The Lancet NCDI Poverty Commission: bridging a gap in universal health coverage for the poorest billion (2) Over prescription of drugs in Africa

5 October, 2020

Dear of Hifa, I accept the suggestion of Neil to publish my article in HIFA. However it contains political aspects that should be taken in due consideration, maybe with a comment done by Neil or Tony. [*see note below]

The article criticises much the 'absence of local health authorities' in curbing the phenomenon of over-prescribing.

Who am I to do so?

Thanks

Massimo

Dodoma

HIFA profile: Massimo Serventi is a long-standing Pediatrician working in Africa since 1982. He has worked for several NGOs in 6 African/2 Asian countries. His interests include clinical and community pediatrics, adherence to clinical guidelines and school education as the major determinant of good health. massimoser20@gmail.com

Citation: Serventi. Over prescription of drugs in Africa. South Sudan Medical Journal 2020; 13(3):124

http://www.southsudanmedicaljournal.com/archive/august-2020/over-prescri...

There is a worldwide 'epidemic' of inappropriate and excessive prescription and selling of medicinal drugs. In Africa many people are poor and often have a low level of education. A large proportion of an ordinary family’s spending may be used to buy drugs. A study done in Tanzania [1] concluded that 84% of children aged under five years coming to outpatient clinics with a cough or diarrhoea are prescribed an antibiotic.

The seriousness of this trend is not perceived or addressed by authorities or politicians who hear people asking for more sophisticated drugs. If fewer drugs, particularly antibiotics, are available there may be less votes. Also, both doctors and patients want more drugs to compensate for the scarcity of them in the past.

Moreover, health insurance schemes may have the unintended consequence of aggravating the situation: patients may feel that their insurance premiums have paid for the drugs in advance and this leads to an increased demand even though a prescription of such medication may be clinically inappropriate.

Widespread privatisation of health services clearly contributes to this problem. Blood and other tests are carried out and then drugs prescribed within the premises of the same clinic. More prescriptions mean more profit for the clinic and hence higher salaries for the staff. Private pharmacies are mushrooming in African towns - many are illegal with inadequately trained staff; people with money can buy any drugs they want without a prescription.

What to do to control this trend? Who has the responsibility to address this serious issue? The World Health Organization (WHO) is aware of the situation, with resistance to antibiotics being a top concern. [2] Antibiotics should usually only be prescribed to less than 20% of patients/children attending a clinic. [personal communication]. WHO recommends more training for doctors so they only prescribe and dispense antibiotics and other drugs when, according to current guidelines, they are needed. [2]

The Integrated Management of Childhood Illnesses (IMCI), first prepared 1995, was indeed a laudable move to optimize medications for sick children.[3] For a while prescribing standards improved but then the market regained momentum; newer antibiotics, that were intended mainly for hospital use, are now widely dispensed and sold today in private clinics. Moreover, pharmaceutical companies have complicated the market with a range of other products including probiotics, vitamins, haematinics, and special foods/ingredients that create an artificial need among the poor.

A political approach should be adopted, based on ethical imperatives: it is a crime to impoverish the poor for personal gain; prescribe according to guidelines and not to gain excess profit; strictly adhere to national (that are available but rarely adopted) or WHO prescribing guidelines.

It is essential that doctors and all prescribers explain to patients their diagnoses, the reasons for a prescription and, also, for not prescribing in certain situations.

References

1. Gwimile JJ, Shekalaghe SA, Kapanda GN, Kisanga ER. Antibiotic prescribing practice in management of cough and/or diarrhoea in Moshi Municipality, Northern Tanzania: cross-sectional descriptive study. The Pan African Medical Journal 2012;12:103

2. World Health Organization. Factsheets; Antibiotic resistance.

3. World Health Organization. Integrated Management of Childhood Illness (IMCI)

[*Note from HIFA moderator (NPW): Thank you Massimo. I hope this will stimulate discussion on this very important topic, which remains unresolved. Tony refers to Tony Waterston, lead moderator of our global child health forum CHIFA: https://www.hifa.org/join/join-chifa-child-health-and-rights ]