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[e-drug] WHO 3x5 strategy on supplies management (cont'd)

E-drug: WHO 3x5 strategy on supplies management (cont'd)
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It may not be politically correct on the eve of the World AIDS Day, but
the "WHO 3x5 strategy on supplies management fort ART"
announcement leads me to raise the following and simplistic
question:

"With the HIV/AIDS era, are we not on the brink of setting up and
trivializing a two-tier healthcare system policy?"

First don't be mistaken about the question.
The HIV/AIDS crisis requires making every effort to control it and to
avoid the looming collapse of so many societies and civilizations all
over the world, as the Black Death did it in the XIVth century. Clearly
the Western world politicians and many in the developing world did
not yet understand what is really at stake. History repeats itself.

When in the 1980s the HIV/AIDS emerged, it has been a kind of
pointer to the healthcare system fragility in the so called developing
world, damaged by years of free market-style structural adjustment
programs and a total mismanagement of healthcare budgets and
facilities, with a World Bank and its unilateral financial powers over
countries still dictating and secreting its ideology. At that time WHO
was self-centred on macro-health figures and vertical programs
management to get success stories to please its Member States -
despite and despairing Alma-Ata, ignored all these ordinary things
such as commodities and facilities good management, or social
implications of delivering healthcare, forgetting that health is not a
mere economic investment but a fundamental human right.

Then with all the emphasis placed on the HIV/AIDS pandemic we
could naively have thought that it would be an opportunity to assess
the scale of the task and change strategy - improving the whole
healthcare system, to after all tackle chronic and infectious diseases
in introducing good management practices of healthcare, meaning
among others functional, available and hospitable healthcare
facilities, meaning as well a social agreement to bear full primary
healthcare costs (the Bamako Initiative approach being a lesser evil
but still transitional).

Meanwhile the gloomy picture of the developing world health situation
is splashed all over the annual reports of international institutions, as
to exorcize the demon of our inability to treat common respiratory
infections in spite of available and cheap medicines and vaccines, to
control TB despite the DOTS, to give a regular access to essential
medicines to most of the population who yet spend a lot of money in
his health, or to renew the neglected diseases pharmacopoeia by lack
of investment in R&D etc.

To respond to the HIV/AIDS epidemic and in particular the essential
need to quickly scale up the ARV therapy, initially only promoted by
NGOs (such as MSF with its access campaign) - seen as iconoclastic
by the international community, WHO finally started a new strategy
with its pre-qualification schemes (to ensure the quality of ARV
generic medicines), and now is launching a supplies management
strategy. Well done WHO! But what about trypanosomiasis, and what
about diabetes mellitus, are those patients not worth of a similar
interest?

Let's only take a concrete but specific example. In Madagascar -
where I live and work, the HIV/AIDS is an emerging concern and will
soon become pregnant with danger, as according to a last survey the
prevalence rate among pregnant women appears to be far greater
than 1%. The healthcare system is not functional: according to
imprecise statistics more than 70% of the population have no access
to essential medicines and the attendance rate of public healthcare
facilities is lower than 40% (because perceived as costly, inefficient,
and inhospitable). Under political and international pressures, and
because there is some money (the mirage of the Global Health Fund)
an HIV/AIDS policy is emerging, lead by the Malagasy MoH. It plans
to set up a specific system (diagnostic, treatment and follow-up). To
make easier the compliance, HIV/AIDS healthcare access will be
free. Of course we cannot find fault with this, even if financing such a
policy will not be an easy task. At least HIV/AIDS patients will get free
and of good quality ARV drugs, will be monitored and followed up, the
same for the opportunistic infections. 

This system will not be perfect - far from it, and yet it is an
unreachable dream for all the other patients suffering from other and
common diseases. Brought out into the open in such a way, the
people who has no say in the matter - and taking into account the
cultural perception and what is left unsaid around the disease, could
summarize the situation by: "we all human beings are equal in our
poverty but some are more equal than others". All in all another
unintentional way of stigmatizing people living with AIDS, and
marginalizing the others because not at the top of the list.

Just a quick and open conclusion:
Can't we break with the past in again repeating the same mistakes?
Let's carry on and deepen all the work done around and for HIV/AIDS
patients but let's not neglect the other diseases because all the
diseases come within the same issue and solution. The health cannot
be sliced up. Otherwise all of us w'll have everything to lose. Then
when will we have a "pre-qualification scheme" and a "WHO 3x5
strategy" generalized to all diseases?

Patrice Trouiller
Technical adviser
Ministry of Health
Antananarivo, Madagascar
e-mail: pat.trouiller@netclub.mg

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