tentative thoughts on ownership: work-in-progress

i am road-testing a few ideas from the conclusion of my thesis, in which i try to bring out two themes recurring throughout the analyses on adoption and implementation of the phase I pilot of the amfm in ghana, between 2010 and 2012. these themes are ownership and risk-taking. i have already written a bit about risk-taking here. below, i share some of my tentative ideas and questions on ownership (slightly edited from the thesis itself, including removing some citations of interviewees for now).

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delighted for comments.

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one undercurrent running throughout this thesis is the idea of ownership of: the definition of the problem and solution at hand, the process of adopting the amfm, and of the program itself and its implementation.

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in chapter 4, i introduced stakeholder ideas of paths not taken, including how the program might have “develop[ed], not negate[d], local production capacity,” including through support to local manufacturers to upgrade to meet WHO prequalification and through work to bring local government and industry (rather than global industry) into closer partnership. both those ultimately receptive and resistant to the amfm acknowledged that all national stakeholders “would have preferred to have had quality, local drugs.” the very strength of the amfm design — high-level negotiations and subsidization — precluded local, structural changes.

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in chapter 5, i highlighted that several key stakeholders refused to take — that is, to own — a stand on whether ghana should apply to the phase 1 pilot. moreover, the key, institutional decision-makers in the country coordinating mechanism for the global fund (ccm) vacillated on whether or not to send the application while a variety of circumstantial stakeholders felt they had stake in the decision and worked to influence the process. in chapter 6, i analyze how global ideas and actors played a role in ghana’s adoption of phase 1. in chapter 7, i describe the way the amfm coordination committee (amfm-cc) was set up which, in composition and process, differs from the ccm.

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these points on alternatives not considered, on vacillation, on avoidance, and on outright resistance relate to conceptions of country ownership of development initiatives, as in the paris declaration. the absence of a national politics and aligned problem stream, in particular, neatly dovetails with the ideas of david booth that clarify what should be meant by country ownership (booth 2012). he proposes that it means an end to conditionality to “buy reform” and an end to channeling aid funding through “projects” as a way of by-passing country decision-making bodies, processes, and institutions (booth 2010)

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the ccm represents an interesting example with which to examine country ownership. their explicit raison d’ětre is to foster ownership and they do indeed bring together representatives of government bureaucracy, business, and civil society, “representing the views and interests of grant recipient countries.” yet this structure allowed for vacillation within and strong views without. we must consider this and also juxtapose the make-up of the ccm versus the amfm-cc in terms of the stakeholders represented, the capacity and legitimacy to make relevant decisions, and a sense of ownership about the work ahead. having done this, it seems that, at a minimum, we must question whether the ccm composition when adopting phase 1 allowed for sufficient ownership. given the effort of ccm members to yield decision-making power to the minister of health, it seems that ccm members did not think so.

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however, it is not fair to critique apparent limited ownership without raising three additional questions:

  • would ghana have tried out the amfm if political or bureaucratic actors had to take initial responsibility for the design?
  • did limited national ownership of the design and adoption decision allow national stakeholders to better, “energ[etically]” implement the initiative, maximizing credit-seeking after minimizing risk for blame during adoption (while recognizing that policy entrepreneurs and others still felt this risk keenly)?
  • how should we interpret ghana’s decision to continue with the global fund’s private sector co-payment mechanism?

these questions offer avenues for further analysis of the role of donors, the state, and the public.

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indeed, ownership is not only an issue for capital-based elites; Fox (2015) recently highlighted that “the current aid architecture deprives both african governments and african publics of agency.” in chapter 7, I introduce views of the citizens and businesspeople at the street-level of implementation. about 20%, during in-depth interviews, spontaneously said they wanted to see the amfm continued — a view that seems to have had no way of entering any debates about the future of the amfm and is absent from the academic literature on this initiative.

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though the minority, some respondents specifically voiced that they should have learned about the amfm through a government agency or professional association. two specifically raised their position as stakeholders. one, who heard from her supplier, said “i think it wasn’t fair because as major stakeholders, we should have been briefed before.” another, who heard first from the media, said “i felt this was wrong since we are a major stakeholder. we should have met as partners.” these concerns relate to relations between ghana and the global fund as well as between accra-based elites and tamale-based retailers.

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the events of both adoption and implementation of the AMFm suggest that ownership is important (in no way a novel claim). note, though, that there may be certain amounts of freedom to innovate accorded by being just an implementer, rather than having clear ownership of a new idea, decision-making power over adopting and implementing that idea, and, accordingly, more risk if the idea does not pan out.

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also, if we accept that ownership is indeed important, which seems a plausible lesson to draw from this thesis, we also learn that simply giving decision-making power to some national stakeholders is insufficient. the right national stakeholders and their existing decision-making structures need to be in play. we may glean something about relevant national stakeholders in this case through the composition of the amfm-cc and the committee characteristics raised as important (transparency, collaboration). but, given the views of some street-level implementers, ownership may require further consideration.

Thinking About Stakeholder Risk and Accountability in Pilot Experiments

This post is also cross-posted here in slightly modified form.

Since I keep circling around issues related to my dissertation in this blog, I decided it was time to start writing about some of that work. As anyone who has stood or sat near to me for more than 5 minutes over the past 4.25 years will know, in my thesis I examine the political-economy of adopting and implementing a large global health program (the affordable medicines facility – malaria or “AMFm”). This program was designed at the global level (meaning largely in D.C. and Geneva with tweaking workshops in assorted African capitals). Global actors invited select Sub-Saharan African countries to apply to pilot the AMFm for two years before any decision was made to continue, modify, scale-up, or terminate. It should also be noted from the outset that it was not fully clear what role the evidence would play in the board’s decision and how the evidence would be interpreted. As I highlight below, this lack of clarity helped to foster feelings of risk as well as a resistance among some of the national-level stakeholders about participating in the pilot. . . as  . .

To push the semantics a bit, several critics have (e.g.) noted that scale and scope and requisite new systems and relationships involved in the AMFm disqualify it from being considered a ‘pilot,’ though i use that term for continuity with most other AMFm-related writing. . .

In my research, my focus is on the national and sub-national processes of deciding to participate in the initial pilot (‘phase I’) stage, focusing specifically on Ghana. Besides the project scale and resources mobilized, one thing that stood out about this project is that there was a reasonable amount of resistance to piloting this program among stakeholders in several of the invited countries. I have been very fortunate that my wonderful committee and outside supporters like Owen Barder have continued to push me over the years (and years) to try to explain this resistance to an ostensibly ‘good’ program. Moreover, I have been lucky and grateful that a set of key informants in Ghana that have been willing to converse openly with me over several years as I have tried to untangle the reasons behind the support and resistance and to try to get the story ‘right’. . .

The set-up of the global health pilot experiment, from the global perspective, the set-up was a paragon of planning for evidence-informed decision-making: pilot first, develop benchmarks for success and commission an independent evaluation (a well-monitored before and after comparison) — and make decisions later. . .

In my work, through a grounded qualitative analysis, I distil the variety of reasons for supporting and resisting Ghana’s participation in the AMFm pilot to three main types: those related to direct policy goals (in this case, increasing access to malaria medication and lowering malaria mortality), indirect policy goals (indirect insofar as they are not the explicit goals of the policy in question, such as employment and economic growth), and finally those related to risk and reputation (individual, organizational, and national). I take the latter as my main focus for the rest of this post. . . . .

A key question on which I have been pushed is the extent to which resistance to participation (which meant resisting an unprecedented volume of highly subsidized, high-quality anti-malarial treatments entering both the public and the private sector) emerges from the idea of the AMFm versus the idea of piloting the AMFm with uncertain follow-up plans. . ..

Some issues, such as threats to both direct and indirect policy goals often related to the AMFm mechanism itself, including the focus on malaria prevention rather than treatment as well as broader goals related to national pride and the support of local businesses. The idea of the AMFm itself, as well as it a harbinger of approaches (such as market-based approaches) to global health, provoked both support and resistance. . . .

But some sources of resistance stemmed more directly from the piloting process itself. By evidence-informed design, the global fund gave “no assurance to continue [AMFm] in the long-term,” so that the evaluation of the pilot would shape their decision. This presented limited risks to them. At the national level, this uncertainty proved troubling, as many local stakeholders felt it posed national, organizational, and personal risks for policy goals and reputations. Words like ‘vilification‘ and ‘chastisement‘ and ‘bitter‘ came up during key informant interviews. in a point of opposing objectives (if not a full catch-22, a phrase stricken from my thesis), some stakeholders may have supported the pilot if they knew the program would not be terminated (even if modified), whereas global actors wanted the pilot to see if the evidence suggested the program should (not) be terminated. Pilot-specific concerns related to uncertainties around the sunk investments of time in setting up the needed systems and relationships, which have an uncertain life expectancy. also, for a stakeholder trying to decide whether to support or resist a pilot, it doesn’t help when the reputation and other pay-offs from supporting are uncertain and may only materialize should the pilot prove successful and be carried to the next stage. . . .

A final but absolutely key set of concerns for anyone considering working with policy champions is what, precisely, the decision to continue would hinge upon. Would failure to meet benchmarks be taken as a failure of the mechanism and concept? A failure of national implementation capacity and managerial efforts in Ghana (in the face of a key donor)? A failure of individual efforts and initiatives in Ghana? .

Without clarity on these questions about how accountability and blame would be distributed, national stakeholders were understandably nervous and sometimes resistant (passively of actively) to Ghana’s applying to be a phase I pilot country. To paraphrase one key informant’s articulation of a common view, phase I of the AMFm should have been an experiment on how to continue, not whether to continue, the initiative. . . .

How does this fit in with our ideas of ideal evidence-informed decision-making about programs and policies? The experience recorded here raises some important questions when we talk about wanting policy champions and wanting to generate rigorous evidence about those policies. Assuming that the policies and programs under study adhere to one of the definitions of equipoise, the results from a rigorous evaluation could go either way.

What risks does the local champion(s) of a policy face in visibly supporting a policy?

Is clear accountability established for evaluation outcomes?

Are there built-in buffers for the personal and political reputation of champions and supporters in the evaluation design?

The more we talk about early stakeholder buy-in to evaluation and the desire for research uptake on the basis of evaluation results, the more we need to think about the political economy of pilots and those those stepping up to support policies and the (impact) evaluation of them. Do they exist in a learning environment where glitches and null results are considered part of the process? Can evaluations help to elucidate design and implementation failures in a way that has clear lines of accountability among the ‘ideas’ people, the champions, the managers, and the implementer’s? These questions need to be taken seriously if we expect government officials to engage in pilot research to help decide the best way to move a program or policy forward (including not moving it forward at all).

learning by asking: a modest proposal to engage those who did the doing

this post was originally published at innovations for poverty action. it represents an effort to follow-through on some themes i have raised before and hope to continue to raise.

most development interventions are carried out and delivered by local research staff and residents. such implementation is rarely a straightforward ‘technical’ operation but, rather, there is social and political nuance in translating an idea into practice. on-the-ground partners therefore often have important insights about research engagement and implementation processes. but researchers often do not solicit such feedback as a requisite part of their work. moreover, even when such questions are asked, the results are often not synthesized into the lessons learnt from the project, either in terms of setting the future research agenda or in terms of tweaking on-going programs and interventions.

the Preserving ACTs (PACT) impact evaluation used text messages (via this code, built by @eokyere and @slawarokicki) to encourage the completion of the most effective anti-malarial treatment (artemisinin-based combination therapies, or ACTs (e.g.)) in and around Tamale, Ghana. as the study drew to a close, we wanted to thank the malaria-drug vendors for implementing the text-message intervention under investigation and for hosting the study’s surveyors. in addition, we wanted to solicit their feedback about the project and research process. our goals were to better understand their experience working with the research team and the study process, of the intervention process, and whether, how, and with what changes they thought the intervention should be scaled following the study.

photo credit: alidu osman  tuunteya

photo credit: alidu osman tuunteya

in mid- to late- 2011, one of our field managers went back to all 73 vendors – hospitals, clinics, pharmacists, and licensed chemical shops, both public and private – that had hosted our study, to thank them and to solicit their feedback on the study process and PACT intervention. 65 vendors were available and willing to be interviewed. these follow-ups took place in the third and fourth week of October 2011 and provide a unique set of data for considering the implementation of this and future studies. they also shed some light on the program that provided the context and basis for this operational research study – the Affordable Medicines Facility – malaria (AMFm) — discussed more at the end of this post.

as a token of our appreciation for their hosting PACT and our surveyors (and the only incentive provided to vendors for hosting the study and intervention), we provided a thank you note / certificate of participation. a few of the vendors noted that our follow-up was appreciated, such as “we thought you left without a goodbye” and  “I really never thought you would be back again after that long time.  But it is great you still remembered us and even come to officially say goodbye to us.”

as described in the paper, drug vendors played an important role in the study, which spanned much of the rainy season in northern Ghana as well as the Muslim fasting period of Ramadan, as mentioned in some of the follow-up interviews.

first, vendors were in charge of distributing the flyers to patients acquiring a malaria treatment. from this flyer, the patient would know to call or ‘flash’ (ring once for no charge) into our ‘mobile health information system,’ from which they were randomized to receive reminder text messages.

second, vendors provided an IPA surveyor a place to sit and talk to patients about their anti-malarial treatment and, if eligible, to recruit them into the study. Sometimes this meant giving them a chair in a hospital waiting room; other times, it meant the IPA team providing a chair for a surveyor to sit in the limited space offered by a one-man or one-woman drug shop.

given the study design, the distribution of flyers and the text messages were kept conceptually and, as feasible, spatially, separate from the IPA surveyor and his or her questions about the patient’s malaria medication. we included a question about this in the follow-up: the full range of vendor responses can be viewed here [link to the spreadsheet], as well as an overview of how responses were coded.* in short, the codes used to categorize responses emerged from the responses themselves in light of themes or ideas repeated across several answers.

given the sample-size needs of the study, surveyors were only placed at vendors that had ACTs in stock and were selling at a reasonable volume. this often meant longer stays at some of the hospitals, clinics, and popular pharmacies and LCSs but shorter stays with other vendors. some of the vendors expressed disappointment about this, such as, “I felt the surveyors did not spend much time in my shop.  You should have stationed a surveyor at my shop for at least three weeks or 4 weeks” and “I did not experience much due to a lack of patients during the study period at my shop.”

experiences with PACT.

though we did not explicitly ask vendors if PACT addressed a problem they thought was important, three-quarters volunteered that non-completion of ACTs was a problem they faced and many welcomed the support of a program like PACT to try to encourage people to finish their medication and to strengthen whatever advice they already gave to their patients – for example, saying that the text messages “made patients to take my advice more seriously” and that they “increase our credibility and patients to stick to these advice we give as a health service provider”.

others felt that the text messages led to patients feeling they were receiving addition concern for their wellbeing. one noted that PACT “gave patients the courage to come back to us and ask questions of the drugs given to them, and then some do come back later to report other issues” and another that “patients that did initially not want to participate have come later to commend the text reminder.”

prior to agreeing to host PACT, some vendors were concerned that the flyer and survey process would interrupt the patient flow, affect their business, or lead to an over-focus on malaria patients at the expense of other clients. after the study, about 40% felt their sales stayed normal during the study while about 20% felt their sales had increased, which they attributed to PACT. Nobody reported a disruption in their sales. about 40% did note that the questionnaires administered by surveyors were long and were uncomfortable for patients who were sick and tired – hence, being at a drug vendor in the first place.

about 20% also felt their status or credibility increased when they were offering the program, such as “business was normal but on social grounds, I earned respect from individuals that were sent SMS…  It was a remarkable experience of the concern they achieved from your end. So, I gained more credibility to my advantage.” some of these benefits may, of course, reflect a novelty effect and would not offer any one vendor an advantage if the program scaled-up to all vendors.

there were also a few unexpected benefits of the program likely not to be replicated in a scaled-up version of the program — for example, one vendor reported that “your surveyor also helped me track a thief that came to steal from me”!

several vendors highlighted that it’s not always easy for them when a study like this – which facilitates their providing an addition service to patients and clients — ends, noting, for example, that “some patients still ask me if they will get the SMS” and that “now I have to explain to my clients that I cannot send SMS to remind them now, which is sort of sad”.

continuing and scaling-up program.

most vendors (97%) explicitly said that it would be good the PACT program – or something like it – could be extended beyond Tamale and the time period of the study but also to other medications. for example, one noted “it should be scaled up so that at least I know my family that does not reside here in Tamale would also benefit from this great experience and education” while another said “the program should be nationwide because I know this attitude” – “the bad attitude of not completing the dosage” – “is widespread” and another similarly stated “the issue of people not completing their dosage is nationwide, so the program must be nationwide”.

about half saw no predictable barriers in being able to continue a program like PACT on their own; nearly a quarter thought that during busy times, it might be hard to make time to explain the program to patients and enroll them. 42% said they would need more training. Half noted that materials (such as flyers) and money for credit would need to be provided to them and several noted that extra components, such as t-shirts, would help motivate them and advertise the program better. for example, “I would also love to be given [something extra], like t-shirts, that could help motivate the vendors to do the work diligently.”

vendors also had a variety of suggestions on how enrollment into the text messaging system could be encouraged. One set of suggestions including removing any costs to patients, such as making the enrollment line toll-free as a way of encouraging more patients to enroll. to clarify what happened in practice, if patients texted into the program, their phone balance was deducted the cost of a text message. for people to ‘flash’ (dial and allow one ring) into the system, it did not cost them any money but phones (rather than our messaging system) required a positive balance to make this call.

more generally, 37 vendors (60%) suggested ways of increasing enrollment into the text messaging program, including the vendor or PACT team doing the actual enrollment as well as providing more information to patients about the program and why it was important. for example, one noted “if people are educated well, they will charge their phones and enroll later.” given the goal of the study — to see whether and how many people would enroll with a limited amount of encouragement and input — vendors provided limited (and surveyors provided no) information to the patient along with the flyer. in retrospect, however, some vendors saw this as a missed opportunity to educate patients about an important problem.

fourteen of the vendors raised concern that the text messages excluded illiterate patients – some suggested using voice calls as well as TV and radio to better educate about the importance of completing an ACT once it is started.

distinctions with AMFm (and implied suggestions for future AMFm-like programs).

the Affordable Medicines Facility – malaria (AMFm) provided the context for the PACT study, although the text messaging program was meant to be seen as independent of the ‘green leaf’ efforts explicit to AMFm marketing. as such, we asked questions of vendors to assess whether they saw the programs as distinct. In so doing, they ended up commenting on differences in the program in a way that may shed light on future AMFm-like efforts. for example, “programs for the ‘green leaf’ have more TV and radio coverage than your PACT program, but then you made more impact of encouraging people to take their drugs.  The other programs only encourage buying and awareness” or that with AMFm, “people do not get education on usage or encouragement to complete dosage”.

to clarify, the AMFm-linked advertisements focused on telling people to act fast when they suspected they had malaria, to look for the “green-leaf” quality logo, and what price these logoed ACTs should cost. as such, one vendor noted “the ‘green leaf’ programs don’t have any sort of attachment to the patient but your intervention seemed to involve and appreciate the patients more, so they felt respected and began to place some emphasis on their health.”

also, it is worth noting that elements of PACT seemed to alter the way patients viewed ACTs as well as the perceptions and stocking decisions of the vendors themselves. overall, 65% of vendors reported such changes. as part of AMFm, vendors should have received trainings provided by various government and professional bodies, as well as the mass media “green leaf” advertisements — but this seems to have not always been the case, at least by the time the PACT study was carried out.

for example, one vendor noted that “people are now more confident in the ACT drugs” and that “I now keep more stock of ACTs and on days that I do not have ACTs, the clients disturb me so much.  So for now, I make sure to keep more stock of ACTs.” Another said, “to be honest, it was the start of your study and the subsequent positioning of a surveyor at your shop that made me to purchase ACTs, and now I have many varieties of ‘green leaf’ drugs” while another reported “we were a bit skeptical about the new ACTs, so we had few in stock, but your presence also made us want to be more serious and also keep different types of ACTs.”

overall, the data presented above and in the spreadsheet (available below) suggest there is much that can be learned from soliciting feedback from program implementers, which can be taken into account in designing future studies and interventions. this type of engagement can ensure that humanity and humility remain part of the implementation and learning process.

you can download the spreadsheet with more information and responses here (excel format).

*where a vendor directly identified themselves or their workplace in their response, we have slightly altered the response, using italics in place of the missing word or phrase.

**important thanks go to Jeff Mosenkis, Corrina Moucheraud, Elianne Oei, John Quattrochi, and the late Elif Yavuz for encouragement in writing-up and thinking-through these results. the data and photographs above were collected by Usama Salifu and Alidu Osman Tuunteya. the biggest thanks go to the vendors for taking the time and energy to provide additional insight.

dear sir – response to AMFm article in the economist

on 24 novemberthis article was published in the economist on AMFm and the Global Fund. below is the response i would have liked to have published because a few things in the article were maddening. particularly frustrating are those celebrating the end of AMFm as though ending a subsidy on ACTs in the private sector are the same thing as removing ACTs from the private sector. it’s not. so far as i know, we have not yet heard whether pharmaceutical companies intend to keep their ACT prices low, in order to tap into the non-premium market uncovered in AMFm. in any case, malaria programs moving forward need to address the reality of treatment-seeking behavior and expectations for fever in the wake of AMFm. 

‘Sir – At least two things on the horizon for malaria treatment – for both the Global Fund and the larger global health community – are not cloudy in the dust of the Affordable Medicines Facility–malaria (AMFm). Yet these points remain under-discussed.

First, the end of the AMFm subsidy for malaria treatment does not eliminate the obligation to scale-up malaria and broader fever diagnosis in both the private and public sectors. The globally recommended treatment for malaria – ACTs – are legally available over-the-counter in three of the seven countries that piloted AMFm. This includes Nigeria, which accounts for one-quarter of global malaria deaths. It also includes Ghana and Uganda.

Even where citizens cannot legally access ACTs over-the-counter, they can often obtain these treatments as easily as if the laws supported such access. Unless the global discussion shifts to changing and enforcing national drug regulations – which it has not – we need to continue talking about scaling-up diagnosis at the gamut of fever-treatment points. This remains the case with or without a subsidy.

Second, it is a false dichotomy that aid money be directed to either a drug subsidy or a community health worker (CHW) effort. Instead, we need to discuss how to apply lessons from successful CHW programs to the variety of workers on the front-lines of treating fevers. Again, those in both the private and public sectors who are, in reality, treating fevers. Researchers working with community health workers suggest that, where in place, CHWs can appropriately distinguish and treat fevers, as well as encourage their charges to complete treatment. However, the CHW model has not proved viable in each context it has been tried. As such, not every malaria-burdened country has trained, scaled-up, and maintained CHWs, despite attempts since the late 1970s. We need to discuss the current realities of safely treating fevers in countries shouldering malaria burdens in order to develop both short- and long-term plans.

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.

AMFm evaluation: joint post with victoria fan

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