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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


7 Responses to “Malaria, aid and shopkeepers: saving lives or playing with fire?”

  1. David Hercot says:

    Dear Dr Moga,
    First of all, I acknowledge that using drugs might create resistance, definitely. But does it mean that we should keep them on a shelve to avoid creating resistance ? Artemisinin based combinatio ntherapies are the recommended treatment nowadays.
    Second, most expert also agree with you that out of pocket payments for health care is considered the worth form of financing health care. Ok.
    Now the reality out there is that people do want treatment for their fever and they are not willing to seek professional advice in the current context for reasons that are their owns. Private companies and among them quacks have seen the market opportunity and provide goods at a price that people think affordable for them at a given moment. No single country in the world has found ways to eradicate quacks and substandard drugs.
    With regard to resistance, you should also mention that emergence of resistance to artemisinin has been facilitated by the use of monotherapies.
    The aim of the AMFm is precisely to “reduce the use of less-effective treatments (…)[and] reduce the use of artemisinin as a single treatment or monotherapy” through market mechanism that seek a lower price tag for quality combined drugs in both for profit and not for profit providers.

    The market is providing inadequate drugs to people who are willing to pay for it. That’s where AMFm aims to act. If is a waste of aid resource can be discussed on philosophical grounds but that it is a risk to Public Health needs to be proven with more solid facts.

    Anna responds:Thanks for the comment David. I think you misread our most important point. We certainly don’t want ACTs sitting on shelves unused. The question is what is the most effective way of reaching people with the right care at scale while simultanously protecting the long-term effectiveness of ACT as a treament for malaria. Why not scale up proven effective routes?

    And we don’t accept that people are actively choosing against taking their sick children to seek professional care in favour of the sale of drugs from unqualified shopkeepers. The reality is that an affordable and accessible quality alternative often doesn’t exist within reach of peoples homes. Where such an alternative exists we have seen massive scale up in access and especially for the poorest. And on your point about no country being able to deal with quacks etc, you will see we touch on this in our paper Blind Optimism. . In countries like Sri Lanka where there has been investment in a universal quality system free at the point of use the private sector has been forced to improve its standards in order to attract patients who can afford to pay. Without such competition from a universal public system you are right, that there is little hope of crowding out the worst elements of private sector provision.

    • David Hercot says:

      Hi Anna,
      Thanks for your clarifications. I agree that the question is how to scale up services for those who need it. Sri Lanka is an example of scaling up public services with an effect on the private sector. There are others who scaled up services too with some success like Ethiopia and Rwanda. Still many countries are not in a position to follow the same path at this moment in time. Hence I do think AMFm as an experience compared to free public services is worth trying. Let evaluations and time show us the advantages and disadvantages of each system in the context where they have been implemented.

      Now regarding priority defined by donors, you have a point. Although we are supposed to be in an era of “Paris Declaration” and IHP+, DFID after pushing for free care in a country pulls out of that same country just two years later… and comes back through AMFm mechanisms. Here the issue to be evaluated is not one intervention against another but the effect of donors changing mind like weather vanes in a storm on access to care for people with limited resources.

      • Steve says:

        Agreed David. Donor funding of pilot projects is often too short and poorly directed. I would like to see to experiment in Zambia renewed because it only lasted one year and most people involved feel it could be redesigned and more successful adopting lessons learned. The problem was not that the coartem was misused, but that the shopkeepers had been given the wrong monetary incentives along with the right training.

  2. A Craven says:

    Dear Anna,

    Great blog, I couldn’t agree more with your analysis. I recall a similar model has also been used for the distribution of ITN in multiple-countries and an attempt was made by some authors to collate evidence that related delivery mode directly to the health outcomes. I do understand that the issue in hand is quite different but are there lessons to be learned or evidence-base that can be created? Here is a link to the paper I am referring to

    I say this partly because the models used for the distribution of ITN varied from country to country with some receiving full subsidy on the products at no cost to the user while others only offering a partial or no subsidy which, as you suggest will pose a greater financial burden on users and invariably exacerbate access barriers. And of course in this case the issue of diagnosis/drug-resistance is a critical one that needs to be looked at more closely. But that said the fundamental question still ends up being then how do we scale up such interventions? As I said there is little in your blog that I disagree with as like you, I do support the provision of free and effective PHC. But needless to say the reality is very different where even with aid harmonisation (although questionable to what extent) some countries would fail to reach the desired threshold for per capita health expenditure and such is continually reflected through drug stock outs, lack of HRH/PHC infrastructure and high opportunity costs in many LMICs . In this context I do believe that commercial supply chains must not be overlooked to scale up distribution. This is not to suggest that the questions you raise are inconsequential at all. But is there room to explore this model with necessary caveats and restriction or can we create an outcome-related evidence-base to make the case against this model more stronger? I would be very interested in hearing your views. Thanks A Craven

  3. Thank God for people like you, for making this public . In Nigeria through the Global Fund supported project the scourge of malaria is gradually reducing Civil society Advocate had been trained to carry out ACSM activities in remote hard to reach communities, conduct RDT test for free and provide ACT (Coartem)to those that tested positive and referral services for those that are negative but shows obvious signs of fever. This AMFm mechanisms will not help us at all The people are already imbibing the culture of diagnosis before treatment These efforts and gains should not be truncated in any way instead More fund should be channeled through the Global Fund to sustain the gain already recorded. Most Coartem distributed through the private patent vendor turn out to out of reach of the poor because of the prices but through our activities at the communities and support provided by The Society for Family Health (the PR) the very poor people access these services at the right price within their communities.

  4. A Alexander says:

    Without vaccines, and without reliance on bednets, malaria was eradicated from Palestine/Israel where malaria had been as severe in many areas 100 years ago as it is in Africa now.

    See as to what is possible . Don’t leave Africa to suffer in this deplorable way.

  5. omoscowonder says:

    Thanks for this, please don leave africa like this.

    Without vaccines, and without reliance on bednets, malaria was eradicated from Palestine/Israel where malaria had been as severe in many areas 100 years ago as it is in Africa now.

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