Spending dedicated to improving rational drug use is very useful social investment both in terms of health and long-term cost savings. There is urgency in developing and implementing comprehensive strategies in this area, because unless addressed, the problems associated with the improper use of drugs can only increase in scope and negative impact due to growing population figures and the very improvements in affordability and availability which drug polices and health sector reform seek. It is for this reason that the incorporation of interventions to improve rational drug use within a larger national drug policy and within the health sector reform process is essential.

6.3.1 STRATEGIC APPROACHES

Irrational drug use is not limited to one area of the health sector, therefore strategies should be designed to cover both the public and private sectors as well as self-medication and prescribing habits. What requires changing is the knowledge and behavioral patterns of the larger societal matrix comprised of individuals, households, communities, health professionals, educational institutions, and industry.

But because financing for interventions is necessarily limited, priority areas need to be identified and targeted. From a health economics perspective, these areas should be those which are expected to yield largest improvement in social benefit (or reduction of unnecessary social costs) for the money invested. The choices will vary from country to country but some possibilities are:

• interventions which make initial product selection more rational (e.g. widespread diffusion of the essential drugs concept, formulary lists, banning of unsafe drugs, clearly visible generic names on all packaging);

• improved access to and education on drugs which, if not used or used incorrectly used, lead to significant health and lost-work costs;

• focus on drugs which are the most misused;

• improved access to and education on drugs to treat serious communicable diseases;

• focus on those groups in society who use the most drugs;

• focus on people influencing the medication decisions of others (depending on the society, mothers may have a significant role here).

There are several tactics which can be used to improve the rational use of drugs and these are further discussed in Table 11.

Additional information describing in detail methods for quantifying drug needs, training and influencing prescribers, and improving patient education exist ([46], [47], [48], [49], [50], [51], [52]).

Unfortunately there is little information currently available which can provide cost-effectiveness information concerning these interventions. What is known is that it is not simply an issue of evaluating each action on its own because many measures, such as making available formulary lists and therapeutic guidelines, become significantly more useful when they are implemented together with other interventions. Further studies in this area are urgently required.

Table 11: Tactics for Improving Rational Drug Use

Source: adapted from table in [45]

In addition to choosing proper activities, it is vital to make the process of implementing them as smooth and as efficient as possible. Dialogue with and the cooperation of other interested parties such as universities, consumer groups and industry are essential to ensure the complementary nature of activities and to avoid conflicting messages which can result in the nullification of the invested efforts.

6.3.2 MARKETING ACTIVITIES

It is worthwhile to highlight an area of particular interest in the context of increasingly liberalized markets: Promotional activities and controls.

Advertising and other promotional activities are normal components of commercial activity. With increasing liberalization of markets, it is not unusual for efforts by firms to influence the market to increase as well. But because drugs are unlike many other goods, their indiscriminate promotion is not acceptable on ethical grounds and guidelines for marketing practices have been developed [53].

Economic considerations are also relevant. A theoretical debate exists as to whether advertising benefits consumers by making available more information and stimulating competition or whether it reinforces product differentiation and brand loyalties, thereby stifling price competition. Empirical studies seem to indicate that while retail pharmacy advertisements may lead to lower prices, drug firm promotions seem to reinforce brand loyalties [54].

There can be no doubt that the primary goal of promotional activities by firms is to stimulate pharmaceutical consumption by shaping or reshaping the “wants” of the market. However, the line between giving products visibility and promoting overconsumption may be too easily crossed in commercial environments focused on sales and profit objectives. The aggregate of pharmaceutical marketing budgets will usually far exceed what governments can spend publicizing appropriate drug consumption. If promotions for rational drug use are overwhelmed by marketing efforts coaxing both prescribers and patients to overconsume, what kind of value can be obtained by the former?

Branding differentiates products based on both real and perceived differences and makes it difficult to draw useful comparisons for the purposes of rational selection. These and other aspects of pharmaceutical marketing can contribute to irrational drug use [55] and hence to the large social cost burden associated with these practices.

The economic gains accrued through increased pharmaceutical sales stimulated by overzealous or inappropriate marketing practices are overwhelmingly offset by the societal cost of subsequent irrational drug use. Markets cannot ensure that drugs are used appropriately. The state and the consumers themselves must intervene in this area if health sector reform objectives, particularly concerning quality and efficiency, are to be met.

Given the impact on health and the magnitude of the social costs linked to the inappropriate use of drugs, serious reconsideration of policy regarding pharmaceutical marketing practices within a health sector reform process is warranted. The issue is not whether to eliminate promotion altogether, but rather, to determine how governments can best ensure that this does not contribute to irrational drug use so that the goals of the health sector can be attained.

One possibility may be to link loosened government price controls with stricter, well-enforced limits on both the extent and forms of promotion. This would require that advertising restrictions be fairly enforced through transparent processes. It would also imply the availability of adequate resources for monitoring and enforcement. Additionally, unbiased, information pertaining to drugs, including new products, should be made widely available. If these conditions can be met, such an approach presents certain advantages:

• a reduction of incentives to overconsume, leading to lower pharmaceutical expenditures and a reduced social cost burden;

• lower marketing expenses which can be reflected in lower drug prices and can also reduce spending on drugs;

• revenues generated from infraction penalties which can be redirected towards health budgets.

It is worthwhile to consider that marketing restrictions may be preferable to strict price controls for the following reasons:

• Limiting competition based on advertising and perceptions will stimulate competition based on price and facts, whereas the control of prices risks stifling price competition.

• The enforcement of low prices does not necessarily stimulate rational use (or even lower overall expenditures); in fact, the opposite situation may arise.

• Control measures, be they of prices or of marketing, usually affect the entire population. With price control, the objective may be to increase affordability for the poor, but the result is that all people pay less, even those who could well afford to pay more. This situation is not necessarily positive. With marketing restrictions, the comprehensive nature of the benefits is clearly positive.

A policy which establishes transparent and effective limits on promotion and advertising is synergistic with a generics strategy. In many countries, this may not imply the creation of new regulations, but rather better enforcement of what already exists. If implemented together, marketing controls and generics strategies can very effectively achieve a reduction in irrational drug use and its societal costs while stimulating competitive markets.