Saving a Program That Saves Lives

Every year, some 30 million children in Africa survive the first few perilous weeks of life, but within five years 2.5 million of them die. More than a half million of these deaths are a result of an easily curable disease: malaria.

In recent years, some progress has been made against malaria, which is caused by a parasite, Plasmodium falciparum, that is transmitted to humans by mosquitoes. The world spends roughly a billion dollars a year trying to contain the disease — mostly through insecticide-treated bed nets — and treating it at government-run clinics.

But just as nets are vulnerable to holes and wily mosquitoes, so, too, have our efforts to treat malaria been plagued by gaps, failures and the extraordinary cleverness of the pathogen itself. In the past, for example, the disease was cured by a decades-old drug called chloroquine that was largely sold over the counter. The falciparum parasites, though, grew resistant to it.

Then, 10 years ago, the World Health Organization recommended abandoning chloroquine in favor of a very effective combination therapy based on artemisinin (A.C.T.). But that regimen has been far too expensive for most malaria sufferers, many of whom end up buying the cheaper, ineffective chloroquine from local shops.

That was the dilemma facing a United States Institute of Medicine committee that I led in 2002. We were asked to recommend ways to make authentic A.C.T.’s available and affordable where malaria is endemic, including in remote areas where public hospitals or clinics are distant, costly and — once reached — often out of the drugs.

The answer we arrived at was remarkably straightforward: to subsidize the therapy and sell it as cheaply as chloroquine in Africa’s private pharmacies and shops, where half of all patients first seek treatment for malaria-like fevers.

That idea was at last put in place in 2010, when the Global Fund to Fight AIDS, Tuberculosis and Malaria began a pilot program in which it provided a “co-payment” to the manufacturers of A.C.T.’s, thereby allowing commercial wholesalers and private or government health services to purchase the drugs at a fraction of the already low negotiated price. The program, known as the Affordable Medicines Facility-malaria (AMFm), was introduced in seven African countries, covering about a third of the area where malaria is endemic on the continent.

Strikingly, it has worked. Since 2010 the private sector has moved subsidized A.C.T.’s rapidly through standard supply chains to urban and rural Africans at prices poor families can afford. Independent researchers from the London School of Hygiene and Tropical Medicine and ICF International, a consulting group, recently published their formal evaluation in The Lancet, concluding that the initiative met high benchmarks for availability and price everywhere it was substantially implemented, even in remote rural areas.

Still, it may not end well for AMFm. The Global Fund is to meet on Wednesday, with American representatives in attendance, to consider what comes next. The recommendations on the table are to cut back, not expand, the subsidy program.

Critics have said that the evaluation of the pilot program is not definitive because it was not designed to count the number of children’s lives saved. In addition, some point out that AMFm allows people who believe they are suffering from malaria, but who may in fact be sick from something else, to buy the drugs without a firm diagnosis.

There is truth to both of these claims. And yes, in an ideal world, all sick people would be properly diagnosed and treated with the right medicine at the right time in a public clinic close to home. But decades of investment have not produced a working health care system in most of Africa, especially in poor rural areas.

This initiative is an interim measure to ensure that fewer children die for lack of effective anti-malarials, while efforts continue to help build effective public health systems. Universal diagnosis is certainly desirable, but even long-established treatment (and much smaller) programs do not properly diagnose every illness. Moreover, diagnosis makes sense only if the treatments that follow are both affordable and accessible.

During the last few years, we have learned a lot about using private markets to deliver lifesaving treatments. “Version 2.0” of AMFm could be improved, perhaps by encouraging the effective use of diagnostic tests.

The risk is that efforts to develop and implement “the perfect” will end up killing “the good” in the process. That has long been the playbook for too many in the global anti-malarial community — the governmental agencies, charities and nongovernmental organizations that have spent billions but found few perfect solutions to date.

These experts have had their say. It’s high time that we also listen to malaria-control program managers from the pilot countries where AMFm has been in place. Last month, at a meeting held by the Institute of Medicine in Washington, those managers voiced unanimous support for continuing and expanding the program and warned of serious consequences if A.C.T. prices rose.

They, and many others are asking now, in what world does it make sense to abandon a simple program that saves lives?

Kenneth J. Arrow, a Nobel laureate in economic sciences in 1972, is an emeritus professor of economics at Stanford University.

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