Drug donations sent to “help” developing countries can actually do more harm than good. Iris Stehmann explores the reasons why and explains what should be done instead

According to the World Health Organization, developing countries already spend 25-66% of their meagre health budgets on pharmaceuticals,¹ and it seems that drug donations could ease the financial burden. But giving the wrong drugs to the wrong country can do more harm than good.

Bombarding the developing world with out of date medicines packaged in incomprehensible languages or giving “gifts” of lip balm, haemorrhoid cream, and breast implants can bring despair, waste, suffering, and extra expense, according to an article in the New York Times.² In 1994, a chartered plane containing a sports soft drink arrived in Zaire to help treat cholera—the drink could be dangerous if given to children. Then, perhaps more ill advised, a Zambian mission hospital received a box of amphetamine based appetite suppressants, which it had to destroy.³

A World Health Organization audit of Albania in 1999 noted that 50% of donated drugs were inappropriate or useless and would have to be destroyed. Two thirds were due to expire, and one third were identified by brand names unfamiliar to Albanian health workers. In 1991 Pharmaciens Sans Frontières, a charity that sends pharmacists to developing countries, found that only 20% of the 4 million kg of drugs collected from 4000 French pharmacies for international aid programmes could be used.² The rest of the drugs had to be burnt in a complicated and costly way to comply with international law.⁴

But inappropriate donations are not only wasteful and expensive to dispose of, they can also threaten local production of affordable generic drugs based on local needs. Contrary to common belief, many developing countries have their own manufacturing capacity, and few countries are entirely dependent on imports or donations. Inappropriate donations can undermine local efforts to promote standard drug lists based on effective and safe treatment of common diseases in the area. Rational prescribing, development of affordable generic drugs and training based on familiar generic names could also suffer. A study conducted by the World Bank in flood ridden Mozambique in 2000 concluded that it was better to help improve a countrys own pharmaceutical sector rather than set up competing and parallel systems.

But although it may seem that drug donations are not the solution, donations made properly can provide essential medicines to developing countries struggling with inadequate health budgets. Of the 17 million deaths from communicable diseases each year, most occur in developing countries and are preventable. The vaccines and treatment exist; the money to buy them does not. One way of overcoming this shortfall is via public-private partnerships with large corporations working alongside local non-governmental organisations (NGOs) and international bodies such as the World Bank and the WHO. If a drug is too expensive and there is no generic equivalent then donations can fill a gap, at least temporarily.

One example of a successful partnership is Mercks Mectizan programme for river blindness (onchocerciasis), which has treated 25 million people in 32 countries between 1987 and 1998 and was available to all those who needed it for as long as it was needed. But questions have been raised about corporate donations impact on wider national health policies and the potential of creating a need that cannot be afforded once the donation stops.

Despite past inconsistencies in drug donations, guidelines for potential donors do exist. In 1996, the WHO interagency guidelines, the first specific guidance on drug donations, were drawn up.⁵ This document stipulates that drugs should be requested by the recipient country and be on their national essential drugs list. They must not be free samples, nor have been returned to pharmacists by patients, and they should have a shelf life of at least one year. The language on labels should be understandable and include the generic name, expiry date, and recommended dosage.

More recently an international consortium of health NGOs has sought to build on the WHO guidelines with a step by step guide on good practices in drug donation, aided by the European Commission. The guide aims to inform an increasingly wide spectrum of donors, from medical students and sympathetic tourists to NGOs, pharmacists, church groups, and industry. Leaflets, flyers, posters and a video, “Making drug donations better with care,” have been produced to get the message across. A website has also been launched (www.drugdonations.org).

Today the consortium is pushing for the WHO guidelines to be given some teeth. It wants drug donations not meeting the guidelines to be banned by decree or resolution. It believes that the next step should be to develop an effective monitoring system to check if WHO guidelines are being followed.

There is currently a means of reporting unhelpful donations via the WHO medicines website (www.who.int/medicines/library/par/unhelpfuldonations.doc). But as yet not a single form has been filled in. The consortium fear that the WHO do not see monitoring as a priority, and therefore plan to raise the issue at a WHO technical seminar for international staff in September. As an alternative and more efficient way of reporting the inappropriate donors, the consortium is proposing that the recipient report on every donation, good and bad, to avoid the impression that they are blowing the whistle.

Up to now, the impetus has been on the donor nations to improve their drug donations, but the focus may well change. As one Tanzanian doctor said: “We at the receiving end have got to learn to say no.”

What does this all mean for you as a student? First of all, it is possible that in your future professional life you may have to check the guidelines to ensure that drug donations are taking place appropriately. But, perhaps more immediately, political lobbying is needed for the improvement of access to quality health care. Students are certainly committed: last year, for example, the International Federation of Medical Students Associations (IFMSA) was actively involved in the Dutch campaign on access to medicines. Or why not support a group such as Wemos (www.wemos.nl/), founded in 1981 by medical students in the Netherlands, which now employs 20 people? Its aim is to influence international policy to create standards, regulations and agreements to protect and promote peoples health in developing countries.

Wemos, PO Box 1693, NL-1000 BR Amsterdam, Netherlands. (Tel: +31 20 468 8388; Fax: +31 20 468 6008; Email: pharmaceuticals@wemos.nl)

This article was written on behalf of Albert Petersen, Difaem, Germany (petersen.amh@difaem.de), Carlota Merchán, Prosalus, Spain (educacion@prosalus.es), Serge Barbereau, ReMed, France (serge.barbereau@wanadoo.fr)