Global Fund Changes Malaria Program, Ends Passionate Debate

The board of the Global Fund to Fight AIDS, Tuberculosis and Malaria yesterday made a major change to a global malaria subsidy plan that has been the subject of an intense debate for the past few months. The Affordable Medicines Facility-malaria (AMFm), as it is called, will cease to exist as a standalone entity and will become part of the fund's regular funding programs—a decision that critics say will make quality malaria drugs more expensive and more difficult to obtain in African pharmacies.

"It's a real tragedy," says Ramanan Laxminarayan, director of the Center for Disease Dynamics, Economics & Policy, which is headquartered in Washington, D.C., and New Delhi. "I think we will see drug prices go up, probably sooner than we expect."

Many Africans get their malaria drugs in the private sector, from local pharmacies or village shops, where the latest and most effective generation of drugs, the so-called artemisinin-based combination therapies (ACTs), are often hard to find and expensive. Instead, many people end up with less expensive but ineffective drugs such as chloroquine and artemisinin monotherapies, which increase the risk of drug resistance. AMFm sought to address this problem through a global subsidy that helped make ACTs very cheap for importers in Africa. The hope was that the drugs would trickle down to patients at low prices. In a pilot held the past 2 years in seven countries, the plan worked, according to an independent evaluation published recently in The Lancet.

But critics of AMFm—including the U.S. President's Malaria Initiative (PMI) and Oxfam, a U.K. charity—argue that it's not clear how many of the drugs reached the most vulnerable group—children under age 5 in poor areas—and that, with malaria rates declining across Africa, many drugs must have gone to people who did not have malaria at all. Backers of AMFm say PMI, which did not help pay for the program, has lobbied hard behind the scenes to kill it, a charge that PMI denies.

Yesterday, as expected, the Global Fund's board decided neither to continue AMFm nor to kill it; instead, after a transition year, the fund will "integrate" the scheme into its normal funding activities, which means individual countries can now apply for funds to subsidize malaria drugs in their private sector. That means that governments will have to choose between subsidizing private sector drugs or funding bednets and drugs distributed through the public sector, says Laxminarayan -- and the private sector drugs will likely lose out. One of the key goals of the subsidy is to prevent the emergence of resistance against ACTs, which would be a major crisis; for individual countries, investing in such a common good is no more attractive than investing in measures to prevent climate change, he adds. Moreover, it appears there will be no new money beyond the more than $350 million that donors have so far paid for AMFm's pilot.

In a recent piece in The Lancet, the members of an Institute of Medicine panel that came up with the idea of a global subsidy in 2002 decried the plan to integrate AMFm into the fund as a way of "killing it slowly."

But in a press release issued yesterday, the Global Fund presented the measures as an improvement and expansion of the plan. "By introducing modifications and integrating it into the Global Fund grant processes, the Board has improved this valuable mechanism and made it available to all eligible countries that wish to implement it," said Gabriel Jaramillo, general manager of the Global Fund, in the statement.