Primary Health Care 3

1
Primary Health Care (3)

• Health facilities, essential drugs and
  laboratories
• HServ/Epi 531
• Fall 2007
• Steve Gloyd

2
Declaration of Alma-Ata (1978)

• Health is a fundamental human right requires
  inter-sectoral action
• Existing gross health inequality unacceptable
• Improved health and peace require economic and
  social development based on a new international
  economic order (NIEO)
• Governments have responsibility to provide
  adequate health and social measures for health
• Primary health care is appropriate, accessible,
  acceptable, affordable and requires community
  participation (Specifies components of PHC)
• Governments need the will to formulate and
  implement PHC policies
• International cooperation is necessary
• HFA 2000 requires redirecting resources from
  military to social expenditures (including health)

Source WHO, 1978
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Essential components of Primary Health Care

• Health education
• Environmental sanitation, especially food and
  water
• The employment of community or village health
  workers
• Maternal and child health programs, including
  immunization and family planning
• Prevention of local endemic diseases
• Appropriate treatment of common diseases and
  injuries
• Provision of essential drugs
• Promotion of nutrition
• Traditional medicine

Source Alma-Ata Conference documents.
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Condition of health facilities

• Worse and better than we think (but dynamic and
  changing)
• Maintenance is key

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Mixed varieties of hospitals in Pakistan
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Philippines clinic franchises
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Many faces of Health Facilities in Mozambique
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Drugs Primary Health Care

• 1978, Alma ata conference of WHO/UNICEF
• essential drugs concept adopted as a component of
  primary health care
• WHO prepared its first EDL, 224 drugs and vaccines

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Why drugs are important

• Drugs save lives and improve health
• Drugs promote trust and participation in health
  services
• Drugs are costly
• Drugs are different from other consumer products
• Substantive improvements are possible

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Historical perspective

• 1897 aspirin
• 1941 penicillin
• 1943 chloroquine (malaria)
• 1944 streptomycin (tuberculosis)
• 1950s oral contraceptives, anti-diabetics, drugs
  for mental illness, vaccines

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Access to drugs

• 30-35 lack access worldwide
• in poor Africa and Asia, 50 lack access
• More accessibility in cities
• Shortages in the supply of the right drugs
• 50-90 drugs in poor countries are paid for out
  of pocket
• burden falls heavily on poor

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Individual private spending on drugs (as a of
total drug spending)
(WHO,97)
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Cost to Governments

• 25-50 of national health budgets for drugs
• many ineffective and expensive drugs in use
• expensive drugs used

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Pharmaceutical spending as of total health
spending is greatest in developing countries
Developed countries (7-20)
Transitional countries (15-30)
Developing countries (24-66)
WHO, 97
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Inappropriate utilization of drugs in poor
countries

• 75 of antibiotics prescribed inappropriately
• 50 of patients worldwide take medications
  incorrectly
• 90 of consumers can only buy 3 days supply or
  less for antibiotics Modified package inserts and
  recommendations
• Drugs with serious side effects (Clioquinol,
  chloramphenicol)
• Polypharmacy toxicity antimicrobial resistance

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Poor quality of drugs

• Unregulated manufacturers (Italy, local)
• 10-20 of sampled drugs fail quality control
• Poor storage (light, cold chain)
• Expired drugs
• Street manufacture
• Counterfeit drugs
• 75B by 2010

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Street sales cures STI
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Proliferation of brands little regulation
Number of brands in country
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Aggressive marketing of drugs
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Drug Promotion

• Inadequate education to providers, public
• Misleading and dubious claims (Squibb-UK cough
  tonic promoted as a brain tonic in India)
• Conflicting drug indications (Antihistamine
  cyproheptadine sold as an appetite suppressant in
  India and Pakistan)
• Advertising practices (package inserts) Free
  drug samples (get providers patients hooked)
• Gifts (pens, books, conferences)
• Pressure tactics (bribes, threats)

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The rise of the Essential drugs concept

• Why not concentrate first on a basic list of
  reliable drugs to meet the most vital needs
• Norway - before WWII
• Papua New Guinea - in 1950s
• Sri Lanka - in 1959
• Cuba - in 1963
• WHO by 1970s

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WHO essential drug program

• 1970-75 Concerns voiced by NGOs, Churches, WHO
• Halfdan Mahler (1975) those drugs considered to
  be of utmost importance and hence basic,
  indispensable, and necessary for the health needs
  of the population should be available at all
  times, in the proper dosage forms to all segments
  of society
• 1975 WHO Expert advisory committee
• 1977 First Model Essential Drug List (EDL)
• 208 drugs
• 1997 306 drugs (166 new, 68 deleted)
• 2007 340 drugs
• 136/192 countries have adopted EDLs

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Additional action Program on Essential Drugs
(1977)

• National drug policies
• Health economics and drug financing
• Drug management and supply strategies
• Rational use of drugs
• Regulation and quality assurance capacity

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National Drug Policy

• Policy and Legal framework (NDP, Legislation,
  Production policy, Regulation)
• Drug management Strategy (selection, procurement,
  distribution, Rational use)
• Support systems (organization management,
  financing sustainability, Information
  resources, human resources)

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Rural Hospital in MozambiquePhysician in
Pharmacy
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Rural Hospital Pharmacy - Mozambique
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Rural Health Center - Mozambique
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Rural health post with one nurse
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Botswana Health Center pharmacy
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Health post pharmacy in Sudan
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Pakistan Essential drugs for ER
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Pakistan public hospital
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Bamako Initiative "Women and Childrens's health
through funding and management of esssential
Drugs at the community level

• Mandate drug charges to recover expenditures
• 180m for 1989-91
• start-up costs for basic equip
• short term provision of basic drugs
• support costs (supervision, training, social
  mobilization)
• first years proceeds as seed capital
• second and successive years as replenishment
• Community health committees planned for 75 of pop

34
WTO and multilateral trade agreements (mandatory
compliance)

• Trade Related Intellectual Property (TRIPs)
• Patent protection harmonized to 20 yrs
• Alternatives
• Compulsory licensing
• a government can license a manufacturer to
  produce a patented product without the agreement
  of the patent holder - as long as the patent
  holder receives substantial compensation
• Parallel importing
• A government can purchase brand name drugs from a
  third party in another country, rather than from
  the manufacturer (prices vary in different
  countries)

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Drug regulation status in selected countries
(WHO, 98)
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Differences in Amoxil, by country
(Consumer project on technology)
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Laboratory Capacity

• Quality varies tremendously at all levels
• Maintenance
• Reagent stockouts
• Qualified Personnel
• Quality control systems

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Varied conditions
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Quality control is possible - Mozambique
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Donations everywhere
Rural Cote dIvoire
Rural Mozambique
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Chem 20
CD4
but no reagents
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Medical equipment in Rawalpindi, Pakistan