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Primary Health Care 3

Declaration of Alma-Ata (1978). Health is a fundamental human right

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Primary Health Care 3

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    1. Primary Health Care (3) Health facilities, essential drugs and laboratories GH 511/Epi 531 Fall 2008 Steve Gloyd

    2. Declaration of Alma-Ata (1978) Health is a fundamental human right & requires inter-sectoral action Existing gross health inequality unacceptable Improved health and peace require economic and social development based on a new international economic order (NIEO) Governments have responsibility to provide adequate health and social measures for health Primary health care is appropriate, accessible, acceptable, affordable and requires community participation (Specifies components of PHC) Governments need the will to formulate and implement PHC policies International cooperation is necessary HFA 2000 requires redirecting resources from military to social expenditures (including health)

    3. “Essential components” of Primary Health Care Health education Environmental sanitation, especially food and water The employment of community or village health workers Maternal and child health programs, including immunization and family planning Prevention of local endemic diseases Appropriate treatment of common diseases and injuries Provision of essential drugs Promotion of nutrition

    5. Condition of health facilities Worse and better than we think (but dynamic and changing) Maintenance is key

    7. Philippines clinic franchises

    8. Drugs & Primary Health Care 1978 Alma-Ata PHC conference sponsored by WHO/UNICEF essential drugs concept adopted as a component of primary health care WHO prepared its first EDL, 224 drugs and vaccines

    9. Why drugs are important Drugs save lives and improve health Drugs promote trust and participation in health services Drugs are costly Drugs are different from other consumer products Substantive improvements are possible

    10. Historical perspective 1897 aspirin 1941 penicillin 1943 chloroquine (malaria) 1944 streptomycin (tuberculosis) 1950s oral contraceptives, anti-diabetics, drugs for mental illness, vaccines

    11. Access to drugs 30-35% lack access worldwide in poor Africa and Asia, 50% lack access More accessibility in cities Shortages in the supply of the right drugs 50-90% drugs in poor countries are paid for out of pocket burden falls heavily on poor

    12. Individual private spending on drugs (as a % of total drug spending)

    13. Cost to Governments 25-50% of national health budgets for drugs many ineffective and expensive drugs in use expensive drugs used

    14. Pharmaceutical spending as % of total health spending is greatest in developing countries

    18. Inappropriate utilization of drugs in poor countries 75% of antibiotics prescribed inappropriately 50% of patients worldwide take medications incorrectly 90% of consumers can only buy 3 days supply or less for antibiotics Modified package inserts and recommendations Drugs with serious side effects (Clioquinol, chloramphenicol) Polypharmacy: toxicity & antimicrobial resistance

    19. Poor quality of drugs Unregulated manufacturers (Italy, local) 10-20% of sampled drugs fail quality control Poor storage (light, cold chain) Expired drugs Street manufacture Counterfeit drugs $75B by 2010

    20. Street sales – ‘cures STI’

    21. Proliferation of brands – little regulation

    22. Aggressive marketing of drugs

    23. Drug Promotion Inadequate education to providers, public Misleading and dubious claims (Squibb-UK cough tonic promoted as a brain tonic in India) Conflicting drug indications (Antihistamine cyproheptadine sold as an appetite suppressant in India and Pakistan) Advertising practices (package inserts) Free drug samples (get providers & patients hooked) Gifts (pens, books, conferences) DTCA (direct to consumer advertising) – legal in USA, NewZealand

    24. Pharmaceutical Representatives 1 drug rep per 6 MDs in USA (~100,000 reps in 2006) 1 per 10 MDs 1n 1995 (38,000 reps), 1/15-20 in 1985 Avg income $81,000; $15,000 per doctor spent In 1990 1/8 Ecuador 1/5 Colombia 1/4 Tanzania 1/3 Guatemala, Mexico, Brazil 1/2.5 Indonesia, Philippines

    25. Third World “Donations” (Dumping) of Pharmaceuticals Dubious “gifts” Genuine gifts clear out stocks of nearly-expired drugs/poor sellers tax write-offs (up to 2x production costs)

    26. Third World “Donations” (Dumping) of Pharmaceuticals Egregious Examples: -Expired Ceclor to Central Africa -Garlic pills and TUMS to Rwanda -50% of donations to Bosnia expired or medically worthless Donation recommendations from WHO: -WHO list of essential drugs -Expiration date at least 1 year away

    27. The rise of the Essential drugs concept “Why not concentrate first on a basic list of reliable drugs to meet the most vital needs’’ Norway - before WWII Papua New Guinea - in 1950’s Sri Lanka - in 1959 Cuba - in 1963 WHO by 1970s

    28. WHO essential drug program 1970-75 Concerns voiced by NGOs, Churches, WHO Halfdan Mahler (1975) “those drugs considered to be of utmost importance and hence basic, indispensable, and necessary for the health needs of the population… should be available at all times, in the proper dosage forms to all segments of society” 1975 WHO Expert advisory committee 1977 First Model Essential Drug List (EDL) – 208 drugs 1997– 306 drugs (166 new, 68 deleted) 2007 – 340 drugs 136/192 countries have adopted EDLs

    29. Additional action Program on Essential Drugs (1977) National drug policies Health economics and drug financing Drug management and supply strategies Rational use of drugs Regulation and quality assurance capacity

    30. National Drug Policy Policy and Legal framework (NDP, Legislation, Production policy, Regulation) Drug management Strategy (selection, procurement, distribution, Rational use) Support systems (organization &management, financing & sustainability, Information resources, human resources)

    31. Rural Hospital in Mozambique Physician in Pharmacy

    32. Rural Hospital Pharmacy - Mozambique

    33. Rural Health Center - Mozambique

    34. Rural health post with one nurse

    35. Botswana Health Center pharmacy

    36. Health post pharmacy in Sudan

    37. Pakistan – Essential drugs for ER

    38. Pakistan public hospital

    39. Bamako Initiative: "Women and Childrens's health through funding and management of esssential Drugs at the community level Mandate: drug charges to recover expenditures 180m for 1989-91 start-up costs for basic equip short term provision of basic drugs support costs (supervision, training, social mobilization) first years proceeds as seed capital second and successive years as replenishment Community health committees planned for 75% of pop

    40. WTO and multilateral trade agreements (mandatory compliance) Trade Related Intellectual Property (TRIPs) Patent protection “harmonized” to 20 yrs Alternatives Compulsory licensing a government can license a manufacturer to produce a patented product without the agreement of the patent holder - as long as the patent holder receives substantial compensation Parallel importing A government can purchase brand name drugs from a third party in another country, rather than from the manufacturer (prices vary in different countries)

    41. Drug regulation status in selected countries

    42. Differences in Amoxil®, by country

    47. Laboratory Capacity Quality varies tremendously at all levels Maintenance Reagent stockouts Qualified Personnel Quality control systems

    48. Varied conditions

    49. Quality control is possible - Mozambique

    50. Donations everywhere

    51. Chem 20

    52. Medical equipment in Rawalpindi, Pakistan

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