E-drug: Private sector drug supply in developing countries
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Dear E-druggers,
I have made some observations on drug supply to patients, with a
focus on the private sector. It is an expansion of what I wrote
earlier on pharmacy practice in the private sector of developing
countries.
In my country, drug-outlets prioritise sales that give most profit to
the owners. Drug-outlets in Uganda are licensed by at least 2
different governmental institutions and there is overlap and
confusion. There is little control or audit of these outlets.
You may find the below article useful. I wrote it as a discussion
document for health and drug policy professionals in Uganda.
Sincerely,
George Kibumba, MPS
Community and Drug Information Pharmacist/Uganda.
[Thanks George for this excellent discussion article, and its
attention for the private pharmaceutical sector, an often forgotten
spot in pharmaceutical system improvement. Good that you
recognise the importance of these facilities in drug supply, and that
there is little control over it. You correctly pointed to the fact that
there are more varieties of private sector drug outlets than only
pharmacies and drug shops. I have a couple of comments on your
article: 1) So far, we know little of what actually happens in private
sector facilities and comments on these practices are often
impressionistic (e.g. selling two caps of penicillin). Drug use
indicator surveys have now been carried out in public sector
facilities of many countries, but on private sector activities we have
remarkably few data. It would be good if such private sector data
on prescribing and dispensing would be made available. this would
allow us to make better decisions about what to focus on if we
really want to change practice. 2) The bottom line of your article is
that control of activities in private sector facilities needs to be
strengthened. However, control often has its limitations, as people
will find ways around control. Although I do agree with you that
proper regulation is necessary, have you thought of creating or
increasing incentives for appropriate pharmaceutical care? Could
private sector organizations be motivated to pay attention to your
arguments? Would there really be no interest at all in making an
income on providing appropriate pharmaceutical care? 3) What I
somewhat missed in your article is what the National Dug Policy of
Uganda says about private sector activities and how it is proposed
to control it. Maybe you could give us some insight in that? HH]
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Overview of legislation on drug distribution and its impact on drug
use problems
By George Kibumba
Introduction
Before the Ministry of Health abolished cost sharing early this year,
83% of the population used to seek first contact treatment from the
private sector3. That trend is not likely to change, as governmental
health facilities frequently fail to supply medicines and the quality of
care is generally low. The majority of the population will certainly
continue to receive drugs and first contact health care from the
private sector.
In the private sector, health care always involves drug use.
Unfortunately, medicines are rarely administered and used properly
by health workers and the general public alike.
This article
� Describes drug distribution to the general public in the Ugandan
private sector
� Explains the effects and causes of the current distribution
system
� Describes proper control and audit of drug distribution at patient
level
� Gives practical recommendations and conclusions on the
subject.
Drug distribution in the private sector
Drug distribution by professional and non-professional health
workers in the private sector is not adequately controlled.
Description of non-professional health providers is outside the
scope of this article. The article will dwell on professional health
workers.
In Uganda, drugs can easily be obtained from every professional
health provider in the private sector. Infact, there is loose
availability and access to essential medicines. Yet uncontrolled
access to useful drug substances is more disastrous than controlled
access.
The sources of drugs to the general public include the following
� Clinics
� Drug Shops
� Pharmacies
� Private hospitals (which may be called medical centers, nursing
homes, etc).
Note that of all drug outlets in this country, The National Drug
Authority (our Drug Regulatory Agency) licenses only drug shops
and pharmacies.
Yet, even in places where pharmacies exist, clinics are major
sources of drug supply to the general public. Clinics are only
licensed (by the Medical and Dental Practitioners Council) to provide
care to outpatients, and not to supply medicines on a retail basis.
Private hospitals are similarly licensed by the Medical and Dental
Practitioners Council to provide patient care. However, private
hospitals are also important drug outlets. Nevertheless, their drug
supply activities are not licensed or controlled by the National Drug
Authority.
According to The National Drug Policy and Authority Statute of
1993, the responsibility to audit and control activities of drug
distribution in Uganda is with the National Drug Authority and not
the professional councils. Power to audit and control activities in
private clinics and hospitals is held by The Medical and Dental
Practitioners Council and Nurses and Midwives Council.
Dispensing clinics and private hospitals hardly meet the minimum
requirements of operating retail or hospital pharmacies. Meanwhile,
The Allied Health Professionals' Council is seeking to license and
handle activities of Class C drug shops and expand the list of Class
C drugs. The desire is to enact a legislation to allow them to stock
and supply antimicrobials and other class B substances.
It is clear that all health workers in Uganda claim the right to
procure, stock and supply the whole range of drugs to the general
public.
The effects of the system
Because of the obvious overlap and overload of duties, health
personnel in the private sector are not properly supervised and
controlled. Lack of appropriate control and supervision contributes
to irrational diagnosis and prescribing; over prescribing and under
prescribing, and incorrect prescribing.
Unnecessary prescriptions increase the cost of treatment. While
underprescribing and incorrect prescriptions contribute to drug
resistance, improper dispensing can result in drug toxicity and
treatment failure.
What are the causes of the above problems?
Health workers incorrectly claim a role of distribution of drugs to
the general public. The laws governing drug distribution are not
harmonized and health professionals distribute drugs to the general
public without control from the Drug Regulatory Agency.
In addition, there is a long-standing wish to embed drug distribution
in clinics and other outpatient facilities. If such wishes are granted,
control of drug distribution in Uganda will remain a myth and there
are many countries to learn from. Thailand, for example, has a
private sector where every drug outlet diagnoses, prescribes and
dispenses. Expenditure on drugs and resistance to infections is
enormous in Thailand.
Retail pharmacies, with are licensed by the National Drug Authority
to handle prescriptions, do not receive them. Such pharmacies will
have to dispense without prescriptions, to make enough income to
cover their running costs. Alternatively, those retail pharmacies will
close to wholesale practice, for lack of retail business. As a result,
inappropriately licensed facilities will dispense drugs.
Where ethical retail pharmacies exist, their effort to have proper
control over access to medicines is frustrated. When such
pharmacies refuse to sell 2 capsules of a penicillin (a
prescription-only product) over the counter -- patients arrogantly
deny advice, since this inappropriate treatment can be easily got
from the next drug outlet.
Control and auditing of drug supply in the private sector
Selling drugs is business, and as the private sector appears to be
motivated by profit, as opposed to service, control of drug
distribution and appropriate auditing can not be ignored. A
meaningful drug supply system in the private sector can only be
realized when there is control and auditing.
Controlling means ensuring that only appropriately licensed facilities
distribute drugs. Auditing activities of drug distribution involves
cross--checking, to find out whether the appropriately licensed
facilities are really complying with the guidelines and set standards.
Auditing and controlling drug distribution is laboursome. That
implies that licensing drug distribution should be handed over to
The Council of The Pharmaceutical Society of Uganda. That will
allow the Regulatory Agency more time to ensure that only
appropriately licensed facilities supply quality drugs and that such
units are adequately audited. This calls for facilitation and
empowerment of The Council of The Pharmaceutical Society of
Uganda.
At the same time, the desire of health workers in the private sector
to license their respective private practices is not bad. However,
non-pharmaceutical Professional Councils should not handle
licensing drug distribution, which they always embed in their
licensing. If licensing drug distribution continues the way it is now,
there will be more confusion and disaster to an already faulty
system.
When Uganda opts for an ill-defined system where every
drug-outlet diagnoses, prescribes and dispenses, treating an
uncomplicated case of malaria will cost at least Shs 10,000/= (5
USD) in the near future. It will also be impossible to control drug
supply and distribution.
Therefore, every responsible health worker in Uganda should
observe a need to revise desires to retail drugs.
Since the 7th Parliament is in place and a new pharmacy and
pharmacy practice bill is ready; the Ministry of Health should
consider the following conclusions and recommendations.
Conclusions and recommendations
1. The National Drug Authority must have the power to audit all
units of drug distribution in the private sector. Such units of drug
distribution to patients include clinics, nursing homes, hospitals,
drug shops or pharmacies. That Regulatory Authority should
implement laws governing drug distribution in a phased manner, as
described in point 3 below.
2. Licensing units of drug distribution should be handled by The
Council of The Pharmaceutical Society of Uganda. Before The
Medical and Dental Practitioners Council or Nurses and Midwives
Council license nursing homes, medical centers, which function as
hospitals, there must be close collaboration with The Council of The
Pharmaceutical Society of Uganda.
3. Where retail pharmacies are available, in reasonable distance,
clinics and other outpatient facilities should not be allowed to retail
medicines. Those facilities should refer prescriptions to the retail
pharmacies. This will stop retail pharmacies from dispensing
prescription-only and pharmacy-only drugs without prescription. It
will also organize the dispensing system in the country and reduce
the burden of drug misuse and overuse.
4. The few pharmacists available (about 140!) in Uganda should be
kept at supervisory level and given adequate continuing pharmacy
education. Employing full-time pharmacists will not stop wholesale
pharmacies from selling drugs to clinics and other outpatient
outlets. Employing full-time pharmacists in retail pharmacies will not
solve the problem of inappropriate drug distribution in the country --
one of the principal factors -- precipitating drug misuse and
overuse.
References
1. National Drug Policy and Authority Statute, 1993.
2. Pharmacy and Pharmacy Practice Bill, 1999.
3. Home Based Management of Fevers, A Workshop in Grand
Imperial Hotel -- Kampala Uganda, 2001.
4. INRUD NEWS, Newsletter of the International Network for
Rational Use of Drugs, Vol 10, Number 2, March 2001.
5. The Medical and Dental Practitioners Statute, 1995
6. The Nurses and Midwives Act.
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