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Five years, the work of multitudes and not a little luck, and the Affordable Medicines Facility for malaria—AMFm—is almost open for business with $220 million in the bank.  The five years dates from a 2004 report produced by the Institute of Medicine (IOM), by a committee chaired by Kenneth Arrow the well respected U.S. economist and Nobel laureate.  In what was referred to as the “central recommendation,” Saving Lives, Buying Time: Economics of Malaria Drugs in an Age of Resistance, the IOM report, called for this:

 “Within 5 years, governments and international finance institutions should commit new funds of US$300-500 million per year to subsidize coformulated ACTs for the entire global market to achieve end-user prices in the range of US$0.10-0.20, the current cost of chloroquine.”

AMFm comes remarkably close to that original blueprint.  What will make AMFm so powerful is getting highly subsidized ACTs into the private sector—from big-city pharmacies down to the smallest shops in remote villages.   That’s the really new piece.  The world already knows how to subsidize the drugs that end up in public clinics, but it has never had a way to enter the private sector supply chain in a big way.  The key here is that the subsidy is very high in the distribution chain.  When a Ministry of Health or a private wholesaler buys the ACT, it pays about a nickel for each course.  AMFm kicks in the other 95 cents to make up the real wholesale price.  In the private sector, the drugs flow just like other drugs, with some mark-ups at each level.  But what goes in cheap should still be pretty cheap at the consumer level.  In trials in Tanzania, that’s exactly what happened.  AMFm will bring the concept to the entire malaria-endemic world.

The subsidy is not just about price, however.  From the beginning, its purpose was two-fold:  1) to facilitate access to high-quality ACTs at “chloroquine prices,” particularly in the private sector reaching even remote villages, and 2) to preserve artemisinins, the class of antimalarial that the world is going to rely on for years, if not decades, from loss to drug-resistant malaria parasites.

Simply put, ACTs will cost less to the consumer than artemisinin monotherapies because only combinations (specifically, ACTs) will be subsidized.  And using drug combinations is the best strategy we have for protecting drugs against resistance:  a malaria parasite resistant to one drug will be killed by the other one. 

So why am I writing about AMFm on an antibiotic resistance blog?  One, because I have been part of the development of AMFm since the very beginning, seven years ago, as the IOM study director responsible for the 2004 report, and in various capacities since then.  I am elated that after five years of trials, tribulations, and powerful opposition, rationality has triumphed and AMFm is a reality. 

It’s also the first global policy for drug financing explicitly designed to delay the emergence and spread of resistance.  The spread of resistant malaria parasites is different from the way bacteria acquire and spread resistance in some important ways, but the principle that a policy can be tailored to the circumstances of disease, human behavior, and drug, should now be the new paradigm.

 

 

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From the Colalife blog (more on this initiative to follow):

At Ojom health centre, Richard Okello, the district nurse, outlines the most common health problems he has to deal with in Katine.

The biggest problem we face on a day to day level is malaria,” says Okello, who describes the disease as “rampant” in Katine. “The problem is that because of the problems with drugs supply, we usually don’t have enough or any malaria medicine to give people.

Currently the Ojom clinic doesn’t have any first-line malaria drugs left in stock.

“The problem is a lot of our patents are very poor so they can’t afford to go straight on to second-line treatment,” he says. “As a nurse you sympathise and feel really bad for them and just pray that the patient will be helped by a drug delivery but it doesn’t always happen.”

 --Maya Sequeira