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Pharmaceutical services in developing countries face particular challenges that are significantly different from those faced by pharmacists in the so-called developed world.Medicines that are normally restricted to prescription in the developed world may be readily available on general sale in developing countries, while other extremely useful medicines such as morphine for severe pain may not be available at all or in such small quantities as to be effectively unobtainable. Many patients will not be able to afford all their prescribed medicines and so must choose which ones to buy. Doctors are supposed to make patients better, so often use irrational choices to achieve a cure. An example of this is prescribing several antibiotics for a single condition or prescribing injections where oral medication is sufficient. The quality of medicines may be substandard or even dangerous. In the early 1990s, children in South Asia died as a result of consuming paracetamol elixir which contained ethylene glycol instead of propylene glycol. In addition, medicines may be poorly or inappropriately stored, thus rendering them useless at the time of sale or consumption.Local and foreign pharmaceutical industry pressure, advertizing and incentives may lead to irrational choices. Doctors can be offered large inducements to promote and prescribe certain medicines. On the other hand, patients may request the contraceptive agent that is advertised on the neon signs in the city center or may believe that the famous brand name is bound to work better than a good-quality generic equivalent.
Ensuring medicines are available Many developing nations have developed national drug policies, a concept that has been actively promoted by the WHO. For example, the national drug policy for IndonesiaWorld Health Organization (1990) Review of the drug program in Indonesia. Report of a WHO mission 16 October-3 November 1989. DAP. 90(11): 1-36. drawn up in 1983 had the following objectives:
Encouraging rational prescribing One of the first challenges is to promote and develop rational prescribing, and a number of international initiatives exist in this area. WHO has actively promoted rational drug use as one of the major elements in its Drug Action Programme. In its publication A Guide to Good Prescribingde Vries TPG, Henning RH, Hogerzeil HV, Fresle DA (1994) Guide to good precribing. WHO/DAP. 11: 1-108 the process is outlined as:
Rational dispensing In situations where medicines are dispensed in small, screwed-up pieces of brown paper, the need for instructions to the patient takes on a whole new dimension. Medicines should always be issued in appropriate containers and labelled. While the patient may be unable to read, the next healthcare worker who seeks to help the patient is is probably literate. There are many tried-and-tested methods in the literature for using pictures and diagrams to aid patient compliance. Symbols such as a rising or setting sun to depict time of day have also been used, particularly for treatments where regular medication is important, such as cases of tuberculosis or leprosy.Georgiev GD, McDougall C (1998) Blister calendar packs - potential for improvement in the supply and utilization of multiple drug therapy in leprosy control programs. ''International Journal of Leprosy and Other Mycobacterial Diseases. 56(4): 603-10.Poverty may force patients to purchase one day's supply of medicines at a time, so it is important to ensure that antibiotics are used rationally and not just for one or two day's treatment. Often, poor patients need help from pharmacists to understand which are the most important medicines and to identify the prescribed items, typically vitamins, that can be missed in order to reduce the overall cost of the prescription to a more manageable level.
The essential drugs concept The essential drugs list concept was developed from a report to the 28th World Health Assembly in 1975 as a scheme to extend the range of necessary drugs to populations who had poor access because of the existing supply structure. The plan was to develop essential drugs lists based on the local health needs of each country and to periodically update these with the advice of experts in public health, medicine, pharmacology, pharmacy and drug management. Resolution number 28.66 at the AssemblyWorld Health Organization (1985) Handbook of Resolutions and Decisions of the World Health Assembly and Executive Board, vol II 1973-1984. World Health Organization. Geneva. requested the WHO Director-General to implement the proposal, which led subsequently to an initial model list of essential drugs (WHO Technical Series no 615, 1977). This model list has undergone regular review at approximately two-yearly intervals and the current 14th list was published in March 2005.World Health Organization (2005) Essential Drugs WHO Model List (revised March 2005). The model list is perceived by the WHO to be an indication of a common core of medicines to cover most common needs. There is a strong emphasis on the need for national policy decisions and local ownership and implementation. In addition, a number of guiding principles for essential drug programs have emerged.
The model list of essential drugsThe model list of essential drugs is divided into 27 main sections, which are listed in English in alphabetical order. Recommendations are for drugs and presentations. For example, paracetamol appears as tablets in strengths of 100 mg to 500 mg, suppositories 100 mg and syrup 125 mg/5ml. Certain drugs are marked with an asterisk (previously a ៛), which denotes an example of a therapeutic group, and other drugs in the same group could serve as alternatives.The lists are drawn up by consensus and generally are sensible choices. There are ongoing initiatives to define the evidence that supports the list. This demonstrates the areas where RCTs (randomized controlled trials) or systematic reviews exist and serves to highlight areas either where further research is needed or where similar drugs may exist which have better supporting evidence.In addition to work to strengthen the evidence base, there is a proposal to encourage the development of Cochrane reviews for drugs that do not have systematic review evidence.Application of NNTs (numbers needed to treat) to the underpinning evidence should further strengthen the lists. At present, there is an assumption among doctors in some parts of the world that the essential drugs list is really for the poor of society and is somehow inferior. The use of NNTs around analgesics in the list goes some way to disprove this and these developments may increase the importance of essential drugs lists.
Communicating clear messages The impact of pharmaceutical representatives and the power of this approach has led to the concept of academic detailing to provide clear messages. A study by Thaver and HarphamThaver IH, Harpharm T (1997) Private practitioners in the slums of Karachi: professional development and innovative approaches for improving practice. In: Bennett S, McPake B, Mills A (eds) Private Health Providers in Developing Countries: serving the public interest? Zed Books, London & New Jersey. described the work of 25 private practitioners in area around Karachi. The work was based on assessment of prescribing practices, and for each practitioner included 30 prescriptions for acute respiratory infections (ARIs) or diarrhea in children under 12 years of age. A total of 736 prescriptions were analysed and it was found that an average of four drugs were either prescribed or dispensed for each consultation. An antibiotic was prescribed in 66% of prescriptions, and 14% of prescriptions were for an injection. Antibiotics were requested for 81% of diarrhea cases and 62% of ARI cases. Of the 177 prescriptions for diarrhea, only 29% were for oral rehydration solution. The researchers went on to convert this information into clear messages for academic dealing back to the doctors. The researchers went on to implement the program and assessed the benefits. This was a good piece of work based on developing messages that are supported by evidence.
Drug donations It is a natural human reaction to want to help in whatever way possible when face with human disaster, either as a result of some catastrophe or because of extreme poverty. Sympathetic individuals want to take action to help in a situation in which they would otherwise be helpless, and workers in difficult circumstances, only too aware of waste and excess at home, want to make use of otherwise worthless materials. The problem is that these situations do not lend themselves to objectivity. There are numerous accounts of tons of useless drugs being air-freighted into disaster areas. It the requires huge resources to sort out these charitable acts and often the drugs cannot be identified because the labels are not in a familiar language. In many cases, huge quantities have to be destroyed simply because the drugs are out of date, spoiled, unidentifiable, or totally irrelevant to local needs. Generally, had the cost of shipping been donated instead, then many more people would have benefited.In response to this, the WHO has generated guidelines for drug donations from a consensus of major international agencies involved in emergency relief. If these are followed, a significant improvement in terms of patient benefit and use of human resources will result.
WHO guidelines for drug donations 2005
Selection of drugs
Quality assurance (QA) and shelf life
Presentation, packing and labelling
Information and management
Evidence-based pharmacy practice While modern practices, including the development of clinical pharmacy, are important, many basic issues await significant change in developing countries.
Conclusions Evidence is just as important in the developing world as it is in the developed world. Poverty comes in many forms and while the form most noticed is famine and poor housing, both of which are potent killers, medical and knowledge poverty are also significant. Evidence-based practice is one of the ways in which these problems can be minimized. Potentially, one of the greatest benefits of the internet is the possibility of ending knowledge poverty and in turn influencing all the factors that undermine wellbeing. Essential drugs programs have been a major step forward in ensuring that the maximum number benefit from effective drug therapy for disease.
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