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    Mosquitoes around the home can be reduced significantly by minimizing the amount of standing water available for mosquito breeding. Residents are urged to reduce standing water around the home in a variety of ways.


    The best way is to avoid being bitten by mosquitoes.This can be accomplished using personal protecting  while outdoors when mosquitoes are present. Treated bed nets should be used sleeping. Mosquito repellent should be used when outdoor.


    Nearly half of the world’s population is at risk of getting malaria. Pregnant women are particularly at risk of malaria. Children under 5 years are at high risk of malaria.


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The new model

The life-saving mechanism to help fast-track the realisation of the 2015 target to end malaria deaths has been modified to ensure a rational use of the best known treatment for malaria.

After a 2-year pilot ended in 2012,the Affordable Medicines Facility-malaria (AMFm) will start a new model in 2014 when it becomes available to all countries that apply for a malaria grant through the Global Fund, the implementing body.

It has also been decided that the second phase of AMFm will be preceded by a one-year transition period in 2013 to ensure that there is no disruption to the plan to make life-saving ACTs accessible and affordable.

The pilot phase which ran since 2010 in Ghana, Kenya, Madagascar, Niger, Nigeria, Tanzania (including Zanzibar) and Cambodia, was heavily criticized for not leading to the realization of its raison d’ etre.

An interesting aspect of the new integrated model is the all-inclusive “country envelope” from which implementing countries of the AMFm will now run the project using stakeholders in the public and private sectors.

While this seems harsh to interested countries, the Global Fund Board (GFB) sees it as a practical way to ensure accountability.

The AMFm is a financial mechanism under which artemisinin-based combination therapies (ACTs), bearing the green leaf logo for easy recognition, are subsidized to help expand access to quality efficacious anti-malarial drugs.

The subsidised facility was implemented to ensure an increased ACT affordability, and its widespread use among vulnerable groups in malaria-prone regions. Ultimately, it was intended to lead to a “crowding out” of oral artemisinin monotherapies, chloroquine and sulfadoxine-pyrimethamine, by gaining market share.

But after an independent evaluation of the AMFm, the GFB and stakeholders seemed not impressed with evidence on ACT use by vulnerable groups, particularly in children under-five who were most at risk.

The US Presidential Malaria Initiative (PMI), a major stakeholder in the fight against malaria, for instance, was concerned about the lack of evidence on whether children under-five and poor rural populations at the greatest risk of dying from malaria were actually reached.

ACT procurements through AMFm indicated that most of the drugs purchased were for adults and only about 35 per cent of the treatments procured by the private sector were child doses.

The AMFm model was also criticised for not taking into account the changing malaria epidemiology throughout Africa which called for country-specific strategy.

The PMI statement on the AMFm noted that Zanzibar has seen major declines in malaria prevalence in the past five years and, while the AMFm pilot resulted in increased ACT market share, without use of a diagnostic test, many of those treatments were probably administered to patients with non-malarial illnesses, possibly causing harm through misdiagnosis of pneumonia or other serious illnesses.  

“And although the intent of AMFm was also to supply the public and private sectors in the pilot countries with ACTs, many AMFm countries experienced severe shortages of ACTs in public health facilities” the report notes.

Based on country requests to fill public sector ACT gaps, PMI procured 14.8 million treatments for the public sector in five AMFm countries (Ghana, Kenya, Madagascar, Nigeria, and Tanzania) in 2011 and 27.2 million treatments for these countries in 2012. This was contrary to expectation, but was necessary to keep the pilot project on track.

According to the independent evaluation there seemed not enough indication that the AMFm played any significant role in “crowding out” artemisinin monotherapies, as was originally intended.

There was a discernment that the AMFm design did not incorporate the WHO recommendations on universal usage of malaria diagnostic testing prior to treatment.

Experts feared there would be a situation where the overuse of ACTs within the private sector that can occur when malaria treatment is provided to patients who do not have malaria may lead to parasites developing resistance to the only effective malaria treatment available.

The Global Fund Board (GFB) decided therefore to modify the business line of the life-saving arrangement by integrating lessons learned from the operations and resourcing of the pilot phase.

Analysing the new dispensation, the Ghanaian AMFm Co-ordinator, Vivian Aubyn said the Global Fund has given all countries the power to decide to engage the private sector in malaria case management to expand access to quality-assured ACTs (QAACTs) at affordable prices.

“This is informed by the independent evaluation of the pilot phase which showed that it is possible to engage the private-for-profit operators who decide to enter a life-saving partnership and forego profits, as a service to humanity” she adds.

“The good thing is that the decision takes into account the wisdom in allowing malaria grants to be used according to country-specific strategies and not just handed down from the Global Fund or any other donor partner.”

“In the pilot phase the co-payment was from a separate pot and so was not an integral part of the grant. With the modified arrangement, the integrated model, however, the AMFm co-payment is part of the country envelopes.

Although some see this as a setback, Ms Aubyn believes that it fosters better collaboration with the private sector and gives a country the power to decide to work with the private- for- profit sector.

“This is because implementing countries have stated passionately and sometimes backed with evidence how the AMFm has helped to foster public-private partnership and how it has helped to expand access to remote and hard-to-reach areas.”

Obviously, this arrangement ensures that countries on the AMFm apply their resources more judiciously and accountably, as opposed to the days when some people traded on the generosity of the Global Fund.

“The transition period will ensure that access to QAACTs in AMFm pilot countries is not disrupted. It will also see that global ACT and active pharmaceutical ingredient markets are not destabilized. It also aims to ensure that countries are well supported to transition to the new model.”

“During the transition year, the pilot countries will have a defined funding allocation to support private sector co-payments and each country will determine the parameters under which that funding is utilized.”

“This means that countries can decide whether to have more adult treatments or have more pediatric treatments. But all of

this must be informed by the country’s disease epidemiology and strategic plans, specifically on the management of uncomplicated malaria,” Ms Aubyn added.

“The new model promises to take on board the notion that although there is a broader global objective of reducing the malarial morbidity and mortality, different countries have different malaria transmission rates, nuances, politics of operations and strategic objectives as well as progress made against the disease.”

“Countries have operated systems that led to reduction in malaria prevalence in many endemic countries over the years. In Ghana for example, the multiple indicator cluster survey (MICS) in 2011 showed that on the average parasite prevalence is now 27.4% and in the capital city, Greater Accra, it is 4%,” said Ms Aubyn.

“This is remarkable success but global partners know that to improve on this success it will require a change in some of the ways programmes are managed and the allocation of country envelopes is one such change in the Global Fund’s new model.”

Ms Aubyn also countered comments that only 35 per cent of the treatments procured by the private sector were for child doses, which raised concerns that most of the drugs purchased were for adults and that children under five and the vulnerable, poor rural populations were not actually reached.

“In Ghana, monitoring by an independent body and the National Malaria Control Programme (NMCP) indicated that quality ACTs had indeed reached rural communities.”

“The implementation of the AMFm was informed by country information on the care seeking behavior of the population and this showed that 60% of care seekers go to private sector. It also showed that parents are more likely to take their sick children to a hospital or clinic rather than seek care from a licensed chemical shop (LCS) unless a clinic or such other health facility is not available. Therefore the private sector demand for adult treatments has been informed by these dynamics.”

“An independent evaluation of the AMFm showed that in Ghana availability of QAACTs rose from 25% to 83% in the private sector. In 2011 the Global Fund also commissioned Boulders Advisors to determine the market dynamics of the AMFm. This showed that the private sector had warehousing and distribution channels that reach deep into the rural areas.”

Ms Aubyn pointed out that while the AMFm Phase-1 did not include a subsidy for diagnosis implementing countries had diagnosis in their malaria control strategies which were also implemented alongside the expansion of access to QAACTs through AMFm.

“In Ghana the NMCP implemented its malaria case management on the premise that knowing what you are treating enables any health provider to offer the most appropriate treatment.  Therefore in 2009 the NMCP began to implement a policy of universal malaria case confirmation by using microscopy and RDTs in all age groups, consistent with WHO guidelines.”

“There are on-going operational researches to determine the feasibility of expanding access to the use of RDTs through private retail outlets and the findings of these will inform the way forward.  So diagnosis before treatment is on-going, but we need to expand it.”

Ms Aubyn also spoke on Ghana’s efforts campaign to get people to adhere to the WHO directive on testing before treatment.

- By Carlton Cofie-Ghana

Tenth Edition