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E-drug: MSH-Bill Gates Foundation Essential Medicines Franchise
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MSH-Bill Gates Foundation Essential Medicines Franchise: towards a
"macdonaldisation" of health care?
[The full title could not fit in the subject heading. This is hot topic! I
hope many E-druggers will participate in the debate which has already
started on sister E-med. KM, moderator]
On April 4, 2002 Management Sciences for Health (MSH), the Bill & Melinda
Gates Foundation, and the Cry for the World Foundation (CFW) announced that
some developing countries (eg, Ghana, Tanzania, El Salvador, later on
Senegal and elsewhere) have been selected to launch an "essential medicines
franchise" programme (see:
http://www.msh.org/features/gates/kenya-release.html and
http://www.msh.org/features/gates/countries-release.html).
The goal of this effort is to establish by countries a network of
private-owned and operated franchised outlets which will provide "a range of
quality essential medicines and services at reasonable prices". Each outlet
owner - "the franchisee", will have incentives and benefits to encourage
provision of "high quality medicines and services at affordable price", and
will sell among others branded medicines (according to the MSH arguments,
"branded medicines are often preferred to medicines sold under generic
names: brand name associated with quality". In MSH slide show: Franchise:
improving access to essential drugs through a public health franchise
model).
We can be surprised and baffled that such an initiative did not spark off
any reaction and controversy, apart from a discussion just starting on the
E-Med network.
Such a mixture between the franchise concept on the one hand, and public
health concerns on the other hand is surprising and distressing. It's a
mismatch.
We can observe sadly that the powerful proposition - first emerged around
150 years ago during the formative years of the public health movement,
putting forward that "social justice is the foundation of public health" is
still contested (see: Krieger N, Birn AE. A vision of social justice as the
foundation of public health: commemorating 150 years of the spirit of 1848.
American Journal of Public Health 1998; 88: 1603-06). Confusing healthcare
delivery (ie, medicines and healthcare services) and micro-enterprise or
franchise business is the best way of widely opening the door to the
selection of patients and diseases, economic criteria (eg, patients
creditworthiness) taking priority over social concerns or recognized public
health concerns.
One can understand but without acquiescence the motivations of some
governments enticed by such a simplistic credo, as a way of reducing quickly
their health care expenditures but above all a way of avoiding their own
responsibilities. With the 1978 "Health for All" campaign already off the
WHO agenda and a move away from the primary health care concept, the
"consumer responsiveness" is becoming the substitute for the "community
participation" of patients, health care facilities having now to act as
client-responsive services (eg, the CFW health shops). Patients and their
health needs are turned into consumers of health goods and services,
provided they pay for.
With this initiative we are witnessing a strong comeback of the 1980s ideas
dominated by the free market economy school of thought relayed by the
International Monetary Fund (IMF) and the World Bank (WB) through the
"structural adjustment" programmes imposed to developing countries, trotting
out again the nineteenth century commonplace notion that economic growth
results inevitably in development with improvements in health and welfare.
We have a feeling of re-reading the World Bank World Development Report
(Investing in health, 1993) when WB encouraged developing countries
governments to "promote competition and diversity in the provision of health
services" and concentrate their efforts in adopting minimal packages of
health care. Such reforms, according to the WB, could "translate into longer
and healthier lives for people" considering that "good health increases the
economic productivity of individuals and the economic growth rate of
countries". We have already observed the disastrous consequencies of those
policies on the conditions of health care facilities and the immediate
effects on the HIV/AIDS crisis management.
While agreeing with MSH that new strategies for enhancing access to
essential medicines are highly and urgently needed,
- May we reasonably and ethically propose the "franchise concept" as a
response to this challenge?
- And what about the essential medicines concept?
We are far from the concept of health as a human right. Sometimes it is good
to come back to basic principles.
Patrice Trouiller
PharmD, MB
M�decins sans Fronti�res
MSF Campaign for Access to Essential Medicines, http://www.accessmed-msf.org
PTrouiller@chu-grenoble.fr
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