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Home > English > More information > It’s time to call a halt to poor drug donations practice
It’s time to call a halt to poor drug donations practice by Philippa SaundersPublished in Scrip Magazine, september 1999. In recent months the World Health Organization has said that many gifts of unusable drugs have arrived
without notice in Albania and Macedonia. this dismaying news is not unusual.Disaster aid provided in the wake of the Armenian earthquake; hurricane Mitch and George in Central America; the civil wars in Rwanda, Sierra Leone and many of the countries of
the former Soviet Union, were all characterized by the accumulation of unusable donated drugs. Similar, widely publicized, problems occurred after the war in Bosnia and Croatia.Clearly the lessons of previous crises have not been learned. Political
and media pressures may explain why some governments, aid agencies, companies and small groups continue to send medicines inappropriately. But if the mindset is to change we need to know more about donations, in
particular where they come from and why they are sent.All too often drug donations do not match the country's needs, and packs are often out of date, lack information and come in quantities which are either too great or too small. Unfortunately, such
donations have become a feature of developing countries' regular health services.In the mid-1980s, working for Oxfam, I visited health institutions and medical stores in East Africa. A Tanzanian nun in charge of drug supply in a remote mission hospital was
forced to identify drugs from an old copy of the British National Formulary her only reference.
Obliged to acceptShe said that she often received drugs from different countries, with brand names she did not recognize. The
labeling could be in Spanish, Dutch, German or French. Only 10% were useful and the rest ended up on the hospital bonfire. She felt obliged to accept this poor quality aid because if she complained the donors might cut
off all supplies. Government recipients also accept inappropriate medicines rather than risk diplomatic repercussions.Only two years ago, when I went to the Caucasus as a member of the review team for a UK government-financed
pharmaceutical aid program, it was clear that nothing had changed. The centralized pharmaceutical supply system had collapsed, as had the economies of the newly independent states of Central Asia.
However basements and spare rooms had become Aladdin's
caves of unusable drugs and medical equipment. The contents of a decommissioned NATO hospital, for example, were stacked in the Armenian national children's hospital. One room was full of catheters and decaying
dressings, dated 1982, serving as a reminder that medical equipment and non-drug supplies are also involved.Such experiences motivated me to begin to work with non-governmental organization (NGO) colleagues to improve
the management of drugs in line with the WHO's essential drugs principles.The WHO estimates that 25-50% of the world's population is excluded from safe access to necessary drugs. Medicines shortage is only part of the picture. The capacity to manage
drug supplies nationally and locally is often undermined because resources to pay for training, transport. systems development and information are lacking.These weaknesses are highlighted in a crises when fragile infrastructures are loaded with uninvited
and inappropriate supplies. Common sense argues that the more fractured the system, the more disciplined and simpler should be the response and the greater the responsibility to respect national regulations, systems,
drug priorities and therapeutic guidelines.
Audit in AlbaniaThis clearly
doesn't always happen. In May, the WHO's European Regional Office sent pharmacists to Albania to conduct an audit applied to conduct an audit of donated drugs. The audit applied to drugs received by the Albanian
authorities, but not to consignments which bypassed the system. In "normal" times Albanian can by only about 20% of its drugs requirement for hospital so the authorities already have procedures to process
donations. However, with the Kosovo crisis Albania was swamped by an influx of 460,000 refugees.The audit found serious quality problems. Donations did not match the most urgent needs: 10% were not
accompanied by any detailed packing list, 36% consisted of small samples, 32% had brad names that were unfamiliar to Albanian health professionals, and 65% had no expiry date or were due toe expire less than a year from
the date of donation.Similar pattern was
found in Macedonia where donated products included garlic capsules and nicotine inhalers, as well as paracetamol in ten different formulations and brand names. Around 40% of products examined by the WHO were unusable.
Addressing the issue
In 1996, the WHO published its widely
circulated'Guidelines for Drug Donations', which were based on guidelines issued 20 Years ago by the Pharmaceutical Program of he World Council of Churches (WCC) to improve the quality of medicines in mission
hospital, especially in Africa.Although
the WHO consulted widely when drafting the guidelines, a degree of friction persisted. Until the March review meeting, for example, no donation distributor or industry representative had been part of the core group, and
in 1998 the WHO was accused of 'blocking desperately needed drugs to the poor', and even of being responsible for unnecessary deaths.The main bone of contention was the requirement that drugs should be donated if they have at least one year
of shelf-life. The argument was that well-organized agencies can ensure even short-dated drugs are used before they expire, and the guidelines now allow for this.Most drugs do not deteriorate by an arbitrary date, and many are usable for months or years after they
expire. Among the exceptions are tetracycline, which can become toxic, and antibiotics and vitamins, which lose potency. But while it may be reasonable for prescribers to use these stocks when nothing else is available.
There can surely be no justification for donating drugs which have either already expired, or are about to do so.
The guidelines aim to improve the quality of drug donations, not to hinder them. And they are intended
to serve as a basis for national or institutional guidelines, to be reviewed, adapted and implemented by governments and organizations dealing with drug donations. About 20 governments have integrated versions of the
WHO guidelines onto their national regulations.One practical measure to expedite drug donations for countries in need has been the development of emergency health kits by the WHO (click here to download a pdf-document from the WHO web site).
These packages were successfully used in the Kosovo crisis and adaptations now exist to meet the needs of emergency mental health, surgery, chronic diseases, reproductive health and other specialized areas.
Kits are useful where administrative capacity is
limited, but they do not meet all eventualities. For example, shortages of anesthetics, anticancers, tranquilizers, microbiological tests and surgical sutures have been reported in Belgrade. There will always be
requirements which change over time or because of unforeseen developments. Donations must match specific needs and the capacity of personnel, be timely, in appropriate quantities and of good quality. Goods which fail to
meet these criteria will not be used and will add to the expense of safe disposal and the workload at the receiving en of the chain.
Stumbling blocksDespite this progress some stumbling blocks still remain to the promotion of effective drug donations to
those in need. Recent articles en the US press have asked if tax allowances provide an incentive for poor quality donations. And the WHO said from the Balkans recently: "We are very concerned that some
pharmaceutical companies are using this humanitarian crisis to get rid of unwanted stockpiles."Indeed, in 1990, Professors Patricia Arnold and Michael Reich published an academic study describing the
'natural history' of US donation practices(1). They said that hundreds of millions of dollars' worth of donated supplies, including drugs are passed to distributors by companies for shipping to the
world's poorest countries every year. Tax allowances, they claimed, can encourage companies to get rid of unsold stock nearing expiry. They omitted to mention that donating drugs also allows companies to avoid the costs
of incineration.Because the efficiency of
the private voluntary organization (PVOs) that distribute the drugs tends to be judged on the ratio of operational activities to administrative overheads, the emphasis is on the monetary value of goods rather than their
health impact. Arnold and Reich argued for greater public disclosure and accountability for PVOs and called for changes in three areas that would improve practice. These are in public accounting standards, tax laws, and
the Us Agency for International Development regulations.In both Europe and the US, the collection and distribution of donated medicines is frequently out sourced to specialized agencies. In Europe, drug samples and medicines that have been returned are a
staple of these schemes.Where drugs are
donated all parties have a responsibility to ensure they do not undermine the disaster response, enter the illegal market or harm the population. It should be remembered that donations in the Kosovo crisis came from
many parts of the world, including Asia, the Middle East, and most European countries. Governments as well as companies and aid agencies sent inappropriate aid.
Lessons from KosovoDrug issues raised by donations are more complex than is often assumed. The failure of drug distribution
systems may extend to the period of post-emergency transition which can last many years. If countries cannot buy the drugs they need for public health this may turn into chronic long-term dependency on donated drugs.
The unequal relationship between donors and recipients lies at the heart of many of the problems. Because donations are seen as 'philanthropic' gifts, they are often not subjected to accepted safeguards.
Another humanitarian disaster will materialize before long
and, where possible, money or the WHO emergency kits, rather than drugs, should be sent to support existing supply networks. In the Balkans, for example, local suppliers are struggling financially having got caught up
in a less obvious casualty of war, the collapse of commercial structures.Government donors, NGOs and companies should have written policies and clear internal guidelines for staff, based on WHO principles. Agencies handling millions of dollars of
drugs, in particular, should employ experienced pharmacists. The who could assist countries to identify their needs early on. These needs could be posted on the newly constructed NGO Drug Donation web site -www.drugdonations.org - so everyone concerned can have ready access to the information.Finally, we should remember that current disease control and eradication programs, which concentrate on
polio, trachoma, malaria, onchocerciasis, Aids and lymphatic filariasis, all have unique and sensitive aspects which must be defined with clarity in an atmosphere of trust. Continuing flows of poor quality donations may
well undermine such initiatives, thus affecting the health of millions of people.
Reference1. P. Arnold and M. Reich, "PVO pharmaceutical donations: making the incentive fit
the need". Journal of Research in Pharmaceutical Economics, 2, 4, 1990. (A four-year study by Dr. Michael Reich into all US pharmaceutical company donations shipped by two private voluntary organizations between
1994 and 1997 was published last month. It is reported in Scrip World Pharmaceutical News 2465, dated August 20, 1999.) Click here for a link toinformation about this study
(*)Philippa Saunders is manager of the Essential Drugs Project on behalf of Oxfam, Save the children Fund and Christian Aid. She represented Oxfam on the expert working party that drafted theWHO guidelines
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