• Sarah Tougher, ACTwatch Group, Yazoume Ye, John H Amuasi, Idrissa A Kourgueni, Rebecca Thomson, Catherine Goodman, Andrea G Mann, Ruilin Ren, Barbara A Willey, Catherine A Adegoke, Abdinasir Amin, Daniel Ansong, Katia Bruxvoort, Diadier A Diallo, Graciela Diap, Charles Festo, Boniface Johanes, Elizabeth Juma, Admirabilis Kalolella, Oumarou Malam, Blessing Mberu, Salif Ndiaye, Samuel B Nguah, Moctar Seydou, Mark Taylor, Sergio Torres Rueda, Marilyn Wamukoya, Fred Arnold, and Kara Hanson.
• London School of Hygiene and Tropical Medicine, London, UK. sarah.tougher@lshtm.ac.uk
• Lancet. 2012 Dec 1;380(9857):1916-26.

BackgroundMalaria is one of the greatest causes of mortality worldwide. Use of the most effective treatments for malaria remains inadequate for those in need, and there is concern over the emergence of resistance to these treatments. In 2010, the Global Fund launched the Affordable Medicines Facility--malaria (AMFm), a series of national-scale pilot programmes designed to increase the access and use of quality-assured artemisinin based combination therapies (QAACTs) and reduce that of artemisinin monotherapies for treatment of malaria. AMFm involves manufacturer price negotiations, subsidies on the manufacturer price of each treatment purchased, and supporting interventions such as communications campaigns. We present findings on the effect of AMFm on QAACT price, availability, and market share, 6-15 months after the delivery of subsidised ACTs in Ghana, Kenya, Madagascar, Niger, Nigeria, Uganda, and Tanzania (including Zanzibar).MethodsWe did nationally representative baseline and endpoint surveys of public and private sector outlets that stock antimalarial treatments. QAACTs were identified on the basis of the Global Fund's quality assurance policy. Changes in availability, price, and market share were assessed against specified success benchmarks for 1 year of AMFm implementation. Key informant interviews and document reviews recorded contextual factors and the implementation process.FindingsIn all pilots except Niger and Madagascar, there were large increases in QAACT availability (25·8-51·9 percentage points), and market share (15·9-40·3 percentage points), driven mainly by changes in the private for-profit sector. Large falls in median price for QAACTs per adult equivalent dose were seen in the private for-profit sector in six pilots, ranging from US$1·28 to $4·82. The market share of oral artemisinin monotherapies decreased in Nigeria and Zanzibar, the two pilots where it was more than 5% at baseline.InterpretationSubsidies combined with supporting interventions can be effective in rapidly improving availability, price, and market share of QAACTs, particularly in the private for-profit sector. Decisions about the future of AMFm should also consider the effect on use in vulnerable populations, access to malaria diagnostics, and cost-effectiveness.FundingThe Global Fund to Fight AIDS, Tuberculosis and Malaria, and the Bill & Melinda Gates Foundation.Copyright © 2012 Elsevier Ltd. All rights reserved.

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