development dialogue 1995:1 Making National Drug Policies a Development Priority A Strategy Paper and Six Country Stories Editorial Note 1 Health and Drug Policies: Making Them the Top of the Agenda. A Strategy Paper 5 Norway’s National Drug Policy: Its Evolution and Lessons for the Future Marit Andrew, Bjørn Jøldal and Göran Tomson 25 A Search for Balance: Pharmaceuticals in Sri Lanka. Pioneering Steps in a Receptive Environment and Subsequent Accommodations Krisantha Weerasuriya 54 Bangladesh: A Tough Battle for a National Drug Policy Zafrullah Chowdhury 96 Australian National Drug Policies: Facilitating or Fragmenting Health? Mary Murray 148 One Step Forward, Many Steps Back: Dismemberment of India’s National Drug Policy Praful Bidwai 193 Drifting Through Time: Pharmaceutical Policies in Mexico Nadine Gasman 223 Editors: The opinions expressed in the journal are those of the Sven Hamrell Olle Nordberg authors and do not necessarily reflect the views of the Dag Hammarskjöld Foundation. Sub-editors: Most contributions to this issue of Development Wendy Davies Jason Pearce Dialogue were ready in revised and edited form at the .. end of 1994. One article was, however, delayed until July 1995. The contributors have all updated their Advisory Editorial Committee: articles during August 1995. The issue was printed in Ahmed Ben Salah the last week of September. Just Faaland Joseph Ki-Zerbo Marc Nerfin Göran Ohlin Juan Somavia Editorial Office: The Dag Hammarskjöld Centre Övre Slottsgatan 2 S-753 10 Uppsala, Sweden Fax: +46-18-122072 ISSN 0345-2328 Telex: 76234 DHCENT S Printers: Subscribers are kindly requested to inform the Dag Motala Grafiska AB Motala, Sweden Hammarskjöld Centre of any changes of address or subscription cancellations. Editorial Note It might reasonably be assumed that the provision of safe, effective and affordable medicinal drugs of good quality and in the right quantity to the whole population would be a priority in the health policy of any country and a relatively uncomplicated goal to achieve. Reality seems to show otherwise. Apparently, it is not enough that the most effective essential drugs have been identified and that they can be produced efficiently, at low cost and at an acceptable level of quality, in most parts of the world. Nor does it matter, it seems, that many lives can be saved and that the financial savings that derive from a ra- tional use of drugs can be considerable. What at first glance looks like a simple matter becomes utterly complicated when confronted with the realities of today’s world, where vested interest, economic gain and professional prestige predominate and where different actors tend to further their own interests rather than those of the majority of the population. Consequently, in most countries, the parties con- cerned have not been able to reach a consensus and form a drug policy which can benefit all strata in so- ciety. The importance of National Drug Policies as an integral part of—and a strong building block in—an over- all national health system came to the fore in the 1970s, although important advances in the field of phar- maceutical policies had been made in some countries much earlier, as is evident from the country stories related here. One important initiative was taken by the Non-Aligned Movement at its Meeting of Heads of State in Colombo in 1976, when the political aspects of the pharmaceuticals problematique were high- lighted and the role of transnational corporations (TNCs) as an instrument of northern domination was particularly criticised. UNCTAD followed up on the recommendations from Colombo with its important work on transfer pricing mechanisms and the patent system, both of which are used to obstruct the devel- opment of indigenous pharmaceutical industries in Third World countries. The UN Centre on Transna- tional Corporations also played an important role during this period by drawing up a Consolidated List of banned, withdrawn or severely restricted products. It was. however, only natural that the World Health Organization (WHO) should take the lead in the com- plicated work of formulating drug policies and supporting their implementation in the increasingly com- plex political, economic, social and technological environment of the modern world. The introduction of the concepts of Essential Drugs and the Rational Use of Drugs, the Nairobi Conference on this subject in 1985, and the Ethical Criteria for Medicinal Drug Promotion should be mentioned as milestones in this work. A wealth of literature on the political, economic and social aspects of medicinal drugs and their use. par- ticularly in Third World countries, was published in the 1970s and stimulated interest in this particular field. However, relatively few countries managed to take up the challenge raised in the international de- bate and to carry through a comprehensive policy; many of those who tried to do so ran into considerable problems with implementation. In the latter part of the 1980s, as neo-liberalism, privatisation and a belief in unrestrained market forces gained the ascendancy, the interest in public initiatives in the area of drug policies decreased and attention was directed elsewhere. Some people may argue that the question of National Drug Policies is purely technical and logistical, and of limited interest to those who work in the broad field of development. A few statistics may correct this false image. About 2.5 billion people—or half the world's population—continue to be denied their right to health. They lack reliable access to essential drugs, while at the same time overuse and abuse of medi- cines is frequently reported. The global pharmaceutical industry is estimated to turn over about USD 220 Development Dialogue 1995:1 - The Journal of The Dag Hammarskjöld Foundation Editorial Note billion annually, out of which Third World countries, with three-quarters of the world’s population, ac- count for only USD 44 billion. About 90 per cent of the world’s production of pharmaceuticals originates in industrialised countries, which also account for 80 per cent of consumption. TNCs are steadily increas- ing in size while their number is decreasing as a result of continuous mergers of companies in a context of intense competition for markets and products. This trend illustrates their powerful domination of the market. Where is the consumer in these developments and who is taking care of his or her interests? It has been noted repeatedly that innovation and the search for new products are not directed towards satisfying the basic health needs of countries in the South, which would prefer to see bold initiatives to combat the most serious illnesses that afflict their populations, such as malaria, tuberculosis and sexually transmitted diseases. Instead, the R&D initiatives of the industry in the North are primarily directed to- wards the development of high-technology, specialised and often expensive medicines for use in industri- alised countries where customers can more easily pay for increasingly expensive pharmaceuticals. The vast majority of people in Third World countries have little or no access to effective and safe medi- cines. Although many Third World governments spend 30-50 per cent of their health budgets, and some- times more, on medicinal drugs, compared to about 10 per cent in many industrialised countries, the over- all health budget and health service coverage in the countries of the South remain severely limited. Moreover, in some Third World countries, up to 75 per cent of the drugs moving in the market may be out- side the control of health ministries. This highly unsatisfactory situation may have become even more seri- ous during the last few years of extensive deregulation. The attitude underlying it contrasts sharply with the previously predominant view that there must be some kind of official control to ensure that drugs are efficacious, safe and of adequate quality, and that the information provided about them is reliable. This state of affairs highlights the regrettable fact that WHO has had little influence over the big private market. Waves of privatisations during the past decade have aggravated the situation and have in some countries reached absurd proportions. Vietnam and Laos are examples of countries where private phar- macies have been mushrooming in recent years and people go and buy whatever they want. In Brazil, ac- cording to recent reports, thalidomide is on sale again without proper safeguards against its misuse. What makes the situation so serious is that the intensive marketing of pharmaceutical products has di- luted the comprehensive concept of health to such an extent that for many people health now equals ‘Doc- tor+Medicine’ or just ‘Medicine’, irrespective of safety, price or quality. In the context of the new philosophy that is spreading all too rapidly, concern for basic factors such as nutrition, clean water and sanitation as the pillars of good health seems to be lost in the remote distance. Another problem is the difficulty of involving the users—the consumers—in a discussion which has been presented to the public as a scientific and technical issue and the preserve of the medical profession. De- spite the work of a few enlightened governments, such as those of Australia and Norway, and the inde- fatigable efforts of Non-Governmental Organisations (NGOs) such as Health Action International (HAI) and the Consumers International (formerly the International Organisation of Consumers Unions, IOCU), attempts to ‘democratise’ the debate on drug policies are proceeding much too slowly. It was with the aim of contributing to a much wider discussion on this theme that the Dag Hammarskjöld Foundation organised a seminar on ‘Another Development in Pharmaceuticals’ at the Dag Ham- marskjöld Centre in Uppsala in June 1985 and a follow-up ‘Third World Journalists Seminar’ on the same Editorial Note 3 subject during the World Health Assembly in Geneva in May 1986.