AMFm – the importance of training malaria medicine providers

When the Affordable Medicines Facility malaria (AMFm) was conceptualized, designers clearly identified several ‘supportive mechanisms’ that would be needed at the country level. In particular guidance called for “RESPONSIBLE INTRODUCTION: IN-COUNTRY SUPPORTING INTERVENTIONS” [1] in five key areas:

  • National policy and regulatory preparedness
  • Wholesaler incentives and pricing/margin-control mechanisms
  • Public education and awareness (IEC)
  • Provider training
  • National monitoring and quality preparedness (resistance monitoring, pharmacovigilance, and quality surveillance)

dscn7970-ghana-shop-amfm.jpgThe planners envisioned the need to, “Train health professionals and private wholesalers/retailers to promote safe and effective use of ACTs, including diagnosis, prescription, and treatment,” since many of these would be in the private and/or informal sector without the benefit of more orthodox health training or recent updated in-service training. Such training could also reinforce other supportive interventions such as consumer education and adherence to recommended pricing levels.

AMFm was designed as a two-year ‘pilot’ to determine subsidized antimalarials could get into the market – both private and public – in such a was as not only to increase overall supply of quality medicines, but also drive out more expensive and inappropriate drugs. As the project comes to a close at the end of this year, many people are looking to see if it would make a difference.

Earlier this year Yamey, Schäferhoff and Montagu [2] raised the question – what would AMFm’s success look like.  Would the subsidized quality drugs really ‘crowd out’ the costlier share of the market?  In the process they too addressed the importance of supportive interventions, noting that, “In addition to the price subsidy, the AMFm involves supportive interventions aimed at boosting ACT use, including in-country branding and associated awareness campaigns for sellers and patients, training for ACT providers and greater access to rapid diagnostic tests for malaria.”

dscn7972-ghana-amfm-meds.jpgNow a preliminary report has come out looking at the outcome issues of Artemisinin-based Combination Therapy (ACT) availability, affordability, use and market share. [3]  A key finding so far has been that, “It is notable that the major benchmarks for success for the upstream indicators of availability, price and market share of quality-assured ACTs have been met or exceeded in 6 of 8 pilot countries, particularly in light of the short implementation period.”

The Advisory group was concerned that, “the evaluated implementation period in each pilot was less than 12 months for assessing the full combined effect of the three components of the model: (i) manufacturer negotiations; (ii) buyer co-payment; and (iii) supporting interventions,” but were excited that even with such drawbacks, progress was evident.

They focused their definition of the ‘supporting interventions’ on consumer education and awareness (IEC/BCC) and provider training and observed that these were, “integral to assuring success of the program objectives of increasing availability and market share and decreasing price” of quality ACTs. They found that “Pilots with higher achievement had the following characteristics: longer period of co-paid ACTs in-country with simultaneous implementation of key supporting interventions (i.e., IEC/BCC and provider training) …”

The initial model for AMFm envisioned that almost 20% of the grant should be devoted to these supportive interventions, and the pay-off seems to be confirmed. The training component will become even more crucial as malaria rapid diagnostic tests (RDTs) become a more common part of provider skill sets, especially those in the private sector.

Not every health management problem can be solved by training and education, but the AMFm experience seems to show that these are crucial components in a comprehensive program to increase access to affordable quality medicines.  Whether the actual structure of AMFm continues past this year or not, we need to take the lessons and apply them in guaranteeing that those in need receive appropriate and affordable malaria medicines at the closest point of care.
[1] Technical Design for the Affordable Medicines Facility-malaria. November 2007. Prepared with guidance from the AMFm Task Force of the Roll Back Malaria Partnership. http://rbm.who.int

[2] Yamey G, Schäferhoff M & Montagu D. Piloting the Affordable Medicines Facility-malaria: what will success look like? Bull World Health Organ 2012;90:452–460.

[3] Expert Advisory Group on the Affordable Medicines Facility-malaria (AMFm) Review of the AMFm Phase 1 Independent Evaluation Preliminary Report Friday 22 June 2012, Geneva

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