E-DRUG: MSF comments on AMFm proposal by Global Fund Board
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The Global Fund Board will discuss and take decisions at the end of this
week on the 'Affordable Medicines Facility malaria - AMFm' (previously
called 'ACT subsidy' - which was a clearer term).
MSF sent these comments to Global Fund board members.
Best,
Tido von Schoen-Angerer
Executive Director, Campaign for Access to Essential Medicines
Medecins Sans Frontieres
Tido.von.SCHOENANGERER@geneva.msf.org
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To the Board members of the Global Fund to Fight AIDS, TB and Malaria
Geneva, 31st October 2008
Dear Board member,
We are aware that the Global Fund will be discussing the proposed
Affordable Medicines Facility for malaria (AMFm) at its upcoming board
meeting, and would like to take this opportunity to contribute a number of
comments on the proposal.
Medecins Sans Frontieres (MSF), as an international medical humanitarian
organisation, has historically strongly supported the use of
artemisin-based combination therapies (ACTs) and in 2007 provided malaria
treatment with ACT to 1.3 million adults and children.
Despite some progress, the present rollout of ACTs in most of the endemic
countries remains disappointing. Only 80 million treatments were distributed worldwide in 2007, whereas an estimated 300-500 million
treatments for malaria are needed.
To seriously decrease malaria mortality, there is an urgent need to replace
old, no-longer effective anti-malarials with ACTs, and to significantly
increase the number of ACTs distributed. MSF has welcomed the additional
financial resources dedicated to ACTs that international donors have made
available. MSF similarly welcomes the possibility to scale up resources for
ACTs through the proposed Affordable Medicines Facility for malaria (AMFm),
while acknowledging its risks and limitations.
During your deliberations on malaria we would like you to take the
following comments into consideration:
1. The Global Fund needs to improve access and quality of care
The AMFm aims to dramatically increase ACT rollout both in the public and
the private sector. While this is commendable, MSF has documented that a
broad increase in coverage of malaria patients to treatment requires that
care is provided for free (not only malaria drugs, but also other related
costs for consultation, other drugs, laboratory tests).[1] Although a main
added value of the AMFm can be to expand access through the private sector,
this alone will resolve only part of the access issues. The main emphasis
of the GFATM therefore needs to continue to be on the further expansion of
access through the public sector to provide free of charge diagnosis and
treatment. This must be ensured in particular for the most vulnerable
groups, children and pregnant women. Increasing the provision of free
malaria care could also be a competitive factor that can impact prices in
the private sector.
New resources for malaria present a real opportunity to change the case
management paradigm for the disease. With the availability of new
diagnostic technologies, it is time to stop treating fevers blindly with
diagnosis based only on symptoms. This approach leads to ignoring other
underlying causes of fever and is an inefficient use of drugs, which
contributes to the development of resistance. Rapid Diagnostic Tests (RDTs)
are not being used enough in Africa (about 10 million in 2007), and their
use should be promoted. MSF's experience is that this could start quickly in services where health professionals are present and is also feasible at the community level. [2] Malaria treatment should therefore be based on diagnosis as much as possible. The GFATM should ensure that all the country programs it funds base malaria treatment on appropriate diagnosis.
2. Remove chloroquine and artesunate monotherapy
In line with progressive roll of ACT, WHO and countries should take steps
to actively remove chloroquine as treatment for Plasmodium falciparum from
the market and enforce the WHO ban on artesunate monotherapy. The AMFm may
crowd out these drugs to some extent but it will not be enough to
effectively remove them. Furthermore, the AMFm should exclusively use fixed
dose combinations to ensure better adherence to treatment and protection
from artemisin resistance.
3. The AMFm must not lead to a global artesimin shortage
Suppliers of active pharmaceutical ingredients (API) need to be given
reliable forecasts and orders as soon as the AMFm is approved, to avoid the
AMFm provoking a global API shortage. The AMFm must be launched in a way
that takes into account the time delay that is needed to increase
plantation and supply.
4. Research that should be supported by the AMFm
The AMFm should be accompanied with research not merely to measure prices
but also to measure actual access, use and health outcomes. In addition,
adequate resistance monitoring must be ensured and AMFm participating
countries should make a commitment to carry out such monitoring (with
assistance by WHO and other agencies as necessary).
We hope these comments make a constructive contribution to the Global Fund
Board discussions and look forward to discussing these issues further with
you.
Yours sincerely,
Tido von Schoen-Angerer, MD
Executive Director
Campaign for Access to Essential Medicines
Medecins Sans Frontieres
[1] No Cash No Care. How 'user fees' endanger health. An MSF briefing paper
on financial barriers to healthcare. MSF, Brussels, March 2008.
http://www.accesstohealthcare.msf.be
[2] Full Prescription: Better Malaria Treatment for More People: MSF's
Experience. MSF, Brussels September 2008. Available at:
http://www.msf.org/source/medical/malaria/2008/MSF_malaria_2008.pdf