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<div class="gmail_quote">From: <b class="gmail_sendername">Anna Marriott</b> <span dir="ltr"><a href="mailto:AMarriott@oxfam.org.uk">AMarriott@oxfam.org.uk</a></span><br><font face="Default Sans Serif,Verdana,Arial,Helvetica,sans-serif" size="2">
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<p style="MARGIN: 0cm 3pt 6pt"><span lang="EN-US" style="FONT-SIZE: 11pt; FONT-FAMILY: 'Times New Roman'">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<a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn1" target="_blank" name="12389c2d31de8d28__ftnref1"><span><span><font color="#800080">[1]</font></span></span></a> the investment in public provision by the other members of the G20 is very interesting. </span></p>
<p style="MARGIN: 0cm 3pt 6pt"><span lang="EN-US" style="FONT-SIZE: 11pt; FONT-FAMILY: 'Times New Roman'">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.</span></p>
<p style="MARGIN: 0cm 3pt 6pt"><b><span lang="EN-US" style="FONT-SIZE: 11pt; FONT-FAMILY: 'Times New Roman'">Privatising health care in China: a failed experiment </span></b></p>
<p style="MARGIN: 0cm 3pt 6pt"><span lang="EN-US" style="FONT-SIZE: 11pt; FONT-FAMILY: 'Times New Roman'">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.</span><span lang="EN-US" style="FONT-SIZE: 11pt; FONT-FAMILY: 'Times New Roman'"></span></p>
<p style="MARGIN: 0cm 3pt 6pt"><span lang="EN-US" style="FONT-SIZE: 11pt; FONT-FAMILY: 'Times New Roman'">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.<a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn2" target="_blank" name="12389c2d31de8d28__ftnref2"><span><span><font color="#800080">[2]</font></span></span></a> Market-based reform has led to a decline in both the fairness of medical services and the efficiency of investment in the health sector.</span><span lang="EN-US" style="FONT-SIZE: 11pt; FONT-FAMILY: 'Times New Roman'"> </span></p>
<p style="MARGIN: 0cm 3pt 6pt 0cm"><span lang="EN-US" style="FONT-SIZE: 11pt; FONT-FAMILY: 'Times New Roman'">There is also a clear link to be made between high rates of household saving and high out-of-pocket payments.<span> </span>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<a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn3" target="_blank" name="12389c2d31de8d28__ftnref3"><span><span><font color="#800080">[3]</font></span></span></a>.<span> </span>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.<span> </span></span></p>
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<p style="MARGIN: 0cm 3pt 6pt"><b><span lang="EN-US" style="FONT-SIZE: 11pt; FONT-FAMILY: 'Times New Roman'">Significant Chinese investment planned in scaling up public provision.</span></b></p>
<p style="MARGIN: 0cm 3pt 6pt"><span lang="EN-US" style="FONT-SIZE: 11pt; FONT-FAMILY: 'Times New Roman'">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<a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn4" target="_blank" name="12389c2d31de8d28__ftnref4"><span><span><font color="#800080">[4]</font></span></span></a>there has been less coverage of the huge expansion in public provision of services that is also being planned.<span> </span></span></p>
<p style="MARGIN: 0cm 3pt 6pt"><span lang="EN-US" style="FONT-SIZE: 11pt; FONT-FAMILY: 'Times New Roman'">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 $124 billion over a three-year period to 2011 to massively expand publicly provided care. Details of the massive expansion include:</span></p>
<p style="MARGIN: 0cm 3pt 6pt 39pt"><span lang="EN-US" style="FONT-SIZE: 11pt; FONT-FAMILY: Symbol">·<span style="FONT: 7pt 'Times New Roman'"> </span></span><span lang="EN-US" style="FONT-SIZE: 11pt; FONT-FAMILY: 'Times New Roman'">at least one clinic to be established in every village before 2011 to improve health care at grass roots level. Township hospitals and clinics will be expanded over 2009 and a further 2,000 hospitals to be constructed at county level so that each county will have a hospital that meets national standards by 2011<a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn5" target="_blank" name="12389c2d31de8d28__ftnref5"><span><span><font color="#800080">[5]</font></span></span></a> </span></p>
<p style="MARGIN: 0cm 3pt 6pt 39pt"><span lang="EN-US" style="FONT-SIZE: 11pt; FONT-FAMILY: Symbol">·<span style="FONT: 7pt 'Times New Roman'"> </span></span><span lang="EN-US" style="FONT-SIZE: 11pt; FONT-FAMILY: 'Times New Roman'">to build or renovate 3,700 community clinics and 11,000 health service centres in urban areas. While the central government will also build 2,400 health service centres in underdeveloped urban areas.<span> <a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn6" target="_blank" name="12389c2d31de8d28__ftnref6"><span><font color="#800080">[6]</font></span></a></span></span></p>
<p style="MARGIN: 0cm 3pt 6pt 39pt"><span lang="EN-US" style="FONT-SIZE: 11pt; FONT-FAMILY: Symbol">·<span style="FONT: 7pt 'Times New Roman'"> </span></span><span lang="EN-US" style="FONT-SIZE: 11pt; FONT-FAMILY: 'Times New Roman'">train 1.37 million village doctors and 160,000 community doctors and extend systems of obligation and incentives for medical staff to serve in rural areas<a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn7" target="_blank" name="12389c2d31de8d28__ftnref7"><span><span><font color="#800080">[7]</font></span></span></a></span></p>
<p style="MARGIN: 0cm 3pt 6pt 39pt"><span lang="EN-US" style="FONT-SIZE: 11pt; FONT-FAMILY: Symbol">·<span style="FONT: 7pt 'Times New Roman'"> </span></span><span lang="EN-US" style="FONT-SIZE: 11pt; FONT-FAMILY: 'Times New Roman'">set up an essential medicine system including 307 different medicines to curb the rise in drug prices and quell public unrest at the poor accessibility.<a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn8" target="_blank" name="12389c2d31de8d28__ftnref8"><span><span><font color="#800080">[8]</font></span></span></a><span> </span></span></p>
<p style="MARGIN: 0cm 3pt 6pt 0cm"><span lang="EN-US" style="FONT-SIZE: 11pt; FONT-FAMILY: 'Times New Roman'">This would represent a huge expansion of public provision of health care by any standards, and should be studied carefully over the coming years. </span><br clear="all">
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<p style="MARGIN: 0cm 0cm 0pt"><a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref1" target="_blank" name="12389c2d31de8d28__ftn1"><span><span><font face="Default Serif,Times New Roman,Times,serif" color="#800080">[1]</font></span></span></a><font face="Default Serif,Times New Roman,Times,serif"> See for example <span style="FONT-SIZE: 11pt"><a href="http://www.huffingtonpost.com/georges-ugeux/heathcare-why-the-world-i_b_275538.html" target="_blank"><span style="FONT-SIZE: 10pt">http://www.huffingtonpost.com/georges-ugeux/heathcare-why-the-world-i_b_275538.html</span></a></span></font></p>
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<p style="MARGIN: 0cm 0cm 0pt"><a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref2" target="_blank" name="12389c2d31de8d28__ftn2"><span><span><font face="Default Serif,Times New Roman,Times,serif" color="#800080">[2]</font></span></span></a><font face="Default Serif,Times New Roman,Times,serif"> Cited in Huong,D., Phuong, N. et al.,(2007) ‘Rural health care in Vietnam and China: conflict between market reforms and social need’, International Journal of Health Services 37(3)<span> </span></font></p>
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<p style="MARGIN: 0cm 0cm 0pt"><a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref3" target="_blank" name="12389c2d31de8d28__ftn3"><span><span><font face="Default Serif,Times New Roman,Times,serif" color="#800080">[3]</font></span></span></a><font face="Default Serif,Times New Roman,Times,serif"> Financial Times: <i>‘</i>China facing health system funding crisis’ <i>The Financial Times</i>, 21 October 2008</font></p>
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<p style="MARGIN: 0cm 0cm 0pt"><a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref4" target="_blank" name="12389c2d31de8d28__ftn4"><span><span><font face="Default Serif,Times New Roman,Times,serif" color="#800080">[4]</font></span></span></a><font face="Default Serif,Times New Roman,Times,serif"> E.g. <a href="http://www.time.com/time/world/article/0,8599,1890306,00.html?xid=rss-world" target="_blank">http://www.time.com/time/world/article/0,8599,1890306,00.html?xid=rss-world</a></font></p>
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<p style="MARGIN: 0cm 0cm 0pt"><a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref5" target="_blank" name="12389c2d31de8d28__ftn5"><span><span><font face="Default Serif,Times New Roman,Times,serif" color="#800080">[5]</font></span></span></a><font face="Default Serif,Times New Roman,Times,serif"> </font><span style="FONT-SIZE: 8pt; FONT-FAMILY: Arial"><a href="http://english.gov.cn/2009-04/07/content_1279450.htm" target="_blank">http://english.gov.cn/2009-04/07/content_1279450.htm</a> </span><span style="FONT-SIZE: 8pt; FONT-FAMILY: Arial">Tuesday, April 7, 2009</span></p>
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<p style="MARGIN: 0cm 0cm 0pt"><a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref6" target="_blank" name="12389c2d31de8d28__ftn6"><span><span><font face="Default Serif,Times New Roman,Times,serif" color="#800080">[6]</font></span></span></a><font face="Default Serif,Times New Roman,Times,serif"> </font><span style="FONT-SIZE: 8pt; FONT-FAMILY: Arial">Ibid.</span></p>
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<p style="MARGIN: 0cm 0cm 0pt"><a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref7" target="_blank" name="12389c2d31de8d28__ftn7"><span><span><font face="Default Serif,Times New Roman,Times,serif" color="#800080">[7]</font></span></span></a><font face="Default Serif,Times New Roman,Times,serif"> </font><span style="FONT-SIZE: 8pt; FONT-FAMILY: Arial"><a href="http://english.gov.cn/2009-04/07/content_1279122.htm" target="_blank">http://english.gov.cn/2009-04/07/content_1279122.htm</a> </span><span style="FONT-SIZE: 8pt; FONT-FAMILY: Arial">Tuesday, April 7, 2009</span></p>
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<p style="MARGIN: 0cm 0cm 0pt"><a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref8" target="_blank" name="12389c2d31de8d28__ftn8"><span><span><font face="Default Serif,Times New Roman,Times,serif" color="#800080">[8]</font></span></span></a><font face="Default Serif,Times New Roman,Times,serif"> </font><span lang="EN-US" style="FONT-SIZE: 8pt; FONT-FAMILY: Arial"><a href="http://english.gov.cn/2009-08/19/content_1395801.htm" target="_blank">http://english.gov.cn/2009-08/19/content_1395801.htm</a><span style="COLOR: black"> </span></span><span style="FONT-SIZE: 8pt; FONT-FAMILY: Arial">Wednesday, August 19, 2009</span></p>
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<p style="MARGIN: 0cm 0cm 0pt"><span lang="EN-US" style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">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.<span> </span> </span><span lang="EN-US" style="FONT-SIZE: 10pt; FONT-FAMILY: Arial"> </span></p>
<p><b><span style="FONT-FAMILY: Arial"><font size="3">Response from DFID to Oxfam.</font></span></b></p>
<p><b><span style="FONT-SIZE: 11pt; FONT-FAMILY: Arial">Tackling malaria – helping people access the best treatment</span></b><span style="FONT-SIZE: 9pt; FONT-FAMILY: Verdana"> </span></p>
<p><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">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. </span></p>
<p><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">Oxfam Response: </span></i></b></p>
<p><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">We are really concerned that implementing this subsidy at a national scale in 11 countries cannot really be considered a pilot.<span> </span>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.<span> </span>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. </span></i></b></p>
<p><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">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: </span><span style="FONT-SIZE: 10pt; FONT-FAMILY: Verdana"></span></p>
<p><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">a) by making the medicines more affordable, more people will use them, resulting in fewer deaths from malaria.</span><span style="FONT-SIZE: 10pt; FONT-FAMILY: Verdana"> </span></p>
<p><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">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. </span><span style="FONT-SIZE: 10pt; FONT-FAMILY: Verdana"></span></p>
<p><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">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. </span><span style="FONT-SIZE: 10pt; FONT-FAMILY: Verdana"> </span></p>
<p><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">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. </span></p>
<p><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">Oxfam response:</span></i></b></p>
<p><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">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. </span></i></b><span style="FONT-SIZE: 10pt; FONT-FAMILY: Verdana"></span></p>
<p><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">Why does the AMFm include distributing medicines through shops? </span><span style="FONT-SIZE: 10pt; FONT-FAMILY: Verdana"></span></p>
<p><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">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 $5-10), people will use the old medicines which will often fail to cure their malaria, or artemisinin monotherapy, which is cheaper than the ACTs but increases risks of resistance.<a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn1" target="_blank" name="12389c2d31de8d28__ftnref1"><span><span><font color="#800080">[1]</font></span></span></a> 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.</span><span style="FONT-SIZE: 10pt; FONT-FAMILY: Verdana"> </span></p>
<p><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">Oxfam Response:</span></i></b></p>
<p><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">We feel that the objective of the global health community should be to improve the reality for the poorest, not simply live with it.<span> </span>It is true that for those who can afford treatment, often shops are the only provider nearby.<span> </span>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.<span> </span>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.<span> </span>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.. </span></i></b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial"></span></i></p>
<p><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">How to address the risk that drug shops give inappropriate treatment? </span><span style="FONT-SIZE: 10pt; FONT-FAMILY: Verdana"></span></p>
<p><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">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.<a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn2" target="_blank" name="12389c2d31de8d28__ftnref2"><span><span><font color="#800080">[2]</font></span></span></a> A recent analysis of studies on how to improve malaria treatment suggests that training of shopkeepers; user friendly packaging and public education can all help to improve the standard of treatment.<a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn3" target="_blank" name="12389c2d31de8d28__ftnref3"><span><span><font color="#800080">[3]</font></span></span></a> </span></p>
<p><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">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. </span><span style="FONT-SIZE: 10pt; FONT-FAMILY: Verdana"></span></p>
<p><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">Oxfam Response:</span></i></b></p>
<p><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">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.<span> </span>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.<span> </span>Prescription of anti-malarials for fevers that are not malaria is also a major problem in many areas.</span></i></b></p>
<p><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">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)</span></i></b></p>
<p><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">There are 2 advantages to working with people in the public sector rather than shopkeepers:</span></i></b></p>
<p style="MARGIN-LEFT: 36pt"><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">1.<span style="FONT: 7pt 'Times New Roman'"> </span></span></i></b><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">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. </span></i></b></p>
<p style="MARGIN-LEFT: 36pt"><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">2.<span style="FONT: 7pt 'Times New Roman'"> </span></span></i></b><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">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. </span></i></b></p>
<p><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">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.<span> </span>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.</span></i></b></p>
<p><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">Will over use of ACTs lead to resistance? </span><span style="FONT-SIZE: 10pt; FONT-FAMILY: Verdana"></span></p>
<p><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">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.<a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn4" target="_blank" name="12389c2d31de8d28__ftnref4"><span><span><font color="#800080">[4]</font></span></span></a> There are many complex issues in the deployment of diagnostic tests.<a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn5" target="_blank" name="12389c2d31de8d28__ftnref5"><span><span><font color="#800080">[5]</font></span></span></a>,<a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn6" target="_blank" name="12389c2d31de8d28__ftnref6"><span><span><font color="#800080">[6]</font></span></span></a> This issue needs research to improve the quality of tests and to change the practice of providers. In the meantime, the AMFm will look into how to increase use of diagnostics alongside increasing affordability of the medicines. </span><span style="FONT-SIZE: 10pt; FONT-FAMILY: Verdana"></span></p>
<p><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">Oxfam Response:</span></i></b></p>
<p><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">As outlined in our email, resistance to ACT has already started (Cambodia.)<a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn7" target="_blank" name="12389c2d31de8d28__ftnref7"><span><span><font color="#800080">[7]</font></span></span></a> This has been reported widely and the link has been made clearly to misdiagnosis and shopkeepers. Although more research is needed in this area it would seem wise to limit inappropriate treatment. </span></i></b></p>
<p><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">It is also our understanding that it is unclear the extent to which AMFm will promote and use diagnostics, so we are pleased that AMFm will<span> </span>‘look into how to increase use of diagnostics’ and would be keen to see the detailed plans. </span></i></b></p>
<p><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">The trade off of incorrect diagnosis is not just about wasting resource on false positives.<span> </span>It is also about the consequences of this for poor people.<span> </span>This could cause a situation where a poor family has spent the scare resource they have purchasing incorrect medicines, and then simply does not have the money to purchase the correct ones. Free treatment and good diagnostics must be the objective of any strategy.</span></i></b></p>
<p><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">Artemisinin monotherapy (AMT) is common in many malaria-endemic settings. This practice increases the risk of widespread resistance to artemisinin by the malaria parasite. AMFm seeks to replace AMTs with ACTs, thereby reducing those risks of widespread resistance. In an ideal world, nobody would be using AMT, high-quality formal health services would be available to everyone, and there would be no need to deploy ACTs in informal private sector outlets. But we are many years from this being a reality; the AMFm is a pragmatic approach based on the world as it is, rather than as everybody would want it to be.<a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn8" target="_blank" name="12389c2d31de8d28__ftnref8"><span><span><font color="#800080">[8]</font></span></span></a> There is a much greater risk of resistance if people continue to use artemisinin on its own - this was studied in detail in developing the proposal to set up AMFm.<a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn9" target="_blank" name="12389c2d31de8d28__ftnref9"><span><span><font color="#800080">[9]</font></span></span></a> </span><span style="FONT-SIZE: 10pt; FONT-FAMILY: Verdana"> </span></p>
<p><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">Why expect poor people to pay for drugs if you want to increase access?</span><span style="FONT-SIZE: 10pt; FONT-FAMILY: Verdana"> </span></p>
<p><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">Whilst it would be desirable for people to have access to diagnosis and medicines for free, the reality in many countries is people, including poor people, use shops and non-government as well as public services.<a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn10" target="_blank" name="12389c2d31de8d28__ftnref10"><span><span><font color="#800080">[10]</font></span></span></a> Recognising that some poor people pay for treatment, we want to make sure they get good quality treatment for their money.</span><span style="FONT-SIZE: 10pt; FONT-FAMILY: Verdana"> </span></p>
<p><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">Oxfam Response:</span></i></b></p>
<p style="MARGIN: 0cm 0cm 0pt"><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">As stated earlier, we feel that the objective of health policy is to change bad reality, not simply live with it.<span> </span>To use the analogy of policing, in Afghanistan or Somalia, the majority of the poorest look to private actors for their security. Very few would suggest subsidising these people. The current reality is not a given, but the product of systematic disinvestment in the public sector over decades.<span> </span>Equally it is not intractable; rapid scaling up of quality public provision is possible.<span> </span>In Ethiopia malaria deaths have been halved in three years. They have trained 17,500 community health workers in two years.<span> </span></span></i></b><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">The idea is simple, broaden the outreach: train two high school graduates per village to act as health advisers. Thirty thousand young women have been mobilized to transfer health skills to the entire community. Their top-up training, disease test kits and drugs are paid for by the Global Fund.<a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn11" target="_blank" name="12389c2d31de8d28__ftnref11"><span><span><font color="#800080">[11]</font></span></span></a> </span></i></b></p>
<p><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">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. </span></i></b></p>
<p><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">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.<span> </span>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.<span> </span>We would be keen for DFID to explore these options. </span></i></b></p>
<p><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">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.<span> </span>It is also the case that large numbers of cases of malaria go untreated, particularly those in the lower quintiles who cannot afford treatment.<span> </span>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.<span> </span></span></i></b></p>
<p><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">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. </span><span style="FONT-SIZE: 10pt; FONT-FAMILY: Verdana"></span></p>
<p><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">Even where there are free public services offered, people do not necessarily use them.<a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn12" target="_blank" name="12389c2d31de8d28__ftnref12"><span><span><font color="#800080">[12]</font></span></span></a> Thus making ACTs free in the public sector is not sufficient to ensure uptake. One reason may be that the public or community based services have run out of supplies.<a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn13" target="_blank" name="12389c2d31de8d28__ftnref13"><span><span><font color="#800080">[13]</font></span></span></a> A study in Kenya showed there were various reasons why health workers were not prescribing ACTs even when they were available in their facility.<a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn14" target="_blank" name="12389c2d31de8d28__ftnref14"><span><span><font color="#800080">[14]</font></span></span></a> Maintaining drug supplies to health facilities and community based workers is a long standing problem in many countries. Countries have plans to address these issues and some are starting to show improvements.<a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn15" target="_blank" name="12389c2d31de8d28__ftnref15"><span><span><font color="#800080">[15]</font></span></span></a> 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. </span><span style="FONT-SIZE: 10pt; FONT-FAMILY: Verdana"></span></p>
<p><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">Oxfam Response</span></i></b></p>
<p><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">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.<span> </span>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. </span></i></b></p>
<p><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">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.<span> </span>Reaching those who do not access any services must be a priority.<span> </span></span></i></b></p>
<p><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">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.<span> </span>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. </span></i></b><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial"></span></p>
<p><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial"> </span><span style="FONT-SIZE: 10pt; FONT-FAMILY: Verdana"> </span></p>
<p><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">Why not focus on expanding access through the public sector? </span><span style="FONT-SIZE: 10pt; FONT-FAMILY: Verdana"> </span></p>
<p><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">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.<a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn16" target="_blank" name="12389c2d31de8d28__ftnref16"><span><span><font color="#800080">[16]</font></span></span></a> This may reflect the timing of the surveys, but suggests that relying on scaling up traditional approaches alone may be insufficient to increase access rapidly.<span style="COLOR: blue"> </span></span><span style="FONT-SIZE: 10pt; FONT-FAMILY: Verdana"></span></p>
<p><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">Oxfam response</span></i></b></p>
<p><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">See our example above from Ethiopia expanding services through training community health workers, financed by the Global Fund and the evidence from Zambia.<span> </span></span></i></b></p>
<p><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">Over a period of years, most governments plan to expand and improve their public health services and increase access to health care. The international community supports this with aid (which has quadrupled since 1990). But such an expansion cannot happen overnight, and meanwhile people are dying of malaria. The AMFm will expand access to ACTs through the private sector <u>in addition to</u> , not instead of, the public sector and NGOs. These provisions are clearly stated in the guidelines for country applications to the Global Fund. <a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn17" target="_blank" name="12389c2d31de8d28__ftnref17"><span><span><font color="#800080">[17]</font></span></span></a> </span></p>
<p><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">Oxfam response</span></i></b></p>
<p><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">We warmly welcome this recognition by DFID that there needs to be a focus on expansion of the public sector.<span> </span>We would question that this would take any longer than the AMFm, and particularly to reach the poorest people who currently get no treatment.<span> </span>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.<span> </span></span></i></b></p>
<p><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">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.<span> </span>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.<span> </span></span></i></b></p>
<p><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">Will it work? </span><span style="FONT-SIZE: 10pt; FONT-FAMILY: Verdana"></span></p>
<p><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">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.<a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn18" target="_blank" name="12389c2d31de8d28__ftnref18"><span><span><font color="#800080">[18]</font></span></span></a> 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. <b><i></i></b></span></p>
<p><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">Oxfam Response:</span></i></b></p>
<p><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">Tanzania has a network of relatively formal drug shops, which employ workers with some training.<span> </span>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.<span> </span></span></i></b></p>
<p><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">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.<span> </span>Charging pregnant women only US$0.75 for an insecticide-treated bednet in Kenya for example reduced demand by 75%. In the same country, a small charge introduced for deworming drugs reduced uptake of this highly cost-effective treatment by 80%.<a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn19" target="_blank" name="12389c2d31de8d28__ftnref19"><span><span><font color="#800080">[19]</font></span></span></a><span> </span></span></i></b></p>
<p><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">The AMFm is an opportunity to learn how we can perform better, faster and at scale. As the Director-General of the World Health Organization remarked in 2008.<a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftn20" target="_blank" name="12389c2d31de8d28__ftnref20"><span><span><font color="#800080">[20]</font></span></span></a> “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.”</span><span style="FONT-SIZE: 10pt; FONT-FAMILY: Verdana"> </span></p>
<p><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">Oxfam Response:</span></i></b></p>
<p><b><i><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">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.<span> </span>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.</span></i></b></p>
<p><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">We look forward to working with all partners, including Oxfam, in this effort. Continuing constructive debate is an important part of this.</span><span style="FONT-SIZE: 10pt; FONT-FAMILY: Verdana"> </span></p>
<p><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">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. </span><span style="FONT-SIZE: 10pt; FONT-FAMILY: Verdana"> </span></p>
<p><span style="FONT-SIZE: 10pt; FONT-FAMILY: Arial">Kind regards,</span><span style="FONT-SIZE: 10pt; FONT-FAMILY: Verdana"> </span></p>
<p><i><span style="FONT-SIZE: 10pt; COLOR: blue; FONT-FAMILY: Arial">John</span></i><span style="FONT-SIZE: 10pt; COLOR: blue; FONT-FAMILY: Arial"> </span><span style="FONT-SIZE: 10pt; FONT-FAMILY: Verdana"> </span></p>
<p><span style="FONT-SIZE: 10pt; COLOR: blue; FONT-FAMILY: Arial">John Worley</span><span style="FONT-SIZE: 10pt; FONT-FAMILY: Verdana"> </span></p>
<p><span style="FONT-SIZE: 10pt; COLOR: blue; FONT-FAMILY: Arial">Team Leader | Health Services Team | Human Development Group | Policy & Research Division | DFID</span><span style="FONT-SIZE: 10pt; FONT-FAMILY: Verdana"> </span></p>
<p><span style="FONT-SIZE: 10pt; COLOR: blue; FONT-FAMILY: Arial">Tel: +44 (0)207 023 0341 | Mob: +44 (0)7810 503 994 | Email: </span><span style="FONT-SIZE: 10pt; FONT-FAMILY: Verdana"><a href="mailto:jm-worley@dfid.gov.uk" target="_blank"><span style="FONT-FAMILY: Arial">jm-worley@dfid.gov.uk</span></a></span><span style="FONT-SIZE: 10pt; COLOR: blue; FONT-FAMILY: Arial"> </span><span style="FONT-SIZE: 10pt; FONT-FAMILY: Verdana"> </span></p>
<div>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 <a href="mailto:amarriott@oxfam.org.uk" target="_blank">amarriott@oxfam.org.uk </a></div>
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<div>Kind regards</div>
<div>Anna Marriott</div>
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<p style="MARGIN: 0cm 0cm 0pt"><a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref1" target="_blank" name="12389c2d31de8d28__ftn1"><span><span><font face="Default Serif,Times New Roman,Times,serif" color="#800080">[1]</font></span></span></a><font face="Default Serif,Times New Roman,Times,serif"> Recent surveys show this, for example, a 2008 outlet survey in Benin found that most sales of anti-malarials were by shops and informal providers. At present these providers do not stock ACTs in Benin , so people are buying ineffective (cheap) medicines. Similar results on lack of ACTs in drug shops and informal outlets, which were commonly used to obtain treatment, were found in other countries surveyed ( Nigeria , DRC, and Uganda ). The surveys also show the problem of widespread availability of artemisinin monotherapy – use of which is risky for increasing resistance. In Nigeria , 8% of drug stores had the recommended ACT in stock, compared to 48% of them having artemisinin monotherapy (even in public facilities, 28% had monotherapy while 30% had recommended ACTs). In DRC, about 20% of public and private outlets stocked the recommended ACT while other ACTs were also on sale, some of unclear quality, and 39 % of public facilities and 58% of pharmacies stocked the risky artemisinin monotherapy. In Benin pharmacies that stock ACTs, they cost around 18 times more than older medicine, which makes them unaffordable for many. See ACTwatch, 2009. Benin , Nigeria , DRC and Uganda Baseline Outlet Surveys, October 2008. <a href="http://www.actwatch.info/results/overview.asp" target="_blank">http://www.actwatch.info/results/overview.asp</a> .</font></p>
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<p style="MARGIN: 0cm 0cm 0pt"><a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref2" target="_blank" name="12389c2d31de8d28__ftn2"><span><span><font face="Default Serif,Times New Roman,Times,serif" color="#800080">[2]</font></span></span></a><font face="Default Serif,Times New Roman,Times,serif"> The Benin survey quoted above found 20% of public providers and 55% of informal outlets did not know the correct dose of ACTs for a child.</font></p>
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<div>
<p style="MARGIN: 0cm 0cm 0pt"><a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref3" target="_blank" name="12389c2d31de8d28__ftn3"><span><span><font face="Default Serif,Times New Roman,Times,serif" color="#800080">[3]</font></span></span></a><font face="Default Serif,Times New Roman,Times,serif"> Lucy Smith et al, Review: Provider Practice and User Behaviour Interventions to Improve Prompt and Effective Treatment of Malaria: Do We Know What Works? Am J Trop Med Hyg 80(3), 2009, p 326-335. <a href="http://www.ajtmh.org/cgi/content/abstract/80/3/326" target="_blank">http://www.ajtmh.org/cgi/content/abstract/80/3/326</a> The review found that while there were not many rigorous studies of these kinds of interventions, those that exist show promising results: for example a shopkeeper training programme in Kenya increased the proportion of shopkeepers prescribing the correct anti-malarial at the correct dose from 0% pre-training to 98% post training. Interventions aimed at shopkeepers and drug sellers had more impact than targeting doctors and nurses. The review also concluded that pre-packaging of drugs is one of the most effective ways of increasing appropriate use of drugs, while public education on correct use of anti-malarials also has good results .</font></p>
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<p style="MARGIN: 0cm 0cm 0pt"><a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref4" target="_blank" name="12389c2d31de8d28__ftn4"><span><span><font face="Default Serif,Times New Roman,Times,serif" color="#800080">[4]</font></span></span></a><font face="Default Serif,Times New Roman,Times,serif"> In malaria-endemic countries, people commonly assume they have malaria when sick and treat themselves accordingly. The AMFm will make effective drugs more available everywhere. The use of microscopy and rapid diagnostic tests (RDTs) for malaria diagnosis alongside AMFm could improve the management of both malaria and other febrile illness, as well as the cost-effectiveness of AMFm. In peripheral areas, RDTs are the only practical option, but available RDTs have limitations. Of equal concern is that negative test results—meaning no malaria—are often ignored and patients treated anyway. For example, one study in outpatient health facilities found that half of those with a negative diagnostic test were still given anti-malarials (Reyburn et al, Rapid diagnostic tests compared with malaria microscopy for guiding outpatient treatment of febrile illness in Tanzania, British Medical Journal, 2007 <a href="http://www.bmj.com/cgi/content/abstract/334/7590/403?eaf" target="_blank">http://www.bmj.com/cgi/content/abstract/334/7590/403?eaf</a> .</font></p>
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<div>
<p style="MARGIN: 0cm 0cm 0pt"><a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref5" target="_blank" name="12389c2d31de8d28__ftn5"><span><span><font face="Default Serif,Times New Roman,Times,serif" color="#800080">[5]</font></span></span></a><font face="Default Serif,Times New Roman,Times,serif"> English M, Reyburn H, Goodman C, Snow RW (2009) Abandoning Presumptive Antimalarial Treatment for Febrile Children Aged Less Than Five Years—A Case of Running Before We Can Walk? PLoS Med 6(1): e1000015. doi:10.1371/journal.pmed.1000015</font></p>
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<div>
<p style="MARGIN: 0cm 0cm 0pt"><a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref6" target="_blank" name="12389c2d31de8d28__ftn6"><span><span><font face="Default Serif,Times New Roman,Times,serif" color="#800080">[6]</font></span></span></a><font face="Default Serif,Times New Roman,Times,serif"> D'Acremont V, Lengeler C, Mshinda H, Mtasiwa D, Tanner M, et al. (2009) Time to move from presumptive malaria treatment to laboratory-confirmed diagnosis and treatment in African children with fever. PLoS Med 6(1): e252. doi: 10.1371/journal.pmed.0050252</font></p>
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<div>
<p style="MARGIN: 0cm 0cm 0pt"><a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref7" target="_blank" name="12389c2d31de8d28__ftn7"><span><span><font face="Default Serif,Times New Roman,Times,serif" color="#800080">[7]</font></span></span></a><font face="Default Serif,Times New Roman,Times,serif"> <i>Fears for new Malaria drug resistance <a href="http://news.bbc.co.uk/1/hi/world/asia-pacific/8072742.stm" target="_blank">http://news.bbc.co.uk/1/hi/world/asia-pacific/8072742.stm</a></i></font></p>
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<div>
<p style="MARGIN: 0cm 0cm 0pt"><a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref8" target="_blank" name="12389c2d31de8d28__ftn8"><span><span><font face="Default Serif,Times New Roman,Times,serif" color="#800080">[8]</font></span></span></a><font face="Default Serif,Times New Roman,Times,serif"> The House of Commons, All Party Parliamentary Malaria Group.<span> </span>The Right Drug at the Right Time: The Power of the Affordable Medicines Facility-malaria to Save Lives. October 2007. Page 8.</font></p>
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<p style="MARGIN: 0cm 0cm 0pt"><a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref9" target="_blank" name="12389c2d31de8d28__ftn9"><span><span><font face="Default Serif,Times New Roman,Times,serif" color="#800080">[9]</font></span></span></a><font face="Default Serif,Times New Roman,Times,serif"> Ramanan Laxminarayan et al, Will A Global Subsidy of new Antimalarials delay the emergence of resistance and save lives? Health Affairs, 2006, Vol 25, 2. The recent country surveys by ACT Watch (see above) show widespread availability of artemisinin monotherapy in two countries.</font></p>
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<p style="MARGIN: 0cm 0cm 0pt"><a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref10" target="_blank" name="12389c2d31de8d28__ftn10"><span><span><font face="Default Serif,Times New Roman,Times,serif" color="#800080">[10]</font></span></span></a><font face="Default Serif,Times New Roman,Times,serif"> This is illustrated by data from Tanzania : <span></span></font></p>
<p style="MARGIN: 0cm 0cm 0pt"><a title=""></a><font face="Default Serif,Times New Roman,Times,serif">Fever treatment by source by socio-economic status, 3 districts in rural Tanzania <span style="FONT-SIZE: 12pt; FONT-FAMILY: 'Arial Unicode MS'"></span></font></p>
<p style="MARGIN: 0cm 0cm 0pt"><font face="Default Serif,Times New Roman,Times,serif">% taking up treatment (not just anti-malarials) for all age groups, 2001 data <span style="FONT-SIZE: 12pt; FONT-FAMILY: 'Arial Unicode MS'"></span></font></p>
<table style="WIDTH: 419.25pt" cellspacing="0" cellpadding="0" width="559" border="1">
<tbody>
<tr>
<td style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 131.25pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; BACKGROUND-COLOR: transparent" valign="top" width="175">
<p style="MARGIN: 0cm 0cm 0pt"><font size="2"><font face="Default Serif,Times New Roman,Times,serif">Source of treatment <span style="FONT-SIZE: 12pt; FONT-FAMILY: 'Arial Unicode MS'"></span></font></font></p></td>
<td style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 72pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; BACKGROUND-COLOR: transparent" valign="top" width="96">
<p style="MARGIN: 0cm 0cm 0pt"><font face="Default Serif,Times New Roman,Times,serif" size="2">Poorest third </font></p>
<p style="MARGIN: 0cm 0cm 0pt"><font size="2"><font face="Default Serif,Times New Roman,Times,serif">% <span style="FONT-SIZE: 12pt; FONT-FAMILY: 'Arial Unicode MS'"></span></font></font></p></td>
<td style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 72pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; BACKGROUND-COLOR: transparent" valign="top" width="96">
<p style="MARGIN: 0cm 0cm 0pt"><font face="Default Serif,Times New Roman,Times,serif" size="2">Middle third </font></p>
<p style="MARGIN: 0cm 0cm 0pt"><font size="2"><font face="Default Serif,Times New Roman,Times,serif">% <span style="FONT-SIZE: 12pt; FONT-FAMILY: 'Arial Unicode MS'"></span></font></font></p></td>
<td style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 72pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; BACKGROUND-COLOR: transparent" valign="top" width="96">
<p style="MARGIN: 0cm 0cm 0pt"><font face="Default Serif,Times New Roman,Times,serif" size="2">Better off third </font></p>
<p style="MARGIN: 0cm 0cm 0pt"><font size="2"><font face="Default Serif,Times New Roman,Times,serif">% <span style="FONT-SIZE: 12pt; FONT-FAMILY: 'Arial Unicode MS'"></span></font></font></p></td>
<td style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 72pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; BACKGROUND-COLOR: transparent" valign="top" width="96">
<p style="MARGIN: 0cm 0cm 0pt"><font face="Default Serif,Times New Roman,Times,serif" size="2">Total </font></p>
<p style="MARGIN: 0cm 0cm 0pt"><font size="2"><font face="Default Serif,Times New Roman,Times,serif">% No. <span style="FONT-SIZE: 12pt; FONT-FAMILY: 'Arial Unicode MS'"></span></font></font></p></td></tr>
<tr>
<td style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 131.25pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; BACKGROUND-COLOR: transparent" valign="top" width="175">
<p style="MARGIN: 0cm 0cm 0pt"><font size="2"><font face="Default Serif,Times New Roman,Times,serif">Any treatment <span style="FONT-SIZE: 12pt; FONT-FAMILY: 'Arial Unicode MS'"></span></font></font></p></td>
<td style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 72pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; BACKGROUND-COLOR: transparent" valign="top" width="96">
<p style="MARGIN: 0cm 0cm 0pt"><font size="2"><font face="Default Serif,Times New Roman,Times,serif">83 <span style="FONT-SIZE: 12pt; FONT-FAMILY: 'Arial Unicode MS'"></span></font></font></p></td>
<td style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 72pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; BACKGROUND-COLOR: transparent" valign="top" width="96">
<p style="MARGIN: 0cm 0cm 0pt"><font size="2"><font face="Default Serif,Times New Roman,Times,serif">80 <span style="FONT-SIZE: 12pt; FONT-FAMILY: 'Arial Unicode MS'"></span></font></font></p></td>
<td style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 72pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; BACKGROUND-COLOR: transparent" valign="top" width="96">
<p style="MARGIN: 0cm 0cm 0pt"><font size="2"><font face="Default Serif,Times New Roman,Times,serif">91 <span style="FONT-SIZE: 12pt; FONT-FAMILY: 'Arial Unicode MS'"></span></font></font></p></td>
<td style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 72pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; BACKGROUND-COLOR: transparent" valign="top" width="96">
<p style="MARGIN: 0cm 0cm 0pt"><font size="2"><font face="Default Serif,Times New Roman,Times,serif">85 <i>509 </i><span style="FONT-SIZE: 12pt; FONT-FAMILY: 'Arial Unicode MS'"></span></font></font></p></td>
</tr>
<tr>
<td style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 131.25pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; BACKGROUND-COLOR: transparent" valign="top" width="175">
<p style="MARGIN: 0cm 0cm 0pt"><font size="2"><font face="Default Serif,Times New Roman,Times,serif">Visited Government facility <span style="FONT-SIZE: 12pt; FONT-FAMILY: 'Arial Unicode MS'"></span></font></font></p>
</td>
<td style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 72pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; BACKGROUND-COLOR: transparent" valign="top" width="96">
<p style="MARGIN: 0cm 0cm 0pt"><font size="2"><font face="Default Serif,Times New Roman,Times,serif">24 <span style="FONT-SIZE: 12pt; FONT-FAMILY: 'Arial Unicode MS'"></span></font></font></p></td>
<td style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 72pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; BACKGROUND-COLOR: transparent" valign="top" width="96">
<p style="MARGIN: 0cm 0cm 0pt"><font size="2"><font face="Default Serif,Times New Roman,Times,serif">21 <span style="FONT-SIZE: 12pt; FONT-FAMILY: 'Arial Unicode MS'"></span></font></font></p></td>
<td style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 72pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; BACKGROUND-COLOR: transparent" valign="top" width="96">
<p style="MARGIN: 0cm 0cm 0pt"><font size="2"><font face="Default Serif,Times New Roman,Times,serif">23 <span style="FONT-SIZE: 12pt; FONT-FAMILY: 'Arial Unicode MS'"></span></font></font></p></td>
<td style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 72pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; BACKGROUND-COLOR: transparent" valign="top" width="96">
<p style="MARGIN: 0cm 0cm 0pt"><font size="2"><font face="Default Serif,Times New Roman,Times,serif">23% <i>136 </i><span style="FONT-SIZE: 12pt; FONT-FAMILY: 'Arial Unicode MS'"></span></font></font></p></td>
</tr>
<tr>
<td style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 131.25pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; BACKGROUND-COLOR: transparent" valign="top" width="175">
<p style="MARGIN: 0cm 0cm 0pt"><font size="2"><font face="Default Serif,Times New Roman,Times,serif">Visited NGO facility <span style="FONT-SIZE: 12pt; FONT-FAMILY: 'Arial Unicode MS'"></span></font></font></p></td>
<td style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 72pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; BACKGROUND-COLOR: transparent" valign="top" width="96">
<p style="MARGIN: 0cm 0cm 0pt"><font size="2"><font face="Default Serif,Times New Roman,Times,serif">3 <span style="FONT-SIZE: 12pt; FONT-FAMILY: 'Arial Unicode MS'"></span></font></font></p></td>
<td style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 72pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; BACKGROUND-COLOR: transparent" valign="top" width="96">
<p style="MARGIN: 0cm 0cm 0pt"><font size="2"><font face="Default Serif,Times New Roman,Times,serif">3 <span style="FONT-SIZE: 12pt; FONT-FAMILY: 'Arial Unicode MS'"></span></font></font></p></td>
<td style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 72pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; BACKGROUND-COLOR: transparent" valign="top" width="96">
<p style="MARGIN: 0cm 0cm 0pt"><font size="2"><font face="Default Serif,Times New Roman,Times,serif">13 <span style="FONT-SIZE: 12pt; FONT-FAMILY: 'Arial Unicode MS'"></span></font></font></p></td>
<td style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 72pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; BACKGROUND-COLOR: transparent" valign="top" width="96">
<p style="MARGIN: 0cm 0cm 0pt"><font size="2"><font face="Default Serif,Times New Roman,Times,serif"> 7% <i>39 </i><span style="FONT-SIZE: 12pt; FONT-FAMILY: 'Arial Unicode MS'"></span></font></font></p></td>
</tr>
<tr>
<td style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 131.25pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; BACKGROUND-COLOR: transparent" valign="top" width="175">
<p style="MARGIN: 0cm 0cm 0pt"><font size="2"><font face="Default Serif,Times New Roman,Times,serif">Visited drug store <span style="FONT-SIZE: 12pt; FONT-FAMILY: 'Arial Unicode MS'"></span></font></font></p></td>
<td style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 72pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; BACKGROUND-COLOR: transparent" valign="top" width="96">
<p style="MARGIN: 0cm 0cm 0pt"><font size="2"><font face="Default Serif,Times New Roman,Times,serif">28 <span style="FONT-SIZE: 12pt; FONT-FAMILY: 'Arial Unicode MS'"></span></font></font></p></td>
<td style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 72pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; BACKGROUND-COLOR: transparent" valign="top" width="96">
<p style="MARGIN: 0cm 0cm 0pt"><font size="2"><font face="Default Serif,Times New Roman,Times,serif">24 <span style="FONT-SIZE: 12pt; FONT-FAMILY: 'Arial Unicode MS'"></span></font></font></p></td>
<td style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 72pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; BACKGROUND-COLOR: transparent" valign="top" width="96">
<p style="MARGIN: 0cm 0cm 0pt"><font size="2"><font face="Default Serif,Times New Roman,Times,serif">27 <span style="FONT-SIZE: 12pt; FONT-FAMILY: 'Arial Unicode MS'"></span></font></font></p></td>
<td style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 72pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; BACKGROUND-COLOR: transparent" valign="top" width="96">
<p style="MARGIN: 0cm 0cm 0pt"><font size="2"><font face="Default Serif,Times New Roman,Times,serif">27% <i>159 </i><span style="FONT-SIZE: 12pt; FONT-FAMILY: 'Arial Unicode MS'"></span></font></font></p></td>
</tr>
<tr>
<td style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 131.25pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; BACKGROUND-COLOR: transparent" valign="top" width="175">
<p style="MARGIN: 0cm 0cm 0pt"><font size="2"><font face="Default Serif,Times New Roman,Times,serif">Visited general shop <span style="FONT-SIZE: 12pt; FONT-FAMILY: 'Arial Unicode MS'"></span></font></font></p></td>
<td style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 72pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; BACKGROUND-COLOR: transparent" valign="top" width="96">
<p style="MARGIN: 0cm 0cm 0pt"><font size="2"><font face="Default Serif,Times New Roman,Times,serif">30 <span style="FONT-SIZE: 12pt; FONT-FAMILY: 'Arial Unicode MS'"></span></font></font></p></td>
<td style="BORDER-RIGHT: #d4d0c8; PADDING-RIGHT: 0cm; BORDER-TOP: #d4d0c8; PADDING-LEFT: 0cm; PADDING-BOTTOM: 0cm; BORDER-LEFT: #d4d0c8; WIDTH: 72pt; PADDING-TOP: 0cm; BORDER-BOTTOM: #d4d0c8; BACKGROUND-COLOR: transparent" valign="top" width="96">
<p style="MARGIN: 0cm 0cm 0pt"><font size="2"><font face="Default Serif,Times New Roman,Times,serif">34 <span style="FONT-SIZE: 12pt; FONT-FAMILY: 'Arial Unicode MS'"></span></font></font></p></td>
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<p style="MARGIN: 0cm 0cm 0pt"><font size="2"><font face="Default Serif,Times New Roman,Times,serif">26 <span style="FONT-SIZE: 12pt; FONT-FAMILY: 'Arial Unicode MS'"></span></font></font></p></td>
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<p style="MARGIN: 0cm 0cm 0pt"><font size="2"><font face="Default Serif,Times New Roman,Times,serif">30% <i>179 </i><span style="FONT-SIZE: 12pt; FONT-FAMILY: 'Arial Unicode MS'"></span></font></font></p></td>
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<p style="MARGIN: 0cm 0cm 0pt"><font face="Default Serif,Times New Roman,Times,serif"><span style="COLOR: blue">Source: Njau 2006. </span>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. </font></p>
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<p style="MARGIN: 0cm 0cm 0pt"><a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref11" target="_blank" name="12389c2d31de8d28__ftn11"><span><span><font face="Default Serif,Times New Roman,Times,serif" color="#800080">[11]</font></span></span></a><font face="Default Serif,Times New Roman,Times,serif"> </font><a href="http://www.theglobalfund.org/en/savinglives/ethiopia/ma1/" target="_blank"><font face="Default Serif,Times New Roman,Times,serif">http://www.theglobalfund.org/en/savinglives/ethiopia/ma1/</font></a><font face="Default Serif,Times New Roman,Times,serif"> Ethiopia Halves Malaria Deaths in Three Years. </font></p>
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<p style="MARGIN: 0cm 0cm 0pt"><a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref12" target="_blank" name="12389c2d31de8d28__ftn12"><span><span><font face="Default Serif,Times New Roman,Times,serif" color="#800080">[12]</font></span></span></a><font face="Default Serif,Times New Roman,Times,serif"> For example a survey in 6 districts of Uganda looked at uptake of ACTs which were in principle available for free from public providers at that time. Despite this, it found that use of ACTs was very low in all districts - about 10% of children received ACTs within 48 hours in three Western districts, less than 4% in three Eastern districts surveyed. Many of these ACTs came from the private sector. MMV, MOH Uganda and PSI, Nov 2007. Understanding malaria health seeking behaviour in selected districts in Uganda – Draft report . In addition, a November 2008 survey shows that while there are ACTs available in 84% of the public facilities surveyed, they were actually distributing more non-ACT antimalarials than ACTs. ACTwatch Uganda baseline survey, 2008.<span> </span></font></p>
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<p style="MARGIN: 0cm 0cm 0pt"><a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref13" target="_blank" name="12389c2d31de8d28__ftn13"><span><span><font face="Default Serif,Times New Roman,Times,serif" color="#800080">[13]</font></span></span></a><font face="Default Serif,Times New Roman,Times,serif"> For example, a 2007 study in Zambia found the recommended ACT was unavailable in 42% of rural health units, 30% of urban health clinics and 25% of hospitals, with average stock out times over 9 weeks for rural units. Zambia Ministry of Health, 2007</font></p>
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<p style="MARGIN: 0cm 0cm 0pt"><a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref14" target="_blank" name="12389c2d31de8d28__ftn14"><span><span><font face="Default Serif,Times New Roman,Times,serif" color="#800080">[14]</font></span></span></a><font face="Default Serif,Times New Roman,Times,serif"> Concerns about future stock outs were a factor, alongside other issues. Wasunna b et al, 2008. Why Don’t Health Workers prescribe ACTs? A qualitative study of factors affecting the prescription of AL , Malaria Journal, 7:29. <a href="http://www.malariajournal.com/content/7/1/29" target="_blank">http://www.malariajournal.com/content/7/1/29</a></font></p>
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<p style="MARGIN: 0cm 0cm 0pt"><a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref15" target="_blank" name="12389c2d31de8d28__ftn15"><span><span><font face="Default Serif,Times New Roman,Times,serif" color="#800080">[15]</font></span></span></a><font face="Default Serif,Times New Roman,Times,serif"> For example, facility surveys for the Global Fund evaluation suggest higher availability in some countries by 2008, e.g. 79% in Zambia , but still only 36% in Burkina Faso . See reference below.<span> </span></font></p>
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<p style="MARGIN: 0cm 0cm 0pt"><a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref16" target="_blank" name="12389c2d31de8d28__ftn16"><span><span><font face="Default Serif,Times New Roman,Times,serif" color="#800080">[16]</font></span></span></a><font face="Default Serif,Times New Roman,Times,serif"> “ While there are data showing that most countries have purchased large amounts of ACT, there is little or no evidence of a corresponding increase in the use of ACT for treatment of children .” They found that Zambia was a notable exception, where 13% of children who were treated for fever were reported to have been treated with ACT in 2006.<span> </span>No other country showed coverage of ACT above 5%. Some countries showed declines in coverage of anti-malarials. They also found no evidence that quality of treatment had improved. Macro International, et al, May 2009. Final Report.<span> </span>Global Fund Five-Year Evaluation: Study Area 3.<span> </span>The Impact of Collective Efforts on the Reduction of the Disease Burden of AIDS, Tuberculosis and Malaria. <a href="http://www.theglobalfund.org/documents/terg/TERG_SA3_ExecutiveSummary.pdf" target="_blank">http://www.theglobalfund.org/documents/terg/TERG_SA3_ExecutiveSummary.pdf</a></font></p>
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<p style="MARGIN: 0cm 0cm 0pt"><a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref17" target="_blank" name="12389c2d31de8d28__ftn17"><span><span><font face="Default Serif,Times New Roman,Times,serif" color="#800080">[17]</font></span></span></a><font face="Default Serif,Times New Roman,Times,serif"> See the AMFm application guidelines at <a href="http://www.theglobalfund.org/documents/amfm/1/AMFm_Phase_1_Guidelines_for_Applications.pdf" target="_blank">http://www.theglobalfund.org/documents/amfm/1/AMFm_Phase_1_Guidelines_for_Applications.pdf</a></font></p>
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<p style="MARGIN: 0cm 0cm 0pt"><a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref18" target="_blank" name="12389c2d31de8d28__ftn18"><span><span><font face="Default Serif,Times New Roman,Times,serif" color="#800080">[18]</font></span></span></a><font face="Default Serif,Times New Roman,Times,serif"> W ithin one month 30% of consumers who purchased anti-malarials in the two intervention districts bought ACTs. After five months, this had increased to 44% of purchases. This compares to 1% of consumers buying ACTs before the pilot and 0.1% in the control district. Of the anti-malarials bought for children under 5, 62% were ACTs. Prices remained low, and dosages were appropriate. Clinton Foundation, April 26 2008, Tanzania Pilot ACT subsidy: Report on findings.</font></p>
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<p style="MARGIN: 0cm 0cm 0pt"><a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref19" target="_blank" name="12389c2d31de8d28__ftn19"><span><span><font face="Default Serif,Times New Roman,Times,serif" color="#800080">[19]</font></span></span></a><font face="Default Serif,Times New Roman,Times,serif"> Cohen, J. and P. Dupas (2007) and Kremer, M. and E. Miguel (2007) cited in Yates, R. (2009) ‘Universal health care and the removal of user fees’, <i>Lancet</i>, 373: 2078-2081.</font></p>
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<p style="MARGIN: 0cm 0cm 0pt"><a title="" href="http://merlin.oxfam.org.uk/mail/amarriot.nsf/($Drafts)/$new/?EditDocument&Form=h_PageUI&PresetFields=h_EditAction;h_New,s_NotesForm;Memo#_ftnref20" target="_blank" name="12389c2d31de8d28__ftn20"><span><span><font face="Default Serif,Times New Roman,Times,serif" color="#800080">[20]</font></span></span></a><font face="Default Serif,Times New Roman,Times,serif"> Dr Margaret Chan, Director-General of the World Health Organization. Report to the Executive Board, 122nd session. Geneva , Switzerland . 21 January 2008. <a href="http://www.who.int/dg/speeches/2008/20080121_eb/en/index.html" target="_blank">http://www.who.int/dg/speeches/2008/20080121_eb/en/index.html</a></font></p>
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