E-DRUG: Inappropriate donations and WHO Guidelines
-------------------------------------------------
The headline “inappropriate donations to Aceh” (e-drug: 10 – 23 June)
has been added to the catalogue of unsuitable medical donations into
post-emergency (PE) situations which helped generate the formulation
and publication of the WHO Guidelines for Drug Donations. (e.g. Eritrea
1989, Sudan 1990, Guinea-Bissau 1993, Rwanda 1994 etc…)
Despite the (claimed) universal acceptance of the WHO guidelines by
governments, commercial donors, NGOs, charities and individuals, we are
reminded that inappropriate medical donations into PE situations are
still taking place. Although we have had the WHO guidelines for a long
time it is evident that guidelines in their present form have not been
effective in educating donor individuals and organisations.
Before we consider any options of either revising the IGDD, or
supplementing the IGDD with UN resolutions offering sanctions for
inappropriate donation, we should consider a closer examination of the
IGDD to begin to understand why inappropriate donations are still
taking place.
After the publication (and universal endorsement) of the WHO
Interagency Guidelines for Drug Donations (IGDD) governments,
organisations and individuals have perhaps been too content to accept
the IGDD and not examine or criticize the guidelines. Neither the
detailed content of the IGDD document, nor the suitability of the
format for defining “good practice” and “educating donors”, have been
subjected to any form of critical examination.
In 2002 the World Bank publication Drug Donations in Post-Emergency
Situations (2002) concluded that there was no evidence to suggest the
need for any improvements in the IGDD. (The evidence of inappropriate
donations into Aceh three years after this high profile publication
clearly appears to contradict this conclusion.)
To my knowledge this is the only published examination of the content
and impact of the IGDD since the publication of the last revision in
1999. However the specific restriction of this review to examination of
drug donations in PE situations reveals the limitations of our
examination of the IGDD.
Although the IGDD were prepared and introduced as a reaction to
large-scale inappropriate pharmaceutical donations into PE situations,
they have been adopted as generic guidelines for all pharmaceutical
donations (including sustained drug donation programmes to support
basic health care in the poolrest communities in the absence of any
disaster or emergency). The origins of the IGDD in drug donation into
PE situations dictated the fact that the guidelines were drafted to
offer good practice guidance to meet the specific demands of the PE
context. However, the strategic and logistic demands of the non-PE
situation are very different to those of the PE situation – the IGDD
were never designed to address the specific challenges of routine
(non-emergency) drug donation.
With this in mind we should perhaps remind ourselves that drug
donations into non-PE situations accounts for more than 75% of drug
donations every year. No review of the impact of the WHO Guidelines
upon deterring inappropriate donations in non-PE situations has ever
been carried out.
Perhaps we should consider examining the appropriateness and
effectiveness of the WHO guidelines for the majority of drug donations
which are made every year in the absence of any immediate disaster or
emergency such as Aceh.
I personally believe that there is an urgent need for two forms of
review of drug donation in the context of the existing WHO Guidelines:
.1. A review of the extent of inappropriate drug donations in non-PE
situations.
.2. A detailed review of the content and interpretation of the
existing WHO Guidelines.
I would welcome any comments and contributions from e-drug subscribers.
In order to stimulate responses I would like to request answers to the
following (possibly provocative) questions:
Q1. Has any-one read the IGDD in detail and tried to write
interpretations of the individual “Core Principles” and 12 Articles?
(If the WHO guidelines represented the equivalent of a professional
code of ethics and practice, lawyers would have crawled all over the
document and published a careful set of interpretations. Although we
have set great store by these guidelines no-one has offered guidance to
interpretation and I believe it is too easy to interpret the present
guidelines in very different ways.)
Q2. The WHO guidelines are available in 4 different languages
(English, French, Spanish & Russian) – has any-one actually compared
the different language editions to see if they are consistent?
(For example the English edition refers to “recipients”, whilst the
French edition refers to “beneficiaries” – these two terms do not have
the same meaning. In the crudest terms a donation delivered to a
central medical store in Africa has successfully and securely reached a
“recipient” - but if some of the medicines never get from the medical
store to the intended physician and patient in a rural community then
we do not have a donation successfully and securely delivered to the
“beneficiary”.)
Q3. We always seem to describe “inappropriate donations” in terms of
the physical quality and suitability of the donated goods - are we
perhaps forgetting cases where the donated drugs are perfectly
appropriate, but the process and methodology of the donation procedure
is not appropriate to the circumstances? Has any-one else looked for
evidence of “inappropriate donation procedures”?
(A donation programme which offers free supplies of an essential drug
with delivery paid “to the point of entry into the country” is surely
not an appropriate donation if the target clinic is 500 miles away from
the airport. The clinic has to find funding to pay for the 3-day
1000-mile round trip to collect the “free” donation - if only it had a
vehicle and could afford the petrol!)
Dr Geoff Crumplin
UK
(geoffrey.crumplin@ntlworld.com)