Essential drugs policy in Bolivia

Since the publication of the WHO list of essential drugs 10years ago, there has been a growing volume of literature onthe topic. This paper on the experience of essential drugs policyin Bolivia is written in the belief that reports on attemptsto implement drugs policies in individual countries are oneof the most instructive sources of information. Coming intopower in 1982, the democratic Bolivian government set up a centrally-controlledagency to be responsible for the procurement and distributionof drugs, with a view to making basic drugs available throughoutthe country. Despite limited technical and institutional resources,the policy proved administratively and organizationally practical.However problems arose at the political level both because theinterests of the industry and pharmacists were threatened andbecause there was disagreement within the government as to whetherdrugs should be seen as commercial goods or health aids. Theagency set up to implement the drug policy was abolished withintwo months of the neo-liberal government resuming power in 1985- emphasizing the symbolic importance of the agency in the overallhealth policy. Only when those concerned with drug policy atan international level concentrate on the political and culturalobstacles to essential drugs policies, and stop giving priorityto the practical issues of procurement and distribution, willtheir policies gain the credibility which is a prerequisitefor success.     

Evaluation of national malaria control programmes in Africa.

Evaluation is an essential management tool for the improvement of public health programmes or projects. As malaria morbidity and mortality continue to increase in most countries in Africa, international agencies and malaria control programme managers have identified the strengthening of programme evaluation as an important strategy for improving the efficiency and effectiveness of malaria control programmes. Managers can develop an evaluation strategy only after they have defined programme objectives and planned specific programme activities. Indicators should be directly related to programme objectives and should be selected on the basis of the following criteria: their validity; reliability; ability to detect change within a reasonable time period and as a result of successful programme implementation; ability to be interpreted; and usefulness in guiding programme change. Only those indicators that can be measured with available programme resources should be selected. Managers will also need to identify the sources of indicator data and to determine how often each indicator will be measured. Programme managers should develop criteria or indicators for the following: programme policies and plans; the process of programme implementation; the outcomes of malaria control interventions in disease management and prevention; and programme impact in terms of reductions in malaria-related mortality and morbidity. Key issues related to the management of evaluation activities within a national programme include the need to begin with available resources and build incrementally; to explore options for administering evaluation activities; to select, train and supervise staff who carry out evaluation activities; to develop quality control strategies; and to ensure that data are managed and communicated in ways that support effective programme decision-making. For evaluation to lead to improvements in malaria control programmes it must be clearly defined as a part of the programme management process. Programme managers should lead this developmental process, ensuring that evaluation methods produce the information they need to monitor and improve their programmes at reasonable cost.     

TB control programmes: the challenges for Africa

Governmental neglect of tuberculosis (TB), inadequately managed and inaccurately designed TB control programs, population growth, and the HIV epidemic account for the resurgence of TB in sub-Saharan Africa. The World Health Organization and the International Union against TB and Lung Disease have developed a TB control strategy that aims to reduce mortality, morbidity, and transmission of TB. It aims for an 85% cure rate among detected new cases of smear-positive TB and a 70% rate of detecting existing smear-positive TB cases. The strategy involves the provision of short-course chemotherapy (SCC) to all identified smear-positive TB cases through directly observed treatment (DOTS). SCC treatment regimens for smear-positive pulmonary TB recommended for sub-Saharan African countries are: initial phase = daily administration over 2 months of streptomycin, rifampicin, isoniazid, and pyrazinamide; continuation phase = 3 doses over 4 months of isoniazid and rifampicin or daily administration of thiacetazone and isoniazid or of ethambutol and isoniazid. A TB control policy must be implemented to bring about effective TB control. The essential elements of this policy include political commitment, case detection through passive case-finding, SCC, a regular supply of essential drugs, and a monitoring and evaluation system. Political commitment involves establishing a National TB Control Program to be integrated into the existing health structure. Increased awareness of TB in the community and among health workers and a reference laboratory are needed to make case finding successful. A distribution and logistics system is needed to ensure uninterrupted intake of drugs throughout treatment. These regimens have been very successful and cost-effective but pose several disadvantages (e.g., heavy workload of recommended 3 sputum smear tests). A simplified approach involves 1 initial sputum smear for 6 months; 6-months, intermittent rifampicin-based therapy, 100% DOTS throughout entire treatment course, and ascertainment of treatment completion rates and mortality rates in all patients.     

Essential drugs in the new international economic environment

Recent global developments in the regulation of trade and intellectual property rights threaten to hinder the access of populations in developing countries to essential drugs. The authors argue for state intervention in the health and pharmaceutical markets in order to guarantee equitable access to these products.     

Essential drugs for ration kits in developing countries

Since the early 1980s drug ration kits have been used to improve the supply of essential drugs to rural health facilities in developing countries. This paper evaluates some of the experiences with kit systems in Angola, Bhutan, Democratic Yemen, Guinea-Conakry, Kenya, Mozambique, Sudan, Tanzania, Uganda and Zambia in relation to the selection of drugs for the kits and their quantities and cost. Data were collected through a review of published papers, annual reports and programme evaluations, by questionnaires among field staff and interviews with key experts. In comparing the 10 programmes, 21 drugs can be identified that are used in at least two-thirds of all kits. This list may be useful for evaluation and planning purposes. Six drugs (ORS, chloroquine and 4 antibiotics) usually account for over 60% of the cost of the kit. Careful monitoring of the price and quantities of these 6 drugs can therefore be very cost-effective. In the absence of reliable data on morbidity and drug needs in the initial phases of a kit system, the median drug quantities in kits from these 10 countries may serve as a starting point. Accumulating surpluses are sometimes perceived as a serious disadvantage of kit systems, ORS, benzylbenzoate solution and iron tablets are the three drugs that have most frequently accumulated. These drugs are relatively cheap and usually have a long shelf-life; in most programmes they have been successfully redistributed to other health facilities while the kit content was being adapted. The overall financial loss due to accumulation of surpluses is therefore limited. Most programmes have reached a stable kit content within two years.     

The design and implementation of effective epidemiological surveillance programmes in Sub-Saharan Africa

Livestock is one of the main sources of wealth in developing countries. The improvement of national herds and of their productivity through controlling the main diseases and preventing epizootics is a major objective in these countries. The organisation of surveillance systems is indispensable to proper animal health management, both nationally and internationally. Therefore, thanks to foreign assistance, developing countries have gradually established epidemiological surveillance networks, despite unfavourable contexts (poverty, lack of resources or infrastructure...). To date, many networks are operating in satisfactory manner and produce tangible results. However, further efforts must be made to improve the quality of sanitary information produced, its performance and sustainability. This article discusses the context and motivations for the establishment of epidemiological surveillance networks in developing countries, especially in Africa, by describing some of their operational specificities and some results. Finally, it presents the example of a Mauritanian animal disease epidemiological surveillance network and its role in managing a health crisis.     

Community financing of drugs in Sub-Saharan Africa.

'Health for all by the year 2000' is unlikely to be achieved in a number of Third World countries, including those in Sub-Saharan Africa, if reliance is placed solely on the public health budget. This article looks at a range of alternative and additional sources of revenue and, in particular, at the scope for community financing of drugs. Developments in the region are reviewed for their insights into the strengths and weaknesses of each financing scheme; and, as a guide to shaping policies that make an appropriate choice of method of health care financing.     

Essential drugs: economics and politics in international health

The World Health Organization since the mid-1970s has expanded its activities on essential drugs from a concept to a list to policies, establishing the Action Program on Essential Drugs and Vaccines in 1981. The global social and political environment, especially the emergence of an international consumers movement, created favorable conditions for acceptance of the concept of essential drugs, despite initial resistance by the pharmaceutical industry. The WHO achieved a major accomplishment in getting other organizations to accept the WHO's evolving definition of essential drugs as legitimate. But the relationship between public and private sectors remains a key issue in achieving the objectives of essential drugs policies, an issue the WHO has not fully or directly addressed. Potentials for conflict and collaboration between the WHO and the industry exist around three topics: the extent of regulation, the role of the market, and local production. The case of essential drugs illustrates a new pattern that has emerged for setting the international health agenda, with open participation in international organizations by industry associations and by consumer groups. These changes in the international agenda-setting process influence national policy but still leave difficult problems of implementation at the country level.     

Potential uses of cost analyses in child survival programmes: evidence from Africa

How can analyses of costs and cost-effectiveness help internationalhealth care specialists to monitor service delivery, evaluateactivities, plan for improvements in programmes, and arrangefor adequate financing? Answers illustrated in this paper includecomparison of the average costs of specific services among localhealth care facilities for monitoring and supervision purposes;interpretation of total and average costs to increase programmeefficiency; consideration of the relative cost-effectivenessof various immunization strategies; projection of recurrentcosts to indicate the magnitude of future financing needs; and,derivation of information incidental to cost analyses, but essentialto programme operations and personnel management. Supportiveexamples include results from child survival programmes in Africa,with particular emphasis on evaluations of some national programmecomponents from the Combatting Childhood Communicable Diseases(CCCD) Project.     

Charging for drugs in Africa: UNICEF'S 'Bamako Initiative'

Recession and economic adjustment policies have led to massiveresource shortages in government health systems in many lessdeveloped countries in Africa. There is growing evidence thatthe IMF- and World Bank-sponsored adjustment programmes areresponsible for negative effects on the health of the poor inthese countries. Calls for a New International Economic Orderand 'adjustment' in the industrialized countries have been ignoredand the resource flow from the poor to the rich countries continues.UNICEF is currently promoting ‘Adjustment with a humanface’ as a means of alleviating poverty and minimizingthe negative impact of adjustment on the poor. In the healthsector, this approach concentrates on the GOBI-FFF strategyand the supply of essential drugs to primary level health services.UNICEF is also in the process of launching the ‘BamakoInitiative’ which aims, by introducing drug/treatmentcharges and setting-up revolving drug funds at community level,to finance drg costs, the operational costs of the MCH programmeand the salaries of community health workers at primary level.Quite apart from the debatable long-term impact of the healthstrategy being advocated, the Bamako Initiative poses seriousquestions related to equity and the implementation of fee systemswhich must be answered.     

Maternal and congenital syphilis programmes: case studies in Bolivia, Kenya and South Africa

Preventing congenital syphilis is not technically difficult, however operational difficulties limit the effectiveness of programmes in many settings. This paper reports on programmes in Bolivia, Kenya, and South Africa. All three countries have established antenatal syphilis control programmes. Early antenatal syphilis screening and management of positive cases were difficult to implement since most women presented for their first antenatal clinic visit after 6 months of pregnancy. Most women had rapid plasma reagin (RPR) testing; results were available on the same day in some clinics but took up to 4 weeks in others. No clinic had a system for tracking RPR-reactive women who did not return for their results. There were no guidelines for providers in Kenya and Bolivia. In all countries, supplies, drugs, notification cards, and other consumables were often unavailable. Health-care providers were unmotivated in Kenya and reported an excessive client load. In South Africa and Kenya some clients reported at their exit interview that they had never heard of syphilis nor had they been informed why blood was collected. Several prevention strategies could be implemented at the clinic level. These include encouraging women to attend for antenatal care before the fourth month of pregnancy, providing point-of-care testing so that results are available immediately and women who test positive can be treated, implementing presumptive treatment of sexual partners of women who test positive, adding a second test later in pregnancy so that incident cases can be managed, and improving the quality of syphilis care during pregnancy, delivery, and the neonatal period.     

Vertical vs horizontal health programmes in Africa: Idealism, pragmatism, resources and efficiency

Argument still rages over whether vertical health programmes—attacking one or a few health problems—should still be set up in developing countries, or whether all their efforts should be devoted to establishing a horizontal multiproblem approach such as primary health care. This paper argues that the debate can be made rather more informed firstly by a consideration of the technologies available to improve health and the methods of delivery to which they are most suited: secondly by a consideration of their effectiveness and the organisational feasibility of different strategies of delivery, and finally, by investigation of the total costs and cost-effectiveness of different delivery systems. Particular attention is given to the contribution of economic analysis to elucidating these issues, and a variety of cost-effectiveness studies are reviewed to see what information is available on the way in which particular health programmes such as malaria control and immunisation activities can be organised in order to maximise their cost-effectiveness.     

Essential drugs for cancer chemotherapy. WHO consultation.

The WHO recommendation on essential drugs for cancer chemotherapy has been updated. General principles on the proper role of cancer chemotherapeutic agents in relation to efficacy and on the classification of tumours with respect to their curative potential are discussed. Curable cancers and those cancers where the cost-benefit ratio clearly favours drug treatment can be managed appropriately based on only 24 drugs. Fourteen of them should ideally be available for the treatment of the ten most common cancers, 8 others should be available only where the resources and facilities exist for the treatment of paediatric tumours and leukaemias, and two drugs were recommended for the treatment of tumours for which there is good evidence that systemic treatment will palliate symptoms but not substantially prolong survival. The adoption of these recommendations should result in considerable reduction in both the mortality and morbidity from cancer throughout the world.     

上海市郊农村社区卫生服务站基本药物调查

目的：了解上海市农村社区卫生服务站“提供基本药物”的现状，研讨其新时期提供基本药物问题。方法：采取分层抽样，对90个站2005年所提供的基本药物作回顾性调查研究。结果：90站中，提供基本药物最少的68种；最多204种；平均129种；社区卫生服务站平均药物种类95％可信区间为122～136种。按药理作用归类，共涉及20大类354种药物。提供品种数量前6类药物依次为：中成药；抗微生物药；心血管系统药；消化系统药；解热镇痛药；呼吸系统药。分别占总量的14．7％；11．6％；10．7％；10．1％；8．5％；7．0％。结论：解决农民基本医疗和公共卫生服务，应制定和完善社区卫生服务站（村卫生室）基本药物目录，在制定和实施基本药物目录过程中应考虑对其进行动态管理。     

Competition for the promotion of essential generic drugs in Africa

Statement of the problem: in most sub-Saharan countries, an extensive economic crisis coupled with a low level of existing resources has put most pharmaceuticals beyond the reach of the general public. This situation was worsened by the devaluation of the Franc CFA in 1994. The supply of lowprice drugs and the improvement of rational drug use is now a priority. Unfortunately, essential generic drugs are little known and used in Africa. Objective: 1. To improve the knowledge of and confidence in essential and generic drugs among providers, prescribers and consumers, through the participation of the general public in an incentive-based, creative competition; 2. To collect locally-adapted promotional material, to be used in the future promotion of essential and generic drugs in Africa. Design, setting and method: a competition was announced in June 1995, via various networks, in French-speaking Africa: the population was invited to create one or several items promoting essential generic drugs. These items included slogans, posters, songs and short plays. Over 550 entries were received before the deadline (15 October 1995), from 22 countries (mostly Sub-Saharan and French-speaking). The entries included 387 slogans, 94 posters, 22 plays, and various (photos, comic strips, songs, poems). Results: 1. Greater awareness of essential generic drugs in Western Africa, through the publicity given to the competition; 2. Selection of a pool of approximately 200 promotional items, produced by the target populations, to be published in a catalog and distributed in African countries; 3. Insights into popular practices and representations of Western medications, and local re-interpretation of the concept. Conclusion: this public competition was effective at achieving three important goals: 1. Dynamic promotion (the competition was the opportunity for school projects, radio talkshows, etc. on generic drugs); 2. Re appropriation of a policy, thanks to a participative approach; 3. Analysis of the population's general comprehension of pharmaceuticals, through analysis of competition entries.     

Use of drugs for malaria control in tropical Africa.

At present, in countries of tropical Africa, chemotherapy is the main and often the only operationally, administratively, and financially feasible method of malaria control. This applies particularly in rural areas. This article reviews experience with chemotherapy in Africa since the late 1940s with mepacrine, proguanil, pyrimethamine, chloroquine, amodiaquine, and sulfones and sulfonamides in combination with dihydrofolate reductase inhibitors. Chloroquine has proved to be the most effective compound and it is the drug of choice as long as malarial parasites remain susceptible to it. Because of reports from East Africa of strains of Plasmodium falciparum resistant to 4-aminoquinolines, it is essential that national and regional policies be developed for the rational use of antimalarials.