The Viewpoint published in The Lancet by Amir Attaran et al - IRIN

ANNEX C
LANCET VIEWPOINT ARTICLE ON MALARIA:
MISREPRESENTATIONS AND INACCURACIES
The Viewpoint published in The Lancet by Attaran et al., titled “WHO, the Global Fund, and
medical malpractice in malaria treatment” (Vol 363, 17 January 2004), identifies the need for
an improved international response to malaria drug resistance. The Global Fund welcomes
its call for a faster shift to effective malaria treatment. The article has served as a platform
for a productive dialogue among parties including the Global Fund, WHO, MSF, the authors
of the Lancet article and other colleagues from the scientific community on ways to realize
this goal.
The Lancet article, however, contains misrepresentations and inaccuracies. The preference
of the Global Fund is to focus on cooperation on the next steps to improve malaria
treatment. But, in response to the requests by the Lancet authors and others, the
misrepresentations and inaccuracies are outlined below.
Misrepresentations
1 The Global Fund’s role in scaling up the delivery of ACT. While the article references the
degree to which a broad range of donor and recipient organizations involved in malaria
control have failed to encourage a rapid transition to ACT, its specific accusations on the
Global Fund suggest that it is a driver of poor practice. There is no basis for these
accusations. The article accuses the Global Fund and WHO of “medical malpractice”.
This term is defamatory and the Global Fund takes exception to this use of language.
The Global Fund has already approved an unprecedented amount of resources for the
procurement and distribution of ACT, increasing existing coverage in Africa from 10,000
in 2001 to a projection of 11 million treatments during the two year lifetime of approved
Global Fund grants. Forty percent of the approved malaria proposals include funding for
ACT. Given the lack of other substantial sources of funds for scaling up ACTs, it can be
argued that the Global Fund is actually the main engine for a change to ACT where
needed. Failing to acknowledge these facts at any point in the article encourages a
misperception about the role and intention of the Global Fund.
Moreover, the accusation does not account for the reality that, in some cases in which
chloroquine or SP protocols have been approved, this choice was based on local drug
resistance surveillance data that did not support change of treatment policy to the use of
ACTs at the time of application. This is described further below in the case of Uganda.
2 Funding decision for Uganda. The article cites data on malaria drug resistance in
Uganda as the basis of its claim that the Global Fund approved funding to treat malaria
in Uganda which is ineffective and inconsistent with recommended protocols. Yet these
data have been disputed by the Ugandan Ministry of Health itself in at least two
responses (Response to the BMJ on 15 December 2003 and Press Release on
16 January 2004, as attached), which have provided the data on which its request to the
Global Fund was based. These data did not, at the time of proposal submission and
according to referenced standards, justify a transition to ACT.
Therefore the accusation that the Global Fund’s decision on Uganda was inappropriate
is disputable. Moreover, if more recent data were to suggest a change in policy, the
Global Fund would welcome – and expect – Uganda to move in that direction. This is
not acknowledged by the article.

2
3. Proposal review for Kenya. The article provides the following account for the Global
Fund’s review of a proposal from Kenya for malaria treatment: “In Kenya, GFATM
rejected the government’s request to finance ACT, but later agreed to finance SP,
despite evidence that SP treatment failure exceeds 50% in some districts.” This
statement implies that inclusion of ACT was the reason for rejecting the proposal. This is
not the case, as the US$ 300 million proposal submitted in Round One for support to
three diseases (malaria, TB and HIV/AIDS), had numerous technical and management
deficiencies which could not justify its approval. (A record of this review is available
publicly). Inclusion of the request for funds to buy ACT was not a factor in rejecting the
proposal. While it is true that the proposal submitted and approved for Round Two did
include funding for SP, exclusion of ACT was not the differentiating factor between the
outcomes of the two proposals.
The approved Round Two application for malaria from Kenya acknowledges high SP
resistance in some areas. The application requests SP in accordance with national
guidelines, but specifies that the Ministry of Health is in the process of gathering
information for a review and likely change of national drug policy. The approved
proposal includes costs for resistance monitoring to support this review. The Global
Fund awaits the outcome of the review and stands ready to support the shift in treatment
as soon as the Kenyan Government requests it.
The procurement of SP included in the approved Round Two grant is predominantly for
the prevention and treatment of malaria during pregnancies. Unlike SP, ACT is not
recommended during pregnancies. The article fails to note this.
The SP procurement constitutes only one of several elements in a high-quality proposal,
including procurement and distribution of insecticide-treated bed nets, training of health
workers and strengthening of distribution systems for malaria treatment. For the
Global Fund to reject this proposal would not serve Kenya’s needs, especially in light of
Kenya’s stated intention to review and change its drug policy in the near future. The
failure to bring to light these elements of the Kenyan story in the article creates a
distorted impression.
Inaccuracies
1 Data on approved funding. The article inaccurately cites the funding approved by the
Global Fund for malaria treatment. Three issues are relevant to this point. First, the
article uses five-year dollar figures rather than two-year figures to represent what has
been committed. Second, it bases its claim of Global Fund commitments on budget data
from proposals rather than signed grant agreements, whereas only the latter commit
funds. Third, it uses specific data on funding commitments to treatment to suggest firm
allocations to these budget line items, when in fact committed funds are more fungible.
Therefore, even accurate two-year figures from grant agreements specifying funds for
the procurement of a specific drug do not represent restrictive commitments, but instead
an anticipated use of funds.
For example, the article claims that the Global Fund “allocated” US$27.7 million for
chloroquine in Africa following Round Two. In fact, data from these approved proposals,
for which US$168.8 million was approved overall for two-years, specify US$11.9 million
as the amount projected for the procurement of chloroquine over two years. This
amount may differ from the data from signed agreements and also may not reflect the
actual use of funds (particularly as a result of cases like Senegal, which subsequently reprogrammed
approved funds to procure ACT rather than chloroquine following change of
treatment policy during implementation of its Round One approved proposal).
.

3
2 Described coverage of chloroquine/SP funding. Following the article’s summary of the
Global Fund’s allocation of funding to chloroquine, SP and ACT, the authors proceed to
describe the targets of that funding as follows: “GFATM plans this budget for countries
where chloroquine and sulfadoxine-pyrimethamine resistance in P falciparum is well
advanced (table)”. The referenced table specifies resistance rates, based on
parasitological and clinical failure, for four countries – Ethiopia, Kenya, Senegal and
Uganda. It is inaccurate, however, to use these countries as the basis of the claim that
the Global Fund’s overall budget for malaria treatment is targeted to settings where
resistance is high. For example, these countries account for a minority (40 percent) of
the funding approved for chloroquine, distributed across 26 countries. Some of these
countries are ones where resistance is not well advanced and where a transition to ACT
is not yet justified. This fact is overlooked in the article.
3 Affirmation of “systematic recurrence” of cited problems. Following the affirmation of the
Global Fund’s approval of inappropriate funding of chloroquine and SP, using four
countries as a representative set, the article states the following: “These problems might
be discounted as aberrations, but for the evidence that they recur systematically.” This
claim is not correct as can be seen from the experience of other countries (for example,
Ghana, Kenya and Mali) where governments are re-evaluating their treatment guidelines
to make a transition to ACT.
Global Fund’s processes to keep pace with a rapidly changing environment for malaria
treatment across a broad portfolio. A country may request funding for particular malaria
drugs, based on available drug sensitivity data and treatment guidelines, but may
change its policy following evaluation of new resistance data. Senegal is an example,
and others are following suit. Encouraging recipient countries to actively and
continuously evaluate their drug policies is in our view plausible. It would only be a fair
criticism of the Global Fund if countries were not permitted to change policy during
implementation despite new evidence. The accusation of “systematic recurrence of cited
problems” as alleged by the authors of the article is not justifiable.
Post-script
The Global Fund shares the authors’ concern that action must be taken as quickly as
possible to introduce effective treatment where none exists. However, misrepresentations
and inaccuracies do not help this process. The Global Fund does not wish to dwell further
on this. The Global Fund wishes to move forward with the process of assisting countries to
review current drug resistance surveillance data vis-à-vis current treatment policies and to
do its part in facilitating a change in policy where there are discrepancies between the data
and current policy. A switch in drugs can be undertaken within approved grants for Rounds
1-3. Furthermore, the Global Fund has explicitly encouraged countries to use its funding in
future grants to finance a shift to ACT, where this is needed.
.