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No 181

MAKING ACCESS TO ESSENTIALMEDICINES POSSIBLE

2 Editorial

4 Trade in medicines afterWTO/TRIPS: Does itsupport or hinderavailability?

9 Effects of pricing onaccess: What the WHO/HAIpricing surveys tell us.

12 Getting medicines to thepeople

16 Human resources: Theengine that drives it all

19 Balancing profit andservice using franchisemodels

23 Community action toimprove access

26 Bible StudyAccess to medicines: Isthere a vision?

27 Reasources, IntroducingEPN

A publication of the World Council of Churches

October-December2005(printed onNovember 15, 2005)

FeaturesExperiences

2 contact n°181 –Autumn/Winter 2005

It is likely that everyone reading thisknows of the welcome relief that

medicines can provide to relieve aheadache, a toothache or some otherpain that they have suffered from.Furthermore, anyone who has observeda child suffer from the ravages ofmalaria, or seen a non-immunized childcrippled by the effect of polio, orhelplessly watched as the condition ofAIDS patients deteriorate rapidly due tolack of antiretroviral drugs, will attest tothe crucial need to make essentialmedicines available and accessible toall.

In a world that has adequate resourcesto provide for the basic needsof all its inhabitants, it isestimated that over athird of the globalpopulation and overhalf of those living inAfrica and Asia,lack access toessential medicines, aresource that canmake the differenceon the quality of lifeor even betweenlife and death. Whyis this so? Is thereanything that can bedone to address thissituation?

There are no easyanswers to thesequestions. This issue ofContact highlights some of theunderlying causes of lack of access toessential medicines and recounts someexamples of the innovative work beingdone to overcome some of theobstacles.

When considering access to medicines,one must start first with ensuring thatthe drug is available. That means thedrug must be manufactured and

MAKING ACCESS TO ESSENTIALMEDICINES POSSIBLE

formulated in usable form and madeavailable in the market. Pharmaceuticalcompanies invest in research,development, formulation andsubsequent sale of drugs. They make aprofit on their investment through patentswhich confer monopoly to the companyfor some years. At the end of patentperiod, other companies can reproducethe drug making it available in cheapergeneric forms. Dr Srinivasan’s articlelooks at the impact of global tradeagreements on the availability the drugs.He highlights India which had becomeone of the leading countries supplyinggeneric drugs in the world. As Indiachanges its regulations in order to

comply with the WTO rules,the country’s ability to remain

a principal source ofgenerics may be limited.

Pricing and affordabilityalso have huge impacton the accessibility ofdrugs. Preliminaryfindings from pricingsurveys conducted byWHO and HAI showthe impact of the pricingmechanism on the final

cost to the user. Price,overstretched health

systems, lack of financingmechanisms, and inadequate

human resources are some ofthe factors that lead tomedicines being unaffordable tolarge proportions of population.

Unless the drugs are within the reach ofthe people who need them, availabilityand affordable prices will have little or noimpact on access. Drug supply anddistribution are therefore key functionsin addressing access. The article byDonna Kusemererwa highlights thefactors that hinder supply and distributionand suggests what can be done to get it

Cover photo:Treatment of patientsincludes access toessential medicinesCredit:: CHAK

EDITORIAL

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Stacking of shelves withessential medicines

Patients waiting to purchasemedicines at a pharmacy

3contact n°181 –Autumn/Winter 2005

EDITORIAL

right. Commitment to address thelimitations and a willingness to learnfrom each o ther and to p romotebes t practices are crucial for movingforward.

Getting essential medicines to wherethey need to be requires an engine tomove things forward; the engine is anadequately trained and skilled humanresources! Unfortunately, there is aworldwide deficit of skilled professionalstaff within the health care systems.Chipupu Kandeke of Zambia and EvaOmbaka of EPN discuss the problemof human resources which isexperienced by both developed anddeveloping countries. The brain drain ofskilled manpower from developingcountries is one of the main contributivefactors to the human resource deficit inlow-income countries. The solutionrequires a global effort.

However, it is not all gloom. Even inthese difficult circumstances, innovativeand encouraging work is going on,proving that something can be done.The experience of CFWshops in Kenyademonstrates how SHEF hasaddressed the issue of geographicalaccess by establishing franchise modelthat balances profit and service.Alternative models such as theCAREshops in Ghana implementedthrough MSH’s Strategies for EnhancingAccess to Medicine (SEAM) project alsoexist. From Central African Republic, welearn of how communities have takenup the responsibility to provide andsupport primary health care servicesincluding supply of essential medicines.

However, even in these encouragingexperiences we are made aware of thefragility of these efforts in the face ofeconomic or, political hardship and otherexternal forces that are obstacles to thedevelopment and empowerment ofcommunities in their work.

These articles have been written bymembers and friends of theEcumenical Pharmaceutical Network(EPN). These are people on the ground,who, on a daily basis, work and dealwith efforts towards making access to

Eva Ombaka is the coordinator of the EcumenicalPharmaceutical Network (EPN). This is an Internationalorganization with its secretariat in Nairobi, Kenya thatbrings together church-related health services toaddress pharmaceutical issues.

Health personnel sortingout drugsessential medicines possible. They are

motivated and committed to the causeand believe “it can be done”. Althoughmore needs to be done, we hope thatthis issue of Contact will encourageeveryone to play their part in contributingtowards the dream of making it possiblefor every living person to have accessto essential medicines.

CH

AK


Patent as a monopoly deviceA patent is a means for creating amonopoly. Since many popular drugsare developed as a result of discoverythrough a publicly funded researchcentre or university there is somethingakin to claiming too much of propertyrights than justified.1 When these so-called intellectual property rights conflictwith the health of nations, the tragedyand the absurdity are even starker.

TRIPS and WTODebate on the World Trade Organization(WTO), patents and Trade RelatedIntellectual Property Measures (TRIPS)usually reflects on at least three broadpositions:

! WTO/TRIPS are part of a country’sinternational commitments andobligations

" Making the best of a bad bargainthat is WTO/TRIPS using theflexibilities in TRIPS Agreement andthe Doha Declaration.

# The TRIPS and WTO go againstthe fundamental grain of openness,creativity and what is at stake is thesurvival, welfare and developmentof all human beings.

The introduction of TRIPS has been asa result of fear among multi-nationalcompanies (MNCs) that countries likeIndia, Brazil, Argentina and China will selldrugs cheaply and dominate the worldmarket. The sale of quality drugs atlower prices would rob MNCs of theirjustification for pricing branded drugs atvery high prices. Big pharmaceutical

TRADE IN MEDICINES AFTER WTO/TRIPS:DOES IT SUPPORT OR HINDER AVAILABILITY?

companies and governments ofdeveloped countries – chiefly the USA –introduced the notion of intellectualproperty rights to protect the idea of freetrade. Ironically, this has turned out tobe a major trade barrier. (For moreinformation on why this is a trade barrier,see Bhagwati, Jagdish: In defense ofGlobalization, OUP, New Delhi,pp.182ff)

Patents and TRIPS: case of Indiaand its implications for otherimporting countriesMost drugs in India in the pre-1970 erawere expensive. Even the KefauverCommittee of the US Senate hadobserved that the prices of antibioticsand other medicines were the highest inIndia before 1970. About 85 percent ofthe medicines at the time weremanufactured and marketed by MNCs.Given the poor price control at the time,many dugs were expensive even for alower middle class person, let alone a

Trade is a necessary part of a human’s life. One of the great debates of our times is the question ofhow free should trade be in the light of globalization. Does free trade necessarily mean free capital

flows? Does it imply free migration of labour or free exchange of information? Is free trade alwaysfair to the poor? Under a framework of free trade, patents and intellectual property rights are

anomalies which act as hindrances to development.The amendments to India’spatent laws may affect global availability of affordable generic medicines.

Since many populardrugs are developed as

a result of discoverythrough a publicly

funded research centeror university there is

something akin toclaiming too much ofproperty rights than

justified

Medicine is depensed to a patient at a clinic in Dili, India

WC

C

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labourer on low wages. Irrational andunscientific prescription practices,corporatization of health care and poorpublic health services in India, alsomade drugs less accessible for the poorperson. This was indicative of a largercrisis in access to health servicesglobally.

After independence in 1947, thegovernment of India was keen to buildup the pharmaceutical sector. Thegovernment appointed two committeesto examine the 1911 patents act. The1970 patents act was an outcome of therecommendations of these committees.This act was groundbreaking both as amodel for other developing countriesand for helping to unleash a revolutionin the Indian pharmaceutical sector.

The 1970 Act did not allow productpatents for pharmaceuticals, food,insecticides and chemicals. Accordingto the act only processes could bepatented for “substances intended foruse, or capable of being used, as foodor as medicine or drug”.The patents forprocesses were held for a maximum ofseven years.

As a result, the post-1970 period sawan explosion in the manufacture offormulations and active pharmaceuticalingredients (APIs) or bulk drugs. By2003, the Indian pharmaceuticalindustry was supplying 20 percent of theworld’s drugs (by volume). Indiacurrently has one of the largestpharmaceutical industries in the world.At least 60 manufacturing plants in Indiahave US Federal Drug Administration(FDA) approval, second only to theUnited States. In 2004, India’s drugprices were among the lowest in theworld (dollar terms and even inpurchasing power parity terms) withChina as the only country able to offereven lower prices.

When India became a signatory to theWTO/TRIPS Agreement in 1995 it wasgiven a 10-year transition period tocomply with WTO requirements. Theperiod came to an end on 1st January2005. In order to comply with therequirements, the Indian government

amended 1970 patents act in 1994 byan ordinance (which subsequentlylapsed); then a bill introduced in 1999and revised and passed in 2002; andfinally a third amendment was madethrough a presidential ordinance on 26thDecember 2004. The last ordinance hadto be ratified by Parliament within sixmonths for it to become an act. TheGovernment of India subsequentlypassed the patents amendment bill inMarch 2005 with the President giving hisassent in April 2005. The April 2005 billtried to address some of the criticismsagainst the December 2004 ordinancefrom health activists and people-oriented groups.

Reversing the gains of the 1970 act?Some of the major issues emergingfrom the recent amendments made to

The effect of India’s new bill on global availability ofgenerics

India is recognized globally as a country that provides genericbrands of medicines at an affordable cost. This is mainly due tothe 1970 patents act which allowed Indian manufacturers to legallyproduce generic versions of medicines patented in othercountries. In 2004, India’s drug prices were among the lowest inthe world. This has ensured that poor countries have access toquality, affordable medicines.

However, this situation could change due to the amendment ofthe 1970 patents act. The amendment gives MNCs monopolyon the drugs and medicines they develop for a minimum of 20years making the medicines expensive and therefore notaccessible to the poor. The situation could revert to what it wasprior to the enactment of the act with the odds balanced heavilyin favour of multinational companies and against developingcountries.

Unless measures are taken to bring down the cost of life-savingdrugs, those to bear the brunt of this amendment are many poorcountries that depend on India as a source of medicines. Themost affected area will be HIV/AIDS since fifty percent of low-cost generic ARV drugs are manufactured in India.

Over the last several years, the production of affordable qualityARV drugs has seen an estimated 700,000 people in developingcountries get access to treatment in developing countries.Although this number is below the intended target, it is a stepforward in curbing the deadly effects of HIV/AIDS on the globalpopulation. It is imperative that India allows the continuedproduction and export of generic versions of new medicines sothat this progress is not negated.

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India’s 1970 patents act with respect tomedicines include:

! Protection for product patents ondrugs introduced for a period of 20years.

" Mailbox facility for product patentapplications introduced withprovision of Exclusive MarketingRights (EMRs) in the periodbetween 1st January 1995 to 1stJanuary 2005. One of the biggestconcerns after passing theordinance was that drugsproduced by Indian companies forwhich patent applications werepending in the mailbox would gooff the market once the patentswere granted. It was also fearedthat MNCs would use their patentmonopoly to hike up the prices ofdrugs. Fortunately the March 2005amendments clarifies that there isno question of patent violation ofdrugs already in the public domainduring this 10-year period.

# Compulsory license procedurescan override product patents butthe procedures for applying forthese licenses are cumbersomeand difficult even after the March2005 amendments. Compulsorylicense procedures would havebeen automatic in cases ofdiseases like AIDS and drugs formajor problems like malaria, TB,diabetes, and for vaccines. TheIndian law provides a number ofgrounds for the granting of suchlicenses such as high prices, non-availability and promotioncommercial activity. For thecompulsory licensing system to beeffective, procedures for grantingsuch licenses need to be simpleand effective.

$ An earlier December 2004ordinance required that to exporta patented product to LeastDeveloped Countries (LDC), onewould need to have a compulsorylicense in India as well as in theimporting country. However itwould have been difficult for a

country with weak patent regulationand no requirements to give patentprotection till 2016 to avail acompulsory license to an Indianexporter. This clause had attractedwidespread criticism, as manydeveloping countries would havebeen unable to import medicinesfrom India if retained. The March2005 amendments now clarifiesthat an LDC can import from Indiaif “by notification or otherwiseallowed importation of the patentedpharmaceutical product fromIndia.”

% “Inventive step”, “novelty” and“product” were less clearly definedin the earlier amendments leadingto fear of evergreening of patents.Evergreening is the perpetuation ofpatents monopoly beyond thestipulated 20 years by repeatedpatent grants based on smallchanges made to the originalmolecules.

The March 2005 amendments tothe Ordinance have now restrictedthe scope for the granting of patentson frivolous claims. It clarifies thatan “inventive step” means a featureof an invention that “involvestechnical advances as comparedto the existing knowledge or havingeconomic significance or both.”The amendments contain a newdefinition for “new invention” in orderto strengthen the provision ofdenying patents on frivolous claimsand on the new use of a knownsubstance.

To minimize evergreening, theamendments clarify that “the merediscovery of a new form of a knownsubstance which does not result in theenhancement of the known efficacy” isnot patentable. Further explanations arethat “salts, esters, ethers, polymorphs,metabolites, pure form, particle size,isomers, mixtures of isopmers,complexes, combinations and otherderivations of known substances shallbe considered to be the same substance,unless the differ significantly in propertieswith regard to efficacy.”

Compulsory licenseprocedures could have

been automatic in casesof diseases like AIDS and

drugs for majorproblems like malaria,TB, diabetes, and for

vaccines

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In summary: According to India’samended patents law, medicinespatented before 1st January 1995,irrespective of the date of launch byIndian companies, can be freelymarketed without any arrangement withthe innovator company irrespective ofthe expiry date of the patent.

Drugs patented subsequently up to 1stJanuary 2005 when the new patent lawcame into force, can be launched bymanufacturers in India with approvalfrom the innovators only. If the drug hasalready been launched prior to 1stJanuary 2005, the Indian manufactureris required to make arrangements withthe patent holder for continuedmanufacture and marketing.

However no compensation can beclaimed by the patent holder for thepreceding period when the drug wasbeing manufactured and sold withoutconsent of the patent holder. What isimportant in Indian law is not the date oflaunch of a medicine or the expiry dateof the molecule but the effective date ofstart of patent2.

Not taking Doha Agreement to thefullest and other issuesThe Doha Agreement has clarifiedTRIPS flexibilities and clearly states thata country’s public health needs to begiven primacy above all. Unfortunatelythis interpretation has not been usedeither in the provisions of the recentamendments of India’s Patents Actregarding more liberal grounds forcompulsory license or for defining whatdrugs can and cannot be patented. Theamendments to the1970 Act could havestated that drugs of a certain therapeuticclass important for certain crucialdisease situations prevalent in India arenot patentable.

The amendments are not clear onwhether the patent holder needs tomanufacture the drug within India asproof of having worked on the patent.However, as no compulsory license canbe granted under the amendedprovisions for the first three years, thegovernment of India cannot control theprice of newly patented drugs as it would

need data of costs of manufacture.Pending knowledge of these, the landedcost will have to be accepted as the costof the drug over which a margin of 50percent is allowed. Patenting newessential drugs without an automaticprocedure for compulsory license incase of overpricing, supplemented byIndia’s ineffective price control regime,is guaranteed to make the situationworse.

The Indian government needed toamend only section 5 of the 1970spatents act to provide for productpatents; instead there are more than 70amendments. India has not thought it fitto use the flexibilities afforded by TRIPSAgreement and the 2001 DohaDeclaration. Primacy has been given toconcerns of MNCs than the needs of thepeople of India. India is now a majorsource of good quality, low-priced APIs

According to India’samended patents law,medicines patentedbefore 1st January 1995,irrespective of the date oflaunch by Indiancompanies, can be freelymarketed withoutany arrangement withthe innovator companyirrespective of the expirydate of the patent

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Branded antiretroviral drugs at the Coptic Hospital in Nairobi, Kenya


and formulations for many third worldcountries. This position will be affectedespecially with respect to new drugs,which would enjoy a patent protectionof 20 years, unless the Government ofIndia issues a compulsory license in theinterest of public health.

The March 2005 amendments to India’spatent laws have restricted the ability ofIndia to produce generic copies of newdrugs that will be granted patents in Indiaafter January 1, 2005. However,according to WHO sources, 90 percentof the medicines on the Essential DrugList are out of patent and thereforeLDCs can still import medicines fromIndia. This overrides existing patentsobligations to innovator companies until2016 after which they can invoke theprinciple of parallel imports, if they havenot signed Free Trade Agreements(FTAs).

TRIPS Plus, Free TradeAgreementsMany developing countries, includingKenya, Malawi and India, have enactedstronger laws than the minimumrequired by TRIPS. Many developingcountries have signed free tradeagreements with the US and/or the EUwhich has given pharmaceutical majorsan advantage through these bilateralfree trade agreements.

Presently 13 countries have signed freetrade agreements with the USA and 47others have begun, or are due to begin,negotiations on trade agreements,which are likely to contain TRIPS plusprovisions.

Business and research: no end inthemselvesBusiness, trade and discovery is foroverall human development, and not theother way around. Unfortunately theTRIPS/WTO thinking endorses thelatter. To leave it to market forces to finda cure for AIDS or drug resistant TB isbeing too callous about our collectivefate. A new paradigm for funding anddoing research for public purposes isrequired.3

There have been discussions on non-patent led drug discovery withsuggestions including:

! Government funded drug research(such as the CSIR in India and NIHin the US);

! Public-private partnerships driven bythe needs and disease profile of acountry;

! What could be classified as ‘opensource’ biotechnology Research andDevelopment;

! The idea of a patent pool whereindividuals and groups develop drugsand put it in the public domain for areasonable remuneration;

! The proposed global biomedicalR&D treaty which would permit eachcountry to adopt its own form ofR&D.

Other important strategies would includeSouth-South technology transfer andtrade collaboration in the matter ofresearch, production and availability ofmedicines. It is also important to resistthe tendency of professionals in WHOand international bodies to go overboardand mystify technology of drugproduction and formulations toharmonize standards. Such tendenciesserve as trade and production barrierseven as the need of the hour isdemystification of productiontechnologies of pharmaceuticals.

Dr S. Srinivasan has been associated with LOCOST(Low Cost Standard Therapeutics), Baroda, India.LOCOST (www.locostindia.com) has been makingquality essential generic medicines which it marketsat low prices for the NGO sector since 1983. Theauthor ([email protected]) and LOCOST have beeninvolved in India, with policy issues of pricing,availability and rationality of drugs nationally.

To leave it to marketforces to find a cure forAIDS or drug resistantTB is being too callous

about our collective fate

References:1 See for instance: The Truth About the Drug Companies: How they

deceive us and what to do about it. Marcia Angell. Random House,2004.

2 Dr Gulhati, Editor, MIMS India (Monthly Index of Medical Specialties.3 For one suggested model see: <http://www.cptech.org/ip/health/rndtf/>

or <http://www.cptech.org/workingdrafts/24feb05WHOen.pdf>

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A ccording to the World HealthOrganization (WHO), there are four

key factors affecting access to essentialmedicines namely: rational selectionand use of medicines, affordable prices,sustainable financing, and reliablehealth and supply systems.

There is limited knowledge about theprices of medicines, or how these pricesare set between the manufacturers’selling price and the price that thepatient pays. Reliable information andprice transparency are needed toensure that favourable purchasingagreements are negotiated and relevantpolicies introduced.

To tackle the challenges of availabilityand affordability of medicines, WHO andHealth Action International (HAI)conducted pricing surveys in severalcountries. So far pricing surveys havebeen carried out in around 40 countriesglobally, including 12 sub-SaharanAfrican countries3.

The surveys sought to answer thefollowing questions:

! What prices do people pay for keymedicines?

! Do the prices and availability of thesame medicines vary in differentsectors?

! Do the prices and availability of thesame medicines vary in differentsectors in a country and acrosscountries?

! What is the difference in prices ofbranded and generic equivalentmedicines?

! How do procurement prices comparewith international prices and with localretail prices?

! What taxes and duties are levied onmedicines and what is the level of thevarious mark-ups which contribute toretail prices?

! How affordable are medicines for thepublic?

EFFECTS OF PRICING ON ACCESSWHAT THE WHO/HAI MEDICINES PRICING SURVEYS TELL US

Around half of the population in poorly developed areas of Africa and Asialacks access to essential medicines. The poorest people often pay thegreatest out-of-pocket expenses for medicines. The World HealthOrganization (WHO) and a number of non governmental and civilsociety organizations that support countries in their efforts to improve accessto health care, have drawn attention to the unacceptably low numbers ofpeople who are able to access essential medicines. They point tounaffordable prices, overstretched health systems, and lack of financingmechanisms and human resources to manage pharmaceuticals as the major factors contributing to limited access to essential medicines1,2.

The processThe surveys in the 12 African countriesinvolved multi-stakeholder participationby all the Ministries of Health, as well asWHO and in several countries CivilSociety Organizations – including theGhana Catholic Health Service, theKenyan branch of the InternationalNetwork for Rational Use of Drugs

There is limitedknowledge about theprices of medicines or how these pricesare set

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(INRUD) and Health Promotion andSocial Development (HEPS) in Uganda– played a key role in the work, throughthe HAI Africa network.

WHO and HAI Africa are involved indeveloping follow-up recommendationsand in contributing to analysis at country,regional and global level. This coherencehas been possible because the pricingsurveys are part of a wider collaborativeprogramme between WHO and HAIAfrica. The collaboration programmeaims at facilitating improved access tomedicines in Africa and is funded by theUnited Kingdom Department forInternational Development (DFID). DFIDalso co-funded the global dimension ofthe pricing survey that has includeddevelopment of the methodology.

The collaboration has enabled WHO toappoint National Professional Officers(NPOs) in 14 countries in Africa, as ofJuly 2005. The NPOs are pharma-ceutical specialists whose work is tosupport Ministries of Health on a widerange of medicines’ access, safety andrational use issues, defined in the WHO(2004-2007) medicines strategy.

Summary of findings from eightAfrican countriesPreliminary findings of the pricingsurveys conducted in Ethiopia, Ghana,Kenya, Nigeria, South Africa, Tanzania,Uganda and Zimbabwe in 2005 are asfollows:

Public sector procurement prices:Overall, fair prices were observed inpublic sector procurement; howeverthere was generally poor availability in thepublic facilities. Five countries reportedtheir procurement prices as being lessthan the international reference price(MSH 2003) (n=6 countries).

Private sector prices: Medicine priceswere considerably higher in the privatesector. The median patient prices for thelowest price generic were twice as highwhen bought from dispensing doctors ascompared to private pharmacies (n=2countries).

Prices of branded and genericmedicines: Prices of originator brandswere considerably higher than the pricesof their lowest priced genericequivalents. In private pharmacies,branded medicines were found to be onaverage four times more expensive thanthe lowest priced generic equivalent.This however varied from around twiceto almost seven times betweencountries (n=8 countries).

Variations in prices within andbetween countries: There was a lackof consistency in the pricing ofmedicines within countries as well aslarge price variations for the same brandor generic entity within and betweensectors. In some countries, there weresignificant variations in medicine pricebetween public sector facilities. In onecountry prices varied, on average, bythree times for the same branded orgeneric entity within the same sector –for quite a number of items this variationwas greater than ten times. There werelarge variations in prices betweencountries for the same medicine; theprice of branded medicines varied onaverage by 220% between countries,and by 217% for the lowest pricedgeneric available (n=8 countries).

Affordability: Medicines were generallyunaffordable for a large proportion of thepopulation – particularly for chronicdiseases.

Figure 1 illustrates the affordability ofmedicines for a family across sixcountries. In the family, there is an

The overall purpose of

the WHO/HAI

medicines pricing survey

methodology is to

systematically collect data

and analyze affordability

of medicines, price

differences within

countries, and pricing

structure - including retail

prices to the consumer

MS

H

A patient receives treatment ata rural treatment centre

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asthmatic child with a respiratoryinfection, an adult with diabetes and anadult with a peptic ulcer.

In country “D”, a lowest paidgovernment worker would need to work107 days or 17.3 days for branded orgeneric medicines respectively to payfor a month’s treatment and the courseof antibiotics. In five of the six countries,it would take an average five or moredays salary to pay for the medicines.

It should be noted that many families’incomes are lower than that of thelowest paid government worker andhence these medicines are probablyunaffordable to the majority of thepopulation. The level of implementingpractices of generic prescribing anddispensing therefore has a major impacton the proportion of income thatpatients have to pay for their medicines.

The out-of-pocket affordability of malariatreatments is critical in malaria endemiccountries. The affordability of a courseof sulphadoxine-pyrimethamine tabletswas found to be as little as 0.1 days andas much as 1.3 days salary for thelowest paid government workerdepending on whether branded orgeneric medicine were purchased. Thevariation between countries inaffordability was 820% for the brandedand 1400% for the available lowestpriced generic.

For most sections of the population,there is often a trade-off between, food,housing, and children’s education, or thepurchase of essential medicines.

References:1 Pharmaceutical Sector Surveys carried out in 11 African countries by

Ministries of Health in collaboration with WHO, and in somecountries HAI-Africa partners, between 2001 and 2003

2 Task Force on HIV/AIDS, Malaria, TB, and Access to EssentialMedicines, Working Group on Access to Essential Medicineshttp://ww.unmillenniumproject.org/reports/tf_essentialmedecines.htm

3 Chad, Cameroon, Ethiopia, Ghana, Kenya, Mali, Nigeria, Senegal,South Africa, Tanzania, Uganda, Zimbabwe

Martin Auton is a consultant working for both WHOand Health Action International on Medicines PricesSurveys in Africa

Abayneh T. Desta is a Technical Officer in EssentialDrugs and Medicines Policy unit of the WHO RegionalOffice for Africa.

Gilles Forte is Team Coordinator in the Departmentfor Technical Cooperation on Essential Drugs andTraditional Medicine, WHO Geneva & ResponsibleOfficer for the WHO-HAI Africa Collaboration Project

Patrick Mubangizi is the coordinator of HAI Africanetwork based in Nairobi and the responsible officerfor HAI Africa on the WHO-HAI Africa collaborationproject. Until June 2005, he was the survey managerfor Uganda medicine prices survey.

Philippa Saunders is the consultant responsiblefor support to the WHO/HAI Africa CollaborationProgramme, working on behalf of DFID.

Next stepsThe strategic approaches identified atcountry level that need to be addressed tomake medicine prices more accessible andaffordable are: improving availability in thepublic sector; improving availability andappropriate use of generic medicinesincluding generic substitution; providingreliable price information; continuousmonitoring of procurement and retailprices; improving efficiency of supplyand distribution systems; regulatingmark-ups, and removing import taxesand levies on essential medicines.

Having identified these areas in need ofimprovement, Ministries of Health canbegin to work with WHO, HAI Africa, andHAI Africa partners on the steps thatneed to be taken at regional and at globallevel in order to make medicines moreaccessible and affordable.

For most sections of thepopulation, there is oftena trade-off between,food, housing, andchildren’s education, orthe purchase ofessential medicines

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6.61.1 8.6 4.9

17.3

107

6.9

24.88.7

71

0

20

40

60

80

100

120

Number of days for lowest paid government worker to buy medicine

for 1 month

A B C D E F

Country

AFFORDABILITY FOR ILLUSTRATIVE FAMILY1

Low est Priced Generic Innovator brand

This example family has the following requirements every month1

- 1 salbutamol inhaler for a child with asthma- 70 ml cotrimoxazole suspension for a child with a respiratory tract infection- 60 glibeoclamide tablets 5mg for an adult with diabetes- 60 ranitidine tablets 150mg for 1 adult with peptic ulcer

A patient purchases medicinesat the Mulanje Hospital Pharmacyin Malawi

Figure 1


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To determine whether or not a groupof people have access to medicines

one has to consider how readily they canavail themselves with the most basicessential medicines. This evaluationhas to take into account cost, physicalproximity to the source of the medicinesand presence of the medicines at thetime they are needed. Other factorssuch as the effectiveness and quality ofthe medicines as well as the informationrequired to use the medicines properlyshould also be taken into account for amore comprehensive appreciation ofaccess.

For populations with low levels of literacyand limited access to information thesituation may be even worse since thereis a general conviction that every ailmenthas a corresponding capsule, tablet, orinjection for its resolution. In such casespeople’s perception of the effectivenessof the health system depends largely onthe availability of medicines. Any effortto strengthen health care deliverytherefore must take into account theissue of improving access to medicines.

Unfortunately it is estimated that nearlyone third of the world’s population haveno access to the medicines that theycritically need for a decent quality of life.The worst affected are the poor in Africaand India. Sadly, this situation exists andpersists even though it is known that ifthe world’s resources were harnessedin the right way it would be possible toprovide the entire global population withat least the basic essential medicines.

Supply systemsAccess to essential medicines dependson a nucleus of key factors includingrational selection, affordable pricing,sustainable financing and reliable supplysystems. A medicine supply system,encompasses the procurementcomponent, warehousing and logistics

GETTING MEDICINES TO THE PEOPLE

management, the transportation, andhuman resources throughout the wholesupply chain. Any good medicine supplysystem should aim at ensuringcontinuous availability of good quality, lowcost, essential drugs with limited stock-outs and low service delivery costs.

Supply systems serving governmenthealth facilities are often based on oneof five approaches: a government ownedcentral medical store, an autonomoussupply agency, a direct delivery system,a prime vendor system or a fully privatesupply system.

The supply systems in developingcountries are varied but in manycountries are said to be ‘inefficient andpoorly attuned to current needs. Even ina country like Namibia, which by Africanstandards spends a significant amountper capita on health, the public drugsupply system is inefficient. Although theNamibian government is often able to getsupplies to facility level, lack of personneland poor inventory management amongothers mean the system is not reliable.

The absence of an effective governmentsupply system often means a lot of otherplayers have to come in to fill the gapscreating, in some cases a complexmultifaceted medicine supply system. InUganda, for example, there is agovernment supply system that primarilyserves government facilities, a churchowned store that supplies mainly Faith-Based Organisations (FBO’s) and NonGovernmental Organizations (NGOs),as well as a lot of privately ownedwholesalers and distributors who targetwhoever is willing and able to buy theirproducts. However, none of thesechannels of supply are exclusive andthere is a lot of overlap (see figure 1).

Despite the fact that there are so manylargely independent players in thesystem on many occasions one finds

Without continuous availability of good quality medicines and medical supplies it is not possible forany health system to provide appropriate care for the people it serves. The existence of a

reliable drug supply systems is one of the essential elements for access to medicines.

Effective distributiondepends on good

communication, costcontainement and a welldesigned, well managed

system.


FEATURE

that suddenly an important medicinecannot be availed in adequate quantitiesfrom any of the major suppliers.

Responsiveness of supply systems

Responsiveness of supply systems inpoor countries is rather limited in thesense that they are not able to keep upwith the changes in the dynamics of thepopulation with respect to numbers,morbidity patterns, population move-ments and demographic profiles.Furthermore, because of inadequatefunds available for health in general andmedicines, in particular the supplysystems often focus on only providingmedicines for which there are sufficientnumbers within the population to makeit economically justifiable. This meansthat medicines for rare conditions arehardly ever availed, or if they are, thenonly for those who can afford to pay.

One of the critical inputs for a supplysystem is a clear and timely indicationof what you need to supply. Havingadopted the Essential Drugs Conceptpromoted by WHO, many countrieshave Essential Drug Lists that aresupposed to provide the basis fornational procurement of medicines.However, Essential Drugs Lists are notupdated frequently enough to keep upwith the product development andchanges in morbidity patterns.

Another problem that plagues supplysystems in developing countries is

corruption. At the procurement level,flawed processes lead to misappro-priation of resources, purchase ofsubstandard products or even completefailure to avail much needed products.

Good procurement procedures areimportant for access. Poorly executedprocurement leads to drug shortages,poor quality products and high prices.In most developing countries there aremany players involved in procurementincluding government drug supplyagencies, NGOs, donor agenciesindividuals as well as private providers.This complex mix can lead to wastageand inefficiency. In addition, drugleakages at various levels in the nationalsupply chain are common and greatlycompromise the quality of care providedby the system.

The development of reliable andeffective supply systems is furtherhampered by the lack of adequatehuman resources. There are notenough people with the skills andknowledge that are needed to movethe r ight medicines in the r ightquantities at the right time to thepeople who need them the most.

Various strategies have been tried outin different situations to try and ensureeffective and efficient supply ofmedicines. In El Salvador, a singlecommercial wholesaler was contractedto take care of the country’s supplysystem after tenders were awarded bythe Government. The vendor isresponsible for managing purchaseorders, storage and distribution. Thismodel was developed to increaseeffectiveness and efficiency in inventorymanagement of which cost-savingswould be translated into broadercoverage to reach the poor and ruralsegments of the population.

DistributionFor players in the medicine supplysystems in poor countries, gettingmedicines and supplies out to wherethey are needed is an unendingchallenge. Poor road infrastructure,even poorer communication, vastdistances and insecurity are among themany factors that have to be taken into

There just are notenough people with theskills and knowledge thatare needed to move theright medicines in theright quantities at theright time to the peoplewho need themthe most


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account. While it is often possible toget supplies into the urban centres,supply to rural and remote areas is oftenhaphazard and unreliable. The fact thatpeople in these areas are on the wholeoften too poor to support commercialmedicine supply enterprises means thateven in the cases where people couldpay for their medicines the medicinesare just not available. Effective distributiondepends on good communication, costcontainment and a well designed, wellmanaged system.

An international perspectiveIn 1999 it was estimated that NGOsdistributed 20% of the global supply ofmedicines. The World HealthOrganization (WHO) has been workingon mechanisms to collaborate withNGOs in medicine supply anddistribution since the early 1990’s.WHO found themselves in a uniqueposition where they could link with orto Ministries of Health, NGOs andNational Drug Programmes, links whichproved beneficial in furthering the workof improving access to medicines.

The 3 x 5 initiative of WHO has ensuring’an effective and reliable supply ofmedicines and diagnostics’ as one of itsareas of focus. In this regard, the GlobalAIDS Medicines and Diagnostic Servicewas set up to ensure that poor countrieshave access to quality medicines and

diagnostic tools at the best prices. Theservice was intended to help countriesmanage and supply products for thetreatment and follow-up of those who areundergoing care. The WHO pre-qualification scheme takes theresponsibility for evaluating medicines,manufacturers, laboratories, procurementagencies and making sure that theycomply with international quality safetyand efficacy standards.

The usefulness of collaboration in supplyand distribution is demonstrated in theprogramme set up by the pharmaceuticalcompany Merck for the donation ofMectizan® (Ivermectin) to help patientssuffering from river blindness. Thesuccess of this global donationprogramme is attributed in part to theevolution of a reliable and effectivedistribution system. The programme,which was set up in 1988, has benefitedpoor patients in over 30 countries. Theprogramme was built on the premise ofenabling communities to manage theirown distribution system for themedicines needed to control anderadicate a disease that was causing illhealth and loss of economic productivity.

Getting things rightEnsuring effectiveness in the supplychain is not an issue for developingcountries alone. Developed nationswhich provide developing countries withtechnical and financial assistance forhealth care must ensure that part of thissupport is channelled to buildingeffective, efficient and sustainablesystems.

New global initiatives such as the GlobalFund to fight AIDS, TB and Malaria andthe US government PEPFAR initiativeprovide opportunities for developingcountries to improve their healthsystems by availing much neededadditional resources. However, itremains to be seen whether things willreally take a turn for the better afterimplementation of these programmes.

Translating opportunities into concretebenefits, not only for today but for the farfuture, has always been a challenge formany countries in Africa. Human

Effective distributiondepends on good

communication, costcontainment and

a well designed, wellmanaged system

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Offloading medical supplies fordistribution


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resource development, for example, isone area that governments could ensurebenefits from these global initiatives.Transfer of skills and expertise from theNorth to the South is vital to ensuresustainability of health programmes andprevention of further decline of thepeople’s health status. Every effortshould be made to build the capacity ofhealth personnel not just from thenarrow perspective of AIDS care but ina way that can make them useful to thehealth system as a whole. Governmentsneed to ensure that these initiatives areimplemented in such a way that existingsystems are strengthened or at the veryleast safeguarded.

Another recommendation made forimproving supply systems is thedevelopment of best practices that canbe shared among countries that needto improve their systems. An exampleof a first step in this direction is theguidelines for Drug Supply Organizationsdeveloped by the members of theEcumenical Pharmaceutical Network(EPN). These guidelines highlight anumber of area which are important inmaintaining a good drug supplyorganization.

A public private mix is also recommendedin order to realize an efficient andeffective supply of medicines. Closerinteraction between the different playersinvolved in supply would ensure thatessential medicines are available.However, public-private partnership isnot easy to put in practice as it seemson paper. Getting governments tocommit to real partnerships and notmarriages of convenience remains aconsiderable challenge. The privatesector must continue to lobby forrecognition as crucial players in theprovision of care and demand for theirefforts to be supported.

ConclusionThe battle for universal access tomedicines appears to be one that hasonly started. The state of the supply anddistribution systems in poor countriesis intimately linked to poverty, corruption,low levels of human development and a

host of other ills that continue toconfound politicians, economists andscientists. Commitment is requiredfrom leaders at the highest level if realprogress is to be achieved. Countriesthat still have to grapple with issues ofaccess must learn from each other anduse existing best practices to move theirsystems forward to a level that canensure that national health goals arerealized and that people enjoy the dignitythat is their right.

Donna Kusemererwa is the General Manager ofJoint Medical Store, a Not for Profit Non-GovernmentalChurch- founded pharmaceutical supply agency. JointMedical Store, Gogonya Road Nsambya. P.O. Box4501 Kampala Uganda Email: [email protected]

Countries that still haveto grapple with issues ofaccess must learn fromeach other and useexisting best practices tomove their systemsforward to a level thatcan ensure that nationalhealth goals are realisedand that people enjoythe dignity that istheir right

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MEDS warehouse in Nairobi, Kenya


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Human resources are undoubtedlythe most important factor in effective

health care. It is people who work toprevent diseases, administer the drugsand vaccines, perform the operations,take care of the invalids and provide thenecessary services for cures.Availability of adequate and qualified andmotivated personnel is therefore key toensuring quality services.

A health care delivery system withoutconsistent supply of essentialmedicines lacks credibility andfrustrates preventive and promotiveprogrammes. With specific regard tothe effect of human resource on accessto essential medicines, what springs tomind immediately is pharmacy staff.However, access and appropriate useof drugs involves other health workers.Drug treatment involves prescribers(doctors, clinical officers), laboratorypersonnel, nurses and dispensers(pharmacists, pharmacy technologists,pharmacy assistants).

Unfortunately, appropriate,qualified and motivated

human resourcesfor health care

delivery are insevere shortageworldwide withthe poorestc o u n t r i e scarrying thehighest burden. Itis estimated

that the worldneeds more than

four millionhealth workers,and that Africa

HUMAN RESOURCES:THE ENGINE THAT DRIVES IT ALL

Availability of appropriately qualified and motivated human resources in any health care deliverysystem increases the quality of services. It usually also results in appropriate or optimal use ofresources within the system including medicines. However, there is currently a crisis in human

resources for health with low-income countries bearing the brunt of the problem.

alone requires one million additionalhealth workers to ensure the staffinglevels required to deliver basic healthinterventions. Currently, there are only750,000 health workers in Africa (0.8health worker for every 1000 people)against a world median density of 5 per1,000 people.

Causes of the human resourcesdeficitMany factors contribute to the shortageof health workers:

Absolute shortage in numbersInsufficient training opportunities meanthat very few people are joining the healthfield. For example, 24 out of 47 countriesin Sub-Saharan Africa have only onemedical school and 11 countries haveno medical school at all. This iscompounded by the fact that manyhighly trained and experienced healthprofessionals from low-incomecountries, are lured to work in high-income countries. Paradoxically the richcountries to which health wo rkersmigrate to possess well developededucation systems. For example acountry like Zambia, which has only oneSchool of Pharmacy and one School ofMedicine is losing its doctors andpharmacists to countries like the UnitedKingdom which has several medicalschools.

HIV/AIDS is the second major factorcontributing to shortage in numbers ofhealth workers. In addition to increasedworkload and the stress on their morale,many health workers are dying fromAIDS-related illnesses. There is alsoloss of man-hours as when workers areeither sick themselves or absent fromwork in order to look after sick spouses

appropriate, qualifiedand motivated human

resources for health caredelivery are in severe

shortage worldwide withthe poorest countries

carrying the highestburden

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A Clinical officer and a nurseattend to a patient at a missionhospital in Zambia


FEATURE

or kin. In some countries between 18percent and 41 percent of the healthworkforce are already infected with thevirus.

Skills imbalanceIn many countries skills imbalancecreate huge inefficiencies. Often, healthcare systems depend too much ondoctors and specialists leading to theneglect of community-based publichealth. This leads to the neglect on thetraining and deployment of healthworkers with skills appropriate to thelevel of care needed such as auxiliaryand community workers.

Urban/rural mal-distributionMal-distribution within the countryincludes urban concentration of workers,a common problem in many countries.For example in Tanzania, the city of Dares Salaam alone has nearly 30 timesas many medical officers and medicalspecialist as other rural districts.Unequal distribution of staff betweenpublic and private sectors is alsocommon. A growing trend in this area isthe movement of qualified staff tointernational organizations and NGOs,sometimes to carry out duties that donot fully utilize their health skills.

Brain drainInternational migration is an issue thatseriously affects the sustainability ofhealth systems in developing countries.The effects are most severe in Englishspeaking countries of sub SaharanAfrica. It is estimated that 60 percent ofdoctors trained in Ghana in the 1980shave left the country. In 2003, the UKalone had 5880 health and medicalpersonnel from South Africa, 2825 fromZimbabwe, 1510 from Nigeria and 850from Ghana.

It is estimated that each migrating healthprofessional represents a loss of US$184,000 and five years traininginvestment to Africa. The idea thatrepatriated overseas earnings couldmake up for the deficiency is unrealistic,as the income does not necessarily findits way into health care improvements.Furthermore, the loss of well trained,experienced personnel who would serve

as role models and teachers of youngerhealth personnel cannot becompensated by monetary terms. Sincevery few health personnel move to thedeveloping countries, the developingcountries experience all drain but nogain.

Poor work environmentsOne of the main issues that makeshealth workers look for opportunitiesabroad is the low level of compensation.For example the average monthly salaryfor a doctor in Ghana and Zambia is justover $400 while a nurse in the UKNational Health Service earns about$2576!

Given the macroeconomic and fiscalreality of the African countries and otherdeveloping countries, large scaleincreases in salaries of health workersis difficult. The poor emoluments arefurther complicated by lack of adequateworking tools such as supplies, facilities,and other non-financial incentives suchas training and career advancementopportunities, housing, educationfacilities for children, governance andmanagement shortcomings and politicalor personal security.

Building human resource capacity in drug managementThe Churches Health Association of Zambia (CHAZ) supportsthe training of Pharmacists and Pharmacy Technologists whoupon completion are posted to member institutions. In addition,CHAZ conducts in service training in Drug Management andAppropriate Use. The programme has been going on for thepast eight years.

To evaluate the effect of posting trained pharmacy staff, CHAZconducts drug indicator studies to compare drug managementand availability of essential drugs in institutions with trainedpharmacy staff and those without. In these studies, managersof the health institutions are interviewed about their perceptionsof drug management and availability of essential medicinesbefore and after the posting of trained pharmaceutical staff.

So far, results show that institutions with trained pharmaceuticalstaff manage drug supply better than those without. In addition,institutions where the doctors in charge have attended in-servicetraining in Drug Management and Rational Use supportprogrammes to improve appropriate use of medicines; and havea higher score in terms of availability of indicator drugs.

The loss of well-trained,experienced personnelwho would serve as rolemodels and teachers ofyounger health personnelcannot be compensatedby monetary terms


Weak knowledge baseData and research on human resourcesare underdeveloped, sparse andfragmented. This hampers planning,policy development and programmingand makes it difficult to set up workforcenorms, standards and documenting ofbest practices.

Addressing the health workforcecrisisThe need to address the healthworkforce crisis has been receivingattention with several meetings andconsultations taking place to contributetowards an action agenda. Amongthese are the High level Forum (HLF)and the Joint Learning initiative (JLI) thathave proposed ways to mobilize andstrengthen the human resources forhealth.

In summary, strategies are proposedto address three core objectives:

coverage strategies to promotenumeric adequacy, appropriateworker skills mix and outreachto vulnerable populations;motivation strategies to focuson adequate remunerations,positive work and careerenvironments and supportivehealth systems; and strategies

focusing on advancing competencies througheducating for appropriate attitudes andskills, training for continuous learning andcultivating leadership, entrepreneurshipand innovation.

Implementing these strategies will needcountry-led action, political commitmentand resource allocation. It will also meana multi-sectoral approach involving theministries of labour, finance andeducation, and other stakeholdersincluding the private for profit and not-for-profit organizations, academia andprofessional associations. The responsemust also include the internationalcommunity as technical support andexternal resources will be needed toovercome macroeconomic constraint ofthe poor countries, and for educationalprogrammes. The establishment of aspecial global education fund open toapplication from individual countries forits education investment plans has beenproposed. The plans are there, thechallenge is making it happen.

Taking steps to retain human resources in ZambiaThe health workers’ migration crisis has put many developing countries on the alert. Zambia is no exception.As a low-income country, the government finds it difficult to retain health workers due to the poor workingenvironment. This has led to the massive brain drain of nurses, doctors, clinical officers, pharmacists andother health workers.

The Zambian government, with support from the Netherlands embassy has developed a scheme aimedat retaining medical doctors within the public health care system. The scheme provides for the doctors’salaries, rural hardship allowances, education allowances as well as postgraduate training for the doctorsafter completion of a three-year contract. The doctors also have access to loan facilities. The scheme hasso far retained 68 doctors who are serving in rural areas.

This scheme does have its limitations; as it only targets doctors, its impact is inadequate. Nurses andclinical officers who in most cases are the only staff serving at the health centre level are not part of thescheme. This means that they are most likely to migrate though they are the most needed particularly inrural settings. Another limitation is that since the scheme only targets doctors in the rural setting, those inurban centres do not have incentives to work in government facilities and therefore prefer to work for nongovernmental organizations or to venture into private practice which is more lucrative than working for thegovernment.

This scheme, though a step forward towards retaining human resource in healthcare, needs to be developedand implemented on a wider scale to accommodate all cadres of health workers.

A health worker conducts aninventory of tablets

SH

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FEATURE

Chipupu Kandeke is the Pharmaceutical andLogistics Manager for Churches Health Associationof Zambia; Lusaka and is the Country Focal Personfor the Ecumenical Pharmaceutical Network (EPN).

Eva Ombaka is the Coordinator of the EcumenicalPharmaceutical Network (EPN).


BALANCING SERVICE AND PROFITEXPERIENCE

USING FRANCHISE MODELS

Few would argue that a single motherliving in the Kenyan interior, or a

widowed father of seven surviving on theshores of Lake Victoria should have“access” to essential medicines thatkeep their children alive and healthy.Many people in rural areas do not haveaccess to basic medicine for the mostcommon and easily cured diseases.

Marcy is a mother of three who lives ina farming village near Mt. Kenya. In thepast, Marcy had to trek one and a halfhours to the government dispensary toget medicine for herself and her family.After waiting for several hours, she oftenfound that the clinic did not have thedrugs she needed. She either had to dowithout treatment and medication ortravel another 20 kilometres using aPublic Service Vehicle, which would costher additional time and money.

Bringing services closer to thepeopleChild and Family Wellness Shops(CFWshops) is a franchised network ofclinics and drug shops that aims toprovide access to inexpensive essentialmedicine to children and families in ruralKenya, to mothers like Marcy. In August2004, CFWshops opened a clinic twohundred metres from Marcy’s home. Asa result, when her five-year old daughterCaro came down with malaria in lateMarch, Marcy did not have to walk to thegovernment clinic or worry whether themedicine would be available.

“Since the [CFWshop] clinic opened weare very happy because before we hadto travel a long way [to the governmenthealth centre]. There we had to wait ina long line and many times they didn’teven have medicine,” explains Marcy.Now she has access to inexpensive,quality medicine a few footsteps awayfrom her home.

Marcy’s story is similar to the stories ofmany other CFWshops’ patients who inthe past have had to travel longdistances to health facilities that oftenlacked essential drugs. The SustainableHealthcare Enterprise Foundation(SHEF) created the CFWshops networkto help solve this problem by developinga sustainable and reliable model for thedistribution of essential medicine.Instead of relying solely on donor supportor government sponsorship, SHEFuses a micro-franchise model.

To start off, SHEF gives the CFWShopsfranchisee a loan, an initial stock ofmedicine, a month-long training courseon basic medical treatment andbusiness management, furniture, andother materials needed to start thebusiness. Once the outlet is openSHEF’s fieldwork staff visits thefranchisee regularly. The staff provide aconsistent supply of medicine and workwith franchisees to ensure compliancewith franchise regulations. Thefieldworkers also assist franchisees todevelop their businesses through

SHEF

Many people in ruralareas do not have accessto basic medicine for themost common and easily

cured diseases.

Child and family Wellness Shops in Kenya

A healthworker consults with apatient


EXPERIENCE

targeted marketing strategies andcommunity awareness. Franchiseespay back the loans for the initial stock ofdrugs in small monthly instalments thatare paid over a three-year period. Ideally,after this period the franchisees shouldbe able to maintain enough profit torestock the outlets while retaining asalary for themselves and anyemployees.

Franchise with a differenceUnlike many social franchisingorganizations that are “fractionalfranchises” and target a portion ofexisting operators’ businesses,CFWshops are stand-alone franchises.SHEF serves as a franchiser, over-seeing the entire outlet from branding toprocurement and the treatment ofpatients. The benefits of this systeminclude the guarantee of quality servicethrough standard regulations for thetreatment of patients, as well as a massprocurement system that keeps costslow for the franchisees and the patients.

The CFWshops mission is similar to thatof many international franchises: toprovide a quality product with efficientservice that is standardized across theorganization. However, unlike mostfranchise operations, SHEF is notlooking to make a profit at the franchiserlevel. Instead, the relatively small“franchise fees” are built into the cost ofthe medicine that the franchisees buy.Currently, these fees support only asmall portion of SHEF’s operationalcosts, with the rest being subsidized byexternal funding; however, as thenetwork grows this gap will decreaseand less outside funding will be neededto support the franchise.

A major difference between SHEF andfor-profit franchises is that CFWshopstargets communities that areinhospitable business environments.Since the goal is to provide access tomedicine for people who may otherwisenot have it, most outlets are located inrural areas where the primary source ofincome is small scale farming. In thesecommunities, irregular cash flowmeans that people may not have moneyto pay for medicine. Even though the

medicine at CFWshops is generally lessexpensive than at other private clinics orpharmacies, extreme poverty, especiallyamong the elderly and single mothers,still makes it impossible for them toafford it.

Given these circumstances, mostfranchisees have developed creditsystems. John Kimenyi, owner of EnaCFWclinic near Embu has establishedcredit facilities for those who have nocash at hand. However, on a daily basishe receives at least two impoverishedpatients who can barely even afford food.In such situations he gives the patientsthe medicine they need, accepting theloss rather than trying to give credit thatwill most likely never be paid.

Despite this less than ideal businessenvironment, SHEF realizes that theprofitability of individual outlets is vital fortheir sustainability. Furthermore,measurable impact increases with theprofitability of the individual outlet. Hencethe more the franchisees sell, the morepatients they can see and help, and themore motivated they become.

Creating trust and demandFranchising has proved a successfulmodel in assisting individual outletsbecome profitable. One reason is thatfranchising requires standardization anda link to a larger network. This in turncreates something invaluable for thefranchisees: trust.

“When the community sees theCFWshop vehicle outside my clinic,”says Rosemary who owns HurumaCFWclinic, “they see that I have supportand I am a part of something bigger, thenthey begin to trust me and my product.”

Even though government health centreshave long been known for theirinefficiency and lack of stock, the peopletrust the government to give them goodmedicine at a fair price (usually about$13) for diagnosis and treatment. Eventhose who have given up on thegovernment system are reluctant to goto a private clinic or chemist who mightsacrifice quality for making a profit.Therefore, as Rosemary observes,seeing that the individual outlets are

A major differencebetween SHEF and

for-profit franchises is thatCFWshops targets

communities that areinhospitable business

environments

SHEF

A mother holds her child and aninsecticide treated net (ITN). TheITN was provided by a SHEFfranchise shop


“overseen” by an umbrellaorganization creates trust.

Prevention rather than cureOnce trust is established and theoutlet earns a favourable reputationin the community, the next step isto create awareness in thecommunity on the importance ofprevention. This increases demandfor preventative products ratherthan curative drugs. SHEF recentlyrolled out a new marketing plan forthe outlets focusing on healtheducation. The result wasimproved sales and patientnumbers, creating substantialimpact in the communities.

In February-April 2005 the outletsran a WaterGuard Promotion.WaterGuard is an inexpensivechemical that kills bacteria andprevents most waterborne diseases.One bottle of WaterGuard costsabout $0.6 and can treat water fora family for six months. For thepromotion, franchisees gave outfree treated drinking water in theiroutlets and were provided withWaterGuard to demonstrate how totreat water. The demonstrationswere conducted in schools,churches and homes. They alsotaught about the importance ofprevention and how buyingWaterGuard is less expensive in thelong run than treating diseasescaused by drinking contaminatedwater. By the end of March the saleof WaterGuard in the network hadincreased by over two hundredpercent. At Karaba clinic in Mbeeredistrict, franchisee Jane Kiswalisold twenty bottles of WaterGuardin just one and a half weeks, andsays that the promotion has had asubstantial impact on the numberof cases of Typhoid and worms inher community.

Since March, SHEF hassubsidized the cost of InsecticideTreated Nets (ITNs) andAmodiaquine (a malaria treatment)by fifty percent. Franchisees wereprovided with posters and

pamphlets on prevention andtreatment of Malaria. The responsewas overwhelming; the outlets sold6,000 nets in the first week of thepromotion. These promotions arethe beginning of marketing plansthat will encourage the sale ofpreventative products.

Growing network

Once the rural consumers realizethe quality and consistency of theservice offered at each CFWshopoutlet, the demand is overwhelming.Magombe CFWshop in Bunyaladistrict near Lake Victoria is oneexample. Margaret, the shop ownerand Community Health Worker(CHW), opened her shop only sixmonths ago, and already thecommunity is urging her to hire anurse so that she can stock anddispense a wider range of drugs.Although there is a chemist and agovernment health centre withinfive hundred metres of her shop,the chemist is more expensive andless reliable, while the governmentcentre is almost always out ofmedicine.

In the past few months, SHEF hasmade a concerted effort to upgradeshops like Margaret’s to clinics. Theshops are run by CHWs who have

Annie Barton is a Communications Officer forthe Sustainable Healthcare EnterpriseFoundation (SHEF) and Executive Director ofthe Franchise Advisory Committee, whichadvises SHEF and other organizationsinterested in social franchising. SHEF, CHAKBldg, Musa Gitau Road off Waiyaki Way, P.O.Box 73860 Nairobi, Kenya Email:[email protected]

been trained only in basic medicalcare. For the shops to be upgradedto clinics, the CHW must employ anurse. The clinics can then stocka wider range of medicine,including antibiotics and injectabledrugs. Furthermore, with a nurseat the outlet, the CHW has moretime to make home and schoolvisits and attend communityevents. This coupled with the abilityto provide a wider range of servicesand products has increased salesand patient numbers of outlets thatare converted to clinics.

With a recent focus on marketingand improving performance at theoutlet level, the SHEF staff islearning exactly what it takes tohave a successful shop/clinic.These lessons are translated intosystem-wide improvements; as themodel is refined new outlets that areopened can be more successfulright away. The advantage offranchising therefore is not onlystandardization, but also thereplication of a successfulbusiness model across a widerange of locations.

SHEF will continue to grow andimprove its network in Kenya. Thegoal is to reach as many people aspossible. Being a pioneer in thismodel has meant that the SHEFstaff has had to work and re-workthe CFWshop system. The ultimatehope is that people in othercountries can learn from theexperience of CFWshops and willbe inspired by the success of theSHEF model to create their ownnetworks to improve access tomedicines for people inmarginalized areas all over theworld.

Clean water for school children

SHEF

EXPERIENCE


EXPERIENCE

In Ghana, as in many developingcountries, pharmaceutical services

are characterized by comparatively highdrug prices, inadequate availability ofquality essential drugs and poor qualityof services. Most of the wholesale andretail pharmacies are located in thecapital city Accra and other urban areas.There are however, over 8,000 licensedchemical sellers (LCS) who provide thefirst line of pharmaceutical services andare widely distributed in the peri-urbanand rural areas. The LCS however haveto spend 30 percent of their timetravelling long distances to obtainmedicines and other supplies. Inaddition they have to visit multiplesources to obtain the range of productsthey require. This process addssignificantly to their costs.

To address these problems aninnovative franchise model calledCAREshops was created in 2002. Thefranchise is a collaboration programmebetween GMSF Entreprises Limitedand Management Sciences for Health(MSH) with funding from the GatesFoundation and DFID. The aim of theCAREShops model is to improve thelevel of pharmaceutical care andservices and the availability of affordablegood quality medicines in theunderserved areas. The programmeworks with LCS who have establishedbusinesses and are willing to add apackage of services to their business.

Part ic ipat ingLCS undergo at r a i n i n gp r o g r a m m ec o v e r i n gmanagementand entre-p r e n e u r i a lskills, drugmanagementand rationaldrug use andthe manage-ment of simple

ailments of common occurrence in theircommunities. They are also trained indata collection and to recognize andrefer clients whose needs are beyondtheir capacities. On their part, GSMF Ltd,acting as the franchiser, procures drugsand supplies centrally and provides door-to-door delivery to the LCS. Thus theLCS outlets benefit through gaining skillsto run their business, upgrading of theiroutlets and improved visibility through theuse of CAREshop logo and colours.

The CAREshop franchise has beensuccessfully implemented in 20 districtsin three regions of Ghana. Starting with41 LCS in 2003, the number has grownto 221 by mid 2005. The participatingLCS report increase in sales and growthof their businesses and the communityis provided with much needed services.The CAREshops model is also havingan impact on local pharmaceuticalindustry through assured sales andcredit management. The data collectedby the CAREshop franchisees is usedin assisting management decisions, inidentifying training needs, in policyformulations on drug consumptions andfor other public health issues by theMinistry of Health. The success of thefranchise has stimulated non-participating LCS to emulate theCAREshops.

Even so, the model does have itschallenges. The rapid growth in thenumber of participating LCS presents achallenge in managing, supervising andproviding logistical support. Training, acrucial component of the model, isexpensive. Furthermore, changingbehaviour needs time and perseverance.However the end result of providing goodquality pharmaceutical care to all whoneed it irrespective of where they live iswell worth the effort!

From a presentation by D. E. Mensah, at Strategiesfor Enhancing Access to Medicine (SEAM)Conference, 2005.

The CAREshops modelis also having impact on

local pharmaceuticalindustry through assured

sales and creditmanagement.

CAREshops in Ghana

A patient visits a rural pharmacy

MS

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EXPERIENCE

COMMUNITY ACTION TO IMPROVE ACCESS

I n 1983, the sub-prefecture ofBocaranga and a population of100,000 inhabitants was served by a

small rural hospital. Consequently, fourdispensaries ran by the EvangelicalChurch of Brothers (Eglise Evangéliquedes Frères, EEF) were started to providemedical care to this population. EEF wassupported by an American project, whichfor years used a small plane for thesupervision of the dispensaries and theevacuation of critically ill patients to itsmissionary hospital at Boguila, 200 kmsaway from Bocaranga. With thecompletion of the American project,access to health care for the majority ofthe communities dispersed in the ruralvillages became difficult, if not impossible.

With the example of EEF in mind, theCatholic Church, which had establisheditself in Ngaoundaye, decided to commititself more in the field of health. A projectof Primary Health Care (PHC) was bornand developed gradually in accordancewith the strategy recommended by WHOto sensitize and mobilize the populationtowards an active communityparticipation.

A small rural hospital was built inNgaoundaye to become a centre ofreference for the northern sector. A teammade up of a doctor, a midwife, threegraduate nurses, a social worker and ahygiene assistant, shared the tasks tobuild the “minimum package” of activitiesin accordance with the national PHCprogramme.

At the same time, coordination efforts withall the stakeholders present in the sub-prefecture made it possible to createalliances and synergistic partnershipsaround the same project. Thus theGerman Organisation GTZ provided thefinancial assistance and the LutheranChurch, which had agreed to return to thearea after 10 years of absence, providedthe technical skills for construction of thebuildings. The Catholic Church ensuredthe training of health staff, and the villagecommunities began to implement theirmanagement committees, to choose

their health agents and to provide workforces for the constructions.

The work developed well thanks to aprocess of “self-promotion throughimitation”: new health posts becameoperational each year. The first essentialdrugs store was inaugurated inNgaoundaye, but soon, because of thedistances, the two sectors, one in the northand one in the South were seperated, andeach one developed an autononmoushospital and drug store.

Two different development models weretested, that of Bocaranga undersupervision of GTZ, and that ofNgaoundaye under communityleadership, with the team of the CatholicChurch as technical adviser.

The Community’s involvementThe community gradually developed andstructured itself in an empirical manner.With the experience gained over theyears and the prevailing circumstances,it has evolved into a form that nobodyhad initially imagined: simple, original,and daring.

In the beginning, the villagecommunities were hesitant to takecharge of their health posts since GTZhad always offered financial support.After four years of awarenesscampaigns, meetings and trainingcourses, each management committeeassumed the responsibility for its health post,

Where there is no artist

The work developedwell thanks to a process

of “self-promotionthrough imitation”: new

health posts becameoperational each year


EXPERIENCE

even if reluctant to do so.

Governing body The health postsfo rmed anassociation namely“Rural CommunityP h a r m a c y ”(“Pharmacie RuraleCommunautaire”,PRC). I tslegislative bodyis the generalassembly of thehealth postsm a n a g e m e n tcommittees ;itsexecutive is aboard of directorsmade up ofelected and

l e g i t i m a t em e m b e r s ,

representing thefollowing institutions:

the hospital, the townhall, the education

sector, the social services,the waste collecting

services, and the religouscommunities. Being of rural origin eachelected member benefits from thetechnical support of a legitimatemember,when in function. Two technicalstaff and a supervisor ensure the dailymanagement of the PRC and theregular supervision of the health posts.They are recruited through a competitiveprocess and are paid regularly. Theother members work voluntarily exceptfor small incentives, which they receivefor specific services.

Drug ProcurementInitially, with the assistance of theCatholic Church, the PRC importeddrugs directly from Europe viaAssomesca (Association of the MedicalCharities of the Church in CentralAfrican Republic). However, this systemsoon became complicated andunsustainable in the absence ofexpatriate personnel and was thereforeset aside. The alternative was to supportthe creation of intermediate depotsbetween the periphery and the central

level. Thus two intermediate depotswere created in two large cities: the oneof Bossangoa where the CatholicChurch is one of the founder members,and the diocesan depot of Bouar. Thesedepots, being members of Assomescaand having a more significant capitaland a higher technical level, can get theirsupplies from either the capital Bangui,or directly from Europe. The peripheraldepot, namely the PRC, benefits froma tiny profit margin, but which is sufficientfor its functioning, in particular theprocurement for the hospital and thehealth posts. There are currently 25health posts which manage to ensure amedical cover of 93% of the population.The area in which the PRC operates isapproximately 60 km, a distance whichcan be covered in a day or two by ahealth agent using a bicycle. To go thereand back, it takes one or two daysexcept if there are small bicycle failuresdue to the bad roads.

ChallengesThe PRC remained undamaged duringthe last civil war in 2001,because itscapital was hidden and safeguarded.Thus it could compensate the otherhealth posts that had been ransackedand recently it also funded theconstruction of a new building for a healthpost which was damaged during the war.

In the future, this rural communitypharmacy has the potential to become thefinancial pillar of any medical developmentin the area it covers.

The rural community is proud of theirachievements and of the results obtained.The PRC is officially recognized, accordingto its duly approved statutes, as a self-managed community depot and anassociate member of Assomesca,because the Catholic mission, being alegitimate member of its board of directors,continues to play the role of technicaladviser.

If the war did not destroy theachievements of these ruralcommunities, two serious dangerscurrently threaten the efforts and darkenthe future of PRC.

A pharmacist dispensesmedicines at a pharmacy inCentral Africa Republic

EPN

This rural communitypharmacy has the

potential to become thefinancial pillar of any

medical development inthe area it covers


EXPERIENCE

The first one is the government whichalways calls upon the denominationalprivate sector for a synergistic andactive partnership, while it does notrespect its own commitments. As thegovernment no longer has the financialmeans to support the regions and thehealth districts, the prefectoral depotshave been created in the large cities inspite of already existing depots. Theprices of drugs were increased to makeit possible to have a profit margin of 40%intended for the functioning of theregions and the health districts. Allhealth facilities, not only thedenominational ones, are forced to gettheir supplies in the new depots. As retaildrug prices are fixed, no profit margin isavailable for the peripheral depots. Asretail drug prices are fixed, no profitmargin is available for the peripheraldepots. As the small health posts do nothave a sufficient drug revolving fund andcannot ask their health agents to covera distance of 300 km by bicycle, theywill gradually be excluded from thehealth system and the posts willbecome dormant.

The second danger is the irrationalinterference of certain organisationsbecause they have significant financialmeans. They seek to impose theirhumanitarian aid projects without takinginto account existing systems. Anexample is an international NGO whichconducted health missions in villages ofthe Ngaoundaye district to consult andtreat for free those aggrieved by war: anaction of charity towards the poor.Missions such as these render the PRCdormant. The health agents will returnto work on the fields, because they willno longer have their small monthlyincentives and the health posts will closetheir doors. At the end of the project,when the NGO will have achieved itshumanitarian mission, the poor will bepoorer.

The poor refuse to be taken as hostages.They are free to choose their suppliesfrom wherever they can and want to.They propose other forms of support:training courses to improve the quality ofhealth care and the use of drugs; the

creation of a budget line for health facilitiesto enable them to give free treatment tothe ones in need; the free offer ofemergency surgical interventions athospital level, and of antenatalconsultations and labour services athealth centre level. There are noshortages of ideas, but so far, the voicesof the poor do not have any echoes.

ConclusionReflections are imperative for all thosewho commit themselves in humanitarianaid projects. What is true charity?Assistance or development? Even theCatholic Church via the voice of the Pope,this great master of charity for manydecades, has recently called upon allpeople of goodwill for “A new imaginationof charity” (Message for the 13th WorldDay of the Patient). “A charity whichsuggests the right approach in varioussituations making it possible to perceivethe particular character of each one andto answer it”. A charity which is not ahumiliating gift but which brings supportto our brothers and sisters to help themto stand up on our sides with the idea ofsharing and true solidarity. Charity anddevelopment cannot be separated fromeach other. It is urgent to engageourselves resolutely with this point of viewin mind.

For those who “do not recognize the faceof Christ in the features of any personwho suffers, and are motivated only byreasons of philanthropic compassiontowards the people in need”, below is anold Chinese proverb to illustrate the beststrategy for PHC:

Go to the peopleLive with them

Like themStart with what they have.

But remember:The best teacher is the one who,

when the work is completed,hears the people say:We did it ourselves!

Ione Bertocchi is a medical doctor, who was incharge of a rural hospital in the Central AfricanRepublic for 25 years. Currently, she is the healthcoordinator of the Diocese of Bouar and president ofASSOMESCA, an ecumenical association of Christianmedical services, whose main objective is to help itsmembers carry out Primary Health Care activities.

Charity and developmentcannot be seperatedfrom each other. It is

urgent to engageourselves resolutely withthis point of view in mind


BIBLE STUDY

UNIVERSAL ACCESS TO MEDICINES: IS THERE A VISION?

Of all the basic needs, one of the most difficultto get especially for impoverished

communities is affordable, efficient and effectivehealthcare and services. Health care is affectedby factors among them: affordability/cost/pricing,geographical setting/locality (rural and urban) andaccessibility/ availability.

These difficulties make healthcare a luxurymore than a necessity for manycommunities especially those indeveloping countries. Should this bethe case? It is time for the vision ofmany to become a reality wherehealth care services are availableand accessible to all regardless ofeconomic status.

Read Ezekiel 47:12

Prophet Ezekiel was one among eightthousand Jewish captives taken toBabylon after the fall of Jerusalem toNebuchadnezzar in 598 BC. While in Babylon,the present Iraq, the prophet saw a vision fromGod depicting Jerusalem’s reconstruction. In hisvision there is a long river with trees on either sideof its banks.

The trees are referred to as being of “all kinds,” tosymbolize their variety and “very many,”symbolizing their abundance in number. Theirleaves do not wither nor their fruits fail - they arenot restricted by seasons. The leaves do notinvolve any commercial activity; they are freelyavailable and are meant for healing. According toEzekiel’s vision, healing is not restricted to a fewrare herbs; this emphasizes the ease of whichmedicines should be accessed.

Our realityIn comparing Ezekiel’s vision with our presentreality, we realize that there are many differences

that have been brought about over the years bythe transformation of society. Patent laws havebeen developed and are now implemented on foodand plants. In most of these cases, the laws areapplied in countries far from the products’ originalcountries. Patent laws give a 20-year period forthe patent holder to have exclusive marketing

rights making prices prohibitive. Pricingpolicies allow profit for traders and

medical professionals while thosein dire need of the medicines donot receive them due to the highcost of the medicines.

The situation has beenworsened by the pharma-ceutical organizations’ financialinfluence. They are in positionsto fund national elections and

influence policies of govern-ments.Essential medicines that save lives

and that are not expensive have beenreplaced with expensive combinations makingthem inaccessible to those who need them themost.

Questions for reflection1. Do we have visions? Our world needs

visionaries with prophetic zeal to announceand act on having life-saving medicinesaccessible universally.

2. What is our vision for health and healing? Dowe identify health and healing with patentrights, brands and exclusive hospitals that onlyoffer specialized treatment? or with food,sanitation and essential medicines?

3. Can we realize the vision of Prophet Ezekielwhere medicines shall be available as easilyas leaves? If so how soon?

EZEKIEL 47: 12 (b)

The following reflection has been prepared by Moses Manohar ofInter-Church Services Association (ICSA)


RESOURCES

Access to Affordable Medicines: DevelopingResponses under the TRIPS Agreement and ECLawThis book provides an analysis of the differencesbetween the WTO’s focus to make it possible forcountries with insufficient or no manufacturing capacityof pharmaceuticals to have effective use of compulsorylicensing and, the EC’s regulation to promote differentialpricing for needed medicines.

Author: Kathreen Gamharter

Published in 2004 ISBN 3-211-22670-2

Millennium Development Report: Prescriptionfor healthy development: increasing access tomedicinesThis report presents an authoritative and in depth lookat strategies for increasing the availability, affordabilityand appropriate use of medicines in developingcountries.

Lead Authors: Paula Munderi, Coordinator, Beryl Leach,Joan E. Paluzzi. Published in 2005.www.unmillenniumproject.org/documents/TF5-medicines-Complete.pdf

Access to essential drugs in poor countries: alost battle?This article by B. Pecoul, P. Chirac, P. Trouiller and J.Pinel, focuses on the problems of access to qualitydrugs for the treatment of diseases that predominantlyaffect the developing world including poor-quality andcounterfeit drugs and; lack of availability of essentialdrugs due to fluctuating production or prohibitive cost.

Available at:www.dndi.org/cms/public_html/images/article/229/JAMA.pdf

Drugs and Money – Prices, Affordability andCost Containment (7th Edition) (WHO, 2003; 158 pages)This report aims to provide policy makers andregulators with a compact and practical review of thevarious approaches that have been developed andtested in an effort to contain the overall costs ofpharmaceutical services and drug treatment. It devotesconsiderable attention to the special problems ofdeveloping countries and those where the economyis currently in transition.

Available at: www.who.it/InformationSources/Publications/Catalogue/20030429_1

HIV/AIDS: Standard Operating Procedures forPharmaceutical and Laboratory ServicesThe Rational Pharmaceutical Management (RPM) PlusProgram manual points to several pilot and small scaleprograms which demonstrate the feasibility of safely,effective use, affordability, geographical accessibilityand availability at facility level of ART in resource-poorsettings in sub-Saharan Africa and Haiti.

Available online at www.msh.org/projects/rpmplus

Progress on Global access to HIV Anti-retroviralTherapy – An update on 3 by 5 (June 2005)This interim report focuses on understanding thereasons for the successes and failures for scaling upHIV/AIDS interventions under the 3by5 initiative. Thereport makes recommendations concerning theapproaches needed to overcome major bottlenecks,the need for sustainable financing mechanisms andgreater harmonization of effort by technical andfinancing partners.

Available online at www.who.int/3by5/Fullreport.June2005.pdf

Moving Mountains: The Race to Treat Global AIDSThis book reports on the discrimination experiencedby people with HIV infection, the risks that women facewhen they cannot negotiate for safe sex and thechallenges faced by primary healthcare systems thatserve for many as the only source for treatment.http://content.nejm.org/cgi/content/short/352/10/1052

Global health challenge: Essays on AIDSThis book highlights how developing countries can beorganized and motivated to combat HIV/AIDS. Itexamines blood vaccine research, governmentstrategies to contain the pandemic and media influenceover the public in relation to HIV/AIDS.

Available at: www.selectbooks.com.sg/titles/32346.htm

Cost-containment mechanisms for essentialmedicines, including anti-retrovirals, in China –health economics and drugs (EDM Series No. 13)(WHO; 2002; 30 pages. In English, French and Spanish)This report tackles the issues of pricing and licensingof medicines in China as well as lessons from othercountries experiences in negotiating price discounts.

Available at www.who.int/medicines/library/par/who-edm-par-2003-6/CostContainmentEnglish.pdf

Access to medicines in under-served markets:what are the implications of changes in intellectualproperty rights, trade and drug registration policyThis is report summarizes studies that examine policyimplications of changes in intellectual propertyprotections and drug registration requirements as wellas how strengthened intellectual property protectionsand heightened registration standards may or may notimprove access in under-served markets.

Available online at www.unmillenniumproject.org/documents/TF5-medicines-NotesReferences.pdf


EPN is an independent, apoliticalnon-profit Christian organizationthat works in a context of increasingpoverty and need for healthservices.

Our goal is to increase positivehealth outcomes through church-related pharmaceutical servicesand our purpose is to increase thecapacity of church-relatedpharmaceutical activities to provideeffective and efficient services.EPN’s ultimate beneficiaries are inline with the ‘Health for All’ ideal;however there is a specificemphasis on the poor andmarginalized. The Network’sintermediate beneficiaries are its

NETWORKING

Contact deals with various aspects of the churches’ and community’s involvement in health, and seeks toreport topical innovative and courageous approaches to the promotions of health and healing.

Contact, magazine of the World Councilof Churches is published quarterly inEnglish, French, Spanish andPortuguese by the World Council ofChurches (WCC).

This issue of Contact was published inpartnership with the EcumenicalPharmaceutical Network (EPN) andsupport from The Christian HealthAssociation of Kenya (CHAK).

Present circulation is 6,000 copies.

Contact is also available on the WorldCouncil of Churches’ Website: http://wcc-coe.org/wcc/news/contact.html

Articles may be freely reproduced,providing that acknowledgement is madeto: Contact, the publication of the WorldCouncil of Churches. A complete list ofback issues is published in the first annualissue of each language version.

Editorial committee: Eva Ombaka, StellaEtemesi, Jacqueline Nyagah.

Design and layout: Stella Etemesi andJacqueline Nyagah.

Printed by Kul Graphics LimitedP. O. Box 18095 Nairobi, Kenya.Email: [email protected]

The average cost of producing andmailing each copy of Contact is US$ 2.50,which totals US $10 for four issues.Readers who can afford it are stronglyencouraged to subscribe to Contact tocover these costs.

Inquiries about articles featured in thisparticlar issue can be directed toEcumenical Pharmaceutical NetworkP.O. Box 73860 - 00200 City Square,Nairobi Kenya. Tel. 254 20 4444823/4445020 Fax: 254 20 4445095Email: [email protected]

members—church-related healthservices and their representatives.

The Network currently has threemain programmes: development ofan active network with increasedpact; maximizing access toessential medicines for churchhealth services and their clients andincreasing the capacity of churchleaders and church-related healthservices to respond to the massivechallenge of HIV/AIDS treatment.

As part of their efforts to increaseaccess to essential medicines, theNetwork members have developeda set of 25 factors (guidelines) andan implementation strategy that willexpose the practitioner, the

consumer and the institution to thecritical issues of access. Theseguidelines include factorsnecessary for the institution toaccess the drugs and others toensure access for the customer ofthe institution.

Other access activities include thestrengthening of the church-relateddrug supply organizations so as toensure appropriate selection,supply, distribution, use andmanagement of themedicines andcapacity buildingto address thehuman resourcelimitations.

ECUMENICAL PHARMACEUTICAL NETWORK (EPN)Increasing positive health outcomes through church-related pharmaceutical services

Forty three health workers, clergyand theologians from 38 churchesand related organizationsrepresenting a spectrum ofChristian traditions came togetherfor this Consultation held inBreklum, Germany fromSeptember 25 to 30, 2005.

The consultation was organised bythe World Council of Churches(WCC), the Northelbian Centre for

World Mission and World Service.

The main objective of theConsultation was to considerimportant new and foreseeabledevelopments in the global healthsituation and the consequencesthese could have for the mission ofthe Church. The participantsengaged in study, dialogue,discussion and prayer in order tobetter understand the factors that

affect global health and healing. Asthe state of the world’s healthworsens, the participants made anurgent call for churches,congregations and individuals totake up the healing ministry in all itsdimensions more seriously.

Further details are available onh t tp : / /www.vehnan jyva .o rg /breklum/

The Global Health Situation and the Mission of the Church in the 21st Century:International and Ecumenical Study Consultation

contact - world council of churches€¦ · 4 contact n°181 –autumn/winter 2005 patent as a...

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