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CONCLUSION TO CHAPTER TWO

Infectious disease in developing countries drives mortality and morbidity to appalling rates, considering a large majority of infectious diseases are curable. Health status in developing countries is continually threatened by unsanitary living conditions, malnutrition, political problems, environmental problems, poor education and meagre funding. Developing a health care system on a limited budget that will care for the health-damaging results of these living conditions is one of the greatest challenges in health care delivery today. Current health programmes in developing countries have flawed infrastructures and a concentration on inappropriate interventions. Because of high associated opportunity costs for inappropriate health interventions, developing countries need to prioritise their health demands in order to meet those that are more pressing. Prioritising tools, such as the DALY, are part of a greater strategy in optimising the concentration on health care interventions. With the development of systematic economic methodologies for health care intervention prioritisation, it is possible that developing countries will be more able to facilitate the formulation of effective health policies. One target for greater economic analysis and a potential for better management is the area of pharmaceuticals, as is shown in the following chapter.

CHAPTER THREE

THE UTILISATION AND CONTROL OF

DRUGS IN DEVELOPING COUNTRIES

To find the impact of resistance on the cost of tuberculosis treatment in developing countries, it is important to show the context in which drugs, including antibiotics, are utilised, managed, marketed and regulated. This chapter analyses the role that pharmaceuticals play in developing countries, tracing their use and abuse and concentrating on those elements that may impede their potential as a comparatively inexpensive and effective health care intervention. Drug management and control will later be discussed within the context of tuberculosis treatment and tuberculosis drug resistance.

In developing countries, drug usage in the past could be described as chaotic at its best. These countries’ lack of control of drugs and their marketing has sadly resulted in a great and unnecessary loss of life. Nevertheless, changes in behaviour and attitudes are allowing for an improvement in this much needed remedy, although there is still a significant area left for improvement. There are many drugs available to cure infectious diseases which are predominant in developing countries, but this relies on these drugs' controlled accessibility, rationalisation of their use as well as a genuine interest in the social welfare of those individuals affected. Section 3-1 describes the impediments to correct drug usage in developing countries. Section 3-2 assesses attempts to better regulate drugs with the Essential Drugs Programme and the Bamako initiative. Section 3-3 looks at the influence of the actions of pharmaceutical producers and how they have affected drug utilisation in developing countries.

Introduction

In November 1935, a little girl named Hildegard unexpectedly pricked herself with an embroidery needle in the soft web of muscle between her thumb and first finger. Shortly after this, the wound became badly infected with streptococcus which spread up her arm in red flares. Her glands

under her armpit became swollen and she was admitted to the hospital for urgent treatment. Current treatment at that time was solely surgical and this girl was given fourteen lancing operations, all having no effect. Some days later, her glands became filled with pus, she developed a temperature of 39°C and her infection became blood-borne. The surgeon in charge wanted to amputate her arm in an attempt to save her life, nevertheless, another doctor suggested an alternative. He treated Hildegard with a new drug, Prontosil, and in only two days, her temperature had became normal. After repeated doses, she recovered completely without amputation. (Ryan, 1992).

The above story illustrates the dramatic effect that drugs can have in the treatment of disease. Many other health interventions pale in comparison, often leaving a patient drastically changed in appearance and well-being. In contrast, drugs have the potential to quickly treat a disease, restoring a patient back to health, with few unpleasant side effects. Modern drugs have revolutionised health care delivery. Compared to other procedures, modern drug therapy is relatively new, but is widely depended on for the treatment of most major diseases. In comparing drugs to surgery, drugs are also much safer. Although surgery is now considered a last resort, in many cases before drug treatment, it was considered the first and only resort. When considering treatment for a critical condition, given the choice between equally effective surgical and drug treatments, a drug treatment will almost always be chosen by doctors as it is assumed to be safer when compared to surgery, which is viewed as quite risky. Deaths in Britain from surgery are an estimated 10 times higher than deaths from drugs (Smith and Quelch, 1991). Also, surgery often requires a highly paid specialist to perform it, invasive procedures, sedatives, anaesthetics, close monitoring of the patient during and after surgery and even long hospital recovery time. What surgery requires is more frequently absent from drug therapy, making drug therapy both a more effective and less costly alternative in a monetary sense and in terms of a patient's time and productivity. With drug treatment, the patient can often spend more time as a productive member of society rather than spending that time recuperating from his or her condition. Additional savings come from the fact that large amounts of manpower are not needed for the administration of most drugs unlike the majority of other health care interventions. Pharmaceuticals are less labour intensive and hence, are of greater value where labour is an expensive component of health care delivery. Indeed, in many countries, drugs encompasses only 10-15% of all health care costs (Smith and Quelch, 1991). A concise example comes from examining antibiotics, which in many cases, are undoubtedly the most efficient method of treating bacterial infections. The majority of them are inexpensive, easily administered, very effective and involve fewer complications than surgery. Where drugs cannot be used to cure major diseases, intervention is comparatively clumsy and costly in terms of the funds spent by the provider, the labour and .equipment, and patient’s time and discomfort. In 1989, for instance, in comparing the cost of drug treatment to the cost of surgery for ulcers, the cost

of ranitidine treatment for one month was approximately US $59.11 whereas the cost of surgery itself was US $7 777.00 in the United States. This is one hundred and thirty-one times the cost of ranitidine, excluding physician services and hospitalisation (Sonnenberg, 1989). Drugs offer an ease of treatment for the doctor and health worker that few, if any, other health interventions provide. Without available drugs for treatment, health care would be very labour intensive and very expensive. Hence, pharmaceuticals play an essential role in cost-effective health care.

Despite the fact that pharmaceuticals are one of the less expensive and more effective health interventions available to health care providers they are not available in a large enough supply to meet the needs of those in developing countries. In 1988, it was estimated that 25% of the world's population consumed 80% of manufactured drugs and 75% of the population only had access to 20% of all drugs. Seven years ago, the WHO estimated that between 1.3 and 2.5 billion people around the world had little or no access to drugs (WHO, 1988).