AMFm – affordable? even available?

Reporting from Nairobi, Inter Press Service (IPS) documents the experience of James Odhiambo who “goes from one pharmacy to the next in search of anti-malarial drugs marked with the Global Fund’s logo of a green leaf. He is looking for this specific brand because he understands that it is more than ten times cheaper than the same drug produced by different manufacturers.” James finds what he needs at the sixth shop.

ips_amfmkenya_wordpress.jpgWithout subsidy from the Affordable Medicines Facility malaria (AMFm), these drugs would cost about $5 or two days salary. See the much sought after medicine packet in a photo on the right by Isaiah Esipisu of IPS.

IPS, on further investigation, attributed the scarcity of the subsidized malaria medicines to the low profit margin that pharmacies who agree to sell the medicines are officially allowed. While the actual price of the AMFm drugs should be $0.50 for adult and $0.12 for child doses, IPS learned form a science reporter of the Nation Media Group that, “Two months ago, we requested our reporters from different parts of the country, including rural areas, to check on retailing prices of the subsidised anti-malarial drugs. As a result, we discovered that pharmacists sold them at varying prices ranging from 80 KES (one dollar), to 240 KES (three dollars).”

IPS learned from a private pharmacist that if she sold the commercial variety of Coartem (the approved artemether-lumefantrine combination drug) she could make $2 profit. The AMFm drugs were permitted only about $0.15 profit. For this pharmacist, ” it would not make any economic … considering her costs of transporting it from the distributors, and other inputs.”

Apparently the Ministry of Health believes the problem can be solved through an “awareness campaign (that) will help consumers make an informed choice and enable them to seek outlets that sell the drugs at the right price.” The cost of transport around town seeking the correctly priced drugs may wind up to be more that the price of the drugs themselves.

AMFm is still a new program. The Global Fund explains that, “Following the Global Fund Board’s decisions on successful applications to Phase 1 in November 2009, grant amendments or new grant agreements have been signed with most AMFm Phase 1 countries and implementation has started in several countries. The first co-paid ACTs were delivered to Ghana and Kenya in August 2010.” Seven other pilot projects are in varying stages of implementation.

Nigeria started implementation of AMFm in March 2011. The Director of the National Malaria Control Program in Abuja hoped that the AMFm subsidies would help crowd out fake and substandard malaria drugs from the market by offering medicines at around $0.50 instead of the $6-8 prices per packet in shops.  Ironically conversations with people responsible for a pre-pilot of sorts carried out under a previous GFATM grant in Nigeria identified similar attitudes about profitability by medicine shop keepers. Might Nigeria be heading down the same road as Kenya?

Word is still out on AFFm implementation in Ghana. So far the Ghana Health Service is touting the benefits of AMFm – the low costs, the savings to the national insurance scheme and the edging out of poor quality drugs from the market. Interestingly, none of the news emanating from implementing countries appear to address the need for proper diagnostics to reduce inappropriate use of the malaria medicines.

Fortunately the Global Fund is planning an evaluation of the AMFm experience. This will address availability, affordability, use and market share.  AMFm is a grand experiment. We hope it is well enough designed from the start to test real life forces in the private sector. Arbitrarily suggesting profit margin is not the way to go, but in the end shop keepers and pharmacists will hold the day through their choice to participate and the prices they set.  Whether these decisions will improve coverage with appropriate malaria medicines will eventually be known when this two-year pilot finishes. In the meantime it appears that some important operational lessons can and should be learned and applied NOW.

PS – see article on low malaria transmission risk in Nairobi in Malaria Journal.

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