MSF's letter to the Global Fund on the AMFm
To the Board members of the Global Fund to Fight AIDS, TB and Malaria
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.
Médecins Sans Frontières (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 into consideration the following comments:
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 always 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.
Tido von Schoen-Angerer, MD
Campaign for Access to Essential Medicines
Médecins Sans Frontières
Dr Michel Kazatchkine, Executive Director, GFATM
Ms Helen Evans, Deputy Executive Director, GFATM