PROMOTING RATIONAL USE OF MEDICINES

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					contact                A publication of the World Council of Churches

    PROMOTING RATIONAL USE OF
           MEDICINES




   Editorial
2 Understanding rational use of                              17 Factors influencing consumer use
  medicines                                                     of medicines
   Features                                                     Experiences
5 Policies and structures to ensure
  rational use of medicines
                                            No   183         22 The challenge of rational use of
                                                                medicines in NIS
                                          October-December
9 Strategies to promote rational use of         2006
                                                             25 Promoting rational use of medicines
  medicines                                                     in Peru
   Opinions                                                  28 Sensitizing the public in Burkina
                                                                Faso about street medicines
10 Making the best use of medicines
                                                             31 Bible Study
12 How “rational” is our use of
   medicines?                                                32 Titles of Resources
   Commentaries
14 Lures to irrational use of medicines
EDITORIAL


 UNDERSTANDING RATIONAL USE OF MEDICINES
   Rational use of medicines requires that “patients receive medications appropriate to their clinical
 needs, in doses that meet their own individual requirements, for an adequate period of time, and at
                                                      the lowest cost to them and their community.”1


                                            M     ore than 50% of all medicines
                                                  worldwide are prescribed, dispensed,
                                            or sold inappropriately and 50% of patients
                                                                                          use of non-sterile injections is leading to
                                                                                          the transmission of hepatitis, HIV/AIDS and
                                                                                          other blood-borne diseases. Irrational use
                                            fail to take them correctly.2 Conversely,     of medicines can stimulate inappropriate
                                            about one-third of the world’s population     patient demand, and lead to reduced ac-
                                            lacks access to essential medicines. Treat-   cess and attendance rates due to medicine
                                            ment with medicines is one of the most        stock-outs and loss of patient confidence in
                                            cost-effective medical interventions known,   the health system.
                                            and the proportion of national health bud-
                                            gets spent on medicines ranges between        Monitoring the use of medicines
                                            10% and 20% in developed countries            From 1990 to date, the World Health Orga-
                                            and between 20% and 40% in developing         nization (WHO) has created a database of
                                            countries. Thus, it is extremely serious      more than 700 published and unpublished
         The proportion of
                                            that so much medicine is being used in an     surveys of medicine use carried out in
    national health budgets                                                               developing countries and countries with
                                            inappropriate and irrational way.
        spent on medicines                                                                economies in transition. Results from this
                                            Irrational use                                database were initially presented at the sec-
     ranges between 10%
                                            Common types of irrational use of medi-       ond International Conference on Improving
    and 20% in developed                    cine are:                                     the Use of Medicines (ICIUM) that took place
    countries and between                    the use of too many medicines per           in Thailand in 2004.3 Some updated results
                                               patient (polypharmacy);                    from this database indicate that the use of
          20% and 40% in                                                                  medicines has remained much the same,
      developing countries                   inappropriate use of antibiotics, often     slightly increasing over the last 15 years.
                                               in inadequate dosage, for non-bacterial    The results further indicate that in Africa,
                                               infections;                                Asia and Latin America, only about 40% of
                                             over-use of injections when oral formu-     all patients were treated in accordance with
                                               lations would be more appropriate;         clinical guidelines.
                                             failure to prescribe in accordance with     Figure 1 shows the treatment of acute
                                               clinical guidelines;                       uncomplicated diarrhoea in the private-for-
                                                                                          profit and public sectors. Generally, such
                                             inappropriate self-medication, often of     cases should be treated with oral rehydra-
                                               prescription-only medicines.               tion solution alone and not with antibiotics
                                                                                          or anti-diarrhoeal drugs. However, the data
                                            Consequences
                                                                                          clearly show that many cases are treated
                                            Lack of access to medicines and inappro-
                                                                                          unnecessarily with antibiotics and anti-diar-
                                            priate doses result in increasing morbidity
                                                                                          rhoeal drugs and that this is more so in the
                                            and mortality, particularly for childhood
                                                                                          private compared to the public sectors. Less
                                            infections and chronic diseases such
                                                                                          than 40% in the public sector and 20% in the
                                            as hypertension, diabetes, epilepsy and
                                                                                          private sector were treated in compliance
                                            mental disorders.
                                                                                          with clinical guidelines.
                                            Inappropriate use and over-use of medi-
                                            cines is a waste of resources – often out-    Towards rational use of medicines
                                            of-pocket payments by patients. It also       The first step to correcting irrational use of
                                            results in significant patient harm in terms   medicines is to measure it. Indeed, prescrib-
                                            of poor patient outcomes and adverse drug     ing, dispensing and patient use should be
Cover photo credit: Gideon Mendel
                                            reactions.                                    regularly monitored in terms of:
Promotion of rational use of medicines is
important in resource poor environments     The over-use of antibiotics is leading to      the types of irrational use of medicines,
                                            increased antibiotic resistance while the        so that strategies can be targeted to-

2                                                                                                    Contact n°183 –Autumn/Winter 2006
                                                                                                                  EDITORIAL




   wards changing specific problems;               with supervision, audit, group process and        Relatively few
 the amount of irrational use, so that the       community case management. Furthermore,
                                                                                                    interventions aimed at
   size of the problem is known and the           the effects of training were variable and often
                                                  unsustained, possibly due to differences in       promoting rational use
   impact of the strategies can be moni-
   tored;                                         training quality and the presence or absence      of medicines have been
                                                  of follow-up and supervision.
 the reasons why medicines are used                                                                implemented and
                                                  The review of intervention impact carried out
   irrationally, so that appropriate, effective                                                     evaluated
                                                  for ICIUM 1997 is presently being revised
   and feasible strategies can be chosen.
                                                  using the data from the WHO database
People often have very rational reasons           on drug use surveys. Of the 700 surveys
for using medicines irrationally. Causes of       included in this database, less than half
irrational use include lack of knowledge,         were conducted in order to evaluate the
skills or independent information, unre-          impact of an intervention or strategy to
stricted availability of medicines, overwork      promote more rational use of medicines.
of health personnel, inappropriate promotion      Thus, relatively few interventions aimed at
of medicines and profit motives from selling       promoting rational use of medicines have
medicines.                                        been implemented and evaluated. Most of
In the last 20 years progress has been made       these interventions were introduced only at
to promote rational use of medicine. In 1977      the local level and only about 20% of them
WHO established the first Model List of            were adequately evaluated for their impact
Essential Medicines to assist countries to        on medicines use.
formulate their own national lists. In 1985,      Although we know from the first review
the present definition of rational use was         in 1997 that some of the most effective
agreed to at an international conference held     and sustainable interventions combine
in Kenya. In 1989, the International Network      managerial and economic strategies, still
for the Rational Use of Drugs (INRUD) was         only 25% of interventions being reported
formed to conduct multi-disciplinary inter-       are managerial or economic, the rest be-
vention research projects to promote more         ing educational in nature.
rational use of medicines. Following this, the
                                                  In 2004, the second ICIUM was held in
WHO/INRUD indicators to investigate drug
                                                  Thailand5. All the evidence presented
use in primary health care facilities were
                                                  at the conference made it clear that the
developed and many intervention studies
                                                  misuse of medicines continues to be
conducted.
                                                  widespread and has serious health and
A review of all the published intervention        economic implications, especially in re-
studies with adequate study design was            source-poor settings.
presented at the first ICIUM in Thailand in
                                                  Although many promising and suc-
1997.4 A summary of the magnitude of pre-
                                                  cessful interventions were presented at
scribing improvement by type of intervention
                                                  ICIUM 2004, global progress seems to
shows the effect varied with intervention
                                                  be confined primarily to demonstration
type. Printed materials alone had little impact
                                                  projects. There were few reports of
compared to the greater effects associated
                                                  effective national efforts to improve the
Contact n°183 –Autumn/Winter 2006                                                                                            3
EDITORIAL
            use of medicines on a large scale and         teach about how to use medicines;
            in a sustainable manner. Three major          • regulating pharmaceutical promotion
            recommendations were made at the              (much of which continues to be excessive
            conference:                                   and inappropriate in many low and middle-
                Countries should implement na-           income countries);
            tional medicines programmes to improve        • evaluating medicines use in chronic
            medicines use and these programmes            diseases and how to promote more cost-
            should:                                       effective long-term use.
            • be long-term (since implementation
                                                          The future
            takes time, continued stakeholder com-
                                                          Irrational use of medicines continues to be a
            mitment and adequate human resources
                                                          serious and widespread public health prob-
            is crucial);
                                                          lem. However, rational use of medicines for
            • cover all levels of health care in public   all medical conditions is fundamental to the
            and private sectors;                          provision of universal access to adequate
            • be based on local evidence from             health care, satisfaction of health-related
            inbuilt monitoring system;                    human rights and attainment of health-re-
            • separate prescribing and dispensing         lated Millennium Development Goals. It is
            functions (since there is evidence that       therefore crucial that measures be taken to
            prescribers who dispense tend to pre-         improve the rational use of medicines.
            scribe more medicines and more expen-         Following the evidence presented at ICIUM
            sive medicines than those prescribers         2004 rational use of medicines was debated
            who do not sell medicines);                   at the World Health Assembly in May 2005
            • extend broad-based insurance cov-           and the resultant draft resolution was set
            erage (since insurance systems have           to be debated at the next WHO Executive
            a strong incentive to monitor use of          Board meeting in January 2007. Further
            medicines and curtail unnecessary over-       debate of the resolution will be at the World
            use);                                         Health Assembly in May 20076. Hopefully
            • measure drug prices which influence          a WHO resolution may galvanize govern-
            access to medicines;                          ments, donors, non-governmental organi-
                                                          zations and the international community to
            • avoid flat patient visit fees which en-
                                                          invest more resources and effort in promot-
            courage polypharmacy;
                                                          ing rational use of medicines.
            • encourage generic prescribing and
            dispensing policies provided there are
            drug quality assurance programmes.
                Successful interventions should be
            scaled up and their impact regularly
            monitored e.g.
            • Prescription of 3-day antibiotic thera-
            py for pneumonia which is just as effec-      Dr. Kathleen Holloway is a medical officer working
                                                          for WHO - Geneva in the Department of Medicines
            tive as 5 days;                               Policy and Standards.
            • Use of multi-faceted coordinated            References:
            interventions which are more effective        1 World Health Organization. The Rational Use of Drugs. Report of the
                                                            Conference of Experts. Geneva: World Health Organization; 1985.
            than single ones;                             2 World Health Organization Promoting rational use of medicines:
                                                            core components. WHO Policy Perspectives on Medicines no. 5.
            • Implementation of structured qual-            Document WHO/EDM/2002.3. Geneva, WHO, 2002. Available at
                                                            URL: http://www.who.int/medicines
            ity-improvement processes possibly            3 International Network for the Rational Use of Drugs (INRUD), 2nd
                                                            International Conference for Improving the Use of Medicines (ICIUM
            through Drug and Therapeutic Commit-            2004), Policies and Programmes to Improve Use of Medicines:
                                                            Recommendations from ICIUM 2004, URL: http://mednet3.who.
            tees.                                           int/icium/icium2004/recommendations.asp
                                                          4 World Health Organization, “International Conference for Improving
               Interventions should address community      the Use of Medicines”, Essential Drugs Monitor; 1997; 23:6-12.
                                                          5 World Health Organization, Database on medicines use in developing
            medicines use by:                               and transitional countries; work in progress. Department of Medicines
                                                            Policy and Standards, WHO, Geneva. Initial results presented at the
            • improving patient adherence as an inte-       2nd International Conference for Improving the Use of Medicines,
                                                            Chiang Mai, 2004. Available at URL: http://www.icium.org
            gral part of global treatment programmes;     6 World Health Organization, Rational use of medicines: progress in
                                                            implementing the WHO medicines strategy, EB118/6, 2006; WHO
            • encouraging school programmes that            Geneva; URL: http://www.who.int/gb/e/e_eb118.html



4                                                                           Contact n°183 –Autumn/Winter 2006
                                                                                                                         FEATURE


   POLICIES AND STRUCTURES TO
ENSURE RATIONAL USE OF MEDICINES
      From the work of the past 20 years and the evidence presented at two international conferences on
  improving the use of medicines (ICIUM 1997 and 2004), much is known about how to promote rational
       use of medicines. Based on this evidence, WHO has developed recommendations for twelve core
  national policies and structures that are needed to promote rational use of medicines. These structures

                                                                 CORE INTERVENTIONS TO PROMOTE RATIONAL
A mandated multi-disciplinary                                               USE OF MEDICINES
national body to coordinate medi-
cine use policies
                                                         A mandated multi-disciplinary national body to coordinate medicine
Many societal and health system factors,                  use policies
as well as professionals contribute to how               Clinical guidelines
medicines are used. Therefore, a multi-dis-
                                                         Essential medicines lists based on treatments of choice
ciplinary approach is needed to develop,
                                                         Drugs and therapeutics committees in districts and hospitals
implement and evaluate interventions to
promote more rational use of medicines.                  Problem-based pharmacotherapy training in undergraduate cur-
                                                          ricula
A national regulatory authority (RA) is the
                                                         Continuing in-service medical education as a licensure require-
agency that develops and implements most
                                                          ment
of the legislation and regulation on pharma-
                                                         Supervision, audit and feedback
ceuticals. However, ensuring rational use
requires coordination with other stakehold-              Independent information on medicines
ers in more activities than those normally               Public education about medicines
covered by RAs. Thus a national body is                  Avoidance of perverse financial incentives
needed to coordinate policy and strategies               Appropriate and enforced regulation
at national level, in both the public and
private sectors. The form this body takes
may vary with the country, but in all cases        developed in a participatory way
it should involve government (ministry of            involving end-users;
health), the health professions, academia,
the RA, pharmaceutical industry, consumer          easy to read;
groups and non-governmental organiza-              introduced with an official launch,
tions involved in health care. The impact on         training and wide dissemination;
medicine use is better if many interventions       reinforced by prescription audit and
are implemented together in a coordinated            feedback.
way, single interventions often having little
impact.                                           Essential Medicines List based
                                                  on treatments of choice
Clinical guidelines                              Essential medicines are those that
Clinical guidelines (standard treatment           satisfy the priority health care needs of
guidelines, prescribing policies) consist of      the population. The use of an essential
systematically developed statements to help       medicines list (EML) makes medicine
prescribers make decisions about appropri-        management easier in all respects.
ate treatments for specific clinical conditions.   Procurement, storage and distribution
Evidence-based clinical guidelines are criti-     are easier to do with fewer items, and
cal to promoting rational use of medicines.       prescribing and dispensing are easier
Firstly, they provide a benchmark of satisfac-    for professionals as they have to know
tory diagnosis and treatment against which        about fewer items. A national EML
a comparison of actual treatments can be          should be based upon national clini-
made. Secondly, they are a proven way             cal guidelines and should be the focus
to promote more rational use of medicines         for government activities in the public
provided they are:
Contact n°183 –Autumn/Winter 2006                                                                                              5
FEATURE
                          sector, e.g. procurement, distribution,      tial medicines lists, can help to establish
                          insurance reimbursement policies and         good prescribing habits. Training is
                          training.                                    more successful if it is problem-based,
                          Only health workers who are approved         concentrates on common clinical con-
                          to use certain medicines should be           ditions, takes into account students’
                          supplied with them. Medicine selection       knowledge, attitudes and skills, and is
                          should be done in a transparent way          targeted to the students’ future prescrib-
                          by a central committee with an agreed        ing requirements (WHO 1994).
                          membership and using explicit, previ-
                          ously agreed criteria, based on efficacy,     Continuing in-service medical
                                                                       education as a licensure require-
                          safety, quality, cost (which will vary lo-
                                                                       ment
                          cally) and cost-effectiveness.
                                                                       Continuing in-service medical education
                                                                       (CME) is a requirement for licensure of
                          Drugs and therapeutics commit-              health professionals in many industri-
                          tees in districts and hospitals
                          A drugs and therapeutics committee           alized countries. In many developing
                          (DTC) is a committee designated to           countries opportunities for CME are
                          ensure the safe and effective use of         limited. In these countries no incentives
                          medicines in the facility or area under      are offered for CME since it is not re-
                          its jurisdiction. Such committees are        quired for continued licensure. CME is
                          well-established in industrial countries     likely to be more effective if it is problem-
                          as a successful way of promoting more        based, targeted, involves professional
                          rational, cost-effective use of medicines    societies, universities and the ministry
Only health workers       in hospitals. Governments may encour-        of health, and is face-to-face. Printed
who are approved to       age hospitals to have DTCs by making it      materials, such as bulletins or newslet-
                          an accreditation requirement to various      ters, that are unaccompanied by face-
use certain medicines                                                  to-face interventions, have been found
                          professional societies.
should be supplied with                                                to be ineffective in changing prescribing
                          DTC members should represent the             behaviour.
them                      administration and all the major special-
                          ties in any given facility. The members      CME should be provided for all cadres
                          should also be independent and declare       of health worker including in the informal
                          any conflict of interest. A senior doctor     sector such as drug retailers. Often due
                          would usually be the chairperson and         to lack of public funds CME is heavily
                          the chief pharmacist, the secretary.         supported by the pharmaceutical sec-
                          Unfortunately many DTCs are pro-             tor and may thus be biased. Govern-
                          curement committees. Their activities        ments should therefore support efforts
                          should however be much broader and           by university departments and national
                          should include developing or adapting        professional associations to give inde-
                          clinical guidelines, medicines selection,    pendent CME.
                          monitoring medicines use and tak-
                          ing corrective action, staff education,      Supervision, audit and feedback
                                                                       Supervision is essential to ensure
                          controlling drug promotional activities
                                                                       good quality of care. Supervision that
                          by pharmaceutical industry within the
                                                                       is supportive, educational and face-to-
                          premises of the health facility and moni-
                                                                       face, will be more effective and better
                          toring adverse drug reactions.
                                                                       accepted by prescribers than simple
                                                                       inspection and punishment. Effective
                          Problem-based training in                   forms of supervision include prescrip-
                          pharmacotherapy in undergraduate
                          curricula                                    tion audit and feedback, peer review
                          The quality of basic training in pharma-     and group processes such as self-moni-
                          cotherapy for undergraduate medical          toring. Many industrialized countries
                          and paramedical students can sig-            have a strong supervisory infrastructure
                          nificantly influence future prescribing.       but resources are often lacking for this
                          Rational pharmacotherapy training,           in low-income countries.
                          linked to clinical guidelines and essen-
                                                                       Independent information on
6                                                                                 Contact n°183 –Autumn/Winter 2006
                                                                                                                  FEATURE

medicines                                        pense or sell medicines. Patients prefer to
Inadequate knowledge and lack of access          get 2-3 medicines rather than one if the total
to independent information about medicines       cost to them is the same regardless of
significantly contribute to irrational use of     the number of medicines. Flat prescription
medicines. Often, the only information that      fees covering all medicines in whatever
practitioners receive is provided by the phar-   quantities within one prescription lead
maceutical industry and may be biased. Pro-      to over-prescription. User charges
vision of independent (unbiased) information     should therefore be made per medi-
is therefore essential. Drug information cen-    cine, not per prescription. Insurance
tres (DICs) and drug bulletins are two useful    policies should provide reimburse-
ways to disseminate such information. Both       ment only for essential medicines,
may be run by government or a university         not non-essential ones.
teaching hospital or a nongovernmental
organization, under the supervision of a          Appropriate and enforced
trained health professional.                     regulation
                                                 Regulation of the activities of
Public education about medi-                    all actors involved in the use of
cines                                            medicines is critical to ensuring
It is essential that the general public have          rational use. Regulations
the skills and knowledge to make informed             only have an effect if they
decisions about when and how to use medi-        are enforced, and the regulatory
cines, and to understand their potential risks   authority sufficiently funded and
as well as benefits. Without such knowledge       backed up by the judiciary.
and skills, people will often not get the ex-
pected clinical outcomes and may suffer          Sufficient government expen-
adverse effects. This is true for prescribed     diture to ensure availability of
medicines, as well as medicines used             medicines and staff
without the advice of health professionals.      Irrational drug use is caused in part
Governments have a responsibility to ensure          by the lack of essential medicines
both the quality of medicines and the quality        and the lack of appropriately trained
of the information about medicines available     personnel. Without sufficient competent          Prescribers who earn
to consumers. This will require:                 personnel and finances, it is impossible to
                                                 carry out any of the core components of          money from the sale of
 Ensuring that over-the-counter medi-           a national programme to promote rational         medicines
   cines are sold with adequate labeling         use of medicines. Poor clinical outcome,
   and instructions that are accurate,                                                            (e.g. dispensing doctors)
                                                 needless suffering and economic waste
   legible, and easily understood by             are sufficient reasons for large government       prescribe more
   laypersons;                                   investment.                                      medicines, and more
 Monitoring and regulating advertis-                                                             expensive medicines,
   ing, which may adversely influence             Monitoring pharmaceutical policy
   both prescribers and consumers;               WHO Geneva has created a database to             than prescribers who do
                                                 monitor the pharmaceutical situation in          not
 Running targeted public education              countries. This database contains data on
   campaigns, which take into account            pharmaceutical policy from all countries
   cultural beliefs and the influence of          who were member states of the WHO in
   social factors.                               1999 and 2003. The data was collected by
                                                 sending a questionnaire to the Ministry of
 Avoidance of perverse financial                 Health in each country. Data show that, while
incentives
                                                 several member states are implementing
Financial incentives that encourage irratio-
                                                 some of the national policies recommended
nal use of medicines should be avoided. For
                                                 by WHO, as described above, a significant
example, prescribers who earn money from
                                                 number of Member States are not using all
the sale of medicines (e.g. dispensing doc-
                                                 available options.
tors) prescribe more medicines, and more
expensive medicines, than prescribers who        The way forward
do not. The health system should therefore       The main recommendations from the
be organized to deter prescribers who dis-       evidence presented at the second ICIUM
Contact n°183 –Autumn/Winter 2006                                                                                         7
FEATURE
          2004 were for countries to:                                    Strategies to promote the rational use of
           implement national medicines                                                 medicines
          programmes to improve medi-
          cines use;                                                                         Governments
                                                                         •Do a situational analysis
           scale up to national level suc-
          cessful interventions and monitor                              •Evaluate the impact of programmes in terms of
          their impact regularly;                                        medicine use, quality of service and costs

           implement interventions ad-                                  •Lobby with doctors and MPs
          dressing community medicines                                   •Involve consumers and the media
          use.
                                                                         •World Health Organization (WHO) country offices to
          Implementation of national pro-                                make recommendations to Ministry of Health (MOH)
          grammes to promote rational use                                to establish units, with sufficient resources, devoted
          of medicines, as recommended                                   promoting rational use of medicines
          by ICIUM 2004, requires imple-
          mentation of the core policies and                                              NGOs and donors
          structures within the health system                            •Advocate for the benefits of rational use of medi-
          as described above. Many of these                              cines from public health and financial perspectives
          interventions are within the techni-                           •Include a rational use of medicines indicator in
          cal and financial capacity of most                              every proposal
          countries. Unfortunately, imple-
                                                                         •Involve NGOs in rational use of medicines activi-
          mentation of these policies has not                            ties
          occured in a significant number of
          countries and without such policies                            •MOH/WHO to coordinate NGOs and donors, in col-
          rational use of medicines can never                            laboration with civil society, with regard to activities
                                                                         concerning rational use of medicines
          be attained. The situation is now so
          serious that the subject will be de-                                                    WHO
          bated at the next Executive Board of                           •Appoint staff in every region with a specific man-
          the World Health Organization with                             date to work in collaboration with MOHs to promote
          a view to adopting a resolution on                             rational use of medicines
          taking a coordinated health systems
                                                                         •Support countries to establish a unit on rational use
          approach to promoting rational use                             of medicines within the MOH
          of medicines at the World Health
          Assembly in May 2007.                                          •Undertaking advocacy
                                                                         •Budget for activities on rational use of medicines
                                                                            Output of group work at WHO technical briefing seminar
                                                                            in September 2006 on how to stimulate governments,
                                                                            NGOs and donors and, WHO to promote Rational Use
                                                                            of Medicines.


          Dr. Kathleen Holloway is a medical officer working
          for WHO - Geneva in the Department of Medicines
          Policy and Standards.
          References
          1 International Network for the Rational Use of Drugs (INRUD), 1st
            International Conference for Improving the Use of Medicines (ICIUM
            1997), URL: http://www.icium.org
          2 International Network for the Rational Use of Drugs (INRUD), 2nd
            International Conference for Improving the Use of Medicines (ICIUM
            2004), Policies and Programmes to Improve Use of Medicines:
            Recommendations from ICIUM 2004, URL: http://mednet3.who.
            int/icium/icium2004/recommendations.asp
          3 World Health Organization. Ethical Criteria for Medicinal Drug
            Promotion. Geneva: World Health Organization; 1988.
          4 World Health Organization. Guide to Good Prescribing. Geneva:
             World Health Organization; 1994.
          5 World Health Organization, Promoting rational use of medicines:
            core components. WHO Policy Perspectives on Medicines no. 5.
            Document WHO/EDM/2002.3. Geneva, WHO, 2002. Available at
            URL: http://www.who.int/medicines
          6 World Health Organization, Database on country pharmaceutical
            situations; work in progress. Department of Technical Cooperation
            for Essential Drugs and Traditional Medicines. Geneva, WHO.
            Some results presented in the document WHO Medicines Strategy:
            countries at the core 2004-7. Document WHO/EDM/2004.5. Geneva,



8                                                                                              Contact n°183 –Autumn/Winter 2006
                                                                                                                              FEATURE

STRATEGIES TO PROMOTE RATIONAL USE OF MEDICINES

   A summary of the recommendations made by participants of the session on Rational Use of
  Medicines hosted by Ecumenical Pharmaceutical Network (EPN) and Health Action International
                 (HAI) at the World Health Assembly on 19th May 2005 in Geneva
                                                                      them and grassroots groups to demand appropriate use of their
Measuring the impact/obtaining the evidence                          medicines.
Studies should be done in areas where rational use of medi-
cines (RUM) policies have been developed and successfully
implemented and the findings documented and disseminated               Providing practical messages
                                                                      Countries that have managed to implement policies with
to all stake-holders. These will provide the evidence that            positive outcomes should document and promote their
RUM can save treatment time and costs and finances and                 successes. This can be done by starting to use simple and
can improve health of individuals, consumers and their com-           practical messages focusing on one issue at a time so to
munities on a large scale. The same data can also be used             avoid information overload that can cause confusion or
to show the negative effects of not having RUM policies in            misunderstanding.
place, e.g. acquiring infections, death due to inappropriate
medication etc.                                                       Proposed activities: marketing widely the Swedish model on
                                                                      antibiotic use; replicating and publicising the positive ICIUM
Proposed activities: conducting cost benefit analysis; providing       outcomes more widely, sharing successful local experiences
cost implication of irrational drug use to politicians; quantifying   within the country through support of local WHO offices and/or
the drug misuse; documenting the cost in terms of burden of           Ministries of Health.
disease, mortality and morbidity due to irrational use; and publi-
cising financial incentive fuelling irrational drug use.
                                                                      Advocacy and lobbying
                                                                      Advocacy for RUM should be done with all stake-holders, i.e.
Formation of alliances                                               governments, donors, training institutions and student asso-
Alliances should be formed between prescribers, consum-               ciations. This ensures that all who are involved in medicines
ers (community members) and politicians to ensure that all            are made part of the political agenda.
stake-holders are working towards common goals. In addition,
policies and strategies to promote RUM should overlap with            Proposed activities: making RUM part of training curriculum;
major health programmes like HIV/AIDS, malaria, TB and                making presentation on RUM at all possible venues; providing
                                                                      politicians with data for their deliberations in parliament; provid-
drug and substance abuse.
                                                                      ing factual sheets on RUM to lobbyists.
Proposed activities: inviting politicians to venues where the
benefits of RUM to their constituencies is highlighted; provide
evidence to youth and communities on the links between irra-
                                                                      Address at global level
                                                                      Policies on RUM should be clearly defined and supported
tional drug use and their lack of access to useful and safe drugs;    by organizations at the global level, e.g. WHO, World Bank,
integrate RUM requirements in development programmes.                 Global Fund, PEPFAR etc. which makes it easier to imple-
                                                                      ment the policies at lower levels i.e. regional, national, and
Communication strategies                                             community level.
By using the media on a wider scale, clear communication
strategies can be developed to put RUM on the political               Proposed activities: passing of a strong resolution on RUM
agenda. This gives knowledge to individuals, consumers and            at the World Health Assembly, allocating of funds for promot-
their communities and raises levels of awareness in areas             ing RUM in the budgets, including RUM as a requirement in
                                                                      agreements, addressing RUM as part of strengthening health
like the risks caused by irrational use, the drug resistance
                                                                      systems.
problem, e.t.c.
Proposed activities: providing regular updates to the media
on positive messages for RUM; highlighting consequences of
                                                                      Address industry power
                                                                      WHO and other international organizations should address
irrational drug use such as deaths from resistant organisms;          “big pharma” issues such as the pharmaceutical industry in
naming and shaming activities promoting irrational drug use.          developed countries which are biased towards producing and
                                                                      promoting drugs mainly for the profitable markets of indus-
Empowerment of consumers                                             trialized countries, while neglecting much-needed medicines
Consumers and communities can be empowered in the use                 for illnesses that affect the poor and vulnerable people in
of medicine e.g. in areas of antibiotics use which are amongst        resource-limited countries.
the most abused medicines.
                                                                      Proposed activities: providing leadership in addressing excess-
Proposed activities: carrying out simple rational drug use            es of the pharmaceutical industry that lead to irrational drug use;
activities within the communities to ensure step by step learn-       holding industry accountable to their social responsibilities.
ing of RUM; providing communities with information to enable


Contact n°183 –Autumn/Winter 2006                                                                                                       9
OPINION


MAKING THE BEST OF USE MEDICINES
                                      A PHYSICIAN’S PERSPECTIVE

                              I nappropriate use of medicines is a
                                s erious concern, especially when it affects
                              the more vulnerable people and occurs for
                                                                               to decide which medicines they think they
                                                                               need. The forces that drive one to use medi-
                                                                               cation include: real or perceived ill health,
                              extended durations. Inappropriate drug use       ignorance, and addiction or dependence on
                              can have dire consequences; it has been          certain medications.
                              associated with hospitalization and even         Self medication may also be facilitated by
                                caused deaths of inpatients in health care     certain situations including:
                                   facilities.
                                                                                Poor access to desirable health care
                                      The management of a patient’s ill-          because of high costs, long distance and
                                       ness is a tripartite engagement            discriminatory policies;
                                        involving the patient, the health-
                                          care provider and the health          Poor regulation and/or implementation
                                           care facility. One seeks health        of regulations on prescription drugs and
                                             care for various symptoms            pharmacy practices (with profit motives
                                              that may arise from: acute          overriding the professional require-
                                               curable disease such as            ments);
                                                malaria or trauma; acute        Overzealous advertisements of medi-
                                                  and chronic disease             cations, that make claims of efficacy
                                                   conditions like pain-          and scope of use but conceal adverse
                                                    ful joint inflammation         effects;
                                                    such as in rheuma-
                                                     toid arthritis; chronic    Poorly informed public on matters of
                                                     non-communicable             health and self-care;
                                                    conditions like hyper-      High burden of diseases, many of them
                                                   tension, mental illness        with overlapping symptoms, e.g. pain,
                                                   and diabetes mellitus;         fever, insomnia and depression are
                                                  and lastly chronic infec-       common symptoms for different condi-
                                                 tious diseases like HIV/         tions which require different medication,
                                                AIDS and Tuberculosis.            but the correct medicine can only be
                                               In each situation the physi-       determined by consultating a medical
                              cian makes a diagnosis of the condition and         practitioner for diagnosis;
                              then prescribes the treatment, which may          Poverty which puts consultations out of
                              be medication. There should be adequate             reach for people who cannot afford to pay
         There should be      accompanying explanation from the physi-            for professional health care services.
    adequate accompany-       cian to the patient on how to administer
                              prescribed medication. If the patient is not     Commonly misused medicines
 ing explanation from the
                              properly advised, or misunderstands the          The most commonly used medications
   physician to the patient   instructions, then the medications may not       world over are analgesics (pain-killers)
    on how to administer      be used appropriately.                           and antibiotics. These medicines are often
                              A variety of situations and circumstances        used inappropriately. They are either taken
    prescribed medication                                                      for the wrong reasons (that is the wrong
                              promote irrational use of medicines. This
                              may take the form of using wrong medica-         drug used to treat particular symptoms) or
                              tion to treat certain indications, or using      used incorrectly (taken for incorrect periods
                              medication for durations beyond the desired      or in incorrect amounts). This misuse has
                              period.                                          undesirable outcomes. Antibiotics are also
                                                                               commonly misused. One common misuse
                              Self-medication                                  is non-adherence many patients fail to take
                              Some people do not consult a doctor be-          the full course prescribed. When medicines
                              fore taking medicines. Instead they opt for      such as antibiotics are misused they gener-
                              self-medication, taking it upon themselves       ate drug-resistant strains of the bacteria.

10                                                                                        Contact n°183 –Autumn/Winter 2006
                                                                                                                                        OPINION
Promoting rational use of medi-                  mentation, these include the establishment               References
                                                                                                          1 The challenge of chronic conditions: WHO
cines                                            of national regulatory bodies and national                 responds. BMJ 2001: 323: 947.
                                                                                                          2 WHO Guidelines for Drug Donations
Rational use of medication saves lives,          drug policies.2                                            Revised 1999 (2nd edition). WHO/EDM/

makes sense and saves cents. It limits           There are many areas of drug use that re-
                                                                                                            PAR/99.4.
                                                                                                          3 Lore W. Rational use of drugs: what is
undesired toxicity and adverse events and        quire tighter controls, such as the regulation
                                                                                                            it and what are the pre-requisites for its
                                                                                                            fulfillment? Editorial .Healthline, Journal
maximizes on the benefits that can be de-         and supervision of drug donations3,4, free
                                                                                                            of Health 2006: 10(2): 15 – 16
                                                                                                          4 Thuo HM, Ombaka E. Drug donation
rived from optimal use of medications.           health camps; and use of medicines.5 While
                                                                                                            practices in East Africa. An exploratory
                                                                                                            study from mission health care facilities.
Patients are encouraged to always obtain         philanthropy is the driving principle for most             Healthline, J of Health 2000: 4:2 – 11.
                                                                                                          5 Nabiswa AK, Godfrey RC. Diagnosis and
advice from a healthcare provider to interpret   drug donations, it is not always guided by                 prescriptions for patients managed during
                                                                                                            a free healthcare day in Eldoret, Kenya.
symptoms of an illness and the appropriate       needs arising from the beneficiaries. Con-                  East Afr Med J. 1994:71:363 -365

remedy. One should avoid self-interpre-          sequently, the donated drugs are not always
tation of symptoms, self-prescription of         the ones required and there is therefore the
medication, and self-acquired remedies. It is    danger that they will be used inappropriately.
equally important for one to view with caution   Some donations are motivated by sinister
advertisements that promote medications.         motives such as dumping of surplus or
Furthermore, it is just as bad for two people    expired drugs, promotion of certain brands,
to share medications simply because they         preliminaries to win future tenders, or politi-
have the same symptoms or their situations       cal expediency.
are similar.                                     On the same note, free health camps bring
Based on the review of innovative best           health care to the people in dire need, albeit
practice and affordable health care models       sporadically. In these situations irrational use
to improve clinical care and outcomes for        may be promoted, for example, antibiotics
chronic conditions, the WHO proposes the         may be prescribed for a short time and not
following nine strategies:1                      be guided by both laboratory tests and good
 Developing health policies and legisla-        clinical diagnosis.
    tion to support comprehensive care;          Conclusion
   Reorganizing healthcare finance to facili-    Governments, private health care insti-
    tate and support evidence-based care;        tutions, individual health care providers
   Coordinating care across conditions,         and patients all have a responsibility
    healthcare providers, and settings;          to promote rational use of medicines.
                                                 The professional and business angles
   Enhancing flow of knowledge and infor-
                                                 of drug acquisition, prescription and
    mation between patients and providers
                                                 dispensing must be regulated quite
    and across providers;
                                                 closely. This is best done by the profes-
   Developing evidence based treatment          sionals themselves, facilitated by the
    plans and support their provision in vari-   governments. Patients must be edu-
    ous settings;                                cated about rational drug use through
   Educating and supporting patients to         the mass media or through private
    manage their own conditions as much          consultation for maximum gains to be
    as possible;                                 derived from the medications available
   Helping patients to adhere to treatment      to them.
    through effective and widely available
    interventions;
   Linking health care to other resources in
    the community;
   Monitoring and evaluating the quality of
    services and outcomes.
The physicians’ role
To ensure RUM, the role of physicians or
health care providers should be enhanced         Dr. C.F. Otieno is a senior lecturer in Internal
                                                 Medicine, in the department of clinical medicine and
through training and multidisciplinary prac-     therapeutics at the University of Nairobi’s college of
tice in healthcare provision. In this regard,    Health Sciences. He is also a consultant physician at
the WHO recommends certain pre-requi-            the Kenyatta National Hospital, and runs a part time
                                                 private clinical practice in Nairobi.
sites to national governments for imple-
Contact n°183 –Autumn/Winter 2006                                                                                                                 11
OPINION


     HOW “RATIONAL” IS OUR USE OF
             MEDICINES?
           I n the practice of medicine, doctors
             recognize the importance of “the pla-
           cebo effect” phenomenon. This refers
                                                         The other extreme of the spectrum
                                                         are patients who visit doctors with the
                                                         expectation of receiving a prescription
           to patients getting better from an illness    for medication. Unless the doctor pre-
           even if the medication used is only a         scribes strong, brightly colored medi-
           “sugar pill.” In some cases this effect       cines, preferably in capsule form, com-
           can be fifty percent or higher.                plemented by a painful injection, such
                                                         patients feel the medical practitioner
                                                         has not taken their cases with sufficient
                                                         seriousness. Many rural people believe
                                                         the severity of an illness is judged by
                                                         the number of pills and injections re-
                                    Many therefore       quired in its treatment. Conversely, the
                                may get better be-       urban rich believe the seriousness of
                               cause of the psycho-      an illness is judged by the number of
                              logical belief that they   investigations and associated high cost!
                             received an effective       If one is suffering from a psychological
                            remedy for the illness       disorder like anxiety or depression, the
                           they are suffering from.      physical complaints associated with
                          This fact alone is of great    these conditions may sometimes take
                         clinical significance for both   greater prominence than the underlying
                       the doctor and the patient.       cause of the symptoms. The patient
                      The former will incorrectly        visits the doctor and complains of pains
                     claim effective treatment of a      and aches rather than that of stress and
                   disease, while the patient will       sadness.These two examples show
                  assume effective treatment from        that, both the doctors and the patients
                the doctor. Many medical conditions      require education on the rational use of
              are self limiting. This means they         medicines.
             come to an end by themselves, with
                                                         Misreading the symptoms
             or without treatment. The common
                                                         Between 25 to 30% of patients who
            cold is a good example of this. In most
                                                         attend primary health care facilities
           cases the symptoms, if left alone, will
                                                         do so because of minor, but common
           subside in a few days. So when doc-
                                                         psychiatric disorders. Many of these
           tors or pharmacists prescribe medicines
                                                         conditions are presented to the medical
           for the common cold are they part of
                                                         providers as complaints of headache,
           the “rational drug use culture” which is
           demanded of all ethical practitioners?        backache, abdominal and other body
           This particularly applies in the use of       pains. In many African communities
           antibiotics. In most such cases medi-         these symptoms are described simply
           cal practitioners prescribe antibiotics       as “malaria” and prescriptions of anti-
           for their own psychological satisfaction      malarials given for what in reality is de-
           and relief, not that of their patients, or    pression or anxiety. The overwhelmed,
           to retain their relevance and influence        overworked and undertrained primary
           over their patients rather than because       health care provider who does not
           these drugs are absolutely necessary          have time to delve into the underlying
           for the condition concerned. Often they       cause of the symptoms simply takes
           do so to save on the time it would take       the shortcut of the irrational drug use
           to educate patients on the rational use       to quickly attend to the high number of
           of medicines.                                 patients.

12                                                                  Contact n°183 –Autumn/Winter 2006
                                                                                                                       OPINION
Typhoid is another condition which          the treatment of complications arising
is often irrationally treated at primary    from the prolonged daily use of different
care level. In the absence of clinical      cough mixtures. Symptoms of addiction
evidence many patients are treated with     to cough mixtures are similar to those
strong antibiotics for typhoid when in      of heroin addiction!
reality they are suffering from depres-     Another problem on the increase is
sion or anxiety.                            the abuse of laxatives and diuretics to                   Public education must be
In Kenya there is currently a large scale   induce diarrhoea and fluid lose respec-                    complemented by the
program between the Kenya Psychiat-         tively. This is done to lose weight. Stimu-
ric Association, Ministry of Health and     lant abuse which is believed to increase                  dissemination of accurate
the Institute of Psychiatry in London,      the passing of wind and encourage                         information
to address these issues. This program       weight loss is also on the increase and
plans to train nearly four thousand pri-    leading to addiction. These are danger-
mary health care workers in Kenya on        ous activities that have led to death in
the diagnosis and rational treatment of     some cases.
common mental disorders.
                                            Conclusion
Bad use of good medicine                    It is evident from the foregoing that ra-
Self medication is another common           tional use of medicines is an important
example of the irrational use of drugs.     current issue that has many important
In many cases it is supported by poorly     psychological aspects, affecting pro-
regulated pharmaceutical practitio-         fessional and lay players and which
ners.                                       demands action by all. Public education
From a psychological perspective, the       must be complemented by the dissemi-
most common cause of self medication        nation of accurate information to these
arises from complaints of insomnia or       professionals who may not be aware of
lack of sleep at night. Insomnia has        the dangers they place their patients in
different causes (both serious and not      by the irrational use of otherwise very
serious), some requiring treatment and      good drugs.
others requiring none. Dependency on
sleeping pills develops because their
initial use was not supported by rational
use of medicines. Transient insomnia
which lasts for only a short time may be
treated for long periods of time without
supervision by qualified persons. This
                                            Dr. Frank G. Njenga is a psychiatrist and the Chairman
leades to addiction to otherwise good       of the Chiromo Lane Medical Centre, a drug and
medicines and gives a bad name, not         alcohol rehabilitation centre. He is also the Programme
only to the medicines but also to the       Director of the Student Campaign against Drugs
                                            (SCAD), Kenya and a Fellow of the Royal College of
doctors who prescribe them.                 Psychiatrists [UK]. He runs a clinic at the Department
                                            of Psychiatry, Upper Hill Medical Centre in Nairobi,
The solution to this problem lies in        Kenya.
public education on the importance
of proper and competent diagnosis of
insomnia. The causes of insomnia are
varied and include anxiety, depression,
bereavement, pain, good and bad news,
excitement or anticipation, such as
preparation for exams and marriage!
Care should be taken before prescribing
sleeping pills to avoid irrational use.
A less common but increasing problem
of irrational use of medicines is the
misuse of cough mixtures containing
codeine. Cases have been reported for

Contact n°183 –Autumn/Winter 2006                                                                                           13
COMMENTARY


        LURES TO IRRATIONAL USE OF
                MEDICINES
              H                        ealth is a personal responsibility.
                                       Taking care of one’s body and
                                   health and the health of one’s family
                                                                              This is not necessarily the case with all
                                                                              physicians and pharmacists, but not all
                                                                              professionals are bound by ethics.
                                   should be the priority of each human       Medical experts are dependent on an
                                   being.                                     industrial-based system (medicines
                                   However, the responsibility of personal    and medical equipment). The industry
                                   health has been handed over to the         is, by nature profit driven. In Germany,
                                   healthcare system. The belief is that      every physician running a practice
                                   doctors, pharmacists and other health      is visited on average 192 times by
                                   care professionals are responsible for     medical representatives from phar-
                                   our health since they have been trained    maceutical companies. These medi-
                                   in that area. This belief results in de-   cal representatives are well trained to
                                   pendency on health professionals and       convince doctors about new medica-
                                   neglect one’s personal responsibility of   tions. The new drugs are always much
                                   his or her own health. The question is:    more expensive though they do not
                                   How confident are we, as lay people,        necessarily have increased efficacy!
                                   that the medical experts, are making the   From research conducted by an in-
                                   best decisions or choices for our well     dependent expert, only 7 of the 450
                                   being? Since the medical practitioners’    new developed drugs since 1990 can
                                   incomes are directly linked to our ill     actually be said to be totally innovative,
                                   health does that mean they would be        25 are partially innovative and the rest
                                   more appreciative of patients rather              have no therapeutic advantages.
                                   than healthy persons?                                 The results of another study
                                                                                             conducted by the Ger-
Influx of information:good or bad                                                              man Government on
for rational use of medicines?                                                                new medicines showed
                                                                                              that 300,000 doctors
                                                                                              were prescribing a new
                                                                                              type of insulin (analogue
                                                                                              insulin) which has no
                                                                                              added advantage over
                                                                                              the existing insulin. As
                                                                                              a result of this finding,
                                                                                              the German Ministry of
                                                                                              Health decided to ex-
                                                                                              clude new drugs from
                                                                                              the list of medications
                                                                                              paid for by the national
                                                                                              health insurance system
                                                                                              as long as they are more
                                                                                              expensive than existing
                                                                                              approved drugs. This is
                                                                                              an important step into
                                                                                              the right direction.
                                                                                           Another disturbing
                                                                                           statistic shows that,
                                                                                           300,000 patients are
                                                                                          hospitalized annually in
                                                             DIFAEM
                                                                                         Germany because of ill-

14                                                                                       Contact n°183 –Autumn/Winter 2006
                                                                                                        COMMENTARY
nesses caused by consumption of               drugs in the German market classified in
medications. There are several possi-         categories depending on the efficacy of
ble causes for the situations described       the drug. The book also provides over-
above. They include:                          views on pricing of which companies
                                              offer a particular drug at the lowest cost.
LURING OF PRESCRIBERS
                                              However, unlike the Rote Liste this book
Most health workers are not regularly
                                              is not free and neither is the monthly
informed by independent sources. In
                                              independent newsletter.
developed countries independent media
which offer independent information are       Software
available but are hardly used.                Many pharmaceutical companies offer
                                              software to physicians to facilitate the
Medical and pharmaceutical jour-
                                              prescribing procedure. The software is
nals
                                              easy to use. It generates a prescription
Most medical and pharmaceutical
                                              for each diagnosis. The snag is that
journals depend on advertisements for
                                              in most cases the drugs displayed for
income from the companies that manu-
                                              each diagnosis are those manufactured
facture drugs or medical equipment.
                                              by the company providing the software.
Such journals cannot provide totally
                                              The suggested drugs are not neces-
objective information as the articles
                                              sarily the most effective in treating the
cannot be too critical of the activities or
                                              illness.
products of these companies.
Until recently, all physicians in the         Training
United Kingdom received a free copy           When many pharmaceutical companies            The British National
of the “Drug and Therapeutics Bulletin        invite doctors for training courses, the
(DTB) which was edited by the British         venue of the training is usually a plush      Formulary (BNF)
consumer organization. Unfortunately,         hotel with exotic surroundings. These         provides healthcare
the UK government decided to cancel           training courses are offered at no cost
                                                                                            professionals with
this service due to financial constraints.     to the participants and in some cases
It costs two million Euros annually (or       the participants are given the option of      authoritative and
0.2% of the UK-Ministry of Health bud-        inviting a guest. The “training” some-        practical information on
get) to publish and distribute the DTB,       times takes place during the flight to the
                                              venue, or in a day or less of the time
                                                                                            the selection and clini-
however, the British Pharmaceutical
Companies spend 2.5 billion Euros on          to allow the participants more time to        cal use of medicines in a
advertisement annually! The amount of         enjoy the venue. These are some of the        clear, concise and
money which could be saved if doctors         incentives given to doctors to prescribe
prescribed medicines rationally if they       medicines manufactured by the spon-           accessible manner
got more independent knowledge from           soring pharmaceutical companies.
publications such as the DTB would be
even higher! In Germany it is estimated       LURING OF CONSUMERS
that the budget of health insurance com-      Consumers are lured to use medicines
panies could decrease by about 3 billion      irrationally through:
Euro annually if the doctors stopped          Commercial promotion of brands
prescribing drugs whose effectiveness         Most medical and pharmaceutical
is questioned by independent experts.         journals carry advertisements of medi-
                                              cines sponsored by pharmaceutical
Reference books
                                              manufacturing companies. Most of the
Every year in Germany all doctors re-
                                              medicines advertised do not require
ceive a free copy of the Rote Liste, a
                                              a doctor’s prescription making them
book which provides information about
                                              appealing for consumers to purchase
all medicines available in the country.
                                              over-the-counter. Often, when asked
The book is edited by the pharmaceu-
                                              about the efficacy and cost of these
tical industry. Another compendium
                                              medicines most pharmacists are not
edited by an independent institute and
                                              truthful as they want to make profits
based on independent scientific re-
                                              from the sales.
search contains information on all the

Contact n°183 –Autumn/Winter 2006                                                                                  15
COMMENTARY
                           In addition to open advertisement, there         invited to grassroots and consumer
                           are covert promotion practices which are         groups activities and presentations
                           even more dangerous. In these subtler            outside the university environment to
                           promotions, articles on a health issue           expose them to different situations.
                           are written and reviewed by purported          Fighting for independent informa-
                           authorities on the subject. The article          tion. To obtain independent informa-
                           carefully focuses on a specific therapy           tion, it is important that the sources
                           and medicine. The medicine proposed              of the information are not linked to a
                           is highly recommended by the “health             pharmaceutical company. Govern-
                           expert” giving the impression that it is         ments should be urged to support
                           the best therapy available. However,             the publishing and wide distribution
                           should one conduct further research              of independent journals for prescrib-
                           on the author of the article, the source         ers, dispensers and consumers of
                           is often found to be the pharmaceuti-            medicines. One needs to be critical
                           cal company which manufactures the               of invitations to events; the presence
                           drug.                                            of a logo/name of a pharmaceutical
                           Direct to consumer advertising                   company whether prominent or in
                           Direct to consumer advertisement for             small print is a sure sign that it is
                           medicines that have to be prescribed by          being used for promotion, whether
                           a doctor is forbidden in most countries. It      openly or covert.
Direct to consumer
                           is however allowed in the United States        Advocating for transparency
advertisement for          of America and in New Zealand. In the            in the health system. This will
medicines that have to     US, pharmaceutical companies invest              ensure openness and allow exact
                           up to 4 billion dollars annually to con-         figures and sources of money to be
be prescribed by a doc-    vince consumers that they should insist          shown.
tor is forbidden in most   that their doctors give them a specific
countries                  prescription. These practices do not
                           promote rational prescribing.

                           CONTROLLING THE SITUATION
                           The negative influence of media on
                           RUM can be mitigated by:
                            Educating health personnel on
                              rational use of medicines. This is
                              a challenge as the health sector is        Albert Petersen is the manager of the Pharmaceutical
                                                                         Aid Department at the German Institute for Medical
                              sometimes dependent on the phar-           Mission – DIFAEM. He is also the Chairperson of
                              maceutical industry. Several univer-       the Ecumenical Pharmaceutical Network (EPN) and
                              sities which educate health person-        Country Focal Point (CFP) in Germany.
                              nel are also financially dependent on
                              the pharmaceutical industry for funds
                              to conduct research studies and
                              projects. Unfortunately governments
                              in most developed countries do not
                              provide enough funds for universities
                              to run independently.For example:
                              a pharma-critical drama group was
                              invited to perform at a university and
                              the professor in charge of the phar-
                              macy department was asked if his
                              department could be the co-inviter of
                              the group. His answer: “If we do it I
                              will lose my job because we are get-
                              ting so much money from these com-
                              panies.” It is therefore crucial that
                              students are, whereever possible,
16                                                                                    Contact n°183 –Autumn/Winter 2006
                                                                                                          COMMENTARY


       FACTORS INFLUENCING
     CONSUMER USE OF MEDICINES
An estimated one third of the world’s population lack regular access to essential medicines with this
 figure rising to over 50% of the population in the poorest parts of Africa and Asia. When available,
  the medicines are often used incorrectly: Fifty percent of all medicines are prescribed, dispensed
   or sold inappropriately, while 50% of the patients fail to take their medicines appropriately (WHO

T    he way consumers use medicines
     is influenced by a wide range of fac-
tors including: knowledge about use, the
                                               knowledge on the use of medicines and
                                               therefore sometimes end up pressurizing
                                               the prescribers and dispensers for the
                                                                                                Some sections of the
                                                                                                population have
cost of medicines at all levels, regulatory    expensive branded medicines in prefer-           developed a
systems, cultural factors, community           ence to cheaper generics which are just          misconception that the
beliefs, communication between them            as effective.
and prescribers to ensure correct use
                                                                                                expensive medicines are
of the drugs, outpatient support, access       Inadequate regulatory systems                    more effective than the
to objective information on medicines,         In most developing countries, national drug
                                                                                                cheaper generic
and commercial promotion.                      regulatory agencies do not have enough
                                               qualified personnel, financial resources           versions.
Cost of medicines                              and equipment. As a result the function
In economic terms, inappropriate use           of regulating the importation, distribution,
has led to the wastage of limited re-          promotion, and sale of medicines is not
sources and to non-availability of es-         adequate. This has resulted in medicines
sential medicines where they may be            being dispensed by unqualified personnel
needed.                                        in facilities that are not licensed to provide
According to surveys conducted in 2004         these services.
by HAI Africa and WHO in 11 Sub-Saha-          In the poor parts of Sub Saharan Af-
ran Africa countries in 2004, the median       rica it is common to find prescription
availability of the essential medicines in
public health facilities was below 70%.
This means that many patients who go to
public health facilities for treatment often
go back home without getting the medi-
cines they need. Some of these patients
have to resort to buying the required
medication from the private sector where
they are more expensive. The problem
is that essential medicines are not af-
fordable to majority of the population. In
Kenya, for example, more than 60% of
the population live below the poverty line.
This results in situations where a family
ends up sharing medicines that were
prescribed to treat one person - a classic
example of irrational use of medicines.
Some sections of the population have
developed a misconception that the
expensive medicines are more effective
than the cheaper generic versions. Middle
class patients in developing countries
who may have the purchasing power
to buy medicines, often have limited

Contact n°183 –Autumn/Winter 2006                                                                                    17
COMMENTARY
                            medicines being sold in the markets and      Poor communication between pro-
                            open areas by unqualified people. Such        fessionals and consumers
                            unregulated scale of medicines has           Communication between profession-
                            increased to fill the gap not covered by      als and consumers is fundamental
                            the public, private and NGO facilities. In   to the improvement of rational use of
                            Nigeria for instance, prescription drugs,    medicines by consumers. Profession-
                            including antibiotics and injectable         als should provide the following infor-
                            drugs which should not be sold over-         mation to the consumers: the name of
                            the-counter, are freely available in the     the medicine, the purpose for which
                            informal sector from drug hawkers, ven-      the medicine is being taken, dose,
                            dors and stores. (WHO 2002). Although        frequency of use, and duration of use.
                            the medicines sold in the formal sector      The prescribed and dispensed medi-
                            are usually cheap they are either of poor    cines should also be properly labelled
                            or unknown quality. The consumers of         indicating the above information. The
                            these medicines are mainly in the rural      shortage of qualified health personnel
                            areas. These consumers are often not         in public health facilities has resulted
                            given adequate information about the         in inadequate labeling of medications
     Professionals should   medicines and end up using them ir-          by prescribers and dispensers, and
                            rationally.                                  in insufficient time spent by them to
    provide the following                                                inform the consumers on how to take
                            To exacerbate the situation, qualified
 information to the con-    health professionals are often concen-       the medicine. Chart 1 depicts status of
sumers: the name of the     trated in the urban areas. In Uganda,        labeling of medicines and the adequa-
                            80% of the 215 private pharmacies            cy of patient knowledge in 5 selected
           medicine, the                                                 African countries.
                            which are managed by pharmacists
   purpose for which the    are based in the main urban centres          Exit interviews were conducted for
 medicine is being taken,   (WHO 2002). To cater for the rural           patients/consumers of medicines in
                            population franchise drug shops which        the public health facilities and it was
 dose, frequency of use,
                            are managed professionally have been         found that the adequacy of labeling
      and duration of use   introduced in Ghana, Kenya and Tanza-        medicines according to the above
                            nia. However, these shops only cover         mentioned criteria was on average be-
                            one or two regions of the country. Faith     low 50% while the adequacy of patient
                            based organizations have also become         knowledge was 80% and below.
                            one of the main sources of quality medi-     Also important are the possible drug
                            cines but they are also inadequately         and food interactions that might occur
                            resourced and the health workers are         after taking the medicines. In cases of
                            often overworked.                            medicines for chronic diseases such as




18                                                                                 Contact n°183 –Autumn/Winter 2006
                                                                                                   COMMENTARY




anti cancer drugs, the adverse effects     awareness on problems with drugs            Adapted from Baseline
                                                                                       Pharmaceutical Survey, 2002
such as memory loss, depression and        and publicizing serious health hazards
many others should be explained to the     related to drugs. However the media
consumer.                                  has at times been used by pharmaceuti-
All this communication requires ad-        cal companies to covertly promote their
equate time between the professionals      medicines. In some parts of Africa the
and consumers which is not always          existence of counterfeits has sometimes
available due to the enormous work-        been used to discredit generic products
load of the health professionals in the    by some media houses. The consumers
developing countries. The situation has    end up with mixed reactions on the use
been made worse by the increase in the     of generics.                                The shortage of qualified
spread of HIV/AIDS and the attendant       The method of administration has influ-
                                                                                       health personnel coupled
treatment issues which have placed         enced the use of medicines. Consum-
further burden on both the health pro-     ers in Uganda for instance believe that     with inadequate staff
fessionals as well as consumers.           medicine injected into the blood stream     time in public health
                                           does not leave the body as quickly
Lack of objective information              as that administered orally. (Birungi
                                                                                       facilities has resulted in
The pharmaceutical market has been         2004)                                       inadequate labeling of
saturated by medical representatives
                                                                                       medications by
whose aim is to achieve higher sales for   Inadequate public education
the companies they represent. These        Developing countries have ineffective       prescribers and
sales professionals have become the        public education programmes. For            dispensers
principal source of information for many   example, in Nigeria although there is
prescribers and dispensers despite the     a high level of self-medication and un-
fact that the information they provide     controlled sale and use of medicines,
is geared towards promoting the sales      especially antibiotics and injections,
of pharmaceutical companies. The es-
                                           there has been little or no public educa-
sential medicines list, standard treat-
                                           tion on rational use of medicines (WHO
ment guidelines, national drug policies
                                           2002).
are often good sources of literature on
medicines use, but these reference         The most important sources of informa-
materials are not widely disseminated      tion for consumers about medicines are
(WHO 2002).                                doctors, followed by the pharmacists,
                                           then nurses and other healthcare per-
When brought to their attention, the
                                           sonnel. Medical professionals must not
media can play a key role in raising

Contact n°183 –Autumn/Winter 2006                                                                             19
COMMENTARY
                               only know the correct information to          Rational Use of Medicines by con-
                               convey, but the skill and the time to do it   sumers in developed and developing
                               well. However, skill and time in this area    countries is highly influenced by other
                               are scarce resources. Patients may not        players. Consumers especially in the
                               be aware of the kind of information they      developing countries are not often con-
                               need or what questions they should            sulted on the treatment decision; this is
                               ask, so there is a significant, general        in contrast to their counterparts in the
                               educational challenge.                        developed countries. Public education
                               The emergence of HIV/AIDS and other           on rational use by consumer organiza-
                               chronic diseases has exacerbated the          tions will empower consumers to be
                               problem since there are higher patient        involved in the decisions that affect
                               numbers but fewer of them are able to         them at policy formulation level and
                               access the medicines they require. In         health professional-to-patient level.
                               the event that the prescribed medicines       This ‘bottom-up’ approach will create a
                               are dispensed, these[HIV/AIDS] pa-            long lasting solution to rational use of
                               tients go back home but most of them          medicines at all levels.
                               do not get regular outpatient support to
                               encourage them to take the medicines.
                               A successful patient follow up mecha-
    Medical professionals      nism has been put in place in many
                               countries to encourage the rational use
 must not only have the
                               of TB medicines. Unfortunately no simi-
  information to convey,       lar mechanisms have been designed at
                                                                             Patrick Mubangizi is the Coordinator of Health
but the skill and the time     the international and national level for      Action International-Africa (HAI-Africa). Mr. Mubangizi
                               other diseases.                               has more than seven years work experience in the
               to do it well                                                 private for profit and NGO sectors in Uganda. He
                               Increasing consumer awareness                 is a registered pharmacist and has been involved
                                                                             in pharmaceutical procurement, medicines policy
                               In countries such as the U.S.A, Canada,
                               Australia, and in much of Europe there        References:
                                                                             1 HAI/WHO (2003) Assessment of the pharmaceutical situation in
                               is a tradition of patient or health con-        Kenya, A baseline survey.
                                                                             2 HAI/WHO (2002) Uganda Pharmaceutical Sector Baseline
                               sumer networks. In Central and Eastern          Survey
                                                                             3 WHO (2002) Baseline Assessment of the Nigeria Pharmaceutical
                               Europe the development of democratic            Sector
                                                                             4 WHO (2002) Baseline Survey of the Pharmaceutical Sector in
                               civil society has enabled the emergence         Tanzania
                                                                             5 FDRE/WHO (2003) Assessment of the Pharmaceutical Sector in
                               of patients’ groups, and in Latin America       Ethiopia
                               similar consumer groups are growing in        6 WHO/EDM (2003) An assessment of the pharmaceutical Sector
                                                                               in Ghana
                               number. In the vastness of Africa and         7 WHO/University of Amsterdam (2004) How to investigate the use
                                                                               of medicines by consumers
                               Asia where access to health care is a         8 http://www.worstpills.org/public

                               major issue, a few consumer groups are
                               emerging, but their impact has not yet
                               been measured. Treatment and con-
                               sumer advocates in these continents
                               have concentrated much more on lob-
                               bying for increased access to essential
                               medicines, but now a few have begun
                               focusing on rational use. Initiatives such
                               as the drug literacy programmes by the
                               Coalition of Civil Society Organizations
                               in Kenya and in the Southern African
                               Development Community (SADC)
                               countries which are geared towards
                               empowering the consumers are antici-
                               pated to have influence on rational use
                               of medicines.

                               Conclusion

20                                                                                           Contact n°183 –Autumn/Winter 2006
                                                                                                                       EXPERIENCE

 RATIONAL USE OF MEDICINES: A PATIENT’S PERSPECTIVE
       The development of Antiretroviral medicines (ARVs) brought with it a lease of hope for people
   living with HIV and AIDS (PLWHA). Like with any other medication, it is important for patients on
       ARVs to understand the treatment they have been put on and to use the medication rationally
   for maximum benefits to be derived and adverse effects to be avoided. James Kamau who is on
                ARV treatment recounts the benefits he has experienced from using ARVs rationally.

 James suspected that he was HIV positive over 14 years          such as these cause irrational use of medicines since
 ago after his wife fell ill and was required to undergo         when the patient falls sick, or when they get opportunistic
 medical tests by her health care provider and was found         infections (OIs), they are unable to travel long distances to
 to be HIV positive. He went for the actual test two years       access the treatment they need and are afraid to ask for
 after his wife was diagnosed. James has been taking             help. They therefore use any drugs they can get but which
 antiretroviral (ARV) drugs for over 36 months. Before he        may be inappropriate.
 started taking the ARVs, he was on prophylaxis for two          The lack of equipment in hospitals to conduct tests includ-
 years. Prophylaxis is a measure taken to maintain health        ing liver function tests and CD4 count tests is another
 and prevent the spread of disease. In James’ case he was        challenge faced by those on ARVs. “You have to go out
 put on antibiotics to boost his immune system and prevent       there [private hospitals] and that is expensive,” James
 him from contracting TB. His CD4 at the time was 300; it        says regarding these tests. Other challenges are the lack
 is currently over 800.                                          of good nutrition. “One has to eat and for some it’s very
 Before he was started on the medication he went through         hard [to get food],” says James. Patients may therefore not
 counselling sessions to make him understand the different       take their medication.
 aspects of the medication including how to take the medi-       According to James the government has a large part to play
 cation, the benefits and side – effects. It is important for     in rational use of ARVs and treatment. “The government
 one on ARVs to take the medication at a scheduled time          needs to get the healthcare workers to understand what
 everyday. This keeps the virus from developing resistance       HIV/AIDS is,” he said. He proved this by explaining how
 to the drugs.                                                   he had visited one of the largest private hospitals in Kenya
 In the 3 years he has been on antiretroviral therapy (ART),     and the laboratory technician would not tell if there was any
 James has only failed to take his medication twice or thrice.   correlation between TB and HIV! In instances such as these
 This was due to travelling for long hours at a time and into    the laboratory technician is not at fault because he has not
 different time zones. When this happended, he waited until      been trained on this aspect of HIV. “We need HIV/AIDS in
 the next scheduled time to take the medication in order to      the school curriculum and before that the teachers them-
 maintain the routine his system is used to. James explained     selves need to be taught so that they can pass the correct
 that he is on first-line medicines which are more readily        information on to the pupils,” says James.
 available and less expensive. Should the virus develop          The government also needs to reduce its reliance on do-
 resistance on these drugs, he would have to start taking        nor aid to provide treatment to its citizens. As most of the
 the second-line drugs which are more expensive and less         funds for treatment of HIV/AIDS are foreign it is difficult to
 readily available.                                              sustain treatment for long periods of time. This would be
 James is well versed with all the aspects of taking ARVs        dangerous should the funding be discontinued or eased
 and Antiretroviral Therapy (ART) in general. He explains        off for any reason.
 that even before he began taking ARVs he was an advocate        Treatment to all those who need it is the government’s
 for access to essential medicines which he says made it         responsibility. “If we can scale up and keep the people who
 easier for him to understand the treatment process. “I am       are there alive and give hope [to them] then we will send
 treatment literate which means I understand what would          a clearer message to the wider population on prevention
 happen should I miss treatment.” He continues, “For me,         issues,” says James.
 it has been easy taking ARVs, I have had no problems.”
 He has been fortunate in this aspect which is however not
 the case for other people on ARVs.
 James is a member of a support group for PLWHA where
 they share their experiences. The challenges most of them        James Kamau is the coordinator of the Kenya Treatment Access
                                                                  Movement (KETAM). KETAM is a Kenya-wide activist movement whose
 encounter in taking ARVs are stigma and discrimination.          aim is to advocate for access to medicines. He is a member of the
 “You will find people leaving [their homes] going very many       steering committees of the Pan African Treatment Access Movement
                                                                  (PATAM) and Women Fighting AIDS in Kenya (WOFAK). He was
 kilometres away [from their homes] to access the medica-         interviewed by Jacqueline Nyagah of EPN on his experiences in using
 tions to get away from that stigma,” he explains. Situations     antiretrovirals (ARVs).


Contact n°183 –Autumn/Winter 2006                                                                                                   21
EXPERIENCE


  THE CHALLENGES OF RATIONAL
    USE OF MEDICINES IN NIS
        The Newly Independent States (NIS) of the former Soviet Union became independent in the
    early 1990s. Since then, the countries have been going through political, economical and social
     reforms, which have been associated with economic crises, political uncertainty and change of
  social structure. The concept of Rational Use of Medicines (RUM) and Essential Drug Lists (EDL)
        is rather new for the NIS since there was no EDL in the Soviet Union and the Soviet System
      considered all registered drugs as essential. In the mid 1990s, the World Health Organization
       (WHO) introduced the RUM and EDL concepts to the former Soviet Union states as a tool to
                                          improve pharmaceutical supply and rational medicines use.

                         T    he essence of an Essential Drugs List
                              is to provide a catalogue of the
                         minimum medicine needs for a basic
                                                                      cases of adverse reaction in Moldova
                                                                      or any of the other NIS countries. This
                                                                      dangerous drug was included in the first
                         health care system in a given country. It    edition of the Essential Drug List of all
                         lists the most efficacious, safe and cost     NIS countries and is still found in many
                         effective medicines for priority condi-      Standard Treatment Guidelines.
                         tions within that country. The process
      The Newly          of implementing the EDL concept in           Drug promotion
 Independent States      the NIS had many obstacles because           The situation is made worse by large-
(NIS) of former USSR     of a lack of willingness among govern-       scale promotion campaigns for any
                         ments to restrict the use of inessential     drugs but most especially for medicines
                         drugs and because of the insufficient         that are banned in developed countries.
                         educational programs for health care         Direct advertisement of drugs to con-
                         providers. In spite of the existance of      sumers was forbidden until the 1990s,
                         the WHO Essential Drug Model List, the       but is now widely prevalent in NIS
                         first edition of EDL in many NIS coun-        countries through all kinds of media,
                         tries had a separate column for brand        including TV, newspapers, magazines
                         names. For almost every generic name,        and direct visits to physicians and phar-
                         a number of brand names were indi-           macists. This has resulted in a flood of
                         cated. In some cases the brand names         new brands in the market.
                         were more than 10. For instance, the
                                                                      Proliferation of brands
                         EDL of Kazakhstan mentioned 7 brand
                                                                      Irrational drug use is directly related to
                         names for diazepam, 11 brand names
                                                                      the number of brands on the market
                         for ibuprofen, and 14 for paracetamol.
                                                                      and to their promotion. Between 4,000
                         The EDL of Tajikistan had a similar col-
                                                                      to 10,000 medicines are registered by
                         umn. It included brand names for most
                                                                      the national drug authorities in NIS
                         of the drugs in the list.
                                                                      countries for populations of between 3
                         In former republics of the USSR danger-      million to 6 million people. As many as
                         ous drugs such as metamizole (dyp-           70% of all registered pharmaceuticals
                         irone) which is banned in other develop-     are duplicate or non-essential drugs.
                         ing countries, is still widely prescribed    Many are variations of prototype drugs
                         by physicians and is even available over     and offer no therapeutic advantage over
                         the counter in community pharmacies.         drugs already available.
                         In Moldova metamizole is registered in
                                                                      The number of brands per drug varies a
                         27 preparations while in Ukraine it is
                                                                      little from one country to another in NIS.
                         registered in 37 brand forms and in 38
                                                                      For example, the number of brands
                         in Uzbekistan. One of the arguments
                                                                      presently registered for diclofenac var-
                         given by pharmaceutical companies
                                                                      ies from between 50 and 65; while for
                         is that there has been no information
                                                                      paracetamol there are between 38 to
                         from the regulatory authorities about the
                                                                      49 registered brands.
                         banning of metamizole, and no reported

22                                                                               Contact n°183 –Autumn/Winter 2006
                                                                                                                                      EXPERIENCE
Prescribing errors                                        the total amount of sold medicines using
Relatively little is known about the in-                  “special” prescription forms. The lack of the
cidences of prescribing errors in NIS                     doctors’ stamps, medical institution seals or
health care system. Knowing what                          the prescribers signatures was also reported
kinds of errors are most likely to oc-                    (See picture 1a).
cur is the first step in trying to prevent                 Another finding of the study was
these errors. The first investigation into                 that doctors may prescribe several
the errors in prescribing in Moldova                      medicines that potentiate, weaken or
was carried out by the Ecumenical                         neutralize each other’s effects when
Pharmaceutical Network Country Focal                      taken together. For instance, com-
Point Organization (EPN-CFPO) - Dru-                      bined prescribing of diclofenac and
gInfo Moldova in 2006. The study was                      diazepam leads to weakening effect of
conducted in 3 public hospitals and 4                     diclofenac.
community practices located within the
same geographical area. Pharmacists                       The study also revealed that quite often
                                                          doctors prescribe drugs fractionally. This                Doctors in the NIS rarely
recorded prescribing errors during a
12- week period. The errors were cat-                     means that they prescribe a half, a third,                use the prescription form
egorized by the survey team composed                      a quarter and even one eighth part of
                                                          a pill. In such cases it is difficult for a
                                                                                                                    approved by the Ministry
of physicians, pharmacists and a clinical
pharmacologist. In total, 84 recorded                     patient to accurately divide the medicine                 of Health for writing
prescriptions were examined using                         into the stated portion. One of the biggest               medicine prescriptions
the British National Formulary (BNF),                     problems is the fractional prescription of
the WHO Formulary and the National                        enzymatic and iron-based agents to chil-
Moldavian Compendium.                                     dren. These medications are contained
                                                          in a shell which is designed to dissolve
The study findings showed that doc-                        in the bowels to give the desired effect.
tors in the NIS rarely use the prescrip-                  By opening up the shell to divide the drug
tion form approved by the Ministry of                     into fractional portions, the desired effect
Health for writing medicine prescrip-                     of releasing the drug when the capsule
tions. Rather they use form-notebooks,                    dissolves in the bowels is not achieved.
known as blanks, which are distributed                    Without the protection of the containment
by pharmaceutical representatives.                        shell, the drug ingredients are destroyed in
Since the names of brand medicines are                    the stomach. In such cases it is therefore
often printed on these forms, there is a                  practical to prescribe iron-based agents
tendency of doctors to prescribe these                    in the form of syrup or drops. There are
specific medications to patients so as                     humorous anecdotal accounts of a doctor
to receive a share of the profits made                     prescribing Aevit, an oil solution in gelatin
by the pharmaceutical representatives.                    capsule, to be divided into three portions
Such cases were reported in 10-15% of                     twice a day!
                                                                                                                  Two examples of prescribing errors




 (1a) Prescriptions written on blank paper without the doctor’s stamp, signature or institutional   (1b) A prescription of 23 drugs for one patient!
                                              logo.

Contact n°183 –Autumn/Winter 2006                                                                                                                  23
EXPERIENCE
                      Another prescription error is the        solution! Another amusing example was in-
                       duplication of medicines. This          structions which indicated the intramuscular
                        refers to doctors prescribing          introduction of pills!
                         2 medications of the same             Children’s prescriptions are an area where
                         pharmacologic group or which          many errors are likely to occur. The prescrib-
                         contain the same ingredients,         ing of drugs which are contraindicated in
                         for example the simultane-            children or which should not be prescribed
                         ous prescription of the same          to children below a certain age is a com-
                         medicine under different brand        mon mistake. For instance: Famotidin is
                         names This is most common             prescribed to younger children in doses of a
                         when prescribing new medica-          half and a quarter pill daily. However it is not
                         tion for a patient who is already     advisable to prescribe the drug to children
                         on medication. The main moti-         less than 16 years old. This is because this
                         vation is that the doctor feels the   drug is contraindicated to younger children
                         need to prescribe a safety net        as clinical investigations have not been car-
                         medicine to ensure therapeutic        ried out to decipher the effects the drug may
                        effects. The consequences are          have on them.
                        an undesirable increase of pre-
                       scribed medicines.                      Finally, the act or practice of prescribing too
                                                               many medicines to one patient known as
                        Errors are also made in the indica-    polypharmacy is one of the main problems
                       tion of drugs doses. For instance,      that is presented in the health care system in
                     some errors occur when converting         all NIS countries. The misconception is that
                   milligrams into grams. Doctors may          a disease or illness should be treated with
              make errors in the quantity by placing           many drugs. (See picture (1b) which shows
             commas or decimal points at the wrong             a prescription of 23 drugs for one patient
             place. Incorrect comma and decimal point          after one visit to the doctor!)
             placement can increase or decrease the
             dosage by dozens or hundreds of times. For        Conclusion
             instance, Diazepam is produced in doses           These examples of irrational drug use in NIS
             of 5 and 10 mg. Doctors may erroneously           countries give cause for concern. With little
             prescribe 50 mg or even 500 mg instead of         or no monitoring of drug prescribing these
             5 mg resulting in an overdose ten and one         could have serious implications for appropri-
             hundred times more the desired amount!            ate drug use and patient care. Moreover, the
                                                               present situation shows that self-regulation
             Prescription without dose indication is also
                                                               by the medical profession has failed. In most
             a common prescribing error. For instance, a
                                                               of the errors deduced professional advice to
             prescription may give only the name of the
                                                               pharmacists would help to avoid them. Day-
             of preparations without indicating the dose,
                                                               to-day tests and regular analysis of prescrip-
             the turnout form or the mode of application
                                                               tions would reform the treatment and reduce
             or a doctor may issue a prescription with
                                                               the risk of adverse reactions which appear
             only one word on it: “Metrogil”. A patient
                                                               as a result of misuse of the preparations. It
             would not know, what drug formulation is
                                                               is necessary to resume cooperation of fam-
             intended, what the correct dose is, how
                                                               ily physicians and pharmacists regarding
             many times it should be taken, and for what
                                                               correct and efficient drugs prescribing. This
             duration. Since “Metrogil”is produced in 6
                                                               cooperation would reform treatment.
             drug formulations (in intravenous injection,
             solution, in pills, as a gel, as a face cream     Natalia Cebotarenco, PhD, is a doctor working for
             and as vaginal suppositories) a patient           DrugInfo in Moldova. She is the EPN Country Focal
                                                               Point in Moldova.
             would not know which of these the doctor
             had in mind.                                      Elena Shkurkina, Svetlana Shetinina, Sergey
                                                               Cebotarenco, Olga Shemshur and Veaceslav Gonciar
             Blunders also cause problems. For example,        participated in the research.
             the following irrational instructions were        References:

             issued in the manufacturing department            1 Health system in Transition, WHO, 2004.
                                                               2 The most popular errors when prescribing medicines, ISDB
             of a drug-store: Rp: Sol. Glucozae 2%; Ca           Newsletter, June, 2006.
                                                               3 Ten recommendations to improve use of medicines in developing
             Gluconatis 0,2; Mf pulv. No 20. These are           countries. Health Policy and planning; 16 (1):13-20, Oxford
                                                                 University Press 2001.
             instructions to prepare a powder from a
24                                                                             Contact n°183 –Autumn/Winter 2006
                                                                                                           EXPERIENCE

            PROMOTING RATIONAL USE OF
                MEDICINES IN PERU
                                              IT CAN BE DONE
Dr. Amelia Villar is the General Executive Director of medicines, production agents and drugs (DIGEMID)
     in the Ministry of Health in the Peruvian government. DIGEMID regulates the use of pharmaceutical
 products, medical materials, instruments and cosmetics which are available in the Peruvian market.She
        was interviewed by Josefa Castro Sáenz and César Aylas Flórez both from Servicio de Medicinas
                                    (PRO-VIDA), a member of the Ecumenical Pharmaceutical Network (EPN).
Q: What is the legal framework for           play in ensuring RUM. In Peru, the Na-
RUM in Peru?                                 tional Committee of Medicines, brings
A: The current National Medicine Policy      these players together and includes the
approved in December 2004, stands on         civil society organizations, professional
three supporting pillars: equal-opportu-     schools, universities, institutions of co-
nity and universal access to medicines,      operation, churches and others.
regulation and quality assurance, and        With regard to specific actions to pro-
promotion of the Rational Use of Medi-       mote RUM, the Ministry of Health has
cines (RUM). The RUM section of the          made significant progress to increase
General Management of Medicines,             access to medication, and to lower the
Substances and Drugs, DIGEMID has            prices of medicines by means of corpo-
developed the national plan for RUM.         rative purchases. We have also made
Several strategies have been put in          strides in encouraging the use of EDLs,
place to ensure the achievement of           the formation of Therapeutic-Pharma-
these intended goals. These include          cological Committees in hospitals and        A training manual for Ministry
                                                                                          of Health staff in the supply of
rational selection, promotion of the         health centres, at the regional level so     drugs, titled: “A guide on training
use of Essential Drug Lists (EDL), af-       that their work is more effective.           methods for the supply of drugs and
fordable prices of medicines, updating       Progress has been made in promot-
                                                                                          productions agents processes”
and strengthening the Pharmacological        ing teaching on the use of medicines,
Committees, training of professionals,       and in integrating curricular contents
sharing of information with and educat-      both in university programs and in
ing communities, and the development         secondary schools. Pro-Vida provides
of research on the use of medicines.         support on designing educative book-
Studies on the use and adverse reac-         lets for schools about RUM. Twelve
tions of the antimicrobial drugs in hos-     universities now teach Pharmacol-
pitals are currently underway. Another       ogy and Pharmacotherapy using the
study has been conducted with proto-         University of Gröningen methodology
cols of evaluation and use of antimicro-     which is recognized by WHO as the
bial drugs in health centres. This is on a   best adapted education for Rational
peripheral level and will help reduce the    Pharmacotherapy.
irrational use of antimicrobial drugs.       At a national level, the government
Q: Who do you think should play the          has developed and implemented best
main role in promoting and ensur-            practices for prescriptions of medicines.
ing RUM and what specific actions             The best practices of dispensing and
have been taken in Peru towards              for therapeutic drug follow-up are in the
this end?                                    process of implementation.
A: The government, through its agen-
                                             Q: What difficulties are there in pro-
cies, those who prescribe, those who
                                             moting RUM policies at a national
dispense and health professionals in
                                             level?
general, the population and the pharma-
                                             A: One of the most critical problems
ceutical industry have important roles to
Contact n°183 –Autumn/Winter 2006                                                                                        25
EXPERIENCE
             is the lack of involvement of the main    the National Drugs Policy and having
             actor. Inadequate and lax laws do not     created DIGEMID, a specific depart-
             guarantee quality and prevent wide-       ment in its management structure, I
             spread access to medication; and the      have confidence that we will continue
             patients quite often, incorrectly use     to promote RUM. Moreover, the 2007
             their medication and usually take them    DIGEMID RUM Annual Plan has been
             without a doctor’s prescription. Health   approved. We coordinate work with dif-
             professionals who use inadequate          ferent organizations to help achieve this
             standards in prescribing and dispens-     goal. For example, there are advances
             ing of medication also contribute to      in the proposal and elaboration of the
             the problem. These standards are          National Essential Drug List. We are
             worsened by excessive and overwhelm-      working to create Drug Therapeutic
             ing advertising campaigns from the        Committees and also to have medicine
             pharmaceutical companies which use        purchases done within the public sec-
             irrational and illegal means to entice    tor. This would greatly lower medicine
             those who prescribe, who dispense,        prices without lowering quality.
             including pharmaceutical technicians
                                                       Q: What do you see as the pharma-
                                                       cist’s role?
                                                       A: The pharmacist is the specialist of
                                                       medicines. It is inconceivable to talk
                                                       of quality pharmaceutical care without
                                                       the promotion of RUM. As someone
                                                       who is aware of drug issues, I believe
                                                       that a pharmacist’s role must be that of
                                                       supervision, quality control of products
                                                       and processes. He or she must assume
                                                       the responsibility of managing, advising,
                                                       informing and investigating, according
                                                       to the principles of RUM. Because of
                                                       his or her expertise in pharmaceutical
                                                       issues, his or her participation is vital in
                                                       the formulation of policies and regula-
                                                       tory mechanisms to ensure appropriate
                                                       use of medicine.

                                                       Q: For the last 21 years PRO-VIDA
                                                       has promoted RUM in Peru in di-
                                                       verse levels. What do you think are
                                                       the positive outcomes of this work
                                                       in the community?
                                                       A: I greatly admire PRO-VIDA because
                                                       it is one of the faith-based organizations
                                                       that helped the poor when the country
                                                       was going through its most difficult
                                                       times.
             and pharmacy aides.                       PRO-VIDA introduced and promoted
                                                       the concept of RUM when it was un-
             Since the government does not have
                                                       known in the universities and in the
             RUM as a priority the lack of resources
                                                       public sector. I believe that PRO-VIDA’s
             is also problem.
                                                       work has been extremely important not
             Q: What future do you see for RUM         only for DIGEMID but for the country as
             in Peru?                                  a whole. We are now reaping the reward
             A: Having considered RUM a pillar of      of PRO-VIDA’s early work in RUM.



26                                                                Contact n°183 –Autumn/Winter 2006
                                                                                                                  EXPERIENCE
Q: What aspects of the community             nizations like PRO-VIDA do is crucial.
work of RUM promotion must be                Although we have managed to increase
supported further? Do you know of            availability in urban areas, shortage of
other countries that have developed          supplies persists in the remote areas.
these strategies successfully?
A: Since it is difficult for the government   Q: Your final comments...
to reach remote places, the health pro-      A: To our friends of EPN and PRO-
moters and the grass roots pharmacies        VIDA, I would like to express my grati-
continue to be a good option to improve      tude for this interview. Let us continue
                                             working on the promotion of RUM.                       Although we have
the access to medicines and healthcare.
Education and training in the handling       Many African countries are developing                  managed to increase
of medicines must continue. DIGEMID,         important strategies in this field and
                                                                                                    availability in urban areas,
together with PRO-VIDA, has devel-           it important to share our accomplish-
oped a manual on the handling and use        ments, lessons learnt, best practices                  shortage of supplies
of medicines for those in charge of the      and the challenges we encounter to                     persists in the remote
Pharmacy’s Office in the health centers.      improve our work and further promote
                                                                                                    areas
This is a handbook used to instruct the      RUM. I believe that more frequent com-
community on the correct use of medi-        munication will facilitate learning from
cines. There has been some success           others experiences.
in implementing strategies to promote        Additionally, I congratulate all the
RUM in Asian and African countries.          churches, all the sectors that support
However in this region (Latin America), I    the work in the community, the work of
have had the opportunity to share expe-      community promoters which is a great
riences with other regulatory authorities    support for all the official systems of
in the South American region countries       health.
including Chile, Argentina, and Brazil.
Unfortunately RUM has not been well
developed in most of these countries

Q. PRO-VIDA was set up to support
the efforts of the community in ob-
taining access to health services and
essential medicines and to make up
for the absence of the government            Dr. Amelia Villar is the Head Director of General
in this area. In your opinion, how do        Direction of Medicines, Production Agents and
such efforts combined with those of          Drugs (DIGEMID) a branch of the Ministry of Health
                                             which regulates the use of pharmaceutical products,
the government ensure that RUM               medical materials, instruments and cosmetics which
becomes a reality?                           are available in the Peruvian market. It contributes
A: I believe that these institutions have    to equitable access of essential drugs, to the
                                             population, based on an integral system of drugs
helped in improving the access to ser-       quality assurance.
vices and medicines in remote settings       Josefa Castro Sáenz is a pharmacist and the Manager
and which government still finds hard         of the Drug Supply Area at Servicio de Medicinas
to reach due to civil unrest, terrorism,     PROVIDA in Peru and the EPN - Country Focal Point
                                             in Peru.
budget constraints or shortage of quali-
                                             César Aylas Flórez is the Pharmaceutical Assistant
fied health care personnel.
The Ministry of Health in Peru has made
an effort to improve access and supply
of medicines. We have also managed to
lower prices of medicines and achieve
the goal of ensuring the lowest price
available is maintained all over the
country. Nevertheless, we still have dif-
ficulties in the distribution of medicines,
for which the work churches and orga-



Contact n°183 –Autumn/Winter 2006                                                                                            27
EXPERIENCE


SENSITIZING THE PUBLIC IN BURKINA
  FASO ABOUT STREET MEDICINES
 The phenomenon of ‘street medicines’ is widespread all over Burkina Faso. Street medicines are
   unregulated products whose origins are often unknown. CINOMADE, a non-profit association in
  collaboration with Pharmaciens Sans Frontières - Comité International (PSF-CI), have developed
   an Interactive Cinema Debate (ICD) strategy to educate and sensitize the public on the dangers
      of street medicines. The strategy involves the screening of a film, in this case “Tiim” (meaning
 “medicines” in Moorè,one of the main Burkinabè lanuages) which focuses on the street medicines
               phenomenon. This is followed by a facilitator-guided debate on the subject of the film.

                               E    nclosed in plastic bags and displayed
                                    on a stand on the sidewalk of a
                               street, carried in open cardboard boxes
                                                                                     street medicines. In 2005 to communicate
                                                                                     and sensitize the public about street
                                                                                     medicines, CINOMADE and PSF-CI used
                               and hawked from one person to another;                the documentary to conduct awareness
                               carried from village to village on a bicycle          campaigns in three provinces in the
                               baggage-carrier for door to door sale, or             Northern region of Burkina Faso.
                               neatly arranged on a mat or on a table                The strategy used to create awareness of
                               in the middle of a market: this is how                street medicines was Interactive Cinema
                               street vendors market their medicines to              Debate (ICD) strategy. ICD consists of
                               consumers. This phenomenon of ‘street                 open-air public screening of a film which
                               medicines’ is widespread all over Burkina             is followed by an audience debate on the
                               Faso. Street medicines are often un-                  subject of the film. The debate is guided
                               regulated pharmaceutical products whose               by two facilitators, one male and one
                               origins are unknown, if not dubious, and              female. An ICD event lasts about four
                               therefore often have harmful effects on               hours, typically running from 8pm up to
                               the health of their consumers. In spite of            around midnight.
                               this, business is booming for vendors of
                               street medicines.                                     In the CINOMADE/PSF-CI campaign,
                                                                                     preliminary visits were made to all of the
                               PUBLIC AWARENESS CAMPAIGNS                            selected locations in the 3 provinces in
                               In 2003, CINOMADE in collaboration with               order to meet local partners (health cen-
                               Pharmaciens Sans Frontières - Comité                  tre workers, owners of pharmaceutical
                               International (PSF-CI) directed a docu-               stores, members of associations, etc.) as
                               mentary entitled “Tiim”1 on the subject of            well as the administrative and community
                                                                                     authorities. This ensured smooth running
                                                                                     of the ICD events. In this campaign, a
                                                                                     unique approach was taken: during the
                                                                                     day in each location, the local people
                                                                                     were interviewed on the subject of street
                                                                                     medicines. These filmed interviews were
                                                                                     shown the same evening to start the ses-
                                                                                     sion before the film “Tiim” was screened.
                                                                                     The evening program also included the
                                                                                     screening of filmed interviews with man-
                                                                          CINOMADE




                                                                                     agers of local pharmaceutical stores and
                                                                                     a cartoon film about generic drugs entitled
                                                                                     “Ya boum yenga.”
                                                                                     The campaign managed to attract ap-
                                                                                     proximately 27,000 people in 12 different
                                                                                     locations. A total of 210 people actively
             Ongoing debate after the screening of the film “Tiim”                    took part in the debates, of which 144

28                                                                                              Contact n°183 –Autumn/Winter 2006
                                                                                                                             EXPERIENCE
were men and 66 were women. The infor-
mation collected from the debates helped
to answer questions such as: Who are
the street vendors? How do they sustain
their businesses? What kind of medicines
do they sell? What alternatives are there
to street medicines?

Who are the Street Vendors?




                                                     CINOMADE
The street vendors of medicines are trades-
men who are hardly concerned for the health
of their clients or the harmful effects that their
products may cause. On the contrary, they
use all kinds of strategies to keep their busi-
nesses thriving. A street vendor of medicines
can be compared to someone who sells sec-
ond-hand clothes or shoes. Their common
                                                                                                               Street vendor Karim Compaoré
goal is to market their goods to encourage                      “On a good day, I can raise up to 10 000       with his bag of medicines
their passers-by to purchase them.                              FCFA (about 20 US Dollars)” said Karim
Asked why he engaged in the sale of street                      Compaoré in the film Tiim.
medicines, R. Salifou a street medicines
                                                                How Do They Sustain The Busi-
vendor interviewed in the village market of
                                                                nesses?
Ingané during one of the filmed interviews
responded, “Since I have a family to take                       Easy accessibility
care of, I must do something, that is why                       Street vendors seek out their clients
I sell medicines.”2 “I don’t have to recom-                     wherever they can find them, be it at
mend a medicine to the client. Usually                          home, at the workplace or on the streets.      Although the sale of
the clients have been treated before for                        They know their clients well as they see
                                                                                                               medicines on the street
the same illness and remember which                             them often and chat with them in their
tablets were prescribed on that occasion.                       own language to establish a bond of trust.     is illegal in Burkina Faso,
Therefore when they fall sick again with                        They often sell their wares on credit for      this business is thriving
the same disease, they look for the same                        the convenience of the customers who
                                                                cannot pay immediately.                        because street vendors
medicine,” declared Alidou, a medicines
vendor interviewed in the village market                        “I live 12 kilometres from here. There is      are rarely challenged by
of Youba.2                                                      no pharmaceutical store there. When I          the authorities
However medicine vendors do not know                            have a headache, I prefer to buy drugs
much about the medicines they sell. Their                       from a vendor who comes to my home,
knowledge is often limited to what they can                     instead of cycling all this distance to come
learn from the pictures on the package.                         here, because the pain might get even
According to Karim Compaoré, a street                           worse on the way here,” said one of the
vendor and the main character in the film                        participants of the ICD session held in the
Tiim, illiteracy is not a barrier for the street                village of Bidi.3
vendor. “Even if you cannot read, you can                       “If my children are sick, I buy medicines
still sell medicines. It is good enough if you                  on the market. Often, the vendors come
refer to the pictures on the boxes”.                            to us and I seize the opportunity to buy
Although the sale of medicines on the                           some medicines,” said S. Azeta, a mother
street is illegal in Burkina Faso, this busi-                   of twins.
ness is thriving because street vendors                         “When he comes, what does he say?”
are rarely challenged by the authorities.                       asked the facilitator of the evening. He
This explains why these vendors con-                            says: “Come and see! Come and buy
duct their trade openly. Furthermore, the                       medicines!”
income that is generated from the selling
of medicines on the streets is often higher                     Cost of the products
than the average income of a Burkinabè.                         The prices offered by the street vendors
                                                                have a big influence on the consumers.

Contact n°183 –Autumn/Winter 2006                                                                                                       29
EXPERIENCE
             “We all know that the packaged medicines         Alternatives to Street Medicines
                from the pharmacy are better than             In the documentary Tiim, and during
                   those exposed to sun and dust. But         the evening debate sessions of the
                      if you are not able to feed your        awareness campaign, essential generic
                        family, it is difficult to go to a     medicines were recommended as the
                         pharmacy. This is what pushes        alternative to street medicines.
                          us to buy in the streets.” Was      Essential generic medicines are not
                          a response echoed by ICD            difficult to get thanks to the pharma-
                           participants.                      ceutical stores set up in the health
                          “If you fall sick and you have      centres. Generics can be used to treat
                          only 50 FCFA (approximately         up to 80% of the pathologies found in
                          10 US Cents) with you, what         Burkina Faso. These medicines are of
                          would you do?” D. Salimata          good quality and can be taken without
                         interviewed in the village of        any risks while their prices are more af-
                         Bidii2 answers: “I’d buy medi-       fordable thus making them accessible
                         cines at the market for 25           to poor populations.
                        FCFA and I would save the             Despite all these, it was noted during
                        rest.”                                the ICD sessions that there is still a
                                                              lot of work to do regarding information
                        What Kind of Medicines do
                                                              and sensitization to guide the public
                       Street Vendors Sell?
                                                              towards the use of generic medicines.
                      Asked “what kind of medicines he
                                                              A lack of communication between the
                     sells”, Alidou a medicine vendor in
                                                              health authourities and the population
                   Youba replies, “Paracetamol, Ibupro-
                                                              on generics was observed.
               fen, ‘Medic 55’, ‘Two colours’, ointments
             and others.”2                                    Several participants of the awareness
                                                              campaign did not know what generic
             While Karim Compaoré, the main char-
                                                              medicines are. When asked the ques-
             acter of the film Tiim explains, “I sell
                                                              tion “What does generic medicine
             medicines to treat human beings, but as
                                                              mean?” Diallo one of the participants
             many people are asking for tablets for
                                                              responded, “I am sorry, but I do not
             their animals, I have started selling them
                                                              know this disease, I have never heard
             too.”
                                                              of the word.”
             Unfortunately street medicines often
                                                              To promote the use of generic medi-
             have harmful effects on the health of the
                                                              cines, interviews of the managers of
             consumers. “I don’t like street medicines,
                                                              pharmaceutical stores explaining the
             because you can take them and a few
                                                              advantages of generics were filmed.
             moments later, you think that you have
                                                              These interviews were then screened
             been cured of your disease, but this is
                                                              for the participants of the evening film
             only temporary. The illness will come back
                                                              session.
             soon and often it even becomes more
             complicated,” stated a participant at the
             evening debate in Ridimbo.3
             You can also buy doping substances from          Moumouni Sodré is audio-visual technician by
                                                              profession and in-charge of the Interactive Cinema
             the street vendors, like the “Blue-blue” and     Debate tours of CINOMADE.
             the “14s” for example. “Out of every twenty
                                                              CINOMADE is a non-profit association based since
             people here, you will not even find three         2001 in Burkina Faso, specialised in creation,
             who do not take the “14s” because if you         animation and sensitisation. They use audio-visual
             take them, you will not be hungry anymore        tools, direct films and diffuse them through four different
                                                              sections (Interactive Cinema Debate, Youth, Women
             and you will have the strength to work hard.     and Video Clubs).
             I started by taking two, then four, five, and
             nowadays I take nine of them per day. And        Reference:
                                                              1 DVD/Video “Tiim”, produced by CINOMADE (www.cinomade.org,
             to make me sleep well at night, I take two          email:cinomade@hotmail.com) and PSF-CI, directed by Berni
                                                                 Goldblat, length 31 minutes, available in Mooré with French or
             “Blue-blue” ” said a participant at the debate      English subtitles, December 2003.
                                                              2 Source on video, available from CINOMADE
             in Kera-douré. 3                                 3 Source on tape, available from CINOMADE




30                                                                            Contact n°183 –Autumn/Winter 2006
                                                                                                   BIBLE STUDY



                 WHAT WOULD JESUS DO?
                                            MATTHEW 21: 12, 13
             The following reflection has been prepared by Manoj Kurian of World Council of
                                            Churches (WCC)




  An indignant Lord Jesus physically cleansed the         responsibility to ensure fair and equitable access
  Temple, as he saw that worship had been com-            to medicines for all.
  mercialised.                                            Increasingly, provision of services is driven by
  Those ‘who were buying and selling’ in the Temple       market forces and not by the needs of the majority.
  traded in animals which were used for sacrifice.         Majority of research, innovation and development
  The ‘money changers’ provided currency that was         is directed by the needs of the minority who can af-
  acceptable in the Temple in exchange for the Ro-        ford. The profit motive of the market seems to decide
  man currency which was considered defiling to            what medicines are good for us, not necessarily the
  God as it bore the image of Caesar, the Roman           ‘Essential Drugs List’.
  Emperor. Although this trade seemed to have
  a legitimate role, in the eyes of Jesus the                       Questions for reflection?
  excessive commercialisation defiled the                            1. Is the situation described above ac-
  holy place of prayer. In response, he                             ceptable?
  acted firmly and with authority, by boldly                        2. Can we allow the instruments cre-
  overturning the tables and out casting the                       ated to serve humanity to be used for
  tradesmen.                                                       the enslavement and impoverishment of
  In the present day, the cleansing of the                         people?
  Temple should not only be seen as an im-                          3. Should business and industry con-
  age of cleansing our souls, but also as a sign to          spire to suppress potentially cheap yet essential
  purify society. I believe Jesus saw the Temple as a        ‘bread’ and only promote ‘expensive pastries and
  place where all believers would have free access           cakes’ which have a higher profit margin?
  to worship God as a fundamental right for every         4. Should nations and societies suppress ‘Essential
  human being.                                               drugs’ in favour of superfluous and non-essential
  Today there is the flagrant tampering of the funda-         medicines, which may bring greater profits?
  mental right of humanity to have fair and equitable     5. What is our role and what should we do?
  access to balanced nourishment and good health.
  There are also glaring examples of societies and        6. What would Jesus do in times like these?
  institutions created by society, thereby shirking its


Contact n°183 –Autumn/Winter 2006                                                                            31
RESOURCES
Essential drugs monitor                                            ABC of Rational Use of Medicines: A handbook
This newsletter aims to address issues on national drug            for community education
policies, current pharmaceutical issues, rational use of           The book is designed to help consumers to understand basic
medicines, access, operational research and educational            issues about medicines use; to create awareness about the
strategies. Published twice a year in English, Chinese,            risks of misusing or abusing medicine; and to help individu-
French, Russian and Spanish, the newsletter is designed            als and groups to take personal and collective actions that
for policy-makers, prescribers, health educators, adminis-         helps the community to use medicines wisely. It is a useful
trators and health development organizations. Readers are          handbook for students, NGOs and people working in health
encouraged to make contributions to the newsletter with the        at the community level.
authors’ guidelines provided.
                                                                   Author: Godwin Nwadibia Aja,
Available online at: http://www.who.int/medicines/publications/
monitor/en/index.html                                              Published by HAI - Africa, ISBN 978-35088-0-6

Promoting Health or Pushing Drugs? A critical ex-                  Guide to Good Prescribing: A Practical Manual
amination of the marketing of pharmaceuticals                      Primarily intended for undergraduate medical students
This book is an excellent resource on the murky world of           about to enter the clinical phase of their studies, this book
the pharmaceutical industry’s promotion practices, critically      provides guidance to the process of rational prescribing. It
examining the key issues surrounding drug promotion. The           contains many illustrative examples and teaches skills that
book discusses a wide range of issues including: the cost of       are necessary throughout a clinical career. Postgraduate
promotion, industry codes and practices, direct-to-consumer        students and practicing doctors may also find it a source of
advertising of prescription medicines, post market surveil-        new ideas and perhaps an incentive for change.
lance studies and the consequences of uncontrolled drug            It is available in print in 15 languages including French,
promotion. The final chapter makes suggestions towards              Spanish, German, Slovakian, Arabic, Japanese and Chi-
solutions to address the excesses of drug promotion.               nese.
To order, email: info@haiweb.org                                   Available in English online at: http://www.med.rug.nl/pharma/
Published by:HAI Europe; 1992; 46 pages;                           who-cc/ggp/homepage.html.
ISBN 90-74006-03-5                                                 Published by: WHO/EDM, WHO; 1994, 115 pages


Practical Pharmacy Newsletter                                      Developing Pharmacy Practice - a Focus on
This newsletter was first published in 1996. It was created         Patient Care
to provide appropriate and practical information on drug           This handbook is written for pharmacists, educators and
supply and management for health workers, particularly             students in all healthcare settings. It presents a step-wise
those with no specific training in pharmacy. In 2000, after         approach to pharmaceutical care within a general practice
fifteen issues, production stopped.                                 environment anywhere in the world.
The newsletter was relaunched in October 2006 by: Health           It can be used for self-directed learning as it provides prac-
Action International (HAI) Africa, Ecumenical Pharma-              tical examples and care models. The book is available in
ceutical Network (EPN), Mission for Essential Drugs and            English and a French version will be available soon in both
Supplies (MEDS), and Sustainable Healthcare Foundation             electronic and print formats.
(SHEF). This issue focuses on the topic of malaria. The
older issues of the newsletter are currently being updated         Available at: http://www.who.int/medicines/ under “latest pub-
                                                                   lications” on the WHO Medicines home page.
and will be reissued soon.To subscribe, send a request to:
practicalpharmacy@gmail.com


 Contact deals with various aspects of the churches’ and community’s involvement in health, and seeks to
 report topical innovative and courageous approaches to the promotions of health and healing.
 Contact, magazine of the World Council of Churches is pub-        Editorial committee: Eva Ombaka, Stella Etemesi, Jacqueline
 lished quarterly in English, French, Spanish and Portuguese       Nyagah.
 by the World Council of Churches (WCC). Present circulation       Design and layout: Stella Etemesi and Jacqueline Nyagah.
 is 2,000 copies.
                                                                   The average cost of producing and mailing each copy of Contact
 This issue of Contact was published by the Ecumenical Pharma-     is US$ 2.50, which totals US $10 for four issues. Readers who
 ceutical Network (EPN). The topic of Rational Use of Medicines    can afford it are strongly encouraged to subscribe to Contact
 is a key area of action for the Network.
                                                                   to cover these costs.
 Contact is also available on the World Council of Churches’       Inquiries about articles featured in this particlar issue can be
 Website: http://wcc-coe.org/wcc/news/contact.html                 directed to: Ecumenical Pharmaceutical Network (EPN)
 Articles may be freely reproduced, providing that acknowledge-    P.O. Box 73860 - 00200 City Square, Nairobi, Kenya.
 ment is made to: Contact, the publication of the World Council    Tel. No.: 254 20 4444823 Fax: 254 20 4441090/4440306
 of Churches. A complete list of back issues is published in the   Email: epn@wananchi.com Website: http://www.epnetwork.org
 first annual issue of each language version.                       Printed by Capital Colours Creative Design Limited


32                                                                                               Contact n°183 –Autumn/Winter 2006

				
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