisinin in Cambodia is by now well known across the international health community. Large-scale sale of the drug by unqualified and unregulated private providers and shopkeepers has been blamed. To tackle this urgent problem the WHO in partnership with the Government of Cambodia and Thailand have taken an evidence-based approach. Among other activities more than half a million mosquito nets have been distributed and more than 3000 village malaria workers have been trained and equipped to deliver free early diagnosis and treatment services on both sides of the border.

A lesser-known measure taken by the government of Cambodia in March 2009 was to officially ban the sale of any kind of anti-malaria treatment in the unregulated private sector within zone 1 – the area along the border where Artemisinin resistance had been identified. This measure, which goes against the underlying principles of the AMFm, is enforced by so called ‘Justice Police’ acting on behalf of the national drug regulatory authority.

Intensive and thorough blood screening across the population in seven of the most affected Cambodian villages indicate dramatic initial results. The tests found only two cases of falciparum malaria, the strain in which the Artemisinin resistance has emerged. It is of course very early days but the positive reports echo results from other countries adopting the same integrated approach using trained community health workers as an extension of the public health system, as opposed to unregulated and unqualified private providers:

Examples of success in other low-income countries

In Eritrea this same approach led to a steep decline in malaria morbidity and case fatality by 84% and 40% respectively.  In Zanzibar the introduction of free ACTs and insecticide-treated bednets resulted in a 77% decrease in malaria-associated illness and an overall decrease in deaths of children to about half within two years.   In Ethiopia and Zambia mass distribution of bednets and nationwide distribution of ACTs through the public sector reduced malaria deaths by half and 66% respectively.

In all cases it has been demonstrated that rapid and effective scale up to reach large numbers of patients is possible through the public sector. In Ethiopia for example, over 30,000 health extension workers were trained and deployed within just four years.  This evidence directly challenges the argument of many private sector advocates that public sector expansion takes too long and the private sector is automatically a faster, and at least interim, alternative.

AMFm goes against WHO advice on malaria treatment

The WHO revised official guidelines for the treatment of malaria now recommends a parasitological confirmation of diagnosis in all patients suspected of having malaria before treating.  This guidance aims to improve quality of care, reduce over consumption of anti-malarials, reduce drug pressure, and in turn delay development and spread of drug resistance. The latter issue is of particular importance given that Artemisinin is the last remaining effective drug for malaria.

Recent evidence from a number of countries, including many of those cited above, has demonstrated the effective use of rapid diagnostic tests (RDTs) at community level to confirm malaria status before treatment. In Uganda research has demonstrated that parents trust community health workers if educated to a minimum level to test and diagnose their children. Surveys conducted in Uganda at low-level health care facilities where RDTs were deployed found their use led to a 2-fold reduction in anti-malarial drug prescription. The authors of the study concluded that ‘RDT use is feasible at low-level health facilities and can lead to better targeting of treatment. Nationwide deployment of RDTs in a systematic manner should be prioritised in order to improve fever case management.’

Unfortunately the AMFm’s approach to subsidise treatment, including for sale through unregulated private providers goes against the WHO guidance. While grantees could include the purchase and distribution of diagnostic tests as part of their proposals this is not a requirement. Furthermore, untrained and unregulated private shopkeepers are not in a position to utilise rapid diagnostic tests on behalf of their clients. Even if they were, it is highly questionable that they would utilise them correctly if this meant losing a potential sale.

The AMFm is still going ahead without evidence to support the approach it will take. This is why Dr. Bernard Nahlen, the deputy co-ordinator of the US President’s Malaria Initiative, described the AFMm as the biggest faith-based initiative in the world of malaria’.

And for Cambodia…..?

Cambodia is one of the pilot countries for the AMFm. The AMFm hopes that subsidised Artemisinin Combination Therapies (ACTs) will crowd out the less effective Artemisinin monotherapy from the market and reduce the spread of resistance. In the light of evidence from the ‘epicentre of drug-resistant malaria in the world’ on the Thai-Cambodia border, along with the increasing body of evidence from other low-income countries, it seems sensible to suggest that rather than use aid to subsidise the sale of ACTs through the unregulated private sector, the Cambodian government would do better by expanding the successful approach of extending the reach of free services through the public sector and community health workers. The question remains whether the staunch defenders of the AMFm will be brave enough to change tack.

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