Threatening to pull the plug on a big malaria project — Metrics Mania?

Metrics Mania
Metrics Mania
Flicky, Beto Ruis Alonso

The future looks bleak for a big anti-malaria project you may not have heard of — the AMFm, Affordable Medicines Facility for malaria.

The idea of the $463-million AMFm, launched in 2004, was to subsidize the supply of anti-malaria drugs so that people in poor countries could afford the life-saving medications. People did get them, and malaria rates have declined significantly since. But as Nature reports, experts are raising concerns about this particular initiative due to lack of clear evidence that it had much impact.

So the push is on to either significantly alter the AMFm initiative or just kill it.

But let’s try to keep in mind that old axiom – “Absence of Evidence is not Evidence of Absence.”

Malaria is a big killer and it turns out we’re not that great at documenting malaria mortality accurately, let alone morbidity (which takes a huge economic toll on many African nations). It’s hard to accurately document deaths averted by prevention or treatment. It’s even more difficult to quantify the impact a particular supplier of medicines is having as distinct from all other suppliers of medicines — or from other factors (bed nets, etc.) that have significantly driven down malaria rates worldwide over the past decade.

So I’d like to challenge the critics to first show evidence of absence before anyone pulls the plug on AMFm. It seems likely that widespread access to cheap anti-malaria medications in poor countries has probably saved some lives. How many? $463 million worth of lives saved? I don’t know. Does anyone?

As Victoria Fan at the Center for Global Development notes in her post on the AMFm debate A Global Health Mystery, there could be some push from the drug industry to get rid of this subsidized drug project. There’s also budget pressures that make politicians look for the easy cut. It may be more than lack of evidence that has brought the long knives out.

Michaleen Doucleff at NPR’s Global Health desk wrote about this a few weeks ago, saying the AMFm has been quite successful and the threat to its future likely comes from budgetary pressures on the Global Fund.

Whatever is driving this, perhaps it’s worth saying that sometimes these projects aimed at fighting poverty, or diseases of poverty, get launched because they just make sense and the need is urgent. They aren’t set up as experiments. And it is these kind of projects that are now being targeted by the new industry of “aid effectiveness” experts. Yes, we should seek evidence of effectiveness.

But let’s not use absence of evidence to throw the baby out with the bathwater … to use a horribly mixed metaphor.

For more of my ranting on all this, see my brief series Metrics Mania.


About Author

Tom Paulson

Tom Paulson is founder and lead journalist at Humanosphere. Prior to operating this online news site, he reported on science,  medicine, health policy, aid and development for the Seattle Post-Intelligencer. Contact him at tom[at] or follow him on Twitter @tompaulson.

  • A humanidade 2012 que projectos para combater a Malária e outras doenças infeciosas

  • Thanks for this post. What seems most frustrating is that folks didn’t – or weren’t offered space to – say at the beginning what it would take to convince them about AMFm, since it was controversial and explicitly set up as an experiment. Perhaps the benchmark-setting process needed to be more participatory? Some things are indeed hard to measure, like DALYs gained or deaths averted. But, perhaps something would have been feasible at the DSS sites in many of the pilot countries to give suggestive evidence of changes in morbidity and mortality.

    More importantly, though, if folks wanted to see X kind of evidence, data collection on X should have been funded.
    I’d be interested in continuing a conversation with you about ‘experiments’ in development, if possible!

    • Gates Keeper

      $468M is not an “experiment” or “pilot” in development, Heather, or really with anything anywhere in this world. However, there’s ample evidence for a full-scale program if the primary goal is to subsidize drug manufacturers and not whether such a program actually has any discernible impact on human disease.

      On a related note, NPR’s and especially Michaleen Doucleff’s coverage of AMFm is not credible. The Bill & Melinda Gates Foundation–which has been the key financial and political driving force behind AMFm since its inception (even though the funds are housed at The Global Fund)–also provides substantial funding for NPR’s global health coverage. So should we be surprised that a paper in Science that doesn’t say anything new but is written by other Gates grantees gets covered, while major critical reports on the AMFm by organizations like Oxfam don’t? Should we be surprised that instead of Michaleen Doucleff seriously considering or even (heaven forbid) reporting on the possibility that AMFm was poorly designed as a health program but better designed as a market program, and that potential non-renewal of AMFm might have more to do with the Global Fund board caring more about health impact as a primary goal, regardless of the size of their budget? I guess it’s easier to pre-emptively blame failure on “budgetary pressures at the Global Fund.”

      It’s too bad that Michaleen Doucleff can’t at least hold herself to the same standard that consultants to pharmaceutical companies are required to when writing for medical journals about pharmaceuticals: declaring relevant conflicts of interest.

  • Hendrik