THE value of drug donations as a means of galvanising support for developing countries' beleaguered health systems is not in doubt; but neither is the potential for damage. In 1996 WHO published interagency guidelines for drug donations1. Now, in an attempt to increase the number of donors who follow these guidelines, comes further advice, in the form of a step by step guide called Good Drug Donation Practices, born out of a 1999 expert seminar of the Medicines Crossing Borders Project. The Project, which is aided by the European Commission, is run by an International Health Consortium of four organizations - Wemos, a Dutch health and development NGO, DIFÄM from Germany, Prosalus from Spain and ReMed, France. The idea is to inform an increasingly wide spectrum of donors, from medical students and sympathetic tourists to NGOs, pharmacists, church groups and the pharmaceutical industry. Available in English, Dutch, French, German and Spanish, the guide comes in the form of a checklist to ensure the quality of donations once ready for shipment, or to evaluate a donation once made.
Leaflets, flyers, posters and a video, Making Drug Donations better with Care, have been produced to get the message across to NGOs and the public in as many countries as possible. A web site has also been launched: http://www.drugdonations.org
The new initiative is necessary because the desire to do good without first seeking proper advice continues to cause waste, frustration and despair among needy developing countries. The Zambian mission hospital that had to bin a box of amphetamine-based appetite suppressants or the Danish medical students bearing a large box of vitamin A injections for a hospital in Tanzania, which the hospital does not use, are examples.
More serious can be the huge cost of disposing of inappropriate donations according to international standards. Of the donated drugs received in Albania during the Kosovo refugee crisis, it was estimated that 50% were inappropriate or useless and would have to be destroyed. Sixty-five per cent of drugs had an inadequate expiry date and 32% were identified only by brand names, unfamiliar to Albanian health professionals. None of the short shelf-life donations were requested, and according to aid workers they could not be distributed and used quickly enough.
Inappropriate donations can also undermine local efforts to promote rational prescribing and standard national drugs lists based on effective treatment of common diseases. For example, in French-speaking African countries efforts are being made to organize public health centres using essential generic drugs, but the constant flow of donations from collected drugs has upset these sustainable national systems. Significantly the youngest nation in the world, East Timor, already has a national standard drugs list and a procurement policy that prevents inappropriate donations.
Donations may endanger local production of affordable generic drugs based on local needs because they are unable to compete with what is sometimes seen as the "dumping" of free drugs. There are relatively few developing countries that are entirely dependent on imports and donations. Some, such as the Dominican Republic and Pakistan, have industry capable of producing finished products for their domestic market from imported compounds. The example of Eritrea is telling. Frustration at having to wait for donated medicines which, when they arrived were often of little or no use, led the Eritreans to develop their own plant manufacturing the most commonly used medicines. This now forms the basis of its national manufacturing programme.
Of course there are donation success stories, such as the programme for treating onchocerciasis launched in 1987, which claims 25 million people treated in 32 countries by 1998. With no commercial market, the donor company simply announced it would donate its drug to all who needed it. However the onchocerciasis programme enjoyed many favourable factors; the disease is endemic in a limited geographical area, can be eradicated and has a simple treatment protocol. The programme also addressed the main corporate drawback, 'sustainability', by offering the drug for as long as it was needed. These factors do not necessarily apply elsewhere. In other cases there may be questions about the impact on wider national health policies, the ability of public sector services to deal with the programme, and the effect of creating a need that cannot be afforded once the donation stops.
Local campaigning successes include an end to the practice of returned drugs becoming donations in The Netherlands. In Germany, Health Minister, Ulla Schmidt, has strongly recommended implementing a declaration on good donation practice (see below), while Spanish NGO, Farmaceuticos Mundi, has started sending generic medicines to NGOs in developing countries rather than returned drugs.
The Consortium is pressing for a monitoring system to ensure that the Guidelines for Drug Donations are used as intended - as a practical document for sustainable change. It is also calling for donations that do not meet the guidelines to be banned by a decree or resolution from European Union countries.
For further information contact: Wemos, PO Box 1693, NL-1000 BR Amsterdam, The Netherlands. Tel: + 31 20 468 8388, fax: + 31 20 468 6008, e-mail: firstname.lastname@example.org DIFÄM e-mail: email@example.com Prosalus e-mail: firstname.lastname@example.org ReMeD e-mail: email@example.com
Part of a publicity brochure from the NGOs' campaign toimprove donations
1. WHO. Guidelines for drug donations. Geneva: World Health Organization; 1996. Interagency document. (Second edition published 1999).