The Affordable Medicines Facility-malaria in Ghana: Factors Accounting for Antimalarial Availability and Pricing Outcomes

University of Minnesota Ph.D. dissertation.June 2014. Major: Health Services Research, Policy and Administration. Advisor: Beth Virnig. 1 computer file (PDF); xii,155 pages.The use of artemisinin-based combination therapies (ACTs), the most effective treatments for uncomplicated malaria, remains far below need. Reasons for low ACT uptake include: unreliable public sector supply; high prices and limited availability in the private sector, which is the most widely used source of treatment in many malaria endemic regions; and patient self-treatment with less expensive monotherapies. The Affordable Medicines Facility - malaria (AMFm), hosted by The Global Fund to Fight AIDS, Tuberculosis and Malaria, is a financing mechanism designed to increase affordability, availability, market share and use of quality assured artemisinin-based combination therapies (QAACTs). AMFm involves manufacturer price negotiations, factory gate price subsidies, and supporting interventions such as Information, Education and Communications (IE&C) campaigns. Between 2010 and 2012, the AMFm was implemented in 8 pilots including Ghana, where its outcomes were independently evaluated. The AMFm Independent Evaluation (IE) was commissioned to gather evidence needed to inform decisions regarding the future of the AMFm. As part of the IE, national level baseline and endline outlet surveys were conducted involving the collection and analysis of primary data to answer three questions related to the availability, affordability and market share of quality-assured ACTs using a cluster sampling approach. With a budget of up 450 million dollars and some uncertainty about its potential for success, AMFm was fraught with controversy, and provoked intense debate within the global health community on whether or not the program should be continued following the presentation of the IE findings to the Global Fund Board. As some kind of "middle ground" stance, at the end of the 2-year pilot period of AMFm, in November 2012 the Global fund Board decided to integrate the AMFm into core Global Fund grant management and financial processes, following a transition period in 2013. In countries like Ghana, where the phase I pilot was shown to be highly successful, stakeholders were disappointed and angry with this decision, believing that the decision would reverse the gains made in availability and affordability of ACTs. The Global fund Board's decision further meant eligible countries would decide whether or not to allocate funding from their core Global Fund grants to subsidies for ACTs, and Ghana has already indicated that it will be moving in this direction. Being a complex intervention, there are many aspects of the AMFm that can be researched. The purpose of this work is to contribute to the emerging body of knowledge on the outcomes of the AMFm in Ghana by exploring "why" and "how" the outcomes documented in the IE report came to be observed. The following specific aims are being pursued: 1. In both the public and private sectors, to assess the differences in characteristics between outlets stocking QAACTs and those not having QAACTs in stock by exploring the relationship between having received training on co-paid QAACTs and stocking of QAACTs. 2. To further examine pricing of QAACT by determining how retailer's knowledge of the recommended retail price for QAACTs and other factors account for outlet's adherence to their recommended retail price in the private-for-profit sector. 3. To identify differences between urban and rural outlets in the impact of training on knowledge of the recommended retail price for co-paid QAACTs in private-for-profit outlets. Findings from this project will shed light on the factors influencing the outcomes of the AMFm in Ghana and inform the implementation of subsequent interventions involving price subsidies on antimalarials and possibly other essential medicines in Ghana