Private sector prescribing
When I worked as a pharmacist in the public sector I found it relatively easy to promote rational use of drugs through adherence to the essential drugs list, standard treatment guidelines and formularies. However, now employed in the private sector, I find these tools difficult to use because of prescribers’ resistance to what they see as restrictions upon them.
Obviously the forces driving the private sector are unlike those in the public sector. For example, cost containment is not a priority, as the consumer (generally those dissatisfied with the public health care system) pays for services, mainly through some form of health insurance. My question is, in the private sector is it really possible to rationalise medicines’ use and still have a good income? I would be interested to hear readers’ views.
- Dr Atieno Ojoo, P.O. Box 13576, Nairobi, Kenya.
A simple solution to outpatient record keeping?
In developing countries the idea of keeping medical records in hospital offices is impractical, and often impossible to implement. Here in Tanzania’s Dodoma region the Out Patient Service has adopted my suggestion of patients keeping a “health booklet”. The booklet is in fact a primary school exercise book, widely available and priced at around US$ 0.06. As the booklet is the patient’s property, a sense of ownership means it is usually well kept and made available whenever requested.
The system’s advantages are that it can provide a full patient history, particularly useful in cases such as hypertension, diabetes, asthma or allergy. Also data are recorded chronologically, whereas before we often had to sort through numerous pieces of paper and put them in date order. When there is a shortage of hospital cards and files, the booklet can also be used as an in patient file or as a growth chart for the under-fives. As senior doctors can comment on and change previous diagnoses and treatments, the system can help in improving junior colleagues’ skills and prescribing practices.
Lack of supplies and of motivated staff should convince hospital managements to rely more on user commitment, and let patients document their own medical histories.
- Dr Massimo Serventi, Paediatrician,
Dodoma General Hospital, Box 1498,
Substandard chloroquine in Ghana
Countries in tropical Africa account for more than 90% of total malaria incidence and the great majority of malaria deaths, with children the most vulnerable to the disease. Cloroquine is one of the most frequently used drugs in prevention and treatment. But in recent years in some endemic areas certain strains of plasmodium falciparum, one of the parasites responsible for malaria, has become resistant to chloroquine. Among the reasons cited for this is the manufacture, sale and use of substandard chloroquine formulations. In Ghana we have completed an eight-year study to discover the scale of the problem, and it has reinforced concerns about the quality of chloroquine available here.
Thirty-eight samples of chloroquine phosphate tablets and 57 samples of syrups, manufactured locally by different firms, were tested in the Ghana Standards Board’s laboratories between 1992 and 1999. All the samples were analysed according to British Pharmacopoiea assay methods. The Pharmacopoiea’s specification for the content of chloroquine phosphate in tablets ranges between 92.5% and 107% of the label claim. In Ghanaian produced tablets 250 mg of chloroquine is the norm and for syrup the acceptable level is between 118.75 and 131.25 per 5 ml.
Of the 38 tablet samples analysed, four contained levels of chloroquine phosphate below the minimum requirement, with one sample at 38.9%. Of the 57 samples of syrup 10 contained levels of active ingredient below the minimum required.
We conclude that during the eight-year study period some malaria sufferers were exposed to significant amounts of substandard chloroquine phosphate in both tablets and syrups. However, lessons have been learned, and steps taken to improve matters. One local manufacturer had to withdraw affected batches of drugs and had his factory closed until an effective quality assurance scheme was in place. Local manufacturers supplying the Ministry of Health must now have their products tested and certified by the national quality control laboratory. The Food and Drugs Board is implementing measures to assure drug quality in manufacture, supply and distribution. And during 1999 an association of drug manufacturers was formed, pledging to comply with WHO Good Manufacturing Practices.
- Charlotte Ohene-Manu and Jonathan Martey, Ghana Standards Board, Drugs and Cosmetics Department, P.O. Box MB, 245, Accra, Ghana.