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ESSENTIAL DRUGS
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Managing drug
and distributed by the WHO Action Pro-
gramme on Essential Drugs. It is pub-
lished in English, French, Spanish and
Russian, and has a global readership of
some 200,000 to whom it is free of charge.
The Monitor carries news of develop-
ments in national drug policies, therapeu-
tic guidelines, current pharmaceutical
supply
issues, educational strategies and opera- knowledge, experience and
tional research.
WHOs Action Programme on Essential
guidance on every aspect of
Drugs was established in 1981 to provide the drug management cycle.
operational support to countries in the de-
velopment of national drug policies and to
Watch out in future issues
work towards the rational use of drugs. of the Monitor for a new
The Programme seeks to ensure that all
people, wherever they may be, are able to
how to section drawn from
obtain the drugs they need at the lowest Managing Drug Supply and
possible price; that these drugs are safe
and effective; and that they are prescribed
from accompanying training
and used rationally. materials currently being
All correspondence developed.
should be addressed to:
What works best in drug
The Editor
Essential Drugs Monitor supply has no simple answer.
World Health Organization As the article posing this ques-
CH-1211 Geneva 27, Switzerland
Fax: +41 22-791-4167
tion on p.7 concludes, it will
e-mail: DAPMAIL@WHO.CH never be possible to state that
one particular system is the
best. Each country brings
IN THIS ISSUE: unique political, economic
Managing Drug Supply 213 and geographical factors to
Benefits of Thailands collective the equation. And to weigh the
bargaining system for drug
procurement pros and cons of one drug sup-
Drug supply choices: what works best? ply system against another
A primary distributor system for drugs
in South Africa cannot be properly done from
Guatemalas strategies for improving a global perspective without
drug supply and access Photo: WHO/E. Lauridsen
And more... detailed study. The Action
OST leading causes of death mid 1970s basic drug management Programme is embarking on just such a
M
National Drug Policy 1314
Meeting promotes African consumers and disability in developing concepts began to evolve in countries as multicountry study to examine in depth
involvement in drug policy countries can be prevented, diverse as Cuba, Norway, Papua New at the country level the outcomes of the
Plus articles on Belarus and Zimbabwe
treated or at least alleviated Guinea, Peru and Sri Lanka. drug supply systems in use. This study
Research 1520 with cost-effective essential Over the last 20 years countries have will look at the advantages and dis-
Reviving the popularity of commune drugs. Despite this fact hundreds of acquired considerable experience in advantages of the systems and the
health stations in a Vietnamese
province millions of people do not have access to managing drug supply. Broad lessons factors which influence the level of
Public education in rational drug use: essential drugs. that have emerged from this experience success or failure.
research study shows the value and
reveals the problems Although the relative frequencies of include: that national drug policy pro- However, what the experiences of
specific illnesses vary among countries, vides a sound foundation for managing countless countries and programmes do
Training 2021
Students taught how to develop a health services throughout the world are drug supply; that wise drug selection demonstrate is that substantive and sus-
personal formulary presented with a fairly common set of underlies all other improvements; that tainable improvements in the supply and
Newsdesk 2125 health problems for which essential drugs effective management saves money and use of drugs are possible. But an equal
Change at WHO have an important role. Mortality figures improves performance; that rational drug or greater number of negative experi-
UK study shows patients dont get the across developing regions reflect a huge use requires more than drug information; ences show that success is by no means
information they need
And more... burden of illness that can be substantially and that systematic assessment and assured. Clear goals, sound plans, effec-
reduced if carefully selected, low- monitoring are essential. tive implementation and monitoring of
Drug Information 2627
Communicating drug safety cost pharmaceuticals are available and Over the years the Monitor has aimed performance are essential ingredients in
information effectively appropriately used. And even in indus- to share both positive and negative expe- pharmaceutical sector development. And
Meetings & Courses 27 trialised countries escalating costs of riences in this critical field. This issue we can be sure that if changes in a drug
health care have placed evidence-based reports on the strengths and constraints supply system are not based on a careful
Netscan 28 and efficient drug supply management of some national, provincial and local analysis of the underlying causes for the
Letters to the Editor 28 high on the agenda. Good drug supply initiatives to rationalise drug supply and weaknesses of the existing system then
management is an essential component use. It also draws on material published they are unlikely to produce the desired
Published Lately 2930 of effective and affordable health care in the comprehensive second edition of outcome. Systems chosen, for example,
Rational Use 3136 services globally. Managing Drug Supply, issued in col- because they function in a successful
How the Netherlands Within a decade after the first modern laboration with the Action Programme on market economy may not prove the
pharmacotherapy discussion groups
have evolved pharmaceuticals became available, Essential Drugs. This publication, which solution to the drug supply problems
Essential drugs concept needs better efforts began to ensure their widespread has long been a fundamental tool in many faced in the context of a developing
implementation
availability. From the mid 1950s to the countries, now compiles state of the art country.
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2 ESSENTIAL DRUGS MONITOR
Health reform
and drug financing
EALTH sector reform is a process a number of reasons, including limited multilateral grants. For some
H
aimed at improving equity,
quality and efficiency in the
health sector through changes in
formal employment and weak state
mechanisms.
There are benefits in providing phar-
countries, internal financing
mechanisms for drugs may
prove insufficient, even after
the organization and financing of health maceutical coverage together with health reforms, and therefore
services. In this context, the role of WHO coverage although challenges, such as external funding can
today is to explore and promote ways of difficulties in tracking prescriptions, prove invaluable to
organizing health services which respond exist. Policy makers and managers need relieving immediate
better to the objectives of equity, quality to be fully informed about the value of human suffering
and efficiency. insurance coverage, alternative mecha- and can allow
Nearly every aspect of national drug nisms for providing pharmaceutical countries to develop
policy and pharmaceutical sector devel- benefits, and methods to ensure quality long-term solutions.
opment is directly or indirectly affected of care, while controlling costs. The challenge
by health reform initiatives. An addition with all external
to DAPs Health Economics and Drugs User charges financing, but par-
Series 1 , which is summarised here, User charges are increasingly being ticularly when it
focuses primarily on certain financial implemented by governments and local involves the financing
aspects of health reform. communities in countries at all levels of of recurrent costs, is to not
development, both to supplement general allow this to substitute for efforts
government revenues or insurance pre- by countries to develop sustainable
DRUG FINANCING REFORMS miums, and to help control use (see Box financing mechanisms. Transitions
Governments have the responsibility 1). Often, however, such programmes from external mechanisms to internal populations and the urban poor, the most
to ensure that drug financing mechanisms have not learned from past experiences, mechanisms need to be incorporated common source of drugs is direct out-of-
are managed in such a way as to achieve are not well managed, and, as a result, in assistance plans from their concep- pocket purchase from the private market.
equity of access to essential drugs. Fi- access shows no improvement, revenue tion. But it should be recognised that Use of generic drugs and price con-
nancing mechanisms include public replaces rather than supplements sustainability may require relatively trols are the two most commonly pursued
financing, health insurance, user fees, government funding, and drugs are long-term commitments by donors. mechanisms to promote affordability.
donor financing and development loans. overprescribed. To promote beneficial drug donations Generic competition with price informa-
User fees can complement govern- and to minimise unintended problems tion is effective in this regard. But generic
Public financing ment allocations for pharmaceuticals, with drug donations, interagency guide- drug markets have grown very slowly in
Some public spending will always be but should not replace them. Future lines2 have been published which set out most countries. The strength of public
needed to ensure access to drugs by the efforts need to ensure that the lessons core principles and 12 specific guidelines policy commitment to generic drugs is a
poorest in society; to ensure provision of from existing research and actual ex- which should be followed in all drug major determinant of the growth of ge-
drugs for tuberculosis, sexually transmit- perience are applied to the design, donations. neric markets. Four essential factors for
ted diseases and other communicable implementation and monitoring of user success appear to be supportive legisla-
diseases; and to ensure care for target fee programmes to ensure that access to Development loans tion and regulation, reliable quality
groups, such as mothers and children. As drugs does improve, and that rational use Development loans through the World assurance, professional and public
a share of national economic output does not suffer. When fee mechanisms are Bank and regional development banks acceptance, and economic incentives
(GNP), public spending on health in instituted at a national level, a top-down may contribute to long-term development (see Box 2).
developing countries is one-quarter to approach, starting with major national of the human and physical infrastructure Various mechanisms exist to control
one-half that of industrialised countries. and local hospitals, may have advantages for the health sector. However, loans gen- producer prices and distribution margins.
Health financing reform should improve in terms of equity, reinforcement of erally should not be used for financing Wholesale and dispensing margins
the use of public resources, but it should the referral system, revenue potential, of the cost of drug supplies, as these re- based on cost plus a fixed professional
not be aimed to further reduce public administrative capacity and impact present recurrent expenses. There can be fee provide a better incentive for rational
spending on health. evaluation. certain exceptions to this which may jus- dispensing than margins based only on a
The level of public commitment for tify the use of loans for procurement (e.g. percentage. The effects of pharmaceuti-
financing health care and drugs should
Donor financing and drug donations seeding of revolving drug funds). As with cal price controls have been mixed.
be a matter of explicit public policy, Donor financing includes bilateral and donor financing, conditions associated Paradoxically, a number of developing
based on an analysis of health care needs with development loans should not dis- countries are relaxing price controls on
and financing options. Policy makers, tort national drug policies defined by drugs, while governments in indus-
managers responsible for health care governments. trialised countries are becoming
financing, and essential drugs managers increasingly concerned with pharma-
ceutical prices. With or without price
should be familiar with the methods for AFFORDABILITY AND
controls, price transparancy should be a
analysing public financing for drugs and
EFFICIENCY central objective.
for planning public expenditures for
drugs. The appropriate choice and use of
drugs is the key to the achievement of ORGANIZATIONAL
Health insurance pharmaceutical policy objectives and
REFORMS
Formal health insurance and various should lead to greater economic effi-
informal community insurance pro- ciency in the health sector. A variety of Reforms to financing systems cannot
grammes represent a growing source of cost-control measures have been applied be made without organizational reforms
health and drug financing in transitional at different levels within public and that should match the structure of
and developing countries. The experience private drug supply systems. The the public and private sectors to their
of many countries has shown that com- appropriateness of different measures responsabilities in fulfilling policy objec-
pulsory social insurance can be the critical varies with the particular health system. tives. Changes may include incorporation
step to a more equitable health care sys- Affordability of drugs for consumers of competitive mechanisms within the
tem. It must be recognised, however, that is a public health concern. Private expen- public sector, decentralisation of health
some developing countries will have ditures for pharmaceuticals in developing service provision, and a greater role for
difficulties in implementing widespread countries typically account for 50 to 90% NGOs and other non commercial third
insurance coverage in the short-term for of all spending on drugs. Even for rural sector entities.
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Recently some governments have ex- Action Programme on Essential Drugs, World
Box 1 plored ways of carrying out public Health Organization, 1211 Geneva 27,
Observations from functions such as standard-setting or qual-
ity control testing through innovative
Switzerland.
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How topping-up
improved drug management
at a small clinic in Ghana
DANIEL SEKYERE MARFO* particularly true in situations of relative procurement is largely on
plenty, in other words where pharmaceu- a replenishment basis.
adoption of the top-up system
HE ticals are generally available, affordable Over-stocking is pre-
T
of drug supply has led to an
improvement in drug supply
management at the Bank of
(at no cost at all to users) and accessible.
Sometimes health workers in such situa-
tions are overwhelmed by the variety and
valent in most government
funded medical stores. It
is our belief that a main
Ghana Clinic in Accra. As a result a small quantity of drugs available, and the cause lies in structures
project that started with injectables has result is excessive and unnecessary and procedures; the suc-
now been extended to other items with expenditure on drug supply. cess achieved with the
equal success. top-up system has sub-
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In fulfilling the goals of a national drug distribution by finance and administration were highly
drug policy government has a central role receiving from the centralised; and a developed and profes-
in ensuring that drugs distributed through suppliers, storing, and sional private sector did not exist.
the public and private sectors are of ac- distributing all drugs Traditional CMS structures continue to
ceptable quality, safe and effective. Also to districts and major be used in a number of countries includ-
government has a responsibility to pro- facilities; ing Ghana, Oman and Zimbabwe.
mote the rational use of drugs. In addition, Fully private supply: However the distribution and financing
Effective supply of essential drugs includes rational selection,
it is necessary to actively promote drug quality assurance, good procurement and storage practices,
in some countries, mechanisms in use vary.
availability (geographic access) and and timely distribution drugs are provided by Using the traditional CMS system the
affordability (economic access) if a large private pharmacies in availability of drugs in the public sector
share of low income and remote or near government has deteriorated in many (but not all)
populations depend on private sector drug drugs. At least five alternatives exist for health facilities. countries as the nature of medical
supply. supplying drugs to governmental and It is possible to identify some advan- practice has changed and real financial
Among the decisions which govern- nongovernmental health services. resources have diminished. At the same
tages and disadvantages for each of the
ments have to face in the pharmaceutical above systems and to make some theo- time the demand for, and cost of, health
sector the most complex and the most ALTERNATIVE SYSTEMS retical comparisons, but true comparisons service provision has increased.
costly often concern the financing and of cost-effectiveness have not been made. The causes are many. The drug sup-
supply of drugs for government health OF DRUG SUPPLY
In part this is because other issues have ply environment has changed drastically
services. In some countries public sector Central medical stores (CMS): made such comparisons very complex. from a range of chemicals and galenicals
drug supply is well financed and admin- conventional drug supply system, in The introduction of policies on user to a multiplicity of manufactured finished
istratively efficient. In other countries the which drugs are procured and distrib- charges, decentralisation, contracting-out products. CMSs have experienced
drug supply system is unreliable and uted by a centralised government unit; and privatisation all have an impact on problems with financial management,
shortages are common. Such systems the drug supply system. quantification of requirements, manage-
suffer from inadequate funding, outdated Autonomous supply agency: a
centralised supply system in which ment of tenders, warehouse management,
procedures, inefficiency or a mixture of transport and security of drugs. These
the management responsibility is The Central Medical
these and other problems. problems have also been exacerbated by
In a situation of diminishing resources devolved to an autonomous or Stores system
semi-autonomous Board; political or administrative influences and
one response is to maximise them by The historical approach to public
increasing efficiency. Can private sector Direct delivery system: a decentral- sector drug supply is the Central Medical ...contd on pg. 8
Thailand... contd from pg. 6 Baht, a very significant saving6. Never- * Dr Mongkol Na Songkhla is Secretary References
theless, this 622.05 million Baht accounts General, Food and Drug Administration, 1. Bureau of Health Policy and Planning, MoPH. Health in
Thailand, Dr Suwit Wibulpolprasert is Assist- Thailand 19951996. Bangkok: The Veteran Press; 1997;
Ministry of Public Health have been sent for only about 10% of the Ministry of p 110, 124.
into each province to ensure its intensive ant Permanent Secretary, Ministry of Public
Public Healths drug budget. Most of the Health, Thailand and Dr Phusit Prakongsai
2. Wibulpolprasert S. (ed.). Thai drug system: a situation
implementation. Nine months later, the drug budget is still spent on individual
analysis for further development. Bangkok: Desire Co.
is Director, Kao Sukim Hospital, Chuntaburi, Ltd., 1995; p 21, 29.
situation has improved with 67 provinces purchasing and procurement through Thailand. 3. Prakongsai P. Summary of provincial bargaining system
now actively implementing the system, for drug procurement in Nakorn Ratchasima Province
GPO. Update: In December 1998 the Ministry of
although in other provinces the old sys- 19901994; 1996 (mimeograph in Thai).
With the economic crisis, political Public Health announced a policy aiming to 4. Tangcharernsathien V. Evaluation of the provincial
tem of individual purchasing prevails or
implementation of the new system is still reform, public sector reform, stronger use the collective bargaining system for 50% bargaining system for drug procurement in Nakorn
Ratchasima Province. Bangkok: Thailand Health
civil society and decentralisation, a of its hospital drug expenses. This would
weak. The impact has been clear in the Research Institute; 1994 (mimeograph in Thai).
transparent and efficient public manage- mean that at least 5,000 million Baht worth 5. Thailand Health Research Institute. Evaluation of the
67 provinces where collective bargaining of drugs would be purchased under the sys- policy for provincial bargaining drug procurement sys-
is used: drug costs were lowered by ment system is essential. This will enable
tem, a possible saving of 1,250 million Baht. tem of the MoPH, 19951996. Bangkok: Thailand Health
24.7%, from 622.05 million Baht (if the provincial bargaining system to Improved drug quality would also be en-
Research Institute; 1998 (mimeograph in Thai).
dig deeper roots and gain wider 6. Rural Hospital Division, MoPH. Progress report on the
purchased under the regular individual sured, thus achieving greater efficiency and drug management under the Good Health at Low Cost
purchasing system) to 468.03 million implementation in the near future. quality in the midst of economic crisis. Policy Package. Report to the Permanent Secretary.
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fleet or subcontract transportation. access for the poor, children, patients equipment maintenance, laundry and food environment where profit will become the
Like other direct delivery contracts, with communicable diseases and other services. Contracting out services is com- motive for supply.
this system depends on sole-source vulnerable groups. mon within the private sector. Often
commitment for the essential drugs list, companies find that outside contractors
though districts and health facilities may who specialise in specific services such
CONCLUSIONS
be allowed to purchase non-tender drugs IMPLICATIONS OF DECEN- as managing staff cafeterias or repairing If a different drug supply system is not
from any source. The system also requires TRALIZATION, CONTRACTING computers can provide those services at chosen as a result of a careful analysis of
the same level of good information and OUT AND PRIVATISATION lower cost and higher quality than the underlying causes for the weaknesses
monitoring. providing the service in house. The of the existing system in a particular coun-
The primary distributor is paid a fee These health reform strategies are
philosophy prevails in industrialised try, the change may not produce the
or commission for storage and delivery among many being tried in developed and
economies that if you can find someone desired outcome. Systems chosen because
services. The primary distributor may developing countries to improve the
else to do a specific task then pay them to they function in the climate of a success-
appear to add an extra middleman and efficiency and outcomes of health care
do it rather than committing the capital ful market economy may not prove to
extra costs, but the expectation is that the delivery. They have often been initiated
resources to do it yourself; for example, be the solution to the problems faced in
cost of the primary distributor will be less in response to the situation in developed
distribution is usually contracted out by the supply of drugs in the context of a
than the cost to the government of run- countries and are being proposed as po-
large supermarket firms. developing country.
ning the warehouse and distribution tential answers to the problems faced in
Primary distributor systems, transport To weigh the pros and cons of one
system itself. Competitive bidding for the the delivery of health care in developing
contracts, port-clearing services and drug supply system against another can-
primary distributor contract is important countries. These strategies have signifi-
related approaches to private sector not properly be done from a global
to achieve this efficiency. cant implications for drug supply systems
involvement require contracting for perspective without detailed study. Each
in developing countries which may not
services in contrast to contracting for country brings unique political, economic
have been factors in their implementation
Fully private supply system in developed countries. products (drugs, for example). However and geographical factors to the equation.
Finally, national policy, insufficient to contract out activities requires the skills It will never be possible to state that one
Decentralisation either as delegation
financing or management problems have of writing, negotiating and monitoring particular system is the best. However
or devolution is intended to improve the
led some countries to avoid responsibil- contracts. Contracting functions most some basic factors will point in the di-
responsiveness, quality and efficiency
ity for providing hospitals and health effectively where there is competition as rection of certain systems, for example,
of health services. Decentralisation
aims to achieve these with any tendering process. Contracting- the existence of an effective private
benefits through greater out also demands a commitment to pay sector is necessary for either direct
local involvement, more the contractors according to the terms of delivery or prime distributor systems to
direct public accountabil- the contract. function.
ity, increased flexibility Privatisation in health is properly de- The Action Programme on Essential
to adjust to local circum- fined as transfer of ownership from the Drugs has initiated a multicountry study
stances, more rapid and public to the private sector. But the term to examine in depth at country level the
more accurate commu- is also applied, less precisely, to contract- outcomes of the drug supply systems in
nication, and quicker ing government services to the private use. This study will look at the advan-
adaptation to changing tages and disadvantages of the systems,
sector (as with direct delivery contracts)
conditions. and the factors which influence the level
or introducing private sector features into
Problems that have of success in correcting problems and
the public sector (as with government
occurred when attempts meeting needs.
owned but semi autonomous supply
have been made to decen- agencies). The full privatisation of This article has been adapted from Drug
tralise drug management drug supply would have implications Supply Strategies, Chapter 6 of Managing
functions include the for equitable access to drugs in an Drug Supply (see reference below).
following:
Lack of capacity:
drug management re-
sponsibility may be
decentralised without Some experiences with competitive
ensuring there are
sufficient local staff
mechanisms for public drug supply
and management ca-
pacity to sustain such Autonomous supply agency in Tamil Nadu, India
Photo: WHO/O. Brasseur
services. The Tamil Nadu Medical Services Corporation (TNMSC) was created in 1995 to
Lack of financial re- contain drug costs and reduce shortages by purchasing and supplying drugs to
government health care facilities. TNMSC is set up as a government company, with a
sources: responsibility
Board chaired by the Secretary of Health, which is accountable to the Minister of
is sometimes decen- Health. The TNMSC created a list of 267 essential drugs from the previous state drug
tralised for all drug list of 900 items.
Sometimes Central Medical Stores leave a lot to be desired, as supply without pro-
can be seen here in a country in Sub-Saharan Africa viding an adequate Drugs are procured through tender and delivered directly to district level stores.
budget. In this case Quality assurance procedures are in place, including sampling of products from
manufacturers and district stores. Testing is contracted to reputable private laborato-
centres with even essential drugs. Where decentralisation simply becomes
ries through tenders. TNMSC adds a 5% charge to fund its own operations. Each
this is the case, retail pharmacies become abandonment of responsibility. facility is given a budget target and issued a pass book in which to record the
the source of supply, especially in urban Increased corruption: because of the value of drugs it has received. Through prompt payment and other administrative
environments. Often the pharmacies are money involved, interference for per- efficiencies, TNMSC has considerably reduced drug costs, while maintaining reliable
located very close to the hospital, and may sonal gain is common in drug supply supply.
be located inside the hospital. Such systems. While decentralisation
pharmacies may be part of a parastatal is meant to improve accountability, Combined supply strategies in Zimbabwe
pharmaceutical enterprise (Sudan), or it makes it easier for local officials The Zimbabwe Essential Drugs Action Programme (ZEDAP) uses different systems for
they might be an institutional enterprise or other special interests to profit different categories of drugs. High-usage drugs on the essential drugs list are pro-
(Ghana), or they may be independent fraudulently. cured, stocked and distributed in bulk through the central medical stores. For
enterprises. In some countries, patients high-cost, slow-moving specialist items, direct delivery contracts are used. For most
Increased cost: decentralisation of specialist items an annual tender is conducted to fix the price for the year. Drugs are
receiving health care through the public
procurement usually means smaller then ordered as needed by the roughly two dozen national hospitals and NGO
sector are left to buy virtually all drugs
order quantities. It can result in higher hospitals which require them. Orders are delivered directly to the hospitals. Finally,
on their own from the private sector. This for cancer agents and some other highly specialised drugs, no contract exists.
prices for essential drugs, although
situation usually results from complete Instead, drugs are purchased by the Ministrys pharmaceutical division by individual
this problem can be overcome
lack of government funds, rather than order, with permission from the Secretary of Health.
with central contracts coupled with
as part of an official drug management
decentralised ordering.
plan.
As with revolving drug funds operated Contracting-out or resourcing in Source: Bennett S, Muraleedharan VR. Personal communication on Tamil Nadu Medical Services
by the government, the greatest concern health care has most commonly been Corporation. 1997.
with fully private supply is equity of tried for non clinical services such as MSH/WHO/DAP. Managing Drug Supply, 2nd ed. Hartford, CT: Kumarian Press; 1997.
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have been suggested as a means
of achieving some of the goals of
national drug policies and essen-
as part of the process of drafting stand-
ard treatment guidelines, has established
a database of conditions and related
have facilitated distribution.
Contracting-out is one of the options
described for public sector/private sector
years experience one of the former
homelands had already used contracting
out services prior to 1995 have
tial drugs programmes1. Because of work medicines, which will lead to drug ration- cooperation in drug supply1. shown the following requirements to be
which showed that contracting-out the alisation in the public sector. The EDL In South Africa all of these factors necessary for a successful system:
procurement and distribution of drugs can currently comprises just over 900 items, needed to be tackled: Procurement: The province must
offer advantages and improve perform- and is being further streamlined.) manage the procurement database
The public sector does not insure stock
ance, two of the countrys nine provinces After the 1994 elections, the newly and have the final say on orders,
against theft, fire or natural disasters,
have opted for this approach. South consolidated provinces had to integrate including prices.
so all losses occur at government ex-
African provinces have a considerable the various pharmaceutical services, in
pense, if services are not contracted Warehousing and inventory manage-
degree of autonomy. common with health and other services.
out. Theft is a major problem in ment: At least one senior pharmacy
In this method, structure, process and Provinces generally had their own ware-
pharmaceutical warehouses in South manager should be on the provincial
outcome specifications are established by houses and sent estimates of their
Africa. payroll for this task. The public sec-
a public sector authority and offered to requirements to the Coordinating Com-
prospective providers on tender. The mittee for Medical Supplies (COMED), Strikes have become increasingly tor should own the warehouse and
authority, usually through a bidding proc- which coordinates the national tender. common since the 1994 elections as equipment. This ensures independ-
ess administered by a tender board, will Payment is made by the provinces directly trade unions are trying to negotiate ence so that if the contractor does not
then select and establish a formal contract to the suppliers. new equitable rules and remuneration perform to specifications, the province
with a provider. The government of the newly consti- in the labour sector. has the facilities to continue opera-
Experience and some critical lessons tuted Province A sought to integrate the Vehicle maintenance, cost-effective tions. However, the contractor is
learned in using this approach in South drug supply systems of four authorities staffing and management information responsible for the maintenance and
Africa are described here, providing as part of its efforts to establish a single are areas where the public sector has insurance of the facilities and stocks.
valuable insight into one of the few docu- health authority. Following recommen- not always been efficient in the past. The Department, in negotiation
mented primary distributor systems dations of a 1994 evaluation, Province Government departments have been with the contractor, determines stock
outside the USA. A, (which has high unemployment, low notoriously overstaffed, but employ- levels. This precaution ensures that
average individual income and a pre- ees were poorly paid and often adequate levels of stocks are kept in a
dominantly rural population), decided in underqualified. Many motivated situation where the contractor pays
BACKGROUND 1995 to contract out the procurement, workers found work more rewarding insurance coverage.
warehousing and distribution of pharma- in the private sector. With limited fi- The contract should include the
South Africa, with a total population
ceutical supplies. These functions were nancial and logistic resources, services installation of adequate computer
of just over 40 million2, had a pharma-
contracted out to a private company at a in remote areas were not easy to hardware and software for inventory
ceuticals expenditure of some 4.8 billion
commission of 8.05% of the value of the manage. management at hospital pharmacies,
Rand in the private sector and 1.8 billion
products. The contract also included a and for on-going staff training.
Rand in the public sector in 1996 (when The decision of two provinces to con-
R1 was approximately US$0.22)3. Annual 2.2% commission for computerisation of Distribution: The contractors own
hospital pharmacies and computer train- tract-out procurement and distribution to
per capita expenditure on drugs for the transport is to be used; courier and
ing of provincial pharmaceutical staff. hospital level provided experience from
85% of the population who rely on public similar services are not acceptable.
From January 1996, medicinal supplies which important lessons can be drawn.
sector health services was approximately When other transport is used, medi-
R52 (US$11). For the remaining 15% have been distributed from a single de- cines are not always regarded as
pot in the centrally situated provincial
served by the private sector the equiva-
capital.
TENDER SPECIFICATIONS priority by the transport contractor and
lent figure was around R792 (US$174). deliveries may not be according to a
To place this figure in context, the World In Province B, an essentially rural area Against this background, clear schedule.
Bank quotes an average drug expenditure with less infrastructure than Province A, structure, process and performance
Management information: The
of US$2.1 for nine African Countries in contractor is required to supply com-
the mid-1980s4. While in 23 Sub-Saharan prehensive management information
African countries drug consumption was
valued at less than US$5 per capita in 19905. Some advantages of Contracting-Out reports at agreed intervals.
Billing: As the contractor is paid a
The procurement and distribution of
1. All losses by fire, theft or natural disasters are the responsibility of the contractor. commission on items delivered to
pharmaceuticals in the public sector is
centrally coordinated; the provinces pro- 2. The staff required to run a warehouse efficiently and effectively is expensive. Cost- hospitals the billing structure must
effectiveness of this component will be monitored closely by the contractor, separate these costs from the cost of
vide estimated quantities to the National
because of the effect of poor performance on profitability. purchasing stocks into the warehouse.
Tender Board, which then calls for and
awards supply tenders. The provinces 3. Strikes and industrial disputes can be a major threat to the health services in a In an earlier South African experience
purchase their requirements from the suc- situation where all medicines are distributed from one depot. The service provider with limited contracting out the com-
will be responsible for ensuring continuity of services. pany received a commission on stock
cessful tenderer through a provincial
depot. 4. Transport is a major cost component in the distribution cycle. Adequate vehicle purchased into the warehouse and not
This system has encountered some maintenance and efficient scheduling of deliveries become the responsibility of on stock delivered to clients. This ar-
the contractor. rangement left many opportunities to
major difficulties over the years. These
mainly revolved around stock losses and 5. Management information on drug availability and use can be improved without purchase inappropriate medicines and
inexplicable variations between recorded major investment by the public sector. quantities.
purchases and actual stock-on-hand. See Chapter l7 of Managing Drug Supply6 for a more detailed description of issues involved in Human resource development: The
There was also a general lack of infor- contracting out pharmaceutical services. entire contract must be seen as a part-
mation, and the selection process was not nership between the Department and
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the contractor. The Department must payment difficulties (see above) Figure 2 Distribution cycle the common factor of the same
also ensure that the contract is carried and poor depot management. Prov- supplier, but which differed
out according to the specifications. ince A faced mainly the first two (Province/
(Contractor) markedly in performance.
This necessitates the active involve- problems, whereas all three applied contractor) Procurement An integrated approach
ment of provincial staff members in to Province B from time to time. Consumption (Contractor)
reports and planning by the public
the entire process from database man-
Receipt sector provider and the
agement, and procurement to receipt and inspection
and distribution. RELATIONSHIPS (Facility) contractor is essential.
BETWEEN THE PLAYERS Collect consumption The provincial drug list,
information which must have the sup-
CURRENT CHALLENGES To obtain a perspective of the (Province/
Storage port of its users, should be
actual difficulties involved we ex- contractor) (at depot) strictly applied and there
Sufficient data are available to enable amined the components of the Delivery (Contractor) should be a provincial veto
an evaluation of how the first two ele- procurement and distribution cy- and payment Ordering/ on non list items.
ments listed above have contributed to cles in terms of the relationships requisitioning
(Contractor) The storage depot needs to
goal of improved drug supply 6. between, and responsibilities of, (Province)
by facility
(Province) be carefully sized and cen-
the two role players (see Figures
Procurement and 1 and 2). trally located.
financial control The provincial authority is involved information at this level have often been Appropriate facilities and systems
Procurement was initially effective in in every element except receipt and problematic. need to be established for current and
Province A. Towards the end of 1997, checking of goods at the depot and future requirements.
however, and for approximately the first A management information system is
quarter of 1998, the situation deteriorated. LESSONS LEARNED
needed to monitor order and delivery
This situation arose because of financial Perhaps the core lesson learned is that status.
difficulties within the Province which led what occurs in contracting-out is a part-
to the transfer of funds from Health to Contractor selection should be based
nership. If either partner does not deliver,
Education to offset overexpenditure on on previous performance and capac-
and there are weak links in the chain, the
the Education budget. process will fail! ity to undertake the work, and include
In Province B, the situation mani- There were differences in perform- quality assurance for service delivery.
fested major difficulties from the start. ance between the two provinces. These Contractual terms and specifications
Initially, accurate demand data had not lay in the partnerships and inputs in each must be fully detailed.
been given to the contractor. Hence, or- case. In the early stages of the process in
der quantities did not match requirements. Province A, there was extensive prepara- Purchasing and payment methods
Cash flow problems surfaced as a result tion by both parties. Facilities had need to be spelt out.
of a backlog in payments during 1997/ adequate stock in place. Stock at differ- Finally, and perhaps most critically,
1998. More recently, the health budget ent depots was checked and consolidated. there has to be a sustained cash flow
was decentralised to district management, This was not the case in Province B. The from recipient to contractor to
which caused major difficulties with cash depot there had been newly set up and supplier.
flow at the depot. Suppliers who had not had encountered difficulties in establish-
Photo: WHO/H.V. Hogerzeil
selection of supplier, who pays contractor Receive Monitor (Province) tempted to identify critical issues, JR, Laing RO, OConnor RW, Hogerzeil HV, Dukes
Contractor and check order status MNG, Garnett A, editors. Managing drug supply, 2nd
may have overtendered and pays suppliers) (Province monitor
lessons and key success factors ed. West Hartford, CT: Kumarian Press; 1997. p. 256
(Contractor)
therefore could not deliver; contractor) from these two cases, which had 269.
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O
drugs;
has followed through its commit- established to review the legal aspects of allow for extended coverage. Meanwhile,
ment to the concept of essential an improved system of logistics for the Government purchases of medicines and quality must be in conformity with the
drugs by developing a range of provision of supplies; medical surgical materials2. US Pharmacopeia, and all medicines
strategies and actions designed to improve establishment of a drug vigilance As part of the modernisation process, referred to by their International Non-
the supply of drugs and ensure wider programme. the law was updated and a new Health proprietary Name. Norms have been
access to them 1. More recently, the Reform of the drug regulatory Code issued3. The regulation4 that this law established for the qualification and
Guatemalan Ministry of Health has drawn authorities and the official quality con- implements facilitates Guatemalas par- awarding of suppliers and products,
up a blueprint for overall health policies trol laboratory was achieved through ticipation in the globalisation process, and together with a procedure and payment
to the year 2000. The proposals include: strengthening the management structure, establishes responsibilities for all person- guarantee to ensure successful relation-
the modernisation of state health services decentralisation of finance, staff training nel involved in the supply of medicines. ships. This agreement provides for
through decentralisation of finance and programmes and a review of salaries. Meanwhile, overall control
administration; strengthening the capac- Other measures included: the establish- remains within the Ministry
ity of governing bodies; improving ment of new administrative procedures of Health.
sectorial and intersectorial coordination; for the register of authorised drug sales; The legal framework pro-
and making better use of existing re- better quality control of medicines; the vides for the development of
sources for health. The Ministry of creation of a standardised system for drug a Programme of Ease of Ac-
Health is also committed to improving the registration; better inspection of Good cess to Medicines5 through
quality of health services and ensuring Manufacturing Practices; the purchase of already established state and
wider access as well as improving the laboratory equipment; and the develop- municipal pharmacies6, and
management of health services. ment of a computerized data system for the establishment of a Sales
Within the Health Ministrys budget, drugs. of Medicines for Community
the largest items of expenditure are medi- Elsewhere, the Quality Standards Benefit scheme7 run by civil-
Photo: A. Rutgers
cines (10%), surgical materials (5%) and Working Group studied the list of 1,400 ian groups to ensure they
medical equipment, including mainte- drugs purchased by the Government are self-financing and sus-
nance and replacement equipment which contained many duplicate products tainable. The proposal for
purchases (6%7%). However, over time, and recommended the use of the 13th the Purchase of Medicine The central drug warehouse in Solola District. The Guatema-
the administration of this budget has edition of the US Pharmacopeia and system, which came into lan Government is implementing measures to improve drug
lacked transparency in the selection, pur- the US Pharmacopiea Dispensing Infor- operation in early 1997, supply
chase and distribution of these products. mation, to define the specifications of adopted the open contract
The quality of the product purchased was products purchased by the Government. system already in force for Government payment within a maximum of 30 days
neither defined in advance nor checked Other products on the list had to be purchases. This is an administrative tool after receiving the product, compensation
on receipt. Meanwhile, suppliers had no ratified from alternative sources, such with centralised negotiation and decen- in the event of fluctuations in the ex-
guarantee of payment resulting in price as the British, French and Japanese tralised execution designed to guarantee change rate and payment of interest on
speculation of up to 400% of the original Pharmacopoeias. the quality of the product, purchased at delayed invoices. Sanctions can now be
price. The Working Group also estimated prices previously determined at central imposed for the supply of poor quality
One of the first steps taken was to form supply needs on the basis of figures pro- level. products and for failure to deliver within
a group of national consultants to work vided by different health units. The aim the agreed timeframe (with a maximum
with the WHO Regional Office for the was to establish quantities that would be penalty of five years suspension as a
Americas and the Pan American Health ENSURING TRANSPARENCY Government supplier).
attractive to suppliers and ensure savings
Organization. The group was to draw up IN SUPPLY The new system allows for a maxi-
through bulk purchase orders. Medical
a strategy to resolve existing problems surgical materials and medical equipment The new drug purchasing system was mum of 3% deviation in the minimum
and capitalise on the then current employ- were handled in a similar way, using modified to include an open tendering price offered by a maximum of eight sup-
ment of an international company with international standards such as those of system, with control over those who make pliers. Meanwhile, an inter-institutional
expertise in drug purchasing systems. the US Food and Drug Administration, the offers, and clear rules to ensure trans- commission has been established to over-
as well as alternative standards. At every parency and bring an end to corruption. see the operation of the open contract
SWEEPING POLICY CHANGES system and apply sanctions for non-
fulfilment. The private sector participates
A Multisectorial Commission for
as an observer in this commission. The
Policies on Medicines was formed within
Process of Public Awarding provides for
the Public Health Ministry with represen-
the participation of personnel from the ad-
tation from both the private and public
ministrative units and executing officers
sector as well as international health or-
from the public health sector as well as
ganizations. The Commissions remit was
observers from private sector organiza-
to advise the Ministry on new policies for
tions and professional colleagues (doctors
the quality control and supply of drugs.
and pharmacists).
Because of the seriousness of the
problems encountered, it was decided to
implement new policies across the board. FOCUS ON QUALITY
These included:
The establishment of administrative
strengthening the drug regulatory and technical norms was also necessary
authorities and the official quality to guarantee that the item gets to the user
control laboratory; in perfect condition, in the correct quan-
Photo: A. Rutgers
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pharmaceutical sector
place to deal with complaints about the
efficacy or safety of products, and take
appropriate action wherever needed.
In late 1997 doubts about the quality
of medicines purchased through prescrip-
tion prompted the launch of clinical HE Ministry of Health in Belarus
studies of some products. The finding that
some products were lacking in efficacy
led to the establishment of the Drug
T has set out its plans for health
sector development, which in-
clude changes in the pharmaceu-
Important steps on the
road to pharmaceutical
Vigilance Programme designed to tical sector. Among proposals are that a
assess complaints about therapeutic network of state and private pharmacies sector reform in Belarus
failure and/or adverse reactions to medi- will develop in parallel, with their activi-
cines purchased through the open contract ties strictly regulated. At the same time,
system. state control of drug pricing will continue.
Drugs will be supplied to the population In April 1991 the first version of
The new policies have met with op- the essential drugs list was adopted.
position from some groups including through both centralised and decentral-
It has been reviewed annually since
prescribers and suppliers who failed to ised procurement, using the countrys
then and is widely used. The list is the
win contracts each preferring to main- list of essential drugs. Other important basis for procurement at all levels of
initiatives include a campaign to pro- the health care system and ensures
tain the status quo on drug supplies.
mote the rational use of drugs, and plans guaranteed coverage of the popula-
Other problems have included inadequate
to hold a national conference to adopt tions pharmaceutical requirements. that should be available in every phar-
supply forecasting leading to drug a new approach for developing the macy at all times.
shortages and budgetary restrictions on pharmaceutical education system. It is In September 1992 the Principal Plans are also underway to: encour-
efforts to ensure vigilance and control. hoped the Government will adopt the Department of Pharmacy, Medical age the more rational use of drugs,
However, failure by some suppliers to public health development package by the Equipment and Regulation was especially within the drug reimburse-
provide the correct amount and quality end of 1998. established. Within this framework
ment scheme; increase the role of the
of drugs has led to the imposition of sanc- The country plans two main ap- the process of developing a national
essential drugs list; introduce drug
tions, including five-year exclusion from proaches for the pharmaceutical industry: drug policy started.
treatment guidelines; improve doctors
the Government supply system. the production of generics included in access to drug information; encourage the
In December 1992 licensing of
Among the major achievements of the the essential drugs list for centralised procurement of drugs in the hospital
the pharmaceutical market was
new system are the savings on drug budg- drug supply, in accordance with state initiated. This allowed the Govern- package; and review the price regulation
ets and the extended coverage with low directives; and the modernisation and ment to preserve its control of the system.
cost, high quality medicines. The Minis- upgrading of existing pharmaceu- pharmaceutical sector and to regu-
try of Health has saved 65% of its budget tical manufacturing enterprises. Three late newly established pharmacies,
and the Guatemalan Institute of Social new factories have already begun regardless of their ownership. FRUITS OF COLLABORATION
Security the countrys other public pharmaceutical production.
Over the next five years it is planned In November 1993 the Pharmaco- International contacts, especially
health service provider saved 23% of those established during 1993/1994, have
to develop and introduce up-to-date logical Commission was reorganized
its drugs budget. Meanwhile, through into the Pharmacological and played a significant role in allowing
requirements for clinical trials and
the Access to Medicine Programme Pharmacopoeia Committees. Require- Belarus to make more rational decisions
standards for drug quality and production,
which benefits from decentralised ments for drug registration in Belarus on how to organize its drug regulation and
and to review other regulations covering
price negotiations medicines are now were defined and legally approved. supply systems.
pharmaceutical issues.
being made available to underserved Agreements on collaboration in the
communities. ln November 1993 the national pharmaceutical sector have been signed
Elsewhere, quality standards have INCREASED ROLE FOR programme for pharmaceutical with the Health Ministries of Latvia and
industry development was adopted.
been established for the purchase of medi- REGULATORS Ukraine, as well as with the French Medi-
The list of drugs produced in Belarus
cines and sanctions put in place to deter The drug regulatory authority is increased from 150 to 300 items.
cines Agency, and the US Food and Drug
the supply of poor quality medicines or expected to have a stronger role and Administration. This allows Belarus to
late deliveries. independent status. Recently, the Minis- In October 1997 the Republican receive much needed drug information
Multidisciplinary teams now partici- try of Health established the Republican Centre of Expertise and Trials in more efficiently, and to organize training
pate in negotiations for the purchase Centre of Expertise and Trials in Health Health Care was established. This for its experts at these institutions.
of drugs and other medical items, and Care. The aim is to help solve current facilitated reorganization of drug Contacts and cooperation with the
the decentralisation of health budgets problems in the drug supply system, and registration and pharmaceutical Pharmaceuticals Programme at WHOs
licensing procedures to meet Regional Office for Europe has also
facilitates the prompt payment of to improve the drug registration process,
international standards. broadened knowledge on all aspects of
suppliers. authorisation of products for medical use
and industrial production, licensing of the pharmaceutical sector.
* Ing. Manuel Enrique Lezana is Chief of the pharmaceutical activities, and control Belarus has also benefitted from an
Interstate Commission for standardisation
Drug Coordination Office, Ministry of Health, over drug imports to Belarus. The Minis- MAJOR CHANGES AHEAD
and quality control of pharmaceuticals
Guatemala. try intends to implement national drug
policy through the Centre, and through Step by step over the next five years, and medical equipment established under
all these measures to exercise effective Belarus will introduce international stand- the Commonwealth of Independent States
control over the pharmaceutical sector. ards for good manufacturing practice. It Council for Cooperation in Health. It has
References
will modernise and increase the capacity allowed better harmonisation of pharma-
1. Working together, learning together. Essential Drugs of existing production plants, build new ceutical standards and requirements for
Monitor [editorial] 1992; 13. ENSURING ACCESS plants, widen the list of drugs produced, products manufactured in these countries,
2. Governmental Agreement 47296, dated 4 November Centralised procurement of certain and strengthen the States role in drug and the simplification of their circula-
1996, related to the quality of medicines and medical
important medicines will continue, production to better satisfy national drug tion within the Commonwealths internal
surgical materials in which the purchasing standards are
established. among them those for treating diabetes, requirements. markets.
cancer and tuberculosis. Such procure- The Ministry foresees the further de-
3. Legislative Agreement 9097 in force from February
1998. ment is done on a large scale, in bulk and velopment of the network of newly
exclusively on a tender basis. This sys- established private pharmacies and im- This article is based on an interview with
4. This regulation is awaiting final Presidential approval. proved regulations that will ensure
tem allows the purchase of needed drugs Gennady Godovalnikov, Head, Pharma-
5. Governmental Agreement 71497 dated 8 July 1997. to be more cost-effective, and ensures increased access to drugs for the rural ceutical Department of the Ministry of Health
access to these vital drugs for the popu- population. There are plans to review ex- of Belarus, which first appeared in:
6. Ministerial Agreement 16198 dated 26 May 1998.
lation. All pharmaceuticals supplied in isting pharmacy regulations and to Pharmacuetical Reforms, WHO News for
7. Ministerial Agreement 16298 dated 26 May 1998. this way are free of charge to patients. introduce a list of compulsory medicines Newly Independent States, No.3, June 1998.
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Zimbabwe launches
information was a funda-
mental consumer right, and
that increased literacy levels
in Zimbabwe had increased
Hospital. Simultaneously the Policy treatment guidelines and essential drugs support the Policy would be
was launched in four other centres lists had also begun. put in place.
throughout the country. The launch is a The launch of the policy is the WHO Representative,
culmination of the efforts of all sectors Governments commitment to the goals Dr Levon Arevshatian, Aidan Chadirikere (right), Director of Pharmacy Services and
of the health system including health described said Minister Stamps, whilst stressed the importance Norman Nyazema (left), Professor of Pharmacology at the
service providers, the pharmaceutical urging everyone to familiarise themselves that WHO attaches to the University of Zimbabwe celebrate the launch of Zimbabwes
industry, various ministries and other with its contents and to identify their development and imple- new national drug policy document
stakeholders. individual roles in its implementation. mentation of national drug
A five-year work plan underlies the Also speaking at the launch was policies. Other speakers underscored choir from the Harare Central Hospital
Policy, and has been in operation even the Consumer Council of Zimbabwes the need for a concerted multidis- School of Nursing was on hand to sing
before the formal launch. Dr Stamps representative, Mrs Keretia Chikowe. She ciplinary approach for successful the Zimbabwe National Drug Policy
stressed that the concept of a National explained that access to correct drug policy implementation. Finally, the into life.
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RESEARCH
I
respect of the public; the reduction of dis- CHSs and therefore improve the chance We therefore used other aspects of im-
health stations (CHSs) in Hai
trict supervision; and the lack of a living of the commune investing in them, proving quality of care as both carrots and
Phong Province, Viet Nam, was
wage which led to increasing numbers of preserving the preventive
in danger of collapse. This was a
health workers starting a private practice care that they offered.
system that had provided a health station
or taking up other income generating We hypothesised that if
in every commune in Hai Phong with a
activities; all illustrated a breakdown of the commune health stations
staff of four to six para-medics, trained
the health services. offered a good service,
for three to four years at the secondary
The consequence had serious where common diseases
medical school (these schools exist in
implications for preventive care. With were well managed; where
most provinces to train nurses, midwives
the reduced esteem of the CHSs due to necessary drugs at affordable
and medical, pharmacy and laboratory as-
declining curative activity, there was a prices were supplied in the
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HAI Phong... contd from pg. 15 workshops was carried out normally previous months and on the diagnoses District supervisors, to develop and
two in each district but this varied with made. This information was found learn methods to monitor the agreed
would please health worker and public the number of staff needing to attend. The either by looking at records or if key drug use indicators that were seen
alike. workshops were with: these did not exist, by supplying to be a problem on the basis of the
Accounting system: developing an duplicate prescription pads to all research findings.
Key commune and CHS leaders, to staff, collecting them after one month
accessible, transparent book keeping sys- At the conclusion of the workshops a
agree the plan of activity of the and analysing the data. Treatment
tem kept by the CHS would help to ensure ceremony was held, where each actor
project. This was basically to enlist guidelines were made for the 10 most
the existence of an ongoing revolving (from the Provincial Health Bureau, Dis-
their support and explain the ap- common conditions that covered more
fund. trict Health Office, Commune Peoples
proach. It included them approving than 80% of patients seen in each
Equipment: the possibility for the Committee and CHS) signed a contract
regular supervision by district staff, particular district. While the process
CHS to choose basic equipment from an to agree their role in the plan of activi-
the formalising of the selling of drugs, was participatory, the final say rested
agreed list every three months for nine ties. A week of retraining for all curative
instigating an accounting system and with the facilitator, who was familiar
months would act as a real incentive to staff was organized through the second-
agreeing that the CHS drug seller with national and WHO policies for
change prescribing habits. ary medical school, to reinforce basic
could purchase drugs from the agreed treating the most prevalent diseases.
Patient load: with an increasing pa- list from any registered drug seller. diagnosis and treatment for common
Compilation of the drug list was
tient load, income would increase. They would also understand that conditions.
then relatively easy, as usually eight
equipment donation was dependent on or nine drugs had been used in the With this done, Save the Children
2. Stick good prescribing. treatment guidelines and then, extra Fund UK transferred an average of
Withholding of equipment: if the drugs were discussed and agreed, us- US$300 to each CHS for them to set up a
CHS curative staff, to create a stand-
agreed treatment guidelines and book ing the same facilitator. Each districts revolving drug fund. It also supplied
ard treatment guideline based on the
keeping system were not followed, then drugs list was slightly different, books and calculators for book keeping.
most frequent diagnoses and to agree
the equipment would not be forthcoming. containing between 29 and 31 drugs. This took around two months in each
a drug list. A senior staff member from
Peer pressure: the withholding of When the programme ended they district.
the Ministry of Healths Education
equipment would be public knowledge. were combined into one list of some In addition an information campaign
and Science Department facilitated
32 drugs. on key drug use issues was launched
Supervision: the regular supervision these workshops. The standard treat-
using television, radio, newspapers,
would also be a form of inspection. ment guidelines were based on CHS book keepers, to develop an
posters and leaflets. The messages were
Public expectation: if, through a se- commune prescribing patterns over appropriate book keeping system.
based on survey results (see Boxes 1
ries of television and radio programmes, and 2).
leaflets and posters, the public were
informed about key aspects of drug use Box 1 Ongoing work
and CHS service, then their demand for
irrational treatment would decrease.
The Information, Education and With satisfactory results from the
Communication (IEC) campaign in Hai regular supervision of the district teams,
at three monthly intervals, each CHS was
PHASED Phong to promote the rational use of drugs allowed to choose around US$250 worth
IMPLEMENTATION of basic medical equipment from an
IEC campaign principles agreed list. This equipment was condi-
The project was implemented, district tional on following the treatment
Messages were agreed and prioritised on the basis of research. These messages
by district, in all 12 districts in 217 com- addressed the same problems found with CHS prescribing. They were repeated as guidelines and book keeping system.
munes in Hai Phong covering a often as possible, using a variety of media channels. Initially some CHS staff found it
population of 1.6 million people. In each difficult to understand and adhere to the
district the whole process took up to one Main problems identified new accounting and prescribing proce-
year. We started with the rural areas and dures. However, the district health teams
Antibiotics are used too often.
ended with the urban and island districts. When antibiotics are used they are used in too small a dose. supervisory visits and at least one early
Work started in the first district in June Injections are often preferred to tablets. visit from a Save the Children team mem-
1994 and the last in January 1996. It The majority of sick people are not using CHSs. ber helped to resolve problems. After this
covered a series of activities aimed at visit, when processing the monthly infor-
improving aspects of quality of care. Agreed messages mation for the district, the project wrote
Never use injections if tablets will do. Injections can be dangerous and are usually to the district health officer highlighting
Pre implementation not necessary. any unsatisfactory practices within
in each district If you need antibiotics, you must use a full dose. Not finishing the dose means that particular CHSs, (such as overuse of
Baseline research on key drug use next time you need them they may be less effective. antibiotics or injections). If, after warn-
indicators and which diagnoses were When you are ill do not self prescribe, ask your local expert. Use your Commune ings, bad practices went unchanged, the
Health Station.
being made at CHSs was carried out in requested equipment was refused until
Save the Children Fund from the UK is here to help upgrade your local Commune
all CHSs of the district. This was either Health Stations. Using your local CHS when you are ill is beneficial for your health
improvements had been made.
done by retrospective examination of out and the station. The supervisors motivation and
patient books or if these were absent, by abilities were another concern. If highly
prospectively giving prescription pads Media used qualified the supervisors were reluctant
and examining them after one month. to travel around to the CHSs. If they
These were variously applied from June 1994 to November 1995.
As a pre-condition for joining the were less highly qualified they were
project, each district health office had to Two posters were designed in Hai Phong for the first two messages and every CHS more willing to travel but did not have
was given four or five of each.
agree to set up and run a team of supervi- the authority to advise the medical
sors to monitor the quality of treatment Four radio programmes (short plays of five minutes starting and finishing with the assistants on their practice. This problem
and of book keeping in each commune message) were written and recorded first by a district radio and secondly by provin- was tackled differently in each dis-
cial radio. They were transcribed onto cassette and distributed to every CHS to
each month. This information was to be trict, but on the whole the supervisors
broadcast on the commune public address system.
fed back to the provincial health office managed to collect the necessary
and project office every month, establish- Four radio spots each 30 seconds long were treated the same way. information. The head of the district
ing a record of key indicators for each TV programmes. Provincial TV recorded four programmes, each approximately five health office reviewed the supervisors
CHS and aggregated for each district. It minutes long, with a respected person talking about one of the messages. These were progress each month when they came in
was mainly on the basis of these records shown several times over several months. to collect their salaries. The review was
that the decision was made whether to TV spots of one minute were treated in the same way. based on the information that had been
donate or not, money for equipment to Newspaper advertisements were taken out for each of the messages on the provincial collected. When information had not
each CHS each three months. The key newspapers back page. been collected for the month because the
indicators used were those that had been Leaflets. A simple leaflet was designed and given to each houshold in five communes. supervisors had not done their work,
shown to be most problematical during equipment distribution was stopped
Meetings. A key physician from each district was trained on the messages, but this
baseline research (see Table1). in the whole district. We also stopped
has not yet been taken any further.
delivery if the information seemed unre-
Preparation Cost. All these inputs came to a total of US$2,200. liable, for example if everything was
In each of the 12 districts, a series of scored at 100%. The reliability of the
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research (see Table 1). In two involved, with particular focus on the con-
districts, after three months, ditional donation of chosen equipment
when the equipment was depending on good prescribing and the
supervisors information was checked effective setting up of district wide
due, we refused to release the
through evaluation exercises and was supervision.
equipment to any of the
found to be very good. Supervision
CHSs, as we felt the super-
results showed a large improvement in At the end of a series of training workshops John Chalker * Dr John Chalker was Project Manager for
vision results were unreliable presents a participant with a set of posters, a cash box plus
prescribing habits and book keeping over the Hai Phong Project, from December 1993
or they had not been pro- padlock and a calculator. Inside the box are all the accounts to March 1996, for Save the Children
the first five months of activity for each
duced. After this things and record keeping books necessary for one year. All Fund UK.
district (see Table 1).
improved. The conditionality commune health stations received these
of equipment donation on
Evaluation
reliable and regular supervision proved an incentive towards rational drug use.
Supervisorsdata were checked by an effective incentive. Patient attendance increased during
quantitative evaluations in December the project and maintained that level for For further information on the Programme
1995, before the project had finished and contact: The Field Director, Save the Children
six months after the projects end (see
then again in September 1996, six months CONCLUSIONS Table 1). This may have been in part due
Fund UK, 218 Doi Can Street, Ba Dinh
District, Hanoi, Viet Nam. Reports on the
after the end of the external inputs. A drug fund was supplied to each to the IEC campaign (see Boxes 1 and Programme evaluations, including the
These were retrospective studies, in CHS, tracked by an accounting system. 2). This means that although each patient public information campaign, are available
the eight rural districts which the origi- Interestingly only an average of US$150 may be treated more rationally, and from this address. Other publications are
nal project covered, and where the (out of the US$300 supplied) was used therefore be given fewer drugs, the pending.
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efforts in both developing and developed countries are being severely
hampered by under-funding, lack of support and a shortage of
expertise. The outcome, says the report, is a vicious circle in which projects
ranged from a novel pill-box informa-
tion campaign in secondary schools in
Belgium (see Box 1), to projects for
are poorly planned, weakly implemented, and not evaluated rigorously enough. younger children in the United States,
involving the use of pharmacy students
The report by the Action Programme A surprise finding was that there were to teach drug safety and compliance, and
on Essential Drugs is based on the first fewer differences than expected between encourage children to take responsibility
ever global survey of public education the types of programmes in developing for their own health.
in rational drug use. The study set out to and developed countries. The most Many of the sample school kits
establish who and what is being targeted significant was the different media used. submitted had been developed in
by rational use programmes; who is While education programmes in devel- collaboration with the pharmaceutical
doing the work, how and why; what are oped countries relied more on the printed industry or pharmacy organizations. Most
the needs and lessons learned; and what word to get their message across, failed to highlight the risk/benefit equa-
future action needs to be taken. The sur- programmes in developing countries re- tion of drug use, or even that the same
vey included data from about 100 ported more frequent use of the mass active substance may be marketed under
questionnaires and educational mate- media, especially radio. In developing different brand names and at different
rial gathered from 38 countries (25 countries, the most popular channel of prices. In addition, little effort was made
developing and 13 developed countries). communication was the mass media (76% to encourage children to develop a
of projects) followed by workshops more objective view of the commercial
AIS Peru
Critical need for (70%) and the distribution or display of promotion of drugs.
public education printed materials (26%). Developed coun- A variety of innovative approaches are
tries focused mainly on printed materials being used by groups in both developed
The report points out that in many and developing countries to get the No words are necessary to convey this
(61% of projects) and the mass media
parts of the world up to 80% of illness message on the dangers of becoming
(56%). message across. In Germany, the BUKO
episodes are self-treated with modern dependent on tranquilisers
Pharma-Kampagne uses street theatre
pharmaceuticals. And even where formal presentations to raise public awareness
health care channels are used, it is the Reaching out to about rational drug use, while in Australia, Box 2
consumer not the prescriber who de- schoolchildren and the the Medicine Information Project makes
termines whether and how the drugs are elderly Michoacan, Mexico holds a
use of trained elderly volunteers as peer
used. These decisions are based on the campaign: Towards the
School projects accounted for a large educators to promote rational drug use
shared beliefs of family, friends or the Rational Use of Drugs
number of education programmes, espe- among the elderly population. Volunteers
wider community; information from pre- cially in developed countries, but only receive an initial five days training, Given evidence of an overabundant
scribers and dispensers; and promotional Sweden had launched a nationwide updated four times a year. The topics use of medications by the general
material. As a result, consumers need ac-
population, of an over-prescription of
cess to accurate and understandable medications by medical doctors, and
information about the potential benefits of unethical drug promotion, a
and risks of medicines in general, includ- Box 1 nongovernmental organization in one
ing possible side effects; how they act Far-Well and Medi-Studt. state of Mexico embarked on a short
within the body; and the limitations of The best medicine for students Belgium but intense educational campaign.
pharmacotherapy and other treatment Participants in the planning were
options. Students are open to new information; learning is their job. Students are also prone prescribers, government officials,
With the exception of Australia, to using medications, especially in order to study well during examination time. community members, students, the
media, and communication experts.
no country developed or developing Knowing this, the higher-educational institutions (non university) in Belgium requested
has undertaken a structured public Projekt Farmaka, a non profit independent organization, to assist. The result, de- The campaign targeted the general
educational programme, targeting all signed and developed by a planning group consisting of a pharmacist, prescribers public, but also prescribers and
members of the community and devel- and students, was an innovative pill-box of information destined for distribution in medical students. Materials devel-
oped by a coalition of stakeholders, says schools and student clubs. The choice of subject matter in these pill-boxes was oped included posters, leaflets, press
the report. The authors point out that in based on the most common illnesses and complaints, and on the most commonly used articles, slides, radio and television
developing countries it is not surprising medicines by students. The main message? Use a medicine ONLY WHEN IT IS programmes, and posters for doctors.
that, in view of the wide range of other NEEDED. Many of the printed materials were
displayed at points of prescription;
competing areas of drug policy, public But activities went far beyond the simple distribution of the pill-boxes. Information others were used during 3-day
education in rational drug use is often stands were set up during school breaks and at lunchtime, with displays and posters. seminars held at the local medical
given low priority. But its neglect by In order to get a pill-box, a student had to complete a quiz form with five pertinent school. The mass-media broadcasts
developed countries is more difficult to questions. Workshops were held with the students to discuss the information. Mass lasted for three months, with increas-
understand. media also participated, with radio interviews and television announcements. ing intensity just prior to the medical
It is more difficult to explain the lack school conferences.
of commitment by developed countries The campaign was well-timed. It was held during the examination period, when
students are prone to taking vitamins and pep pills, and to having sleep-related Feedback after the campaign was
to systematic and structured public edu-
problems. The students were particularly open to discussions about medications, and very positive. Medical professionals
cation in rational drug use, given the wanted to learn more. Some schools have established a medicines panel to and students expressed increased
potential economic and public health disseminate additional information about problem drugs, and to discuss issues like awareness of the problems. The
benefits, the report states. sports and diet. Other schools are organizing question-answer sessions focusing on pharmacology curriculum of the local
Until now few public education in medications. university was revised. Articles
rational drug use interventions have been published in the local and national
documented or evaluated. As a result, The pill-box concept was innovative and sparked peoples curiosity. The materials press suggested a significant change
experience cannot be shared or built on. could be improved, to be sure, and future campaigns will take into consideration in general knowledge about rational
more of the students views on content, in addition to design. drug use.
The DAP survey was intended to help
close this gap.
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covered include consumer rights and developed countries. to have been a failure.
responsibilities, use of specific medica- The report highlights the failure of The main problems faced
tions, assertiveness, problem-solving, as most projects to evaluate the impact of by projects included:
well as presentational and listening skills. their activities. As a result, cost/benefit shortage of funds;
analysis is impossible
deterring many potential inadequate external col-
donors. Very few projects laboration and support;
were able to provide evalua- poor coordination;
tion reports. And, with the shortage of time and
exception of rational use of personnel;
drugs projects in Australia
and Viet Nam, most focused opposition from vested
on activity monitoring rather interests (both commer-
Photo: WHO/D.A. Fresle
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treatment of malaria is more cost-
effective, in terms of both time
and money when antimalarials
available materials.
Acceptability to both staff and pa-
tients.
be given either more or less chloroquine
than they need. This is important because
failure to comply with the full course of
with these instructions. The proportion of
people obtaining at least enough chloro-
quine on each of the three days of
are pre-packed in daily doses. Preliminary treatment affects both the patients cure treatment increased from 29% to 54%.
observations in six districts indicated that Because of the clear advantages of and the drug resistance of parasites. The proportion of children who obtained
some of the major problems in malaria pre-packaged antimalarials, Ghanas at least the recommended
control programmes are: high cost of district medical officers are eager to minimum dose of chloro-
treatment; high chloroquine consumption extend the practice to other commonly quine syrup on each of the
(in syrup form); long waiting times at used drugs. three days increased from
dispensaries; and a large number of The Ghanaian study adds to the 59% to 85%. Sample sizes
untrained/unqualified dispensers who are evidence from similar research on used in the study were
unable to give advice. pre packaging in South-East Asia. For between 55 and 75 patients.
Two types of pre-packaging were used example, in China, blister packaging of This work shows that a
in the study plastic bottles for chloro- antimalarials produced 97% adherence to little time invested in provid-
TRAINING
I
courses, Leeds Metropolitan
University in the UK sets out
clearly the benefits of health edu-
implementation of a project that they
designed at Leeds.
The aims of the course are to provide
medicines; the work of WHOs Ac-
tion Programme on Essential Drugs,
international pressure groups and con-
help groups, community pressure
groups, training of pharmacists, and
training in the informal sector.
cation: the awareness it creates among skills in research, planning, management sumer movements; and problems
Planning for programmes to promote
the community, policy makers and health and evaluation of health education, and arising from inappropriate use of
care providers of the advantages of a appropriate use of medicines: selec-
provide opportunities to apply these skills medicines.
rational drugs programme and the proper tion of indicators for monitoring and
to a problem from the participants own Health seeeking behaviours: self- evaluation.
use of medicines; the increase in the skills work setting. Applicants should be expe- medication, informal market sectors
of health care providers in the delivery rienced managers and staff within field The course is expected to cost 3,000
of sensitive, appropriate and effective pa- for medicines and problems of
projects who require a short course to for academic tuition and field visits, with
tient education; and the encouragement implementing essential/rational drug
improve their capacity to plan, implement subsistence/accomodation expenses of
it gives for community and political policies.
and manage the health promotion com- approximately 2,500.
action to prevent the misuse of drugs and Assessment of needs for health
medicines. ponents of projects.
education/health promotion support
The University is offering a 10-week for appropriate use of medicines.
course in community-based health Module on medicines and Community, social and economic
education and health promotion with essential drugs For further details contact: Overseas Admis-
influences on use of medicines and the
specialist options, including one on medi- sions Tutor, Health Education, Room F505,
cines and essential drugs. Participants Among topics covered in this module role of multinational companies.
Leeds Metropolitan University, Calverley
either finish after 10 weeks and receive a will be: Health education and health promo- Street, Leeds LS1 3HE, UK. Tel: + 44 113
certificate of attendance or study further Appropriate use of medicines, includ- tion methods in various settings: 28322600, fax: + 44 113 2835921,
by distance learning within their own ing an introduction to: the essential national campaigns, mass media, e-mail: health-promotion@lmu.ac.uk
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TRAINING
T
tablet 25,50,100 mg Beta blocker atenolol
the Netherlands is proving to be a valuable tool for students in learning Atenolol is a selective beta blocker without intrinsic sympathicomimetic activity. It depresses myocardial
how to prescribe drugs rationally. The personalised compendium of drugs contractility and reduces the heart rate. This initially causes a fall in blood pressure. With continued
treatment the cardiac output returns to normal but blood pressure remains low because the peripheral
not only helps students learn about the drugs they prescribe, it also helps vascular resistance is reset at a lower level. In addition it may also increase the perfusion of the
them choose alternatives in case one drug is unsuitable for a particular patient. ischaemic area. It has very limited solubility in lipids (limited capacity to pass Blood Brain Barrier).
Check indication
The personal formulary is a practical Guide to Good Prescribing). Indication Angina pectoris, Hypertension
elaboration of the P(ersonal)-drug One side of the page contains the Alternatives Hydrochlorothiazide, Captopril
concept, which is outlined in Part 2 of the information needed to check not only
Check suitability of the patient
WHO Guide to Good Prescribing. It con- whether a specific drug is indicated for
Side effects Hardly any in normal dosages. Sometimes slight sedation, reduced exercise
sists of a sequential approach for selecting the disease but also whether the drug is tolerance, or bronchospasm.
a personal set of drugs for the treatment suitable for the individual patient (see Contra-indic. Sinusbradycardia, AV block, hypotension, cardiogenic shock, heartfailure, asthma.
of specific diseases. By using a loose-leaf Figure). If the doctor or student has de- Interactions Some calcium antagonists, some anaesthetics.
notebook and a small manual, practical cided that the drug can be prescribed,
information about the selected diseases they then turn to the other side of the Betty H. O. Student 12-06-98 Pharmac 95 Page 2
and P-drugs can be inserted, changed or page. Here a prescription can be made out
tablet 25,50,100 mg Beta blocker atenolol
deleted. In this way a personal formulary together with the necessary information
can be developed. and instructions for the patient, as well Dosage
The personal formulary is divided the date of the next appointment, where Adjust to each patient individually, start as low as possible. Raise the dose after 2 weeks if needed.
into sections. The first section is used appropriate (see Figure). Information Higher dosages do not increase therapeutic effect, but may increase side effects.
to list selected diseases. For each disease, about monitoring the drug treatment can Hypertension Start with 50 mg in the morning; average 50100 mg per day
a chosen standard drug and non-drug also be inserted here. With the loose-leaf Angina pectoris 100 mg per day in 12 doses
treatment can be described extensively system, the content of the personal Give patient information
or merely summarised. For example, formulary can be easily changed. Information Hypertension: drug decreases blood pressure. You will usually not notice any effect
(Dutch Standard Guidelines): The simplest way is to write or type but the drug is needed: it will prevent complications of high blood pressure (angina,
heart attack, stroke).
Essential hypertension: start with the information about each P-drug. A Angina pectoris: decreases blood pressure, prevents heart from working too hard,
weight, salt, and stress reduction. If no computer programme has been developed preventing chest pain.
result: for this with technical support from the Hardly any side effects; sometimes slight sedation. In some cases shortness of breath;
in that case phone me.
1. atenolol or hydrochlorothiazide; if no WHO Collaborating Centre for Pharma-
Instructions Take the drug times per day, for days;
result: cotherapy Teaching and Training at
Warnings Angina pectoris: do not suddenly stop taking the drug
2. atenolol + hydrochlorothiazide; if no Groningen University. Using this
programme, the data can be typed, and Appointment Hypertension: one week
result:
Angina pectoris: within one month, earlier if attacks occur more frequently, or
3. captopril; if no result: printed in a standard format as shown become more severe.
4. consider calcium antagonist, alpha in the Figure. Students can also add and Follow-up Hypertension: first few months check BP and pulse weekly; try to decrease dosage
1-blocker, or referral. remove drugs, and revise any of the in- after three months, and to stop after one year.
The second section contains practical formation about an individual drug. In Angina pectoris: in case frequency or severity of the attacks increase, more diagnos-
tic tests or other treatment are needed. Try to stop drug treatment from time to time.
information for prescribing the drugs this way students build up their own
listed in the previous section. Each page personal formulary. To help make it
has information on a single drug, and the more personalised, each printout includes a personal computer. formulary and the syllabus for US$20.
information is organized along the lines the name of the student. The programme In the computer network of the Free They also receive the Dutch Drug Com-
of the sequential approach to treating can be installed on a computer network University of Amsterdam, information on pendium free of charge from the National
patients (outlined in Part 3 of the a university network, for example or on over 90 drugs has been included in the Sick Fund.
reference database. Clinical experts Initial results so far from the personal
within the university consider these drugs formulary system have been promising.
NEWSDESK appropriate for the treatment of 129 dis- During a realistic training session, involv-
eases and symptoms. At the end of the ing three simulated patients, the second
six-year undergraduate course medical year students taught in this way pre-
students must be able to treat correctly, scribed drugs more rationally and
M and the Eastern Caribbean Drug medical store management and inventory + 31 20 444 8100.
Next they are trained in developing and
Service offered a special eight- control and drug utilisation reviews. Par- using their personal formulary. Up to the
day course on managing drug ticipants discussed their own experiences fourth year they practice in small groups
supply, held in Dominica from 1928 and worked hard to complete realistic by treating both textbook and simulated Guide to Good Prescribing
January 1998. The 18 participants in- work plans and timelines for improve- patients. A syllabus has been developed available in more languages
cluded central medical stores managers ment projects to be implemented upon for this which includes about 200 text-
and hospital drug supply managers from their return to work. These plans were To add to the list of locally produced
book cases together with treatment plan
versions of Guide to Good Prescrib-
all nine countries in the Organization of shared with the Ministries of Health and forms (following the sequential approach ing, editions have now been
Eastern Caribbean States. will receive support and follow up from of the Guide to Good Prescribing) and published in Brazil (Portuguese), in
The course was specially designed to the Eastern Caribbean Drug Service. suggestions for patient role-playing ex- India (in Bengali), Iraq, Italy, Japan
address the specific drug supply issues of ercises. During the internships in the fifth and Pakistan. A Spanish edition will
the island countries, including: lack of and sixth year, the students practice with follow by the end of 1998.
national drug policies; lack of current Source: INRUD News, February 1998. real patients. Students can buy a personal
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NEWSDESK
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rational use of drugs brought
together an enthusiastic group of
health workers, nurses, pharma-
Palestinians.
Held at Beir Zeit University in Octo-
ber 1998, the conference was organized
with the Action Programme on Essential
Drugs, has developed the AFRO Intensi-
fied Essential Drugs Programme. The
MON ITOR
cists and doctors from throughout the by the Union of Palestinian Medical
new programme will focus on capacity The Essential Drugs Monitor
health sector. Speakers from international Relief Committees with the support of
building, strengthened drug supply encourages the reproduction of
and local NGOs, Palestinian universities, the French Government and the United
and physicians and pharmacists associa- Nations Development Programme. systems, including quality assurance, and articles for non profit uses.
tions helped to raise awareness of rational the rational use of drugs.
use issues. Discussions ranged from the One priority activity is the AFRO Please clearly credit WHOs
impact of inappropriate drug use to stand- For further information, contact: Nadine
Essential Drugs Price Indicator. This new Essential Drugs Monitor as the
ard treatment guidelines, essential drugs Kamal, Head Pharmacist, Union of Palestin- publication shares information on current source, and send us a copy of
policy, drug information, continuing edu- ian Medical Relief Committees, P.O.Box drug procurement prices in Africa with
the reprinted article to the ad-
cation for pharmacists, quality assurance 51483, Jerusalem. Tel: + 972 2 5834 021, the aim of providing purchasing bodies
dress given on page 1.
and drug donations. The event is seen as fax: + 972 2 5830 679, e-mail: with a better negotiating position. Data
an important step in moves to design a NadineKamal@hotmail.com in the first edition are based on the latest
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NEWSDESK
P denied access to reliable informa- effect excluded from the decision raised by patients. The language used complained about lack of information.
tion about treatment options, making process. should be simple without being patronis- Im still none the wiser about the facts
according to a new study1 from The report details a study in which 62 ing. It should be honest about benefits and and my own condition.
the Kings Fund, an independent British patients and 28 clinical experts reviewed risks of treatment. So far, the National The Kings Fund is urging the
health charity. Health professionals either a wide range of leaflets, videos and Health Service Executive has failed to Government, the National Health
do not know the answers to questions, audiotapes in current use. It concludes take the initiative on patient information, Service Executive and health authorities
withhold the information or simply fail that the information they contained was the report states. Informing Patients to support good quality information, to
to present the whole picture about ben- often out-of-date and inaccurate, and recommends that they should fund enable patients to participate in decisions
efits and risks. Despite endless surveys sometimes seriously misleading. It did not development and evaluation of materials about their treatment and to improve the
demonstrating that patients want good, include full details of treatment options, about common clinical conditions. These effectiveness of clinical care.
clear information, the study concludes information about outcomes and treat- could be used alongside the clinical guide-
that it is not forthcoming. Yet it is highly ment effectiveness was often omitted or lines to be commissioned by the National Informing Patients: An Assessment of the Qual-
likely that good information would save was unreliable, and patients questions Institute for Clinical Excellence. There ity of Patient Information Materials is available
the health service money in the long run, were left unanswered. should also be a system for accrediting from the Kings Fund Bookshop, 1113
the Fund believes, since it would help written and computerized materials, the Cavendish Square, London, W1M OAN,
patients to look after themselves in terms Fund believes. UK. Tel: + 171 307 2591. Price: 16.95.
Change necessary
of prevention and self-treatment. A patient participating in one of the
The study report, Informing Patients: The patients involved in the study felt focus groups for the research, said:
An Assessment of the Quality of Patient that many of the leaflets were patronis- When they measured my cholesterol lev- Reference
Information Materials1, demonstrates that ing and failed to recognise their right to els, I tried to find out what the numbers
good quality information can improve the be actively involved in decisions about meant, what the safe levels were and the 1. Materials were studied about the following conditions:
back pain, cataract, depression, glue ear, high choles-
effectiveness of patient care. Without it, their care. The report recommends that role of triglycerides. I also asked whether terol, hip replacement, infertility, menorrhagia, prostate
patients are unable to make informed above all, information should start by the tamoxifen I am taking for breast and stroke.
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NEWSDESK
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coming century and assessing their implications for future health systems is a
daunting task. Yet this was the remit of the Seventh Consultative Committee
on Organization of Health Systems Based on Primary Health Care. The Com-
mittee met in Geneva in February 1997, and, in view of the far-reaching implications
of its findings for WHOs future agenda, it was decided to issue a short Statement
summarising its conclusions.
Copies of the Statement and the full report of the Seventh Consultative Committee on Organi-
Photo: IDA
zation of Health Systems based on Primary Health Care are available, free of charge, from:
World Health Organization, Division of Analysis, Research and Assessment, Health Systems
Development Programme, 1211 Geneva 27, Switzerland. Professor Graham Dukes, opening IDAs symposium
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NEWSDESK
H
particularly with regard to fraudulent development of a model guide for gov-
and Technologies Action Group (AHRTAG) which has been active in the product information and lack of indi- ernments to educate people using the
field of health information since 1977. The new name reflects the vidual counselling for consumers. At the Internet on how best to obtain reliable,
organizations focus on health and describes its way of working globally 1997 Assembly delegates had already ex- independent and compatible information
linking information and health workers, linking partners, linking policy and pressed the view that advertising, on medical products.
practice. promotion and sale through the Internet
Healthlink Worldwide continues AHRTAGs aim of improving the health of might result in uncontrolled cross border Fears for the future
poor and vulnerable communities by strengthening the provision, use and impact trade of medical products or fraudulent Consumer groups were critical of the
of information. Working with more than 30 partner organizations in developing imitations that may be unevaluated, current lack of controls on companies,
countries, Healthlink Worldwide runs programmes to support particular health unapproved, unsafe, ineffective, or used with HAI issuing a report at the Assem-
needs. These include continuing education and training for health workers in inappropriately. bly calling for new international
The Fifty-first WHA adopted a plan agreements to regulate product promotion
Africa and the Middle East, and programmes on AIDS and sexual health, child
for tackling these concerns. While the and sales on the Internet. The group wants
health and disability.
plan leaves it up to individual govern- commercial or educational information
Healthlink Worldwides practical training and education materials in printed ments to decide their own course of from commercial sources to have the
and electronic forms reach nearly two million health and development workers all action it urges them to: review their ex- company name clearly and prominently
over the world. The organization provides technical support to partner organiza- isting legislation, regulations and stated on the screen. HAI argues that all
tions and others in setting up and developing resource centres and information guidelines; take regulatory action where advertisements should have to meet the
services. This work draws on the organizations extensive collection of health appropriate against violation of their same regulatory standards for content as
learning materials from developing countries. national laws; and set up and/or advertisements in other media, and direct
strengthen mechanisms to monitor prob- links to a companys home page should
lems. Delegates also urged governments be regulated as if they originated from the
For further information contact: Healthlink Worldwide, Farringdon Point, 2935 Farringdon to collaborate on a range of issues, espe- company.
Road, London EC1M 3JB, UK. Tel: + 44 171 242 0606, fax: +41 171 242 0041, e-mail: cially the exchange of information on
info@healthlink.org.uk, website: http://www.healthlink.org.uk difficult cases, and specific national Source: Scrip No. 2336, 1998.
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DRUG INFORMATION
T
and risk in drug therapy, drug
scares, patient non adherence to
treatment, anxiety and uncer-
equals. Patients and consumers, espe-
cially, need a stronger voice in
determining not only the risks acceptable
tainty about the risks of drugs, and secrecy to them individually, but also to society
and suspicion in pharmaceutical matters, as a whole. For this, more and much
were among the pressing concerns which better communication was essential.
gave rise to an international conference The conference produced a declara-
on Effective Communications in tion of principles, the Erice Declaration,
Pharmacovigilance, held in Erice, Sicily, which is available on the Internet1 and
in September 1997. from the Uppsala Monitoring Centre (see
Over 70 professionals from 30 coun- address below). A full report of the
tries, representing patients, doctors, conference proceedings is currently in
nurses, pharmacists, pharmaceutical com- preparation.
panies, lawyers, academics, regulators, The work of the conference will form
journalists and communications experts the basis of a working group of the
put their collective brain power to the Council of International Organizations
of Medical Science (CIOMS) which will
question of how drug safety information
publish its findings and recommendations
could be better communicated between
in late 1998. The work will be continued
all interested parties in the ultimate
in a series of CIOMS meetings, leading
interest of patient welfare.
to guidelines for good practice in
It was acknowledged that even the
1998.
best scientists and clinicians may lack the
specialised skills of effective modern * Bruce Hugman is Managing Director,
communications, and that insufficient EQUUS Communications, London, UK.
time and priority had been given to dis-
Len Munnick
cussion and training in this area. Much For further information contact: The Uppsala
more attention needed to be paid not only Monitoring Centre, Collaborating Centre for
to the content of communications, but also International Drug Monitoring, Stora Torget
Quality of care starts with communication
to their form, production quality and the 3, S-753 20 Uppsala, Sweden. Tel: + 46 18
656060, fax: + 46 18 656080, e-mail:
media chosen for their dissemination. this field with professionals in other Conflicts between public health pri- who.drugs@who.pharmasoft.se
areas where significant influence can be orities and the needs of individual patients
The danger of secrecy exercised (with teachers and schools, for were noted among the dilemmas to be
Reference
example, where childrens attitudes and faced. This was one of the many aspects,
The climate or context in which knowledge are established). which could be resolved only by 1. www.who.pharmasoft.se
communication takes place was also seen
as a critical variable: in a climate of se-
crecy, suspicion and uncertainty would
flourish, and leaks of information and
media scares would be all the more likely.
These, in their turn, would lead to an un-
dermining of public confidence in
Improving drug information
medicine, in the judgement of doctors,
and in the integrity of clinicians and
pharmaceutical companies in general.
in Moldova
Participants from developed and
N the Republic of Moldova the Use from 1317 April 1998. Thirty-six Formulary); structures for disseminating
I
developing countries alike agreed that a
collapse of the Soviet system has postgraduate students and residents from information on medicines; the creation
climate of openness and trust, particularly brought a flood of medicines on the Pharmaceutical Faculty of the State of hospital formulary lists and formulary
in relation to the activities of regulators to the market which are virtually Medical and Pharmaceutical University committees; drug information for
and pharmaceutical companies, was an unknown to doctors and pharmacists. of Moldova joined other faculty members, patients; and the role of advertising in
essential prerequisite to a better under- The sale of medicines by prescription has and staff from the State Quality Control drug promotion. Course training materi-
standing of benefit-risk issues and to almost ceased, with doctors recommen- Laboratory on the course. als were drawn from WHO, HAI,
increasingly rational therapy. Accessibil- dations often ignored as patients are lured The five days passed quickly, with an University of Arizona, USA, the US Phar-
ity of information was a core requirement. by drug store offers. Collaboration be- atmosphere of trust rapidly developing macopeia, and the US Food and Drug
Practitioners needed to be encouraged tween doctors and pharmacists has between all involved, as discussions, Administration.
to see feedback of information from prac- diminished dramatically. The risk of pa- working groups and business games The post course questionnaire
tice, especially adverse drug reactions, tients purchasing unsafe medicines is broke down any initial barriers. Students revealed that the participants high level
as a major professional responsibility. increasing as some drug store staff, driven who had only intended participating in a of motivation can partly be explained
by the profit motive, advise patients to few sessions found themselves reorgan- by the fact that for the majority (76%)
The value of partnership buy the most expensive rather than the izing their schedules to remain on the the information they received was new
most appropriate drugs. course. Among the topics discussed were: (31%) or new in many aspects (45%).
The concept of partnership was seen A modern information system for the essential drugs concept, national es- The course ended with participants
as the ideal to be pursued in the whole medicines is seen as a priority to improve sential drugs lists; guidelines for drug presenting their own ideas for a structure
area: partnership especially between cli- the situation, and a prerequisite is to train donations; the role of independent to facilitate the flow of drug information.
nician and patient (the notion of informed personnel. Therefore Moldovas Asso- drug information centres; systematic All participants were convinced of the
choice by patients was seen as a high ciation DRUGS, a pharmacology approaches to information searches; benefit of introducing such a structure at
priority); between professionals and the information centre, organized a training analysis of major references, (such as every level of Moldovas health system,
media (so often at apparent variance with course entitled A Model of a Modern Martindale, the US Pharmacopeia but stressed the need for state support to
each other); and between professionals in Information Network on Rational Drug Drug Index and the British National achieve this.
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DRUG INFORMATION
drug bulletin editors meet out the meeting. The challenge is to put
into practice the many ideas and concepts * Editors at the meeting decided to create
an e-mail network to facilitate exchange of
that were discussed before the next
NFORMATION is a vital component in ensuring the efficacy and safety of meeting, which is planned for 1999. information. The network offers the possibil-
I medicine, and commitment to providing such information is evident in the ity to post short announcements and news of
increased number and quality of drug bulletins in the Asia-Pacific Region. A report of the meeting is available from: common interest, and initiate discussion on
Thirty editors, representing countries extending from Pakistan to New Zea- International Society of Drug Bulletins, topics of mutual interest. To participate in this
land, attended the first Asia-Pacific Regional Meeting of the International Society of PO Box 459, 75527 Paris Cedex 11, exchange contact: dzul@prn.usm.my
Drug Bulletins (ISDB). Held from 67 October 1997 at the Universiti Sains in Penang,
Malaysia, the meeting showed that, despite their diversity, bulletins in the region share
common issues, opportunities and challenges. These include the need to provide in-
formation on safe and effective drug use to consumers. This is especially true in countries
where consumers can access prescription medicines with little or no advice from health
WHO information on the move:
professionals. The need for bulletins to be reader-friendly was highlighted, as in many
countries bulletins were compet-
introducing the blue trunk library
ing for doctors reading time
EADY-TO-USE mini-libraries have been compiled by WHO Library Services,
R
against the profusion of pharma-
ceutical company literature. to help to ensure that district health teams in English- and French-speaking
African countries receive the medical and health information they need. The
selected books are contained in blue metal trunks for their protection and
Working together
easy transportation. Priority is given to practical manuals edited by WHO. Modules
The meeting, which received on essential drugs, general medicine and nursing, maternal and child health, diarrhoeal
DAP support, was highly diseases and primary health care are among those available. As well as choosing the
interactive with numerous books, WHO Library staff index and package them, and have created an electronic
workshops on offer. Lengthy de- database to go with the mini-library.
bate followed the sessions which Providing much needed publications is only one
focused on criteria for produc- part of the blue trunk library project. Another ele-
ing useful, quality bulletins. The ment concentrates on raising the awareness of health
need to marry scientific informa- workers about the importance of information, and of
tion with practical implications strengthening documentation services in ministries
was discussed, as were read-
of health. The aim is to set up a network capable of
ability, author credibility,
sharing medical and health information in Member
referencing and peer review.
States.
Participants developed an action
plan covering issues such as col- The price of the mini-library, containing around
laboration*, improving access 100 books and four journals is US$2,000, including
and use of technology, and administrative, transport and training costs.
establishing an evaluation meth- For further information contact: World Health Organiza-
odology for bulletins. tion, Office of Library and Health Literature Services,
The number of drug bulletins in the Asia-Pacific Region is The willingness of editors to World Health Organization, 1211 Geneva 27,
WHO
International Congress on practice, and to network with colleagues Problem-based Sloof, WHO Collaborating Centre for
from around the world.
Clinical Pharmacy pharmacotherapy teaching Pharmacotherapy Teaching and Training,
For further information contact the Secretariat at: course Department of Clinical Pharmacology, Uni-
To help commemorate the 20th ICMS Pty Ltd, 84 Queenbridge Street, Southbank, versity of Groningen, A. Deusinglaan 1,
anniversaries of the founding of both the 3006 Victoria, Australia. Tel: + 61 3 9682 0244, This course introduces a logical, step- 9713 AV Groningen, the Netherlands. Tel:
European Society of Clinical Pharmacy fax: + 61 3 9682 0288, e-mail: cpapac@ by-step approach to patient problems: + 31 50 363 2810, fax : + 31 50 363
and the American College of Clinical Phar- icms.com.au
setting therapeutic objectives, selecting 2812, e-mail: summer.course.pharmaco@
macy, the two organizations are holding
an International Congress. Scheduled for appropriate (pharmaco)therapy, and med.rug.nl, web site: http://www.indepth.
monitoring the response to therapy. It
1114 April 1999 in Orlando, Florida, org/courses
the main theme of the Congress will Efficient drug management also emphasises the importance of correct
be Documenting the Value of Clinical prescribing and good patient-doctor
The problem-based pharmacotherapy
Pharmacy Services. The Robert Gordon Universitys tenth communication. Intended for teachers of
postgraduate certificate course, Efficient teaching course will be held in the Philip-
pharmacology and therapeutics, the course
For fur ther information contact: Theda Drug Management and Rational Drug pines, in 1999. For further information
Mansholtstraat 5b, 2331 JE Leiden, the
(developed at the University of Groningen
Use, will be held from 17 May to 16 in the Netherlands) is now available in a contact: Professor Tony Smith, WHO Col-
Netherlands. Tel: + 31 71 572 24 30, fax: + 31
71 572 24 31, e-mail: secretariat@escp.nl
July 1999. Run in collaboration with the growing number of countries. laborating Centre on Pharmacotherapy
Action Programme on Essential Drugs, the The next course based at the Univer- Teaching and Training, University of New-
course is intended for health care profes- castle, University Drive, Callaghan NSW
sity of Cape Town, South Africa, will be
sionals, especially pharmacists, who are 2308, Australia. Fax: + 61 6 289 8846,
involved in the management and control held from 29 November to 8 December
1999. For further information contact: e-mail: smith@mail.newcastlr.edu.au
The Pharmaceutical Society of pharmaceuticals at national, institutional
Department of Pharmacology, Medical
of Australia and programme levels. Fees are 3,300,
including course books/materials and School, University of Cape Town, Observa- La Plata, Argentina, will be the venue
With the theme of Practice Excellence accommodation. tory 7925, South Africa. Tel: + 27 21 406 for the first South American course (this will
through Technology, the Commonwealth 6355, fax: + 27 21 448 0886. be held in Spanish), in either July or No-
For further information contact: Marthe Everard,
Pharmaceutical Association Conference
Course Tutor, School of Pharmacy, The Robert vember 1999. For further information
and the Pharmacy Australia Congress Gordon University, Schoolhill, Aberdeen AB10 And make a note
will be held from 1115 March 1999. The contact: Professor Hector Buschiazzo,
1FR, Scotland, UK. Tel: + 44 1224 626559, fax:
occasion will provide an opportunity to Course dates for the University of School of Medicine, National University
+ 44 1224 262555, e-mail: edmrdu@rgu.ac.uk
hear a variety of speakers on the applica- Groningen course are 19 to 30 July 1999. of La Plata, 60 & 120 (1900) La Plata,
tion of technology in all areas of pharmacy For further information contact: Dr Wessel Argentina. Tel/fax: + 54 21 820117.
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NETSCAN
Website on WHO health- WHOs Model List of Essential Drugs available on Internet DAPs homepage
trade related issues The 10th WHO Model List of Essential Drugs is now available on the web site of the The Action Programme on Essential
For information on health care, trade WHO Division of Drug Management and Policy: http://www.who.ch/dmp/edl-10.htm Drugs homepage on World-Wide-Web
disputes and WHO see: http://www. The List of Essential Drugs is a model guide to countries and health services in devel- introduces users to the essential drugs
cptech.org/ip/health/who/ oping their own national and local lists. Such lists should be evidence-based, considering concept, national drug policies, and the
prevalent diseases, treatment facilities, training and experience of health personnel, work of WHO and the Action Programme.
financial resources, and genetic and demographic factors. Over the last 20 years The information, which is frequently up-
the WHO Model List of Essential Drugs has been an invaluable tool for saving lives dated, is being made even more user
and improving health through more rational use of drugs, wider access to drugs and friendly.
improved drug quality. The titles of selected WHO, DAP and
Evidence-based medicine One important advance in the new Model List is the addition of a new drug, other pharmaceutical publications are
list in Spanish triclabendazole, for the treatment of liver and lung flukes. This illustrates the way the List available on the homepage. The complete
can be used to highlight a therapeutic need and speed up availability of new drug English, French and Spanish versions of
EVIMED provides a new electronic treatment. the Monitor (from number 22 onwards) can
forum in Spanish for those wanting to be found in PDF format. In addition, text
discuss new ideas, research, education or
from other selected DAP publications can
practice of evidence-based health care. be viewed and downloaded. For exam-
Primarily dedicated to the Spanish health Two new web sites ple, users can print out the Guidelines for
care community, non Spanish, particularly The Medical Lobby for Appropriate Marketing (MaLAM) is up and running with its Drug Donations and Guide to Good
Latin American, views are also welcome. new web site at http://www.camtech.net.au/malam Prescribing.
To subscribe contact: RafaBravo@ So too is the International Society of Drug Bulletins at http://prn.usm.my/sites/ You can find DAPs homepage at:
bitmailer.com isdbdrul.html http://www.who.ch/dap
Working for change in Ghana intentioned but misinformed individuals the hundreds of volunteers taking part in junior doctors in India. This has shown
and institutions that wish to make their the campaigns and of the pharmacists that most received no information on the
Dear Editor, modest contribution can hardly imagine working in the field could be truly essential drugs concept during their train-
By chance I recently came across a the harmful consequences that result from effective. ing. Carried out by the Calcutta-based
copy of your journal, the Essential Drugs large-scale donations for the recipient Since self sufficiency in drugs for all NGO, Foundation for Health Action, the
Monitor, and although it was a 1993 countries. Lack of training in the man- countries is a long way off, we have to be pilot survey aimed to discover what re-
issue it was very educative. Since com- agement of essential drugs often means realistic and work in more than one di- cently qualified doctors thought about the
pleting my pharmacy studies in Ukraine that part of the donations are useless. rection at once. As donations will still be adequacy of their undergraduate training
and returning to Ghana I have found mis- In almost two years experience in needed in the future, we should direct our in rational use of drugs. It also sought their
use of drugs (particularly antibiotics and Zaire and Rwanda, during the refugee efforts towards ensuring that 100% of the opinion on the feasibility of initiating a
sedatives) on a massive scale. I have come crisis of 19941996, I witnessed the ar- donations made are actually of use to the compulsory refresher course on rational
to the conclusion that irrational drug use rival of tons of drugs that nobody had recipient. To this end society must be use towards the end of medical training.
is mainly due to the lack of effective requested. Many of them are still stored informed and educated. A structured multiple-choice question-
sources of information for patients, phar- there either they have expired or the Knowledge of the problems, of its naire was given to the doctors, who
macists and doctors. At my community local population does not know how to causes and possible solutions, the reali- worked in various disciplines at seven
pharmacy I have tried in my own small use them pending a means of eliminat- sation that the situation can be changed training institutions in four regions of the
way to educate people, but their insults ing them without risk either to health or and a commitment to put change into country. Analysis of responses showed
and the potential loss of revenue for my to the environment. practice is the main challenge facing that most participants wanted standard
business sometimes overwhelm me. At the time, any form of assistance health professionals in general and health therapeutic guidelines to be produced for
The Monitor gave me the idea of was welcome, but attempting to make use cooperation NGOs in particular1. commonly occurring ailments. Almost all
creating an effective, independent drug of the unclassified drugs arriving from were in favour of a compulsory refresher
information service, where information Spain took away valuable time from an Natalia Herce, course on rational drug use for interns
will be given free of charge, or, when nec- essential task: distributing drugs to phar- Pharmacist and Medicus Mundis during the internship period. It is antici-
essary, for a token fee. While I work on macies and health centres, and advising Project Manager in Rukoma, Rwanda. pated that such a course would be held
turning this idea into reality, I would ap- local workers on their correct use. for two hours weekly over four weeks,
1. For further information on improving drug donations see:
preciate it if you could continue to send For more than three months, four of Guidelines for Drug Donations. Geneva: World Health and run collaboratively by staff from de-
me your journal and also help me to con- us, pharmacists responsible for manag- Organization; 1996. WHO/DAP/96.2. partments of pharmacology and clinical
tact organizations that already have a drug ing drugs provided by Spanish assistance, medicine. The emphasis would be on
information unit. We can then liaise and I had to spend on average four hours each causes and consequences of therapeutic
can benefit from their experience to cre- day sorting out those that were suited to failures, assessment of therapeutic
ate a substantive, effective, independent immediate needs. Those we threw away outcomes, alternative drug therapy,
information unit for my people. included drugs that had expired, others Indian survey reveals doctors adverse drug reaction monitoring,
that were unsuited to the diseases preva- misgivings on training in RUD drug interactions, and risk-benefit and
Justice Dogbey, Pharmacist, lent in the area, others in amounts which cost-effectiveness of drug therapy.
P.O. Box KB516, Korle-Bu, Accra, Ghana. were insufficient to treat a patient, many Dear Editor, The study concludes that there is an
not included in WHOs Model List of Criticism about the lack of input on undoubted need for reinforcement of
Essential Drugs and many others. rational therapeutics in Indias under- knowledge. In particular it demonstrates
Despite all these drawbacks I must graduate medical curricula was voiced by a need for further inputs on prescribing
emphasise that many of the drugs were a number of participants at a national con- guidelines in the later stages of the
Drug donations in Rwanda used and helped to treat thousands of sultative meeting on the rational use undergraduate curriculum.
patients, thereby saving considerable of drugs (RUD) held in Calcutta in 1995.
Dear Editor, Krishnangshu Ray,
expenditure. Nevertheless it might have Delegates called for an increased focus
Assistant Professor of Pharmacology,
Drug donations to developing coun- been preferable to load one of the humani- on needs-based clinical pharmacology Department of Pharmacology, Calcutta
tries have become a key factor of tarian assistance aircraft sent from Spain teaching at undergraduate level, and for National Medical College, 32 Gorachand
international humanitarian assistance in with urgently needed drugs which had the gap between students knowledge Road, Calcutta-700014, India,
the field of health. People respond enthu- been purchased directly from specialist about drugs and knowledge of their and Pijush Kant Sarkar,
siastically to each emergency appeal firms. Alternatively the drugs might have optimal use to be narrowed. Professor of Pharmacology and Director,
made by NGOs, out of a desire to help been sorted more systematically in Spain Concerns expressed at the Calcutta School of Tropical Medicine,
those most in need. Nevertheless, the well before they were sent, so that the work of meeting prompted a survey of 2,200 Calcutta, India.
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Globalization and Access to Drugs, WHO, Health Economics and Drugs, Evaluacion de la Situacion de los Medicamentos en el Peru, Ministerio de
DAP Series No. 7, WHO/DAP/98.9, Nov. 1997, 58 p. Salud, Direccion General de Medicamentos, Insumos y Drogas, 1997,
136 p.
The latest in DAPs series on health General Agreement on Tariffs and Trade to
economics and drugs informs people in the the advent of the World Trade Organization. This overview of the drug situation in Peru programmes should be systematically
health sector with no particular legal The second part analyses the section on is intended for all those working in the public evaluated to determine if the programmes
background about the impact of globalization patents of the TRIPS Agreement in relation health sector, but principally objectives are being met.
on access to drugs. In particular it focuses on to access to drugs. in drug authorities. The The publication includes
the World Trade Organization agreement on publication aims to help information on the National
intellectual property (the TRIPS Agreement) readers to analyse problems in Formulary, the Health Ministry
that may have repercussions in the Available, free of charge, in English, French the pharmaceutical field and budget, and drug purchasing
pharmaceutical field. The first part of the and Spanish from: Action Programme on to facilitate planning and policies. It also provides
document gives an introduction to the Essential Drugs, World Health Organization, interventions. statistical information on
international commercial system from the 1211 Geneva 27, Switzerland. The authors state that patients access to drugs in
drugs should be available to all different areas of the country.
Peruvians, adequately selected
in terms of efficiency, safety,
Pharmaceuticals and Health Sector Reform in the Americas: An Economic cost and need, be of guaranteed Available from: Ministry of
Perspective, I. Madrid, G. Velasquez, E. Fefer, WHO/PAHO, 1998, 93 p. quality and be used rationally. Health, Avda Salaverry, Lima,
They recommend that drug Peru.
Do health services work proactively or reactively? Why are pharmaceuticals important?
What is health sector reform? What is the scope of pharmaceutical reform? What can be done to
ensure that reform leads to progress and not simply change? These key questions, addressed by
this publication, are particularly important when increasing pressures on health systems and Antimicrobial and Support Therapy for Bacterial Meningitis in Children.
economic changes in many Latin American and Caribbean countries make health sector reform Report of the Meeting of 1820 June 1997, WHO, WHO/CHD/98.6, 1998,
imperative. Directed particularly to decision makers in health and finance, the publication helps 25 p.
them to evaluate and put into operation necessary changes.
The authors argue that the fundamental principle of Bacterial meningitis is an important cause the choice of antimicrobial therapy and the
optimal health sector reform is that access to quality health of childhood morbidity and mortality, and a implications of antimicrobial resistance;
services is a universal right. Each country must shape health number of differences exist in its management the pharmacokinetics and current use of
sector reform in accordance with its priorities and social and from one region to another. This is a report of chloramphenicol; the role of dexamethasone;
economic conditions. Pharmaceutical sector reform must be a WHO meeting to review current treatment and fluid management in bacterial meningitis.
incorporated within health sector reform and should seek to and make recommendations for future
ensure that all individuals have access to essential drugs and practice. Chapters cover four issues Available, free of charge from: World Health
to quality health services. The publication focuses on five concerning the management of bacterial Organization, Division of Child Health and
areas central to reform strategy: the roles of the public and meningitis in children in developing countries: Development, 1211 Geneva 27, Switzerland.
private sectors; drug financing alternatives; pricing policies;
generics strategies; and rational use of drugs.
Available, free of charge, from: Action Programme on Update on new formularies, treatment guidelines,
Essential Drugs, World Health Organization, 1211 Geneva essential drugs lists, drug bulletins and newsletters
27, Switzerland.
The Action Programme on Essential Drugs has a new publication, Progress of WHO
Member States in developing national drug policies and in revising essential drugs lists,
1998, (WHO/DAP/98.7). This comprehensive global listing also includes details of which
countries have produced national formularies and standard treatment guidelines, and of
European Pharmacopoeia Supplement, 3rd ed., 1998.
progress made in providing access to essential drugs. The publication is available, free of
The updated 3rd edition of the European Pharmacopoiea provides a single regulatory charge, from the Action Programme.
reference for the quality of medicines in 25 European countries, including those of the European Listed below are some recent additions to DAPs global index. (Please note that we
Economic Area. The supplement contains 120 new standards or monographs and 130 revised are unable to supply copies of the publications themselves. Requests should be made
monographs that incorporate the latest scientific advances. These 250 new harmonised European direct to the countries concerned).
monographs became obligatory in 25 European countries on 1 January 1998, superseding the Chad: Guide de Diagnostic et de Traitment des affections courantes au Tchad, 1998.
national standard where one existed on the same subject. Ministre de la Sant Publique. Intended to increase rational prescribing among doc-
In total the Pharmacopoeia contains approximately 1,300 European standards on subjects tors and paramedics at the first and second health care levels. The publication covers
ranging from synthetic molecules to biologicals to vaccines for human or veterinary use to the main illnesses found in Chad and includes advice on information, education and
herbal preparations; 250 general methods of analysis and 800 reagents; and a specific chapter communication interventions.
on dosage forms. Gabon: Liste nationale des Mdicaments Essentiels, 1997. Ministre de la Sant
The publication is available in English and French. For further information contact: Council Publique et de la Population. The Essential Drugs List by generic name in 24
of Europe, 226 Avenue de Colmar, BP 907-F67029, Strasbourg, France. Tel: + 33 3 88 41 20 therapeutic groups. The List will be updated every two years.
36, fax: +33 3 88 41 27 71. Mali: Formulaire Thrapeutique National, 1998. Ministre de la Sant, des Personnes
Ages et de la Solidarit. The Formulary begins with advice on good prescribing and
storage practices, and then presents drug monographs, organized in alphabetical
order by generic name for three levels of care.
District Health Care, 2nd ed., R. Amonoo-Lartson, G.J. Ebrahim, H.J. Lovel, Nepal: Hospital Formulary, 1997. Tribhuvan Teaching Hospital, Institute of Medi-
J.P. Ranken, 1996, 296 p. cine. This teaching hospitals formulary includes 371 drugs and 16 non drug items.
The drug list is based on the WHO Model List of Essential Drugs.
The publication gives practical advice and many of the evolving principles of Spain: Manuel del Medicamento, 1998. Farmacuticos sin Fronteras de Espaa. A
support to district medical officers and district management which have been adapted for drug manual which includes donation guidelines and WHOs Model List of Essential
health teams in planning, organizing, application to health care, and which will be Drugs.
managing and evaluating of use in restructuring health The Gambia: The Standard Drug Treatment Guidelines, 1998. Department of State
health services. Since the first services. Drawing on their for Health, Social Welfare and Womens Affairs. Covers diagnosis and treatment of
edition in 1984 health care experience in a number of the countrys main health problems to achieve more rational and cost-effective use of
costs have escalated, even in developing countries, the drugs in hospitals, health centres and dispensaries.
richer countries. There is authors have produced a Uzbekistan: National Drug Formulary, 1998. Ministry of Health. The countrys first
increasing emphasis on pre- valuable aid for medical, national formulary, which includes the Essential Drugs List.
ventive and promotive care health and nursing personnel
the fundamental principles involved in the planning, Drug bulletins and newsletters
on which primary health care organization and running of The WHO Regional Office for Africas Essential Drugs Programme has produced the
is based, the authors argue. district health services. first in a series of monthly newsletters. The AFRO Pharmaceuticals Newsletter will
They believe that as countries report on what the Regional Office is doing in the pharmaceutical field in collabora-
have oriented their services tion with Member States, and on developments in the Regions pharmaceutical sector.
towards primary health care, For further information contact: Dr Moses Chisale, WHO Regional Office for Africa
the need for planning, Available from: Macmillan
(Attention EDP/AFRO), P.O. Box BE 773, Belvedere, Harare, Zimbabwe.
managing and evaluating Education Ltd, Houndmills,
Basingstoke, Hampshire A change of name for Drugs Today, the newsletter of the Christian Medical
service programmes is greater
Association of India, which is now called Rational Drugs.
than ever. RG21 6XS, UK. Price:
The new edition includes 10.50.
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RATIONAL USE
A therapy discussion groups in the in the objectives of discussion group con- groups were using relevant prescription ness of the pharmacotherapy discussion
Netherlands has highlighted a sultations since the previous survey. data, due in part to efforts by the Dutch group network remain essential in order
major shift towards establishing While information exchange and discus- Pharmacological Society, health insur- to modify goals and develop fresh ap-
standards and guidelines for prescribing, sion on prescribing practices are still high ance companies and the Dutch Institute proaches, methods and content. Other
coupled with a growing determina- on the agenda, there is an increasing em- for Effective Use of Medication to ensure challenges include the development and
tion to monitor compliance by general phasis on the need to reach agreement on the availability and proper use of relevant implementation of regional formularies
practitioners (GPs). standards, policies and guidelines. The data. At present, the figures are used exploiting the full potential of computer-
The study, carried out by the mainly to gain an insight into existing ized data and an increase in international
Dutch Institute for Effective Use prescribing patterns. For just over half the cooperation. In Eastern Europe, the Dutch
of Medication, reveals that the groups these data serve as a tool in policy Institute for Effective Use of Medication
number of discussion groups has development, while 44% of groups using recently responded to a request from
increased by a third to more than the data do so to check adherence to the WHO to give presentations on rational
800 over the past five years, and policies and guidelines agreed within the drug use strategies. Elsewhere, collabo-
that up to 95% of the countrys discussion group. ration is already underway, with similar
GPs and pharmacists are now One of the conclusions of the 1992 discussion networks in Belgium, Canada,
involved. survey was that regular monitoring of Germany and the UK. In November 1998
The nationwide network of prescription data was essential in order the Institute collaborated with the
local pharmacotherapy discus- to bring about effective change in pre- WHO Regional Office for Europe in
sion groups was launched by scribing practices. However, only a organizing a consultative meeting to
the Institute in early 1992 (see minority of groups currently monitor GPs share problems experienced with guide-
EDM-20). The idea was to pro- prescription practices for compliance with line implementation and to discuss
mote rational drug use by agreed group guidelines and policies. pharmacotherapeutic committees.
More widespread monitoring of data Meanwhile, Institute advisers are
bringing together GPs and phar-
would offer a way of comparing prescrib- working on new programmes generic
macists to exchange information
ing practices among colleagues, and of prescribing, polypharmacy among the
about pharmacotherapy and
verifying compliance with agreed stand- elderly, pharmaceutical care and transmu-
develop local guidelines.
ards, policies and guidelines. ral pharmacotherapy (where people are
Since then a team of 16
advisers (communications con-
sultants) have helped establish What GPs and pharmacists
regional networks as well as pro- think
Stichting DGV
Stichting DGV
tor compliance with them (compared with understanding of the scope of their pre-
Latest findings scription practices, partly as a result of
49% and 9% respectively in 1992).
The new survey was initiated in 1997 In preparing activities groups rely participation in a group. In addition they
to update information about the organi- heavily on the use of specially developed report improved relations with other GPs A patient information leaflet from the generic
zation and operation of pharmacotherapy working materials. Most groups (82%) and pharmacists. Meanwhile, the discus- prescribing project. It says that you can have
discussion groups and to find out whether have, at some time, used the series of pre- sion group system has helped define the the same medicine in a different coat
pharmacists role as an adviser to the GP. generic drugs are just as good but cheaper
any changes had occurred since the 1992 parative booklets issued by the Institute
study. The number of groups had in- for Effective Use of Medication. Both Pharmacists are now paying more atten-
creased from 629 in 1992 to 827 in 1997, GPs and pharmacists were very positive tion to supervising medication schemes referred from hospital to have their
and 83% of these took part in the latest about the booklets and the case studies. and giving advice to GPs, due in part to prescription dispensed in a community
survey. During 199596, the most frequently dis- their participation in pharmacotherapy pharmacy) to ensure that all GPs, phar-
The study found that an increasing cussed topics were asthma, hypertension, discussion groups. Pharmacists also say macists and specialists have expertise in
number of both GPs and pharmacists the use of antibiotics in the treatment of they are now more inclined to contact a auditing and cost-effective use of medi-
played an active role in organizing respiratory infections, the use of anti- GP when they have a query. Another cation. In addition, the Institute continues
group activities (up from 78% in 1992 to microbial drugs to treat urinary tract improvement, noted by both GPs and to offer a range of new working materi-
88% in 1997). Most groups meet six infections and the use of antidepressants pharmacists, is that both parties have a als and support to pharmacotherapy
times a year and about two-thirds of them (50%60% of groups). clearer understanding of how tasks should discussion groups to boost their effective-
are assisted by an adviser recognised Although the Institute advises groups be shared between them. ness. This can involve evaluation
by the Dutch Association of General not to discuss new medicines until On ways of improving the discussion exercises, help in solving cooperation
Practitioners. these have been assessed by autho- group system, almost a third of the groups problems or in starting up compliance
Contacts with specialists in hospitals ritative publications, such as the maintained that consultations need to be- monitoring, or efforts to revitalise the dis-
a need highlighted in the earlier Dutch Pharmacotherapy Compendium come more efficient, while over 40% said cussion group process whenever it gets
study have become more frequent (Farmacotherapeutisch Kompas), the the agreements reached should become bogged down.
(41% compared with 27% in 1992). The Dutch Society of General Practice Stand- less voluntary a view expressed more
* Geert Kocken is a health consultant at
Institute for Effective Use of Medication ards, and the Dutch Drug Bulletin frequently by pharmacists than GPs.
Stichting Doelmatige Geneesmiddelen
is currently trying to improve commu- (Geneesmiddelenbulletin), 70% of groups Greater use of prescription data would not Voorzieninq (DGV) Dutch Institute for
nication between pharmacotherapy reported having done so. Indeed, many only help develop and clarify policies but, Effective Use of Medication, Postbus 3089,
discussion groups and hospitals at the in- groups have agreed not to prescribe new more importantly, also enable groups to 3502 GB Utrecht, the Netherlands. Tel. +
terface between primary and secondary medicines before consultations within the more effectively monitor compliance with 31 24 360 6200, fax: + 31 24 360 6644,
care. The discussion group infrastructure pharmacotherapy discussion group. agreed policies and guidelines. e-mail: berkldgv@wxs.nl
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T been widely adopted today by countries throughout the world. But its
implementation is proving a lot more difficult than envisaged.
few situations, another cheaper one
may be equally effective in the majority
of situations making it more cost-
included in the national essential drugs
list thereby enabling hospitals to buy
the drug and ensuring its inclusion in
effective. reimbursement schemes.
The idea providing priority drugs to by doctors working in the private sector,
The essential drugs list is also criti- As countries have increasingly recog-
meet the health care needs of the major- who had a larger range of drugs to choose
cised for failing to include a drug for a nised the need for a national drug policy,
ity of the population was simple, from than those employed in the public
particular disease. However, the list was the national list has provided the corner-
socially just, and both technically and sector. However, this opposition has less-
never meant to cover all diseases. The aim stone for this policy development.
economically sound. By having a care- ened, over time.
was to ensure the availability of drugs to Meanwhile, the knowledge that a limited
fully designed, scientifically sound list of Another frequent criticism is that the
treat the majority of diseases that occurred list of drugs can meet the majority of
a limited number of drugs, procurement essential drugs list is a second class list,
in a specific country. The exclusion of a health care needs has also created an
could be made easy, the drug storage determined on the basis of financial strin-
drug from the list does not prevent it from awareness that more is not necessarily
problem simplified, prescribers would gency rather than the effectiveness of the
being purchased if needed. The fact better and that newer is not necessarily
have safe and effective drugs, and costs drugs. However, the belief that countries
that the essential drugs concept accom- better. The list has also enabled health
could be reduced. will abandon the list, once the economic
modates this should be seen as its administrators to assess whether appro-
The system entailed no reductions in situation improves, and switch to better
strength. priate drugs are being supplied.
health services, and health administrators drugs is based on a misconception. The
did not have to make difficult choices list does not include less effective drugs Although the essential drugs concept
between the competing needs of differ- simply because they are cheaper. The aim IMPACT IN DEVELOPING has consistently focused on the impor-
ent groups or assess the social and health is to include more cost-effective drugs tance not only of the selection but also
COUNTRIES
implications of different strategies. The that can be used by the majority of the the proper use of the drugs, progress in
money allocated for pharmaceuticals population. For example, among the H2 Over 120 developing countries have encouraging the rational use of drugs has
20%40% of limited health care budgets receptor blockers, ranitidine has an ad- now adopted the essential drugs concept been slow. Even where essential drugs are
could now be spent on less expensive, vantage over the much less expensive and developed a national essential drugs available, their full potential is not being
essential drugs, facilitating wider access drug cimetidine, in that it can be used by list based on the WHO Model List2. The realised. This is mainly due to the failure
to drugs without any increase in costs. the elderly and has fewer interactions with exclusive use of generic drugs in the list to provide unbiased drug information for
Rarely had administrators been offered other drugs. However, cimetidine was has contributed to increasing awareness prescribers. Whereas suppliers of other
such a clear, simple solution to so many chosen for the model list not only because of generic names. While some countries forms of goods routinely spend a propor-
problems. The essential drugs concept it was cheaper but because it has similar have closely followed the criteria for se- tion of sales revenue on evaluating how
was an idea whose time had come. efficacy to ranitidine, and lection of drugs, others have lists that the goods are used, very few developing
But the simplicity was beguiling. because the majority of include over 350 products (Pakistan) or countries have access to independent drug
Although the concept was well patients using it would two or more similar drugs rather than the information let alone the capacity to
accepted by most countries, its im- be neither elderly nor recommended single drug (Tanzania) spend a proportion of their drugs budget
plementation has proved a daunting on providing information on the
task. More than two decades after rational use of drugs. It is esti-
it was conceived, the essential mated that both developing and
drugs concept has still to make the developed countries currently
full impact that was anticipated spend less than 1% of their
demonstrating that technical drugs budget on rational drug
soundness and economic ra- use. However, the essential
tionality do not necessarily drugs concept has been influen-
ensure political viability1. tial in preventing the import of
ineffective drugs.
ESSENTIAL
DRUGS
In some developing coun-
tries, the implementation of the
CONCEPT UNDER FIRE
essential drugs concept has been
Len Munnick
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accessibility and affordability of essen- evaluated for quality, safety and efficacy4. UNICEFs activities involving in this way it is taken for granted and not
tial drugs. Once registered, a drug is then assessed pharmaceuticals have been guided by the seen as a major advance. Because of this,
Although the essential drugs concept for possible inclusion in the reimburse- essential drugs concept in order to ensure it is a difficult concept to promote.
was designed to meet the health care ment scheme. Approval at this stage equity, and donor countries/institutions Another problem is the wide range
needs of the majority of the population, depends on evidence of cost-effective- have focused on national lists when sup- of objectives involved: equity in the
the private sector has tended to drag its ness. This two-stage process has resulted plying drugs. Meanwhile, the guidelines provision of basic health care needs, effi-
feet in implementing the concept. This is in the registration of drugs, such as for drug donations developed by WHO cient use of available resources, and
largely due to fears that the resulting finasteride, that are expensive but and other agencies have also stressed the responsiveness to societies rather than
changes in the pharmaceu- Photo: WHO/Zafar importance of donating only to market forces. While this elicits
tical sector might have an drugs that are included in widespread support, the involvement of
adverse effect on multi- national lists7. numerous players with different strengths
national corporations, the The Model List is re- and objectives can hamper the concepts
urban elite, and, to a lesser vised regularly by WHO implementation.
extent, physicians. In order with the latest revision in In developed countries, the weak
to succeed, the concept 1997. The number of items implementation of the essential drugs
should have broadly-based included has risen from concept has been driven by fears that the
support which reaches to the 208 in 1977 to 306 today international pharmaceutical industry
highest political levels. as new products are added would suffer a prospect that generated
However, with the excep- and older, less effective strong opposition from powerful groups
tion of the Philippines and products removed. Pro- and governments. Meanwhile, in some
Sri Lanka, this has rarely grammes covering malaria countries, implementation strategies have
occurred3. and cancer control have not been carefully thought through.
The lack of acceptance helped refine the selection Effective implementation of the concept
of the essential drugs con- of drugs included in the List. requires careful planning, backed up by
cept within the private Meanwhile, the participa- strong political commitment at country
sector is also due to the frag- tion of the pharmaceutical level, together with a clearer understand-
mented nature of health care industry associations pro- ing of the role of the different players
in this sector in developing vide an opportunity for involved. Better implementation of the
countries. Patients pay for them to discuss the List as essential drugs concept could make all
their drugs out of pocket well as propose products for the difference between success and
and are individual buyers inclusion. On several occa- failure.
who purchase what the sions, inclusion of a drug
doctor prescribes. However, in the Model List has * Kris Weerasuriya is Professor, Department
large health care providers encouraged pharmaceu- of Pharmacology, Faculty of Medicine, Uni-
such as insurance schemes, tical companies to either versity of Colombo, Sri Lanka, and Pascale
which are common in the continue manufacturing Brudon is Chief, Development of Programme
developed world, can per- the drug or to start manu- Evaluation, WHO and was formerly a Sci-
entist in the Action Programme on Essential
suade prescribers to use a facturing it.
Drugs.
restricted list of drugs known
to be effective. When such BETTER
schemes are established in IMPLEMENTATION References
the developing world the
NEEDED
same trend towards using 1. WHO/DAP. Comparative analysis of national drug poli-
known effective drugs would Essential drugs are not a poor mans medicine, and the essential drugs
cies. Second workshop, June 1996. Geneva: World Health
The essential drugs
concept is as important today as it was 20 years ago Organization; 1997. DAP Research Series No.25. WHO/
develop. concept is today a key issue DAP/97.6.
on the international health
2. WHO/DAP. WHO essential drugs strategy: objectives,
A RESPONSE TO RISING PRICES minimally effective without their agenda. Together with the concept of priorities for action, approaches. Geneva: World Health
approval for reimbursement. primary health care, it is one of the major Organization;1997. DAP/MAC(9)/97.4.
Acceptance of the essential drugs con-
Elsewhere, in the UK, where 17 achievements of WHO over the last two
cept and the essential drugs list faced 3. Reich MR. The politics of health sector reform in devel-
benzodiazepines are available, the Na- decades, and its most durable pharma- oping countries: three cases of pharmaceutical policy.
different hurdles in developed countries,
tional Health Service supplies only five ceutical initiative. Other initiatives, such Health Policy. 1995; 32:4777.
due to the different socioeconomic and
of these, each a generic drug. Although as promoting the local production of
industrial circumstances. In the developed 4. Murray M. Australian National Drug Policies: facilitat-
the other 12 benzodiazepines are equally pharmaceuticals, have achieved neither ing or fragmenting health? Dev. Dialogue.
countries, governments saw the pharma- 1995;1:148192.
effective, they are more expensive and not the sustainability nor the prominence of
ceutical industry as a vibrant one,
reimbursable. Although this is not a strict the essential drugs concept. 5. World Bank. World development report 1993: Investing
providing useful products as well as con-
tributing to the economy through the interpretation of the essential drugs con- Yet, while the concepts scientific in Health. New York: Oxford University Press;1993.
employment of skilled labour, the produc- cept (which allows only one drug from a validity remains unchallenged, it has still 6. World Bank. Better health in Africa. Experience and les-
tion of substantial export earnings, and a therapeutic class) a focus exclusively on to be implemented to its full potential. sons learned. (Report No.12577AFR). Washington DC:
drugs that are known to be safe, effec- One of the problems is that it is a public The World Bank; 1994.
contribution to scientific and industrial
research. Money was usually available to tive, and cost-effective is in keeping with health concept and not a curative inter- 7. WHO/DAP. Guidelines for drug donations. Geneva:
buy more expensive pharmaceutical prod- the spirit of the concept. However, both vention. When drugs are made available World Health Organization; 1996. WHO/DAP/96.2.
ucts and it was believed that restricting countries promote the export of these
access to these products would be coun- drugs a clear example of industrial
terproductive in the long run. Unlike the priorities overtaking health ones outside
developing countries, health care provid- the countrys own borders.
New Belgian committee promotes
ers in developed countries (either the state
or state-sponsored social insurance INTERNATIONAL ORGANIZATIONS rational prescribing
schemes) had immense buying power and PROMOTE THE CONCEPT
could negotiate a reduction in prices. HE Belgian Minister for Public Health, Dr Marcel Colla, has set up a
However, these products are becoming
increasingly expensive and are often be-
yond the reach of cash-strapped health
Although, initially, a number of inter-
national organizations failed to appreciate
the relevance or importance of the essen-
T scientific committee aimed at encouraging rational and cost-effective
prescribing. The committee, which will implement a project for independ-
ent information on medicines will be made up of representatives from the
service providers. As a result, both gov- tial drugs concept, today most accept and Belgian pharmaceutical information centre, the transparency commission, the
ernments and health service providers in promote it as a good tool for organizing Health Ministry, the pharmaceuticals inspectorate and general practitioners asso-
the private sector have now adopted the the pharmaceutical sector and improving ciations, Le Journal du Mdecin reports. Other health professionals, such as
essential drugs concept albeit by another health care. The World Bank, which plays specialists and pharmacists, may also be asked to participate. A number of product
name. an increasing role in the health sector in categories have already been put forward for examination, including anti-ulcers,
Most countries have adopted a two- the developing world, has based most of antidepressants and antibiotics for upper respiratory tract infections.
step procedure for introducing a new its activities in pharmaceuticals on the
product into the health system. In concept and national drug lists mainly
Australia a new drug is scientifically to facilitate managerial efficiency 5,6. Source: Scrip, No. 2312, 25 February 1998.
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L
tions, Mdecins sans Frontires
(MSF) is facing new problems as
international pharmaceutical
frequently been abandoned because there
would be no return on the required invest-
ment. The same market economy logic
on occupational health (inef-
fective treatment) and public
health (development of
trade is reorganized to the detriment of has resulted in drugs that are obsolete in resistance).
the worlds poor. In a new initiative MSF developed countries no longer being Action: In collaboration
has set up a Research Group on Essen- made even when the drugs are still use- with organizations involved
tial Drugs, which will benefit from the ful in developing countries (where price in supplying quality essential
knowledge and experience of MSFs affects both access and adherence to drugs, the MSF Research
medical teams in 50 countries. The teams treatment). Group will set up a network
not only work with national decision Action: The Research Group on Es- for drug quality monitoring
makers and prescribers but are in contact sential Drugs will make a detailed that will identify countries,
with a wide range of people, and can pro- analysis of the problems arising from non manufacturers and distri-
vide valuable insight into the current availability of essential drugs in devel- butors with good control
problems. In seeking solutions the Group oping countries. Disease by disease and procedures. The network
T
protected by patent, remain beyond the provide the appropriate managerial tools
Pakistans largest Province, has 1988 Drug Rules, the second to screen
reach of developing countries. for underprivileged environments.
initiated a major campaign to re the Provinces medical stores in the light
Action: By making contact with the
form the pharmaceutical sector. of existing licensing policy and to take
Disturbed by increasing news of spuri- steps against those violating the law; and
manufacturers and international organi- Cooperating on research
zations concerned, ad hoc agreements can Some therapeutic regimens can be
ous/substandard drugs and aware of the the third to suggest measures, including
be made to take account of both the com- modified to ensure greater efficacy, to
non implementation of the 1988 Drug further legislation, against unqualified
mercial constraints of pharmaceutical reduce secondary effects, costs and drug
Rules, the Chief Minister, Muhammad people practising medicine.
companies and the resources of poor resistance, and to improve adherence to
Shahbaz Sharif, has set up a Task Force
populations. However, more lasting so- treatment. Assessment of the efficacy of
to try to find a long-term solution to the
Reference lutions must be sought to match the prices short courses of treatment, or study of
problems. As a start he has suspended all
of vital modern drugs with the resources the appropriate galenic forms are areas
of the Provinces drug inspectors and put 1. The News on Sunday, 9 August 1998, p.2829.
of poor countries. The current debate on of operational research that have been
a moratorium on issuing any new
AIDS treatment illustrates the urgency of selected to improve the therapeutic
licences for setting up retail phar-
the problem. With other organizations effectiveness of existing drugs.
macy outlets.
working on the same question, the Action: The Research Group on Es-
Research Group on Essential Drugs will sential Drugs will encourage independent
No compromise on help to promote the idea of international research institutes to conduct studies or
quality solidarity in access to drugs. clinical trials. Networking with the MSF/
The Government is publicising EPICENTRE teams1 on cooperation in
its campaign in front-page articles Promoting rational use local studies is necessary.
in all the main local and English Achieving the rational use of essen- The Research Group on Essential
language newspapers, which invite tial drugs remains a constant struggle: it Drugs, in collaboration with existing
suggestions from the public on becomes imperative in times of shortage. networks, hopes to become a source of
how to improve the situation in the There is still much work to do in promot- information for both decision makers and
pharmaceutical sector. The cam- ing the essential drugs concept, in view field workers, and a force for ideas and
paign received a major boost with of the number of useless or dangerous action to improve health, particularly
a special report on a range of drug drugs that are still used in most countries. in countries which are currently
quality and rational use issues At the same time, a considerable propor- disadvantaged.
which appeared in a Sunday news- tion of available essential drugs is badly
paper1. managed. In terms of information, inde- * Jacques Pinel is Coordinator of the Re-
Although the issue of spurious/ pendent medical journals and guides can search Group on Essential Drugs, Mdecins
substandard medicines is central, provide prescribers and other health sans Frontires, 8 rue Saint-Sabin, Paris
in the Task Forces first meeting professionals with reliable advice, but in Cedex 11, France.
the authorities made it clear that most countries, most pharmacothera-
they are very serious about chang- peutic information is distributed by Reference
ing the whole system. Three A clear message from the Punjab Government, which drug companies. Dubious promotional 1. The EPICENTRE teams are responsible for epidemio-
sub-committees were formed: one appreared in several popular newspapers activities and misleading advertising are logical programmes and data collection.
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