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WHO's Essential Drugs Monitor on drug donations (1999).
WHO's Essential Drugs Monitor on drug donations
Number 27 (1999) of WHO's Essential Drugs Monitor (EDM) has several articles on drug donations. Below these articles are reproduced with permission of the magazine's editor. To download (pdf-file) the full EDM pleaseclick here. For a free subscription to the EDM please click here and request for a subscription.
Contents:
Strategies to strengthen effectiveness of drug donations
Once again the urgent need to improve the quality of drug donations worldwide
has been underlined, this time by participants at a European Expert Seminar on Appropriate Drug Donations in Leiden, the Netherlands, in June 1999. Representatives from 60
organizations in 16 countries met to share experience and to discuss effective strategies for awareness raising and for promoting good donation practice.
Click here for a report on the plenary day of the seminar.
Participants heard that, despite the
efforts made by health ministries in recipient countries, WHO and other international governmental and nongovernmental agencies in the field to promote good donation
practices, reports indicate that large quantities of donated medicines are unusable and wasted. About 30% of drugs are donated directly by countries, and not coordinated
through programmes by international agencies. In Albania, for example, only an estimated 20% of the donated medicines have been channelled through appropriate coordination
structures. Tons of medicines to treat cholera and acute diarrhoea are stockpiled, while medicines for non communicable and chronic diseases are in great need.
A familiar pattern...
This same situation was repeated in October 1998, in Central America after Hurricane Mitch, one of the worst natural disasters in history. In
Honduras alone, more than 1.5 million people were affected. The health infrastructure was devastated - 23 of the 30 hospitals had their water distribution system either
partially or completely destroyed; 123 health clinics suffered serious damage and 68 were destroyed. According to a representative from the Pan-American Health
Organization (PAHO), there was a massive response from the international community.
"In Honduras, we found that despite the good intentions of many charitable
organizations, inappropriate donations were received. For example, drug information was in unknown languages; many donations had expired or were about to expire; and some
did not correspond to the country's disease patterns", the PAHO representative reported. As a result, she told participants, drugs and medical equipment are being
stored in a temporary warehouse, and valuable time that could be spent more effectively elsewhere has to be given to sorting the donations.
The recent events in the
Balkans and Central America highlight the need for implementation of theWHO interagency guidelines,
according to conference organizers. Developed three years ago and revised in March 1999 (see p...).
"Drug donations in emergency situations are essential, but
they can cause as much harm as they can do good", according to Mark Raijmakers of WEMOS, a Dutch-based NGO concerned with international health issues. "With the
Kosovo crisis, we have the opportunity to bring the problems to light and underscore the need for appropriate donations. We simply cannot risk repeating the mistakes that
were made in the past".
Among other issues discussed was how to overcome recipient countries' fears that they will receive no more donations if they turn away
inappropriate medicines. The seminar also highlighted that often it is not doctors but other medical staff, such as nurses, who deal with donated drugs and that training
should take account of this. Disposal of inappropriate drugs in recipient countries is another major concern. As one participant pointed out, expired pharmaceuticals turn
into chemical waste, with all of the associated costs and potential health threats to the area.
Awareness campaign...
The seminar organizers, WEMOS, DIFAM and
PIMED (NGOs from the Netherlands, Germany and France respectively) used the occasion to launch a Europe-wide awareness campaign. This is designed to inform national
governments and donors of the urgent need to implement the WHO Guidelines for Drug Donations. A new web site is available -http://www.drugdonations.org
Main messages from the Seminar
Good donations save lives and are very welcome;
There are unfortunately still many examples of unhelpful donations;
Adherence to theinteragency Guidelines for Drug Donations greatly enhances the quality and usefulness of the donation.
Two videos promote good donation practice
As part of the increasing efforts to improve drug donations, an educational video has been
released. Making drug donations better with care presents the interagency guidelines for drug donations1, paying special attention to alternatives for the donation of
medicines that have been unused or returned to pharmacies or hospitals. The 15-minute video is especially targeted at small-scale aid organizations that want to know more
about good donation practices.
Making drug donations better with care, developed by the Dutch Wemos Foundation, is part of the awareness-raising campaign of the
Committee on Drug Donations in the Netherlands, which Wemos coordinates. Dutch and English language versions of the video are available, and a Spanish translation is in
preparation. Parts of the video will be shown on the following web site: www.drugdonations.org.
For a direct link to this video click here
Drug donations also feature in another new video, Partners in healing, produced by the
Pharmaceutical Programme of the World Council of Churches and Community Initiatives Support Services International. However, this video drama also covers other issues
connected with drug management and supply, such as the need for staff training, the value of hospital pharmacotherapeutic committees and the advantages of revolving drug
funds. Filmed at a hospital in Nairobi, Partners in healing is a training tool which aims to promote discussion, particularly among those concerned with pharmaceutical
management at hospital level. Teaching notes for use with the 50-minute video are in preparation.
Partners in healing is available from: Community Initiatives
Support Services International, PO Box 73860, Nairobi, Kenya. Tel: +254 2 445020, fax: 254 2 440306. Price Sw.fr.10 (a concessionary rate may be available on application).
Making drug donations better with care is available from: Wemos Foundation, P.O. Box 1693, NL-1000 BR Amsterdam, the Netherlands. Tel: + 31 20 468 8388, fax: + 31
20 468 6008, e-mail:mailto:pharmaceuticals@wemos.nl
Price: Euro10 (approximately US$10), excluding mailing costs.
Promoting good donation practice in Kosovo
A WHO audit of humanitarian drug donations received in Albania during May 1999
revealed serious quality problems(1). It was estimated that 50% of the drugs coming into the country during the Kosovo refugee crisis were inappropriate or useless and would have to be destroyed.
The assessment of all donations received in May by the Albanian State Drug Distribution Authority revealed that 400,000 tablets and 1,200 large volume intravenous
fluids were already expired upon receipt. Two million tablets, 85,000 vials for injection and 16,000 tubes of cream for external use will expire before the end of 1999.
Fifty per cent of donation lists mentioned trade names only, many unknown to local health professionals. Only 28% of donations were packed in the large-quantity units
recommended by international guidelines and 18% contained small packs of free samples or drugs returned to pharmacies. A few donations raised the suspicion that some
pharmaceutical companies were using the humanitarian crisis to rid themselves of unwanted stockpiles, a practice known as "inventory purging".
The
Albanian health authorities relaxed import controls in April 1999. This was done to speed up the entry of urgently needed drugs and medical supplies for the 460,000
Kosovar refugees, and to meet the continuing needs of the rest of the Albanian population. Even before the refugee crisis, the Albanian health care system depended heavily
on drug donations. The country could cover only 20% of the drug and medical supply needs of its hospitals. Efficient administrative procedures aimed at controlling the
quality of incoming drug donations were in place. WHO's audit analysed donor compliance with national and international drug donation guidelines.
Clear advice for donors
As the preferred destination for drug donations now shifts to Kosovo itself, good coordination of drug donations from the outset will be crucial
to avoid duplication, waste and the arrival of yet more unneeded and inappropriate drugs. Once again donors are urged to adhere strictly to the international guidelines
for drug donations (2).
For further information contact: WHO Humanitarian Assistance Project Office, Commission for Humanitarian Aid, Ministry
of Health, Boulevard Bajram Curri, Tirana, Albania. Tel: + 355 42 71 831 or + 355 42 72 522.
References
1. WHO. Press release 9915, EURO/15/99, 30 June 1999. Copenhagen: World Health Organization, Regional Office for Europe.
2. WHO. Guidelines for drug donations, 2nd ed. Geneva: World Health
Organization; 1999.
Drugs in disasters: encouraging the good, paying for the bad
Early in the Kosovo crisis drug needs were
swiftly and efficiently met by donations. Essential drugs in the form of New Emergency Health Kits arrived in sufficient numbers for 1.5 million people for three months.
They were welcome, beneficial, and responded to the immediate needs of the Kosovar refugees who had fled into Albania and Macedonia. Such donations save lives. Later into
the crisis, however, concerns about the quality of other drug donations led WHO to undertake a survey of drugs sent to Albania during May 1999.
Every disaster
results in good and bad donations. In 1997 a study by Epicentre and Pharmaciens sans Frontières estimated that 50-60% of donated drugs in Bosnia were inappropriate.
Similar problems have been reported from Rwanda, Somalia, Kenya and Honduras. The emergencies following the earthquakes in Turkey and Taiwan were probably no different.
Most bad donations are not intentionally so. Donors may be unaware of the complexity of issues involved and fail to take account of the recipient's actual needs. The
1999 revised interagencyGuidelines for Drug Donations (1) describe the basics of good donation practice, for both donors and recipients. The key is to respond to actual recipient needs: there must be good communication between donors and recipients. Recipients must make their needs clear to donors and be prepared to say NO to unhelpful donations. If recipients of bad donations remain silent they will continue to receive bad donations.
There are encouraging signs that the drug donation situation is slowly improving. The first edition of the interagency Guidelines for Drug Donations was issued in
1996. A recent global survey of experience with the guidelines showed a positive impact. Six donor and 13 recipient countries have developed their own drug donation
guidelines. Additionally, 40% of all responding organizations had changed their donation practices to follow the guidelines, 45% of recipients reported an improvement in
donation quality, and 52% now find it easier to refuse unwanted donations.
The challenge is to improve unsatisfactory donation practices further. How can situations
seen in Croatia, Bosnia and Herzegovina, Kosovo and Albania be stopped? Pressure to name offending donors is mounting. In the case of 11 particularly unsatisfactory
donations sent to Albania during the Kosovo crisis, one government, three nongovernmental organizations and 10 companies have been asked for comments on their donations.
Two nongovernmental organizations are untraceable. WHO would prefer to avoid the naming of names in public. The strategy to improve donations remains active promotion and
dissemination of good donation practices, based on the second edition of the Guidelines for Drug Donations.
To encourage implementation of good practices,
organizations and companies are being asked to underwrite the guidelines. The implicit agreement is that those who endorse them will keep to them. The success of the
scheme depends on the vigilance and willingness of recipients to report unhelpful donations.
Making a bad situation worse
The cost of unhelpful donations in
terms of time, effort and money is high. The price is borne by recipients, as it is they who pay for disposal. In rich countries the disposal method of choice is high
temperature incineration in purpose-built facilities. Discarded drugs are chemical waste and if they cross a frontier become by definition toxic waste. Movement of
discarded drugs across frontiers is governed by the Basel Convention on the Control of Transboundary Movements of Hazardous Waste and their Disposal. A recent estimate in
Croatia costed disposal of 1,000 metric tons of donated inappropriate pharmaceuticals and medical supplies at US$2-4 million.
Countries which receive unhelpful
donated drugs neither have purpose-built incineration facilities nor money for shipment to other countries. In response to the need for straightforward clear advice on
disposal WHO has issued interagencyGuidelines for the Safe Disposal of Unwanted Pharmaceuticals in and
after Emergencies (2) The guidelines are intended for relevant ministries, health authorities, environmental and waste management authorities and experts at regional and local levels. They describe the process of management, sorting into categories and the selection of different disposal methods involving minimal risks to public health and the environment.
This is one publication which WHO hopes will have a short shelf-life.
References
1. WHO. Guidelines for drug donations, 2nd ed. Geneva: World Health Organization; 1999. WHO/EDM/PAR99.4.
Co-sponsors of the Guidelines are: Caritas Internationalis, International Committee of the Red Cross, International Federation of Red Cross and Red Crescent Societies,
International Pharmaceutical Federation, Médecins Sans Frontières, Oxfam, Pharmaciens Sans Frontières, UNAIDS, UNHCR, UNDP, UNICEF, UNFPA, the World Bank, the World
Council of Churches, and WHO.
2. WHO. Guidelines for safe disposal of
unwanted pharmaceuticals in and after emergencies. Geneva: World Health Organization; 1999. WHO/EDM/PAR/99.2.
Co-sponsors of the Guidelines are: ECHO International
Health Services Ltd, International Committee of the Red Cross, International Federation of Red Cross and Red Crescent Societies, International Pharmaceutical Federation,
International Solid Waste Association, Médecins Sans Frontières, Oxfam, Pharmaciens Sans Frontières, UNHCR, UNICEF, UNIDO, the World Council of Churches, and WHO.
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