Bitter Pills:Medicines & The Third World Poor | Page 144

are secured cheaply for some of the poorest. But only a minority benefit from
these free drugs-an estimated 9% of Brazil's population in 1973. Meanwhile the
majority of the poor are still vulnerable to high prices and non-esssential products
in the private market. (22)
These shortcomings, common to many countries, are no argument against the
importance of limited drug lists. They underline the need for curbs on promotional
pressures and for controls to apply also to the private market.
Sri Lanka, Mozambique and Afghanistan are exceptional in having taken measures
to restrict both the health services and the private market to a selection of essential
drugs.(231 In Sri Lanka the National Formulary Committee reviewed 4,000 drugs
imported for use in the private sector in 1962 and recommended that they should
be reduced to 2,100. After a major policy review in 1971 import licences were
withdrawn from all but 600 approved drugs. This rationalisation of the private
market was achieved by removing all irrational combination drugs, products of
doubtful efficacy and unacceptable safety hazards and brands of almost identical
drugs. (241
Private medical practice was banned in Mozambique immediately after
independence, and the number of drugs granted import licences was cut from 13,000
to 2,600. This selection was further reduced with the removal of drugs considered
either non-essential or unnecessarily expensive. Now only the 355 drugs included
in the 1980 National Formulary are routinely supplied and prescribed. (25)

SAFER, MORE EFFECTIVE DRUG USE
Limited drug selections have major advantages in encouraging the safe and
effective use of medicines. Many health authorities draw up much shorter lists
of drugs that can be safely and effectively used by paramedics. For example,
Bangladesh has selected 31 drugs for primary health care use and in Sri Lanka
no more than 60 drugs are dispensed at rural clinics. In Mozambique the agentes
polyvalentes, paramedics with only primary school education and 6 months'
training, are restricted to using about 50 drugs. (26)
With fewer medicines in use it becomes a more manageable task for governments
to ensure that health workers and doctors receive vital drug information. For
example, the 1981 Proposed Essential Drug List for Zimbabwe includes details
of cost-effective treatments for common diseases and specific guidance on the
use of some categories of drugs like antibiotics. (27) Peru has compiled
information sheets on each basic drug and a number of countries have developed
standard treatment schedules. Mozambique's Therapeutic Guidesets out the firstline treatment for TB as a combination of streptomycin, isoniazid and
thiacetazone. Only if this fails should the second-line treatment of rifampicin and
ethambutol be given, as it costs 8 times more. Health workers are also urged to
avoid expensive syrups and drops unless they are strictly necessary as these
preparations can cost 20 times more than tablets. (28)
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