Bitter Pills:Medicines & The Third World Poor | Page 143

Up until independence in 1975, health spending in Mozambique had been allocated
almost exclusively to expensive curative services for the urban elite. Since then
there has been a radical reallocation of priorities and health resources. For example,
whereas 47% of the national drug budget was once consumed by the central
teaching hospital, it now receives only 10%. Priority is given to preventing disease.
But beacuse of the need for essential drugs, spending on drugs rose five times,
in real terms, in the five years after independence. ""
Mozambique stands out as having developed and implemented a comprehensive
drugs policy to support its overall health strategy. Within months of independence
all drug policy-making was centralised under the Technical Committee for
Therapeutics and Pharmacy which immediately started work rooting out wasteful
and unnecessary drugs. "4)

ESSENTIAL DRUG LISTS
Countless WHO reports have concluded that the single most important measure
n eeded to cut costs and ensure that drugs are used effectively is to limit the number
available to those "most necessary for the health care of the majority of the
population"." 5 '
As early as 1959 Sri Lanka acted to rationalise prescribing in the public sector. Under
the impetus of serious economic problems and resulting drug shortages, the
Government restricted all health service prescriptions to the 500 drugs on the Ceylon
Hospital Formulary. (16) Mozambique introduced similar legislation and its more
restrictive National Formulary in 1977 - the same year that WHO produced its first
model list of essential drugs. Since then a growing number of countries have made
their own selections of essential drugs based on local needs. At the last count, in
April 1982, 70 countries had restricted drug lists. (l7)
Many of these lists, however, represent little more than policy goals because they
have yet to be strictly enforced. Virtually all are intended to apply only to the
public sector. Moreover, even in the public sector only a minority of countries
have rationalised drug use to the same extent as Mozambique where doctors need
special permission to prescribe a non-formulary drug. "8) In many cases controls
on government purchases can be circumvented. Just one example is the situation
in Mexico, where company sales representatives can still promote their products
and distribute free samples in the hospitals. As a result doctors put pressure on
hospital administrators to buy drugs not included in the country's 'Cuadro basico'
- its list of 426 essential drugs. " 9)
Limited lists can only reduce drug costs if they are backed by an efficient purchasing
system. In Brazil the central procurement agency, CEME, bases its purchases on
a restricted list and has succeeded in buying drugs at under 50% of local commercial
prices. |20) A report of the United Nations Centre for Transnational Corporations
(UNCTC) describes this system as a trade-off in which the government agency
"applies its list to a restricted market, and the private sector collaborates by
providing it with drugs at preferential prices ... as long as the richer markets are
left unaffected". <2l) The obvious advantage of the system is that esential drugs
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