MSF Access: Making Access a Reality

All organizations must start somewhere, and Médecins Sans Frontières (MSF) is no different. As with any startup story, its foundation lies loosely on a combination of historical facts and anecdotal tales. “Loosely” because the startup story of any organization is much like the game “telephone” many may have played as children: the basis for the story starts concrete, but is reiterated and remembered differently from those who were there at the beginning versus those telling it now. 

History

In any event, the standard version starts with a group of young French doctors who were working in a Red Cross hospital in Biafra, Nigeria in 1968.¹ After witnessing the thousands of deaths from malnutrition and genocide, these junior doctors wanted to tell the world of this travesty. The Red Cross, however, had a more discreet agenda. The French doctors would not remain silent as they angrily tore off their Red Cross armbands and publicly criticized the Nigerian government. After returning to France to raise awareness of what they witnessed, they formed a group of doctors devoted to emergency medical aid.² Shortly after, a Paris medical journal called out for volunteers to help victims of natural disasters, and in 1971 these two groups joined forces to form Médecins Sans Frontières³, one of the largest humanitarian organizations in the world. 

28 years later, in 1999, MSF had won the Nobel Peace Prize.⁴ A major problem, however, was the lack of access to life-saving medicine for people living in developing countries. To combat this, MSF launched its “Access to Essential Medicines” campaign, which pushed not only for the availability of these medicines to people in the developing world but also the research and development of medication for neglected diseases unique to the developing world.⁵

As the years passed, the campaign broadened its goals and sought to combat a multitude of factors such as the rising cost of drugs caused by monopolies, the lack of medical tests and vaccinations in certain parts of the world, and the complex models of medical care, which often hindered effective treatment.⁶

The primary mission of MSF Access is to find efficient solutions to bring life-saving medication to those who cannot afford it. Their central talking point, “Medicines Shouldn’t be a Luxury”, implies that medication developed not to enhance the quality of life, but to treat a fatal and debilitating illness, should not be denied to any individual, based on their ability to pay for treatment. The reality, however, is that such medications are often so overpriced that most individuals in the developing world cannot afford them. With the annual cost of the medication often exceeding their annual income by exponential amounts, health is becoming more a luxury than a basic human right.⁷

Recommendations in Brief

MSF should refocus on its founding mission to provide medical needs for under-served communities. At this point in MSF’s development, the organization needs to reconsider whether it is aggressive, verging on adversarial, the campaign against pharmaceutical firms is helping MSF achieve its goals of providing universal life-saving medical access. While the emotional campaign run by MSF might raise awareness and garner donations, neither MSF nor the patients can boycott the pharmaceutical industries. The pharmaceutical industry is a necessary piece of any solution that MSF Access could provide its target constituents.  Therefore, MSF should engage in dialogue and negate the arguments against generics and free access put forward by the big pharmaceutical firms.  An understanding of the fears of the pharmaceutical firms, and a willingness to satisfy some of their concerns will help to engender a willingness to make some concessions for those most affected by these diseases.

Coalition Building

MSF has to augment its central mission of bringing attention to the access issues for HIV medication by building coalitions that can help affect the policy, lifestyle, education, and access changes to make HIV medications available. It must select the coalition partners from a careful network of WHO, health care professionals, policymakers, political leaders, HIV+ stakeholders, media, educational institutions, African Union, and community leaders.  

One of the current problems is that MSF puts a Band-Aid on the burgeoning problem by focusing on just the medical aspects, and not on cultural and societal aspects of the treatment regimen. Along with providing affordable access to healthcare and life-saving medicines, MSF has to be more systematic about engaging partners in coalition-based work. An integrated approach would include educational programs, strong public advocacy, and policy programs, and local doctor peer networks supported by their counterparts from MSF.  

Complex Problems Require Multi-Pronged Solutions

Given the complexity and the urgency of the HIV epidemic, coalitions would be the most effective way to minimize the loss of human lives. Coalitions also empower the communities to take control of the situation with a vested and equal say in its future.⁸ Often mandates are necessary before behavior change can take place—and coalitions are powerful mechanisms for moving mandated policy changes forward.  Coalitions can support the multi-pronged approach needed for an effective HIV treatment and prevention strategy for effective delivery of medicine and programs while eliminating unnecessary duplication.  “Unnecessary duplication” is critical because, given the magnitude of the problem, the solution will more than likely include several organizations providing similar services to the same community.

Communications and Information Flow

Coalitions allow organizations to pool resources and to accomplish tasks that no single private, public, or government organization could have achieved. Working cooperatively via open communication also keeps a clear flow of information that is arriving and changing at a rapid pace. Along with open communication, there is important learning and sharing of information that may bring about better and faster solutions to the complex problems.  Coalitions are also key to keep the momentum and energy going when the process towards a solution is long and challenging, with different initiatives coming together to address issues of access, education, and community development.⁹

Creating and Sustaining Long-Term Change

A strategic partnership with organizations and individuals lends credibility to the change process and can bring political and social pressure from all sectors of the community to move the process forward.  MSF Access has worked for many years and has raised awareness of access to medication, but hasn’t been able to move the pharmaceutical industry to support open patents.¹⁰ Even if MSF Access can achieve initial momentum, real, sustainable, and long-term, social change will require structural changes that the organization must address in phases over a longer timeline. 

Suppose there was a drastic change in the vector of the HIV epidemic, coalitions would have a flexible structure in place that would be resilient and better able to respond to these random shocks.  MSF must seriously consider coalitions if it is to advance its access campaign.

The best and most realistic option to meet the needs of HIV+ patients and to answer the criticisms of the pharmaceutical industry is for MSF to create a powerful focus around the medical needs and engage sister organizations for non-medical tasks.  It is becoming clear that MSF has to create powerful alliances that attack the virus from multiple fronts through education, infrastructure development, and entrenched poverty issues. 

Engaging Doctors and Research Scientists

Studies show that HIV is tremendously adaptive, and the global outbreaks require focused treatment.¹¹ We risk drug-resistant strains of HIV becoming prevalent when the more advanced treatments are only available in wealthier countries, and we send the older medical treatments to developing countries.¹² Doctors and scientists should work with MSF in developing key healthcare mandates that push for sustainable and systemic changes in health policy experts such as the World Health Organization.  

Myth: Lack of Infrastructure to Support Drug Regimen in Developing Countries

Pharmaceutical firms have long argued that the developing countries lack the ground level infrastructure to store the medication, lack instilled self-care habits within their population, and are awash in corruption on a fundamental level.  While all these points may have some merit, they do not absolve the drug company’s responsibility towards taking care of global health needs.  

For example, Washington DC’s HIV infection rates are close to that of some developing countries.¹³  DC residents have relatively advanced healthcare systems, ways to store/take the medication as directed, and can typically establish health regimens (I.e. brushing their teeth).  Despite these foundational health benefits, infection rates are going up in urban localities throughout DC and the US. This leads us to believe that a small subset of a population will continue to disregard the medication dosage, storage, and regimen, regardless of access or delivery systems. 

Policymakers cannot decide for an entire country or region based on a relatively small percentage of people — this is a red herring used, often effectively, by the pharmaceutical companies to avoid supporting the less wealthy nations. 

Attacking the Business Problem

A major problem with MSF’s proximate strategy is that it places too much emphasis on the emotional factors of medicinal access. Perhaps there is some merit in using the emotional strategy to garner support for a cause on a population level basis (I.e. more individuals will feel a need to support your organization and its cause), it may not be the most efficient strategy when working with corporations, particularly pharmaceutical firms. 

While perhaps emotions can have a dramatizing influence on the decisions a corporation will eventually put out, as seen with Oxfam versus Starbucks, it is important to understand a few key differences, and why emotion may be a good strategy in one case and not the other. The public emotional appeal worked when used on Starbucks. It worked because Starbucks sells a consumer novelty and is well aware of this. Consumers always have the option to boycott novelties and have done so for quite some time. With pharmaceutical companies, however, particularly those with patents on medications, a boycott is rarely a workable solution. While individuals may decide whether they want a cup of Starbucks coffee, they do not have that luxury of choice with medication, particularly essential medication.  It is because of that rationale that the emotional angle is the wrong strategy for MSF Access.

A better approach for MSF Access would be to attack the business angle, appeal to the practical aspects on which a corporation would place more emphasis. While many for-profit corporations try to incorporate a corporate social responsibility (CSR) strategy, it is usually not the primary motive, profit is.  MSF Access can seek to leverage the profit motive of such corporations to ensure compliance that would be parallel to its mission.  In the example of pharmaceutical companies not releasing patents for third-world access, MSF Access can highlight the negative effects of such a policy, and how it would adversely affect the pharmaceutical companies’ bottom line. 

Engaging Big Pharmaceuticals

Potential solutions to compensate the pharmaceutical firms for the capital invested in R&D could involve creating a triangular partnership between governments, research universities, and pharmaceutical companies. Educational entities could receive subsidies to carry out the basic research that becomes a feeder system for the pharmaceuticals. This would cut down on Pharmaceuticals’ R&D overhead while providing unique research opportunities to college students. Having government subsidies would ensure infrastructure and policy support both for education and for pharmaceuticals.  

Engaging Management at Pharmaceuticals

MSF should engage with the management at the pharmaceuticals to understand their constraints and needs so they can provide effective solutions or alternatives. Aligning the measures of success used for managers with MSF’s initiatives will help ease some tension between pharmaceutical managers and MSF. Since managers are focused on cutting costs and increasing revenues, the government-subsidized partnership with the research universities will be an attractive solution for them. From a purely profit-driven standpoint, the developing countries represent growing markets for pharmaceuticals, and they stand to make long-term gains by positioning themselves as the first movers in these countries as their patents run out in developed economies.¹⁴

Future Market Share

The large multinational pharmaceutical companies may also miss a market opportunity by underserving the developing world.  Sub-Saharan Africa and the Indian subcontinent accounted for only 3.1% of total drug sales worldwide.¹⁵ This is due to a variety of factors, but the world’s highest concentrations of tropical diseases are coupled with some of the lowest overall penetration by drug companies.  Positioning themselves to take advantage of this enormous market over the long-term should entice these firms, but MSF can help them realize where market opportunities may lie, and be prepared to counter them in negotiations.

Large multinational pharmaceutical firms have used market forces to justify their pricing schemes for years, claiming that the high R&D costs and uncertainty associated with the development of new pharmaceutical drugs offset failed endeavors.  MSF can focus on negating these claims with research into their fallacies and then use these insights to aid in negotiations.  

As an example, the median R&D expenditure in terms of revenue was 12.4% versus 37.3% for marketing in 1999.¹⁶ Research does not uphold the dominant position of R&D costs that the large pharmaceutical companies are claiming.  One way to exploit this knowledge is to organize vulnerable nations into collective bargaining units with the purchasing power to entice the pharmaceuticals to lower their price.  This has already been proven to be effective, as MSF has shown that the Pan American Health Organization could achieve discounts of between 86-99% below US prices on a range of vaccines.¹⁷ MSF can handle much of the groundwork to get these negotiations started and ensure their success in the long-term by helping their coalition partners maintain a competitive edge.

Conclusions

With the aforementioned strategies, two angles can play out, and while they are not dependent upon one another, they supplement each other well. The first angle is that of an under-served market. While most of the developing world is not an ideal marketplace in terms of profit, there is a substantial volume advantage. Pharma will always make the vast majority of profit in the developed world, however, the untapped market in the developing world is nothing to gloss over. 

If MSF Access can convince pharmaceutical companies to produce a generic version of their drugs for distribution to the developing world, they still have the potential to make a profit, albeit marginal in comparison. The driving factor here is not direct profit, but indirect and future profit gained from a first-mover advantage in an unserved market.

The second angle enhances MSF’s skills in medical research. Drug-resistance is a major problem for particular strains of diseases, and it manifests mainly through human action. 

Take hand-washing as an example. When you wash your hands with regular soap, you wash away much of the bacteria. With antibacterial soap, you not only wash away the bacteria but also kill the majority on contact. However, a small percentage of these bacteria are inevitably left behind. When using regular soap, this small percentage varies from strong to weak, and all reproduce at relatively equal rates. When using antibacterial soap, only the strongest are left behind, and those are the ones that can continue to reproduce; you are selecting for the more resilient strain. There is an upper limit on population when only the strong ones are left to reproduce, they become increasingly strong through the artificial selection that they develop a resistance to the antibacterial properties within the soap.¹⁸ 

The same phenomenon happens with drugs. Much of the developing world is still using decades-old medication. These medications are effective initially, but as a disease evolves and mutates, the medications become less efficient. Eventually, the strain will become strong enough that it would render medication useless. When newer medication is available later down the line, it would be far less effective than if it were given earlier on. 

Effectuating this information to pharmaceutical companies would show them that by not providing modern, patented medication to the developing world population, they would decrease the efficacy of their drugs, and as a result, eliminate potential profits.

A multi-pronged approach following the suggested strategies mentioned within this review would allow MSF Access to fulfill its proximate and ultimate goals of providing access to life-saving medications and creating a sustainable path to the long-term health and resiliency of under-served populations.

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References

1. Bortolotti, Dan. Hope in hell: inside the world of Doctors Without Borders. Richmond Hill, Ont.: Firefly Books, 2004.
2. “Founding of MSF.” MSF USA. http://www.doctorswithoutborders.org/about-us/history-and-principles/founding-of-msf (accessed April 1, 2014).
3. ^Ibid.
4. MSF Article (1999). “The Nobel Peace Prize speech”. msf.org. Retrieved 03 April 2014.
5. “About Us”. MSF Access. The Access Campaign. Retrieved 02 April 2014.
6. ^Ibid.
7. ^^Ibid.
8. University of Kansas Work Group for Community Health and Development. “Section 5: Coalition Building I: Starting a Coalition.” Coalition Building. http://ctb.ku.edu/en/table-of-contents/assessment/promotion-strategies/start-a-coaltion/main (accessed April 4, 2014).
9. ^Ibid.
10. Boulet, Pascale, Christopher Garrison, and Ellen Hoen. Drug patents under the spotlight: sharing practical knowledge about pharmaceutical patents. Switzerland: Médecins sans frontières, 2003.
11. Maldarelli, Frank. “Adaptation of HIV-1 Depends on the Host-Cell Environment.” PLoS ONE (): e271.
12. Bertagnolio, Silvia. WHO HIV drug resistance report, 2012. Geneva, Switzerland: World Health Organization, 2012.
13. PBS. “How Does the HIV/AIDS Rate in D.C. Compare?.” PBS. http://www.pbs.org/newshour/spc/multimedia/africa-dc/#.U06rQPldVp0 (accessed April 2, 2014).
14. Gehrke, Mirjam. “Pharmaceutical industry neglects developing countries | Sci-Tech | DW.DE | 26.10.2012.” DW.DE. http://www.dw.de/pharmaceutical-industry-neglects-developing-countries/a-16331939 (accessed April 8, 2014).
15. “Chapter 9: Drug Pricing.” In South African health review, 2000. Durban, South Africa: Health Systems Trust, 2000.
16. ^Ibid.
17. ^^Ibid.
18. Levy, Stuart B. “Consumer Antibacterial Soaps: Effective Or Just Risky?.” Clinical Infectious Diseases (): S137-S147.