Availability of Subsidized Malaria Drugs in Kenya

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The Issue:

ImageThe Affordable Medicines Facility – malaria (AMFm) is a policy scheme implemented in Kenya in August 2010 and managed by the Global Fund to Fight AIDS, TB, and Malaria with support from the United Nations, the UK Department for International Development (DFID) and related donors such as the Bill & Melinda Gates Foundation and the Roll Back Malaria (RBM) Partnership. The AMFm scheme subsidizes artemisinin-based combination therapies (ACTs), so that an adult dose is supposed to retail at 40 Kenyan Shillings (KES) or 50 cents, in contrast to the average retail price of 400 KES (about $5) in Kenya. The issue is that many pharmacies and/or first line buyers and manufacturers across the country have taken advantage of the subsidy to maximize profits, with the result that the drugs are selling at varying prices, between 80 KES ($1), to 240 KES ($3). Additional information can be found here. This photo (credit IPS News) shows the package of ACTs, identified by the green leaf in the top left corner.

Availability of ACTS and Impact on Health:

Malaria patients are the direct benefactors of the subsidized drugs, and the availability of these drugs are essential to the livelihood of many families. Without the lower cost option, many patients could not afford anti-malaria drugs at all, and would suffer or potentially die as a result. However, these patients have no influence over the prices set by the first line buyers or the pharmacies.

Kenyan Government and NGOs Can Lead the Way In Establishing and Enforcing Subsidy:

The government of Kenya has been making efforts to educate the public on the availability of the subsidized drugs. The government does recognize the importance of enforcing the AMFm policy, given the benefits it can have on public health, but does not have control over drugs sold in pharmacies in the private sector because the pharmaceutical market in Kenya is based on ‘a willing seller, willing buyer’ concept.

The Global Fund and other NGOs are essential players, as they host the AMFm financing mechanism and have negotiated with manufacturers a reduced price for the anti-malaria drugs. The Global Fund pays the majority of the reduced price of these drugs to manufacturers, thus lowering the cost to first-line buyers.

The Critical Role of First Line Buyers and Pharmacies:

First line buyers purchase anti-malaria drugs at reduced prices from manufactures and are expected to pass on the highest possible proportion of this price benefit so that patients are able to buy ACTs across the public, private, not-for-profit and for-profit sectors at prices that are less than those of monotherapies. First line buyers play a key role in determining the price of the ACTs to pharmacies, which is subsequently passed onto the patients.

The pharmacies in Kenya are directly responsible for ensuring that these drugs are available to consumers at the lower price, but many have chosen to ignore the AMFm price standards because selling them at the recommended retail price is not economically beneficial to them.

Role of Hospitals/Clinics: How Can they Support Enforcement?

Although district hospitals and clinics provide direct care to malaria patients, they often offer ACTs at the average retail price and do not adhere to the AMFm requirements. Patients are often required to obtain medication on their own, usually at a private pharmacy. However, there is opportunity for these hospitals and clinics to step up and begin to offer drugs in house, at AMFm prices.

Drawbacks/Weaknesses of AMFm:

As described in this article, some argue that the Global Fund is placing minor reductions in the price of anti-malaria drugs above the value of health. The availability of anti-malaria drugs in Kenya, where approximately 13 million people contract malaria every year and an estimated 48,000 die, the successful procurement and distribution of anti-malarial drugs can be a matter of life and death, and many argue that drugs should always be available in all clinics regardless of price. Other drawbacks/weaknesses of AMFm, as described in this article, include AMFm products being sold in non‐AMFm countries, ACT manufacturers also acting as first‐line buyers, and 70% of AMFm treatment being ordered in adult doses despite the fact that malaria is mainly a childhood disease.

Policy Recommendation:

The Kenyan government should be given enforcement power over the pharmaceutical industry in Kenya, and then enforce the subsidized price for the drugs set by AMFm through frequent surveillance and pharmacy visits, combined with a continued emphasis on public awareness campaigns through the media. These campaigns would inform Kenyans of the availability of the drugs and the recommended prices per dose so that the public may help enforce the low price of drugs.

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6 Responses to “Availability of Subsidized Malaria Drugs in Kenya”

  1. sbfphc Says:

    AMFm has been controversial from the beginning. In fact it is at present only a 2-year experiment in 8 countries. People in our IH Department are involved in the evaluation of AMFm, after which hopefully we will know the fate of this experiment – something that will be scaled up to other endemic countries, or a program option left to individual countries.
    A variety of early reports show a variety of ‘results’. Last year in Ghana it was seen that the price of ACTs varied from the desired 50 US cents to $4.00. Even some ‘success’ was seen here in that a normal commercial price for ACTs was $8.00 for an adult dose.
    Reports from Kenya’s neighbor, Tanzania, have been more positive with findings that the program has increased ACT supplies at the grassroots where most needed. Again, the policy implications and actions will become more evident in each participating country at the end of the two-year period when they have to decide whether to continue the subsidy or not. Even before the advent of AMFm one of the Global Fund Principal Recipients in Nigeria was experimenting with a malaria drug subsidy, and even then learned that medicine shops and pharmacies had misgivings about the profitability of the scheme for their businesses. Many stakeholders will have views on this when the time comes to regularize it into policy or shrug it off as just an experiment.

  2. jzuspann Says:

    Thanks for your comprehensive post. I find this controversial topic both at the forefront of our malaria control efforts and, personally, very interesting.

    In theory, I think AMFm is a good idea, but one thing that is always surprising to me when programs like this are implemented and cost hundreds-of-millions of dollars (in this case 225 M) is the general lack of oversight. In practice, this effort requires immense collaboration between AMFm, pharmaceutical manufacturares, first-line buyers (who should be distinct entities from the manufacturares), pharmacies and patients. Clearly, we all recognize the importance of increasing patient access to combination therapies by reducing cost, yet the process is often piecemealed, political and results in a failed attempt over time. It’s unfortunate that we don’t think through the complexities prior to delving-in since the people who are really hurt from our unsuccessful efforts are the patients suffering from diseases.

    As of last fall, I know AMFm didn’t really have the capacity (in terms of finances) to scale-up beyond the four countries they are working with now. My concern is that AMFm will prioritize ACT procurement for participant countries and that stockouts in non-participating countries will increase, advancing the prospect of artimisinin resistance due to increasing demand causing more widespread use of monotherapies and/or counterfeit ACTs.

    Convening all stakeholders and including all countries where people suffer from malaria should be the first priority so as not to cause inadvertent outcomes in the long-term. Secondly, improved monitoring and evaluation should be a central component of oversight (this is definitely the case in Kenya), since in practice, programs often malfunction due to inherent operating differences that were never considered when first implemented.

  3. kakuete Says:

    Thank you for your post this was very informative I am interested to see what the results of the studies show because of the affect it could have on the malaria treatment forefront but despite the findings I feel that you present a very interesting issues because if these price issues are present with these drugs are the same issues present with other medications? I agree the government should have closer monitoring of these pharmacies to make sure the prices of medications in general are appropriate.

  4. diwadt Says:

    I keep wondering if a community based malaria drug distribution program would not work better. Although some hurdles might still exist as long as there is a secondary market for the drugs, this may offer improvements. I also wonder if a Bamako type program may not yield better results. Nevertheless, easy access to malaria medication absent a healthcare intermediary as is the case in many African countries is often a double edge sword. There tends to be overuse and therefore inappropriate treatment of malaria where access is not controlled. Although a good case can be made for self-management of malaria in rural areas, true cases of malaria are sometimes poorly managed with self-diagnosis and treatment. In the end, complicated cases of malaria reach treatment facilities when prognosis is poor.

  5. jwanyiri Says:

    The policy proposed here will be very difficulty or almost impossible to implement in Kenya. Largely due to logistics as well as political will. Drugs are not only sold in regulated pharmacies (well if there was something like this in Kenya) but also in small roadside kiosks. I agree with diwadt that probably community based malaria drug distribution would be an alternative . Otherwise nearly every part of Kenya has government clinics and dispensaries and these could be used as distributions points for these drugs as they could be easier to regulate .

  6. smlabuda Says:

    It seems that subsidies and price regulation, along with other interventions such as community-based treatment with ACTs via CHWs need to be combined in order to really make an impact on the burden of disease. There are several journal articles showing that these are possible – even teaching CHWs to perform RDTs and only treat positive cases of malaria.

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