Evidence-based pharmacy in developing countries

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Many developing nations have developed national drug policies, a concept that has been actively promoted by the WHO. For example, the national drug policy for Indonesia^[1] drawn up in 1983 had the following objectives:

To ensure the availability of drugs according to the needs of the population.
To improve the distribution of drugs in order to make them accessible to the whole population.
To ensure efficacy, safety quality and validity of marketed drugs and to promote proper, rational and efficient use.
To protect the public from misuse and abuse.
To develop the national pharmaceutical potential towards the achievements of self-reliance in drugs and in support of national economic growth.

To achieve these objectives in Indonesia, the following changes were implemented:

A national list of essential drugs was established and implemented in all public sector institutions. The list is revised periodically.
A ministerial decree in 1989 required that drugs in public sector institutions be prescribed generically and that Pharmacy and Therapeutics committees be established in all hospitals.
District hospitals and health centers have to procure their drugs based on the essential drugs list.
Most drugs are supplied by three government-owned companies.
Training modules have been developed for drug management and rational drug use and these have been rolled out to relevant personnel.
The central drug laboratory and provincial quality control laboratories have been strengthened.
A major teaching hospital has developed a program on rational drug use, developing a hospital formulary, guidelines for rational diagnosis and treatment guidelines for the rational use of antibiotics.
Generic drugs have been available at affordable costs to low-income groups.

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Well. I hope you're all healthy and I hope you all will remain healthy for the indefinite future. But that hope is a little bit unrealistic and so I've got a second back-up hope. This second back-up hope is that insofar as we have health problems, we will have good medicines to take care of them. Medicines are very cheap to produce and they're very effective. Much more pleasant actually than the alternatives: hospitalization, operations, emergency rooms, the morgue... None of these are good things. So we should be very grateful that we have pharmacologists around, people who research these things and develop new medicines, and we should be grateful that we have a pharmaceutical industry that supports their activities. But there is a problem and you can tell from the fact that the pharmaceutical industry isn't well-loved. In fact, in terms of popularity, they rank just about with the tobacco companies and the arms manufacturers. So that's the problem that I want to talk about with you today. How would you organize the pharmaceutical industry? If we did it all over again, how would you do it? I think we would think of three main principles. The first one is: we want patients to have access to all the important medicines. Remember, these things are very cheap to produce. So everybody in the world should have access to all the important medicines. Secondly, we want innovative activities, the research and development that pharmaceutical companies do, to track the diseases that are the most important, the most damaging. We want them to aim for the greatest health impact. And thirdly, we want the whole system to be efficient. We want as little of the money that goes into the system to go to waste. To go for overhead, for red tape, and so on. Very simple three points. Now, what about the existing system? I think it does poorly on all these three counts. First: Universal access. Forget about it. The vast majority of human beings do not have access to medicines, at least not while they're still under patent. There are extremely high mark-ups and that's the problem. The problem is that even though these medicines are very cheap to produce, they cost a great amount of money during the time that they're under patent, and the reason for that is that rich people can pay a lot of money, pharmaceutical companies have a temporary monopoly, they price for the rich, they forget about the poor. The second problem is innovation. Again, we don't focus on the diseases that do the most damage, and that's often put into the phrase of the 10/90 gap. Ten percent of all the money spent on pharmaceutical research is focusing on diseases that account for ninety percent of the global burden of disease. And vice versa: Ninety percent of the money is spent on diseases that account for only ten percent of the global burden of disease. So there's a huge mismatch between where we spend the research money and where the greatest problems are. Now, both these problems, the problem with innovation and the problem with access have to do with this: The distribution of money in the world. It's extremely unequal. The blue area here is the top quarter of the human population. They have more than ninety percent of the global household income. The bottom half of humanity on the other hand has not even three percent of global household income. So if you're a pharmaceutical company and you look for profit opportunities, you look at this sort of chart and you say: "Well, where's the money? What am I gonna research? Who am I going to provide with medicine?" And again, that is in the context of there being only one way in which pharmaceutical companies make money under the present system, that is through patent-protected mark-ups. That's how they make their money. Through mark-ups. And if you make money through mark-ups, then obviously you will go to where the people have the most income. Now in terms of overall efficiency, the system also does very, very poorly. A lot of money goes for lobbying politicians in order to extend patent periods to "evergreen", as it's called. Data exclusivity and so on. A lot of money goes for gaming, where brand name companies pay generic companies to delay entry, for example. A lot of money goes to take our patents into all the different jurisdictions. Money goes – even larger amounts – for litigation. They're litigating endlessly. Brand name company against brand name company, brand name company against generic company – enormous amounts go there. People say pharmaceutical companies make a lot of profit. Well, yes and no, they do, but a lot of it goes to these wasteful activities. Deadweight losses, I won't even tell you what they are because it's too complicated. But there's also wasteful marketing. A lot of the money that pharmaceutical companies make goes into advertising campaigns, trying to win favor with doctors, trying to persuade patients to try this medicine. And these marketing battles, of course, are a pure waste, because what one company spends to get patients over to their drug another company spends to win them back. And then there is counterfeiting in the developing countries. A lot of the drugs there, often more than fifty percent of what's sold, are counterfeit drugs where people say, "Because the drug is so expensive, I can offer you a cheaper version." But of course it's not the real thing. It's either diluted or it's completely inert. So on the whole, all the money that is spent on pharmaceuticals, and it's roughly a trillion dollars now, per annum, much of that money is absolutely going to waste, it's not going to where it should be going, namely to the development of new medicines and to the manufacturing of [the] ones we already have. Now, many people think that the solution to the problem is moral pressure on pharmaceutical companies. And, sure, pharmaceutical companies have moral obligations just like we do. When we have to make a choice, often between having a little extra money and saving a human life, we often feel that we have a duty to spend the money and save the life. And why should pharmaceutical companies be any different? But really, it isn't realistic to expect pharmaceutical companies to act as well as you or maybe I might act. And the reason is threefold. One is that pharmaceutical companies are bound to their shareholders. The executive of such a company wouldn't last very long if he gave a lot of money away, or she, for good purposes, and thereby lost money for the shareholders. They would be replaced. Also, pharmaceutical companies stand in fierce competition with one another and if you do more, if you are nicer than the other company, sooner or later, you'll be driven off the market. You will not survive. The other company will gain market share. And finally, remember, the entire industry is dependent for its income on one thing and one thing only: mark-ups. And ultimately you have to be sustainable. If you spend a lot of money on helping poor people and you don't get paid for it, you lose this money, you cannot continue with your innovative activities. So for these reasons it's just unrealistic to expect that pharmaceutical companies will solve the problem on moral grounds. Who, then, should solve the problem? I suggest it has to be us. We, citizens and politicians, have to do better in terms of regulating the pharmaceutical industry, focusing them, giving them the right incentives, focusing them on the problems that really matter. The potential gains here are enormous. About one third of all deaths each day, each year are due to the diseases of [poverty] in the developing world. Fifty thousand people every day die prematurely from these diseases. And that's not even counting all the diseases we know only too well in the rich countries. Cancer, heart disease and so on. Again, poor people die often much earlier, because they don't have good medical care including good medicines. And even in rich countries, many patients are not getting the best medicine. That's sometimes due to the fact that insurance companies won't cover it, because the prices are absolutely ridiculous, and it's also due, sometimes, to the fact that doctors and patients are falsely influenced by advertising campaigns of pharmaceutical companies. So what can we do? How can we change the system? I want to show you a way in which we can better incentivize pharmaceutical innovation and the provision [of] medicine to poor people and rich alike. And that is the Health Impact Fund. The Health Impact Fund is basically opening up the second track with which pharmaceutical innovators can be rewarded for their activities. They have a choice. They can either go with the old system, patent-protected mark-ups, or they can go with the new system, being rewarded on the basis of the health impact of the medicine that they develop. And with each particular medicine, they have their choice. So they can be partly on one track, partly on the other with different products. Now, how would the Health Impact Fund work? There would be a fixed reward pool every year. We start with maybe six billion dollars, but that can eventually be revved up. Remember that the total money that the world spends on pharmaceuticals is a trillion, so it's a thousand billion, six billion is a drop in the bucket. It's relatively small but it would work with six billion and we would get a lot of bang for the buck if we introduced the Health Impact Fund with just six billion dollars. Any registered product, if you have a product and you want to register it with the Health Impact Fund, you will be rewarded for a period of ten years. During these ten years, you get a share of these annual reward pools, and that share would be proportional to your share of the health impact achieved by all these registered products. So if your product accounts for eight percent of the health impact of all the registered products, you get eight percent of the reward money that year. That repeats for ten years and at the end of the ten years, your product goes generic, so you basically lose any further income from it. Each year, the health impact from your product would be evaluated and you would be paid on that basis. Now, if you take that reward from the Health Impact Fund, you can't claim the other reward. You can't mark up the price. You have to sell at cost. What does that mean? Well, it doesn't mean that the pharmaceutical company tells us what their cost is, but rather, our preferred way of determining what the real cost is of making a medicine, of manufacturing it, is to ask the registrant to put the production of the medicine out for tender, let generic companies compete for the production and then the innovator would buy the product from the cheapest supplier and would sell it at that same lowest possible price to patients. So the innovator would make no money at all on selling the product, but would make all its money from the health impact rewards. Now, how do we assess the impact of the introduction of a medicine? Well, we assess it relative to the preceding state of the art. So some people before the medicine came along, had no treatment at all, now for the first time they have treatment, because it's cheap, people can afford it. So here, the impact is the difference between being treated and not being treated. In other cases, the new product is better than the old products and so a person gets switched over to a better product and we pay for the impact, for the difference that the new product makes. If you have a product on the Health Impact Fund and you simply switch somebody from an existing product to another product, to your product, and it's no better, you get no money. That's in stark contrast to the existing system, where you get a lot of money for switching somebody from one product to an equal product that is your product. The Health Impact Fund does not pay for that. We quantify health impact in terms of quality-adjusted life years. That method has been around for about 20 years, and it's very easy to explain. Just think of a human life as a kind of plank, it's eighty inches long, one inch high, and when you die prematurely before you reach 80, well, the plank is a little shorter. And if you're sick during the time that you live, the plank is a little bit thinner. And what diseases can nibble away, well that, medicines can restore or medicines can avert the taking away of these parts. And they get paid for that. That's the method, basically. Now, we look – of course, each year, we have to assess. We have to spend a considerable amount of money looking at how these various medicines that are registered with the Health Impact Fund are doing in the various countries, and here, statistics is extremely helpful. You all know how exit polling works and this is a similar method. You look for a statistically significant sample, you look for a sample and then you try to figure out what the health impact of the medicine is in different locations, in different demographic groups, and of course you look very carefully at the actual world. This is in contrast to how medicines are rewarded today. Sometimes, there is a reward based on performance, but it's the performance in clinical trials, in the laboratory, if you like, but not the performance in the real world. The Health Impact Fund would look at real world impact, it would look not just at the quality of the drug, but also at how widely it is distributed, whether the innovator manages to target those patients who can benefit the most, and also, how well the drug is used in the field. So innovators would have much stronger incentives than they do now, to make sure that every patient who takes the drug knows exactly how to take it to optimal effect. Today, most packaged inserts are not even translated into local languages and so it's not surprising that patients don't make the best use of the product. Now, how would the financing work? Basically, the Health Impact Fund, as I said, could start with something like six billion dollars, it's not nothing, but it's also not a lot of money compared to what the world is already spending on pharmaceuticals. So the best way to think of it is as a new way of paying for what we are already paying for, namely new medicine. You pay with one hand through the tax system, but you get something back, with the other hand, because you also get these medicines for cheap. This is not just for poor people. Everybody would have this Health Impact Fund registered medicine at cost, at a very low price. Now, one very important hurdle, politically, is, we have to make sure that we have longterm visibility for innovators, that innovators know that the money is actually there, and so we need governments to fund the Health Impact Fund, because only governments can make predictable commitments for a long period of time. Because the Health Impact Fund registration is voluntary, you basically have a self-adjusting reward rate. As the rate rises too high, innovators will come in and drive the rate down. Conversely, if the rate falls too low, innovators would be reluctant to register and the rate will recover. So the rate will always be at a reasonable level. The Health Impact Fund is beneficial for all parties. It benefits innovators by giving them a new market, and most importantly by overcoming their public relations problems that we started with. It benefits patients, because patients are much more likely to get the right medicine, and also for these medicines to be developed, the medicines that we most need. And it also benefits governments or tax payers if you like, because it creates a permanent source of pharmaceutical innovation that will be here for all future times. It's a kind of machine that always directs pharmaceutical innovation to where we have the greatest problems, maybe for diseases that don't even exist yet. The Health Impact Fund will always channel innovation in the direction where it's most needed. Now, we have a little bit of help already. You can see here the number of people who have agreed to help us, but we want your help as well. We want you to join us, maybe to talk with your government to help us with publicity, to help us with your ideas in perfecting the Health Impact Fund scheme, and what we most urgently need for the moment is to start a pilot. A pilot would introduce one medicine into one jurisdiction on the Health Impact Fund model. The innovator would get paid according to the cost of the medicine for the sales, and would then get additional money on the basis of the health impact. Here, we need funding for the rewards, funding for the assessment, and in particular, we need political support to get politicians to support a pilot of that sort. If you have any further questions, don't hesitate to write us and contact us at this address. Thank you very much. (Applause)

Encouraging rational prescribing

One of the first challenges is to promote and develop rational prescribing, and a number of international initiatives exist in this area. WHO has actively promoted rational drug use as one of the major elements in its Drug Action Programme. In its publication A Guide to Good Prescribing^[2] the process is outlined as:

define the patient's problem
specify the therapeutic objectives
verify whether your personal treatment choice is suitable for this patient
start the treatment
give information, instructions and warnings
monitor (stop) the treatment.

The emphasis is on developing a logical approach, and it allows for clinicians to develop personal choices in medicines (a personal formulary) which they may use regularly. The program seeks to promote appraisal of evidence in terms of proven efficacy and safety from controlled clinical trial data, and adequate consideration of quality, cost and choice of competitor drugs by choosing the item that has been most thoroughly investigated, has favorable pharmacokinetic properties and is reliably produced locally. The avoidance of combination drugs is also encouraged.

The routine and irrational use of injections should also be challenged. One study undertaken in Indonesia found that nearly 50% of infants and children and 75% of the patients aged five years or over visiting government health centers received one or more injections.^[3] The highest use of injections was for skin disorders, musculoskeletal problems and nutritional deficiencies. Injections, as well as being used inappropriately, are often administered by untrained personnel; these include drug sellers who have no understanding of clean or aseptic techniques.

Another group active in this area is the International Network for the Rational Use of Drugs (INRUD). This organization, established in 1989, exists to promote rational drug use in developing countries. As well as producing training programs and publications, the group is undertaking research in a number of member countries, focused primarily on changing behavior to improve drug use. One of the most useful publications from this group is entitled Managing Drug Supply.^[4] It covers most of the drug supply processes and is built up from research and experience in many developing countries. There a number of case studies described, many of which have general application for pharmacists working in developing countries.

In all the talk of rational drug use, the impact of the pharmaceutical industry cannot be ignored, with its many incentive schemes for doctors and pharmacy staff who dispense, advise or encourage use of particular products. These issues have been highlighted in a study of pharmaceutical sales representative (medreps) in Mumbai.^[5] This was an observational study of medreps' interactions with pharmacies, covering a range of neighborhoods containing a wide mix of social classes. It is estimated that there are approximately 5000 medreps in Mumbai, roughly one for every four doctors in the city. Their salaries vary according to the employing organization, with the multinationals paying the highest salaries. The majority work to performance-related incentives. One medrep stated "There are a lot of companies, a lot of competition, a lot of pressure to sell, sell! Medicine in India is all about incentives to doctors to buy your medicines, incentives for us to sell more medicines. Even the patient wants an incentive to buy from this shop or that shop. Everywhere there is a scheme, that's business, that's medicine in India.'

The whole system is geared to winning over confidence and getting results in terms of sales; this is often achieved by means of gifts or invitations to symposia to persuade doctors to prescribe. With the launch of new and expensive antibiotics worldwide, the pressure to sell with little regard to the national essential drug lists or rational prescribing. One medrep noted that this was not a business for those overly concerned with morality. Such a statement is a sad reflection on parts of the pharmaceutical industry, which has an important role to play in the development of the health of a nation. It seems likely that short-term gains are made at the expense of increasing problems such as antibiotic resistance. The only alternatives are to ensure practitioners have the skills to appraise medicine promotion activities or to more stringently control pharmaceutical promotional activities.

Rational dispensing

In situations where medicines are dispensed in small, twisted-up pieces of brown paper, the need for patient instruction takes on a whole new dimension. Medicines should be issued in appropriate containers and labelled. While the patient may be unable to read, the healthcare worker is probably literate. There are many tried-and-tested methods in the literature for using pictures and diagrams to aid patient compliance. Symbols such as a rising or setting sun to depict time of day have been used, particularly for treatments where regular medication is important, such as cases of tuberculosis or leprosy.^[6]

Poverty may force patients to purchase one day's supply of medicines at a time, so it is important to ensure that antibiotics are used rationally and not just for one or two days' treatment. Often, poor patients need help from pharmacists to understand which are the most important medicines and to identify the items, typically vitamins, that can be missed to reduce the cost of the prescription to a more manageable level.

The essential drugs concept

The essential drugs list concept was developed from a report to the 28th World Health Assembly in 1975 as a scheme to extend the range of necessary drugs to populations who had poor access because of the existing supply structure. The plan was to develop essential drugs lists based on the local health needs of each country and to periodically update these with the advice of experts in public health, medicine, pharmacology, pharmacy and drug management. Resolution number 28.66 at the Assembly^[7] requested the WHO Director-General to implement the proposal, which led subsequently to an initial model list of essential drugs (WHO Technical Series no 615, 1977). This model list has undergone regular review at approximately two-yearly intervals and the current 14th list was published in March 2005.^[8] The model list is perceived by the WHO to be an indication of a common core of medicines to cover most common needs. There is a strong emphasis on the need for national policy decisions and local ownership and implementation. In addition, a number of guiding principles for essential drug programs have emerged.

The initial essential drugs list should be seen as a starting point.
Generic names should be used where possible, with a cross-index to proprietary names.
Concise and accurate drug information should accompany the list.
Quality, including drug content stability and bioavailability, should be regularly assessed for essential drug supplies.
Decisions should be made about the level of expertise required for drugs. Some countries make all the drugs on the list available to teaching hospitals and have smaller lists for district hospitals and a very short list for health centers.
Success depends on the efficient supply, storage and distribution at every point.
Research is sometimes required to settle the choice of a particular product in the local situation.

The model list of essential drugs

The model list of essential drugs is divided into 27 main sections, which are listed in English in alphabetical order. Recommendations are for drugs and presentations. For example, paracetamol appears as tablets in strengths of 100 mg to 500 mg, suppositories 100 mg and syrup 125 mg/5ml. Certain drugs are marked with an asterisk (previously a ៛), which denotes an example of a therapeutic group, and other drugs in the same group could serve as alternatives.

The lists are drawn up by consensus and generally are sensible choices. There are ongoing initiatives to define the evidence that supports the list. This demonstrates the areas where RCTs (randomized controlled trials) or systematic reviews exist and serves to highlight areas either where further research is needed or where similar drugs may exist which have better supporting evidence.

In addition to work to strengthen the evidence base, there is a proposal to encourage the development of Cochrane reviews for drugs that do not have systematic review evidence.

Application of NNTs (numbers needed to treat) to the underpinning evidence should further strengthen the lists. At present, there is an assumption among doctors in some parts of the world that the essential drugs list is really for the poor of society and is somehow inferior. The use of NNTs around analgesics in the list goes some way to disprove this and these developments may increase the importance of essential drugs lists.

Communicating clear messages

The impact of pharmaceutical representatives and the power of this approach has led to the concept of academic detailing to provide clear messages. A study by Thaver and Harpham^[9] described the work of 25 private practitioners in area around Karachi. The work was based on assessment of prescribing practices, and for each practitioner included 30 prescriptions for acute respiratory infections (ARIs) or diarrhea in children under 12 years of age. A total of 736 prescriptions were analysed and it was found that an average of four drugs were either prescribed or dispensed for each consultation. An antibiotic was prescribed in 66% of prescriptions, and 14% of prescriptions were for an injection. Antibiotics were requested for 81% of diarrhea cases and 62% of ARI cases. Of the 177 prescriptions for diarrhea, only 29% were for oral rehydration solution. The researchers went on to convert this information into clear messages for academic dealing back to the doctors. The researchers went on to implement the program and assessed the benefits. This was a good piece of work based on developing messages that are supported by evidence.

Drug donations

It is a natural human reaction to want to help in whatever way possible when face with human disaster, either as a result of some catastrophe or because of extreme poverty. Sympathetic individuals want to take action to help in a situation in which they would otherwise be helpless, and workers in difficult circumstances, only too aware of waste and excess at home, want to make use of otherwise worthless materials. The problem is that these situations do not lend themselves to objectivity. There are numerous accounts of tons of useless drugs being air-freighted into disaster areas. It the requires huge resources to sort out these charitable acts and often the drugs cannot be identified because the labels are not in a familiar language. In many cases, huge quantities have to be destroyed simply because the drugs are out of date, spoiled, unidentifiable, or totally irrelevant to local needs. Generally, had the cost of shipping been donated instead, then many more people would have benefited.

In response to this, the WHO has generated guidelines for drug donations from a consensus of major international agencies involved in emergency relief. If these are followed, a significant improvement in terms of patient benefit and use of human resources will result.

WHO guidelines for drug donations 2005

Selection of drugs

Drugs should be based on expressed need, be relevant to disease pattern and be agreed with the recipient.
Medicines should be listed on the country's essential drugs list or WHO model list.
Formulations and presentations should be similar to those used in the recipient country.

Quality assurance (QA) and shelf life

Drugs should be from a reliable source and WHO certification for quality of pharmaceuticals should be used.
No returned drugs from patients should be used.
All drugs should have a shelf life of at least 12 months after arrival in the recipient country.

Presentation, packing and labelling

All drugs must be labelled in a language that is easily understood in the recipient country and contain details of generic name, batch number, dosage form, strength, quantity, name of manufacturer, storage conditions and expiry date.
Drugs should be presented in reasonable pack sizes (e.g. no sample or patient starter packs).
Material should be sent according to international shipping regulations with detailed packing lists. Any storage conditions must be clearly stated on the containers, which should not weigh more than 50 kg. Drugs should not be mixed with other supplies.

Information and management

Recipients should be informed of all drug donations that are being considered or under way.
Declared value should be based on the wholesale price in the recipient country or on the wholesale world market price.
Cost of international and local transport, warehousing, etc., should be paid by the donor agency unless otherwise agreed with the recipient in advance.

Evidence-based pharmacy practice

While modern practices, including the development of clinical pharmacy, are important, many basic issues await significant change in developing countries.

Medicines can often be found stored together in pharmacological groups rather than in alphabetical order by type.
Refrigerator space is often inadequate and refrigerators unreliable.
There are different challenges, such as ensuring that termites do not consume the outer packages and labels or that storage is free of other vermin such as rats.
Dispensary packaging and labelling can be woefully inadequate and patients leave with little or no understanding of how to take medicines which may have cost them at least one week's earnings.
Medicines are often out of stock, not just for a few hours but for days or even weeks, particularly at the end of the financial year.
Protocols and standard operating procedures are rarely found.
Even when graduate pharmacists are employed, they often have little opportunity to perform above the level of salesperson, simply issuing medicines and collecting payment. For example, several hospital pharmacies in Mumbai, India, are open 24 hours per day for 365 days per year but only to function as retail outlets selling medicines to outpatients or to relatives of inpatients who then hand over the medicines to the nursing staff for administration.

Conclusions

Evidence is as important in the developing world as it is in the developed world. Poverty comes in many forms. While the most noticed are famine and poor housing, both potent killers, medical and knowledge poverty are also significant. Evidence-based practice is one of the ways in which these problems can be minimized. Potentially, one of the greatest benefits of the internet is the possibility of ending knowledge poverty and in turn influencing the factors that undermine wellbeing. Essential drugs programs have been a major step in ensuring that the maximum number benefit from effective drug therapy for disease.

References

^ World Health Organization (1990) Review of the drug program in Indonesia. Report of a WHO mission 16 October-3 November 1989. DAP. 90(11): 1-36.
^ de Vries TPG, Henning RH, Hogerzeil HV, Fresle DA (1994) Guide to Good Prescribing. WHO/DAP. 11: 1-108
^ Management Sciences for Health (1998) Health Center Prescribing and Child Survival in East Java and West Kalimantan, Indonesia. Child survival pharmaceuticals in Indonesia. Part II. Report of the Ministry of Health and Management Sciences for Health.
^ Management Sciences in Health (1997) Managing Drug Supply: the selection, procurement, distribution, and use of pharmaceuticals. Kumarian Press. Connecticut.
^ Kamat VR, Nichter M (1997) Monitoring product movement: an ethnographic study of the pharmaceutical sales representatives in Bombay, India. In: Bennett S, McPake B, Mills A (eds) Private Health Providers in Developing Countries: serving the public interest? Zed Books, London & New Jersey.
^ Georgiev GD, McDougall C (1998) Blister calendar packs - potential for improvement in the supply and utilization of multiple drug therapy in leprosy control programs. International Journal of Leprosy and Other Mycobacterial Diseases. 56(4): 603-10.
^ World Health Organization (1985) Handbook of Resolutions and Decisions of the World Health Assembly and Executive Board, vol II 1973-1984. World Health Organization. Geneva.
^ World Health Organization (2005) Essential Drugs WHO Model List (revised March 2005).
^ Thaver IH, Harpharm T (1997) Private practitioners in the slums of Karachi: professional development and innovative approaches for improving practice. In: Bennett S, McPake B, Mills A (eds) Private Health Providers in Developing Countries: serving the public interest? Zed Books, London & New Jersey.

Useful sources of information

The following is a list of useful publications from the WHO Department of Essential Drugs and Medicines Policy about essential drugs programs.

General publications

Essential Drugs Monitor - periodical issued twice a year, covering drug policy, research, rational drug use and recent publications.
WHO Action Programme on Essential Drugs in the South-East Asia Region - report on an Intercountry Consultative Meeting, New Delhi, 4–8 March 1991. 49 pages, ref no SEA/Drugs/83 Rev.1.

National drug policy

Report of the WHO Expert Committee on National Drug Policies - contribution to updating the WHO Guidelines for Developing Drug Policies. Geneva. 19–23 June 1995. 78 pages, ref no WHO/DAP/95.9.
Guidelines for Developing National Drug Policies - 1988, 52 pages, ISBN 92-4-154230-6.
Indicators for Monitoring National Drug Policies - P Brudon-Jakobowicz, JD Rainhorn, MR Reich, 1994, 205 pages, order no 1930066.

Selection and use

Rational Drug Use: consumer education and information - DA Fresle, 1996, 50 pages, ref no DAP/MAC/(8)96.6.
Estimating Drug Requirements: a practical manual - 1988, 136 pages, ref no WHO/DAP/88.2.
The Use of Essential Drugs. Model List of essential drugs - updated every two years. Currently 14th edition, 2005. The list is available at: www.who.int/medicines
Drugs Used in Sexually Transmitted Diseases and HIV Infection - 1995, 97 pages, ISBN 92-4-140105-2.
Drugs Used in Parasitic Diseases (2e) - 1995, 146 pages, ISBN 92-4-140104-4.
Drugs Used in Mycobacterial Diseases - 1991, 40 pages, ISBN 92-4-140103-6.
Who Model Prescribing Information: Drugs Used in Anaesthesia - 1989, 53 pages, ISBN 978-9-241-40101-2.
Guidelines for Safe Disposal of Unwanted Pharmaceuticals In and After Emergencies - ref no WHO/EDM/PAR/99.4.

Supply and marketing

Guidelines for Drug Donations - interagency guidelines, revised 1999. Ref no WHO/EDM/PAR/99.4.
Operational Principles for Good Pharmaceutical Procurement - Essential Drugs and Medicines Policy / Interagency Pharmaceutical Coordination Group, Geneva, 1999.
Managing Drug Supply - Management Sciences for Health in collaboration with WHO, 1997, 832 pages, ISBN 1-56549-047-9.
Ethical Criteria for Medicinal Drug Promotion - 1988, 16 pages, ISBN 978-9-241-54239-5.

Quality assurance

WHO/UNICEF Study on the Stability of Drugs During International Transport - 1991, 68 pages, ref no WHO/DAP/91.1.

Human resources and training

The Role of the Pharmacist in the Health Care System - 1994, 48 pages, ref no WHO/PHARM 94.569.
Guide to Good Prescribing - TPGM de Vries, RH Henning, HV Hogerzeil, DA Fresle, 1994, 108 pages, order no. 1930074. Free to developing countries.
Developing Pharmacy Practice: a Focus on Patient Care - 2006, 97 pages, World Health Organization (WHO) and International Pharmaceutical Federation (FIP). [1]

Research

No 1 Injection Practices Research - 1992, 61 pages, ref no WHO/DAP92.9.
No 3 Operational Research on the Rational Use of Drugs - PKM Lunde, G Tognoni, G Tomson, 1992, 38 pages, ref no WHO/DAP/92.4.
No 24 Public Education in Rational Drug Use: a global survey - 1997, 75 pages, ref no WHO/DAP/97.5.
No 25 Comparative Analysis of National Drug Policies - Second Workshop, Geneva, 10–13 June 1996. 1997, 114 pages, ref no WHO/DAP/97.6.
No 7 How to Investigate Drug Use in Health Facilities: selected drug use indicators - 1993, 87 pages, order no 1930049.

External links

Evidence-based practice

Key terms

Applications

Methods and concepts

People

Groups

Non-profit	James Lind Alliance Cochrane Collaboration Campbell Collaboration Science-Based Medicine
Governmental	Agency for Healthcare Research and Quality (AHRQ) Canadian Agency for Drugs and Technologies in Health (CADTH) EUnetHTA German Agency for Quality in Medicine (AEZQ) National Institute for Health and Care Excellence (NICE) Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU) WHO Evidence-Informed Policy Network (EVIPNet)
Academic	Centre for Reviews and Dissemination
Other	Examine.com

This page was last edited on 29 May 2024, at 11:48

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