The Challenge
In 2001, the World Health Organization (WHO) recommended the use of artemisinin-based combination therapies (ACTs) to treat malaria patients, replacing artemisinin monotherapies and other sub-standard drugs that have the potential to cause drug resistance. In response to these new guidelines, many countries shifted to providing ACTs for malaria treatment in the public sector, but ACTs remained unaffordable for most seeking treatment in the private sector – the primary source of treatment in many malaria-endemic countries. Despite the adoption of the new global guidelines, artemisinin monotherapies and other sub-standard drugs remain the primary malaria treatment in many countries, and biological resistance has now emerged in Southeast Asia.
To address this issue, the Affordable Medicines Facility for Malaria (AMFm) was born. Phase 1 of the AMFm, launched in July 2010, was organized under the Roll Back Malaria Partnership (RBM) and hosted by the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GF). The AMFm was piloted in eight countries (Cambodia, Ghana, Kenya, Madagascar, Niger, Nigeria, Tanzania, and Uganda) in 2010-11, to increase ACT availability, affordability, and use, and crowd monotherapies out of the market.
After less than two years of piloting, results from an independent evaluation showed that the AMFm had been a “game-changer” by achieving a 29-78% reduction in price and a 26-52% increase in availability, through negotiations with manufacturers and a co-payment mechanism to subsidize the user price of these high-quality malaria medicines.
Despite those successes, some groups expressed doubts about continuing the AMFm in a changing malaria landscape. They questioned the efficiency of the subsidy arrangement and its possible capture by private sector suppliers, and voiced concerns that a lack of malaria testing was leading to over-dosing and waste of ACTs.
The Opportunity
In 2012, the GF Board asked the AMFm Working Group (WG) to advise it on the future of the AMFm. In order to help it reach a decision, the WG requested R4D, with support from the Bill and Melinda Gates Foundation, to provide technical and policy analysis of three options: to continue, modify, or terminate AMFm.
Our Work
R4D’s work included a review and synthesis of available literature and data on the AMFm, consultations with key informants, analysis of the benefits and risks of future AMFm options, and the development of cost estimates for these options. The R4D team collaborated with the Clinton Health Access Initiative, the Center for Disease Dynamics, Economics, and Policy, and others to flesh out sub-options to the “modification” option, including 1) retaining the AMFm as a standalone fund and 2) merging it into the Global Fund’s overall grant-making machinery.
In November 2012, the Board decided to adopt the second of these “modification” sub-options, integrating the AMFm into core Global Fund grant processes following a transition period in 2013. This decision preserved two key elements of the AMFm: the manufacturer negotiations to lower prices and the co-payment mechanism to enable the GF to partially fund the purchase of ACTs for the private sector.
R4D is currently involved in two follow-on projects. The R4D AMFm team is working with the UK Government and RBM to scope out a Catalytic Fund that could supplement GF funding for private sector ACTs and other malaria commodities. A second team in Market Dynamics, supported by the Bill and Melinda Gates Foundation, is exploring the market for malaria rapid diagnostic tests (RDTs) and examining possible subsidy schemes and other incentive options that could address market failures for these tests.
