Safe drugs for everyone : WHO interview , O. Ransome-Kuti

4 World Health • Morch-Aprill992 WHO Interview Safe drugs for everyone N igeria passed new drug legislation in 1989 to help solve problems in distribution and utilization of medicines. Professor 0. Ransome-Kuti, Minister of Health of Nigeria, was interviewed by Daphne Fresle, Editor of the Essential Drugs Monitor, WHO, Geneva. Professor Ransome·Kuti, what were the maior areas of concern that led to Nigeria's new drug legislation passed in December 1989? When the present Government took office a national essential drugs list was already under preparation by a group of doctors, pharmacologists and pharmacists. The list was meant to contain those drugs considered necessary to treat the diseases afflicting our people. At that time it comprised about 200 drugs, but actually about 3000-4000 varieties of drugs were circulating in the country and being sold. Another problem was that, although so many drugs were imported, when people went to the pharmacist and tried to buy what I would call "ethical drugs"-for example those necessary for treating conditions such as diabetes, hypertension, arthritis, or peptic ulcer-they were not available. Instead, the pharmacists preferred to stock mainly 'over the counter' drugs that they could sell freely, without a prescription. Rather than practising pharmacy they were behaving like drug peddlars. So a major goal of the legislation was to create a situation in Doctors in Nigeria have not in any way opposed the essential drugs list. They are all now learning how to improve their prescribing habits. As far as the doctors are concerned there is no problem. which pharmacists would stock all drugs necessary for our health care, while at the same time banning nonessential drugs from the country. Moreover, some 50-60% of drugs in circulation were fake or substandard, which represented another problem we faced. We discovered that people were importing into the country drugs which looked like the genuine article but which only contained inactive substances, such as powdered chalk. Such 'products' were also being manufactured within the country. People had imported machines, such as capsule- or tablet- making equipment, and were producing these fake drugs. A further concern was that our people were being bombarded with misleading advertisements. For example, there might be ten or more varieties of chloroquine on the market, all sold for treatment of malaria under different brand names. The general public, without realizing that all these drugs are in reality the same thing, buy one product, and if the patient Professor 0/ikoye Ransome-Kuti Minister of Health , Nigeria didn't improve they change to another brand of what is actually the same pharmaceutical substance. What were the main thrusts of the pharmaceutical legislation you enacted? Firstly, under the new law any drug which is not on the essential drugs list cannot be imported, manufactured, sold, exposed for sale, or distributed in Nigeria. Secondly, drugs have to be advertised and sold under the generic name (the pharmaceutical name of the basic component). This means that when the pharmacists label their drugs the generic name must appear very boldly under the brand name: it should be at least three-quarters the size of the brand name. After the brand name is given it has to be followed by the words "brand of' followed by the generic name. Another decree also made it a punishable offence to sell any drug which was found to be World Health • Morch-Aprill992 substandard or fake. We set up a task force, headed by an army officer, in all the Nigerian states, which went round checking market-places and pharmacies to see that none of these counterfeit drugs were being sold. How do you manage to check the quality of the drugs? One of our major deficiences has been quality control. The Federal Government has made available US$ 2 million to set up quality control facilities in various parts of the country. This should enable us to determine the quality of any drug within a very short time. We hope that this new investment will enable us to establish an effective quality control service to check the quality of any drug immediately it is suspected. In some countries that have made radical changes in drug policy there has been considerable organized opposition, for example from industry and also from professional groups, to the new legislation. Did that happen in Nigeria? Doctors in Nigeria have not in any way opposed the essential drugs list. They are all now learning how to improve their prescribing habits. We are holding workshops on the rational use of drugs in our hospitals and doctors are now beginning to prescribe generically. As far as the · doctors are concerned there is no problem. The pharmacists are another matter. They mounted a spirited campaign of opposition. The first thing they said was that if you limit the number of drugs in the country you are going to limit the ability of the doctors to prescribe. We replied, "The doctors are not complaining and they are the ones who prescribe, not you. Let the doctors complain first." So then they said, "Why don't you use the list for the public sector and Jet the private sector import any amount of drugs they like." I said, "If you can demonstrate to me that the diseases affecting people in the private sector are different from those affecting the people in the public sector we shall adjust the list accordingly. Drugs are meant to treat diseases and if there is any difference in the incidence of disease between the p~vate sector and the public sector, make a case and let the doctors present it." Moreover, if any doctor finds that a drug needs to be imported for a particular case there is provision under the decree for a special permit to be requested. So we are not limiting the doctor in any way. During my travels I am sometimes challenged by multinational groups. They request a discussion and ask why we have passed this legislation. I explain its rationale and goals. Sometimes I get the impression that they believe that we were copying the WHO essential drugs list. I say to them, "No, we developed our own essential drugs list. We know our patterns of disease, we have listed the drugs we need for each disease and we produced our national essential drugs list." While not in any way denying WHO's valuable work in this area, we s do not need anybody to tell us what our national essential drugs list should contain. The multinational groups also call for a difference to be made between the private and the public sectors, so I tell them what I told the pharmacists: "Drugs are meant for diseases not for sectors." Yet often there is no dear distinction because drugs may be prescribed in the public sector but bought in the private sector. Exactly, and so I explain that if you allow all these nonessential drugs in the private sector nothing will stop the two becoming mixed. Anybody can just go to the private sector and order. Even after you establish a stable supply of rationally prescribed drugs, if the general public and patients, without understanding how to use them, put pressure on health professionals for inappropriate therapies or modes of administration, or buy 'over the counter' products in a completely irrational way, then all that previous work is wasted. We believe the public should be enlightened on what drugs are for. to create a situation in which pharmacists stock necessary drugs while banning non-essential ones. 6 When we attempted to improve prescribing practice through the use of standard treatment plans (known in Nigeria as "standing orders") we met the objection that this would make health professionals obsolete. We were accused of saying that anyone could treat themselves. But what I want is that doctors should get down to treating conditions that are serious and not waste their time treating minor ailments such as insignificant coughs. I would like to see our "standing orders" become freely available so that people could learn appropriate and simple therapies. Finally, how do you see the future development of Nigeria's pharmaceutical policy? I think we should proceed in an orderly manner. For example, we should first of all fully implement the Essential Drug decree. Then we need to implement and learn from the experience of our Essential Drugs Programme. We must begin to educate the public and get our doctors to adopt rational prescribing habits. Then the next step is to begin to manufacture our own drugs in support of our essential drugs policy; that is very important. And then we need to World Heahll • Mordt-April1992 get the pharmacists to meet their professional responsibilities so that they form the vehicle by which these drugs can reach the public and contribute to the solution and not the problem. I also believe that we must extend our system of quality control so that we can effectively monitor what is going on in the drug scene. These are the steps that I believe will enable us to reach our goal of ensuring the national availability and rational use of effective medicines. • Professor 0. Ransome-Kuti is the Nigerian Minister of Health, Federal Minis try of Health, PM.B. 12597, lkoyi, Lagos, Nigeria.