metadata: authors: 0: author: Foster,Susan D.
count: Africa
docna: 0: docna: Improving the supply and use of essential
            drugs in sub-Saharan Africa
docty: Policy Research Working Paper
subtopic: Pharmaceuticals Industry,Health Care Services Industry,Urban Solid Waste Management,Pharmaceuticals & Pharmacoeconomics
teratopic: Health, Nutrition and Population
abstracts: cdata!: Few people in sub - Saharan Africa have
            access to essential drugs. And where drugs are available,
            they are inequitably distributed and improperly used.
            Shortages of drugs in Africa are caused not only by lack of
            funds, although in many countries this is the major reason.
            Poor utilization and wastage of drugs in public and private
            sectors are also responsible and can be improved; and the
            wastage of available foreign exchange can be reduced. While
            the private sector has a role to play, it is important to be
            realistic about its ability to serve the whole population
            and about the quality of the service it provides. Producing
            local drugs would need to be evaluated in a realistic manner
            taking account of individual country circumstances. Specific
            measures to improve selection, quantification, procurement,
            storage and distribution, and prescription and use of drugs
            have been implemented in a number of African countries,
            resulting in significant improvements in the availability of drugs.
repnme: repnme: Improving the supply and use of essential
            drugs in sub-Saharan Africa
display_title: Improving the supply and use of
            essential drugs in sub-Saharan Africa
listing_relative_url: /research/1990/06/700258/improving-supply-use-essential-drugs-sub-saharan-africa
topicv3: Generic Drugs m1326797 1358,Essential Medicines m1327279 1352,Pharmaceuticals m1327740 1350,Health m1504661 3480,Private Pharmacies m1583829 4505
publishtoextweb_dt: 2010-07-01T00:00:00Z
historic_topic: Health, Nutrition and Population
origu: Policy, Research & Ect Affairs
no_of_pages: 42
author_keys: 0: author_key: 770308
model_extractions: **Policy, Reserch, and** **_Extwna_ Affairs**

**Population, Heauth, and Nutrition WPS 456**

- This paper a product of the Population, Health, and Nutrition Division, Population and Human - Resources Department is part of a larger study in PRE of African health policy. A policy paper is being written based on the study. Copies of this paper are available free from the World Bank, 1818 H Street NW, Washington DC 20433. Please contact Zarine Vania, room S6-266, extension 33664 (38 pages with tables).

Few people in Sub-Saharan Africa have access to essential drugs. And where drugs are available, they are inequitably distributed and improperly used. The main problems -- and possible solutions -- are: Drugs are distributed through the private sector, nonprofit organizations, and govcmments. The private sector consists of a large proportion of unqualified illicit peddlers of drugs who dispense adulterated or expired drugs without prescription. Pharmacies run by qualified pharmacists are a small minority. Nonprofit organizations -- usually humanitarian, secular, or religious -- and public agencies run by govemments also distribute drugs.

African countries do not have the capacity to produce the drugs they need. Phannaceutical industries in Africa depend on imported raw materials that are expensive when bought in small quantities. It is generally cheaper to import generic drugs than to produce them locally. The paper discusses procurement strategies that have resulted in savings in several countries.

Drugs are wasted due to poor storage conditions, inadequate security, and deficient inventory control systems. Proper selection, quantification, storage, and inventory management of drugs could alleviate this problem.

Drugs are also wasted because of inappropriate and over-prescription, and noncompliance by patients. Efforts to involve prescribers in using standard treatment schedules and to inform patients about the proper use of drugs could result in improved efficiency.

Africa has special characteristics in its landuse pattems. population density, and road infrastructure that affect the distribution of drugs. Counterfeit drugs and difficulties in financing essential drugs are also serious problems. The advent of AIDS has presented new challenges in the provision of essential drugs.

Thc PRE Working Paper Serics disseminates the findings of work under way in the Bank's Policy, Research. and External Affairs Complex. An objectivc of the scries is to get thesc findings out quickly, even if presentations are Iess than fully polished. The findings, interprctations, and conclusions in these papers do not necessarily represcnt official Bank policy.

Produced at the PRE Dissemination Center
WHO estmates that worldwide, as many u 2.5 billon people-half the worls population-hae Uttle or no regular accs to esaential drugs (WHO, 1988b). The 435 million people in sub-Saharan Aftica are even wose o0, since only one-third are thought to have access to essential drugs (Annez 1). TIs paper will attempt to review the causes of this situation. Th fiSt pan desrt. -4 drug supply systems in Africa, both public and private; the second describes opponunities for improving efficiency and reducing waste and gives evidence for the savings to be made; and the third reviw sever issues of specific importance to Afria, namely, geographic and spatial constraints; the problem of counterfeit drugs; financing of drug supplis and cost recovery or "cost sharing;" and the impact of AIDS on drug SUppis.

How much are African countries actually spending on drugs? Table 1 gives an estimate of annual per capita drug imports for eight countries in Africa from 1982-84.

How does this compare with what is estimated to be needed for adequate drug supply? Table 2 provides some data on treatment costs by _level_ of health fcility from a variety of countries in Afrika These are only indicative, and in some senses are not comparable, as in some of the countries drugs are locally produced and therefore may be more expensive; p~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.
2

**Table** 1. Drug Imports Per Capiia in Eighlt Afkan Countries, 1982-84

|Country|Per Capita<br>Drug Imports<br>USS|
|---|---|
|Senegal|7.40|
|<br>Zambia|6.50|
|Swaziland|4.80|
|Etopia|1.47|
|<br>Burkiba hso|1.36|
|Rwads|Q93|
|Uanda|Q93|
|Guione|0.86|

- uojustea; inacrrent terms **(795Z-4).**

SOW= **C_ambi ad** Ftu, **19lS** t pOl ests vai greatly from one county to another as we lThese fpre do, however, e an idea of the relative order of magnitude required to provde bask treatments using essential dmgs Whether a given amount of drugs i *sufficient depends on coverage of health servics, and on how many annual contas with the halth services for some form of treatment are thought to be 'adequate.

Data on per capita drug consumption may also overstate the availability of drugs in rural areas, s drugs tend to *stick' at central levels and in hospitals. Unless specific measures have been taken to ensure regular availabity of drugs in rural health centen, as in Zambia, Kenya, Uganda, Zimbabwe, Tanzania and a number of other countries, it is likely that virtually no drugs are reaching the lower level health facilities. In Tanzania Table 2 Average Costs per Treatment Episode at Various Levels in Several African Countries (USS)

|Countly|Year|Village|Dispensary|health<br>Center|i<br>Hospital<br>OPD|
|---|---|---|---|---|---|
|Kenya|1984||U.Z9|U.2U||
|<br>Kenya|1985||||_0.50_|
|<br>Sudan|1985|Q15|032|032|0.59|
|Bwundi|1986||0.37|037||
|Gambia|1967|0.12|0.24|_035_|0.50|
|Guln-Blsaau|1987|||031||
|Ugda (a)|1988||0.29|0.29|0.29|

(a) Represents total number of outpatient treatments, without designation -o **level.**

**_Som_** WHO **DMa**
3 in 197 prior to the introduction of a 'it' stem of drug distribution, the nstonal per capita expenditure was USt1.20. At the national teaching hospitaL however, the avwrage expenditure was US$9, with a much as USS13 in the ward which received private patients and senior offidals, but S5.90 in the gcne ward. But in rural dispensaries, only $0.02 wa spent per patient (Yudkin, 1980). A similar ture of mal-distribution within a facility is reported from Nigeria; one author reports that *drup and other equipment said to be out of stock in the general ward, meant for the masses, are stock fl;! in the amenity ward" (Ityavar, 1988.) EoDnomlc, pographicaL and cultural fators, thorefore, all combine to reduce the effectiv access of many Africs to basic rugs, in all lkelihood exacerbating the generally high morbidity and mortality observed in Afica

# Drug Distbution Systems in Africa

Dus are distributed in most Africn countries through three sysm; one priate cDmmercida, one private non-profit, and another public or goverment-run. A fourth possibility is a parastatal agency which although owned by the government often operates along commercial lines Mme reatve imporunce of these varies greatly from one country to awther, with the private commeral setor virtually non-existent in some and the gotvrment-run networ nearly defunct in otbhea The importance of the prvate non-profit sector varie greatly as well, with a relatively greater presence in English-speaking East Africa and in the coastal countries of West Afric. BEach of these will be descnbed briefly.

## _The Private Pharmaceutical Sector_

It is customary to compare drug distribution in public and private sectors by the relative value of their sales or throughput This may lead to an underestimation of the volume of drugs distributed by the public sector, however, as the private commercial sector typially distnbutes brand-name drugs which are usually 4-5 times more expensive than generic equivalents (Szuba, 1984; Sepulveda-Alvarez, 1985). In order to give a more accurate picture of the volume of drugs distributed by both public and private sectors, Table 3 presents the results of an adjustment by the relatively conservative factor of 2 to make public sector value comparable to that of the private sector, enabling a comparison of overall drug volume to be made. This shows that for wevral Afian countries, the value of dugs distnbuted by the public sector is significantly higher than the unadjusted value would indiate; for four of the six countries, the public sector acunts for at kast half of the drup distributed. Adjustment by a factor of 3 would bring the public sector share to over two-thirds of the total in four of the countries Thi of course amumes that the public sector procures drugs which are lss expensive than those procured by the private sector, which may not be the cue for all drugs Most publc sector drug agencies, however, do purchase some part of their
4 drup in bulk, generic form In some case, the same drugp purchased in bulk **throg** compotitive bidding by the pubUc sector are significntly cheaper than thoe purchased directly by the private pharmacies; in Zaire, the same drug was purchased by the public sector for las than balf of the priate sector price (Gluchberg and Singer, 1982).

Private sector pharmaies in Africa are concentrated in urban areas. For enmpk, of a total of 542 pharmacess in 9 French-speakdng West Afrian countries, 301 (56%) were loated in tJo capital city (Scrip, November 27, 1985) In Mali, the World Bank project zone of Kita, BDfoulabe, ad Kenieba circles (districts) had 7% of Mali's population, but _only 13%_ of the Pharmacie Populaire du Mali's (PPM) sales were made in that area Half of the PPM's sales are in Bamako, wre 10% of the population liv (World Bank, 1983). While the situation in many Englishspeaki countries and particularly in East Afica is somewhat better, the same concentation of private pharmacies in urban area pertains Even the pesoe of phrmacie Table 3. Relative Importance of Public and Private Sector Drug Distribution

|Coutry|(1)<br>Public<br>by Value<br>(Unadjusted<br>(Percent)|(2)<br>Ae,asted<br>) Cotal<br>--ercent)y|(3)<br>Public<br>as Percent<br>of Adjusted<br> <br>Total|(4)<br>Private<br>by Value<br>(Percent)|_(5)_<br>Public<br>by Value<br>(Percent)|
|---|---|---|---|---|---|
|Burkin Faso|64|36|72|136|53|
|Niger|57|43|86|143|60|
|Rwanda|77|23|46|123|37|
|Senegal|85|16|32|117|27|
|Zambia|57|43|86|143|60|
|Zimbabwe|_50_|50|100|150|67|

a Value of public sector drugs adjusted to private sector prices for comparison by multiplication by factor of 2

# SOW WOd BUnk Pbraeutka in the ThtW **WorId** PHN TecL Note 86-31, 1966, and WHO data

may not in itself guarantee access; the nrban poor are also prevented from having acss to drugs due to the high prices of drug available through the privte sector and the sbortages of free or low-cost drug available in the public sector facilities In Burkina Faso and Mali, for example, the price of French brand-name drugs in private pharmacies was fixed at 15-2C0% of the retail prke in France, despite the very much lower purchasing power of the clients and the fact that reimbursement is virtually non-eistentL A study in Abidjan, Ivory Coast found that the average cost of a prescription was the
5 eqivent of 100 French franca (about USS17); a similar study carried out in Paris found the awvrage prescription price was 112 French francs (Bessard et. aL, IQ( In Frane, however, in addition to income leveb being 15 times **greatew** than in hvry Coast, most (if not all) of this price would be reimbused by Socal Security.

What is a 'private pharnacy' in the African coatext? It may have little in common with a 'pharmau in the Western sens. Pharmacists are so few in number that in most countries it would not be possible to require the presence of a pharmacist in a pharmacy. As a result, there is some indication that unliensed private drug selers are the targets for distributors of counterfeit drup (Atueyl, 1988). In Nigeria, a survey of retail pharmacies in Maiduguri, Borno State, found that there were 90 retail pharmacies in the town. Of these, 10 were 'ethical pharmacies' run by qualified pharmacists, **and the remainder** wer *dry drug peddler shops, by unqualfied oesons. These had Ucense to sell only propriety (non-prescription) medicin but in fact had a wide range of drugs availabk. Many were expired and we adulterations of popular drugs. TMe drug peddlers often had an 'Ijaction room' whe customers judged to be 'safe' were taken. The public appartly did not distinguish between the two types of pharmacy, and used both a cinics where they consulted and were given prescriptions and treatent. Health problek for which they sought treatment were (in order) malaria, cuts, eye pains, general body pains, dysentery/diarrhea, skin Infection, abdominal pain, family planning, cough, chest pain, and venereal dies The most freqaent treatment was antibiotics, especiaUy injections; antibiotica represented 35% of treatments given. The second most frequent treatment was drug for diarrhea (not ORS', followed by treatment for malria. Th reasons most frequently cited for seeking treatment at the pharmacies **wa** that treatment was expeditious, drugs were rarely out of stock, and the drugs given were efficacious and often better than nospital treatment (Igun, 1987). In Africa, drug shops or peddlers are much more common than pharmacies rn by qualified pharmacists. VUlage drug shops are often patronized because they are close, not because they are considered to be suitable. In Saradidi, Kenya, people cited lack ot transport and distance to alternatives, and that they were open in emergencies, as major reasons for patronizing the drug shops. Prior to introduction of a scheme whereby village health workers provided antimalarial treatments, _53%_ of the people obtained their antimalarial treatments from a shop, and the shookeeper provided advice on dosage, etc. But when antimalarial treatment ws available from the village health worker, 85% of the people preferred to get their treatment there. When the scheme was in place, use of the shops declined significantly, with 90% reporting that they no longer used the shops for antimalarial treatments (Mburu et. aL, 1987).

Another type of drug outlet is the ilicit drug seller who does not opcrate from a fixed pharmacy premises. In Pikine, a suburb of Dakar, Senegal, 102 ilLicit drug sellers were identified and a sample of ten were intervwed in depth. They had set up in markets, on street corners, or were itineant. On average they had 14.5 clients per day. Drugs were sold primarily for symptomatic treatment, with pain and fatigue accounting for 77% of visits; aspirin in combination or alone is part of more than half of
6 sales, Other dmru sold for actual cure were prmarily antibiotia and antimalarals. Antibiotms induded mainly tetracyie, sulfaguanidine for diahea, and isoniazid (an antl-tubercuiwis drug) for cough. AntimalarFils included prlmarily choroquine and amnvxaquine Most people consulted tee sellhs beause prices are low, rince the dru are sold in small amounts-one or two tablts. Sucb a pratice may lad to selction of reastant organism. Te risk might be small gien the fact that these drug are not sold often; of the 147 consultations, 9% received tetrayline, 7% an atImalarld and 1% sulfauanldine. Yet the value of dru sold on the street in this way wa almost as grat is that provided through official public drug outlets (Fan, 1988) IA Cameroon, informal drug _sellr_ were popular cspecally with poor peopl, since unlike the registered pharmadces, they would sl drup in any qmtity. This worha to the advantage of the pharmacst, who sells drugs tO the informal vendors who then undertake the uapoitable part of the reil trade for them (van der Geest, 1967).

Yet a Wtird type of drug seller is the tradtional healr who uses modern dru, especially antibiotics, in his practic. This is an increasingly common occufrence in Afia as well as throughout the developing world (Bedae and Goubaud, 1985; Haak and Hardon, 1988).

A urher priate commercial drug source is the sale of drugs piffred from public health facUities by health staft Ti may take tCe form of an exta charge for government drugs which are supposeo to be free, 'prvte practice in the afternoon or evening using government drugs, or fm the sale of drus o other selles In many countries, the risk of getting cauot and the potential penalties are ls than the pig to be made by rn.moving small amounts of materials and drugs from the system, primarily for personal use. Typically everyone does it", and pilferage is merely an income supplement, which people may have come to thinlk of as a perquisite of their position. Yet even though the scale of individual acts of pilferage is relatively small ,several dollars or tens of dollars would typical ee involved), in some countries, pilferage is so widespread that its cosL.d consk.erable. In Cameroon, health service personnel sell enough of the public drugs to be considered whoksalers' since they in<sup>t</sup> urn sell to drug vendors. Yet another category would be the port workers and customs officials, who use their position to obtain medicines for sale to others, and thus cDuld be considered wbolesalers (van der Geest, 1987). In Kenya, prior to introduction of the lit system, losses were estimated at 25%; these were reduced to ess than 5% when the kit system was in operation (Ministry of Health, Kenya, eL aL). A similar situation has been described in Sierra Leone (Bldsoe and Goubaud, 1965).

The fact that so many people benefit from the system creates grt resitance to needed improvements and control procedures; no one has an incentive to improve logistics, and the pressures to maintain the status quo are considerablW (van der Geest, 1982) In Sierm Leone, the local dispenser realized that he would lose his livelihood if WHO-recommended oral rehydration therapy and malria treatments were adopted, and he sucefully
7 preured town leaders to prevent the health educators ffom the hespital from coming back (Bledaoe and Goubsud, 1985).

Tbe privte non-proflit sector X quite different, and s usually operated by misionarIes or other non-governmental humantarian organizatios such Mdecins sanu frontieres, Save the Chilkden, etc. In the best of cawe, the non-profit sector uses private sector management techniques in the pursuit of social goals. They ofti purchase their drugs overseas through spedal purbasing agencies su.6h as ECHO, IDA. or UNICEF in some ces, in bulk and using generic names In a grwing number of ouwtries they are foming their own procurement and distribution abencies to enable the differeat nionm ad organtions to benefit from bulk purcha ad consequently lower prces. many of these orpaizations bave to charge a user fee for their servios to complement any support they may st om oversea or from 'he **poernment** in form of a capitation fee or a bed-day subsidy, they are eager to kcep prices low so that utlization do. nOt decline due to vatients' inability to pay the fee In Kenya, for camp, where missions **and** NOas _ar_ responsble for about 25% of all healt car, provided, overpresatption and asig drug prices were **having a** srm impact on utilization. Each hospital was purchasing small qntities of a large number of mostly brand-name drus. In ooperation with WHO, the various hospitals and church organizations created a drug procu,rment and distribution agency (MEDS). As a result, prices dropped **and** efficliecy was improvd.(Hogerzeil and Moore, 1967) A similar orgsnItlo. exists in Gh,n (Christian Health Association of Ghana, CHAG) (.Iogerzeil and Lamberts, 1984) and is being contemplated in a number of other countries including Sierra Leone, Zambia, Uganda, and Nigeris.

What is the contribution of the private sector in the distribution of ential drugs? As noted above, the private non-profit sector is increasingly turning to bulk generic drugs, in part to keep their fees low and thus ensure their continued financial health. The private commercial sector, however, has yet to play a significant role. Tbis is mainly because in most African countries where private pharmacies operate, the income of the pharmacist or owner is derived from a profit margin calculated on the basis of the wholesale price. There is therefore no incentive to carry low prced essential drugs. Indeed many such incentives have backfired; typically the tetdency has been to permtit a lower margin on already low-priced esentil drugs, which further reduces the pharmacist's incentive to carmy these drugs If the private commercial sector is to become more involved in distnbution of essential drugs, new pricing mechanisms will need to be found to reverse the pattern of innentives.

A related question is the albcation of foreign exchange between publc and private sectors. Inevitably, in cases of foreign exchange shortage, the import of a high-priced product precludes the import of a larger volume of a cheaper equivalent essential drug. Health benefit considerations need to be taken into account; and the authorities responsible for allocation cf foreig exchange need to ensure that the basic drug needs of the public sector are met, whDe remaining aware of the private sector's demanc.
(C3tAmbas and Foster, 1986) Both private sector importers and the Ministy of Health have a responsibility to use available funds as efficiently _a_ posibl The ministry of finance must support rationalization efforts by making required foreign exchange available, since intenational competitive bidding-usually the most advtagous method of procnement-is out of the question unles the necessary foreign exchapge is availablc It is aspecially important for the public sector to avoid the necd for emergency purchases from the local private traders who have had privileged accs to foreign emchange, whose prices typically are as much as three times **t&** international market price. (Catsambas and Foster, 1986)

# _Tw Public Sector_

Two types of publk drug distribution structure are commonly found In Atka, **and** may exist side by side in some cauntrieL One is known in English-speakling countris usually as Central Medical Stores (CMS) and in precb-speaking countries as the Pharmacie d'approvisionnement or Phaappro'. It is usualy wholly government owned, under the Ministry of Health. Although some of these are poorly run and ineffident, in a number of countries they have been rehabilitated and are able to provide a fuHlly stisfactory service. The other type of structure is the parastatal or pan-public drug importing and distributing enterprise, often a monopoly, which is partly government owned and usually administered under a ministry other than the Ministry of Health. Typically these operate along _im il line and depending on the depee of gvernment intervention in their affairs, they are often indistinguishable from the commercial private sector. In most cases they are permitted to cver most or aUl of their costs. In some cas they also carry out manufacturing or formulation activities on behalf of the government. Several of these organizations maintain their own network of retail pharmacies as well as selling drugs to the Ministry of Health for distribution through its own health facilities.

In both cases, the typical public sector drug supply system relies at least in part on the existing network of health facilities as distribution points. Potentially, thereiore, the density of distribution points is as great as the density of overall health facilities coverage. In the three circles of the western region of Mali mentioned above, for /- unple, there were only 3 pharmaces but 21 dispensaries and 3 health f',aters, all of which could serve as drug distribution points. The typical structwe of a drug import and distnbution system involes aUl drugs transiting a central warehouse and then being distributed either to regional stores or to depots at regional hospitals From there, the drus are distributed to lower evel health facilities.

What problems does the public sector face in distributing drugs especially to rural areas? One problem is that typicaly, the public sector relies on gnwernment budgetary support which is uncertain and often insullicient, and is prevented from charging the ful cost of its services. As a result, it is often running a deficit. This in turn means that there is not
9 enough money to provide the quantity of drug needed in the system to permit enough to flw dovn to al! levels; the 'pipeline' is not full. Insuffcient wpreswure of drup flowing through the system means not enough b available at tbe end point Another constraint is that the public sector s responsible for reaching all the population and cannot content itself with serving those who are easiest to reach, or those whose incomes aow them to purchase high-priced drug. Tbe average costs of providing **services nrease as** they are extended to more remote areas and to undersoned populations, and diseconomies of scale begin to appear. (Ov.v, 1986) A third problem is that typically, low priority and prestige are attachod to drug supply and more generally, logistic in public health. Lagistics has a sort of negative prestige in that it is only important when It is time to apportion the blame. Ministries of health are often run by mei doctors who may lack appreciation for the difficultie and imporace of logistcs; logistics specialists, usually not medical doctors, may not be viwed as professionals". Logistics is not considered a stepping stone in a pubic halth career. In a number of countries, this most Impoftant of posts has been given as a sln'sre to someone who is past retirement age and **hs** little trining or aptitude for the job. (Foster, 1987) Ti may be in part responsible for the presence of some degree of corruption and pilferage in a number of publc systems. Suggested mesures for reducing corruption include high-level commissions to conduct inquiries, cours and seminars to heighten awarness of the problem, and simplification of administrative procedures and strengthening of financial maagement. (Gould and Amaro-Reyes, 1983). Some countries have temporarily solved the problem by employing expatriates, who are outside of the bureaucrati **c** ulture and have no kinsluo ties to the local population, for seasitive posts 'Pilferage' on the other hand, is usually more widespread but on a much smaller scale. The main remedy for pilferage is better management controls, including punishment of those caught pilfering. In many countries. the risk of getting caught and the potential penalties are less than the gain to be made by removing small amounts of material and drugs from the system, primarily for personal use. The fact that so many people benefit from the system creates great resistance to needed improvements and control procedures; no one has an incentive to improve logistics, and the pressures to maintain the status quo are considerable. (van der Geest, 1982).

What can be done to improve the efficiency of the public sector, and to enhance the usefulness of the private sector? The following discussion wil attempt to trace the elements of a rational approach to drug supply. Areas of complementarity between public and private sectors will be noted, as well as areas where the goals appear to be in conflict.
10

## Improving Efficiency and Reducing Waste in Drug Supply

# _.Selecdon and Quantification of Dtgs_

The staring point for an esential dus polity is the careful sekction and quantfication of drug needs acrd1ng to the ealth needs of the population to be served. Selection invohl **balancing** considertions of com with those of efficay, safety, aem of administration, and other lcal coiderationo An cumple of the range of costs of treatment with various compsrble dru is quito usde to aid in the section process. In 1975, an anicle appeared which used Tanzanian data to compare the prices of treatments with various drugs The author dIstIguisbhd betwen utype A drus, wc are older, poen drugs, and often available in generic form; and 'ype BO drugs, invented more recently and still under patent and avaiable only under brand nams and usually much more expensivem Th ngeS betwen the che t (uswually an older drug avilable in generic form) **and** the most expensie brand-name drug were quite wide; for mxapb, anpalc treatment with a brnd of ibuprofen was 150 times the urt of treatment with aspirin; the range for tranquilizers wa 50.60 times for hookm m, 130 times, and for oral antibiotica, 10.50 times. He made the argument tha unnecsay use of more expensive drugs exhausts the drug budget and deprives tillow citizens of needed treatment. (Speight, _1975)_

**A** more detailed treatment of the subject was provided in 1980 with the publication by AMREF ot a manual on therapeutic guidelines which was later reorinted under the tite, Guidelines to Drmg Usage. (Upunda et al, 1983) in it the authors compared the various drugs used for the major diseases. Although the coSts are now out of date, the relative comparisons stil remain vaLid. A few of the cost comparisons are pres..nid in Table 4.

Clearly the costs of different drugs need to be taken into account in selecting drugs Expenditures on antibiotics are particularly important in Table 4. Cost Comparisons of Alternative Drugs for Common Conditions

|Condition/courws|Lowest cost|USS|Highest cost|rerceni<br>USS|Diflerence|
|---|---|---|---|---|---|
|arhrtis(Wi)<br>**ascrsis**<br>(dose)|aspirin<br>piperazine|O.Z1<br>0.08|lbuprolen<br>mebendazole|1.8<br>0.60|750|
|hypenension (yr)|reserpine|24.50|methyldopa|141.25|576|
|infammtion<br>(wk)|aspirin|0.21|naproxen|2.67|1271|
|epiepsy (yr)|pbenyto.in|3.56|carbamazepine|219.83|6209|
|urnay" tract in (wk)|nitrofurantoin|0.46|ampkilin|2.80|609|
|otitis media (wk)<br>NB: Prices in19e2 USS.|phenoxym.pen.|0.84|amodcillin|3.50|417|

Source: Upunda, Yudkln, and Brown, Guidelines to Drug Usage, 1983.
11 many developing cmintriep, so particular care is called for in selecting antibiotic for use at various levels of the health care system. Countries with high burdens of chronic disase, such as arthritis, epilepsy, diabetes, and hypertension, need to py p. cular attention to the costs of drugp used, since treatment for these conuitions is lifelong and inevitably costly.

In addition to the decision as to which essential drug is to be recommenccd as the first line drug for a given condition, there is also the decision as to whether ion-essential drugs will be used, and if so, under what conditionLs One author conduded in TIailand that while enough money was spent on drug, the actual consumption of needed drugs was in most cases below 15% of the requirement, while more expensive items, indu4ing analgeias, diuretics, tranquilizers, hormones, and antibiotics, were 'viy-and posibly wildly-overconsumed.' Between 1969 and 1976, the annual growth of consumption of psychotherapeutics and diuretics were 189% and 154% respectively. (Sepuhteda-Alvarez, 1985). In the Yemen Arab Republic between **1993** and 1987, as much as 20% of the drugs budpet was spent on drio4 human plasma and albumin injection, which are not consdered to be vital drugs. (Van Haperen, 1988) Clearly much can be done to improve decision-making about which drugs should be purchased St -n the overa scarcity of resources.

After the decision has been made as to which drugs are needed, the nr cual question cncerns the quanw:. of each drug which will be required over a gien perod, usually a year. While it may seem diMcult to amve at a **good** estimte, methods have now been developed to make use of available morbWity data and appropriate treatment scheduls in arriving **at** a workable timate. (WHO, 1988a) Such estimates can be invaluable in procurement, and can help a country to avoid such anomalies as have been reported, such as the order of 46 years' worth of consumption of a drug by a corrupt officiaL (Yudkin, 1978) However, such estimates are only as good as the morbidity data on which they are based, and the linking of the data with the provision of drugs could proVide an incentive to health staff to improve the quantity of the data they provide.

Excessive stock levels of low priority drugs tie up needed funds and run the risk of expiring unused. Surprisingly, in view of the overall scarcity which prevails, expiration of drugs is a major problem in many low-income countrieS. In Mauritania, the drug supply authorities estimated that Slm worth of expired drugs were on the shelves of the governmeut drug supply organization. On the assumption that this had accumulated over, say, 4 yeas, this mens an annual wastage of S250,000. In 1986, the government drup budget was S1m, so the value of the expired drugs represented about 25% of the totaL (WHO, 1986) In Liberia, of 318 drugs on the shelves, 44 were expired or unusabl. On the assumption that their average value was roughly equivalent, the wastage due to expiration was on the order of 15%. (Managcment Ssiences for Health, 1984) Similarly, in Ghana, a World Bank-funded quantification of drug **needs** for the public sector, based on morbidity, was recently carried out by
12 the Ministry of Health. The overall estimated needs came to approximately US$4 milion equivalent-only half of what had actually been spent on drug. The high wastage of drugs was confirmed by a Bank-funded audit of drug stocks throughout the country-45% of the drup were either expired (33%) or due to expire within the next six months (12%). In part this may be due to the introduction of user charges in 1985, which has reduced utilization of health facilities signifcantly and shifted drug purchase to the private sector, ordering of pharmaceuticals for the pubic sector has not yet caught up with the trend.

Stockouts of high priority drugs, on the other hand, may result in costly local purchases from private suppliers. Local purchases are commonly twice or three times the cost of imported drugs, and price differentials of up to 10 times have been reported. (See below, 'Procurementg.) Once the drug needs have been quantified, it is a relatively easy step to cost them and then establish the overall cost of drugs This link, between estimating and costing drug needs, and using the results in dscuuss with the financial authorities. is a crucial step towards improving the financing of drug supplies. Financial authorities-those rspo8sib for budget allocations and for release of foreign exchange-have shown themselves responsive to such iron-clad proof and justification of needs In fact, Zimbabwe recently used its drug quantification to obtain an agreement from the financial authorities that the needed foreign exchange would be made milblb.

# _To Make or Buy? Local Producion of Drugs_

In 1982, production of pharmaceuticals in Africa was estimated to be worth approximately USS750 million, accounting for less than 1% of the world total of USS 95 billion.(Scrip, May 6, 1985) As much of this was done by local affiliates of foreip companies, with production of active ingredients and research taking place elsewhere, this may overstate the extent of local production. African countries continue to import significant quantities of drugs from Europe, with 96% of imports coming from Europe and only 0.7% from elsewhere in Africa in 1984. Africa is an important market for Europe, with an estimated 12.7% of European exports going to Africa By comparison, Latin American regional trade is more important, with 32% of imports coming from within the region and only 49% from Europe, and 13% from North America.(WHO, 1988b) This low level of pharmaceutical production activity in Africa conceals an important fact: virtually all Afrcan countries already have some installed capacity for drug formulation, if not production. (Formulation is the final stage in drug production, such as the tabletting, packaging, etc of pharmaceutical intermediates produced elsewhere.) Yet most of these fatories are operating significantly below capacity, and some are closed for long parts of the year. The reasons for this situation are complex
13 and not amenable to **easy** solutions. In many cases, countries decided to proceed with Oshowpiece pharmaceuticals production, while continuing to import even basic goods such as soap, canned fruit and preserves, bottles and plastic packaging materials, bicycles, and so on. Pharmaceutical production was expected to provide a stimulus to development of ancillary industries, such as chemicals, glasswae, packaging, etc. Foreign exchange savingp were also expected to be significant and this alone was taken to be justication enough. These views were encouraged by a number of development agencies and financing was relatively easy to arrange; the result is a number of uneconomic factories in need of rehabilitation or closure.

A number of key assumptions were made about lcal production of pharmaceuticals which need to be reexamined in the light of experience and changes in the world market for pharmceuticals, Fhlt, the economic and financal analyses which were carried out often used the prices of the brand-name drug which the oally produced ones were expected to replace. But in the last seven or so years, the international trade in generic drugs has increased substantially and the prices have fallen significantly. Febility studies carried out in 1980, therefore could not have predicted that drug prices would fail to a half or lss of then current prices But now, gtven budget constraints when faced with procurement decisions, goverments have to prefer the lss expensive international generics to localy-made equivalentsL The locally-made products were rarely able to compete with imported brand-name drugs and therefore the private market was also losed to them, unless there was heavy tariff protection or an outright ban on import of products made loally. (Foster, 1989) A second assumption was that foreign exchange savings would be considerable. It appears that raw materials and interuediates would be cheaper imported in bulk. However, even raw materials are not necessarily cheaper than the finished product; often the manufacturers ignore very small orders or charge the price of their smallest packing unit (often 100 kg or more) even if the order is for less than 10 kg; opening and breaking down the package is simply not interesting for them. Large manufacturers order tons of a given material at a time, and enter into long-term contracts; they therefore benefit from significant price discounts, which are not available to small African manufacturers. Payment terms are often not advantageous, since foreign exchange shortages often cause delays in payments which the suppliers factor into their prices. Another problem was the lack of price information for most pharmaceutical raw materials and intermediates, which suppliers were quick to take advantage oL The recent establishment of the Pharmaceuticals Market Intelligence System by WHO should help improve the availability of price information for a limited range of basic intermediates used in production of essential drugs Other foreign exchange expenditures need to be taken into accounL In many countries, packing materials are imported, as is the machinery used in production and quality assurance; spare parts, repair, etc. must be paid for in foreign exchange. Elecricity production and water purification may require imported fueL Training of staff and expatriate management staff are often provided from abroad and paid for in foreign exchange. Technology
14 may nave to be purchased, espedally when patents or license arc involved. An effective export strateV means that a network of distribution points and agents must be developed and maintained; advertising is another expenditure which requires foreign exchangc (Foster, 1989) The case for foreign exchange savings, therefore, has to go well beyond the import of raw materials and intermediates A third assumption was that employment would be created. Unfortunately, pharmaceutical manuhfcture is not labor-intensive; it rather requires small numbers of highly skied technical workers-the type of worker which is must scarce in developing countris. Management skills are also of capital importance and are vety scarce in Afric Creation of a few hundred jobs may in fact cause the average consumer to be wors off, in Aeat, a survey of the phamceutical industry, conduded that 'Subsdizing domestic firms through high drug prices can have negative socal effect In a ountry with ...drums accunting for about 40% of the peonal health budget, a uniformly high price for pharmaceuticals is a burden which fas heaviy on the poorer sectors of the population.' (.UNCTC, 1984.) If it results in higher drug prices, therefore, creation of a few poorly paid jobs can have a negative impact throughout the economy, and especially on those outside of the formal wage-earning sectors.

A fourth assumption was regarding the nature of the markLet. It u thought that it would be possible to become 'self-sufficient' on the one hand, and that it would be possible to export to neighboring countries on the other. The fact that only a small range of lbs than 40 products (in many ases even fewer) are produced by most factories meant that on the oe hand, they were not able to produce the ful range of 250-300 drugs needed for health care, and on the other, that their *neighbors' were to a **large** extent producing the same limited range of simple products The self-sufficiency argument largely ignores the fact that raw materials and intermediates are imported in any case.

A final assumption made by many firms is that they can become profitable by producing a wide range of products. Since the patents for most essential drugs have expired, profit margins are usually quite low and price competition is stif£ In order to overcome this constraint, a 'mixd-product' strategy is often adopted by local firms, which produce both esential drugs and other drugs (and possibly cosmetics) for which demand and profits margins are high. UNIDO has in the past recommended this strateV to countries planning to produce drugs locally. Unfortunately, however, the result is often that the non-essential products made are of little or no use; they may even be harmfuL Health goals are therefore sacrificed in favor of industrial development and commercial goals.

How can public health and commercial objective both be reached? The guiding principle should be a pharmaceutical version of tae Hippocratic oath. *do no harm'. This kads to several possible 'mies', ranging from the idal to the unacceptable, s follows:
_15_

1. Produceaoo esmential drup: this strategy avids wastage of forein exhange on products witbout thempeutk benefit Te disadvantap b that profitability may remain low and therefore endanger the exstence of the firm.

- 2 Produce esential drugs and non-drug Items, such a wsmetica, hair tonic, toothpaste, skin lotions: If consumem demand these items, some foreign exchange savings may be posible and profitability may be high, permitting subsidization of the esential drug lie by sales of non-drug item.

3. Produce both essential and non-essential drugsp: Tis strategy, in fact in common application, presents a real danger that the non-ssential drugs are used as substitutes for appropriate, effective therapy or as expensive placebos Foreipn ochrnge is also wasted on dubious products It is partkularly unacceptable to produce drugs which are dangerous, either in and of themsehe or because of their mode of administration, Le. injectible vitamins, liver extrct, etc. A number of products which have been removed from the market for safety reasons by their original multinational manufctu are still being made and sold by Afian firms-becuse they are highly profitabl It should be possible to meet both public health and industrial dvelopment goals without endangering the health of either the population or the enterpris. (Foster, 1989) When all the problems and disadvantages of domestic drug productin in Afcn countries are wghed, it would be asy to become pessmnistic about the future prospects. Tere is no denying that the obstacles are numerous, and that past experience has been mixed at best Recent price trends have dealt a severe blow to local production efforts Yet there are types of production which are likely to be economically and financialy feasible in many African settings:

- Local packaging of bulk imports: This is an area which has not received the attention it deserves It employs unskilled or semi-sklled labor, takes advantage of local packing materials, permits labelling in local languages and packing in prtet 'ldtso or course-of-therapy packages if this is desired. At the same time the countzy can benefit from low international bulk generic prices

- Production of intravenous fluids: Ths may be feasible both economically and technially, especialy in view of the high cost of shipping the products and the relative abundance of the main raw material-water. The technology is widely available. Often the main problem is the packaging, since imported plastk bags are vely expensive. Problems with quality asurance must not be minimized however, since in this area more than others, quality problems can easily prove fataL
16

- Oral rehydration salts: 'hese can often be produced locally-, again the question of high shipping costs relative to the cost of raw materials and packaging makes it likely to be economically attractive in many African settings

- Formulation of simple preparations such as ointments, creans, syrups, and so on: This can be done locally with semi-skilled staff using widely available technology and possibly some loa raw materials as **welL**

- Bilateral and regional production and quality control: These types of rrangement could be made in many more instances than bi the present ca. More could be done to rationalize the we of existing production capacity. This, however, requires a high degree of political will and cooperation.

- Procurement of raw materials, intermediates, and packing materials: This could be done, by UNICEF or some similar ,rganization, for sale to developing countries. This combined _with_ raw materials price information now available from WHO would most likelr result in significant price reductions for these items, which in some cases, could make existing plants economicaily viabl.

The objective of domestic drug production should be to get good quality, tberpeutically useful **drugs** to the people who noed them at prices they can afford. It should not be to enhance national prestige, or to achieve self-sufficiency, or to generate employment, although all of those things might be desirable. If domestic production can provide good quality, low-price drugs, all to the good. If not, it is probably better to buy drugs abroad as cheaply as possible, package them locally--and choose another sector to lead industrial developmenL

# _Procurement_

Whether there is a local pharmaceutical industry or not, procurement of imported drugs will have to be carried out for at least part of the drug requirements Experience has shown that procurement is the area in which the geatest savings are to be made. A procurement evaluation in Mozambique for the ten drugs on which the most foreign exchange was spent showed that the difference in total acquisition cost represented by the price differentials quoted was more than **$3** million, or 25% of the total annual expenditure on pharmaceuticals (Marzagao and Segall, 1983) Similarly, bulk purchasing of carefully selected essential drugs was estimated to be able to save nearly 40% of the annual drug bill for church health institutions in Kenya-a total of $700,000 in 1985. (Hogerzeil and Moore,
17 1967) In Central America, an Essential Drugs Revolving Fund (FORMED) financed t4e joint purchase of drugs valued at USS1.3 million, which would have oost USS3.8 m at prices previously paid by those countries the average saving was 64% and the range was from 26% (Costa Rica) to 75% (Guatemala). (Anon., 1988a) In the Yemen Arab Republic, an estimated 20.30% could have been saved by improved procurement ant drug quantification. (Van Haperen, 1988) And when six Eastern Caribbean states established the Eastern Caribbean Drug Servis (ECDS), prices of the top 25 pharmaccuticals in the region were reduced by an average of 44%, with reductions for some countries as great as 66%. (Management Sciences for Health, 1988) A carefully designed pocurement strategy can free up very signfflcant funds which can then be applied to the purchase of more drugs. In the discussion which follows, only drugs are considered; however, in a numter of countries non-drug items (dressings, radiological supplies, etc.) take up as much as a third of the total drugs and supplies bill. Special care is also called for in procuring and using these supplies.

In developing a procurement strategy, a quantification of drug needs can be very usefuL A ranking by value will probably show that about 25-30 esential drugs account for half or more of the drugs bilL Therefore, if aperienced procurement staff are scarce, procurement efforts should concentrate on getting the best price possible for these high-value, high-priority items, and in making sure that the quantities are appropriate.

A number of possible procurement methods are available, and most procurement strategies will use a mixture; it is in getting the mixture right that significant savings are possible. Possibilities range from direct purchase of brand name drugs from the manufacturer to international competitive bidding for generic drugs. Decisions must be made regarding the following:

- whether to purchase by brand name or generic name (international non-proprietary name, INN)

- whether to purchase directly from the manufacturer, through competitive tendering (either local or international), or from an international procurement agency

- whether to purchase locally, either from a local importer or a local facory, or to impor.

Each has advantages and disadvantages, which are reviewed below.

# _Brand Name or Generic?_

Generic drugs are significantly less expensive than their brand-name equivalents. Furthermore, quality need not be sacrificed in order to take advantages of these lower prices. A study comparing prices indicated that the brand names were about _5_ times more expensive than the generic
18 equivalents (Szuba, 1964) Simlilarly, a study of the pharmaceutical market in Thailand showed that for 18 commonly-used pharmaceuticals, the average brad name drug was 5.4 tmes more expensive than the generk equValknt; for ampicillin, the range was 175 times more crpenMive, and for reserpine 275 times more expensive. (Sepulveda-Aharez, 1985) Sri Lanka procurement authorities found price ratis of brand name drup to generls of 2.2 for mltremo e, 10.2 for propranoloL and 62 for diazepa (Jayawardene, 1980) Another experiece, from Mali, shows the potential pins from concentrating procurement improvements on high-value, high-priority dru and from buying **generi.** Injetible ampicklin represented about 30% by value of drugs consumed at a large health center, and was widely used througbout MalL The price being paid for a brand name ampicillin wa 23-3 times the international price. As a result, if the procurement strategy could be chanpd for this one drug alone, it would be posble to sav from 15-20% of the drugs budget. (WHO, 1965) A simila Result was found in anoter Aian country, where cOe author estimated that use of generics oDuld sive 30% of the total drug budget. (Yudkin, 1978) _Competive Bidding, Drect Purcuse, Or Purchasing Agency?_ International competitive bidding is often thought of as the most effent and cbeapest way of procuring drugs. For **large** countries, and depending on the volume involved, this is probably cortcL However, orpnizing competitive bidding requires special administrative skills and a knowledge of the international pharmaceuticals market which many of the smaller countries lack and cannot be expected to develop. A solution, especially for smaller amounts of essential, generic drugs, is to use a not-for-profit international procurement agency (UNICEF Supply Division, International Dispensary Association, ECHO, etc.) which does have the specialized skills required, and which uses international competitive bidding for its own purchases. These agencies buy such large quantities of drugs that they obtain very low prices, and their operating margins are very modest. They provide an attracive alternative to international competitive bgddin Their main drawback is that they require payment in foreign **exapnge** eitber upon delivery, or in some cases, upon placement of the order.

Direct purchase from the manufacturer is rarely the most economic type of procurement, and should probably be used only for drugs which are absolutely essential and available from no one ele. LesS than 10% of the drugs on the WHO Model List of Essential Drugs fall into this category. It may be possible to drive prices for brand name drugs down by using
19

**competitt** e tedierng ratber than direct purchase a teater isued by Mall mrulted reductions of about 40% for the same brand name drugs it had been purchasing for year Negotiations are lo poible, and a few of these endtial drug still under patent (paziquantel, for cumple) are avaiable at preferatial prices througn WHO and UNICEF. If a country is doing sigpnifcart amounts of direct purcbase, it **seems** likely that **as** much **_as_** _10-15%_ could be saved.

Specal mention needs to be made of the credit acilities offered by some brand-name manufacturers to verv poor countries with poor repayment rewrds Ths credit is sometimes offered with the bacing of the exporting countrys gvernment and the promise of a buil-out if payment is nver made. This credit is extremely expense, and can add as much **as** 200-300% to the already high prices of brnd-name drus. A number of countriea are **usin** this type of source because they have no choice since no one else will seU to them; but this s rrely eonomicaL Few will ever be able to pay off their accumulated debts to these supplies Countries which are in such **poor** fanim l shape that this is the only type of supplier which they can use neod special istace in getting their finances straightened out and in rtionalizing their drugs policy.

Drg donations and tied supplier credits another set of problems. Doato are often made of usekss drug, or **drugs** near expiration. In lmos all cses they are overalued. In some countries the drug importing agny must pay customs fees (a much as **35%** in some countries) and port hading charge (typically 5-10%) on the declared value of the donations. -l-d credits impose limitations on which products may be purchased and what prices are paid; and prices are often excessve. In one West African ountry which relie heavily on donations and tied credits, donated drugs _and_ the purchaed with tied credits cost up to 9 times the prevailing intemational prices. In addition, in this country, some 40% of tbe drugs budget is transferred to other parts of the government in the form of port fees, bank fees, and customs duties.

# _Local Purchase Or Import_

In some cases, purchase of locally produced drugs from a domestic manufacturing plant can be economically attractive, especially if they compete with foreign manufacturers and win competitive tenders. Some countries alow lal producers a _515%_ price differential in tenders; World Bank tender procedures allow a 15% margin tO local suppliers of most **goods At** price differentials above 15-20%, however, the tradeoff between encouraging loal industry and -eating _15-20%_ **less** patients with a given drugs budget begins to be troublsome. The number of people provided local employment is usually insignificant compared **to** the number of patients denied proper treatment due to higher prices Lol purcha of imported drugs poses a completely different set of problms Price differentials are often significant and represent pnmarily
20 the profit margin of the importer. In some countries, private imponers have better access to foreign exchange than the government drug procurement agency. Failure to allocate foreign exchange, and poor estimation of needs may result in costly local purchases of imported drugs. In LUberia, local purchases accounted for up to 75% of total purchases, and on average, they cost 13% more than imported goods lbe extra cost was estimated at $150,000 over three years on a total drug purchase of about S3,230,000, or about _5%_ of the totaL (MSH, 1984) Similarly, in the Yemen Arab Republic, a review of procurement conduded that localy produced drugs were 2-5 times more expensive than the imported equivalents, but that due to foreign exchange shortages, the government had nevertheless been obliged to purchase loally. (Van Haperen, 1988) In Serra Leone, loal purchases were even more costly. A comparison of local prices with overseas prices for a specific range of drugs revealed that the local purcbas would be 2.3 times the cost of the identical drugs, imported. Some drugs were as much as 10 times more expensive oalyt. Similarly, local purchases of Le 24m could have been bought intaationally for Le 883,500; local purchases result in payment of a premium of 2.8 times the import price. (Africare, 1984) Savings of 5 to 15% ar frequently possible, and depending on the local price levels and the amount of the drugs which are being purchased locally, could be signiffcantly higher and possibly as much as 50-60%.

# _Storage and Dishibution_

Drugs are wasted during storage and distribution in three main ways:

- they deteriorate due to I or storage conditions (excessive heat, moisture, light, etc.)

- they expire due to poor needs estimation or poor inventory control and management

- they 'grow wings' and disappear either through pilferage by employees, theft by outsiders who break in (or simply walk in due to Ix security), or are lost during distribution to lower level facilities.

The typical structure of a drug import and distribution system invohes all drur,; transiting a central warehouse (often called 'Central Medical Stores' e r CMS)from where they are distributed either to regional stores or to depots at regional hospitals. From there, the drugs are typically distnbuted to lower level health facilities. The potential losses are greater at higher points in the system, and highest at the central medical store. If all drugs pass through the CMS, and if osses are significant at this
21 point, then fewr drug are available for distribution to lower levels, whose importance (and responsibility) is correspondingly diminihed. One author esmates that in Cameroon, 35% of the medicines are lost from the central medi:al stores due to poor storage conditions and expiration due to poor inventory controL (Van der Geest, 1982) The importance of a well-managed, efficient, secure Central Medical Store, therefore, can hardly be overstated. The CMS is the place to begin if one wants to have a major impact on the drug supply situation.

Drugs are fragile chemical substances and as such need special care and handling. They must be protected from excessive heat and moisture, and from infestation by insects and other pests. It is surprising how many modical stores have leaking roob, and no ventilation, or are otherwise unsuitable Some countries are forced to store their dcogs outdoors. This state of affairs is aU the more surprising when one considers the value of the drug which are stored at any giVen time; if a country's annual drug. budget is **S5** million, then at any point in time, it is likely that as much as $2.3 million worth of drugs is stored in the central medical stores. Investment in creating proper storage conditions could under some cirumstances repay itself virtually overnight through reduction of waste due to poor storage. Under the worst imaginable conditions, wastage may run to 25% or more.

ses due to expiration of excessive stocks are another matter. The remedies are better inventory control and proper quantification of drug **nees, and** in som. **cse,** removal of a corrupt officiaL The range of potential koses due to expiration is quite significant, with as much as 25.30% having been reported. Ecessive and repeatea losses and write-offs due to cepiration should lead the authorities to look for possible fraud in procurement, specifically, for a pattern of over-ordering of certain drugs, perhaps from the same manufacturer. In such a case the loss is double; first, the country pays much too high a price for the drugp, and secondly, the drum. cannot be used and expire, so the money spent is completely wasted. In a country with a limited drugp budget, this wiUl cause many people to be deprived of needed drugs.

Security problems are difficult to resolve Dmrugs are highly portable, easily concealed in clothing, and they have a high market value. The incentive to steal is great, and where there are no counter-balancing security measures or penalties for infractions, it is not surprising that very high percentages of drug stocks are pilfered. The theoretical upper limit to the losses is 100%-it is possible for all of the drug. to be stolen. More typically, losses from central stores are estimated at 20-25% but it is difficult to get accurate estimates. Losses from lower level health facilities are also geat; estimates have been made that in Cameroon, as much as 3040% is withdrawn for private use by health staff. (Van der Geest, 1982) In Kenya, implementation of the 'kit system" whereby drugs were packed in sealed boxes for distribution to lower level facilities, resulted in a reduction of losses during distribution from an estimated 25% to less than 5%. (Ministry of Health, Kenya, et al, 1984).
22

# _Improving Prescription_

Major savings can be made by improving prescription practices, but progress in this area is slow. Prcribers have strong opinions about drugs which are influenced by their medial training and colleagues, patient expetations, and not lat, the efforts of the pharmcutial industry to encourage them to prescribe newer, more expensive drugs. There are, however, indications that if the prescribers are fully involved in the selection and quantification process, and if they have experienced a situation of helpkuncs due to lack of even basic eenXtl drugs, they are often wiling to change their prescribing behavior.

Ibo potential pitsfrom improved prescribing are enormou. Much of what **ha** been said about secion above appLies to prescription; whereas selection ki done DUectively, by a group of prescnbers who have both the helth of patients and the coUactive health of the community in mind, prescription i selecion of drugs done on an idividual basis by a single prescriber. Yet too often the prescriber fails to take accunt of the ecnomic circumstances of his patient and of the community.

Reducing overprescription may be a major field for potential savings In Mall, for example, a survey found that the average prescription conaia 10 dru; it may include duplication in the form of the same antibiotic under different brand names In most cams the patient in quetion really needs only one or two drugs, and if the average price of al the druo is roughly equivalent (which is not usually the case, but for the **sake** of illustration we will assume it to be so), then a 10.drug prescription represents a potential waste of 80-90%. In fact, however, :be patient seldom recves all 10 drugs since neither the health services nor his own financial situation permit this extravagance.

Experience shows that a realistic figure for savings from improved prescription may be on the order of 60-75%. A study in Ghana in 1980 examined prescriptions at several health centers and found that 96% of visits were treated with at kast one injection, and that an average of 3.9 items was gien on each prescription. When actual prescriptions from a number of health centers were compared with best practice' for the condition as established by the health authorities, the drugs cost would have fallen by 70%. (Barnett, Creese, and Ayivor, 1980) Alternatively, approximately 3 times as many patients could have been treated for the same budget Similarly, in Nigeria, of 299 cases of diarrhea, poor prescription and over of antibiodta resulted in a wastage of N2526, or 97% of the amount spent on treating the cases Similarly, prescription of a brand name antibtic which was three times more expensive than a generic which was also availabk, resulted in an estimated over-cxpenditure of 78%. Despite the fact that 7 of the 11 doctors at the hospital knew that the brand name wa more expenshe, they prescribed it in 77% of cases Curiously, the
23 brand name drug wa judg#d to have been used unnecesarly in 82% of cai, whle the pneric was used unnecsurily in only 13% of cases. (seaumbe and Oviawe, 1988).

Other posible savin would result from the use of fewer injections; not only are Injectible forms signicantly more expensie, they also require the purhae of syringes and needks. Sterilization of injection equipment require fuel and tkes up te of the health staul Inadequate sterilization now carie the added risk of tansmitting AIDS; the costs to the patient and his ful, and to society of a case of AIDS are difficult to calculate at thi pOinL In recogition of the fact that private sector drug sellers are de Ikto preabe of drus a well as seles, there have been a number of initiatve to improve their prescribing sllt In Nepal, a training programme wo provded for the drug sellers and a prescribing manual was producd. IitW ly there wa some resi tance ad suspicion on the part of the drg sllkrs, but eventualy they came to appreciate the progamme and to takes an ative part In Ohana, a contraceptive social marketing project (SOMARC) provided trining for drug sellers in the prescription of contraceptives, induding the oral contraceptive pill, and similarly a manual wu producod Such progrmmes could be a viable way of improving the presripton and use of drugs in Africa However, the question of the ilegalty of these activities might need to be addressed prior to actual mplementation of such programmes Overprescriptionand inappropriate prescription, includingexcessive ue of injectables and antibiotics, can represent a major source of wastage in drg suppliL Efforts to involve prescnbers in drawing up and using standrd treatment shedules can be effective in reducing overprescription, and can save as much as 50-70% of the drugs bilL

# _Patient Infomation and Compliance_

When the patient finally gets his drugs, does he take them as intended by the prescriber? Evidence from industrialized countries shows that complance is, on average, about 50%-only half of patients take drugs as intended. There is reason to expect that the situation is worse in developing countries, given the lack of instructions, low Uteracy, dispensing practices which may involve simply handing the patient some pills without explanaton, and so on. Efforts to improve dispensing practices and provide information to patients regarding dosage, mode of administration, and so on are being undertaken in various countries and although most have yet to be fuly evaluated, it seems that they can make a difference in the way the patieons we their drug. Too often this last link in the chain is forgotten; the prescriber and dispenser breathe a sigb of relief that the drugs have reached the hands of the petient, only to learn that he has thrown them away upon kaving the pharmacy or simply stashed them for another ilness
24 Efforts at building trust between prescriber and patient, and in explaining the use and administration of drugs, and in improving patient information and dispensing prctica, can be useful in improving patient compliance.

The impact of the price of drugs on compliance should not be underestimated. In a study in Nigeria, It was found that when the cost of a prescription was NI-9, it was filed in 83% of mues. But when the cost exceeded N20, tbe rate of filling dropped to 21%. (Isenalumbe and Oviawe, 1988) Table S. Estimated Potential Savings from Rational Drug Use

||Average<br>(Percent)|highest<br>(Percent)|
|---|---|---|
|1. Selection using cost-effectiveness<br>criteria<br>|10|60|
|- Quantification as basis for ordering|15|30|
|3. Procurement:|||
|a) use of generic names<br>|25|30|
|b) use of competitive bidding procedures<br>|10|_15_<br>|
|c) direct import from low-price sources<br>|_5_|_15_|
|4. Storage and distribution:|||
|a) proper storage conditions<br>|10|25|
|b)**good**inventory mgt and low expiration<br>|_15_<br>|20<br>|
|c) reduction of theft and pilferage|20|60|
|5. Rational prescription<br>|_50_|70|
|6. Improved patient xmpliance<br>|20|25|
|Sources: See text|||

# _Sunmary of Potential Savings from Improving Efficiency_

The previous discussion has pointed up possibilities for significant savings in most areas of drug supply management and use. Potential savings from individual rationalization measures (summarized in Table 5) range from 10-60% or more. The biggest gains appear to come from better procurement and better prescribing.

Each sub-optimal decision has a cost, and as drugs flow through the system, poor decisions successively reduce the value of drugs left in the system The most costly decisions are made at the top. A procurement official can make a decision, for example to purchase using brand names, which costs $5 million. A decision made by any one of 5,000 individual prescnibers will have only a limited impact by i,self. Cumulatively, of course,
25 if all prescribers make the same poor dacsior, the effect Ii te same as a poor decision at the top.

## Special Issues in Drug Supply in Africa

# _Geographic Factors_

Comparisons are often made between African countries and such countries as Thailand or India, with the implication that what is feasible in Thailand should be feasible in Africa But the geographical situation of much of Africa is quite different and such factors as land use patterns, the distr.bution of the population, and their income levels clearly have an impact on service delivery and logistics. The average cost per person of providing service rises quickly as more remote areas are reached. (Over, 1986) This is often a particularly strong constraint in African countries where low rainfall and consequently extensive agricultural techniques have produced low population density.

Table 6 shows the differences in population density between several oDuntrie Assuming that 90% of people said to be part of the agricultral work force are livng in areas desinated as agricultural areas (the remaining 10% are asumed to be living on marginal lands not designate:' as agricultural), in Mall, for example, population density wou1d be about 20 **penom** per square kilometer in agricultural areas. In Zambia, it would be 12 Kenya, with 263, is atypical of Africa in many ways and is more like some of the Asian countries, its agriculture is in general more intensive, some of the land is very ferile, with abundant rainfall, and much of the agriculture is on plantations or large cooperatives.

By comparison, i.n many Asian countries, such as Bangladesh, agriculture is highly intensive with very small plots farmed by an individual fanner, perhaps with landless laborers as well, resulting in a high density per square kIlometer even in rural areas. In Bangladesh rural areas have a density of over 720; in Thailand the density in agricultural areas is about 183, and in India and Indonesia, about 270. Clearly the costs per person served
26 Table 6. Population Density in Agricultural Areas in Several Countries

|(a)<br>Total<br>Pop<br>(1986)<br>(millions|(b)<br>(JNP/<br>capita<br>(1986)<br>) (USS)|(c)<br>Pop.<br>density<br>overall<br>(pop/<br>sq km)|(d)<br>Area<br>(000<br>sq Ian)|(e)<br>%<br>urban<br>(1986)|(1)<br>% of<br>land in<br> <br>agric|(g)<br>% of<br>labo, i<br>agric|(h)<br>Density<br>rn agric<br>areas|
|---|---|---|---|---|---|---|---|
|Zambia<br>7|3W|9|75Z|48|S3|73|1Z|
|Mali<br>8|180|6|1240|20|25|86|20|
|Mcxico<br>80|1860|41|1973|69|_50_|37|27|
|Thiland<br>53|810|103|514|18|36|71|183|
|Kenya<br>21|300|36|583|20|10|81|263|
|India<br>781|290|238|3288|25|_55_|70|272|
|Indonesia_166_|490|87|1919|25|16|57|277|
|BangladeshlO3|160|715|144|18|67|75|721|

NB: The assumption made was that 90% of t!le labor force workcing in agricllture lives on the part of the land designated as agricultural, e.g. (a x g x 0.9) - (d x _f)._ Source: Data from World Development Report, 198& are much higher in an area with only 12 persons per square kilometer thanin an area which has nearly 700. An area with high population density Is also more likely to have a well-developed road system and transportation infatructure; tadis, private trucking firms, and other transportation is more often found where a population exists to support these businesses.

The implications of population density for costs of service delivery are significant as well. If for example one wanted to distribute antimalarial drugs to people in agricultural areas, in Bangladesh about 9000 people would be2 found within a radius of two kilometers from a central point (3.14 x 2 km x 721 persons/sq km). In India, Kenya, and Indonesia, one would find about 3200 people; in Thailand, about 2400. But in thinly populated rural Mexico one would find about 300, and in Mali and in Zambia, less than 200. Therefore, to reach 10,000 people with antimalarial drup within a 2 km distance of their home, one would have to establish 45 times as many distribution points in Zambia as in Bangldesh. Delivery costs per person reached would of course be 45 times higher. More likely, one would hold down costs by expecting people to walk a greater distance, for example S or 10 km to the distribution point in less densely populated areas. Tbe success of the intervention would then be highly dependent on the value people place on the intervention, and the time and travel costs they incurred in travelling the extra distance. (Foster, 1987) For Africa, this means that costs of drug supply (and of other services) are significantly higher in rural areas, and many of the models tried
27 in otber pars of the world wW be too costly. The Thai drug banks, for example, require an intensity of supervision and supply which is not feasible in Africa due to the higher costs of transportation. rraining of mothers to use ORS by health educators travelling on foot, as was done _in_ the BRAC projet in Bangladh. would not be feasible in rural Africa Other modes of transporttion need to be envisioned; for example, motorcycles with small trailr might be suitable under certain circumstances Paying individuals to use their private transportation to come to a central point to collect druos may be more wset-effective than maintaining an outward-reaching delivery capability. The cost of collcting money recovered through user charge will be much higher than would be the case in Asia, and might prove prohibitiv Other types of senvice delivewry need to be developed for ural Afica, and the constraint of low population density needs to be taken into account when planning health services in generaL

# _Coun eit d&ugs_

Counterfeit drugs are a growing concern in a number of countries around the world, including several in Africa. A counterfeit (or 'spurious' or' kel) drug is one which is not what it is claimd to be. It may contain too little of the actve ingredient, no active ingredient at aL, or be a differnt drug entirely from what it is purported to be (chloroquine labeled as quinine, etc.) Such products are often imitations of well-known brands, using the same atrade dress', ie. packaging, capsule color, etc.; faking the drug ts advantage of the market share and promotional success of the original drug. In other cases, they are substandard copies of established pwducts, whkh fail to meet the requirements of the established product. The most dangous type of faking, however, is when the drug in question contains substances completely different from what they are purported to be. They may contain starch, baby powder, etc. Another type of faking is the frudulent alteration of expiry dates on expired drugs. (Igboechi, 1988) Typically they are distributed by unregistered drug sellers and through market traders, although registered premises have also been found stocking and dispensing such products, sometimes unwittingly. (Atueyi, 1988) Counterfeit drugs are manufactured in many parts of the world, induding developing Asia and Africa; and there are European sources as welL One investigation agency estimated in 1985 that 'fake drugs are now a billion-dollar industry.' (Hall, 1985) Within a few hours of his arrival in a European city, an investigative reporter was able to establish contact with three companies supplying counterfeit drugs. The sources offered to fll capsules with inactive ingredients to look like the real products; they produced samples and a price list, and stated that they could provide one millon tablets of several drugs within six weeks Prices were approximately one-fi to one-tenth those of the real products A sample which was later analsd was found to contain 232 mg of the active ingredient, not 400 mg as stated on the label; and it took 105 minutes for the tablets to dissolve compared with 15 minutes for the original product, _making_ the product Inefftive (Mahmood, 1987)
28 At the World Health Acisbiy in May 198 a number of countries eressed concern about counterfeit drugs which were circulating on their markets. Tese are primarily drugs which are manufactured clandestinely and marketed with the connivance of unscrpulous retailers*. (WHO, 1988c) In many cases, those involvet in such practices are not breaking any laws in the countries concernd; and it is difficult to bring these practices under the law in view of the international basis of such transactions and the segmentation of operations, whereby a drug might never transit the country to which the money was ultimately sent. It is hoped that the WHO cenifcation schem might improve the situation, which will be kept under review, guidelines are to be developed. (WHO, 1988c) Concern was also expressed by the European Economic Commission, and the Intemnational Chamber of Commerce Pharmaceutical companies whose products have been copied ve undertaken legal proceedings in several countries to put a stop to the practie. (Scrip, July 29, 1985) In Nigeria a number of companies have been blacklisted for the production and distnbution of fake or adulterated drugs and are no longer eligible to supply drugs to any public institution in Nigeria. (Anonymous, 1988c) The measures which can be taken against counterfeiting include improving the legislative framework, increasing quality control inspections, and prosecuting offenders A first step is to make sure that laws exist to enble the prosecution of counterfeiters if they can be caught. Catching them requires reinforced quality control capabilities. But customs officials, quality control inspectors, and police and legal authorities are susceptible to corruption, and the problem is likely to persist for some time. (Atucyi, 1988) Unfortunately an African country is often powerless against counterfeiten operating from another country, and while the local offenders are caught akd punished, their uverseas correspondents are untouchable. A more likely outcome would be that pharmaceutical corupanies whose products are being copied will take measures to halt the traffic in counterfeit drugs which is clearly against their interests.

# _Futancing Essentia Dnugs_

The simple response to the complex problem of shortage of drugs in rural areas has recently been to propose that people in rural areas pay for drugsL In particular, UNICEFs Bamako Iniliative has proposed that MCH services would be financed in rural areas by sale of essential drugs at two or three times the cost price. (Anonymous, 1988b) There are many problems with this proposaL Equity would in all likelihood fall by the wqyside, as services would be priced weil beyond the means of the poorer income groupL A recent epidemic of malaria in Madagascar is reported to have kdlled a large number of people (as many as 100,000 according to some reports) and although there was chloroquine available, it was out of reach of some of the poorest segments of the population. (Anonymous, 1988d)
29 The management implications of cost recovezy schemes are considerable and there is little evidence that they have been studied in the ncesary depth. 'Me schemes would pnerate only loal currency, how would this be converted into foreign **exchange** after the inevitable departure of the external donors? In al lkelihood, the scheme would encourage inappropriate use and overprescription of drugs as availability of funds for MCH and preventive care would be cosely tied to the lvel of drug use. The scheme would do little to improve the efficiency of the drug supply systemi Participants in a WHO workshop on fnancing essential drugs, held in Harre, Zimbabwe in March 1988 came to three main cnclusions. Furst, there was agreement that considerable savings are to be found within the drug supply systemn As has been shown in the dsbcion above, the typical drug supply system has many inefficiencies which can be corrected, with significant savings to be made. The fst step in increaing availability of drugs should be to rationalize procurement and use. Another possiblity is to increase resources for drugs through realocation of health sector expeiditures (WHO, 1988d) A second conclusion was that *cost recovery brought with it hidden costs, both in terms of decreased utilization of health facilities, and in terms of the administrative costs such schemes entailed. Giving drugs away free was much easier than charging for them. Special care would need to be taken to ensure that the fee system did not disourage vulnerable groups most in need **Lif** care, but klat able to pay. Manaement of the funds was a concern; and when the costs of improved accounting, transport and supervion, etc. were taken into account, the ratio of administrative costs to atual funds reuwered w lihkely to be less fvorable in rural area.

The inequity of charging the rural poor while urban dwellers continued to receive free care was of concern as welL A recent World Bank study suggested that a 'modest' fee would be 1% of annual income, which should suffice for two annual visits. (World Bankr, 1987) But the significant inequality of income distribution patterns in many African countries, with income highly concentrated in the upper 10% or 20% of the population, is another cause for concern when setting a fee. Data for nine low-income countries showed that on average, the top quintile had about 52% of incme; the second quintile, 20%; the third quintile, 12%; the fourth quintile, 10%; and the owest quintile, 6% of income. (World Bank, 1985) In Guinea-Bissau, for eanmple, average per capita income was estimated at $170 in 1986; yet if income distribution followed this pattern, the owest income quintile would have an average per capita income of about $50. Roughly half of the population would have kl than $100 per year, and the highest quintile would have about $425. If the World Bank proposal were adopted in setting the fee, the lvel might be set at $1.70 for two visit. Such a fee would represent over 3% of per capita income for the lowest quintile, but only about 0.4% for the highest quintie. Furthermore, per capita income usually counts goods which are not traded (such as home-consumed produce) and thus not cownerted into csh; and
30 lower income groups have only about 25% of their income in actual cash. (P. Gertler, personal communication) rune costs, travel expenses, and lost income are other costs which are often not taken into acunL Each visit for which a theoretical 0.5% of income would be charged, could easily represent a much higher percentage of income when travel costs, lss of a day's wages, and other factors are taken into accounL The statement is often made that 'people are willing to pay for drugs,' the point of reference being what people have paid in the past, and thereby demonstrated themselves willing' to pay. But people often make expenditures on drugs in what are perceived (rightly or wrongly) to be life-or-death situations. Since economic barriers to seeking care are greater for poor people, they may tend to delay seeking cae until the situation really i life.threatening. They may go into debt or seU important posa ions (cale, etc.) to be able to purchase drugs and medical care in an emergency situation. 'Willingness to pay' data, therefore, must be used areflly, with the understanding that the poorer the person, the more likely it is tQat the expenditure recorded reflects an extraordinary situation-and cannot be taken to represent an amount they would be willing (or able) to pay on a regular basis. Special caution must be exercised when using such data to predict revenues from or utilization of routine health services.

Finally, the workshop participants concluded that in view of the very low income levels in much of rural Afia, charging people for drugs would be more useful as a rationing mechanism than as a major source of revenue. It was important to be realistic about the potential of cost recovery, experiec with user fees has shown that in many low-income countries, such fees do not contribute greatly to revenue. Even full cost recovery for drugs has not been possible to achieve in many countries. (WHO, 1988d) The Bamako Initiative, which proposes to recover 2-3 times the base cost of drugs, could disqualify a considerable proportion of the poor inhabitants of rural areas. (Anonymous, 1988b)

# _Impact of the AIDS epidemic on drug supplies_

In countries with a high prevalence of HIV infection, the epidemic represents signfficant additional morbidity and mortality in a group of primarily young adults who were not previously ilL It will make demands onA all health resources including hospital beds, staff cae, and drugs, and will make it difficult to maintain present levels of care for other illnesses. There h already some indication that other non-HIV positive patients are being crowded out of the health care system in some countries. As HIV seropositivity often causes a longer hospital stay, the overall number of admissions may stagnate or decline as occupancy rates reach or surpass 100%. The intensity of care may also increase since only very sick people will be able to be admitted to hospital, and more care wi have to be provided on an outpatient basis; this in turn can be expected to result in an overall higher cost per admission and per bed/day.
31 _Drugs_ have an imporlant role to r'.y in the care of HIV-positive patients at all stage of the disease. Many of the symptoms can be managed adequately and much relief and comfort provided with inexpensive essential drus. As regards specifc needs for drugs and supplies, for the most part they are the same essential drugs provided for primary health care througbout Ahia. In particular, needs are for antibiotia, anti-fungals, antidiarrheal and oral rehydration solutions anti-tuberculosis drugs, analgesi and antiseptics and supplies, particularly gloves The more complex and expensive drugs such r imphotericin B, acydovir, experimental drugs, and some of the anticancer drugs, require diapostic, nursing, laboratory, and management skills which are usually available only at the central teaching hospital leveL As a result, the overall economic impact of the purchase of these drugs may not be overwhelming, prvidig tbey are purchased only in quantities which can be used properly at the appropriate lewis of car. The most significant economic impact is likly to be caused by the more routine essential drugs, which wili be required in large quantitieL In view of the expected numbers of new **patients, special** effort will need to be made to procure them as cheaply as posibl, and distribute them widely. Many sexually active HIV-positive patients are willing to use condoms both as contraceptives and to protect thir partnes Provision of adequate supplies of condoms to those who know they are HIV-positive and are willing to use them should be a very high priority. Condoms were added to the WHO Model List of Essential **Drugs** in December 1987.

Decisions will soon need to be made about what conditions can be cared for at which lewls of the bealth system The fact that many of the mast commonly used drugs for HIV are provided to rural health centers sugets that with the addition of only a few drugs, treatment of some manifestations of HIV could be decentralized to a lower level, provided staff were given guidelines, training, and appropriate quantities of drugs. Management protocols for HIV are urgently needed, to prevent shortages of essential drugs from reducing the quality of care for both HIV-negative and HIV-positive patients alike. They are also needed to prevent the sense of helplessness and frustration on the part of the medical and nursing staff from expressing itself in requests for 'Whigh-tech' solutions to the problem and sophisticated drugs and test kits, or in "burn-out of medical staff. Realistic, feasible treatment guidelines and protocols would do much to reassure staff that they are doing as much as can be expected for their patients. As the epidemic spreads, some consistency of management across hospitals would reduce "shopping" and resultant double counting of cases since management would be approximately the same in most places.

# Conclusions

Shortages of drugs in Africa are caused not only by lack of funds, although in many countries this is the major reason. Poor utilization and **watap** of drug in both public and private sectors are also responsible and
32 ca be improved; and the wtage of available foreip exchange can be reducedL Whie the private _sector bas_ a role to play, it is important to be realistic about Its ability to seon the wbole population and about the qualty of the service it provide. L1a producion of drup, although a superfically attactive solution, needs to be wsed realistially, takdng acunt of ndividual country cicumstc In some uss, rehabilitation of misting factories is a promising avenue. Specific meurm to improve selection, quantification, procureent, storage and distnbution, and prescription and use of drugs have been implemented in a number of Acan countries, resulting in sigifict improvements in the availability of drugs Poliymaken need to realize that tochiques and experience CDst to solve or at kst improve mat of the drug supply probkm in Africa, but that the ieient whkh mak the difference is political will and support Isues for the future in drug supply for Africa, for whib dear aswes do not yet ex.st, indude finding ways to overcome Afica's geographic constraints; taing steps to deal with the problm of counterfeit drug; improving the finacing of essential drugs without discouraging udlition by the groups mast in need; and planning for the provision of drug during the AIDS epidemic. A spirit of opennus and willingness to disu all available options on the part of governments and donors alike will diUitate the search for solutions