E-drug: What motivates drug donations? (cont'd)
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[The subject of drug donations keeps on generating very thoughtful
messages. Apparently there is a lot of appetite for it and my call to
close this discussion was not honoured. So, let's go on and enjoy!
Hilbrand Haak, E-drug co-moderator].
Dear e-drugers,
First I have to apologise for the length of the mail. I am following quite
interested and in some parts nearly amused (if it would't be so sad)
the discussion about drug donations here on e-drug. There are good
and valid points in each of the contributions, but I think some points
haven't been touched yet. Surely donations do a lot of good and
finally that's what they all should be about. But we all know that there
are also some donations that might do, let's say, less good.
My experience is limited to emergency context, the situation of drug
donations as part of development aid might be different. I was
involved in an evaluation of the quality of drug donations carried out in
Albania last year. I was looking at documents provided to the
Pha/Dept in the MoH in order to receive an import authorisation for the
donation. These documents represented all information available to the
person in charge to get an idea (I don't dare to say 'to judge') of the
quality of the donations in terms of expiry dates, relevance in terms of
essential drug status etc.
A significant part of the documents evaluated (nearly 40%) either
declared the drugs only with their brand names, or worse, with
pharmaceutical groups (antibiotics...). How should anyone in an office,
even if it is a competent professional, being able to judge quality in
terms of relevance without doing extensive research? Concerning
expiry dates and remaining shelf-life the situation was no better. Only
about 33% of the donations evaluated complied with Guideline 6
(version 1996, valid at the time when the evaluation was carried out)
by including only drugs with a remaining shelf-life of more than one
year. More than 40% hadn't declared any expiry dates on their lists
(what remaining shelf-life they may have had, one only can guess),
36% of the donations evaluated were packed exclusively in sample
packages (including display packagings and free professional samples
with 2 tablets each etc). I don't want to go into more details, but the
picture I am drawing only concerns those donations cleared through
official channels. What might we have found if we could have
included into the evaluation the donations that arrived in military
cargoes and through other channels?
We were able to look physically at some donations that were stored in
the central warehouse in Tirana. What we saw confirmed the
impression we had gained after the document study. We found useful
drugs in large quantity units with good expiry dates, but also palettes
of drugs from various sources expiring in 1999, some in OTC brand
name displays, or the 2 tablet samples cited earlier (and I am sorry Mr
Russo, a significant part of them were coming from the US). Do we,
'the professional e-drug community', expect a country like Albania (or
any other country) refusing these donations in an emergency context?
But this is only half of the picture, perhaps the easier one to tackle
because easier to identify. A significant proportion (sorry, but I don't
have any figures) of donations that I came across during the time I
spent in Albania originated from small charities (mostly non-medical)
and private individuals. Most of us, I guess, have already seen this
kind of donations: boxes with collected drugs of all sorts, labelled with
brand names, some expired etc. Like another colleague in an earlier
discussion on e-drug correctly mentioned, there might be very useful
and urgently needed drugs among them which would not have been
donated if everybody would stick to essential drug status. But who
should find them at the right time in the right quantity? And what
about the rest? This kind of donation can add up into a real problem
as we saw in Bosnia Herzegovina (see Berchmans et al 'Inappropriate
drug donation practices in Bosnia Herzegovina, 1992 to 1996', New
England Journal of Medicine, 1997, Vol 337, No. 25, p 1842-1845).
Addressing these charities or individuals is not an easy task. WEMOS
developed a video on 'Making drug donations better with care'
targeting exactly this group, and campaigns in several countries are on
the way. But do we reach them? Are these charities or individuals
aware that Guidelines for Drug Donations exist? I have some doubts.
In my experience they are often not easy to identify, new ones are
emerging and others disappearing from the humanitarian platform, but
all together contribute to a significant proportion of donations
especially if the quality is not up to standard.
Perhaps my findings may not be representative for the overall drug
donation process in a statistical, quantitative sense but I think they
give a good qualitative summary of what was going on, not limited to
the Albanian situation.
The core principles in the Guidelines state under point 1: "Maximum
benefit to the recipient"
Shouldn't we be much more accountable to the recipient in terms of a
client? Most donations originate from the 'capitalist' Western World.
Have we forgotten all basics about client satisfaction just because the
recipient normally doesn't pay for the donation (at least not in a direct
form)? This would imply to enable the recipient to comment on or to
refuse a 'poor' donation, like many colleagues suggested. But
therefore we first of all have to provide to the recipient the information
needed to identify a 'poor' donation (generic names, expiry dates etc).
It sounds so obvious but apparently seems to be so difficult, even in
times of information technology.
In discussions so much emphasis is put on remaining shelf-life, which
of course is an extremely important aspect, but in my experience
communication of accurate information (donor-recipient, different
NGOs among each other..) especially in emergencies is at least as
important.
At the end I would just like to raise a few ideas to discuss:
1. Very often in donation context the need for co-ordination is
expressed and I only can strongly agree. But in real life and in our not
perfect world: Who would accept the authority (if we are not talking
about facilitating meetings) of a co-ordination body (of which kind?)
without any contractual relations? And who would fund this body? In
the context I worked in, a multitude of actors were involved all with
their own agendas.
2. I absolutely support the idea of systematic evaluation of drug
donations. It should be in a standardised form to allow for action and
comparison. But again, who can carry it out and who would fund it?
3. Do we perhaps also need to 'educate' the donors that projects of
evaluation and co-ordination are worthwhile funding?
4. What about an accreditation system for NGOs? Would it be
feasible, would it improve the situation?
5. How could we be proactive in a practical sense? (Idea: Why not
create a file at the very beginning of an emergency including the
Guidelines for Drug Donations, a national essential drug list (if
available), otherwise the up-to-date WHO Essential Drug List, an
illustration of a detailed packing list, key persons, departments or
agencies in that emergency to contact on the field, a not exhaustive
list of procurement agencies specialised in drug procurement in
different countries (or their web sites) etc, to summarise: simple,
basic, available, and relevant information? This file could then be sent
by email to the headquarters of any NGO, charity...after their first
contact with a custom point or with the MoH? It would nearly have no
cost implications and would be feasible where ever a telephone line
and a computer would be available.
Finally I agree with Mr Russo in saying let's go back to work, but let's
go back to work in the sense of trying to find also incremental
improvements on an operational level in addition to all the policy and
advocacy work.
With best regards,
Regine Seer
Regine Seer
Pharmacist, MBA (HPN)
Centre for Health Planning and Management
Keele University, England
Tel: +49-172-63 75 523
e-mail: Regineseer@aol.com
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