You have placed far more weight on Dr. Kim’s leadership of WHO’s ’3 by 5′ programme than it deserves. While there can be no doubt that he is without peer when it comes to the administration of single therapies in resource litted settings, this micro-level experience didn’t transfer into a his macro-level leadership at WHO. For one thing, most observers didn’t understand why WHO had to initiate an AIDS program when other global programs were well underway and had been for years, e.g., the UN/Accelerated Access Initiative–in which WHO was a founding member; PEPFAR; the World Bank’s MAP Program; the Global Fund to Fight HIV/AIDS; and private sector programs in ten Southern States of Africa. At a time when global AIDS coordination was badly needed, ’3 by 5′ was an unnecessary and expensive intervention. Most importantly, it was inexplicable why a clinician of his reputation would recommend a fixed dose combination ARV from India, Triomune, as the “backbone” of treatment. The drug had been licensed by the Drugs Controller General (India) in June 2001. Of the twelve conditions for its use, one was: “no reference in the advertisements or medical literature is made that the Government has approved the drug”. Another: “to be prescribed only by a R. M. P.”. Beginning in May 2004 and running through September, WHO had to de-list 36 of the ARVs on its Prequalification Programme. The stated reason: lack of proof of bioequivalency. None of the 36 ARVs had been approved by any stringent regulatory authority. All of these products had been produced in India. The leadership of ’3 by 5′ never requested a post-marketing survey to determine if any patients had experience adverse reactions–a standard requirement of stringent regulatory authorities. In 2006, PEPFAR, the Global Fund, and the UN/AAI Programme announced that 1.51 million patients had been enrolled in ARV treatment programs. The number which could have been attributed to ’3 by 5′ was never publicly acknowledged by WHO in its final report. In addition, there was an antocratic bent to ’3 by 5′. Dr. Kim went public in 2005 and accused South Africa of refusing to adhere to its assigned coverage of 375,000 patients for AIDS treatment. He said that ’3 by 5′ would miss its goal because of South Africa’s refusal to follow numerical directives from Geneva. This forced an unusual public response from its minister of health. She stated: “WHO had not consulted South Africa on its plan and that the country was not chasing numbers but treating AIDS patients responsibly”.

Before his nomination, Brazil, Russia, India and China had been advocating for a BRIC Bank to undertake much needed infrastructure programs in the developing world. Dr. Kim will be elected. Yet, his limited and unremarkable experience at the macro-level in WHO will be seen as a convincing rationale for the formation of a BRIC Bank.

Sincerely,
Jeremiah Norris
Director
Center for Science in Public Policy
Hudson Institute
Washington, D. C.

However, it will be far more difficult to utilize franchised health clinics to deliver primary care in global health. The franchising model depends on sustainable growth and profits; while this may be possible in the US, it is far more difficult in low resource settings. Many poorer patients will not be able to pay for primary health services at all and the profitability of such health clinics may be questionable. Furthermore, huge challenges with determining how much care should be provided and maintaining quality of primary care exist. For instance, it may not be economically feasible for franchised health workers to perform surgeries even if it would increase patient accessibility of such health services.