Gaps in our understanding of public and private roles in the pharmaceutical sector are evident. Governments, international agencies and academics must use existing data (where available) or special research efforts to address the following questions:
• What are the implications of globalization for public and private roles in the pharmaceutical sector? In particular, how will the GATT and TRIPs agreements affect access to drugs in developing countries and what will their health impact be?
• How effective have attempts been to introduce market mechanisms into public drug supply systems? Many such efforts have been made but no considered evaluation of experience has been undertaken to date.
• What are the advantages and disadvantages of different regulatory strategies? Regulatory objectives (improving availability, drug quality and rational drug use) may be pursued through a variety of strategies. Which strategies are better? How does this vary with the size and nature of the private sector and the capacity of government?
• What mix of price competition and price control is best able to make drugs affordable and contain costs? How do governments' regulatory and negotiating capacities affect the implementation of these different instruments? Although some evidence from industrialized countries is available on this topic, the situation and concerns in developing countries are rather different.
• What strategies are appropriate for governments to deal with existing publicly-owned pharmaceutical manufacturing enterprises? In particular, what has been the experience with the divestment of government-owned production plants and contracting-out of their management?
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Box 17. Evaluating evolving public-private roles in Guinea
Until 1984 Guinea's pharmaceutical sector - like most other sectors - was characterized by a state monopoly. When the regime changed, the old structures broke down but there was nothing to replace them. There were virtually no drugs in the country. The Guinean government adopted a two-pronged approach:
• A public primary health care programme was established which involved the rehabilitation of infrastructure, community involvement, cost recovery, preventive programmes, essential drugs, rational drug use and staff training.
• In the private sector, government created substantial profit margins on drugs in order to encourage entrepreneurs to start private pharmacies.
Ten years later the changes are dramatic. Over 80% of subdistricts have functioning health centres. There is a large number of private pharmacies in urban areas, and drugs are available. A 1995 evaluation of the pharmaceutical sector highlighted some successes and continuing problems.
|
|
Public sector |
Private sector |
Parallel market |
Indicator |
|
|
|
Availability of drugs |
|
|
|
% of a selection of essential drugs available at remote health centres |
93% |
n/a |
n/a |
% of a selection of essential drugs available as generics in private pharmacies |
n/a |
33% |
46% |
Affordability of drugs |
|
|
|
Cost of treatment of pneumonia case as % of family food cost for 1 day |
26% |
166% |
29% |
% of drugs prescribed by generic name |
91% |
21% |
37% |
Quality of drugs |
|
|
|
% of drugs failing quality standards |
23% |
19% |
24% |
Rational drug use |
|
|
|
% of prescriptions with injections |
20% |
21% |
34% |
% of patients knowing dosage schedule of drugs received |
86% |
79% |
30% |
• Availability, affordability and rational drug use in the public sector are good.
• Availability and rational drug use in the private sector are good - but affordability is not.
• Due to the limited affordability and geographical inaccessibility of the private sector a large parallel drug market has emerged.
• Availability and affordability in the parallel drug market are good - but rational drug use is not.
• In all three subsectors the quality of drugs is poor.
Challenges ahead
The evaluation highlighted a number of key areas for improvement in the national drug policy. These included:
- encouraging and promoting generics in the private sector;
- strengthening the CMS so as to enable it to buy good quality drugs at competitive prices;
- improving coordination between government departments so as to have stricter control over the importation and sale of drugs.
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