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Africa: Global Health Fund Issues
Africa: Global Health Fund Issues
Date distributed (ymd): 020422
Document reposted by Africa Action
Africa Policy Electronic Distribution List: an information
service provided by AFRICA ACTION (incorporating the Africa
Policy Information Center, The Africa Fund, and the American
Committee on Africa). Find more information for action for
Africa at http://www.africaaction.org
+++++++++++++++++++++Document Profile+++++++++++++++++++++
Region: Continent-Wide
Issue Areas: +economy/development+ +security/peace+ +health+
SUMMARY CONTENTS:
The board of the Global Fund to fight AIDS,Tuberculosis, and
Malaria (GFATM) is meeting in New York April 22 to April 24 to make
decisions on its first grants. The fund faces enormous challenges,
including pledges which only cover 7% of the estimated annual need
and the urgent necessity of providing funds for treatment as well
as prevention and care.
This e-mail posting contains excerpts from three recent documents
highlighting these issues, (1) an article by Tim France, Gorik
Ooms, and Bernard Rivers comparing pledges with the equitable
contribution each rich country should provide, (2) a letter from
Health Gap, Act-Up Paris, and the African Services Committee, and
(3) a letter from Medecins sans Frontieres. The full version of the
first article is available on the web sites indicated; the full
version of the two letters will be available in the web archive of
this posting, at
http://www.africafocus.org/docs02/gf0204.php>
The web site of the Global Fund is
http://www.globalfundatm.org
Also today, the World Health Organization released new guidelines
for treatment of HIV/AIDS, unambiguously affirming the need for
treatment in "poor" settings as well as in rich countries, and
endorsing the inclusion of antiretrovirals in its essential
medicines list. See
http://www.who.int/inf/en/pr-2002-28.html
+++++++++++++++++end profile++++++++++++++++++++++++++++++
THE GLOBAL FUND: WHICH COUNTRIES OWE HOW MUCH?
By Tim France, Gorik Ooms and Bernard Rivers (21 April 2002)
[excerpts only: for full article, including formatted table, see
http://www.hdnet.org and
http://www.aidspan.org]
Nearly one year ago, the majority of the world's nations resolved
at `UNGASS', a major UN conference on AIDS, to increase annual
expenditure on the AIDS epidemic to $7-10 billion by 2005, with
much of this money to be raised and disbursed by a new global fund.
When the fund was eventually set up, its mandate was extended, and
it was named the Global Fund to Fight AIDS, Tuberculosis and
Malaria.
AIDS, an unprecedented and accelerating emergency, is already
having a devastating impact in Africa, with similar impacts
unfolding on other continents. Every day, 8,000 die, and 13,000
more become infected. Experts agree that reasonable expenditures
on prevention and treatment of AIDS, tuberculosis and malaria can
be of dramatic benefit not only to human health, but also to
economic development.
Thus far, efforts have been made to raise the money needed by the
Global Fund through ad hoc voluntary donations. These efforts have
failed. Governments have pledged a mere $1.8 billion.
Contributions from the private sector have been even more
disappointing, with not a single meaningful pledge since the Bill
& Melinda Gates Foundation offered $100 million ten months ago.
It's time for a new approach. The Global Fund needs to grow
rapidly to the point where it raises $10 billion a year.
Contributions to the Global Fund should be equitably shared among
the countries whose citizens live the most comfortable and
unthreatened lives. This means that the wealthiest countries, such
as the US, should contribute considerably more than they currently
do. But it also means that contributions should come from the
likes of Australia, Singapore, and the United Arab Emirates -
relatively wealthy countries that have not yet contributed a penny.
Part of the problem is that to date, nobody has proposed which
countries should give how much. The following table therefore
offers an `Equitable Contributions Framework' that can be used as
a starting point for working out an appropriate contribution level
for each country, and for measuring how well each country is doing
against that level.
The Framework suggests that $1 billion a year should come from the
private sector, as a minimum to justify the label `public/private
partnership' and the two seats it has out of the 18 voting seats on
the Fund board. The remaining $9 billion a year should come, in
proportion to Gross Domestic Product (GDP), from the 48 countries
that have a `high' Human Development Index, or HDI. (The UN's HDI
measures the overall quality of life based on standard of living,
life expectancy, and literacy plus school-enrolment.)
The proposed contribution comes to 0.035% of GDP for each country.
Not one country has yet given at this level. ...
It is to the credit of countries like Uganda and Nigeria that, poor
as they are on a per capita basis, they have made
multi-million-dollar contributions to the Fund. And it is to the
shame of many of the 48 relatively wealthy countries that they have
contributed little or nothing, without even stating why.
The Global Fund represents a bold new approach. The Fund's leaders
say that it will be more fast-moving, participatory, transparent
and accountable than traditional channels. The Fund needs a chance
to prove itself. It would be a shame if it were to fail simply
because it did not receive the funding it needs to get properly
established and to respond to the most urgent and obvious needs.
The authors are:
Dr. Tim France, Health & Development Networks (US EST +11 hours)
Thailand: Tel: +66 9 950 0685; Email: tfran@hdnet.org;
Web: http://www.hdnet.org
Gorik Ooms, Medecins Sans Frontieres (MSF) Luxembourg (US EST +7
hours) Mozambique: Tel: +258 82 311 075; Email:
msflmoz@teledata.mz;
Web: http://www.msf.lu
Bernard Rivers, Aidspan (US EST) USA (New York): Tel: +1 212 662
6800; Email: Rivers@aidspan.org; Web: http://www.aidspan.org
[display table in courier font to line up columns; better formatted
versions available on web sites indicated. For accessible format, with
more country detail, see
http://www.aidspan.org/GlobalFundContributions21April2002.htm. Word,
PDF, and Excel versions are also available on that site.]
Table: Equitable Contributions Framework for the Global Fund,
based
on GDP (21 April 2002)
1. G7 "high Human Development Index" countries:NI | Suggested | Total pledge | Estimated | I
| "equitable | to GF thus far| portion of | I
| annual | ($m., and | total pledge | I
|contribution"| as % of Col 2)| that applies | I
| (US$m) | | to 2002 |
I--------------|-------------| ------ | -----| ---- |------ | I
United States: | 3,479 | 450 | (13%)| 250 | (7%) | INJapan: | 1,646 | 200 | (12%)| 68 | (4%) | I
Germany: | 658 | 158 | (24%)| 35 | (5%) | I
United Kingdom:| 498 | 219 | (44%)| 67 | (13%) | I
France: | 453 | 151 | (33%)| 51 | (11%) | I
Italy: | 376 | 215 | (57%)| 73 | (19%) | I
Canada: | 243 | 100 | (41%)| 38 | (15%) |
I--------------|-------------| ------ | -----| ---- |------ | I
G7 total: | 7,352 | 1,493 | (20%)| 580 | (8%) |Nb) Non-G7 "high Human Development Index" countries:NI | Suggested | Total pledge | Estimated | I
| "equitable | to GF thus far| portion of | I
| annual | ($m., and | total pledge | I
|contribution"| as % of Col 2)| that applies | I
| (US$m) | | to 2002 |
I--------------|-------------| ------ | -----| ---- |------ | I
Spain: | 195 | 58 | (29%)| 19 | (10%) | I
Netherlands: | 128 | 125 | (97%)| 42 | (32%) | I
Switzerland: | 85 | 10 | (12%)| 3 | (4%) | I
Belgium: | 81 | 19 | (24%)| 6 | (8%) | I
Sweden: | 80 | 58 | (73%)| 20 | (25%) | I
Austria: | 67 | 4 | (5%)| 1 | (2%) | I
Denmark: | 57 | 2 | (4%)| 1 | (1%) | I
Finland: | 42 | 2 | (4%)| 1 | (1%) | I
Greece: | 39 | 2 | (4%)| 1 | (1%) | I
Portugal: | 37 | 1 | (4%)| 0 | (1%) | I
Ireland: | 33 | 10 | (31%)| 3 | (10%) | I
Kuwait: | 10 | 1 | (10%)| 0 | (3%) | I
Luxembourg: | 7 | 3 | (41%)| 1 | (14%) | I
Others: | 1 to 161 | 0 | (0%) | 0 | (0%) |
I--------------|-------------| ------ | -----| ---- |------ | I
Non-G7 total: | 1,648 | 294 | (18%)| 99 | (6%) |
c) Totals from the above table
(i) Total for all 48 high HDI countries:
* Suggested "equitable annual contribution" to Global Fund:
US$9,000 million * Total pledge to Global Fund thus far: US$1,788
million * Estimated portion of total pledge that applies to 2002:
US$679 million
(ii) Total for all non-'high HDI' countries that have
donated**:
* Suggested "equitable annual contribution" to Global Fund: $0 *
Total pledge to Global Fund thus far: US$33 million * Estimated
portion of total pledge that applies to 2002: US$11 million
(iii) Total for private sector (foundations and corporations) ***:
* Suggested "equitable annual contribution" to Global Fund:
US$1,000 million * Total pledge to Global Fund thus far: US$101
million * Estimated portion of total pledge that applies to 2002:
US$34 million
(iv) Grand total
* Suggested "equitable annual contribution" to Global Fund:
US$10,000 million * Total pledge to Global Fund thus far: US$1,922
million * Estimated portion of total pledge that applies to 2002:
US$725 million
The final column is based on private sources plus our own
estimates, because the information is not published. We understand
that total pledges are: 2002=$725m., 2003=$487m., 2004=$132m.,
2005=$67m., 2006=$27m., plus $484m. for which the year(s) are not
specified. We also understand that the pledges for 2002 (before
adding shares of the EU pledge, when appropriate) include
USA=$250m., UK=$60m., Netherlands=$40m., Canada=$37.5m., and
Germany=$26.5m. For other countries and for the private sector,
the 2002 portion is not known, so we have assumed it to be 33.8% of
the total pledge, in order to bring the overall 2002 total to the
known figure of $725 m. Further information received will be
reflected in future versions of this table.
Accompanying note to readers and editors
The above article was written by three people who work with
non-governmental organizations (NGOs) in three different
continents. They `met' electronically through their active
involvement in the Break-the-Silence (BTS) dedicated e-mail
discussion forum, which has over 3,000 members worldwide. BTS
serves to support civil society participation in international
debates on HIV/AIDS and other health-related issues. Since October
2001, BTS discussions have mainly focused on the Global Fund.
Financial contributions to the Fund have decreased significantly in
recent months, and are far below the originally intended level.
The first funding requests for grants from the Fund, in March 2002,
were already for far more money than the Fund can currently provide
in any sustained way. ...
The article, written in response to that frustration, proposes the
establishment of an `Equitable Contributions Framework' to serve as
a guide to appropriate contribution levels to the Fund.
If you or your organization are encouraging contributions to the
Fund from your own country, you can use the Framework to highlight
your country's appropriate contribution, its total pledges already
made, its apparent pledge for 2002, and the consequent shortfall.
To join the BTS forum, send an e-mail message to:
join-break-the-silence@hdnet.org
To read previous BTS postings on the Global Fund process, go to:
http://archives.healthdev.net/bts
Health GAP (Global Access Project), Philadelphia, USA
Act Up-Paris, France
African Services Committee New York City, USA
18 April 2002
To all Members, Board of Directors, the Global Fund to fight AIDS,
Tuberculosis, and Malaria (GFATM):
People living with HIV/AIDS, their allies, and experts around the
world will be monitoring closely the outcomes of this second,
pivotal Board meeting of the GFATM.
This letter sets out several concerns held by our organizations
regarding outstanding policy issues that will come before you for
consideration and action during the 22-24 April meeting.
Summary:
We insist on a concerted effort on the part of this Board to
correct and redress the devastating cumulative impact of years of
indifference to untreated HIV/AIDS in developing countries, where
95% of people with HIV/AIDS live.
The Board must emerge with a clear statement prioritizing massive
scale-up and implementation of antiretroviral treatment programs in
developing countries.
The acute need for more money for the GFATM must not be reserved
for internal, hushed Board discussion. On the contrary, the
desperate need for more resources must be publicly emphasized by
the Board. Bona fide demand for funding‹especially funding for
programs that include antiretroviral treatment, on the scale
necessary for substantial impact‹tremendously outpaces the funds
available to the Board for spending for the first and subsequent
tranches of 2002.
This gross lack of resources is an untenable situation that can
either be corrected through advocacy and appeal on the part of the
Board, or can be tacitly endorsed by the Board through its
inaction.
Without swift and decisive action in these areas, the GFATM will
become defined to potential contributors and other influential
actors as another irrelevant mechanism supporting only slow,
incremental shifts in international response to the global AIDS
disaster‹contradicting the consumer-led demand for affordable AIDS
drugs that energized leaders to create the GFATM.
1. Prioritizing antiretroviral treatment‹redressing the crisis in
HIV medicines access
HIV treatment access is a human rights and public health necessity.
As a new, non-duplicative mechanism that includes funding HIV
treatment programs among its objectives, the GFATM at its launch
was seen as the best hope for sustainable, accelerated scale-up and
implementation of antiretroviral treatment programs in developing
countries.
However, applicants and potential applicants have received mixed
messages from the board and from bilateral donors regarding
proposals that include funding requests for antiretroviral
treatment. When the historical exclusion of treatment was coupled
with donor pressure to scale back the size and scope of proposals
at the Country Coordinating Mechanism (CCM) level, many countries
chose to submit proposals with very modest treatment components,
that under-represented the capacity of a country to deliver
medicines for AIDS, tuberculosis, and malaria treatment.
The GFATM as a multi-disease entity is constructed to fund a range
of interventions, which require a range of costs. In the
traditional language of Ýcost-effectiveness,Ý antiretroviral
treatment programs will always be eclipsed by less costly
interventions such as HIV prevention, or the treatment and
prevention of other infectious diseases. This is unacceptable.
Applicants and potential applicants therefore require clear
information and guidance about how this Board will prioritize
funding among AIDS, tuberculosis and malaria, and among public
health responses such as prevention and treatment.
If the GFATM is to take up its task of remedying the disparity in
HIV treatment access, the Board must clarify through a public
communication that viable antiretroviral treatment programs are
feasible, fundable, are a required aspect of a comprehensive,
effective response to the AIDS pandemic. Funding requests
containing components for AIDS treatment must not be downgraded in
consideration because of relative higher cost.
The direct and measurable impact of treatment access on morbidity
and mortality, as well as its spillover benefits to HIV prevention
efforts, are outcomes necessary to demonstrate for donors the value
and impact of GFATM funded interventions. The most dramatic
outcomes possible with the scarce resources available will be
produced by funding discrete sectors with antiretroviral treatment,
effectively delivered.
The Board should encourage exactly such applications, and commit
all available resources on hand.
2. Patents and the procurement of medicines by the GFATM
Commitment to the procurement of lowest possible cost, quality
medicines‹including quality generic drugs‹must be communicated by
Board members.
Generic competition has been shown to be the most powerful tool in
exerting downward pressure on drug prices. (2) The procurement of
quality generic versions of HIV medicines will increase
life-extending treatment access by extending finite resources as
efficiently as possible.
In most developing countries, there is little viable market for
pharmaceuticals. Given the decimation of adult populations in some
countries due to untreated HIV disease, the interest of brand name
pharmaceutical companies in guarding patent monopolies and
concomitant high prices must not determine the policy of the Board
regarding health commodities procurement.
We note with concern the application submitted by the government of
Malawi, where the cost of antiretroviral drugs was calculated based
on the reference of proprietary medicines, as per 'consultations
with WHO and the donor community and initial documents from the
Technical Support Secretariat.' (3) It is incumbent on the Board to
clarify immediately the potential benefits of the use of lowest
cost, generic versions of HIV medicines.
The declaration at the World Trade Organization (WTO) Ministerial
at Doha, Qatar clarified the right of WTO Member States to utilize
safeguards in international trade agreements medicines to achieve
public health goals, such as increasing access to affordable HIV
medicines.(4) In addition, the recent list published by the World
Health Organizations Essential Drugs and Monitoring Project of
initial 'pre-qualified' HIV medicines suppliers includes generic
products. (5) Consistent with these and other recent favorable
policy developments, the Board must publicly state its support for
the procurement of quality generic antiretroviral and other
medicines, as a policy of amplifying the impact of the finite
resources of the GFATM.
The GFATM is not the appropriate venue to interpret or enforce
international trade agreements. There are bi- and multilateral fora
established to concerns that arise regarding intellectual property
rights. The GFATM has no reason to include itself in these
discussions.
3. The cupboard is bare: the Board must communicate publicly the
need for billions in additional annual funding
By any estimation the GFATM is being starved of the resources
necessary to mount an effective response to the global AIDS
disaster. The gap in resources is clearly the result of rich
countries' decision not to invest significant resources in the
GFATM. Several of the world's wealthiest countries have donated the
least to the GFATM as a percentage of overall country wealth. For
example, in 2002 Rwanda's contribution was 10 times as generous as
the United States', when contributions are measured as a proportion
of total country wealth. (6)
The Board should play a critical role in transforming the kind
words of wealthy countries into action. Lack of funds is blunting
the impact of the GFATM. The Board must call on wealthy countries
to contribute the billions of dollars needed in new contributions,
primarily to fund HIV treatment access.
As the board meeting takes place, activists and elected officials
in the U.S. are campaigning for an additional $750 million
contribution from the United States for 2002 through an emergency
supplemental spending bill now before the U.S. Congress. If
successful, this would increase the U.S. contribution to
approximately $1 billion for 2002, leveraging additional donations
from donor countries and others. Thus far, every dollar contributed
by the U.S. has been matched more than fourfold.
4. The GFATM, technical assistance, and transparency
Until very recently, antiretroviral treatment programs in
developing countries have been ineligible for funding by most donor
countriesÝ assistance programs. (7) Regardless of political
commitment at the country level, developing countries have
little-to-no experience in composing comprehensive and accurate
grant applications that include provisions for establishing or
scaling up antiretroviral treatment access programs.
Supporting applicants in their efforts to secure funds for
treatment requires not only unequivocal endorsement of the
importance of antiretroviral treatment, but also requires that the
GFATM extend technical assistance to applicants. Without this
provision, applicants will consistently be rejected for funding not
for lack of need or capacity, but for lack of guidance. The Board
must quickly develop a basic plan for providing technical
assistance, in order to increase the facility with which applicants
can complete fundable proposals.
A tenet of the GFATM is transparency in operations. In our
experience people with HIV and their allies in developing countries
have had extreme difficulty in getting even basic questions
answered and comments addressed regarding their CCMs completing
applications. We see this as a significant problem, as the
expertise of people with HIV, their loved ones and care providers
are those often best situated to asses the needs of impacted
populations. Disregarding or excluding such participation can lead
to corruption and ineffectiveness.
The Board must not disregard these concerns‹conditions at the
country level which exclude the substantive participation of people
with HIV only worsen the crisis in lack of access to AIDS
treatment. Therefore the Board must facilitate involvement of
people with HIV in their CCMs, and must rigorously and publicly
investigate complaints regarding the exclusion people with HIV.
We also call on this Board to require each applicant to submit a
brief summary of the content of their funding request, for public
consumption and posting to the GFATM website. This simple step
would increase accountability of governments to civil society. In
addition, such a measure would go a great distance to address
concerns of donors.
Given the relatively poor outcomes of extant interventions that
have been restricted to palliative care and prevention, and the
international demand from people living with HIV for fulfillment of
the human right to affordable AIDS medicines, the Board must take
leadership by affirming the need for expanded antiretroviral
treatment access and calling for dramatic increases in
contributions to the GFATM.
During this meeting, the GFATM will establish itself either as a
crucial mechanism, or as an entity making untenable decisions in
the midst of an ever-worsening crisis. Your decisions next week
will have far-reaching impact, and as such they will be closely
monitored by people living with HIV/AIDS and their allies.
Sincerely,
Asia Russell Coordinator, International Advocacy Health GAP
(Global Access Project), Philadelphia, USA
Gabrielle Krikorian Coordinator, North/South Commission Act
Up-Paris,
France
Kim Nichols, Sc.M., MPH, Development and Policy Director African
Services Committee New York City, USA
cc: GFATM Technical Review Panel (TRP) GFATM Technical Support
Secretariat (TSS)N
1 Given the expertise and orientation of our organizations, these
comments are restricted to policy issues regarding HIV treatment,
care, and prevention.
2 eg, 't Hoen, Ellen and Suerie Moon. 'Pills and Pocketbooks:
Equity Pricing of Essential Medicines in Developing Countries,' 11
July 2001.
http://www.accessmed-msf.org/prod/publications.asp?scntid=318200146197&contenttype=PARA&
3 Submission to GFATM, Government of Malawi, available at:
http://www.cid.harvard.edu/gf/proposals.html
4
http://www.wto.org/english/thewto_e/minist_e/min01_e/mindecl_trips_e.htm
5
http://www.who.int/medicines/organization/qsm/activities/pilotproc/pilotproc.shtml
6 Rwanda's GDP (2000) = US$6.4 billion. US GDP (2000) = US$9.963
trillion. Rwanda's donation to the GFATM (2002) = US$1 million.
US donation to the GFATM (2002) = US$200 million.
7 The United States Agency for International Development (USAID),
for example, a substantial HIV/AIDS funding source, has
historically disqualified HIV treatment projects from funding as
outside its development mandate.
Medecins Sans Frontieres (MSF)
OPEN LETTER TO MEMBERS OF THE BOARD OF DIRECTORS AND TECHNICAL
REVIEW PANEL OF THE GLOBAL FUND TO FIGHT ADS, TUBERCULOSIS AND
MALARIA
18 April 2002
Original version with footnotes and malaria report referenced
available upon request from:
rachel_cohen@newyork.msf.org
Dear Members of the Board of Directors and Technical Review Panel
(TRP),
On behalf of M‚decins Sans FrontiŠres (MSF), I m pleased to submit
this letter to you on the occasion of the second Board of Directors
meeting of the Global Fund to Fight AIDS, Tuberculosis and Malaria
(Global Fund), scheduled to take place in New York City, April
23-24, 2002. In November 2001, we submitted a similar letter to all
members of the Transitional Working Group and Technical Support
Secretariat as part of the NGO consultation process. This letter
seeks to highlight our ongoing concerns and priority
recommendations at this critical juncture, based on our experience
in the field working to prevent and treat HIV/AIDS, TB, and
malaria, and to request specific, immediate action by Board members
individually and/or collectively in relation to the financing of
desperately needed medicines for the treatment of all three
diseases.
Treatment: a medical and ethical imperative
As a medical humanitarian organization, MSF believes that the
Global Fund must provide financing for treatment programmes for
HIV/AIDS, TB, and malaria. This is an ethical imperative. It is now
widely accepted that treatment and prevention are mutually
dependent and synergistic; that one reinforces and strengthens the
other, and that prevention-whether through condom distribution,
bednets, or general health education-has failed to control these
three diseases alone. We know this firsthand from our experience in
the field. We are therefore encouraged by the news that proposals
that include well-designed treatment interventions will be eligible
for funding.
However, the Fund has failed to clearly spell out the critical need
for addressing treatment as part of a comprehensive approach to
controlling HIV/AIDS, TB or malaria, relying instead on general
statements in support of "an integrated and balanced approach
covering prevention, treatment, and care and support in dealing
with the three diseases." We are deeply concerned that patients
already living with HIV/AIDS, TB, or malaria will be written off
despite pronouncements of support for treatment programmes that
would extend or save their lives because donors and some in the
international health community traditionally favour prevention at
the expense of treatment, and because at least one alternate member
of the Board has indicated that, particularly in the first round of
funding, grants will likely "ramp up" existing programmes rather
than starting de novo to introduce new interventions in order to
have the "greatest impact." This does not bode well, for example,
for antiretroviral (ARV) treatment programmes or malaria programmes
using artemisinin-based combination therapy (ACT), as there are
very few existing programmes, particularly in Africa, that
currently offer such treatment interventions. This is due in large
part to the chronic neglect of the donor community over the last
two decades, a lack of political will in some developing countries,
and the high cost of ARVs, ACT, and other essential medicines. It
would be a grave mistake to continue this cycle of neglect.
The Global Fund must take bold steps to support new, scientifically
sound, and life-saving treatment programmes. This means, among
other things, pushing for the acceleration of operational research
to increase knowledge on best practices for implementing new
combination treatments and diagnostic strategies in resource-poor
settings. Furthermore, the Fund must commit itself to ensuring that
newer, more effective, field-relevant medicines and medical
technologies are made available to poor countries at affordable
prices as soon as they are developed.
It is vital to improve treatment interventions, not expand use of
ineffective treatments
It is of vital importance that the Global Fund be used to support
improvement of treatment interventions, and that it does not
inadvertently facilitate the expanded use of ineffective
treatments. Yet the Fund has not taken a clear stand on the need to
make ARVs, second line TB treatments, or new, more effective
anti-malarials available (at the lowest possible cost). For
instance, in the case of malaria treatment, it would be wrong to
support programmes that continue to use treatments in areas where
they have lost their effectiveness due to resistance on the basis
that they are inexpensive. Where resistance to traditional
first-line treatments-especially chloroquine and
sulfadoxine-pyrimethamine (SP)-is high, malaria treatment must
include not only traditional antimalarials, but also
artemisinin-based combination therapy (ACT), as per the
recommendations of the world's leading malaria experts convened by
WHO in April 2001, and the February 2002 statement of Roll Back
Malaria on Malaria and Resistance.
MSF has witnessed this critical need firsthand. For example, in
response to the outbreak of malaria in Burundi at the end of 2000,
MSF teams diagnosed and treated malaria in the hard-hit provinces
of Kayanza, Ngozi, Karuzi and Cankuzo and over a period of six
months treated over 1.2 million patients. The epidemic is estimated
to have affected nearly 3 million people in Burundi and resulted in
thousands of deaths. These 3 million patients were treated with
ineffective medicines-not only by the Burundian health authorities
and other NGOs, but also by MSF itself-because chloroquine remains
the first-line treatment in Burundi's national protocol due in
large part to the cost of more effective alternatives such as ACT.
During the course of the epidemic, MSF teams carried out several
resistance studies and found that resistance to chloroquine in
Burundi is as high as 90% in some areas, and resistance to SP is as
high as 63% in some areas. The World Health Organization recommends
changing treatment protocols when resistance to first-line drugs
reaches 25%.
To address the broader issues raised by our experience in Burundi,
MSF recently released a report about changing malaria treatment
protocols in Africa where resistance to first-line drugs is high
(please see the enclosed report entitled "Changing National Malaria
Treatment Protocols: What Is the Cost and Who Will Pay?"). The
central concern of the paper is with the growing rates of
resistance to chloroquine and SP in Africa, namely in Kenya,
Rwanda, Tanzania, Uganda, and Burundi, and the possibility that
these countries, which are ready to change their national malaria
treatment protocols, will, possibly for financial reasons, settle
on a sub-optimal "mid-term" protocol (e.g. amodiaquine + SP) rather
than the clearly more effective choice of ACT. The paper provides
a cost analysis for the region of the proposed mid-term solution
versus the proposed optimal solution, and estimates that US$19
million in additional funding is needed annually for the five
target countries to make the medically appropriate treatment
protocol change-an investment that is surely worthwhile for the
number one killer of African children. MSF's report urges
international donors to step in to provide the necessary funds and
specifically calls on the Global Fund to address this issue. The
needed treatment is already available in Africa, but only at high
prices in some private pharmacies. By financing malaria treatment
programmes that include ACT, the Global Fund can play a crucial
role in overcoming this inequity and ensuring that all people who
need it, including the poorest and most vulnerable, have access to
effective malaria treatment.
Purchasing drugs at the lowest possible cost is essential
We are deeply concerned about the sort of technical advice being
given to potential recipient countries-by donor governments, the
World Health Organisation, and others-in relation to purchases of
medicines. Specifically, we are outraged that countries have
apparently been advised that they will only be able to purchase
patented drugs for their programmes. In the proposal to the Global
Fund from Malawi, for example, it clearly states the following:
"At present, we are assuming that the Global Fund will only finance
patented drugs. This is in line with consultations with WHO and the
donor community and initial documents from the Technical Support
Secretariat. If however, Global Fund rules permit the use of
generic drugs, the proposal and programme budget will be amended to
reflect this."
To ensure that international funding mechanisms, including the
Global Fund, offer treatment to the highest number of people
possible, it is essential that funds be available for bulk
purchases of medicines and medical technologies at the lowest
possible cost, through international tender. In its statement of
underlying principles, the Fund claims that "[i]n making its
funding decisions, the Fund will support proposals which...[a]re
consistent with international law and agreements, respect
intellectual property rights, such as Trade-Related Aspects of
Intellectual Property Rights (TRIPS), and encourage efforts to make
quality drugs and products available at the lowest possible prices
for those in need." As we pointed out in our letter to the TWG and
TSS of November 9, 2001-and as confirmed by the above quotation
from the Malawi proposal-this statement is easily misinterpreted
and must be clarified publicly.
The TRIPS Agreement can and does have negative consequences for
public health in poor countries. However, it also has safeguards to
balance public and private interests and ensure that patents do not
pose a barrier to access to medicines. At the 4th Ministerial
Conference of the World Trade Organization held in Doha, Qatar, in
November 2001, the world's trade ministers issued a landmark
Declaration on the TRIPS Agreement and Public Health, which stated:
"We agree that the TRIPS Agreement does not and should not prevent
members from taking measures to protect public health. Accordingly,
while reiterating our commitment to the TRIPS Agreement, we affirm
that the Agreement can and should be interpreted and implemented in
a manner supportive of WTO members' right to protect public health
and, in particular, to promote access to medicines for all. In this
connection, we reaffirm the right of WTO members to use, to the
full, the provisions in the TRIPS Agreement, which provide
flexibility for this purpose."
This Declaration was an important achievement because the text
gives clear primacy to the protection of public health over private
intellectual property, as well as an unambiguous road map to all
the key flexibilities in the TRIPS agreement. The Global Fund must
make clear beyond the shadow of a doubt that applicants have the
option of purchasing generics with Global Fund money.
We therefore call on all members of the Board, whether individually
and/or collectively, to issue a clearly articulated public
statement during the Board meeting indicating that the Global Fund
explicitly supports purchases of lowest cost drugs, whether generic
or brand-name, and the use of TRIPS-legal safeguards to override
patents when they constitute a barrier to access. The Global Fund
should also clearly specify that these measures are fully compliant
with TRIPS and in keeping with the spirit and letter of the Doha
Declaration.
Without a deliberate strategy to ensure that funding can be used to
purchase quality drugs from both generic and proprietary
producers-including those located in developing countries-funds
will be squandered. To secure drug quality, the Fund should also
explicitly support the WHO's project to pre-qualify manufacturers
of drugs and diagnostics related to HIV/AIDS, and encourage its
expansion to other diseases, including malaria and TB.
These principles related to procurement of drugs and diagnostics
are crucial because prices of medicines and other essential health
care goods will have a profound impact on the reach and
effectiveness of the Global Fund. Antiretroviral drugs for the
treatment of HIV/AIDS provide a good illustration: the cost of ARVs
from proprietary companies-even at deeply discounted prices-are,
for certain regimens, three times more expensive than ARVs from
generic manufacturers. Using the lowest cost suppliers will
increase by as much as three times the number of patients who can
be treated with the same amount of money, and will allow for
greater investments in other important components of care and
prevention. We know this firsthand from our experience in the field
in our ARV demonstration projects. For example, in our ARV project
in Khayelitsha, a poor township on the Western Cape in South
Africa, the cost-savings generated by switching from
patent-protected brand name ARVs to generic versions made a
tremendous difference in the overall cost of the programme. These
cost-savings have allowed us to expand our programme from a total
enrollment capacity of 180 to 400 on virtually the same budget.
More funds desperately needed
The Global Fund holds a promise-yet unfulfilled-for the millions of
people in Africa, Asia, Latin America, Eastern Europe, and other
high-burden countries living with HIV/AIDS, TB and malaria who
desperately need access to life-saving and life-prolonging
treatment. To date, the Fund has received funding requests totaling
US$5 billion over five years, and yet the total amount of
multi-year financing pledged is merely US$1.9 billion and the
amount of funding available for disbursement in the first funding
cycle is approximately US$200 million. This falls drastically short
of the needs and will be a major disappointment for all of those
who have placed great hope in the ability of the Fund to reduce the
death rates from these three treatable diseases. We call on you as
members of the Board to take whatever steps necessary to ensure
that donors immediately allocate additional resources to the Global
Fund and other financing mechanisms to fight these three diseases.
Conclusion
It is essential that a long-term, sustainable solution to the
access to medicines crisis be developed and supported by
governments and multilateral agencies, which are responsible for
responding to global public health needs. Your leadership on the
Board of the Global Fund to Fight AIDS, Tuberculosis and Malaria
will be key if it is to succeed, and will ultimately determine
whether it becomes a crucial part of an effective global response
to HIV/AIDS, TB, and malaria. We urge you to strongly support the
recommendations presented in this letter and the enclosed reports
to guarantee access to effective and affordable medicines and
medical technologies at the best possible price. We believe that
unless the Global Fund urgently addresses these issues, it will not
be able to make good on its promise to alleviate the burden of
AIDS, TB and malaria. For millions of people in developing
countries, this is a matter of life and death.
Sincerely,
Bernard Pecoul, MD, MPH Director,
MSF Access to Essential Medicines Campaign
This material is being reposted for wider distribution by
Africa Action (incorporating the Africa Policy Information
Center, The Africa Fund, and the American Committee on Africa).
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