Awareness raising and advocacy to improve drug donations.

Drug donations and awareness raising

Monitoring of Guidelines on drug donations is needed!

The International Health Consortium ’Medicines Crossing Borders’ - consisting of Difäm from Germany, Prosalus from Spain, ReMed from France and Wemos from the Netherlands – will be presenting their ideas on a monitoring system for the Guidelines on drug donations during the WHO technical briefing seminar, taking place from 30 September until 4 October 2002. Read more.

Examples of good practice

The Netherlands, June 11-12 1999: "Education and communication are key if the quality of drug donations is to be improved". This was the dominant message by the participants to the first NGO European expert seminar on appropriate drug donations. Fortunately, education activities provide already a consistent body of good practice in this field.

This article presents concrete examples on awareness raising concerning drug donations. It takes into account several contexts and target groups. What these activities have in common is the commitment to inform and to educate both key actors and the general public about minimum requirements for drug donations and the dangers involved in not meeting such standards. If minimum requirements are followed quality of drug donations improves.

There is a general acknowledgement that drug donation practices present legitimate differences. Unfortunately, there are many examples of drug donations which cause problems instead of being helpful ('Examples').

A common core of "Good Drug Donation Practice (GDDP)" is the basis for the inter-agency guidelines on drug donations which have recently been issued by the World Health Organisation after consultation with all relevant United Nations agencies, the Red Cross, MSF, and other major international agencies active in humanitarian emergency relief. These guidelines are available also at this web site click here.

To promote information and education activities concerning the contents of the guidelines can effectively reduce inappropriate drug donations. For instance, in the Netherlands eleven NGOs formed the Committee on Drug Donations. The Committee started its activities in 1995 and with government support launched a national campaign to improve the quality of drug donations. The campaign included:

the production and dissemination of 35.000 copies of a leaflet addressed to the general public and made available through pharmacies and general practitioners;

approaching and discussing with the pharmacists through their national professional fair (FarmaVisie);

to co-operate with the Dutch Ministry of Health and the Dutch Foreign Aid department to produce the Dutch guidelines for drug donations and to set up an information centre on drug donations within the Royal Dutch Pharmaceutical Association (based in the Hague).

In less than two years, research showed that the percentage of pharmacists providing aid organisations with returned drugs had dropped to 25% and that the general attitudes towards drug donations were becoming increasingly in line with the guidelines' recommendations. At the end of 1997 the Dutch Health Inspectorate sent a letter to all pharmacists, general physicians and hospitals to officially disapprove the use returned drugs for donation purposes. Beginning of 2000 the Dutch campaign successfully ended with only 5 % of pharmacists regularly donating returned drugs. For more information on the Dutch campaign please click here (in Dutch).

Many more examples of awareness-raising activities are available and they indicate the positive results that can be obtained in disseminating, informing, educating, and discussing the guidelines in donor as well as in recipient countries. However, this article will mainly focus on awareness raising activities taking place in donor European countries. Educational programmes in this field have focused on a number of effective means and practices including among others:

1. Setting up a consortium
2. Developing a web site
3. Working with media
4. Working with enterprises
5. Producing an educational video
6. Publishing a brochure

1. Consortium

"Towards appropriate drug donations" is a European umbrella organisation originally including DIFÄM from Germany, ReMed from France, and the Wemos Foundation (co-ordinator, Netherlands). Their common objective is improvement of the quality of drug donations. Part of the project is supported by a grant by the European Commission, though it took the Commission 18 months to process and approve the application. The present project format is meant to last at least until December 2000.

One of the concrete objectives of the Consortium is to reach out for new partners. Prosalus from Spain has already joined in while significant contacts have been established with Farmacisti Senza Frontiere (Italy) and The Essential Drugs Project (UK) who are likely to collaborate in their respective countries. The consortium is working also with partners in the Health Action International working group on drug donations. The web site that makes the present article available is one of the concrete outcomes of the consortium and its multilingual approach facilitates its consistent outreaching strategy.

In practical terms the members of the consortium meet three times a year and share information about the activities in their respective countries, besides planning and co-ordinating activities at the international level such as the production of the video "Making Drug Donations Better with Care" and common advocacy activities at European level.

2. Web site

The "Drug Donations" web site, which hosts this article, is an initiative of the NGO-consortium "Towards appropriate drug donations". It provides information in seven languages and a mailing list. It is organised in 11 sections and it has become an international reference concerning the implementation of the inter-agency guidelines on drug donations, providing updated information and links to practically all-existing on-line information in this field.

Further information and useful Internet links can be consulted at the links-page of the drugdonations.org web site.

3. Working with the media

Simply consulting the on-line information about drug donations shows a significant increase of articles and case studies over the last three years. However, the general public and even humanitarian aid donors might not necessarily be familiar with key issues such as essential drug policies, rational drug use, not to mention the specific pharmaceutical and health care situation in the recipient countries. It is crucial for NGOs concerned with appropriate drug donations to target specialised reviews as well as national and local media. All these media play a crucial role in bringing about long term widespread changes in donation practice.

Scientific Media
Inappropriate Drug-Donation Practices in Bosnia and Herzegovina, 1992 to 1996 is a six-page article published by The New England Journal of Medicine in 1997. It is based on the results provided by a research implemented by a team co-ordinated by Patrick Berckmans on behalf of the European Association for Health and Development (based in Brussels) and supported by a grant from Médecins sans Frontières (Belgium).

The work provides both quantitative and qualitative assessment concerning the roughly 30.000 metric tons of drugs and medical materials that were donated to Bosnia and Herzegovina from 1992 until mid-1996. 50%-60% of the received drugs and supplies were found to be inappropriate. A large number were actually dumped resulting in some 17.000 metric tons of inappropriate and useless drugs lay waiting in storehouses and medical clinics in the region.

The large-scale investigation proves its independence from potential stakeholders' interference, it is of scientific quality and it was carried out in the field. The quality of the investigation, of the article, and of the journal that published it facilitated further media coverage. They make the contents of the article still relevant, especially since it makes reference to concrete recommendations and to the use of the inter-agency Guidelines on Drug Donations, therefore suggesting the appropriateness of its use during educational activities and ad-hoc workshops. Copies can be obtained from: European Association for Health and Development.

Other examples of on-line article published by scientific papers include:

Hogerzeil, H.V., Couper, M.R., Gray, R., Guidelines for drug donations, BMJ, 314:737 (8 March), 1997: it provides a useful historical background and the key issues concerning the guidelines issued by the WHO.

Nemecek, S., Not What The Doctor Ordered, Scientific American, 1998: a short and accessible article concluding that the WHO policies have increased the awareness among all players about the complexity of the donation process.

Saunders, P., It's time to call a halt to poor drug donation practice, Scrip Magazine, September 1999: an overview focusing on the "Lessons from Kosovo" and stressing that "the unequal relationship between donors and recipients lies at the heart of many of the problems".

Mainstream Media
Scientific articles and awareness raising activities have started to have an impact on public media as well and today articles with accessible language and information can be found in widespread publications such as World Consumer and The New York Times (see for example the articles about Kosovo by Reed Abelson dated June 29, 1999 and August 16, 1999).

The Goodwill Pill Mess was published by the Time magazine in 1996 and is still available on-line. The article was a major contribution to get the subject of drug donations on the agenda of Northern American key actors and provided HAI with a concrete opportunity to reach the general audience in the USA and to approach policy makers.

WHO's Essential Drugs Monitor (EDM) also published various articles on drug donations and awareness raising. Click here for a PDF version of the 1996 Essential Drugs Monitor (see page 2 and 3). Click here for 1999 articles on donations from the EDM.

4. Working with enterprises

At the general level, one of the most significant European experience is summarised in "Talking with Industry: The BUKO Experience", an article that can be obtained from BUKO Pharma Kampagne from Germany, and the HAI-Europe office. It reports about the long-term experience of the BUKO Pharma-Kampagne in approaching German pharmaceutical enterprises. BUKO's strong argument is that many drugs distributed in developing countries are manufactured in Germany and therefore German pharmaceutical companies should feel an obligation to bring their marketing practices there in line with those in place in Western countries.

In France, ReMed organised a workshop on appropriate drug donations already in 1991, involving pharmaceutical companies (Tulipe) as well as the French Health Ministry and NGOs. Though it focused both on information sharing and on confronting different viewpoints to promote awareness raising concerning the dangers of inappropriate drug donations, there was little evidence of changes in the attitudes and behaviours of key actors after this first debate. It indicated that changes in this field require a more structured approach and a long-term strategy, which goes beyond the single workshop event. However, the press conference linked to the meeting proved very useful and sparked interest and a number of articles by national papers. In April 2000 a similar seminar is held in Paris (click here for more information in French language).

In the USA the fact that there was very limited knowledge about the inter-agency guidelines for drug donations led Medical Assistance Programs (MAP) International join other agencies in setting up a steering committee (Partnership for Quality Medical Donations, PQMD) involving both NGOs and pharmaceutical companies in 1996. This has helped to spread knowledge about the Essential Drug List and to create a framework for dialogue conducive to less reluctance on the side of pharmaceutical companies to produce to donate and to allow NGOs to request specific products to be donated through aid programmes.

5. Video

"Making Drug Donations Better with Care" is a fifteen-minute educational video. The programme presents the inter-agency guidelines for drug donations, which have been published by the WHO. It is meant for people who are involved with drug donations and want to know more of the background to this issue, for example relief workers or pharmacists. Most of the footage comes from a project, which is being implemented in Romania, and from visit to specialised agencies in the Netherlands.

The programme provides a good balance of general information about drug donations project and of the guidelines whose key issues are summarised through ten specific slides. Special attention is given to alternatives for the donation of medicines that have been unused or returned to pharmacies or hospitals. The format and the length of the video make it very suitable to introduce the issue during targeted meetings and educational activities and to stimulate discussions around the basic elements contained in the guidelines for drug donations.

To maximise the impact of the video at the international level the English version was produced at the time of the European expert seminar on Appropriate Drug Donations which was held in the Netherlands June 11-12 1999. The video is targeted at national and local educational activities. The original version in Dutch was produced as a part of the awareness raising campaign of the committee on drug donations (Werkgroep Geneesmiddelendonaties). Developed by Wemos and produced by Small World Media (Amsterdam), the video has already been distributed along with a handbook to more than three hundred pharmacists and voluntary organisations. Copies are available from Wemos and cost 10 Euro each. Besides Dutch and English, versions in German and Spanish are due to appear soon. Please click here for more information.

6. Brochure

DIFÄM is active in Germany with outreach educational work. The organisation has produced a brochure that pays special attention to communicate these issues in a language that is clear and quite accessible. It has proved a good working tool in approaching and working with other NGOs and private organisations.

Please click here for an HTML-version of the brochure in German language.

The brochure includes action points and it suggests that an NGO should explicitly mention in its programme its commitment to the guidelines on drug donations (60 organisations sent a positive reply). The brochure has been distributed in 6000 copies and backed up by a portable exhibition, produced in six formats and already staged in numerous venues all over Germany. DIFÄM is now following-up this work by addressing small-scale aid organisations with targeted leaflets and media-articles. Copies can be obtained from DIFÄM.

Examples

Example 1
H V Hogerzeil, M R Couper, R Gray (1997) report that: " After the 1988 earthquake in Armenia, 5000 tons of drugs and medical supplies worth $55m (£36m) were sent, which took 50 people six months to sort out. Only 30% of the drugs were easy to identify and only 42% were relevant for an emergency situation. Most were labelled with only brand names. (...) Of all drugs received by the World Health Organisation field office in Zagreb in 1994, 15% were completely unusable and 30% were not needed. By the end of 1995, 340 tons of expired drugs were stored in Mostar. Most of these were donated by European nations, and the mayor has written to the European Union requesting international help to have them destroyed".

Example 2
In December 1997 researchers led by Patrick Berckmans of the European Association for Health and Development in Brussels published a troubling study of drug donations sent to Bosnia and Herzegovina between 1992 and 1996. Their article in the New England Journal of Medicine described donations that included "army medical supplies from World War II" as well as "a drug for the treatment of leprosy, a disease not found in the former Yugoslavia." The investigators estimated that by mid-1996 there were "17,000 metric tons of useless and unusable medicines stockpiled in warehouses and clinics in Bosnia and Herzegovina"--a figure the authors say is between 50 and 60 percent of the original donations.

For more examples please click here.

Author: Alessio Surian (March 2000)