In 2004, the Institute of Medicine (IOM) proposed a simple solution to a pressing global problem (Arrow et al. 2004). The price of artemisinin-based combination therapies (ACTs), the most effective malaria treatment in many countries, would be subsidized at the factory-gate to make them as affordable as ubiquitous, sub-optimal monotherapies such as chloroquine. This would, the IOM theorized, lead to widespread crowding out of the less effective drugs through both public and private channels, thereby improving immediate health outcomes and delaying the development of devastating resistance to artemisinin.

The subsequent process to translate that theory into a corresponding global initiative, however, was complex and lengthy, with 3 years of debate. Sceptics of the subsidy argued that it would not have the necessary impact because middlemen would capture excessive profits, poorer patients would not access the drugs through private shops regardless of price, and most ACTs would be purchased by individuals without malaria and would be wasted (Oxfam International 2009; Kamal-Yanni 2010). Proponents countered that market forces would ensure affordable pricing and broad supply, and that the problems of ensuring the equity and targeting of ACTs were not unique to the private sector and had not hampered major investments in distribution of drugs in the public sector (Roll Back Malaria Partnership 2007). After significant negotiation and compromise, the Affordable Medicines Facility-malaria (AMFm), as the subsidy concept is now known, opened its doors in July 2010. One of the most important compromises was that the AMFm would not begin as a global initiative, but would rather be ‘piloted’ at national-scale in selected malaria-endemic countries with an extensive evaluation of that initial phase. The Board of the Global Fund to Fight AIDS, Tuberculosis and Malaria, which hosts the AMFm, eventually set December 2012 as the target date to review the evaluation and determine whether to continue, accelerate, expand or terminate the facility.

Despite this process, the debate that defined the formation of the AMFm continues, with both sides using issues such as the scope of the evaluation and anecdotes and early results1 on the uptake of subsidized drugs as fuel to advance their positions (Esipisu 2011; AMFm Ad Hoc Committee 2010). The evaluation is looked to as the means to definitively resolve the debate, but the restricted timeline (see below) and the nature of the national-scale, global-level intervention defy clear answers—the results will undoubtedly present a mixed and nuanced picture that will require careful interpretation. As a result, if the current dynamics continue, the dialogue at the review will mirror those during the initial design process despite years of work and hundreds of millions of dollars spent.

We accordingly propose here a means of redefining that debate prior to the completion of the pilot phase to ensure the decisions on the future of the mechanism are as productive as possible. In short, we argue that the dialogue should be redirected from the question of ‘if’ the AMFm should continue, to ones of ‘how, when and where’ it should be used. Rather than an initiative that is applied universally and that warrants unique scrutiny—and fierce argument—the AMFm should be considered part of the toolkit of interventions that can be used to control malaria. And as is now best practice in global health, malaria-endemic countries themselves should lead decisions on how and when to use that intervention to fit local needs and context.