[Ip-health] MSF comments on AMFm proposal

[Tido.von.SCHOENANGERER@geneva.msf.org]

The Global Fund Board will discuss and take decisions at the end of this=0D
week on the 'Affordable Medicines Facility malaria - AMFm' (previously=0D
called 'ACT subsidy' - which was a clearer term).=0D
MSF sent these comments to Global Fund board members.=0D
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To the Board members of the Global Fund to Fight AIDS, TB and Malaria=0D
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Geneva, 31st October 2008=0D
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Dear Board member,=0D
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We  are  aware  that  the  Global  Fund  will  be  discussing  the proposed=
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Affordable  Medicines  Facility  for  malaria  (AMFm) at its upcoming board=
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meeting,  and would like to take this opportunity to contribute a number of=
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comments on the proposal.=0D
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M=C3=A9decins  Sans  Fronti=C3=A8res  (MSF), as an international medical hu=
manitarian=0D
organisation,    has   historically   strongly   supported   the   use   of=
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artemisin-based  combination  therapies (ACTs) and in 2007 provided malaria=
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treatment with ACT to 1.3 million adults and children.=0D
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Despite  some  progress, the present rollout of ACTs in most of the endemic=
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countries   remains   disappointing.   Only   80  million  treatments  were=
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distributed  worldwide  in  2007,  whereas  an  estimated  300-500  million=
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treatments for malaria are needed.=0D
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To seriously decrease malaria mortality, there is an urgent need to replace=
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old,  no-longer  effective  anti-malarials  with ACTs, and to significantly=
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increase  the  number  of ACTs distributed. MSF has welcomed the additional=
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financial  resources  dedicated to ACTs that international donors have made=
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available. MSF similarly welcomes the possibility to scale up resources for=
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ACTs through the proposed Affordable Medicines Facility for malaria (AMFm),=
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while acknowledging its risks and limitations.=0D
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During  your  deliberations  on  malaria  we  would  like  you  to take the=
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following comments into consideration:=0D
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1. The Global Fund needs to improve access and quality of care=0D
The  AMFm  aims to dramatically increase ACT rollout both in the public and=
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the  private  sector.  While this is commendable, MSF has documented that a=
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broad  increase  in coverage of malaria patients to treatment requires that=
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care  is  provided for free (not only malaria drugs, but also other related=
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costs  for consultation, other drugs, laboratory tests).[1] Although a main=
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added value of the AMFm can be to expand access through the private sector,=
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this  alone  will resolve only part of the access issues. The main emphasis=
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of  the GFATM therefore needs to continue to be on the further expansion of=
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access  through  the  public sector to provide free of charge diagnosis and=
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treatment.  This  must  be  ensured  in  particular for the most vulnerable=
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groups,  children  and  pregnant  women.  Increasing  the provision of free=
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malaria  care  could also be a competitive factor that can impact prices in=
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the private sector.=0D
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New  resources  for  malaria  present a real opportunity to change the case=
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management   paradigm  for  the  disease.  With  the  availability  of  new=
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diagnostic  technologies,  it  is time to stop treating fevers blindly with=
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diagnosis  based  only  on  symptoms. This approach leads to ignoring other=
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underlying  causes  of  fever  and  is  an  inefficient use of drugs, which=
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contributes to the development of resistance. Rapid Diagnostic Tests (RDTs)=
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are  not  being used enough in Africa (about 10 million in 2007), and their=
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use  should  be promoted. MSF=E2=80=99s experience is that this could start=
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in  services where health professionals are present and is also feasible at=
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the  community  level.  [2]  Malaria treatment should therefore be based on=
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diagnosis as much as possible. The GFATM should ensure that all the country=
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programs it funds base malaria treatment on appropriate diagnosis.=0D
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2. Remove chloroquine and artesunate monotherapy=0D
In  line  with progressive roll of ACT, WHO and countries should take steps=
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to  actively remove chloroquine as treatment for Plasmodium falciparum from=
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the  market and enforce the WHO ban on artesunate monotherapy. The AMFm may=
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crowd  out  these  drugs  to  some  extent  but  it  will  not be enough to=
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effectively remove them. Furthermore, the AMFm should exclusively use fixed=
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dose  combinations  to  ensure better adherence to treatment and protection=
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from artemisin resistance.=0D
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3. The AMFm must not lead to a global artesimin shortage=0D
Suppliers  of  active  pharmaceutical  ingredients  (API)  need to be given=
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reliable forecasts and orders as soon as the AMFm is approved, to avoid the=
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AMFm  provoking  a  global API shortage. The AMFm must be launched in a way=
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that  takes  into  account  the  time  delay  that  is  needed  to increase=
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plantation and supply.=0D
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4. Research that should be supported by the AMFm=0D
The  AMFm  should be accompanied with research not merely to measure prices=
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but  also  to  measure actual access, use and health outcomes. In addition,=
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adequate  resistance  monitoring  must  be  ensured  and AMFm participating=
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countries  should  make  a  commitment  to  carry out such monitoring (with=
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assistance by WHO and other agencies as necessary).=0D
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We  hope these comments make a constructive contribution to the Global Fund=
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Board  discussions and look forward to discussing these issues further with=
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you.=0D
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Yours sincerely,=0D
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Tido von Schoen-Angerer, MD=0D
Executive Director=0D
Campaign for Access to Essential Medicines=0D
M=C3=A9decins Sans Fronti=C3=A8res=0D
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[1] No Cash No Care. How =E2=80=9Cuser fees=E2=80=9D endanger health. An MS=
F briefing paper=0D
on financial barriers to healthcare. MSF, Brussels, March 2008.=0D
http://www.accesstohealthcare.msf.be=0D
[2] Full Prescription: Better Malaria Treatment for More People: MSF=E2=80=
=99s=0D
Experience. MSF, Brussels September  2008.  Available at:=0D
http://www.msf.org/source/medical/malaria/2008/MSF_malaria_2008.pdf