Essenlial Drugs · in Mozambique
lntroducing an essential drugs list is not a simple matter, as Mozambique has learnt. To be effective, it must be backed up by changes in importation and prescribing practices, and also by a major education effort. But the rewards are well worthwhile
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he patients queue at the pharmacy window. Inside, workers take tab- lets from large tins marked only with numbers. They put the pills into neat white paper cones, which are folded, closed and handed to the patient.
Sorne pay a few cents, others nothing.
Each person is given careful instructions as to how to take the medicines. There are no trade names, no fancy packets, and no high charges. All this is in sharp contrast to the position at Independence eight years ago.
Mozambique bas completely trans- formed its health service. Changes in the drugs policy rated a high priority, and today this African republic bas a re- stricted drugs list, bulk importing, and new ptescribing rules. The per capita cost of imported drugs is much the same as it was before independence: US$ 1 per person per year. But the country is getting a lot more for its money, despite inflation. The ten drugs on which the most foreign exchange was spent last year are all basic drugs: aspirin, chloro- quine, antibiotics, tuberculosis drugs, and an anti-schistosomiasis preparation.
Furthermore, for the first time, basic drugs are generally available in rural Mozambique.
Immediately after independence in 1975, the Ministry of Health set up a Pharmaceuticals Commission. In early 1977, even before WHO published its essential drugs list, the Commission is- sued a restricted list with 430 medicines.
A revised list in 1980 eut this total 26
by Joseph Hanlon
to 343. With few exceptions, only pre- scription drugs on this list are imported, whether for sale at private pharmacies or at state pharmacies and through the national health service.
Cost eff ectiveness is . the basis for inclusion in the list, and the accent is placed on basic drugs for the most common treatable illnesses. The Phar- maceuticals Commission meets each week and studies technical journals and research reports to determine efficacy and side effects. Then it looks at price lists. A drug budget of only $1 per person per year means that bard deci- sions have to be taken, and some effec- tive but expensive drugs must be left out. Drugs are listed only by their inter- nationally known generic name. No trade names are used in Mozambique.
Syrups, children's preparations, and suppositories are all five to 30 times more expensive than ordinary tablets. A child's 100 mg aspirin tablet costs more than an adult 500 mg tablet; but it costs far less to eut an adult tablet in quarters and give that to children. So most of these special formulations have been dropped from the list.
Although the formulary was de- veloped before the WHO essential drugs list, both have the same underlying philosophy and many similarities. What differences there are reflect some of the compromises Mozambique bas made.
For example, the list bas three times as many gastro-intestinal drugs as WHO's
list, which "reflects one of our local
preoccupations," as one Commission member explained.
Sorne popular but useless or dubious drugs still remain on the list, such as multivitamins and heparinoid ointment for muscular pains. Professor Carlos Marzagâo, a member of the Commis- sion, argues that a major education effort is required, and that to take these - drugs out of circulation now, even though they are ineffective, would turn people against the new policy: "People will object to the new system and say 'Frelimo ( the Front for the Liberation of Mozambique) won't even let us have vi tamins' . "
They are popular too with the doctors and nurses who do the prescribing. A study made by the Commission in south- ern Mozambique found that 14 per cent of all medicaments prescribed were use- less or doubtful. This is probably a low percentage by world standards, but the Parmaceuticals Commission remains unhappy about it. lt will still be some time before· health workers believe that an ointment of menthol and methyl salicylate, made up cheaply in the local pharmacy, is a serviceable painkiller, while the more expensive imported heparinoid ointmenr in its fancy tube bas no effect on muscle pains.
A pharmacist in Mozambique hands medicines to the patients, and explains in detail how they should take each drug.
Photo J. Hanlon ©
The restricted drugs list was just the start. The next step was to reduce the cost of drugs by bulk buying. A state company, Medimoc, was set up in 1977 to import drugs, and .the remaining pri- vate importers were closed two years la ter. Medimoc buys through open in- ternational tender, normally choosing the lowest bidder. More than 200 com- panies from all over the world offered bids on at least part of the list last year.
As a result, the cost of individual drugs has dropped dramatically, in some instances to one-tenth of their pre- Independence levels.
Dr Aranda Correia, Medimoc's direc- tor, points out that, in colonial Mozam- bique, a number of factors common to other developing countries pushed up drug prices. Buying trade name drugs in small quantities and in fancy small pack- ets is clearly more expensive than buy- ing in bulk, in hospital packs and by generic name. Sorne private importers engaged in "transfer pricing" : drug prices were inflated in collusion with the foreign supplier and part of the differ- ence went into a foreign bank account.
Toda y, the very fact of inviting bids clearly encourages competition. Dr Cor- reia notes that the Portuguese bought only from the capitalist multinational companies, while Mozambique now buys 28
half its drugs from socialist countries at lower prices.
No drugs are actually made in Mozambique, although atone time local manufacture had been seen as a way to eut costs still further. But bulk buy- ing has pushed drug prices lower than was expected, and while many drug companies make finished products, only a small group of multinational companies control the bulk drugs and the fine chemicals that are used in drug manufacture. These companies are increasing their prices, partly in an apparent effort to discourage Third World manufacture.
Essential drugs in large quantities are of little use, however, if health workers do not know how to use them. New health workers, of course, are trained in the new system and do not even know the brand names of drugs. But prescrib- ing is still done by health workers who were trained before . independence. Their prescribing habits are often based only on propaganda from multinational pharmaceutical companies. How are these people to know the rationale be- hind the new system?
To give one example. In colonial times, children with diarrhoea were al- ways given antibiotics. Because of per- suasive advertising, the use of chloram-
Essential Drugs in Mozambique
Left: A young boy is carefuJly watched as he drinks his dose of piperazine. If he wastes it, or spits it our, the problem he is having with round worms will take longer to resolve.
Right: "Lectures" in preventive health use- fully pass the time for patients waiting for their medicines to be dispensed at Machava Health Centre in Mozambique.
Photos J. Hanlon C
phenicol was especially common, even though this drug can have nasty side- effects, including fatal aplastic anemia.
Today the stress is on oral rehydration salts, which are both cheaper and more effective, and children are given antibio- tics only in special cases. But chloram- . phenicol remains on Mozambique's list
(and on WHO's list), because it is the best drug for typhoid. How is a nurse in a rural health post, who was trained in colonial times, to know that now it should be prescribed only for typhoid?
Mozambique's answer is four-fold:
compulsory treatment schemes for cer- tain conditions, prescribing restrictions, recycling courses aimed at health work- ers, and a "therapeutic guide."
National compulsory treatment schemes now exist for malaria, tuber- culosis, leprosy, schistosomiasis, and in- testinal parasites. And only doctors can prescribe from the full drugs list; medi- cal technicians with nine years of school- ing and a three-year medical course have access to half the list; and medical agents with six years of primary school- ing and two years of training can use only one-third of the list.
Doctors are expected to keep a close check on the prescribing habits of health workers below them, who are also given frequent short training courses. Diar-
rhoea treatment has been a special target, because oral rehydration salts were unknown in Mozambique before independence. The effect has been dramatic. A WHO evaluation mission last year found that nearly all health workers use oral rehydration. And in a random survey of households, they found that
"there was a substantial level of com- munity awareness of oral rehydration therapy: 65 per cent of the urban house- holds and 41 per cent of the rural sample were familiar with oral rehydra- tion salts and their use."
The final step was the publication in 1981 of the "therapeutic guide." This lists each drug with indications, dose, contra-indications, and side-effects. Ex- pensive drugs are marked "for excep- tional use only." After each vitamin is a list of foods which can be used instead of a vitamin pill. And it suggests specific treatment schemes for illnesses not covered by compulsory ones.
Obviously it will take a long time to change prescribing habits. The prescrib- ing study showed that eight per cent of prescriptions still contain commercial names for drugs. People still waste time going from pharmacy to pharmacy look- ing for drugs which are not in the formulary, while equal or better alterna- tives are readily available. But there
have been considerable improvements.
For example, the study found that on average .each prescription had only 2.3 drugs, which is well below what is common elsewhere in the world.
Most drugs are distributed through the health service. Prescription charges range from nothing to Medimoc's minimum bulk import price, depending on the drug and the patient's income.
But the health service covers less than half the population,·and will not include everyone until 1995. In an attempt to make basic drugs available to people more rapidly, the Ministry of Health has turned to private shops and chemists to fill the gap. More than 300 shops, main- ly in rural areas, are now licensed to sell over-the-counter drugs, and more are being encouraged to do so.
In urban areas, there are still chemist shops. They fill prescriptions, although at higher prices than hospital and health post pharmacies, and sell over-the- counter medications. They, too, repre- sent one of the compromises necessary during the introduction of an essential drugs policy.
Farmac, the state company which operates half of the chemist shops, is beginning to fill a major gap by mixing children's syrups, salves, cough mixtures and the like, using local bases such as
vaseline, alcohol, and sugar water, at much less than it would cost to import these mixtures.
lt is in the chemist shops that the transformation in drugs policy is clear- est. In the colonial period, there was a prescription law, but it was totally ig- nored. Anyone could buy whatever they wanted without difficulty.
This has steadily changed. Injectables that could only be given in hospitals, as well as narcotic drugs, were removed from the chemist shops. In 1980 the government passed a rigid prescribing law, which covers virtually all medicines.
Mr Joaquim Durâo, director of Farmac·, admits that there has to be a major education effort to explain to people why they can no longer buy whatever drug they want.
The real test of Mozambique's drugs policy, however, is not to be found in city chemist shops. lt is seen in the hundreds of rural health posts at the end of long dusty tracks far out in the bush.
There the WHO evaluation mission found that most health posts do, in fact, have sufficient stocks of basic drugs. But it has taken Mozambique seven years to reach this point. And it was not simply a case of adopting a list. lt required a total transformation in the practices of buy- ing, prescribing, and distributing drugs. • 29
