Update on the Affordable Medicines Facility-malaria (AMFm) /
Private Sector Co-payment Mechanism for ACTs
Interagency Pharmaceutical Coordination Group Meeting 18-19 June 2015
Dr. Melisse Murray
Specialist, Sourcing Department
Key events leading to the start of Phase 1
2004 IOM releases report Saving Lives, Buying Time
- Global-level subsidy for ACTs an urgent “public good” to address increasing ineffectiveness of
widely available treatment, risk posed by oral AMTs and the high cost of ACTs
2006 Roll Back Malaria (RBM) Partnership fosters multi-institutional process
2007 AMFm Technical Design approved by RBM Board
- Included the addition of “supporting interventions” (SIs) to promote the appropriate use of ACTs
Hosting and management by the Global Fund
- 2008 Global Fund Board requests the Secretariat to begin operations
- 2009 select countries invited to submit applications, Technical Review Panel
recommendations, Global Fund Board approvals
- By mid 2010, Global Fund grant amendment processes completed for each pilot to
permit initiation of country-level operations
IOM = Institute of Medicine ACT: Artemisinin-based combination therapy AMT = artemisinin mono-therapy
Phase 1 was a “Test of Concept”
Purpose:
Widely  availability of quality-assured ACTs
Sharply  retail prices of quality-assured ACTs
 use of quality-assured ACTs, including by vulnerable groups
Displace oral artemisinin monotherapies
Displace use of ineffective medicines
AMFm comprised three elements:
1) Negotiations with ACT manufacturers
 price of ACTs and offer public sector prices to private sector buyers
2) Buyer subsidy (co-payments) at top of global supply chain
 price to importers; use pre-existing supply chains
3) “Supporting interventions” to ensure effective ACT scale-up
Including communications campaigns, private sector training, etc.
AMFm Phase 1  Private Sector Co-payment Mechanism
Mid 2010 to end 2012: AMFm Phase 1 implementation
> Mid 2010 to end 2012 in nine pilots in eight countries:
Cambodia, Ghana, Kenya, Madagascar, Niger, Nigeria, Tanzania, Uganda and Zanzibar
> Four donors funded co-payments (US$ 333 million):
ZANZIBAR
Co-paid ACTs Delivered
(treatment courses,
in millions)
> Global Fund grants funded supporting interventions (IEC/BCC, private sector training, etc.)
> 290 million co-paid treatment doses delivered by end 2012, mostly A/L
120
100
80
60
40
20
0
5
4
3
2
1
0
12%
ASAQ
FDC
3%
ASAQ
Co-b
0%
DHAPPQ
85%
A/L
November 2012 Global Fund Board Decision*
> Based on evidence from AMFm Phase 1 Independent Evaluation*, following a transition period, and building on lessons learned,
grantees permitted to use grant funding for co-payments and supporting interventions
> Going forward: private sector only; each country to determine subsidy level and demand-shaping levers
*Board Decision and full AMFm Phase 1 Independent Evaluation Report available in public domain.
3
Questions asked by IPC:
• How have changes since the end of AMFm Phase 1 impacted the
availability of co-paid ACTs in private sector outlets in these countries?
• How have changes since the end of AMFm Phase 1 impacted the
price of co-paid ACTs available in private sector outlets in these countries?
4
Summary of key changes since the end of AMFm Phase 1
Key change
Participating
countries
AMFm Phase 1
(mid-2010 to end-2012)
2013 Transition
9 pilots in 8 countries
6 countries
Source of copayment funding
2014 Transition/
Integration
5 countries
(6th to resume in 2015)
plus grant funds
in 2 countries
Co-payment
financing
Resources mobilized for
co-payments across all
pilots for the period
Country-specific financial amounts for co-payments
Subsidy level and
demand-shaping
levers
Set by Secretariat and
applied across all pilots
simultaneously
Set by each country and applied on country-specific
basis, evolving over time
Timing of order
approvals
Price negotiations
with ACT suppliers
On demand then monthly
Aug 2011 to Dec 2012
Bi-monthly
Maximum price approach
Quarterly
Competitive tender resulting in
supplier- and product-specific
prices (~ 30% reduction)
5
Annual quantities of co-paid ACTs delivered to private sector buyers in
six participating countries since the end of AMFm Phase 1 (end 2012)
have decreased or increased, depending on the country
AMFm
Phase 1
25
Peak in 2013
Peak in 2011
Peak in 2012
70
1.40
60
1.20
50
1.00
40
0.80
2011
30
0.60
2012
20
0.40
10
0.20
0
0.00
20
2010
15
10
2013
2014
5
0
Ghana
Kenya
Tanzania
Uganda
Nigeria
Madagascar
6
AMFm Phase 1
Co-paid treatment doses delivered to
private sector buyers, in millions
Annual quantities of co-paid ACT treatment doses delivered to private sector buyers 2010 to 2014,
as reported to the Global Fund by ACT suppliers
Trends in Availability and Price of Co-paid ACTs
•
No formal post-AMFm Phase 1 evaluation has been undertaken.
•
Trend data is available from surveys implemented by Health Action International*
- Commissioned by Global Fund during AMFm Phase 1 and beyond in select countries.
- Not intended to substitute in scope or depth for the Independent Evaluation, which reported
on urban and rural availability, price and market share of all categories of antimalarials, and more.
-
Intended to provide visibility on availability and price of co-paid ACTs to facilitate
in-country discussions by implementers, technical partners and the Global Fund, with a view of
informing adjustments as and when appropriate.
-
•
Four rounds of surveys conducted between Jun and Nov 2011, four rounds between Jan
and Sept 2012, two rounds in 2013, plus four rounds in DFID-supported countries in
2014, using the same methodological approach.
30 formal and 30 informal outlets were visited per country, per round.
•
•
•
Formal outlets defined as registered retail pharmacies;
Informal outlets defined as unregulated, unlicensed outlets.
Availability of products bearing the ACTm logo and their prices are recorded, along with some
additional information (e.g., price of originator brand and lowest priced generic).
* For additional detail on the use (and limitations) of WHO / HAI methodology to analyze medicines availability, see www.haiweb.org/medicineprices.
Annual trends in availability of co-paid ACTs in formal outlets appear
to follow trends in quantities of co-paid ACTs delivered.
Average annual availability of any co-paid ACTs in formal outlets, as reported by HAI, 2011-2014, and annual quantities of
co-paid ACTs delivered to private sector buyers, as reported to the Global Fund by ACT suppliers, 2010-2014
Nigeria
Uganda
100% 70
100%
90%
90%
60
80%
60%
80%
50
70%
60%
40
50%
10
40%
30%
30
40%
30%
20
20%
10%
2014
0%
2013
0
2012
2014
2013
2012
2011
2010
2014
2013
2012
2011
2010
2014
2013
2012
2011
2010
2014
2013
2012
0%
2011
0
1
70%
60%
0.8
50%
0.6
40%
30%
0.4
20%
10
2011
10%
80%
50%
2010
5
90%
1.2
20%
0.2
10%
0
0%
2014
15
100%
2013
70%
1.4
2012
20
Madagascar
2011
25
2010
Co-paid treatment doses delivered to private
sector buyers, in millions
Tanzania
2010
Kenya
Ghana
8
Annual trends in availability of co-paid ACTs in informal outlets appear to show greater
variation/more sensitivity over time than measures in formal outlets in some countries.
Average annual availability of any co-paid ACTs in formal and informal outlets, as reported by HAI, 2011-2014, and annual
quantities of co-paid ACTs delivered to private sector buyers, as reported to the Global Fund by ACT suppliers, 2010-2014
Nigeria
Uganda
100% 70
100%
90%
90%
60
80%
60%
80%
50
70%
60%
40
50%
10
40%
30%
30
40%
30%
20
20%
10%
2014
0%
2013
0
2012
2014
2013
2012
2011
2010
2014
2013
2012
2011
2010
2014
2013
2012
2011
2010
2014
2013
2012
0%
2011
0
1
70%
60%
0.8
50%
0.6
40%
30%
0.4
20%
10
2011
10%
80%
50%
2010
5
90%
1.2
20%
0.2
10%
0
0%
2014
15
100%
2013
70%
1.4
2012
20
Madagascar
2011
25
2010
Co-paid treatment doses delivered to private
sector buyers, in millions
Tanzania
2010
Kenya
Ghana
9
Countries achieved different prices at the end of 2011 as documented in the
AMFm Phase 1 Independent Evaluation, with different paces and
scale of implementation of supporting interventions, particularly of IEC/BCC
Median cost to patients of one AETD
of QAACTs in public and private forprofit outlets (US dollar equivalent)
6.00
5.28
5.00
4.47
4.00
3.42
3.00 2.74
2.63
2.79
2.47
1.96
2.00
1.00
5.99
1.19
1.13
0.94
1.48
0.58
0 0
0.60
0.14
0 0
0 0
1.17
0.94
0 0
0 0
0 0
0 0
0.00
Ghana
Kenya
Madagascar
Public health sector (Baseline)
Private for-profit sector (Baseline)
Niger
Nigeria
Tanzania
Uganda
Zanzibar
mainland
Public health sector (Endline)
Private for-profit sector (Endline)
10
Since the end of AMFm Phase 1, retail prices of co-paid A/L 6x4 have generally increased, possibly linked
to either decreases in deliveries of co-paid ACTs or a reduction in subsidy level (or both), with the
exception of Madagascar. Further, it should be noted that nearly every country has scaled down
communications campaigns regarding the subsidy program following a peak during AMFm Phase 1.
Country
Outlet
Type
Formal
Ghana
Kenya
Nigeria
Tanzania
Madagascar
Uganda
Median
PerRetail Price
Median
centNumber of
of co-paid
Number of Retail Price
age
unique price
A/L 6x4
unique price of co-paid
change
observations
AMFm
observations
A/L 6x4
in price
Phase 1
2013-2014
period
359
$ 0.93
54
$1.20
28%
Informal
103
$ 0.96
10
$1.50
Formal
Informal
Formal
Informal
Formal
Informal
Formal
Informal
Formal
Informal
371
207
450
370
285
211
73
29
440
191
$ 0.52
$ 0.53
$ 1.44
$ 1.50
$ 0.63
$ 0.70
$ 0.51
$ 0.57
$ 1.24
$ 1.81
227
109
283
260
63
50
33
8
227
128
$1.17
$1.15
$2.01
$1.81
$0.92
$0.92
$0.46
$0.69
$1.81
$1.95
Key observations
Peak deliveries late 2011, further
decline in 2013 linked to
56%
2013 Transition envelope
125% Peak deliveries in Q3 2012; subsidy
level reduced to 70% in 2013
117%
40% Peak deliveries Q3 2013; subsidy level
reduced to 85% in 2013
20%
47%
Peak deliveries in Q2 2012; subsidy
level reduced to 80% in 2013
33%
-11%
Peak deliveries in 2013, when
implementation was on hold.
22%
46%
8%
Peak deliveries in early 2014, just as
subsidy level is reduced to 50%
* Data as reported by HAI, per methods described in previous slides. Key observations noted by Global Fund.
11
25
Co-paid treatment doses delivered to
private sector buyers, in millions
Nigeria
Kenya
Ghana
$1.60
Introduction
of subsidy
reduction
25
$1.40
20
$1.60
70
$1.40
60
Introduction
of subsidy
reduction
$3.00
$2.50
20
$1.20
$1.20
50
$2.00
$1.00
15
$1.00
15
40
$0.80
10
$0.60
$0.80
$1.50
30
10
$0.60
$1.00
$0.40
5
$0.40
20
5
$0.20
0
$-
2011
2012
2013
$0.20
0
$2011
2012
2013
2014
$0.50
10
0
$-
2011
2012
2013
2014
12
Highest, lowest and weighted average median prices
of co-paid A/L 6x4 , formal outlets, reported by HAI
Three examples of country-specific variation regarding changes in deliveries of
co-paid ACTs, prices of co-paid A/L 6x4 and changes in subsidy levels over time
HAI data from February 2015 reports prices of subsidized ACTs
below those of unsubsidized originator brands and
lowest priced generics.
Median price trends of A/L 20/120 mg (6x4): co-paid (AMFm) versus
unsubsidized originator brand and lowest price generic, February 2015
13
Key conclusions
• Several changes have been implemented since the end of AMFm Phase 1 in
countries that have chosen to implement the Private Sector Co-payment
Mechanism.
• Data available for the six AMFm Phase 1 countries implementing the Private
Sector Co-payment Mechanism indicate variations across countries in the
annual supply of co-paid ACTs delivered to private sector buyers each year,
availability and price of co-paid A/L 6x4 in retail outlets.
• These need to be interpreted in light of implementation changes that have
occurred with the private sector co-payment mechanism, including
reductions in subsidy levels in some countries.
14
Additional Resources on AMFm Phase 1
and the Private Sector Co-payment Mechanism
From RBM:
•
Key Learnings from AMFm Phase 1
From the Global Fund:
• AMFm Phase 1 Independent Evaluation Report
• Information Note on the Private Sector Co-payment Mechanism
• Operational Policy Note
• HAI Price Tracking Survey Reports
Thank you
16
Data for slide 12: HAI survey data
2011: 4 rounds; 2012: 4 rounds; 2013: 3 rounds; 2014: 4 rounds
Ghana
Formal
Informal
Kenya
Formal
Informal
Tanzania
Formal
Informal
Uganda
Formal
Informal
Nigeria
Formal
Informal
Madagascar Formal
Informal
2011*
Median
N
Price
168 $ 0.97
38 $ 0.99
229 $ 0.43
118 $ 0.43
153 $ 0.62
109 $ 0.75
204 $ 1.13
81 $ 1.74
213 $ 1.30
167 $ 1.40
23 $ 0.60
9 $ 0.54
2012*
2013**
Median
Median
N
Price
N
Price
191 $0.90 54 $ 1.20
65 $0.94 10 $ 1.50
142 $0.67 67 $ 1.17
89 $0.67 34 $ 1.17
132 $0.64 63 $ 0.92
102 $0.64 50 $ 0.92
236 $1.33 79 $ 1.95
110 $1.86 40 $ 1.95
237 $1.57 111 $ 2.04
203 $1.59 91 $ 1.73
50 $0.48 33 $ 0.46
20 $0.58
8 $ 0.69
2014*
Median
N
Price
160
75
$1.18
$1.14
148
88
172
169
$1.73
$1.95
$2.00
$1.85
17
Trends in availability of co-paid ACTs in private sector outlets
late 2011 to 2014, as reported by HAI International
Availability of co-paid ACTs in informal outlets appears to be more sensitive than that in formal outlets.
Availability as reported by HAI appears to track with deliveries of co-paid ACTs to each country as
reported to the Global Fund by ACT suppliers.
Formal Outlets
100
50
0
Ghana
Kenya
Madagascar
Nigeria
Tanzania
Uganda
Ghana
Kenya
Madagascar
Nigeria
Tanzania
Uganda
100
Informal Outlets
Percentage of facilities having
any ACTm ACT available
•
•
50
0
Aug-11
Oct-11
Nov-11
Jan-12
Apr-12
Oct-12
Apr-13
Aug-13
Jan-14
Apr-14
Aug-14
Oct-14
18
Price trends of co-paid ACTs
•
•
A February 2015 round of data collection by HAI International revealed a decrease and
increase in formal and informal outlets in Kenya, decreases in Nigeria and Uganda. Data
was not collected during 2014 in Ghana and Tanzania.
It should be noted that subsidy levels decreased in several countries from AMFm Phase 1
levels of ~95% (to 70% in Kenya, 85% in Nigeria and 50%/70% in Uganda).
Price trends of A/L (20/120 mg) (6x4) in private sector outlets
19