Nature | Editorial

Too much to ask

A market-based malaria-control programme may not be perfect, but it deserves to continue.

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The ravages of malaria are most damaging where they are hardest to combat: in rural areas in Africa that have little or no public health infrastructure. In response to that quandary, scientists and economists in 2004 dreamed up a scheme called the Affordable Medicines Facility — Malaria (AMFm). It aims to get artemisinin-based combination therapies (ACTs) — the most effective malaria treatments known — into the private pharmacies and village shops that are the only source of medicine in many rural African areas. Now, this grand experiment seems likely to end, its successes underrated and potential improvements not yet explored (see page 508).

The high costs of ACTs have often meant that few rural outlets stocked them. Instead, shops sold cheaper but often ineffective drugs such as chloroquine — or, worse, artemisinin monotherapies, which are a recipe for the emergence of drug resistance. To overcome these problems, the AMFm first secures much cheaper prices from makers of ACTs by generating and negotiating massive bulk orders. Next, it offers importers subsidies to bring prices down further, to levels that are affordable in rural Africa. The scheme has been tested since 2010 at the country level in Ghana, Kenya, Madagascar, Niger, Nigeria, Tanzania and Uganda, and last month an independent evaluation found that it had performed remarkably well on the main benchmarks of success, increasing the number of outlets stocking ACTs and lowering prices (S. Tougher et al. Lancet; 2012).

Last week, however, the Global Fund to Fight AIDS, Tuberculosis and Malaria decided to end the AMFm as a stand-alone programme, by integrating it into the fund’s core system for awarding malaria-control grants to countries. This integration probably spells the end for AMFm, because there will be no new money for the programme after the end of next year.

The fund’s decision may be related to long-standing US opposition to the AMFm. Congress has passed legislation discouraging support for the programme until the concept has been proven, and the US President’s Malaria Initiative maintains that private-sector treatment efforts should be carried out in partnership with governments. Other critics say that trained community health workers, not shop-keepers, should be at the front line of malaria treatment. In an ideal world, that may all be true. But whatever its detractors might say, the programme has succeeded in getting effective antimalarials to the only places in rural areas where most parents can get treatment for a child whose life is threatened by malaria.

“Whatever its detractors might say, the programme has succeeded in getting antimalarials to rural areas.”

More sensibly, the AMFm’s critics also note that because not all cases of fever are malaria, selling ACTs over the counter inevitably leads to overtreatment, resulting in waste. But overtreatment has long plagued all malaria-control programmes, and would happen with or without the AMFm. It is only within the past few years that progress in rapid diagnostic tests for malaria — which use just a finger-prick of blood to check for proteins specific to the malaria-causing Plasmodium parasite — has made routine testing feasible. Only in 2010 did the World Health Organization begin recommending the use of diagnostics before treatment of malaria.

There is plenty of scope for improving the AMFm’s approach, which is still young. Combining diagnostics and treatment is clearly the next step, for example, and there is a major need — social scientists listen up — to devise clever ways to market tests and drugs together.

But it would be senseless to give up on the AMFm’s strategy of using the vast existing private-sector infrastructure in Africa to get good medicines where there were none before. Anyone who doubts the power of the continent’s private-sector distribution networks should consider how the free market has made Coca-Cola and other soft drinks available in even the remotest locations. That force should be harnessed equally for lifesaving malaria therapies.

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