London School of Hygiene & Tropical Medicine

A scheme providing lifesaving antimalarial drugs at cheap subsidised prices has rapidly increased access to effective artemisinin combination therapies (ACTs) in seven African countries accounting for a quarter of the world’s malaria cases, and could save millions of lives, experts from ICF International and the London School of Hygiene & Tropical Medicine have concluded.

The first independent evaluation of the Affordable Medicines Facility-malaria (AMFm) programme is published in The Lancet.

Dr Kara Hanson, Reader in Health System Economics at the School and one of the lead authors, said: “Africa is home to 80% of malaria cases, yet most of the population do not have access to affordable ACTs.

“Access is restricted by unreliable public health facility supply, high prices, and limited availability in the private sector where most people go to buy medicines.

“Cheaper, less effective antimalarials currently dominate the market. Worryingly, artemisinin monotherapies are also widely available in some countries, and use of these medicines can encourage development of resistance to ACTs.”

The study evaluated eight national AMFm pilot programmes in Ghana, Kenya, Madagascar, Niger, Nigeria, Tanzania (including Zanzibar), and Uganda. Changes in availability, price, and market share were assessed in each country using nationally representative surveys of public and private sector outlets that stock antimalarial drugs before, and 6–15 months after, the introduction of subsidised quality-assured ACTs (QAACTs) and supporting interventions (e.g. communication campaigns).

QAACT availability more than doubled in five countries and market share more than doubled in four. The effect of AMFm was more limited in Niger and Madagascar, where AMFm ACT orders were lower.

AMFm had a particularly dramatic effect on the private sector and private for-profit QAACT prices fell substantially (by up to 80%) in six countries, with the decrease ranging from US$1.28 to $4.82 per dose.

Although AMFm had less impact on public health facility ACT supply, the authors point out that there were substantial delays in ordering drugs and implementing the full programme in some countries. 

“But not all of the changes observed can be attributed to AMFm”, the authors warned. “There was some evidence from two countries that prices had already begun to fall before AMFm started and the market share of ACTs had started to increase, although most of this increase occurred in the public sector.”

Dr Hanson added: “It is clear that tapping into the private sector distribution chain can have a major influence on which antimalarial treatments are available and their price and quality in just a few months, but more information is needed about whether the subsidised drugs are reaching those most in need and on how diagnostics can be scaled up in the public and private sectors.”

• Details of the evaluation will be presented at the Global Symposium on Health Systems Research in Beijing this week. Dr Hanson and a number of staff from the School will be taking part in the conference. Other topics for discussion will include a new paper, "Introducing vouchers for malaria prevention in Ghana and Tanzania: context and adoption of innovation in health systems", which looks at why the introduction of a voucher scheme for insecticide treated nets failed in one country but succeeded in another. Ghana and Tanzania share striking similarities in health systems but although the scheme was successfully sustained in Tanzania, it was replaced with other strategies in Ghana due to differences in the business sector. Dr Jayne Webster and her co-authors explain that in Tanzania the business sector was well developed with factories able to make mosquito nets and a strong history of social marketing. However, in Ghana the private sector in mosquito nets was more focused in the ‘informal sector’ which was not included in the voucher scheme. Attempts to build and expand the formal business sector hit problems from both the health systems and business sector perspectives, leading to a loss of trust in the voucher scheme and its eventual withdrawal. The paper is part of a special supplement on systems thinking for health systems strengthening in low- and middle-income countries in the journal Health Policy and Planning.