PHM-Exch> Oxfam:Privatising hlth care in China: a failed experiment - DFID' Affordable Medicines Facility for Malaria: a critique

[Claudio Schuftan]

From: Anna Marriott AMarriott at oxfam.org.uk



Oxfam’s report Blind Optimism: Challenging the Myths about Private Health
Care in Poor Countries, included evidence on the devastating impacts of
introducing market based health care reforms in China. Since Blind Optimism
was published China’s government has made significant announcements
acknowledging the failure of this approach and laying out their plans for a
significant and urgent expansion of publicly funded and publicly provided
health care. In the midst of the debate about US health care
reform[1]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn1>the
investment in public provision by the other members of the G20 is very
interesting.

Also, following on from my last email about the malaria subsidy, we received
a detailed response from DFID to our criticisms. Please see this below with
our responses included. This is clearly a debate that will continue, and we
welcome this as it crystallises many of the key issues contained in Blind
Optimism.

*Privatising health care in China: a failed experiment *

>From 1952 to 1982 the Chinese government-owned, funded, and operated
health-care system achieved enormous improvements in health and health care.
Infant mortality fell from 200 to 34 per 1,000 live births, and life
expectancy almost doubled. Since the 1980s, cuts in government health
spending and wide-scale privatisation have had devastatingly inequitable
consequences for people’s lives. Services that were once free are now
charged for by profit-driven hospitals. Insurance to cover costs has been
introduced but 80 per cent of the rural poor are not covered. The numbers
and quality of health-care facilities and personnel in rural areas are
inadequate resulting in huge disparities in health outcomes. Infant
mortality is now 3 times higher in rural than urban areas. Illness is now
the leading cause of impoverishment in rural areas.

In 2007 a government-endorsed report concluded that the success of China’s
health system during the planned economy period was based on the dominant
role played by the
government.[2]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn2>Market-based
reform has led to a decline in both the fairness of medical
services and the efficiency of investment in the health sector.

There is also a clear link to be made between high rates of household saving
and high out-of-pocket payments.  This is thought by many to have
contributed to relatively low levels of domestic spending and demand in
China, which in turn has helped to fuel global macroeconomic
imbalances[3]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn3>
.  So what is good for the health of the Chinese is good for the economic
health of the global economy, further underlining that public investment and
public provision of health care is essential to underpin more equitable and
sustainable growth. This is a mirror of the current debates in the US where
at 16% of GDP and rising healthcare is both grossly unfair and increasingly
unaffordable.

**

*Significant Chinese investment planned in scaling up public provision.*

In April of this year the government unveiled reforms that have been much
anticipated and intensely debated. Whilst much of the coverage of these
plans has focused on reform of healthcare
financing[4]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn4>there
has been less coverage of the huge expansion in public provision of services
that is also being planned.

The plan for the first time in China defines basic health care as a ‘public
service’ for all citizens with the government committed to spending $124
billion over a three-year period to 2011 to massively expand publicly
provided care. Details of the massive expansion include:

·         at least one clinic to be established in every village before 2011
to improve health care at grass roots level. Township hospitals and clinics
will be expanded over 2009 and a further 2,000 hospitals to be constructed
at county level so that each county will have a hospital that meets national
standards by 2011[5]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn5>

·         to build or renovate 3,700 community clinics and 11,000 health
service centres in urban areas. While the central government will also build
2,400 health service centres in underdeveloped urban areas.
[6]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn6>

·         train 1.37 million village doctors and 160,000 community doctors
and extend systems of obligation and incentives for medical staff to serve
in rural areas[7]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn7>

·         set up an essential medicine system including 307 different
medicines to curb the rise in drug prices and quell public unrest at the
poor accessibility.[8]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn8>


This would represent a huge expansion of public provision of health care by
any standards, and should be studied carefully over the coming years.
------------------------------

 [1]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref1>See
for example
http://www.huffingtonpost.com/georges-ugeux/heathcare-why-the-world-i_b_275538.html

[2]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref2>Cited
in Huong,D., Phuong, N. et al.,(2007) ‘Rural health care in Vietnam
and China: conflict between market reforms and social need’, International
Journal of Health Services 37(3)

[3]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref3>Financial
Times:
*‘*China facing health system funding crisis’ *The Financial Times*, 21
October 2008

[4]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref4>E.g.
http://www.time.com/time/world/article/0,8599,1890306,00.html?xid=rss-world

[5]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref5>
http://english.gov.cn/2009-04/07/content_1279450.htm Tuesday, April 7, 2009

 [6]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref6>
Ibid.

[7]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref7>
http://english.gov.cn/2009-04/07/content_1279122.htm Tuesday, April 7, 2009

[8]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref8>
http://english.gov.cn/2009-08/19/content_1395801.htm Wednesday, August 19,
2009



In the spirit of continuing debate, the following is a response from DFID to
our last email about the malaria subsidy, and within this our comments on
their response in bold italics.

*Response from DFID to Oxfam.*

*Tackling malaria – helping people access the best treatment*

Thank you for sharing Oxfam's views on the Affordable Medicines Facility for
malaria (AMFm) in your email dated 22 June.  You raise some important
concerns about the approach of the AMFm.  DFID has decided to support the
first phase of the AMFm based on evidence about what works and what does not
work.  At the same time DFID recognises that this is a new and innovative
approach, which is why it is being piloted in up to 11 countries with a
thorough evaluation to see whether it works and if it does, how it could be
improved.

*Oxfam Response: *

*We are really concerned that implementing this subsidy at a national scale
in 11 countries cannot really be considered a pilot.  Also as we said in our
email, although following NGO pressure the AMFm initiative is open to
supporting pubic sector distribution, it remains weighted in favour of
commercial sales of ACTs.  A requirement for successful country applicants
to the AMFm is a focus on increasing accessibility to ACTs through the
private sector. Does this mean that malaria endemic countries, who lack the
capacity to safeguard ACT delivered by shops, and who choose instead to
focus on scaling up to universal access through the public sector, will be
denied support from the AMFm? We feel that a fairer pilot would look to
support both public and private solutions equally and then draw conclusions
about which has been more successful. *

The AMFm is a funding mechanism that will make life saving malaria drugs,
artemisinin combination therapies (ACTs), available at much lower prices in
developing countries. The objectives are to have two major impacts:

a) by making the medicines more affordable, more people will use them,
resulting in fewer deaths from malaria.

b) by making the combination drugs cheaper than artemisinin on its own
(artemisinin monotherapy), this should delay the development of resistance
to artemisinin, extending the life of most effective drug the world has for
malaria.

The idea is that reduced price drugs will be made available to the various
channels for getting malaria treatment such as government health services,
faith based health services, NGOs running health programmes, private medical
clinics, pharmacies and the drug shops or sellers that are common in
developing countries. The details on who can access and sell the drugs will
depend on countries’ national policies.

Oxfam has questioned the use of “largely unregulated shops” to deliver the
treatment, arguing the sale of drugs through shops risks misdiagnosis and
mistreatment, because patients do not have malaria or do not take the full
treatment, and that this could increase resistance. You argue that selling
drugs is against the objective of increasing access as poor people cannot
afford to pay for medicines.  We argue that while there are risks, the
benefits of increasing access to life saving drugs are so important that
these risks should be taken and managed.

*Oxfam response:*

*Oxfam does indeed feel that there are tremendous risks in relying on
unregulated shopkeepers to roll out the last remaining effective drug for
malaria. There is not nearly enough evidence that these ‘risks can be taken
and managed’. Managing this risk, and in particular the effective regulation
and supervision of shopkeepers is incredibly difficult. Our evidence shows
that in fact scaling up public services is an alternative that is not being
adequately addressed. This means that the efforts and resources put into
regulating ordinary shops could yield better results if directed towards
investing in community health workers as part of public service delivery as
exemplified by the experience of Ethiopia and Zambia. Both of these
countries managed to cut malaria mortality and morbidity via public sector
delivery of integrated prevention and treatment. *

Why does the AMFm include distributing medicines through shops?

It is important to get treatment to people with malaria quickly, preferably
within 24 hours. To do so, treatment needs to be available near where people
live and include places they normally seek treatment. The evidence is clear
for many countries that most people seek treatment for malaria from
non-government providers such as shops and private clinics. If these
providers do not have the effective medicines, or as now they are too
expensive (currently they cost around $5-10), people will use the old
medicines which will often fail to cure their malaria, or artemisinin
monotherapy, which is cheaper than the ACTs but increases risks of
resistance.[1]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn1>
 The
AMFm is intended to help make sure people can buy good quality, effective
medicines rather than outdated medicines.  And the reality is that for many
people, including poor people, these sorts of outlets are often the only
places available where they can get medicines at short notice when they need
them.

*Oxfam Response:*

*We feel that the objective of the global health community should be to
improve the reality for the poorest, not simply live with it.  It is true
that for those who can afford treatment, often shops are the only provider
nearby.  It is also true that many more people cannot afford treatment at
any cost. But there are clear risks in working with the status quo.  Doing
so was one of the main reasons resistance developed to chloroquine, a cheap
and effective medicine for tackling malaria. Poor people could not buy the
full course when they or their children had malaria, and inappropriate use
meant resistance developed.  This was contributed to by shops giving
inappropriate treatment, and this is one of the risks we see with taking
action that accepts the status quo.. ***

How to address the risk that drug shops give inappropriate treatment?

Incorrect treatment such as prescribing the wrong dose is a risk, and can be
a problem in health facilities - including public health facilities - as
well as shops.[2]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn2>A
recent analysis of studies on how to improve malaria treatment
suggests
that training of shopkeepers; user friendly packaging and public education
can all help to improve the standard of
treatment.[3]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn3>

These types of interventions are built into the AMFm. All AMFm countries are
expected to include provider training and public education in their plans,
and they can also include user friendly packaging. Thus the risks are being
addressed as an integral part of AMFm.

*Oxfam Response:*

*Its true that incorrect treatment and prescription is a problem in both
public and private facilities, but the reality is that it is a far greater
problem in private facilities.  In the first study quoted, the private
facilities did not know the correct dose in 55% of cases, compared to 20% of
cases in the public facilities.  Prescription of anti-malarials for fevers
that are not malaria is also a major problem in many areas.*

*Whilst training and packaging can help and are a good idea in both public
and private spheres, in the second study quoted it is also clear that there
are not many rigorous studies for these kinds of interventions. The study
adds ‘it has been frequently shown elsewhere that changes in knowledge do
not necessarily correlate with changes in behaviour’ (pg 331)*

*There are 2 advantages to working with people in the public sector rather
than shopkeepers:*

*1.       **In the public sphere you are dealing with individuals whose
primary role is as a health provider and who are ultimately accountable to
their employer, the government. Shopkeepers are retailers who may also sell
salt and telephone cards as well as malaria medicines, and they are not
accountable for their actions. *

*2.       **No matter how much training is given or how user friendly the
packaging, the problem of incentives and the need to make a profit will
always present problems in trying to ensure that shopkeepers and private
clinics give the right prescription. This is especially true as the ability
of governments in low income countries to enforce regulation is often weak.
The public sector does not have to turn a profit, removing this set of
incentives. *

*And there is no evidence that governments will get better value for money
by regulating/supervising shop keepers, rather than by training and
supervising community health workers to diagnose and treat malaria.  Given
these concerns and the current economic environment, it is imperative that
governments use their scarce financial and human resources in the way that
will have the greatest impact.*

Will over use of ACTs lead to resistance?

A long-standing problem in malaria is that providers tend to treat fevers
with anti-malarials although sometimes the cause is not malaria. This is
recommended by WHO for young children in highly malarial areas as a
precaution. An important challenge is the trade-off between two
undesirables: treating false-positives, which wastes money, and failing to
treat false-negatives, which loses lives. It is preferable to have a proper
diagnosis but even after a negative diagnostic test, providers often still
treat with anti-malarials, even in public
facilities.[4]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn4>There
are many complex issues in the deployment of diagnostic tests.
[5]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn5>
,[6]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn6>This
issue needs research to improve the quality of tests and to change the
practice of providers. In the meantime, the AMFm will look into how to
increase use of diagnostics alongside increasing affordability of the
medicines.

*Oxfam Response:*

*As outlined in our email, resistance to ACT has already started (Cambodia.)
[7]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn7>This
has been reported widely and the link has been made clearly to
misdiagnosis and shopkeepers. Although more research is needed in this area
it would seem wise to limit inappropriate treatment. *

*It is also our understanding that it is unclear the extent to which AMFm
will promote and use diagnostics, so we are pleased that AMFm will  ‘look
into how to increase use of diagnostics’ and would be keen to see the
detailed plans. *

*The trade off of incorrect diagnosis is not just about wasting resource on
false positives.  It is also about the consequences of this for poor people.
This could cause a situation where a poor family has spent the scare
resource they have purchasing incorrect medicines, and then simply does not
have the money to purchase the correct ones. Free treatment and good
diagnostics must be the objective of any strategy.*

Artemisinin monotherapy (AMT) is common in many malaria-endemic settings.
 This practice increases the risk of widespread resistance to artemisinin by
the malaria parasite.  AMFm seeks to replace AMTs with ACTs, thereby
reducing those risks of widespread resistance.  In an ideal world, nobody
would be using AMT, high-quality formal health services would be available
to everyone, and there would be no need to deploy ACTs in informal private
sector outlets. But we are many years from this being a reality; the AMFm is
a pragmatic approach based on the world as it is, rather than as everybody
would want it to
be.[8]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn8>There
is a much greater risk of resistance if people continue to use
artemisinin on its own - this was studied in detail in developing the
proposal to set up
AMFm.[9]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn9>


Why expect poor people to pay for drugs if you want to increase access?

Whilst it would be desirable for people to have access to diagnosis and
medicines for free, the reality in many countries is people, including poor
people, use shops and non-government as well as public
services.[10]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn10>Recognising
that some poor people pay for treatment, we want to make sure
they get good quality treatment for their money.

*Oxfam Response:*

*As stated earlier, we feel that the objective of health policy is to change
bad reality, not simply live with it.  To use the analogy of policing, in
Afghanistan or Somalia, the majority of the poorest look to private actors
for their security. Very few would suggest subsidising these people. The
current reality is not a given, but the product of systematic disinvestment
in the public sector over decades.  Equally it is not intractable; rapid
scaling up of quality public provision is possible.  In Ethiopia malaria
deaths have been halved in three years. They have trained 17,500 community
health workers in two years.  **The idea is simple, broaden the outreach:
train two high school graduates per village to act as health advisers.
Thirty thousand young women have been mobilized to transfer health skills to
the entire community. Their top-up training, disease test kits and drugs are
paid for by the Global
Fund.[11]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn11>
*

*Not only do these workers not have to make a profit and are accountable to
government, they can also be part of a comprehensive malaria response that
focuses on bed nets and in door spraying and other preventative measures. *

*If the same resources that will be used in the distribution/training/
supervision/ regulation of the private sector could be used to train
community health workers to distribute free drugs, this could achieve more
coverage, particularly of the poorest.  There is a long history (positive
and negative) of CHWs delivering a variety of health services in their
villages. Support/supervision and small payment make a lot of difference to
the quality of their services.  We would be keen for DFID to explore these
options. *

*Many studies have shown that the cost of treatment for a health shock is a
key cause of driving families below the poverty line. The WHO estimates that
100 million people fall into poverty every year because of medical costs.  It
is also the case that large numbers of cases of malaria go untreated,
particularly those in the lower quintiles who cannot afford treatment.  We
are keen to explore ways of reaching these people too, not simply
substituting the drugs used by the relatively better off, and we feel that
the public sector option is not being sufficiently considered.    *

The AMFm is one way of improving what people can get from the private sector
and discouraging use of relatively expensive artemisinin monotherapy that is
liable to lead to resistance.  The AMFm will also make drugs available to
public services and NGOs at a low price. They decide whether to charge for
the medicines or distribute them for free. With cheaper drugs, it will be
more affordable to provide ACTs for free.

Even where there are free public services offered, people do not necessarily
use them.[12]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn12>Thus
making ACTs free in the public sector is not sufficient to ensure
uptake.  One reason may be that the public or community based services have
run out of supplies.[13]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn13>A
study in Kenya showed there were various reasons why health workers
were
not prescribing ACTs even when they were available in their
facility.[14]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn14>Maintaining
drug supplies to health facilities and community based workers
is a long standing problem in many countries.  Countries have plans to
address these issues and some are starting to show
improvements.[15]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn15>
Of course, supporting the AMFm does not mean we lessen the support we
provide to help countries strengthen their public health systems and drug
supplies.

*Oxfam Response*

*The overall claim that people do not necessarily use free public services
is based on one study of three districts in Tanzania (Njau 2006). Free
services have led to rapid increases in the numbers of poor people seeking
treatment in many other country contexts, and the introduction of free care
is a high priority for the UK government.   In Tanzania a system of social
health insurance with exemptions is the norm, and we would be keen to see
what role if any this played in deterring the public from using public
facilities. *

*The Tanzania study also shows that the 17% of the poorest do not seek any
treatment, a figure that is much higher than the average for Africa; half of
all of the poorest children in sub-Saharan Africa do not get any treatment
at all.  Reaching those who do not access any services must be a priority.
*

*Stock outs are a problem in many countries, and Oxfam works with others to
campaign for supply side reforms that can be relatively rapid, given enough
investment in public sector expansion.   Stock outs reflect the underlying
lack of investment in public services, especially drug supply chain
management. It is an urgent call for donors and governments to pool
resources and sort out the structural problems that affect not only malaria
treatment but all medicines. *



Why not focus on expanding access through the public sector?

The Global Fund to Fight AIDS, TB and Malaria has provided unprecedented
levels of support for malaria, most of which is used to expand prevention
and treatment in the public and NGO sectors. The evaluation of the Global
Fund found that uptake of ACTs was
disappointing.[16]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn16>
This
may reflect the timing of the surveys, but suggests that relying on scaling
up traditional approaches alone may be insufficient to increase access
rapidly.

*Oxfam response*

*See our example above from Ethiopia expanding services through training
community health workers, financed by the Global Fund and the evidence from
Zambia.  *

Over a period of years, most governments plan to expand and improve their
public health services and increase access to health care. The international
community supports this with aid (which has quadrupled since 1990). But such
an expansion cannot happen overnight, and meanwhile people are dying of
malaria. The AMFm will expand access to ACTs through the private sector *in
addition to* , not instead of, the public sector and NGOs.  These provisions
are clearly stated in the guidelines for country applications to the Global
Fund. [17]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn17>

*Oxfam response*

*We warmly welcome this recognition by DFID that there needs to be a focus
on expansion of the public sector.  We would question that this would take
any longer than the AMFm, and particularly to reach the poorest people who
currently get no treatment.  The rapid scaling up of provision of ARVs
across Africa is proof that this need not take a long time, with sufficient
will and commitment to public sector reform and health service expansion,
often in close collaboration with mission and other not for profit
facilities.   *

*Aid to healthcare has increased, but aid for health systems, and in
particular for primary health care has fallen by almost half in the last
decade according to the World Bank.  The rapid scaling up of comprehensive
primary health care systems is an urgent priority that is not being
adequately addressed, a fact recognised and championed by the UK government.
We remain concerned that the AMFm is a dangerous distraction from this
critical endeavour at this time.  *

Will it work?

The important question is how well the AMFm will work in comparison to the
status quo. The approach of delivering subsidised health commodities through
shops and other suppliers has been around for several decades, in the form
of social marketing. For ACTs specifically, a pilot in Tanzania demonstrated
rapid results.[18]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn18>
Whilst this is a small pilot, it suggests the AMFm can work, and a
similar
scheme in Senegal has shown that low prices are passed on to patients. We
concluded that AMFm is a promising model; the next step is to test it on a
national scale in selected countries and evaluate it before it is offered to
more countries. **

*Oxfam Response:*

*Tanzania has a network of relatively formal drug shops, which employ
workers with some training.  It is not useful to extrapolate from this
success. Also in Tanzania, whilst the AMFm was successful in substituting
for other malaria medicines, the numbers of the poorest accessing treatment
was relatively unchanged.   *

*The fact that social marketing of medical supplies has been around for
several decades does not mean that it is a successful strategy in all health
products by any means. Recent work in Africa has shown how even small
payments associated with the social marketing of mosquito nets reduce
uptake, and make such investments far less cost-effective than free public
distribution.   Charging pregnant women only US$0.75 for an
insecticide-treated bednet in Kenya for example reduced demand by 75%. In
the same country, a small charge introduced for deworming drugs reduced
uptake of this highly cost-effective treatment by
80%.[19]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn19>
*

The AMFm is an opportunity to learn how we can perform better, faster and at
scale.  As the Director-General of the World Health Organization remarked in
2008.[20]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn20>“Several
partners are now considering an innovative funding facility for
making ACTs more affordable. This approach involves heavily subsidized
prices at the point when these drugs leave the manufacturer, thus cutting
prices for both the public and private sectors.  This is the kind of
hard-nosed pragmatism that gets results in public health. It looks at the
reality of conditions in the developing world, identifies the forces that
shape the reality, and then outsmarts them. If price affects access, make
the price of the best products competitive, and thus drive ineffective,
substandard or counterfeit products off the market. We must keep such
approaches in mind as we consider broad ways to improve access to essential
medicines.”

*Oxfam Response:*

*Once again our concern is that the AMFm seeks to reinforce a deeply
unhelpful reality rather than “outsmart” it as the quote says. Shaping
reality means ensuring that fevers are properly diagnosed and properly
treated by a trained health worker and that ability to pay does not dictate
who gets the medicine.  It also means prioritising action that will ensure
we meet the goal of access to health care for all, and not focusing on
short-term action that could compound the problems.*

We look forward to working with all partners, including Oxfam, in this
effort.  Continuing constructive debate is an important part of this.

I am indebted to Veronica Walford for help in preparing this response.  I
hope you will feel able to share it with those on your mailing list.

Kind regards,

*John*

John Worley

Team Leader | Health Services Team | Human Development Group | Policy &
Research Division | DFID

Tel:  +44 (0)207 023 0341 | Mob: +44 (0)7810 503 994 | Email:
jm-worley at dfid.gov.uk
We would like to continue to share information and evidence on this debate
about scaling up health care delivery in poor countries with you.  We intend
to send an email approximately once a month. If you do not want to receive
these emails please let me know at any time in an email to
amarriott at oxfam.org.uk


Kind regards
Anna Marriott

------------------------------

[1]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref1>Recent
surveys show this, for example, a 2008 outlet survey in Benin found
that most sales of anti-malarials were by shops and informal providers. At
present these providers do not stock ACTs in Benin , so people are buying
ineffective (cheap) medicines. Similar results on lack of ACTs in drug shops
and informal outlets, which were commonly used to obtain treatment, were
found in other countries surveyed ( Nigeria , DRC, and Uganda ). The surveys
also show the problem of widespread availability of artemisinin monotherapy
– use of which is risky for increasing resistance. In Nigeria , 8% of drug
stores had the recommended ACT in stock, compared to 48% of them having
artemisinin monotherapy (even in public facilities, 28% had monotherapy
while 30% had recommended ACTs). In DRC, about 20% of public and private
outlets stocked the recommended ACT while other ACTs were also on sale, some
of unclear quality, and 39 % of public facilities and 58% of pharmacies
stocked the risky artemisinin monotherapy. In Benin pharmacies that stock
ACTs, they cost around 18 times more than older medicine, which makes them
unaffordable for many. See ACTwatch, 2009. Benin , Nigeria , DRC and Uganda
Baseline Outlet Surveys, October 2008.
http://www.actwatch.info/results/overview.asp .

[2]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref2>The
Benin survey quoted above found 20% of public providers and 55% of
informal outlets did not know the correct dose of ACTs for a child.

[3]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref3>Lucy
Smith et al, Review: Provider Practice and User Behaviour
Interventions
to Improve Prompt and Effective Treatment of Malaria: Do We Know What Works?
Am J Trop Med Hyg 80(3), 2009, p 326-335.
http://www.ajtmh.org/cgi/content/abstract/80/3/326 The review found that
while there were not many rigorous studies of these kinds of interventions,
those that exist show promising results: for example a shopkeeper training
programme in Kenya increased the proportion of shopkeepers prescribing the
correct anti-malarial at the correct dose from 0% pre-training to 98% post
training. Interventions aimed at shopkeepers and drug sellers had more
impact than targeting doctors and nurses. The review also concluded that
pre-packaging of drugs is one of the most effective ways of increasing
appropriate use of drugs, while public education on correct use of
anti-malarials also has good results .

[4]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref4>In
malaria-endemic countries, people commonly assume they have malaria
when
sick and treat themselves accordingly. The AMFm will make effective drugs
more available everywhere. The use of microscopy and rapid diagnostic tests
(RDTs) for malaria diagnosis alongside AMFm could improve the management of
both malaria and other febrile illness, as well as the cost-effectiveness of
AMFm. In peripheral areas, RDTs are the only practical option, but available
RDTs have limitations. Of equal concern is that negative test
results—meaning no malaria—are often ignored and patients treated anyway.
For example, one study in outpatient health facilities found that half of
those with a negative diagnostic test were still given anti-malarials
(Reyburn et al, Rapid diagnostic tests compared with malaria microscopy for
guiding outpatient treatment of febrile illness in Tanzania, British Medical
Journal, 2007 http://www.bmj.com/cgi/content/abstract/334/7590/403?eaf .

[5]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref5>English
M, Reyburn H, Goodman C, Snow RW (2009) Abandoning Presumptive
Antimalarial Treatment for Febrile Children Aged Less Than Five Years—A Case
of Running Before We Can Walk? PLoS Med 6(1): e1000015.
doi:10.1371/journal.pmed.1000015

[6]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref6>D'Acremont
V, Lengeler C, Mshinda H, Mtasiwa D, Tanner M, et al. (2009) Time
to move from presumptive malaria treatment to laboratory-confirmed diagnosis
and treatment in African children with fever. PLoS Med 6(1): e252. doi:
10.1371/journal.pmed.0050252

[7]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref7>
*Fears for new Malaria drug resistance
http://news.bbc.co.uk/1/hi/world/asia-pacific/8072742.stm*

[8]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref8>The
House of Commons, All Party Parliamentary Malaria Group.
The Right Drug at the Right Time: The Power of the Affordable Medicines
Facility-malaria to Save Lives. October 2007. Page 8.

[9]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref9>Ramanan
Laxminarayan et al, Will A Global Subsidy of new Antimalarials delay
the emergence of resistance and save lives? Health Affairs, 2006, Vol 25, 2.
The recent country surveys by ACT Watch (see above) show widespread
availability of artemisinin monotherapy in two countries.

[10]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref10>This
is illustrated by data from Tanzania :

Fever treatment by source by socio-economic status, 3 districts in rural
Tanzania

% taking up treatment (not just anti-malarials) for all age groups, 2001
data

Source of treatment

Poorest third

%

Middle third

%

Better off third

%

Total

%         No.

Any treatment

83

80

91

85        *509 *

Visited Government facility

24

21

23

23%    *136 *

Visited NGO facility

3

3

13

  7%      *39 *

Visited drug store

28

24

27

27%     *159 *

Visited general shop

30

34

26

30%     *179 *

Source: Njau 2006. Fever Treatment and household wealth: the challenge posed
for rolling out combination therapy for malaria . Tropical Medicine and
International health, 11, 3, pp 299-313.

[11]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref11>
http://www.theglobalfund.org/en/savinglives/ethiopia/ma1/ Ethiopia Halves
Malaria Deaths in Three Years.

[12]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref12>For
example a survey in 6 districts of Uganda looked at uptake of ACTs
which
were in principle available for free from public providers at that time.
Despite this, it found that use of ACTs was very low in all districts -
about 10% of children received ACTs within 48 hours in three Western
districts, less than 4% in three Eastern districts surveyed. Many of these
ACTs came from the private sector. MMV, MOH Uganda and PSI, Nov 2007.
Understanding malaria health seeking behaviour in selected districts in
Uganda – Draft report . In addition, a November 2008 survey shows that while
there are ACTs available in 84% of the public facilities surveyed, they were
actually distributing more non-ACT antimalarials than ACTs. ACTwatch Uganda
baseline survey, 2008.

[13]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref13>For
example, a 2007 study in Zambia found the recommended ACT was
unavailable in 42% of rural health units, 30% of urban health clinics and
25% of hospitals, with average stock out times over 9 weeks for rural units.
Zambia Ministry of Health, 2007

[14]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref14>Concerns
about future stock outs were a factor, alongside other issues.
Wasunna b et al, 2008. Why Don’t Health Workers prescribe ACTs? A
qualitative study of factors affecting the prescription of AL , Malaria
Journal, 7:29. http://www.malariajournal.com/content/7/1/29

[15]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref15>For
example, facility surveys for the Global Fund evaluation suggest
higher
availability in some countries by 2008, e.g. 79% in Zambia , but still only
36% in Burkina Faso . See reference below.

[16]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref16>“
While there are data showing that most countries have purchased large
amounts of ACT, there is little or no evidence of a corresponding increase
in the use of ACT for treatment of children .” They found that Zambia was a
notable exception, where 13% of children who were treated for fever were
reported to have been treated with ACT in 2006.  No other country showed
coverage of ACT above 5%. Some countries showed declines in coverage of
anti-malarials. They also found no evidence that quality of treatment had
improved. Macro International, et al, May 2009. Final Report.  Global Fund
Five-Year Evaluation: Study Area 3.  The Impact of Collective Efforts on the
Reduction of the Disease Burden of AIDS, Tuberculosis and Malaria.
http://www.theglobalfund.org/documents/terg/TERG_SA3_ExecutiveSummary.pdf

[17]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref17>See
the AMFm application guidelines at
http://www.theglobalfund.org/documents/amfm/1/AMFm_Phase_1_Guidelines_for_Applications.pdf

[18]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref18>W
ithin one month 30% of consumers who purchased anti-malarials in the
two
intervention districts bought ACTs. After five months, this had increased to
44% of purchases. This compares to 1% of consumers buying ACTs before the
pilot and 0.1% in the control district. Of the anti-malarials bought for
children under 5, 62% were ACTs. Prices remained low, and dosages were
appropriate. Clinton Foundation, April 26 2008, Tanzania Pilot ACT subsidy:
Report on findings.

[19]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref19>Cohen,
J. and P. Dupas (2007) and Kremer, M. and E. Miguel (2007) cited in
Yates, R. (2009) ‘Universal health care and the removal of user fees’, *
Lancet*, 373: 2078-2081.

[20]<http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref20>Dr
Margaret Chan, Director-General of the World Health Organization.
Report
to the Executive Board, 122nd session. Geneva , Switzerland . 21 January
2008. http://www.who.int/dg/speeches/2008/20080121_eb/en/index.html
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