AMFm post over at CGD – a few thoughts on the conversation

here’s the series:

http://blogs.cgdev.org/globalhealth/2012/09/what-the-pre-post-evaluation-of-amfm-can-tell-us.php

http://blogs.cgdev.org/globalhealth/2012/11/the-future-of-amfm-making-sense-from-all-the-noise.php

http://blogs.cgdev.org/globalhealth/2012/11/the-future-of-amfm-realpolitik-and-realistic-options-part-ii.php

@altmandaniel pointed out that our position on what the Board should decide in the final post was not entirely clear. this is true – our goal was to lay out the positions and process rather than take a strong stance on the outcome. with regard to outcomes, the matching-based funding model would be the preferable option if you support facilitating private-sector delivery of drugs, while the integrated model represents a likely vote against intervention in the the private sector – at least absent a strong mandate for the TRP.

what @fanvictoria and i take a stand on is who and what needs to be considered by the Board. we further take a stand on the requisite transparency of the Board’s consideration.

this is a Big Moment for how evidence-based policy making plays out – and the decision at the end of the large-scale pilot period is neither as clear nor as technical as many people seem to have expected. both continuing AMFm and abruptly terminating it have strong implications for access to malaria drugs – but also in the political and policy spheres within implementing countries.

frankly, despite fast-paced and extensive evaluation efforts, what we learn about the AMFm is not really enough to say whether it is the ‘best’ approach to increasing access to malaria treatment. it is a reasonable proof-of-concept that the world does not fall apart when the private sector is used as a supply mechanism for increasing access to aid-subsidized drugs. beyond that, the debate remains both largely speculative and, in place of evidence about the relative impact on malaria morbidity and mortality, ideological.

given this, we step back in order to lay out the actual options and trade-offs that should be considered. some of these – how to improve dosing practices, how to encourage proper completion of doses by patients, how to strengthen in-country regulatory mechanisms and monitoring capacity, how to improve demand generation & information dissemination, how to include local pharmaceutical manufacturers – all often seem to be drowned out by either rancor over whether the private sector (in low and middle income countries) is an appropriate target for aid dollars or by discussions of specific types of subsidies and diagnostics. these are important moving parts in the bigger picture but they are not the only moving parts.

as a closing point on the Board’s decision, i‘d like to point out that many countries have already made a choice on whether it is right for ACTs to be sold in the private sector  because they have given ACTs over-the-counter status. this is not a decision about where people do seek treatment for fever and whether that is the ‘right’ place. rather, the discussion should proceed from the positive reality that the private sector is utilized for fever treatment. thus, the needed normative and positive discussions are about

(a) whether it is ‘right’ for aid-subsidized drugs to be distributed in the private sector;

(b) whether people in low- and middle-income countries should pay for medicine at all;

(c) how aid money can be used most effectively to strengthen front-line worker and patient practices across sectors, including learning lessons from experiments with community health workers, nurses and pharmacists in the public sector, and drug shop staff in private sector; and, finally,

(d) how we can better design, test, evaluate, and cooperate on an approach or combination of approaches to reduce malaria morbidity and mortality that also strengthens systems for supplying treatment more generally.