The future of the Affordable Medicines Facility–malaria (AMFm) will be decided at the Global Fund Board meeting on 14–15 November 2012. The outcome appears anything but certain. The AMFm was launched as a two-year pilot phase in April 2009 and began operations in July 2010. The AMFm is hosted by the Global Fund but its programme funding comes from other donors.
An independent evaluation of the AMFm was generally positive on the impact of artemisinin-based combination therapies (ACTs) in most countries. However, the Board’s AMFm Working Group says that the AMFm should not continue without some changes. In addition, an article in the journal Nature says that many people the journal spoke to said that the AMFm must be changed or be phased out. Finally, the (US) President’s Malaria Initiative publicly stated its concerns with the programme, including what it referred to as “overuse of ACTs” by people who did not need them.
Evaluation of the AMFm
The final report of the independent evaluation of the AMFm, which was released on 28 September 2012, said that the AMFm is a “game changer” for the private sector in most countries. The evaluation showed that as a result of the AMFm, significant quantities of quality-assured artemisinin-based combination therapies (ACTs) have been quickly and widely distributed through pre-existing private sector networks, reducing or closing the gaps in availability between rural and urban areas in a very short period.
The Global Fund commissioned the evaluation to find out whether the objectives of the AMFm’s pilot phase have been achieved. The aim of the AMFm is to increase availability of ACTs, particularly through private outlets where most people seek their treatments.
The AMFm also aims to bring down the cost of ACTs by subsidising the price. To date, the AMFm has subsidized nearly 270 million ACT treatments. This global subsidy is financed through contributions of $336 million from UNITAID, the governments of the UK and Canada, and the Bill and Melinda Gates Foundation. Technical support is provided by members of the Roll Back Malaria Partnership.
There are eight pilots operating in seven countries: Ghana, Kenya, Madagascar, Niger, Nigeria, Tanzania (with Zanzibar as a separate pilot) and Uganda. The independent evaluation covered all eight pilots.
The evaluation was led by a consortium of ICF International and the London School of Hygiene and Tropical Medicine. The Global Fund also contracted Data Contributors to undertake the fieldwork, data analysis and country reports.
The main results of the evaluation can be summarised as follows:
- Availability: The objective of increasing by 20 percentage points the availability of quality-assured ACTs was met in both urban and rural outlets in five of the eight pilots.
- Price: The objective of reducing the price of quality-assured ACT to less than one third of the most popular antimalarial that was not a quality-assured ACT was met in five pilots.
- Market share: The objective of increasing by 10 percentage points the market share of quality ACTs in outlets carrying antimalarials was met in four of the pilots.
While the findings varied considerably across the countries, the report said, there was an overall increase in the volumes of quality-assured ACTs, and a reduction in the volumes for the less effective anti-malarials across the pilot countries.
The Technical Evaluation Reference Group (TERG), an independent group advising the Board of The Global Fund, has established a sub-committee to conduct a technical review of the independent evaluation. The TERG will present a report on the results of this review to the Strategy, Investment and Impact Committee at its October 2012 meeting.
Findings from the evaluation will contribute to the decision by the Global Fund Board on the future of the AMFm project. It is expected that the Board’s discussion will consider the evaluation findings alongside broader recommendations from working groups established by the Board and Roll-Back Malaria to advise on next steps.
Editor’s Note: At its 13–14 September 2012 meeting, the Board decided to continue hosting the AMFm to the end of 2013. The Board considers 2013 a “transition” year because whatever decision the Board makes in November 2012 concerning the future of the AMFm, there will need to be a transition period to implement that decision.
Comments from the Board’s AMFm Working Group
In a paper submitted to the Global Fund Board at its last meeting in September 2012, the AMFm Working Group, which is part of the Strategy, Investment and Impact Committee, noted that there has been several important changes to the malaria landscape since the Global Fund agreed to host and manage AMFm Phase 1 in 2008. These changes are as follows:
- Malaria endemicity has fallen significantly due to the scale-up of malaria prevention efforts over the past several years.
- Countries have begun to scale-up access to diagnosis in the public sector.
- International funding for malaria declined in 2011 for the first time in a decade.
- Resistance to artemisinin has been detected in Southeast Asia, and there have been strong efforts to reduce the availability of oral artemisinin monotherapies in many countries through regulatory intervention.
The Working Group said that any successor to AMFm Phase 1 will need to take these developments into account. It added that AMFm should not be continued without some changes. The Working Group believes that a future AMFm model must ensure more sustainable funding; that quality-assured ACTs must be available to support implementation of regulatory interventions to limit availability of artemisinin monotherapies; and that the model should be flexible enough to account for different country circumstances.
Article in Nature
In an article in the journal Nature on 2 October, Amy Maxmen wrote: “Although no official decision has been announced about whether to continue the programme … many of those familiar with it have told Nature that it must change or be phased out after this year.”
The article quotes Alan Court, senior adviser to the United Nations special envoy for malaria, and chair of the Global Fund Board’s Working Group on the AMFm, as saying: “For me, the problem is that it has not been proven that the AMFm made a difference to malaria. There has to be a public-health purpose or else there is no purpose.”
President’s Malaria Initiative
In an announcement posted on its website at the end of September, the President’s Malaria Initiative, which has a seat on the AMFm Working Group, expressed its concerns about the pilot phase of the AMFm. Among other things, it said that the independent evaluation report provides no evidence on ACT use by vulnerable groups, particularly for children under five; and that the report does not indicate that “the AMFm has played any significant role in ‘crowding out’ artemisinin monotherapies, as was originally intended.”
According to the article in Nature, the US did not support the AMFm pilot directly because officials questioned whether a top-down subsidy to importers would get drugs to the most vulnerable groups.
Editor's Note: This article was revised on 15 October primarily to correct an error in the number of pilots and to replace two mentions of "percent" with "percentage points" in the first set of bullets.