GUYANA NATIONAL MEDICINES BO || Cw, FIRST EDITION.MEDICINES POLICY GUYANA NATIONAL FIRST EDITIONTABLE OF CONTENTS | Preface Acknowledgements List of Acronyms. Introduction Policy Implementation and Management Policy Objective Goal Strategy Legislation and Regulations.. Policy Objectives. Goal : sev Strategy a Human Resource Development 9 Policy Objective mr) Goal 19 Strategy. 19 Education and Training 2 19 Quality Assurance Mechanisms. 20 Selection and Rational Use of Met Policy Objective. Goal Strategy 21 Standaed Treatment Guidelines 24 Facility Medicine and Therapeutics Committees... 25 Education & Information wn. a) Prescribing, Dispensing Pharmacovigilance ‘Traditional and Complementary Medicine... Policy Objective Goal Strategy. TABLE OF CONTENTS II Research and Development. Paliey Objective Goal Strategy Capability and Capacity to Conduct Research Drug Utilisation and Management Drug Research and Development. Procurement and Supply Ms Policy Objective. Gost strategy. Procurement. Storage Disteibution Disposal of Expired Medicines : (Quality, Safety and Eficacy of Medicines. Policy Objective Goal strategy Legislation and Regulations to Ensure the Quality of Medicines, Licensing of Premises And Personnel, Licensing of Retail Pharmacies. Quality Use of Medicines Inspection Medicine Advertisement and Promotion Falsified Medicines Drug Registration Inspection Pharmaceutical Quality Testing Post-Marketing Surveillancei TABLE OF CONTENTS [1 Financing. Policy Objective Goal Strategy ‘Technical Co-Operation... Policy Objective Goal Strategy National. International i cnsnnsnne : Medicine Regulations and Quality Assurance and Other Relevant Areas. 7 ‘Monitoring and Evaluat a Policy Objective : a Goal a aa ~ 34 5 Strategy Annexe.. PREFACE ‘he Guyana National Medicine Policy (GNMP) isthe main policy document which governs the pharmaceutical sector of Guyana, This policy was developed in alignment with the \date of the Ministry of Public Health (MOPH), with strategic collaboration among stakeholders representing each an of Public Health are. was developed primarily to: + Provide a framework that would facilitate improved health ‘outcomes through safe, effective, flordable, accesible and ‘quality pharmaceutical commodities and services to the population, + Ensure that the research, manufacturing, procurement, storage, distribution, prescribing, dispensing administration and disposal ofall medicines are dane according to best practices and legislative requirements to guarantee the safety and efficacy of medicines, ‘The National Pharmacy Services (NPS), with its mandate to advance the health and well-being of Guyanese through quality pharmaceutical services, ithe arm of the MOPH responsible for the establishment and implementation ofthe GNMP. A draft GMP previously prepared in 2007, was used as a base document in the formulation of the GNMP. Current international practices were then incorporated. These efforts wore directed by a technical team from the NPS, under the guidance and supervision of the Chief Medical Officer (CMO) and the National Director of Pharmacy Services (NDPS). Revision ofthis document was done at a national consultation involving a wide range of stakeholders. The final draft was thenSS —>S>——————— presented tothe Health Policy Commitee (HPC) ofthe Mopy where it was reviewed and approved for implementation, ‘the GNMP comprehensively coversallaspects of pharmaceutical services within Guyana, sch as manufacturing, supply charg system, medicine regulation, quality assurance, financing Selection and rational use, as well as monitoring and evaluating ‘The policy also includes the development of human resources towards providing a skilled and competent workforce, research and development, and strategies for international co-operation toimprove the pharmaceutical sector in Guyana, ‘This policy docament will be complemented by a GNMP Inmplementation Plan (GNMPIP), which will present strategies, activities and goals to guide the suecessfl implementation ofthe GNM. I would like to thank all those involved in the process of developing this critical document and I also solicit your Continued support and interest as we now seek to succeslly Implement the GNMB, and improve the quality, availability and accessibility of pharmaceutical products to the citizens of our beloved country. Ns Dr. Shamdeo Persaud (Chief Medical Officer Ministry of Public Health ACKNOWLEDGEMENTS “The drafting ofthe GNMP has its genesis in the initially drafted GNMP document prepared in 2007 by a select workgroup comprising stakeholders from the MOPH and Pan-American Health Organisation (PAHO), The work ofthe group responsible for that document must be acknowledged. Revision and amendment ofthat base dacument required the input of many stakeholders; whose hard work, going even beyond the call of| duty, as facilitated it inaisation, We are grateful to Hon, Volda Lawrence, Minister of Public Health, as wells Hon, Dz Karen Cummings the former Minister within the MOPH, for their leadership and for recognising the ‘urgent need for this policy. Our highest appreciation is extended to the Chief Medical (Officer, Dr. Shamdeo Persaud; Deputy Chief Medical Offices, Dr. Karen Campbell: and Programme Director, Dr. Julian ‘Amsterdam: for thee echnical and administrative support. ‘The hard work, valuable insights and enthusiasm of the participants at the GNMP Review Workshop (see Appendix 1) are acknowledged, Without their contcibution, this policy could ‘not have become reality Sincerest thanks are extended to our partner, the Pan-American Health Organisation/ World Health Organisaton (PAHOY WHO), notably Dr. William Adu-Krow, PWR and Dr, Peul Edwards, Advisor, Health System and Services, PAHO/WHO, Office, Guyana; for their technical and financial support in this endeavour. We would also like to thank the United tates Agency 3for international Development (USAID), which provided ‘hcl expen aah che thal lad pay ee LIST OF ACRONYMS Procurement and Supply Management (GHSC: PSM) proj Finale would ket acknowledge the Saf ofthe Neg ADR Adverse Drug Reaction TTenecia Johnson and Abena Glasgow, who speatheaded the ev ep ceca CMO Chit Medical Oticer process and moved it forward with great enthustasm arg CRS Caribbean Regulatory Sytem fommitnent DNPS Director National Pharmacy Services DRA Drug Regulatory Authority GAFDD Government Anat Food and Drug Mad Department cP Goad Cina Practice = GDP Good Dispensing Practice ‘Mr. Oneil Atkins GEML Guyana Essential Medicines List National Director of Pharmacy Services & Gerona Es Ministry of Public Health GFATM Global und for Tuberculosis and Malaria GHSC-PSM__ Global Heath Supply Chain Procurement & Supply Management cu Good Laboratory Practice GMP Good Manufacturing Practice GNE Guyana National Formulary GNMP Guyana National Medicine Policy GNMPC Guyana f ational Medicine Policy Committee :MPIP_ Guyana National Medicine Policy Implementation Plan GoG Government of Guyana GPa Guyana Pharmacists Association GPHC Guyana Pablic Hospital Corporation Grp ‘Good Pharmacy Practice Good Storage Practice Health Commodity Supply System Health Management Committee Health policy Committee Inter-American Development Bank International Non- Proprietary Nameunc LMU Mal MMU MOPH Tc NHISS NMPC NMQCL Nt NPS PAHO, TRIPS. uc UsaID ves we WHO wro inden Hospital Complex Logistics Management Unit Monitoring & Evaluation Materials Management Unit Ministry of Public Health Medicine and Therapeutics Commit National Centte for Pharmacovig tional Drug Information Centre National Director of Pharmacy Services, Non-Governmental Organisation National Health Commodities Specifications and Quantification Database National Health Sector Strategy National Medicines Policy Committee ‘ational Medicines Quality Control Laboratory ‘ational Medicines and Therapeutics Committee National Pharmacy Services Pan-American Health Organisation Pharmacy Council of Guyana, Pharmacy and Poison Board Private Sector Commission Regional Health Officer Sustainable Development Goal Standard Treatment Guidelines Traditional Medicine ‘Trade-Related Aspects of Intellectual Property Rights University of Guyana United States Agency for International Development Vector Control Services World Bank. World Health Organisation ‘World Trade Organisation INTRODUCTION Guyanals Health Sector comprises the Public Health Sector, run by the Government of Guyana (GoG), in which the cost ‘of services and supplies is generally free or subsidised, and the Private Health Sector, whose patients are required to pay for services and supplies. Its widely accepted that the Public tor s the major provider of health care in the country, while Non-Governmental Organisations (NGOs) may partner with or fund services and supplies in both the Public and P Sectors. The GOG has increasingly expanded and decentralised the health services, resulting in increased demand on the Public Health Sector and particularly on the pharmaceutical sub-sector, pharmaceutical personnel, procurement and supply ‘management. This in turn, affects access to and availabilty of these services ‘The Pharmacy Sector of Guyana is supported by four sub. sections of the MOPH: The National Pharmacy Services (NPS), the arm of the -MOPH whose mandate sto provide the leadership, policies and legislative framework requited to strengthen the practice ‘of pharmacy, 2. The Government Analyst Food and Drug Department (GAFDD),ischarged with the responsibilty ofadministering and enforcing the Food & Drugs Act 1971 and its supporting Regulations of 1977; to ensure that foods, medicines, cosmetics, medical devices and water that is distributed, ‘marketed, produced, imported or exported meet the highest standards of quality and safety. To this en, the Department carries out the following activities:Analytical Inspectorate Enforcement ofthe Legislation, 5. The Pharmacy Couns f Guyana (PCS), i the atstory toy responsible for the registration of Pharmacy Prsttoners monitoring of ethical standards of practice any the promation of pharmacy education within the country, through the organisation of internships and continuing ducati sessions, to positively influence the quality ot pharmacists within Guyana. 4. The Pharmacy and Poisons Board (PPB), is responsible for the registering of patent shops (those licensed to sell over-the counter medicines) and pharmacies. ‘The MOPH, in collaboration with its strategic partners, particularly PAHO/WHO, continues to work tirelessly to achieve ‘Goal #3 of the Sustainable Development Goals (SDGs), which seeks to “ensure the health and well-being for all at all ages”. Equitable acess toand affordability of quality assured medicines ae vital to effect this goal. Significant effort and resources have been invested in improving procurement and supply chain ‘management with the support of the USAID and PAHO/WHO, asa means of improving access. However, it should be noted that this piecemeal approach has been tried in many countries in the past and though gains were made in the improvement of acces, it didnot result in any significant improvement in the rational use of medicines and thus, treatment outcomes. This and other experienceshave demonstrated that the pharmaceutical problem is better dealt with through a comprehensive national medicine policy. A revision ofthe draft Guyana National Medicine Policy (GNMP) of 2007 was therefore commissioned. In a study entitled “Access to Essential Drugs in Guyana: A Public Health challenge”, published by Enrique Seoane- Vasquez and Rosa Rodriguee-Monguio (2008), significant bartiers to the access of medicines were identified. These inched: > Lack of national drug policy and regulation, and the limited role of the regulatory authority > Inefficient drug (medicines) selection and irrational drug (medicine) use, > Insufficient financial resources and lack of drug (medicine) pricing policy; > Inefficient planning and managing of public supply system; > Deficient epidemiological and information systems and > Inadequate infrastructure and human resource shortage. Among their recommendations for improving access to medicines, the Consultants recommended the {implementation ofa national medicines poliey and pricing Policy, streamlining financing, procurement, better planning, and managing medicines supply, adequate infrastructure and human resources The WHO Medicine Strategy 2004-2008 also mentions the development and implementation of a national medicine policy foreach ofits Member States as a priority. As such, the GNMP is expected to facilitate equity, ational use and sustainability ofthe pharmaceutical sector its general objective being to ensure that the citizens of Guyana have access to safe and effective medicines that are of ood quality and at an affordable cost to the county,revive drugs (medicines) appropriate fo their clinical hea. thc foe er 18 to the “The GNM in essence wll provide the enabling environmen forthe pharmaceutical sector. Tis core objectives are covey related to the essential medicines concept and are essential realising SDG #3 fo "ensure the health and well-being for ally all ages"; > To make essential medicines available and affordable to those who need them, efficacy and quality ofall medicines > To ensure the safety provided tothe public. > Toimprove prescribing and dispensing practices, to promote ethical practices among health professionals, and the correct use of medicines by health workers and consumers, Work on the GNMP began as far back as 2005, with the assistance of PAHO. Committees were convened to assess the situation in different areas of the pharmaceutical sector and propose a new policy. A draft questionnaire was developed and copies of National Medicine Plans (NMPs) from different «countries examined. This activity was not completed until 2007, when a draft GNMP was produced. That draft, however, was ‘not implemented. A renewed commitment by the GOG in 2017 resulted in a concerted effort to strengthen the pharmaceutical -10- a sector and environment. This has led to the revision and. updating ofthe draft GMP, thus creating the framework for improving access to quality pharmaceutical products. ‘The GNMP articulates the critical statepies forthe following policy objectives: > Policy Implementation and Management: To ensure the successful implementation of the GNMP. fo ensure medicines and > Legislation and Regulatio medical products made available to the public are safe, fective and are ofthe highest quality to meet the health care needs of citizens, and that th with best practices sale and use are consistent > Human Resource Development: To havea sufficient number of suitably trained and competent human resources in the [Pharmaceutical sector to ensure the proper management and tse of medicines. » Selection and Rational Drug Use: To maximise benefits, prevent or minimise adverse medicine events and improve health outcomes > Traditional and Complementary Medicine; To promote the sustainable use of safe and effective herbal medicines of approved quality, while protecting the public against any possible adverse effects, > Research and Development: To improve safe medicine selection, use and management and encourage research and development of medicines. <1.scurement and Supply Management: Toensure equitable, aaa sured medicines to every citizen of Guyana, uality ality Safety and Efficacy: To ensure medicines marketed nm 1 care are safe effective and quality assured Iocally for patient toomeet the health needs ofall citizens. snancing: To have quality medicines at affordable prices oth inthe Private and Public sectors to meet the treatment needs ofthe citizens of Guyana. 1p Technical Cooperation: To ensure technical co-operation is explored standards are upheld best practices are encouraged to optimise the use af resources, and strengthen National al polices. \g and Evaluation (M&E): To develop an [Ma plan that will facilitate the annual assessment of the performance of the GNMP implementation by established strategies, objectives, and activities in the GNMPIP. Implementation of the GNMP will be guided by the GNMPIR, and the policy will be evaluated and updated periodically to censure that it aligns with the overarching MOPH plans and strategies. <2. POLICY IMPLEMENTATION AND MANAGEMENT POLICY OBJECTIVE All stakeholders shall be committed to the successful implementation of the GNMP, which is aligned with the National Health Sector Strategy (NHSS). GOAL ‘To ensure the succesful implementation of the GNMP. STRATEGY > A governance structure and master plan shall be developed to facilitate the implementation ofthe GNMP. > The MOPH shall establish the Guyana National Medicines Policy Committee (GNMPC) to be the guiding body to oversee the development, maintenance and implementation ‘of the GNMP, > ‘The GNMPC shall report to the Health Management Committee (HMC) of the MOPH, which is the highest policy and decision making forum within the MOPH, > The MOPH shall establish the NPS, whose function will include implementation ofthe GNMP. The National Director vices (NDPS) shal be the lead technical oficer Pharmacy implementing the GNMP. -3-a eee seNPSsal develop 5-year GNMDPIP. which wil ite LEGISLATION AND REGULATIONS Plan i consistent wih, and actively supports ye thatthe HSS and other relevant health policies ang POLICY OBJECTIVES goals ofthe N ‘Shall seekits approval by the HMC, Legislation and regulations governing the practice of pharmacy, ‘manufacturing, procurement, storage, handling and utilisation ‘the NPS shal establish an intersectoral committe of ‘of medicines ate prequisiies to ensuring best practices. Specific ‘elevant stakeholders to faciitate the implementation of the GnMP Menbershp shall include, but shall not be limites te: Private Sector Commission PSC), Guyana Pharmacisy, sAsocation (GPA), Consumers Associations, Georgetown Pablc Hospital Corporation (GPHC), University of Guyana ), GA-FDD and MOPH. objectives include Supporting legislation and regulations governing all aceas related topharmaceuticalproducts, including manufacturing, procurement, storage, sale, distribution and utilisation, > Empowering regulatory agencies to effectively execute their mandate to safeguard the quality of medical and pharmaceutical products, the practice of personnel and the licensing of premises involved in the pharmaceutical busines. GOAL ‘Toensure medicines and medical products made available to the public are safe, effective and are of the highest quality to meet the health care needs of citizens, and that their sale and use are consistent with best practices STRATEGY > The NPS shall be given the legal authority to carry out its ‘mandate. Additionally, existing legislation and regulations governing the control of medicines will be strengthened and enforced thus empowering inspectorate, building capacity <4 +15.laboratory facilites and Joys impeving lab fostering ercmphasies safety and quaty mall are snd pharmaceutical products in empl anatmosphere related to medical 19s shall be responsible for the monitoring ang be NI ° | medicine regulatory functions, whieh evaluation ofall reade but ae not restricted to: 1 egitratonofmedisinsandallod substances including Traditional and Alter control af all medieines and allied substances on the ‘market in Guyana, tative Medicines, and subsequent Registration of pharmacies and all other premises trea or the handling of medicines, Le, manufacturing, Storage, distribution, drug quality conttol, laboratory ‘work, import, export and sales. Regulation ofthe handling of medicines and allied substances; among others, the development and ipaintenance of standards for all operations, inclusive Of prescription formats and disposal of sub-standard or expired medicines and allied products. «| Byaluation, monitoring, control and support supervision ofall pharmaceutical personnel + Regulation of medicine advertisements + Regulation of post-market surveillance, ‘+ Inspection of medicines, premises and professionals {including training, capacity building, law enforcement and inspections at ports of entry). -16- ‘+ Monitoring of adverse drug reactions + Providing information on medicines to health, professionals and the general publi: ‘The GA-EDD shall provide reports to the NPS on the Inspectorate, medicine quality and (medicine) registeation activities. The GA-FDD shall be re-organised as the regulatory/enforcement arm of the GNMPC, and shall be sustained by Government and other foe revenues. ‘The PCG is responsible for setting and maintaining the standards for pharmacists and the practice of pharmacy, setting the standards for pharmacy-related training and the admission of pharmacists to the pharmacy practice. Formal linkages to the NPS shall be developed to allow for collaboration between the NPS and the PCG. ‘The public procurement of medicines and allied substances shall be reorganised to ensure compliance with the Public Procurement Act 2002. Guyana Health Sector Donations Policy and Operational Guidelines willbe reviewed and implemented based on the WHO Guidelines for Drug Donations. Donated medicines will: ‘+ match the health needs ofthe country and hence appear ‘on the Guyana Essential Medicine List (GEML) or the Guyana National Formulary (GNF); 1+ be compatible with overall Government policy: a7‘eof appropriate quality efficacy and safety, be accompanied by appropriate legal and administrative documents be reviewed through the Draft Regulatory Authoriy (DRA) fast-track procedure that will issue a Cestifcay ‘of Approval for every donation before shipment, ‘The Doha Declaration on Trade-Related Aspects of Intellectual Property Rights (TRIPS) and Public Health vas adopted by the WTO Ministerial Conference of 2001, ‘on November 13, 2001 in Doha. It reaffirmed flexibility of "TRIPS Member States in circumventing patent rights for better acess to essential medicines. The adaptation of Guyana's Intellectual Property laws and regulations to the World Trade Organisation (WTO) agreements (eg-TRIPS) will include only the minimum requirements established by WTO with regard to patent regulation, and the maximum flexibilities permitted under the Doha Declaration: 1o ensute optimal access to essential health commodities. -18- OE EE eee HUMAN RESOURCE DEVELOPMENT POLICY OBJECTIVE ‘The human resource needs ofthe pharmaceutical sector shall be forecasted, planned for, developed and sustained GOAL “To have a sufficient numberof suitably trained and competent professionals inthe pharmaceutical sector to ensure the proper ‘management and use of medicines. STRATEGY Planning for and effective development of human resources shall be implemented and achieved through appropriate recruitment, training and valorsation ofthe pharmacy profesional, EDUCATION AND TRAINING > The minimum requirement for a practising Pharmacist in Guyana shal be the Bachelor of Science Degree in Pharmacy (BPharm) from UG oF any other recognised and duly accredited pharmacy progeamme:and successful completion fof an internship fora period of not less than one year (12, months). 1» The minimum requirement for a Pharmacy Assistant shall be a Certificate in Basic Pharmacy Practice ftom the MOPH, Department of Health Science Education, or any other duly amacy Assistant Programme dane over not accredited Phat 12 months) that is recognised by the Jess than one year ( PCG. “The NPS shall, collaboration with the PCG and other profesional Pharmacy Bodies, advise UG and the Fepartnet of Health Science Education on relevant trend se eorent practice to inform the training curricula QUALITY ASSURANCE MECHANISMS jechanisms shall be strengthened Quality assurance mech ee censure that training institutions achieve and maintain required standards Accreditation of programmesoffered by institutions of higher learning and other taining centers shall be established to ‘maintain the quality of professionals produced, All categories of healthcare providers shall be trained on the principles ofthe GNMP, Standard Treatment Guidelines (TGs), essential medicines and quality use of medicines > The governing bodies ofthe various categories of healthcare workers shall develop appropriate, client-oriented, continuing, professional development training programmes; distance learning and virtual campuses to improve the performance of healthcare workers both in the Private and Public sectors, > TheMOPH shallensurethedevelopmentandimplementation of programmes aimed at providing clear career paths and opportunities for attracting and retaining qualified personnel SELECTION AND RATIONAL USE OF MEDICINES POLICY OBJECTIVE Only safe and efficacious medicines that meet prescribed standards, and quality health commodities, shall be selected and registered for use in Guyana, udicious prescribing and the promotion of rational medicine use shall be encouraged, Goat ‘To maximise benefits, prevent oF minimise adverse medicine events and improve health outcomes. STRATEGY > Developing, maintaining, upgrading and actively using the GNE, GEML, STGs and alist of other essential Health Commodities, including Surgical, Radiology and Laboratory Supplies; > ‘Therapeutic Governance, through the implementation of Pharmacy and Therapeutic Committees at all major hospitals, for medicine safety guided by independent, evidence-based drug information; > Prescribing practices that follow STGs and other standards of professional practice; > Education and training: <2.hic promation of medicines; Enforcement of relevant Legislation; Revision and implementation of the Donation Policy (Guyana Heath Sector Donations Policy and Operations) Guides. ‘The Minister shall establish a National Medicine and ‘Therapeutic Commitee (NMTC), which will report to the cerarching HMC, The NMITC shall be a multi-disciplinary ‘committee comprising members from both the Public and Pivae Sectors and shall be chaired by the CMO, with the [DPS serving as Secretary. ‘The NMTC shall have responsibility for all activites related to the development and maintenance of STGs, the GEML and ists with other essential Health Commodities (surgical, radiology; laboratory supplies, et.) as well asthe GNF. “The GEML shal form the basis for: + procurement and use of medicines in the Public Sector; + prossion of information to service providers; + suppor fr the national pharmaceutical industry: + evaluation of donations of medicines ‘The Essential Medicines and Formulary Sub-Committee (a ‘sub-committee ofthe NMTC) shall develop and maintain the GEML andthe GNF The criteria of the WHO Essential Medicine List wl be applied -2- he, ee “The GEML shall be updated once every two (2) years and the GNF once every four (4) yeas. ‘The GEML shall be in alignment with the Package of Essential Health Services in Guyana. ‘The medicines shall be identified by their generic or International Non-Proprietary Name (INN). ‘When several drugs are available fr the same indication, or ‘when two (2) or more drugs are therapeutically equivalent, selection shall be based on +The pharmaceutical products, dosage form and unit size that provides the most favourable benefitrisk ati; + Thebest cost advantages + Reliability ofsuppliee/ manufacturer; “+ Patient compliance. As a general rule, only products containing a single pharmacological active ingredient shall be selected, Fixed tatiocombinations shall be acceptable ifthe clinical condition justifies the use of more than one drug, and ifone or more of the following criteria are met: + The therapeutic efficacy ofthe fixed-dose combination is greater than the sum of effects ofthe individual drugs; + Thecost of the combination product isles than the total ost ofthe individual products; -23-+The fxed-dose combination improves compliance: + Thefixed: dose combination reduces the rsk of resistance. > Appiation for amendments to the GEML shall be made in ‘ain to the Minister of Public Health on the presctibed, form, including a justification for each suggested change. The addition of new medicines to the GEML shall only be approved if they offer distinct advantages over existing medicines Medicines shall be withdrawn from the listand replaced with safer alternatives if current information shows that they no longer havea favourable rsk/beneft ratio, Monitoring of compliance concerning the use of STGs shal be established and sustained by the relevant medicine regulatory authorities “Medicines that are not on the GEML, but are on the GNF, shallony be obtained by the Public Sector after authorisation ‘byan expert panel appointed by the NMTC. Ol metinesht onthe GNF shal be imported into ‘ayane for use inthe local healthcare system (Public and rat). unes the Miniter grants water STANDARD TREATMENT GUIDELINES (STS) > TheNTCsaleoe STG, harmonise wt by experts inrlaed pharmacists) inatethedevelopmentofevidencebased th existing clinical practice guidelines. Aiscipline (including physicians and STOsshallndude the mostcost-fetve therapeutic option ore besedon clinical evidenceand define the relevant prescribing and medicine use behaviour to promote quality drug use by halt care professionals, FACILITY MEDICINE AND THERAPEUTICS COMMITTEES (MTCS) > The NPS, in collaboration with the CMO, shall provide ‘guidelines and ensure the establishment of MTCs in all major health facilities (Government, quasi-Government and Private) in the country to ensure safe, efficient and cost- effective management of medicines. > The membership of the MTCs shall include representatives ofthe medical, pharmaceutical, nursing and administrative services ofthe institution, The NDPS shall be a statutory ‘member ofthe GPHCs MTC. > The committees shall, amongst other duties, be responsible for: + Selection of drugs for use based on the GEML and the GNF; Accurate estimation of pharmaceutical requirements for both the hospital and any peripheral health units served by the hospital + Control and management of drug. related budget and ‘expenditure; ‘+ Monitoring of use ofthe standard treatment guidelines and overall drug utilization; 3.Insttting appropriate measures forthe prompt, safe and efficient cisposl of expired drugs Instituting measures to address cases of medicine shortage in keeping with relevant regulations; «Any other matters relating to the rational use of medicines EDUCATION & INFORMATION > The MOPH, through the CMO and the NPS, shall ensure that the WHO Essential Drugs Concept and the principles of rational use of medicines are incorporated inthe curricula of allinsitutions involved in training health workers ‘Training curricula and continuing education programmes for all health professionals shall be revised as necessary to include a component on patent counselling about drug use, since counselling on the use of medicines is a critical part of| the presribing and dispensing process. > Regular public awareness campaigns relating to the use of medicines will be organised by the NPS, its subcommittees, and the PCG. > The NPS shall be responsible for providing information telated to medicines by establishing and maintaining a National Drug Information Centre (NDIC) with collaborative efforts of al stakeholders, including Traditional and Alternative Medicine Practitioners, to facilitate the collection, compilation, processing and dissemination of information egarding appropriate medicine use, including traditional and herbal medicines -26- re | > Public information and education on medicines shall be disseminated to ensure that, while the public has ready access to sufficient unbiased ‘common ailments and treatment options itis also made aware that medicines may cause significant adverse events and diseases, i practical information on > The NPS shal collaborate with the relevant Department responsible for health promotion to facilitate dissemination ‘of information tothe public > Prescription only medicines shall not be advertised for the direct use of consumers, Research on the social and cultural factors which affect the use of drugs shall be promoted to provide information on attitudes and belief that contribute to inappropriate drug, PRESCRIBING Prescription drugs shall only be prescribed by registered ‘medical, dental and other practitioners s0 qualified and authorised bylaw, > ‘The NPS shall develop a prescribing format that gives adequate information on: + Thepaien + Hiver disease conditions + The drugs + Thepresriber. -27- | | |a > Alldrug shllbe prescribed by their generic (INN) name > tormation on prescriptions shall include + Generic name ofthe medicines «+ Nameand gender ofthe patient 1 Strength of the medication: + Complete dose regimen: + Dateand duration of treatment Name, address and registration number ofthe prescriber » The NMTC, through the NPS, shall monitor prescribing practices tocnsureefficent safeandcost-ffective prescribing, and compliance with STGs. DISPENSING > Medicines shall only be dispensed by qualified licensed and registered persons duly authorised by the appropriate authority, > The NPS shall develop Good Dispensing Practice (GDP) Guidelines to standardise and improve dispensing, as well toprovidea minimum standard of practice > All medicines shall be dispensed and labelled using generic (INN) names, and the brand name may be inserted in parenthesis. > The minimum information to appear on the label includes: + Name ofthe patient + Generic name ofthe drug + Strength of the ive ingredients + Quantity of dispensed product; + Complete dose regimen in written and/or graphic form; + Name and address of the dispensing facility and dispenser; + Special instructions; + Date of dispensing; + Duration of use Education of the public on subjects including disease prevention, health promotion, self-diagnosis self-medication, first aid and suitable alternative non-drug treatments, shall be promoted through al available information and communication media Where a prescribed medicine fora given indication is not available, the pharmacist shall contact the prescriber for necessary modification, In cases where a specified brand fof prescribed medicine is not affordable or accessible to @ patient, pharmacist may substitute an equivalent gene form, after informing the patient and the prescriber where possible ‘TheNMTC will make available alist of medicines that should not be substituted unless under close medical supervision. 229.Ee PHARMACOVIGILANCE > ‘The NMTC (see Section Legislation), supported by the MOPH and other professional agencies, shall set up and maintain a National Centre for Pharmacovigilance (NCPv) as pat ofthe reorganised branch of the GA-FDD. > The NCPv shall be responsible forthe regular collection of structured reports from health care practitioners, pharmacies and pharmaceutical industries/wholesaers and the general public on Adverse Drug Reactions (ADRS) occuring The NCPv shall be responsible forthe identification of risk factors for, and underlying mechanisms of, ADRs occurring in Guyana, > The NCPy shall disseminate information on ADRs to all stakeholders, including the general public, and shall comply ‘with Guyana’ international reporting obligations TRADITIONAL AND COMPLEMENTARY MEDICINE POLICY OBJECTIVE “Thebenefits of Traditional Medicines (TMs) shall be maximised, ‘and where possible, integrated int the healthcare system. GOAL ‘To promote the sustainable use of safe and effective herbal medicines of approved quality, while protecting the public ‘against any posible adverse eects. STRATEGY > Collaboration with various stakeholder organisations, led by the NMTC activities shall be geared to ultimately develop 8 national formulary of traditional medicines to improve safety and monitor possible adverse events > TheNMTC shall beresponsibe for promoting, co-ordinating, and monitoring the implementation of multi-sectoral TM. activites. >The MOPH shall develop and implement a programme for the registration of TM practitioners. > UG and other agencies shall promote research inthe area of| TM J°TM knowledge and practices in their various ted Preservation forms shal be promoted and fa -31-evelopment of the herbal medicine industry, which will oy sustainable cultivation of medicinal plant resources, mpl shall be promoted, ‘The NMTC, through an expert committee, shall develop a formulary of traditional medicines. This formulary shall Serve as a guide forthe use of approved traditional and complementary medicines by healthcare providers. > The MOPH shall collaborate with relevant Ministries (such 4s the Ministry of Agriculture) and other stakeholders to promote the cultivation and sustainable use of medicinal plant. RESEARCH AND DEVELOPMENT POLICY OBJECTIVE Research in utilisation, management ‘medicines shall be promoted and enhanced, id development of GOAL To improve safe medicine selection, use and management;andto encourage drug research and development, STRATEGY Partnerships will be formed with policy makers, healthcare providers, industry, academia, research institutions, professional bodies, NGOs and consumer asociatons in the CAPABILITY AND CAPACITY TO CONDUCT RESEARCH > Training and development of competent researchers > Promotion of research culture among healthcare providers: > Creation ofa conducive environment for research, including funding: Integration and enhancement of drug research facilities and capabilities -33- as |DRUG UTILISATION AND MANAGEMENT regulations willbe introduced to safeguard the integeity of clinical tials and the welfare af tral subjects. Research to identify the best approach for managing medicine delivery systems and pharmaceutical care shall be emphasised. Research in traditional medicines shall also be encouraged and explored. ss > Thepriority areas include 4+ Impact of the National Medicine Policy: + Pharmacoeconomies; 1+ Issues relate to prescribing and dispensing; Behavioural and socio-cultural aspects of drug use; +) Medicine Safety DRUG RESEARCH AND DEVELOPMENT > Research for sale, effective and efficacious drugs aimed at alleviating common diseases and conditions, as well as newly emerging and re-emerging health problems, shall be encouraged. This shall include both basic and industrial research, Research priorities shall be determined based on the major health problems found in Guyana. > Transfer and acquisition of technology by domestic ‘companies shall be strongly zecommended, > Drug-related clinical tras shall be organised and conducted in accordance with Good Clinical Practice (GCP) Guidelines, including the need for institutional ethics reviews, Relevant -35-PROCUREMENT AND SUPPLY MANAGEMENT POLICY OBJECTIVE Maintain an efficient and integrated medicine supply chain management system. GOAL ‘To ensure equitable, adequate and uninterrupted availabilty of safe elective and quality asured medicines to every citizen of| Guyana STRATEGY > Careful selection of medicines, ethical procurement ‘procedures and improved supply chain management will be implemented > The Procurement Unit established by the MOPH shall execute an efficient and transparent procurement system as required by the Procurement Act and accompanying Regulations. > The MOPH shall establish a structure to oversee, among ‘other things, the administration ofthe Procurement Unit and procurement proces Standard operating procedures (for procurement and supply management) shall be developed, implemented and Periodically updated by the Procurement Unit >The Regional Health Officer (RHO) of each Region and the Head of each MOPH Programme shall be responsible for providing to the Logistics Management Unit (LMU) of the ‘MOPH, an annual list of tems to be procuted, "These lists shall be collated by the LMU to compile a National List of Pharmaceuticals and Health Commodities (to he procured) Technical approval ofthe national procurement ist shall be given by the NDPS and the CMO; MOPHL, > The Procurement Unit shall be responsible for procuring essential medicines and ather health commodities for the Public Health Sector. However, where medicines cannot be procured centelly, Regions shall be allowed to purchase following established guidelines, regulations and authorisation, > Only Level 5 (National Referral Facility) and specialist facilities in the Public Sector, having obtained authorisation from the NMTC in collaboration withthe NPS, are allowed to procure special medicines”, > The LMU shall manage al supply chain and logistics data, Including the collection an analysis of data to guide the procurement of medicines, The Materials Management Unit (MMU) and other relevant MOPH stakeholders shall use the data to make informed procurement, supply strategy and policy decisions. Data shall also be used for monitoring, medicine utilisation reviews and a trend analysis on a ‘quarterly basis, or as required ‘The LMU will conduct support visits to the various Regions to ensure compliance with logistics procedures for improved data management to inform procurement and distribution, “37.=ao—_—‘“‘iS™S—S The LMU shall maintain a National Health Commodities Specifications and Quantification Database (NHCSQD) to sid inform policies relevant to procurement and supplies ‘management. This database will include all medicines and other health commodities, along with their corresponding specifications. > The information flow required from the MMU database will be aligned to the MOPH’s Database, allowing key functionaries to access and track medicines and medical supplies PROCUREMENT > Procurement of medicines shall be restricted to items registered by the GA-FDD for use in Guyana, as stipulated. by the Food and Drugs Act 1971 and Regulations, 1977. 38. Le IITIESTSTS~—— Medicines shall be procuted for the Public Health Sector in accordance with the GEML by INN or generic names only > The Procurement Unit shall procure based on the latest {guidance ofthe WHO Interagency Operational Principles of Good Pharmaceutical Procurement, Procurement shall be planned, and performance of suppliers monitored. > The Procurement Unit, in consultation with the NPS, shall establish a system for pre-qualification of suppliers and manufacturers of medicines an allied products, > The Procurement Us shall produce an annual cost of procurement & supply management plan, The procurement planning process will be aligned with the annual GoG budgetary process. > The Procurement Unit shall employ a “Best Value for Money” policy in order to obtain the best procurement prices for essential medicines atthe central level. ‘This will be done by organising public tenders and monitoring ofthe bid prices from local as well as foreign companies. Where possible, framework contract shall be established. > ‘The GA-EDD shall confirm that marketing authorisations exist for all medicines before procurement or donation to Goyana, STORAGE > The GA-FDD shall ensure that all storage facilities in theand Private Sector Medicine Distribution System are Pablic hance withthe National Legislation and Guidelines incom storage faites shall be appropriately managed according th the WHO Good Pharmaceutical Sorage Practices, Facies that store and dispense medicines shall maintain, felevant and updated records of all medicines atthe facility. ‘Additionally, the facility shall comply with Good Storage Practice (GSP) requirements to ensure the maintenance of quality throughout the period of storage “The GA-EDD shall implement a monitoring programme to determine the quality of medicines tall Ievels of the supply js maintained under the storage chain, and to ensure quali «conditions at each level. Deteriorated, obsolete or atherwise sub-standard medicines shall be disposed of in accordance with national guidelines, prevailing envizonmental laws and regulations. DISTRIBUTION > Only medicines registered by the GA-FDD shall be distributed in Guyana > The MMU shall establish and maintain a regular distribution schedule fr all public health facilites. > The distribution of pharmaceutical and other health ‘commodities in the Regions shall be a collaborative effort between the MOPH and the Ministry of Communities; and, where necessary, the Ministry of Indigenous Peoples’ Affairs. > All facilites used in the distribution of medicines shall comply with the relevant national legislation and guidelines, DISPOSAL OF EXPIRED MEDICINES. > ‘The GA-EDD will ensure the identifcation, collection, and safe disposal of expired medicines and related waste. The GA-EDD shal be responsible forthe development and implementation of a National System for the Disposal of Expired and Unwanted Pharmaceuticals and Other Health Commodities. -a1-QUALITY, SAFETY AND EFFICACY OF MEDICINES POLICY OBJECTIVE Only safe, efficacious and quality assured medicines and allied ‘products that meet approved standards and specifications shall, be registered and made availabe for use in Guyana, GOAL ‘To ensure medicines marketed for patient care are safe, effective and quality assured to meet the health needs of ll citizens. STRATEGY Strengthening the GA-FDD and collaborating with related agencies such as Caribbean Public Health Agency (CARPHA) ‘through the legislative framework and enhanced pharmaceutical ‘quality assurance measures LEGISLATION AND REGULATIONS TO ENSURE THE QUALITY OF MEDICINES > TheGA-FDD, established under the Food and Drug Act 1977, is the Authority responsible for enforcing pharmaceutical regulations. The NMPC, in conjunction with GA-FDD, shall develop regulations and policies concerning the quality, salety and efficacy of drugs. » The NPS shall support the GA-EDD in executing its mandate -a2- by requesting evidence of safety, efficacy and effectiveness of 4 medicine fora specific condition or indication in advance ofa requisition forthe said product. Effective and comprehensive legislation shall be instituted to ensure the Full implementation of the GNMP and fulfil the obligation under law to make available only safe and efficacious medicines to consumers Regulation of medicines shall be managed through rational and transparent criteria and processes. Regulations shall be strengthened to ensure appropriate practices are followed in the development, production, Importation, supply, marketing, sale and management (including prescribing, dispensing and disposal) of medicines; ‘The level of regulation shall be consistent with potential benefits and risks forthe country and based on appropriate rlsk-assessment processes ‘The NPS shall develop and enforce National Guidelines for Quality Assurance forthe Supply Chain of Medicines. ‘The NPS shall develop and enforce standards forall premises ‘where medicines and allied products are being handled All processes prior to procurement are intended to ensure quality, safety, efficacy and timely delivery. The NCPV shall establish a robust post-marketing strategy to provide ‘ongoing monitoring of medicine safety. -43-———— LICENSING OF PREMISES AND PERSONNEL > Only licensed manufacturers, importers and wholesalers Shall be permitted to trade in registered medicines/ harmaceatcl products. Trading in controlled medicines Tall be undertaken only by a registered and licensed pharmacist atthe address om his or her Hence ‘These activities must be carried out in premises licensed for the said purpose and operating under the requirements of Good Manvfacturing Practices (GMPS), GSPs and other requirements as specified by regulations. LICENSING OF RETAIL PHARMACIES, The retail sale of controlled medicines shal be cartied out in licensed premises by licensed pharmacists. Dispensing of medicines shall be carrie out by a registered pharmacist, while registered medical and dental practitioners may dispense drugs forthe treatment and use oftheir patients on an emergency bass, with a limited amount of medication, > The sale of registered products other than controlled ‘medicines should only be made through licensed premises. > All dispensing of medicines shall comply with GDP. Guidelines to meet the requirements of quality, effective and safe drug supply > Allpharmaciesshallbe under the responsiblity ofa registered pharmacist. > Premises of registered medical and dental practitioners 48 involved in dispensing shal also conform to the same standards (QUALITY USE OF MEDICINES > Whether prescribed or self-selected, medicines must be used judiciously, and traditional alternatives may be considered where appropriate > An appropriate choice of medicine must take into consideration the potential sks and benefits ofthe medicine being used, the clinica condition being treated, dose, length of treatment and cost ofthe product, > Misuse of medicines consists of either overdose, underdose or nodose; such occurrences should be minimal > Claims of therapeutic benefits of medicines must be ‘evidenced by a change in the health outcomes of consumer > Consumers and health professionals, including prescribers, ‘must have access to current information and education on the safest way to use medicines. > Development and use of clinical guidelines and protocels shall be implemented for safe medication use. > Reporting of issues related to medicines must be done in an sccurate and timely manner by professionals and consumers. INSPECTION 1 shall be supported by > Medicine legislation and regulace and effective professional inspections in required vigilan drdertcnsure that activites in the medicines manufacturing nd supply chain are in compliance withthe requirements of the relevant licences and regulations > Pharmacy enforcement officers shall perform inspections of healthcare facilities in relation to medicines. Inspection of manufacturing facilities and wholesale premises shall be conducted by quality assurance pharmacists. MEDICINE ADVERTISEMENT AND PROMOTION > The MOPH shall egulateall advertisement and promotion of ‘medicines, including traditional medicines. The regulations shall be inline with the WHO ethical criteria for medicinal promotion. > Current relevant legislation shall be reviewed and strengthened where and when when necessary. FALSIFIED MEDICINES > An appropriate legal and technical framework for concurrent «enforcement of laws and regulations for market surveillance shall be established by the MOPH, supported by GA- FDD and CARPHA, to combat the problem of counterfeit medicines. DRUG REGISTRATION > Only medicines registered by the GA-FDD shall be allowed tobe marketed and used in Guyana, 46 > Assessment of safety, quality and efficacy based om adequate and scientific data is the prerequisite for registration. Registration of traditional medicines willbe based on safety and quality until research in traditional medicines ean be developed t0 enable efficacy to also be a prerequisite. The registration shall only be valid for a specified period as ‘deemed appropriate by the GA-FDD, ater which every drug is required to be re-evaluated for re-registration. Medicines recommended by the Caribbean Regulatory system (CRS), a regulatory unit within CARPHA, shal also be considered for registration by the GA-FDD. » There shall be appropriate procedures for the timely registration of life-saving products and essential medicines, without jeopardising the elements of safety, quality and efficacy > The Minister of Public Health, under advice from the NMTC, may exempt medicines for the specific use of individual patients from registration requirements, bt such medicines may be subject to testing, once so advised by the relevant Authorities > Such requests shall be certified by a local medical specialist inthe related field and an import permit obtained from the GAEDD. > Medicine donations shall be exempt from registration ‘requirements; however, they must conform to the National Guidelines on drug donations. -a7-INSPECTION > Inspections shal be conducted to ascertain that all activities within the drug manufacturing and supp with the regulations. Current Gi y chain comply MP and GSP principles and anyother requirements deemed necessary by the regulatory authority shal form the basi ofthese inspections. The inspections shall be extended to drug quality control laboratories to ensure compliance with current Good Laboratory Practices (GLP). The clinical trial centers shall be inspected to ensure conformity with GCPs, > Legal provision shall be made for the medicine regulatory auditors to enforce the regulations immediately whenever necessary, > Training programmes for auditors shall be developed in collaboration with relevant training institutions, and inspection guidelines shall beestablished to facilitate effective Inspection services PHARMACEUTICAL QUALITY TESTING > The GA-EDD shall implement and maintain an effective pharmaceutical quality testing system to prevent oF remove falsified and sub-standard medicines from entering the supply chain and to assure the quality of medicines during the period of thet shelf life, > The pharmaceutical quality testing system shall include: + The establishment of an adequately equipped, staffed and resourced National Medicine Quality Control Laboratory (NMQCL)s Enforcement of legislation to control both the quality of and services, which medicines and professional activities will inflaence medicine quality Strategic testing on imported and locally manufactured medicines to safeguard against sub-standard and counterfeit medicines «| Integration of semi-quantitative quality control test, such as the Minilab Testing Initiative, into the activities ofthe NMQCL, POST- MARKETING SURVEILLANCE > Aneeffective postsmarketing surveillance system, including ‘monitoring of ADRs, shall be ongoing to ensure drug quality, safety and efficacy -49-FINANCING POLICY OBJECTIVE A reliable mechanism shall be maintained to have sufficient financial resources available, accessible and appropriately disbursed to procure all medicines needed; and a National Pricing Policy put in place for essential medicines GOAL ‘To have quality medicines at affordable prices, both in the Private and Public Sectors, © meet the treatment needs of the citizens of Guyana. STRATEGY > Implement a pricing policy supported by the appropriate ‘xerption of duties on essential medicines. > The GoG will make adequate provisions within the National Health Budget forthe implementation and monitoring ofthe strategies ofthe GNMP. > TheGoG shall finance the procurement of adequate quantities ‘of essential, good quality, affordable medicines and other ‘essential health commodities in the Public Sector Health Facilities. Where appropriate, the GoG shall collaborate with developmental partners and the Private Sector in the Funding of medicines for the Public Sector. > The MoPH shall advocate the exemption from taxation (Duties and Value Added Tax) of a basket of medicines and their associated and essential health commodities aw and packaging materials, to increase affordability nd, subsequently, their availability t0 patients. All other medicines and health commodities may be subjected to the relevant taxation Incentives shall be given forthe local production of essential generic medicines. The Procurement Unit shall establish 2 reasonable domestic preference percentage for national manufactures, a distinct ftom distributors and agents, [A Pharmaceutical Pricing Policy shall be developed and implemented to facilitate increased availability through improvement in the affordability of medicines. -s1-eee TECHNICAL CO-OPERATION POLICY OBJECTIVE “Technica llaboration and co-operation in the implemen and strengthening of leant ares inthe Pharmaceanleoace thalbecstablihed with development panes and sakehoae, at the National, Regional and International levels. a GOAL ‘To ensure that technical co-operation is explored, standards are ‘upheld, and best practices are encouraged to optimise the se of resources and strengthen national and Regional Policies, STRATEGY > Partnerships, strategies, setting goals, training, sharing of information, skills, expertise and facilities supported by legislation, regulations and guidelines related to medicines regionally and internationally. NATIONAL > The MOPH shall facilitate and co-ordinate the co-operation and sharing of information among Private and Public ‘pharmaceutical agencies for planning and implementation > There shall be an effective partnership with the following stakeholders: consumers, professionals, practitioners, Government Agencies and NGOs to support continued progress and development in the Pharmacy Sector. sesthrough mutual and shared understanding sion, consultative arrangements, the stakeholders, the siategialiane Sproles. open communica and cons ‘plats and implements Standard of regulations ancl enforcement. Sppoprite standard of regula vensus agreements amon rs shall be fostered t0achie INTERNATIONAL Collaboration with international development partners seh as PAHO/WHO, USAID, CARICOM, IDB, WB, GE aerpathers will be encouraged, established and sustained in ‘greed technical areas. [MEDICINE REGULATIONS AND QUALITY ASSURANCE [AND OTHER RELEVANT AREAS Operational research will focus on the implementation of the GNMB, development and implementation of the revised Health Commodity Supply System (FCSS) in the Public Sector, as well as economy of provision, use and quality assurance of medicines A global information network for effective communication shallbe established to provide a framework fr the exchange and sharingofinformation. This will comprise internationally recognised Insitaions within the Health Sector.MONITORING AND EVALUATION POLICY OBJECTIVE An effective M&E system shall be developed and maintained to factate objective data gathering and analysis for determining the progress of implementation, as well a to provide feedback to have informed decision-making Goal ‘Todevelop and implementan M&E Plan that wil facilitate annual assessment of the performance ofthe GNMP implementation, in accordance with established strategies, objectiv outlined in the GNMPIR ind activities STRATEGY > ‘The GNMPC shall develop a comprehensive Plan for assessing the progress ofthe GNMP implementation process. ‘This plan shall be subject to the approval of the HMC. > The HMC shall appoint alead agency to perform the M&E of the GNMP and its accompanying GNMPIP > Periodic assessment ofthe effectiveness of the policy shall bedone, and the feedback used to revise priorities, strategies and activites as necessary 54 ANNEXE ME 7 Designation Organization Represented Siem ON one Pama apie A) ee 1 | ‘alin mono ayia ‘Sma oF al “manda Bate LHUMOPH cr Paitin ov a er a ~ [ene monson-arter_ 06 stove ag TR eae ig nie OP orth aa ete Feet Deo GSC DPE PAHO eset or [ong om as ones ria espa (een sig es PD cet Gone nr euehanla Een Dts oI Dees es vc Sle wom [ita ands ec -55-: ET Ine area Jeo = a in [MR FE [Simtateedy ——_——_| PH > pater as DcShanaeoPeraud __| [sanoyFoney | SH00 Ene [be hishore Ramdas Grae | B.Umoittn ‘| MOP eae ‘enfaberon hana Lg Os UNDA palsbeton | GADD | anager AAUP [Rorenton ae a ListofParipans Second tage Review Cree iad tin [Destin [wists Dict onl Pay Sens Tcottactus Chaian, Pharmacy ouncl | ! [bute Depay 0 | | Jewel Edmnanson-Carter | Lectueet, Department Pharmacy, UG [cate saa ian | [Macao uty age OP | [mana ae |i bie maint al eben Seri npct D0 Bc Pal brs com dor T -56-