BOOKS & ELECTRONIC MEDIA

Making medicines affordable: studying WHO initiatives

Nuria Homedes

University of Texas - Houston Health Science Center, School of Public Health, 1100 North Stanton, El Paso, TX 79902, USA (email: nhomedes@utep.edu)

Authors: Ranjit R Chaudhury & Nirmal K Gurbani
Publisher: Anshan Ltd, Tunbridge Wells, England; 2005
ISBN: 1-904798-26-8; hardcover; 106 pages; price £25.00

The increasing cost of medicines is threatening the viability of many health systems, including those in developed countries. Some 30 years ago, WHO recognized that health systems need sound pharmaceuticals policies and since then has provided world leadership in implementing rational drug programmes, preparing useful manual and guidelines, and offering technical assistance. This book represents a very comprehensive review of worldwide pharmaceutical programmes that have implemented WHO recommendations. The case studies that it presents focus mainly on drug procurement strategies, while recognizing that ensuring the availability and affordability of drugs is only one aspect of rational drug use.

Starting with an analysis of the Bamako Initiatives and ending with a scrutiny of the Trade-Related Aspects of International Property Rights (TRIPS) safeguards, the book draws lessons that are useful to a broad range of policy-makers and administrators ranging from managers of health centres to global trade negotiators and public–private partnerships. One minor clarification is that Brazil has not issued compulsory licences as the authors assert, citing other sources.

I was impressed by the clarity and the balanced description of the case studies. The tone of the book is generally positive but it does not fail to point out the shortcomings of the interventions and how to address these to improve the appropriate use of available medicines. One issue that the authors could have emphasized is that making drugs available without modifying other practices and behaviours could easily result in an inefficient use of resources and oversubscribing. This is particularly important for evaluating programmes aimed at increasing access to drugs because the distribution of drugs is of interest to politicians, international lenders, and charitable organizations.

Also not covered is the fact that many attempts to improve drug procurement practices have failed. In the area of pharmaceuticals there is a gap between knowledge and practice. Reading the case studies, I began to think about the special circumstances that allow some managers to balance the pressures from pharmaceutical companies, physicians' associations and the community at large. Clear guidelines have been provided by WHO for this purpose. Nevertheless, the use of essential drug lists and of generic drugs remain limited, drug shortages in health facilities continue to be a problem in many countries, drug prices vary widely among countries and are increasing at a rate higher than that of inflation. Also, unnecessary drugs continue to be registered and marketed, self-medication using prescription-only drugs is rampant in many developing countries, prescribing practices are deficient, and consumers contribute to the inappropriate use of pharmaceuticals by demanding medicines they do not need or by not adhering to prescribers' recommendations. Access to needed medicines is increasing and hopefully this moments tum will force policy-makers to resolve the theory–practice gap.

Surprisingly, the book does not mention the recent WHO initiative for prequalification of products and manufactures in relation to HIV/AIDS, tuberculosis and malaria. By many accounts, this initiative has been a very useful and could be extended to other pharmaceutically based therapies. Perhaps the initiative had not been sufficiently evaluated when the book was sent to press, but in my view it is a good example of new far-reaching strategies that can improve access to affordable medicines. Other issues that require stronger global attention are: increasing the transparency of drug pricing; ensuring that trade agreements do not benefit industry at the expense of populations; opposing new legislation and limiting the use of loopholes in existing laws to extend market exclusivity; enforcing regulations that penalize industry's pay-offs to and influence on drug procurement officers; and controlling drug promotion to prescribers and consumers.

In summary, Making medicines affordable is a solid, comprehensive, and well researched compilation of worldwide experiences that have increased access to pharmaceuticals. It is didactic, easy to read, and offers committed managers a range of options that have proven feasible and useful. It certainly broadens the readers' perspective and offers hope. Despite its above-mentioned shortcomings, this book will be very useful for health and pharmaceutical managers, policy-makers, students and academics alike.