EPN - Ecumenical Pharmaceutical Network

Netlink is the members’ email newsletter for the Ecumenical Pharmaceutical Network (EPN). Netlink aims to help members keep in touch with what is going on in the Network. If you have any information to contribute or comments on the content, or if you would like to unsubscribe, subscribe or recommend someone to receive it, please contact info@epnetwork.org

First thought: “Because we have this hope, we are very bold” II Corinthians 3:12

• PAG: Reminder - Reminder - Reminder
• Comments on draft PEPFAR SOW for supply chain management
• Meeting report from Ouagadougou
• Francophone course: Promotion of the Rational Use of Drugs
• MEMS Newsletter: Issue No. 3
• Article: "Is PEPFAR a knight in shining armour or a Trojan horse?"

PAG: Reminder - Reminder - Reminder

The countdown has begun to our annual meeting, 5^th to 8^th October, 2004 in Moshi, Tanzania.

Remember that the PAG has been extended by one day to offer an opportunity to discuss PEPFAR.

• Tuesday 5^th October - Quality session
• Wednesday 6^th October - PEPFAR discussion
• Thursday 7^th October - EPN Annual General Meeting
• Friday 8^th October - Celebrations at St. Luke's Foundation.

Please do prepare to contribute to discussions by learning about experiences in your countries.

Comments on draft PEPFAR SOW for supply chain management

On 16^th August 2004, the Network sent a letter to USAID giving comments on the draft Statement of Work (SOW) for the Supply Chain Management System (part of PEPFAR). The letter repeated concerns raised by others, and strongly proposed that contractors be required to ensure full participation at all levels and the strengthening of established systems on the ground, such as the church drug supply organizations (DSOs). A copy of the letter will be sent to all EPN members. The secretariat will also be sending out an article highlighting some ways that members can minimize some of the problems of PEPFAR.

Meeting report from Ouagadougou

Jérôme Wolo, CFP Niger, and Hans Peter Bollinger, EPN Burkina Faso, attended the “Coordinating a Christian Response to HIV/AIDS in Francophone Africa” meeting, organized by PACANet in Ouagadougou, Burkina Faso, 8–11^th June 2004. Although a wide range of topics were presented and discussed, ARV treatment issues were hardly touched upon during the meeting. Recommendations that were made highlighted, amongst others, the need for research to be done in specific countries before interventions are planned, and the need for training and mobilization regarding knowledge and attitudes concerning HIV/AIDS.

Francophone course: Promotion of the Rational Use of Drugs

EPN is extremely pleased to announce that we are organizing, in collaboration with WHO Geneva, a Francophone course on the “Promotion of the Rational Use of Drugs", from November 29^th to December 11^th 2004. Following the success of the first ever French course on this topic last year in Rwanda, the course this year will be held in Ouagadougou, Burkina Faso. Interested participants should please request more information on the objectives of the course, the planned programme, the application form, and the subscription fee from http://www.epnetwork.org/en/epn.faso@cenatrin.bf. The closing date for applications is 17^th October 2004. We are looking forward to an interesting course and hopefully a good number of representatives of faith-based organizations!

MEMS Newsletter: Issue No. 3

The newsletter of the Mission for Essential Medical Supplies and Services is now available at http://health.elct.org/projects/newsletter3.pdf. It includes updates on various aspects of their ongoing project, "Development of an Innovative Service and Supply System to Improve Access to and Usage of Quality Drugs and Medical Supplies".

Article: “Is PEPFAR a knight in shining armour or a Trojan horse?”

EPN Coordinator, Eva Ombaka and EPN Board Chair, Albert Petersen have written the following article, raising concerns around the US President’s Emergency Plan for AIDS Relief (PEPFAR).

It is estimated that today more than 38 million people are living with HIV/AIDS, of whom 6 million are in urgent need of treatment and only 400,000 are getting the life-prolonging antiretroviral treatment. The world’s reaction to this disaster, through a number of funding mechanisms including the US President’s Emergency Plan for AIDS Relief (PEPFAR) can only be welcomed. But is PEPFAR a knight in shining armour in these times of great need or a Trojan horse, likely to cause harm in the long run? This is a question that is of concern to the Ecumenical Pharmaceutical Network (EPN) Board, whose members come from church-related health services and their drug supply units.

Worldwide solidarity funds such as the Global Fund for HIV/AIDS, Tuberculosis and Malaria, while providing funds for drug procurement, have also been working through strengthening of infrastructure and the development of platforms for governments and civil society to define country-specific priorities. All this is meant to make for sustainable health care systems. The drawbacks on this have been the complexities in applying for the funds and the slow implementation of the plans in situations where urgency is needed. Partners have therefore become disappointed and are looking for, and open to, alternatives.

In 2003, the US Government (USG) started a 15 billion dollar 5-year programme (PEPFAR) to fight HIV/AIDS and to get 2 million people on treatment by 2008. In 2004 many local contacts and contracts between PEPFAR and hospitals, NGOs, and faith-based organizations (FBOs) have been developed and it seems that the goal to get 190,000 people in treatment by the end of this year will be reached. This is very encouraging! But this success is possible only because this is a strong vertical program. The decisions are being made in the US and a very detailed system, managed by mainly US organizations, has been introduced resulting in minimal bureaucracy at country level. This practical and result-oriented way of working has allowed for a very quick identification of hospitals and an immediate supply of the needed drugs. A number of EPN members are involved in the system and more are likely to join. But what are the pitfalls of this system?

The EPN Board members, after meeting on 29–30 July in Abuja, Nigeria, and analysing available documents and learning from experiences of some of its members, strongly propose that there are several issues in the PEPFAR model that need to be negotiated or even changed if sustainability and independence is to be maintained. Implementing partners at a local level need to be particularly cautious so as to ensure that they get sustainable support for their organizations and the best care and treatment for the people they serve.

The board highlighted the following areas in particular:

• One-donor programmes are prone to political instability
  PEPFAR is a US funded programme that can be influenced or terminated by political changes between the country and the USA or by changes in US policies. While one would hope this will not be the case, it is nonetheless imperative for countries to continue supporting multi-country programmes such as the GFATM whose decisions are not dependent on a single country.
• Decisions on treatment protocols must be national
  PEPFAR requires that drugs used in the programme be approved by the FDA (thus favouring US products) or a “stringent regulatory body” (but not the WHO prequalification programme). This means that the drugs will be expensive branded products, which may not necessarily be those on the national treatment protocol and which cannot be sustained by the health system at the end of the project.
  It is therefore very important that the national AIDS programme or similar body is consulted and national treatment protocols with drugs on the national essential drugs list are followed. This will ensure that patients are getting drugs that they and the national health system can afford, even when the PEPFAR programme ends.
• Exclude drugs for opportunistic infections (OI) from FDA approval
  It is understood that the PEPFAR clause requiring approval by the FDA also applies to drugs for opportunistic infections (OI). Drugs for OI are, in many cases, produced locally. Local initiatives to build and strengthen the local industry have meant that many of these drugs are also available in good quality generic forms. Using drugs approved only by the FDA will make them very expensive and in the long run may kill the local industries and threaten the sustainability of the already existing drug supply chains. This must not be allowed to happen.
  Furthermore, unlike ARVs, these drugs are not used exclusively for HIV/AIDS patients and neither are all the HIV/AIDS patients who need drugs for OI’s going to be on PEPFAR-funded ARV’s. A condition where certain patients are given different brands of the same drugs would therefore create a multi-cadre patient system in an institution, leading to not only misunderstandings but also a lot of additional work for an already overstretched health staff. This too must not be allowed to happen.
• Supporting the WHO prequalification system
  PEPFAR is currently ignoring the WHO prequalification system that has made it possible for good quality and less expensive generic alternatives to be available to the many people needing treatment. Furthermore, the access campaigns supported by governments, UN agencies including WHO, NGOs, and many civil society groups succeeded in encouraging generic manufacture. The resulting competition brought down the prices of both generics and branded ARVs. The continuation of this competition and the encouragement for production of more user-friendly dosage forms face possible discontinuation should the PEPFAR programme continue to ignore this global essential process. This must be resisted at both local and international levels.
  This would also mean, at a local level, encouraging and supporting local industries to improve their quality and seek WHO prequalification.
• Constrained supply chain management systems
  PEPFAR is in the process of making plans for supply chain management contracts that will provide the needed drug distribution system. Whilst the final contract terms are still being negotiated, the draft has some clauses that raise concern. These include the lack of clarity on local capacity building where already there is an observed influx of expatriates and foreign organizations into the earmarked PEPFAR-supported countries. Others are the restriction on use of PEPFAR-funded facilities, the exclusivity of data to the US government, and the commitment by partners to unspecified US government health and development objectives. Efforts must be made to ensure that these concerns are addressed in this early stage.

PEPFAR has the potential to make a difference. But to guarantee sustainable programmes and to break the yoke of dependence and build national dignity, support should ensure full participation and capacity building of the local partners and the existing health infrastructures. While PEPFAR rightly focuses on getting treatment to the patients as soon as possible, its vertical one-donor approach may collapse the very system it needs to strengthen.

Currently available HIV/AIDS treatment options require that the drugs be taken for life. Thinking long-term must therefore be an essential component of any funding programme.

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