Cataclysmic: The Proposed Dismantling of the MSF Access Campaign Strikes At the Heart of Influential Activism, Political-Legal Battles in Global Health At Stake
Newsletter Edition #221 [The Files In-Depth]
Hi,
There is a fire out there, and firefighters have been put on leave. This is what occurred to me while working on this edition.
Today’s story is not about kitchen sink politics in one of the world’s most powerful, influential and effective Global Health and Humanitarian NGOs. It has the potential to have some real consequences for patient communities all over the world, including in the most vulnerable settings.
It is hard to overstate the importance of this development, where MSF’s Access Campaign is expected to be pruned to such an extent that will impact dynamics in Free Trade Agreements, the Pandemic Treaty negotiations, and the fight against some of the most stubborn diseases of the world including HIV and diabetes.
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I. ANALYSIS
Cataclysmic: The Proposed Dismantling of the Médecins Sans Frontières Access Campaign Strikes At the Heart of Influential Activism, Political-Legal Battles in Global Health At Stake
In recent days, access to medicines activists in many parts of the world are grappling with developments that have struck at the heart of the movement.
Médecins Sans Frontières, arguably one of the most powerful, influential and well-funded activist organization in the space, has proposed a restructuring its well-regarded and highly admired Access Campaign that currently works all over the world in the most political and challenging settings and one that consistently led and expanded the access to medical products for a range of diseases. MSF has programmes in more than 75 countries across the world.
From ensuring treatments, to challenging patents, from fighting for lower prices of drugs, to working with governments silently to improve health outcomes, the Access Campaign has been at the frontier of not only taking on the might of the pharmaceutical industry, but also making states more accountable.
After 25 years of path-breaking work including contributing to the creation of the Drugs for Neglected Diseases Initiative (DNDi), this crucial work of the Access Campaign is now under challenge from its own organization, that seeks to radically downsize existing staff, essentially pulling the plug off sensitive work on multiple fronts that the Access Campaign is deeply involved with, internal sources say.
For this story we spoke to a range of employees including at MSF, and former staffers. We also spoke with others outside the organization who have worked with the Access Campaign over decades and attest to the importance of the team.
It is clear that what is at stake is much more than people losing jobs at a Civil Society Organization, a team that is known for sinking its teeth in the toughest battles in global health, not only during the COVID-19 pandemic, including pushing for the TRIPS Waiver at the WTO, and but in years after across diseases and geographical regions. Disruption in the work of the Access Campaign has implications for millions of people around the world, whose interests and in fact, lives have been safeguarded by its work for over two decades.
So strong has been the influence of this multi-disciplinary team of lawyers, doctors, pharmacists, logisticians, lab technicians and others, that letters from activists, scholars from all over the world have been flying thick and fast in the past few days, fervently urging MSF leadership to reverse decision on the Access Campaign. At this point, we are not aware whether this would have any impact on reversing this move.
This week in Geneva, MSF bosses meet for an International General Assembly. Sources say the matter of the Access Campaign could likely come up at the meeting.
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THE HISTORY OF THE ACCESS CAMPAIGN
A document from the late 1990s says:
“The Campaign for Access to Essential Medicines (Access Campaign) was started in the mid–nineties because MSF operational leaders realised that it was too difficult for medical teams in the field to get adequate drugs to treat the patients. More and more drugs had become ineffective and had not been replaced with new ones. Initially the Access Campaign had four objectives: restart research and development for tropical diseases and related areas; make new drugs and vaccines affordable for disadvantaged populations; ensure the production and commercialisation of targeted orphan drugs; and humanise the World Trade Organisation (WTO) and the trade-related aspects of intellectual property rights, which was an agreement between all the members of the WTO. Presented in March 1998, the Campaign was fully endorsed by the international council in November 1998. An international committee, composed of operational section representatives, and an internationally autonomous team were created to run the project. This was one of the first completely international projects to be funded by the MSF movement.”
Employees say there has been a determined shift away from these early goals as the leadership is keen to focus on the humanitarian work of MSF. They allege that MSF is essentially shying away from engaging with the structural, political factors that underpin the practice of global health, in the way the Access Campaign has done.
So therefore what is like an earthquake in the access to medicines movement, will not be limited to activism in global health. Its reverberations will be felt all over the world including in the outcomes of on-going Free Trade Agreements, in the continuing negotiations for a Pandemic Treaty and on the field in countries globally, where millions of people live and die determined by the access to medical products.
THE DECISION OF THE MSF LEADERSHIP
Rumblings of a change have been there at least for the last two-three years, several employees told Geneva Health Files.
Last week, the Access Campaign team was informed that their work will be shut down by end of 2024. Contracts of nearly 35 staff and 15 consultants will conclude and they will be offered severance packages. A new structure is being proposed called as the “Access to Products for Healthcare” (APH). About half of the current staff are expected to be absorbed in the new structure, but that they would have to reapply for these positions. The new APH structure is scheduled to begin functioning from 1 October 2024. Staff have described this as MSF’s access work “falling off a cliff”.
(Last year’s financial report suggests about 54 million Euros as expenses on account of Awareness-Raising and the Access Campaign. [Access Campaign personnel costs is about 5.5 million Euros]. Overall operating expenses for MSF in 2023 was about 2.3 billion Euros.)
Some employees believe that these developments, and the manner in which they are being handled, raises questions on the overall leadership and the strategic direction of the organization itself. The discussions around the Access Campaign are understood to be led by MSF International President Christos Christou, and Christopher Lockyear, Secretary General, MSF International sources said.
Privately employees raise questions on the changing role of MSF even in humanitarian operations. Some say there is a tension between the humanitarian work where MSF has to take political positions, and also its contribution towards norm setting activities of other actors. The current leadership, employees say have not reconciled with these responsibilities.
“Over the years, MSF has become less-activisty”, one long-time employee told us.
On Bearing Witness: “témoignage”
Employees also pointed to MSF’s stated policy on 'témoignage’.
A web page from MSF explains the concept of 'témoignage’:
“For many, Médecins Sans Frontières is synonymous with emergency medical teams tackling disasters, wars and epidemics around the world. But we also work to raise awareness and create debate about these crises through our policy of 'témoignage’.
This means Médecins Sans Frontières acts as a witness and will speak out, either in private or in public, about the plight of populations in danger for whom we work. In doing so, we set out to alleviate human suffering, to protect life and health and to restore respect for human beings and their fundamental human rights.
The word 'témoignage’ comes from the French verb ‘temoigner,’ which literally translates as ‘to witness’.
Témoignage – or witnessing – is simply the act of being willing to speak out about what we see happening in front of us.
For us, this means a willingness to speak on behalf of the people we assist: to bring abuses and intolerable situations to the public eye.”
RESPONSE FROM MSF
We received formal responses from MSF to our queries:
On the reasons for the closure for a successful Access campaign:
“In recent years, both the MSF Movement and the access landscape have gone through significant changes. Technological breakthroughs, new political players, and new legal and commercial realities and regulations all impact populations’ access to products of healthcare. These developments offer both new opportunities but also challenges for our work. For our patients and also our supporters, we have a duty to ensure that we remain optimally organised to leverage our unique positions for improving access to products for healthcare for those deprived of them.
In 2020, we launched a project tasked with clarifying the strategic direction and oversight of all activities and objectives related to MSF’s work on access. Last year, we agreed on a new collective vision for our work with improving access to products for healthcare. It confirms our shared ambition to do more in this area.
The vision broadens our focus, listing six types of activities that MSF conducts, like improving sourcing and supply models and conducting operational research. None of these activities are new to MSF. However, historically, they have not all been considered to fall under the umbrella of access to products for healthcare, which has primarily been associated with our advocacy work.
Based on this broader vision, we are now implementing a new structure that will replace the MSF Access Campaign by building on its remarkable achievements.”
On the future plans that could take the place of the Access campaign:
“Over the coming decade, MSF will redouble its efforts to deliver tangible improvements in access to products for healthcare, proudly building on the exceptional work that the Access Campaign has done for the last 25 years,” Christos Christou, MSF international president has said.
The new structure will be closer to our medical humanitarian operations, to better support the needs of the communities we assist. Five regional offices (in Kuala Lumpur, Malaysia; Nairobi, Kenya; Dakar, Senegal; Rio de Janeiro, Brazil; and Brussels, Belgium) will work together with our operational teams and patients as well as with our partners and networks. A dedicated internal fund will also be set up to support access-related initiatives throughout the organisation.
See MSF press statement here from earlier in the week.
Excerpts from an internal statement by MSF International President Christos Christou:
“I want to emphasize that this has been a long process of consultation and engagement (including, of course, with Access Campaign staff). We are now in our implementation phase, and the new structure is scheduled to replace the Access Campaign from January 2025.
I do acknowledge the difficulty of the situation, and I know how tough it is to announce to people that they may not all be absorbed into new projects.
Throughout this change process, we are trying to retain as much of MSF’s unique access to products for healthcare expertise, networks and initiatives, and as many of our talented colleagues, as possible.
There are around 35 staff contracted to the Access Campaign today (plus a number of others with temporary contracts), and at least 19 of them have the immediate opportunity to work for the new structure. Those that choose not to apply, or those who are not recruited into the new structure, will be offered a transition support and severance package. Others may also be absorbed (due to their expertise) by other MSF Sections, Operational Directorates or projects.
In 2025, the new structure will continue the work of the Access Campaign that aligns with our new collective access to products for healthcare priorities, including dossiers on vaccines, diabetes, AMR, TB, and diagnostic tools. Next year will also be dedicated to developing the new structure's strategic plan for 2026-2031, bringing it in line with the Movement’s strategic planning and resourcing cycle. This plan ensures that the new structure can lead the development of the longer-term plan that it will ultimately be responsible for implementing and be optimally placed to consider the regional needs and perspectives of our operational teams.”
WHAT IS AT STAKE
Apart from being a contested transition for an internal team in a big organization, the consequences of this disruption could be far-reaching, given how intricately the work of the Access Campaign is woven with other stakeholders in global health.
On Medical Dossiers
An MSF employee on the condition of anonymity said: “The thing is that they may not be taking the right decisions, even from a medical point of view. The judgment about drugs we will work on, if we will not work on FTAs we work on… So I think, I am concerned about how these decisions are being taken. You know this is much more beyond an internal restructuring process, because it is going to have an impact on other stuff, basically, that others are dependent on.”
Employees suggest that there is no clarity on the spectrum of issues the Access Campaign works on. “There is no transversal view on R&D, IP and other matters we work on across diseases. We are really concerned,” a current employee told us.
“Have they consulted government officials who have worked with access campaign? Have they come spoken to the patient networks? So why not consult before you move?”, another current employee asked.
Access Campaign employees also want to know the extent of MSF’s engagement on the policy battles around weight-loss drugs for example. Glucagon-like peptide-1 (GLP-1), a class of drugs that help reduce blood sugar and energy intake by activating the GLP-1 receptor. MSF’s costing study earlier this year, illustrated that diabetes drugs, including insulin are exorbitant in the US.
“You know, it took us 20 years to break monopolies on TB. Will the current leadership have the appetite for that when it comes to these new challenges?”, a current employee asked?
(See guest essay we published last year: Johnson & Johnson’s Patenting & Pricing Strategy for TB Medicine Bedaquiline: A Cautionary Tale for New TB Medicines)
An Access Campaign staffer told us, “Our the work usually is a combination of medical dossiers with a critical analysis of the ecosystem. So my question is, they have answered the question on what medical dossiers we will work on, but they haven't answered the question about what they will do for the FTAs, patent law reforms, licensing, among others. Because these are daily things that come up in the medical dossiers.”
On HIV
There are also concerns that HIV may not be priortised as before. Activists allege that pharma monopolies delay timely access to key ARVs and PrEP.
“We are at the cusp of a massive breakthrough on HIV, and it will benefit transgender sex workers, the most marginalized you know, who have not who have been left at the periphery of the scientific benefits from HIV. We want to know how MSF can work together to ensure that companies like Gilead don't turn around and leave the low and middle income countries out. So some of us are also questioning the ethics of these decisions by the leadership,” the staffer said.
(Also see Medicines Law & Policy on this)
On FTAs
Many view that the potential restructuring plans are insensitive to the political contexts in developing countries. “In general there have been shrinking space for civil society organizations. They have not been able to deal with move to the rise of the right. In addition, if you shut off the only strong voice in some countries you would be hurting generic competition,” a source said.
An uncertainty or a cessation of the Access Campaign’s work could in effect have implications for millions of people worldwide. The ongoing discussions of the UK India FTA is a case in point.
In a Politico story, Rohit Malpani, former director of policy and analysis at MSF is quoted as saying that the decision on the Access Campaign is a “gift for pharmaceutical companies that often act with impunity and ignore the needs of the world’s most vulnerable people.”
A MESSAGE FROM MEDICS AT MSF
To be sure the discontent around the future of Access Campaign has other teams at MSF worried too.
See below excerpts from a letter from MSF medics seen by Geneva Health Files:
“In the absence of a more clearly developed strategy and structure, we urge MSF to maintain and secure continuity for the many important work portfolios we are actively engaged in with the Access Campaign.
We see unclarity both in the problem statement(s) and the actual problems proposed to be solved with the current proposed restructuring. To state in simple medical terms: what is the diagnosis and what set of ailments are we treating here? This was flagged by many people and MSF entities at an earlier phase of the consultations two years ago. Despite that, there remains a lack of clear and justified rationale for the extent of dismantlement of the Access Campaign that is planned.
We do not accept that the current dossiers that MSF and the colleagues in the Access Campaign are working on should abruptly end or suffer from disruption in 3 months’ time. There are key dossiers on access which impact the lives of many patients we treat in the wide medical field around our operations: advanced HIV disease, paediatric TB and HIV, long acting injectables for prevention and treatment of HIV, GeneXpert price drops for a multitude of diseases (hepatitis, Ebola, HIV, TB, etc), hepatitis, snake bites, compassionate use for new TB drugs, transparency for laboratory test manufacturing and drug prices, creating precedents against evergreening with secondary patents, creating conditions for commercialisation of products that have benefitted from public funding, a focus on diabetes and access to insulin.
Ongoing advocacy dossiers, some of them many years in the making, are left hanging, with limited to no resources to safeguard their continuation.
Effectively halving the current workforce of the AC in a very short timeframe (without analysis of what the workload will be) will critically undermine continuity and expertise for MSF’s work on access to medicines. Expecting that those dossiers will be absorbed by the operational directorates (ODs)/OCs/sections and will compete with the operational resources is, very obviously, not realistic within this time frame.
At current such commitments would not be aligned with the budget cycles within the ODs nor has the planned APH-fund brought into function. We need concrete commitments from the ODs as an immediate priority to avoid losing the progress made on these issues.
Regardless of the lines and process of decisions that have led to the point where we are today, we strongly request that the knowledge, networks on the different portfolios shared between different medical advisors, advocacy units and members of the access campaign are safeguarded with a tangible workplan to the point of clarity on the new proposed structure and organisation we recommend to keep the key people currently working on these files from the AC involved. We request that the AC is not dismantled until the plans for the new structure are more concrete with at minimum a strategic plan and a way forward for all the current dossiers.
The message that is being conveyed by this abrupt closure is that MSF is giving up on all matters related to ‘access and equity’ and will focus their attention elsewhere or exclusively centred on MSF’s own operational needs. This is not the message or the intent of MSF, moreover contradictory to the APH-Vision as agreed upon by the Full Excom. Therefore, the Access Campaign transition should be done in way that does not interrupt the current ongoing work and respects the public engagements we have made to the populations we are working for and maintains a strong internal and public commitment to this.
We, as leaders of the intersectional medical working groups, medical advisers, specialists, medical staff in the field and health care workers in MSF, feel our views have been ignored and misrepresented during the consultations and process of reviewing the campaign, and the outcome demonstrates a failure of our governance and decision-making- in particular on medical issues, reminding us again of the importance of reviewing and improving how this organisation makes decisions on medical issues. The process has not included consultations with the working groups on what are the medical access priorities in the movement. The new APH lacks medical voices so far, and the position as well as feedback coming from the intersectional medical platforms has been largely neglected. We believe that MSF makes a difference for the patients we treat directly in projects. But also, in the importance of the broader global impact that we are able to have for vulnerable populations beyond those directly treated by MSF, to which the Access Campaign work has contributed invaluably.
This critical reflection is also required in the scope for the ongoing exercises of other large fundamentally important dossiers such as ‘the MSF we want to be’
The access campaign is a goldmine of people experienced in medical advocacy, human rights, and aspects of law that are essential to access to health products issues; they are dedicated, knowledgeable and internationally recognized and reputed. To throw this expertise away in such a way shows a lack of understanding of the intricacies of the work of advocacy and access and the importance of multidisciplinary teams working on each topic, as well as a disrespect for something that has taken many decades to evolve. We reject the risk of losing such a significant part of this invaluable expertise in such a sudden manner. AC staff were left with a weekend to contemplate postulating for one of the 17 posts that have been opened as part of the new APH set up, in competition against their colleagues. Posts which will be part of an APH which has no strategic plan and no delineated ways of working. Just a list of priorities….”
THE CONSEQUENCES OF DISINTEGRATING THE ACCESS CAMPAIGN
We spoke to a cross section of activists in global health who have worked with the Access Campaign.
I-MAK
“MSF’s decision to terminate the MSF Access Campaign has been brewing for a while. It is shortsighted and will be a terrible loss to those in the global south and elsewhere working to make medicines more available and affordable. I and my organisation I-MAK have partnered with the MSF Access Campaign team fighting for an array of treatments for HIV, Hepatitis C, TB and various vaccines over the past 20 years. While I have not always agreed with all of MSF Access Campaign's approaches to resolving access issues, most notably their role in creating the Medicines Patent Pool and pushing the voluntary licensing route to the detriment of deeper structural changes, which caused fissures within MSF itself, they have always been pivotal to the work. It's a sad day and this decision will leave a huge hole at a time when we need every hand on deck given all the work that is going on to address the fallout of COVID-19, amongst many other needs,” Tahir Amin, Co-Founder and Chief Executive Officer at Initiative for Medicines, Access & Knowledge (I-MAK) told us last week.
HEALTH JUSTICE INITIATIVE
Fatima Hassan, Founder of South Africa-based Health Justice Initiative, said: "We want to stress the unique, unprecedented, and multi-disciplinary skills that reside in the AC, its sharp political lens, and the real and genuine benefit it provides to and for our work here in the Global South. There are no other groups right now in the world that can replicate its work or fill its large shoes. MSF has created one of the world’s most knowledgeable team on medicine access, across diseases. It should not be diluted.
It has also been a long standing and successful advocacy and research project at MSF that has been instrumental in improving equitable and affordable access to medicines, vaccines, and diagnostics for many people, especially in the Global South.
Altering the structure of MSF's AC work is a blow to our continued work, especially for greater medicine access for key diseases in the Global South. Our collaboration with the AC has been a notable example of how a major international health organisation can work alongside and support local groups while each maintaining its independence. So we are concerned that the announcement by MSF and the closure of the AC, will place that collaboration at risk and so too the partnerships that the AC has built that serve vulnerable patient communities in the Global South.
The solidarity that we have experienced with the entire AC team has helped us better understand the politics and systems of global medicine access and root causes of inequity; the IP, price basis and positions of Global North countries and Pharma CEOs. That has in turn has benefited our work to improve the course of health care and medicine access equity in South Africa- from medicine selection to the use of better priced generics.
As lawyers, academics, researchers, doctors, and AIDS activists, we recall MSF’s historical work to help us promote the right of everyone living in our country to access ARVs. MSF used research, advocacy, science, and the law on IP, to make the political, and socio-economic case for the use of ARVs in Africa, when world leaders and Pharma CEOs doubted its effectiveness and our ability in resource constrained settings.”
THE DELHI NETWORK OF POSITIVE PEOPLE
Loon Gangte, Delhi Network of Positive People, said: “In the Asian region, particularly in India, the Access Campaign (AC) plays a crucial role in partnerships with patient networks, health organizations, legal aid groups, and governments. Together, these efforts challenge patent monopolies on essential medicines, oppose harmful intellectual property clauses in trade agreements, and advocate for compulsory licenses to foster generic competition. These initiatives are vital for addressing patient needs and advancing treatment programs.
The recent decision by MSF leadership to halt the Access Campaign as part of a restructuring process jeopardizes the significant progress made in combating HIV, DR-TB, Viral Hepatitis, snakebites, and expanding access to treatments for non-communicable diseases. Prior to initiating restructuring, we urge MSF to engage in a comprehensive consultation process with stakeholders in the region. This consultation should involve civil society organizations dedicated to treatment access, policymakers, and patient networks that have partnered closely with MSF through the Access Campaign.
Without immediate steps to mitigate the impact of this restructuring, there is a risk that pharmaceutical corporations will exploit the situation in India. India is currently engaged in multiple Free Trade Agreement (FTA) negotiations that include detrimental intellectual property provisions aimed at blocking the supply of affordable medicines from India. These provisions could hinder the supply of generic medicines from India to developing countries across the globe. Recently, with the support of the MSF Access Campaign, we successfully opposed data exclusivity in the EFTA agreement, preventing delays in generic drug registrations.
We appeal to the MSF President to reconsider the decision, as it could potentially endanger millions of lives.”
(Gangte was a part of Novartis Drop the Case, EU HandsOff Our Medicines Campaign, won patent oppositions on key HIV medicines including tenofovir in partnership with MSF Access Campaign, Lawyers Collective, IMAK.)
KNOWLEDGE ECOLOGY INTERNATIONAL
James Love from Knowledge Ecology International, a vanguard of the Access movement, said: “MSF has a high profile global brand, significant resources that do not depend on external A2M funders, presence in many countries and diverse technical expertise. The MSF access campaign has had its ups and downs at the leadership level over the years, but the campaign staff has consistently been very good, and by this I mean technically good, respected, and good colleagues, and even on its worst days MSF has been a great asset to everyone working on access to medicine. It will be an enormous blow to the movement if MSF dramatically shrinks and modifies its role.”
A WORD FROM THE EMPLOYEES:
Employees told us that they are feeling humiliated about reapplying for their own positions. Some allege inadequate consultations with staff.
Excerpts from the letter from Access Campaign staff:
“New APH plan falls cruelly short:
Over the last 25 years, we have worked tirelessly to ensure that MSF staff and patients have access to the products needed to save lives, and to try and prevent future access issues. We have fought battles that are incredibly emotive, distressing – and that are becoming more and more frequent, particularly in the current political and economic climate. We have won on issues with a mix of multidisciplinary analysis, long-term advocacy, coalition building and communications and campaigning activities. In the past year alone, Access Campaign’s team of doctors, pharmacists, lawyers, communication specialists, lab scientists and policy analysts and advocates has worked fruitfully with colleagues in operations and civil society to contribute to:
- a 20% price reduction of the GeneXpert TB cartridges with the Time For Five campaign, saving MSF around $150,000 a year and saving the Global Fund $32M a year;
- a successful patent opposition on the most important TB drug to have been developed in the last 50 years, bedaquiline, so that generic production in India and other countries can start right away, leading to 50% price decrease and $26 M Global Fund saving;
- Gavi, the Vaccine Alliance providing catch-up vaccines to children up to age 5 free of charge until the end of 2025;
- research that has shaken up the diabetes world and is helping hold corporate profiteers to account;
- creating a tool to publish clinical trial costs, to challenge corporations’ uncontested messaging on the cost of R&D to justify their exorbitant prices;
- securing access to new long-acting cabotegravir for prevention of HIV for MSF operations in Mozambique, Malawi, Zimbabwe and Eswatini”
Tailpiece
The timing of such a development on shrinking the Access Campaign will need to be seen in the wider context of the structural changes in global health, power imbalances between public and private sectors, the agency of patients and their networks, among others.
Correction (12 pm CEST, June 27th): We regret an error in the financial figures on personnel costs associated with thr Access Campaign. This has now been reflected to rectify costs at 5.5 million Euros, and not 32 million Euros as first published. We apologize for this error.
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