with the private sector has been very successful in reducing prices (thus increasing affordability) and increasing availability of subsidized ACT, even in remote areas, and it has facilitated an increased market share for ACTs.27

The public sector has also benefited from the private-sector involvement, as public-sector purchases of AMFm-subsidized ACTs from the private sector have served to offset public-sector procurement delays.28 Adeyi warned, however, that a mechanism like AMFm, designed to work upstream to change the architecture of financing, cannot by itself change the downstream portion (the community level), which requires a reinforcement of quality at the case-management level.

Applications for MDR TB

Adeyi suggested that AMFm-style strategies that might improve access to MDR TB treatment include the use of wider public-sector channels for distribution, new approaches to financing and reducing prices, and determining the lowest-quality level of delivery system that should be eligible to participate in the system. He characterized the latter as constituting a necessary trade-off between “reach” and “richness” in the short term in order to progress toward the ideal extent of access to treatment. All of the above strategies would require pre-agreed scope, measures of success, and approaches to evaluation.

Adeyi emphasized the need to question and address the fundamental assumption that beneficiary countries necessarily have well-functioning central public medical systems. This assumption underpins the central medical store procurement approach that often causes major bottlenecks in the supply chain. As a possible alternative, he suggested taking advantage of and improving existing drug distribution systems in-country. Other efforts are under way to gather information and initiate improvements in the operation of the SLD supply chain, and workshop participants discussed these related efforts and their goals (Box 3-1).

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27 With the attendant effect of “crowding out” oral artemisinin monotherapy, which carries an increased probability of widespread onset of resistance.

28 Adeyi remarked that concerns about middlemen taking advantage of the subsidy, rural areas being excluded from subsidized ACTs, and the private sector depriving the public sector of ACTs were ultimately unfounded.



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