on financing ACTs. Even subsidizing drugs
only for children may be infeasible, given
that adults will likely purchase these drugs
and receive an incorrect dose. However, the
level of needed subsidy should fall with time
as ACT prices decline as a result of techno-
logical improvement, greater demand for
products from AMFm, and economies-of-
scale increase. More resources would then
be available for introducing antigen-based
malaria rapid diagnostic tests (mRDTs), the
subject of our next recommendation.
Rapid diagnostic tests for malaria are
needed in the private sector. Because many
fevers in malaria-endemic countries are not
caused by malaria (9), WHO, in 2010, rec-
ommended a move from presumptive treat-
ment of fever with antimalarials for children
under 5 years of age to universal parasito-
logical diagnosis (where feasible) before
treatment. Surveys done in 2010, during the
course of the AMFm pilot program, indi-
cated that availability of mRDTs was gen-
erally low, under 10% of all outlets in all
countries except Zanzibar, where availabil-
ity was 36%. In most countries, low avail-
ability reflected the situation in private for-
profit outlets (under 5% in all countries). In
public health facilities, availability ranged
from a low in Uganda (4%) to the highest in
Presumptive treatment with antimalarials
wastes precious treatment resources, poten-
tially increases selection pressure for emer-
gence of resistance, and delays access to the
appropriate treatment for the actual cause
of febrile illness (10). Significant improve-
ments in quality and reductions in cost of
mRDTs have been achieved over the past
few years—they are expected to cost about
half as much as malaria treatment. How-
ever, there is little private sector demand
for mRDTs; they were routinely available
in private shops and clinics only in Kenya,
Uganda, and Zanzibar (6, 7). Public-sector
clinics in pilot countries were more likely to
perform malaria diagnostics; nonetheless,
public-sector availability of diagnostic tests
ranged from a low of 29% in Nigeria to a
high of 98% in Zanzibar.
The challenge raised by the diagnos-
tic tests is what to do for a child with a
high fever and an anxious mother when an
mRDT reveals no evidence of malaria. The
need of health providers to do something
in this circumstance explains the common
provision of antimalarials for febrile illness,
regardless of its cause. In the public sector,
a significant proportion of patients who test
negative for malaria receive an antimalarial
(11), ranging from 12% in Zanzibar to more
than 80% in Burkina Faso. Clearly, patients
who test negative for malaria need appropri-
ate treatments that may include antipyretics
or antibiotics (12). Development of rapid
tests and other diagnostic tools for non-
malaria fevers (including pneumonias) is a
major research opportunity. Even without
them, however, community health workers,
with some training, can distinguish severe
pneumonia in children and effectively treat
it with antibiotics (13).
Termination of AMFm will create instabil-
ity in artemisinin production, will reduce
access to affordable ACTs, and will be seen
as abandonment—both by the many people
who depend on AMFm and by ACT produc-
ers. It will cause the kind of reaction that
will detract from efforts to reduce deaths
from malaria, to engage the private sec-
tor in providing community-based health
care in poor countries, and to build cred-
ible health diplomacy. In the short term, we
would recommend expanding ACT access
to negotiated manufacturer prices to private-
sector wholesalers in more malaria-endemic
countries and allocating financial resources
to support both ACTs and rapid diagnostic
tests. The longer-term direction is support-
ing a broader, patient-centered approach to
treatment of febrile illness.
References and Notes
1. WHO, Antimalarial Drug Combination Therapy: Report of
a WHO Technical Consultation (WHO, Geneva, 2001).
2. WHO, WHO urges regulatory measures to stop marketing
of oral artemisinin-based monotherapies and to promote
access to artemisinin-based combination therapies
(AC Ts); www.who.int/malaria/publications/ who_
3. H. Noedl et al., N. Engl. J. Med. 359, 2619 (2008).
4. K. J. Arrow, C. B. Panosian, H. Gelband, Eds., Saving
Lives, Buying Time: Economics of Malaria Drugs in an
Age of Resistance (Institute of Medicine, Washington, DC,
5. O. Adeyi, R. Atun, Lancet 376, 1869 (2010).
6. Independent Evaluation of Phase 1 of the Affordable
Medicines Facility—malaria (AMFm): Multi-Country Independent Evaluation Report (ICF International, Calverton,
MD, and the London School of Hygiene and Tropical
Medicine, London, 2012).
7. AMFm Expert Advisory Group, AMFm, and the Global
Fund for AIDS, TB, and Malaria, meeting report of the
review of the preliminary independent evaluation of the
AMFm Program; www.theglobalfund.org/en/amfm/
8. G. Yamey, M. Schäferhoff, D. Montagu, Piloting the
Affordable Medicines Facility-malaria: what will success
look like? Bull. World Health Organ. 90, 452 (2012).
9. V. D’Acremont et al., PLoS Med. 6, e252 (2009).
10. J. M. Cohen et al., Science 338, 612 (2012).
11. D. H. Hamer et al., J. Am. Med. Assoc. 297, 2227 (2007).
12. L. J. Frost, M. R. Reich, in Access: How Do Good Health
Technologies Get to Poor People in Poor Countries?
(Harvard Univ. Press, Cambridge MA, 2008).
13. K. Yeboah-Antwi et al., PLoS Med. 7, e1000340 (2010).
14. I. M. C. I. Handbook, Integrated Management of
Childhood Illnesses; http://whqlibdoc.who.int/
15. Every Woman Every Child, www.everywomaneverychild.
16. UN Commission sets out plan to make life-saving health
supplies more accessible [press release], www.unicef.org/