MILLIONS OF LIVES could be saved by a new international scheme providing antimalarial drugs at subsidised prices, according to the first independent evaluation of the programme.

The Affordable Medicines Facility-malaria (AMFm) programme has rapidly transformed access to effective antimalarials in seven African countries which together account for a quarter of the world’s malaria cases, the study published in The Lancet reports.

The evaluation asserts that, by providing access to artemisinin combination therapies (ACTs) to local populations at affordable prices, the scheme could save “millions of lives”.

“Africa is home to 80 per cent of malaria cases, yet most of the population do not have access to affordable ACTs”, explains Kara Hanson from The London School of Hygiene and Tropical Medicine.

Access is restricted by several factors, including unreliable public health facility supply, high prices, and limited availability in the private sector – where most people go to buy medicines. Hanson explained that, as a result, cheaper, less effective antimalarials currently dominate the market.

More worryingly, artemisinin monotherapies are also widely available in some high-risk countries, and use of these medicines can encourage development of resistance to ACTs, she said.

The study evaluated the pilot programme in eight countries – Ghana, Kenya, Madagascar, Niger, Nigeria, Tanzania (including Zanzibar) and Uganda. The assessment examined changes in availability, price and market share using nationally representative surveys of public and private sector outlets that stock antimalarial drugs. The study looked at the period before the introduction of subsidised quality-assured ACTs (QAACTs) and supporting interventions (like communication campaigns) and then 6 – 15 months after their introduction.

Between August 2010 and the end of 2011, more than 155 million doses of QAACTs were subsidised under the programme – meaning QAACT availability more than doubled in five countries and the market share more than doubled in four.

The study notes that the effect of the programme was more limited in Niger and Madagascar, where orders were lower.

Private sector

The scheme has a notably dramatic effect on the private sector, where QAACT market share increased in all pilots, with the increase exceeding 30 percentage points in five of these. Futhermore, private for-profit QAACT prices fell substantially (by up to 80 per cent) in six countries, with the decrease ranging from US$1.28 to $4.82 per dose.

The market share of artemisinin monotherapies also experienced large declines in Nigeria and Zanzibar, the two countries where their presence on the market was highest at the start of the scheme.

Although the programme had less impact on public health facility ACT supply, the authors of the study say there were “substantial delays” in ordering drugs and implementing the full programme in some countries.

Despite the positive findings, they also issued a caution:

“Not all of the changes observed can be attributed to AMFm. 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.

Hanson said it was 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 said that 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.

In response to the survey, some of the world’s most eminent scientists* have warned that, despite the programme’s success, its future could be under threat:

In November, 2012, the Board of the Global Fund will vote to either continue AMFm in a modified form after December, 2013, or terminate the programme. There is a strong push from donors (though not from countries) to integrate AMFm into the regular Global Fund model, whereby countries would choose how much of their country budget envelopes, which are already committed to other priorities supporting the public sector, to reallocate to AMFm. We believe that this approach will create instability in artemisinin demand, lower the number of ACT manufacturers, increase ACT prices, and abandon the millions who depend on AMFm-subsidised ACTs.

Worse still they say, “With the world’s largest global health funder [the US President’s Malaria Initiative (PMI)] expressing unremitting opposition, even after the positive independent evaluation, 13 the programme’s future is uncertain. PMI has yet to suggest an alternative that would come close to the access afforded by AMFm in the private sector.”

*Kenneth J Arrow, Patricia M Danzon, Hellen Gelband, Dean Jamison, Ramanan Laxminarayan, Anne Mills,Germano Mwabu, Claire Panosian, Richard Peto, Nicholas J White.