Posts or Comments 20 July 2024

Monthly Archive for "February 2012"

Efficacy &Pharmacovigilence &Treatment Bill Brieger | 26 Feb 2012

Tanzania: fake drugs, wrong drugs, more drugs

Selling malaria medicines in Tanzania and elsewhere in Africa is a big business. The market is not one that is easily dominated by a few brands, although the Affordable Medicines Facility malaria (AMFm) would hope otherwise. It appears that volume of relatively low or lower cost malaria drugs is the path to profit, not sales of a pricey mega-drug.

New from Tanzania is that this vast market is attractive to all sorts of manufacturers, even those making fake drugs. According to The Citizen, “The Tanzania Food and Drugs Authority (TFDA) yesterday issued a public warning against the sham product marketed under the name Eloquine (Quinine Sulphate 300mg USP) and packed in a bottle containing 1,000 tablets each.”

IPP Media reported that, “the authority has seized 155 tins of the fake drugs in Dar es Salaam which were yet to be distributed” and a suspect has been detained. The company headquarters in Nairobi helped point out differences in packaging between their products and the fake ones. A major concern of course is that role the fake drug was supposed to play. Normally quinine would be used in a limited way such as for pregnant women, so it is unclear how the fake drug would have been marketed to make a profit.

All of this comes amid efforts of AMFm to ensure that prequalified anti-malarial drugs reach the market (public and private) at prices people can afford. Cheap fake drugs threaten this effort.  A Tanzania study sponsored by the Clinton Foundation/CHAI, “showed promising results: subsidizing the ACTs at the top of the supply chain successfully increased the stocking of ACTs in drug shops and brought down the price of ACTs significantly.”

Prior to AMFm, but after Tanzania changed its malaria drug policy from SP to ACT, “the saleability of ACT was negligible. SP was best-selling.” Pre-AMFm price differentials between ACTs and cheaper but less effective medicines, put ACTs at a disadvantage.
addo2.pngPart of Tanzania’s approach to improving quality of malaria case management in medicine shops is upgrading the quality of these.  Accredited drug dispensing outlets (ADDOs) are places where the sales people and the products are both upgraded. When Tanzania changed its malaria drug policy from SP to ACT, access to ACTs in the private sector was low, while focus was on the public supply of ACTs.  It appears that with the event of AMFm ACT supplies in ADDO shops and other private outlets, but this does not preclude the presence of inappropriate or substandard drugs in non-accredited shops known as duka la dawa baridi.

Despite improved access to ACTs and improved quality of front line medicine store outlets, Tanzania cannot let up on its pharmacovigilence. As we move closer to malaria elimination – for example in Zanzibar in Tanzania – the importance of appropriate parasitological diagnosis and prompt treatment will increase. We cannot afford to have fake and inappropriate drugs compete with ACTs.

Indigenous Medicine &Social Factors &Treatment Bill Brieger | 19 Feb 2012

Questions Raised on Indigenous Medicine in Ghana

Azusa Sato raises an important question in a research article on health service choices by Ghanaians – why do individuals turn to traditional medicine only as a second recourse?

In general, Sato’s review of literature on health care choices cite the maxim that indigenous medicine is easily accessible, affordable, available and acceptable. The irony in this study is that indigenous medicine is a more popular second choice than first.  Sato shows that “The most common acute complaint was ‘fever, headache and hot body’ (334/460, or 72.6%),” which people may interpret as possible malaria in a local context.  Interestingly, only 45 respondents used indigenous medicines first whether they sought acute care from outside or found/made it at home.

When a second or additional recourse was added, the number using indigenous medicine rose to 103 people for acute illnesses. Respondents who chose indigenous medicine at some point overwhelmingly had a favorable opinion (77%) of this form of medicine.

dscn3872sm.jpgGhana has a dynamic health system that is attempting to bring more people into the orthodox care orbit.  The national health insurance scheme to which over 60-70% of people subscribe, make care seeking at orthodox health facility (either public or private) more attractive and affordable.  Ghana is also working on expanding primary health care through establishing community health compounds – a local building donated by the community and staffed by government trained community health officers. Although these measures are a ways from attaining universality, they may in part explain a tendency to choosing orthodox care first.

Another interesting irony of Ghana’s pharmacy system is the the health authorities have actually approved some indigenous malaria medicines (see picture). These are sold alongside Coartem and artesunate-amodiquine in licensed shops and pharmacies.

Pharmacy stocks and consumer care seeking choices support Sato’s recommendations for seeking more evidence to develop an integrated system of care in Ghana.  With global health funding in seeming decline, any effort to find additional efficacious local resources to expand malaria treatment are most welcome.

Community Bill Brieger | 16 Feb 2012

New Ministry Directorate Coordinates Village Health Workers in Burkina Faso

Burkina Faso has had an active volunteer community health worker (CHW) scheme for many years. CHWs were the mainstay of guinea worm elimination, for example. At a point they even provided community case management (CCM) of malaria when chloroquine was the first line drug.

In 2008 the Ministry of Health realized that the system of multiple volunteers for multiple health issues was not providing integrated services at the grassroots. At this point the Ministry produced two valuable documents. The first documented that various tasks that CHWs can play in the community, while the second developed an integrated communication strategy for CHWs.

dscn7742-chw-flipchart.jpgIt was also during this period that Burkina Faso was successful in winning two Global Fund Rounds to support malaria, Rounds 7 and 8, which have now been merged for easier management. One component of the combined Round 7/8 is delivery of malaria CCM by the workers known locally as Agents Sante Communautaire (ASC). PLAN Burkina is leading that effort and has revised ASC training guides and produced behavior change materials – a flipchart – for ASCs to use in educating the public about cause, prevention and treatment of malaria (see photo).

Normally there are two ASC per village is the population is 3000 or less and at least 4 in larger villages. The Global Fund supported work asks the community to designate one ASC to be trained for malaria CCM and educational activities.

But back to the Ministry – recognizing the need for a well coordinated delivery of an integrated minimum package of community services, the Ministry created just one year ago a new Directorate for Community Health. This Directorate works closely with all program areas in the MOH to ensure and coordinate community delivery of those basic services.

The Directorate draws on existing health staff. Of the seven or eight members of the District health Management Team, one person is specifically in charge of community activities. Also at the primary care health center level there is what is termed an ‘itinerant’ health worker whose job is outreach to and mobilization of communities and especially the supervision and support of ASCs.

In the meantime the Global Fund project implementers have hired animators to work with the malaria ASCs in the catchment of a health center and district supervisors to coordinate the animators. Although this appears to be a parallel system, the ASCs still must link with their nearest health center to get supplies of malaria medicines, and th animators help summarize malaria ACS records for onward transmission to the health center.

At present the system of itinerant health workers cum ASC supervisors needs strengthening because public the sector experiences staffing and funding shortages that often keep these theoretically mobile workers in the clinic.

The new Directorate of Community Health has begun negotiations and discussions with all parties to harmonize the overall ASC scheme with the specific needs of the malaria ASC effort. Ideally all ASC in a village should be able to provide the integrated package including malaria services so that the current single malaria ASC is not overburdened and frustrated.

While still a work in progress, the new Burkina Faso Community Health Directorate points to the future where the aims of the Alma Ata Primary Health Care Declaration can still become a reality for neglected rural populations around the world.


PS – the VOICES Project website is undergoing some major improvements. In the process the original link to this blog has become a link to the new Voices blog. Therefore you can keep up with Voices activities and those of partners at Happy reading of both blogs!