A two-year-old pilot program that aims to protect the most effective drug for malaria from resistance, through a novel economic strategy that supports the use of combination therapy, is in danger of being discontinued. The goal has been to boost the availability and affordability of artemesinin-combination therapies (ACTs) for treating the disease to assure that the key drug, artemesinin, remains effective. Barry R. Bloom, Joan and Jack Jacobson Professor of Public Health at Harvard School of Public Health (HSPH) co-authored a November 2, 2012 policy paper in the journal Science urging that the program be kept afloat but modified.
In 2010, the Global Fund to Fight AIDS, Tuberculosis and Malaria launched the program—the Affordable Medicines Facility for malaria (AMFm)—in seven African countries. Through the program, retail prices for ACTs have been significantly lowered and availability has increased in most of the pilot countries. Keeping the price of ACTs competitive is crucial, said Bloom, because people who can’t afford this therapy typically turn to artemisinin monotherapy or, worse, ineffective or substandard drugs. Because increasing resistance to artemesinin is already being seen in Asia from continued use of monotherapy, the World Health Organization recommends that only the combination therapy be used.
Through the AMFm program, prices of quality-assured ACTs have been kept low largely because of price negotiations with drug manufacturers and, to a lesser extent, through subsidies, and the drugs have been made available to both the public and private sectors in malaria-endemic countries, said Bloom, who chairs the Global Fund’s AMFm Expert Advisory Group. Now, though, the Board of the Global Fund is poised to vote on the future of the program, and it may vote either to modify or terminate it.
In the Science article, Bloom and his co-authors—Ramanan Laxminarayan, research scholar at Princeton University and director of the Center for Disease Dynamics, Economics and Policy; Kenneth Arrow, economics professor at Stanford University and a 1972 Nobel laureate in economics; and Dean Jamison, professor of global health at the University of Washington—argue that, without the program’s continuation, malaria deaths could increase, prices for ACTs would rise, and resistance to artemesinin could increase.
Program generates policy questions
Major opposition to continuing the program has come from the President’s Malaria Initiative, part of the U.S. Agency for International Development (USAID), Bloom said. The international anti-poverty and human rights organization Oxfam is also opposed. While USAID officials haven’t given clear reasons for their position, Bloom suspects it is because many don’t like the idea of subsidized products being made available to the private sector, where two-thirds of antimalarial purchases now occur. Instead, they believe public health measures should go through governments or nongovernmental organizations (NGOs).
But in a recent interview, Bloom pointed out that a detailed evaluation of the pilot study about the AMFm program, published online October 31, 2012 in The Lancet, showed that it has resulted, for the most part, in large increases in the availability of quality-assured ACTs at low prices—driven rapidly mostly by activity in the private sector.
“Somewhere between 65% and 70% of children with fevers in the pilot countries receive medications from the local drug shops, not the district hospital,” said Bloom. “A mother whose child has a high fever is unlikely to walk 10 or 20 miles to a district hospital where they may not find an available doctor or the drugs they need.” Because of this reality, Bloom thinks it’s crucial to continue to take advantage of the existing private infrastructure, such as local drug shops, by providing them with reasonably priced, high-quality ACTs and training them in their use.
“It’s not a simple issue,” he acknowledged. “But our position is that people should continue to have access to the best available treatment for malaria and other fevers. We regret the United States is not supporting a program that is working.”
A broader view of fever management
Bloom and his co-authors call for expanding the AMFm program to more malaria-endemic countries, which would further lower the price of ACTs by growing the market. They also recommend greater use of rapid diagnostic tests (RDTs) for malaria. Because the availability of these tests is generally low and antimalarial drugs are widely available—and doctors and patients don’t want to take any chances—people with nonmalarial fevers often get treated for malaria.
Bloom and his co-authors say this is a waste of precious antimalarial drugs and is ineffective for treatment of non-malarial diseases. They believe that treatment of febrile illness in developing countries, rather than being determined by ideology or source of donor funds, should be focused on strengthening the ability of both the public and private sectors to provide the best diagnosis and treatment for children and adults with fevers, including life-threatening pneumonias as well as malaria.
— Karen Feldscher
photo: Arturo Sanabria, courtesy of Photoshare