STD Drugs
Preview Chapter 7
Introduction
This chapter presents a framework for achieving an adequate level of drug availability, accessibility and affordability for STD treatment by: 1) increasing the efficiency of pharmaceutical services; 2) allocating adequate funding; and 3) implementing user charges and other mechanisms to recover costs.
Increasing Efficiency
Rational use of drugs is the ultimate goal of national drug policy. One of the first steps is to select the most appropriate drugs. For STDs, drug selection is based on the following criteria:
Quantification
Quantifying drug needs is a critical step in the process of supplying drugs for STD treatment and requires the merging of three sets of data:
A list of drugs used for the treatment of STDs that are registered in the country, with their unit prices
Average drug quantities required for the treatment of every STD condition
Epidemiological data (STD prevalence or absolute numbers); strategies for estimating prevalence are described
Procurement
Procedures for procuring STD drugs are similar to the techniques and rules guiding procurement of other drugs. Low-price procurement may be achieved through the following:
- International open vendors for generic products
- Nonprofit organizations such as UNIPAC, the International Dispensary Association, WHO and the Pan American Health Organization
- Joint drug procurement, another mechanism to a lower price through economies of scale, overhead sharing and higher volumes, has been successfully achieved by Comité Maghrébin d'Achats en Commun in Northern Africa and the Eastern Caribbean Service.
Storage
Since antibiotics are very sensitive to light and temperature, proper storage is essential. Poor storage may lead to loss of drug potency. This increases the risk of resistance or even toxicity.
Distribution
The majority of drugs used in STD treatment are commonly prescribed for other infections. Health problems posed by STDs are often addressed within the existing framework of primary health-care services rather than through specialized STD clinics. Therefore, the challenge is to ensure that STD drugs are actually used for STDs. STD kits and syndrome selective packaging are useful distribution strategies for ensuring that STD drugs are used primarily for STD infections.
Rational prescribing and strategies for improving adherence to prescribed treatment are other approaches to maximizing the impact of STD drugs.
Funding
Funding is usually the most critical factor in the success of STD care and prevention programs. Reconciling budgets and needs is one step in the process. Sensitivity analysis is a technique for doing this. Additional funds can be found through reallocation from other budget line items, from external donors, or by introducing some form of cost-recovery or cost-sharing for use of health services.
Recovering Costs
- Cost-recovery, cost-sharing
- Social marketing
Conclusion
Due to the high cost of effective STD drugs, having an adequate supply involves a compromise between therapeutic requirements, financial constraints and the orientation of national drug policies.
Introduction
Sexually transmitted diseases may rank as the fifth leading cause of morbidity in developing countries.1 In addition, the presence of an STD, particularly one that produces genital ulcers, increases the risk of HIV transmission.2 To interrupt the transmission of STD and take advantage of synergism between STD and HIV prevention requires that effective drugs for STD treatment be available, accessible and affordable; and that appropriate information and education be provided to patients.
Unfortunately, the most effective antibiotics, such as quinolones or third generation cephalosporins, are under patent protection and have higher market prices than public health institutions and patients in many developing countries can afford. Therefore, providing drugs for STD treatment is often a compromise between therapeutic requirements and financial constraints. The challenge for many countries is to reach such a compromise in accordance with their national drug policies.
The purpose of this chapter is to provide a framework to guide STD program managers in achieving an adequate level of drug availability, accessibility and affordability for STD treatment. The three key strategies of this framework, as shown in Figure 1, are: 1) increasing the efficiency of pharmaceutical services; 2) allocating adequate funding; and 3) implementing user charges and other mechanisms to recover costs.3
Increasing Efficiency
The ultimate goal of a national drug policy is to ensure the rational use of drugs. This means that the appropriate drugs are prescribed, available at the right time, affordable those who need them and dispensed correctly. It also means that they are taken in doses as directed at the right intervals and for the necessary length of time.4 The first step to achieving this goal is to select the most appropriate drugs.
Drug Selection
General criteria
Selection of essential drugs follows well-defined criteria based upon:
- Pattern of prevalent diseases
- The health infrastructure (e.g., types and levels of health institutions)
- Training and experience of health personnel
- Socioeconomic factors
- Characteristics of the drug, which include quality, safety, efficacy, price, availability and cost-benefit ratio5
Achieving consensus on the drugs to be used can be relatively easy when treatment is well-established and requires generic products only. Prescribers, dispensers and administrators face a more complex task when additional criteria further complicate the process, as in the treatment of STD.
Criteria for STD drugs
At a 1993 meeting organized by the World Health Organization (WHO),6 members of an advisory group on STD treatments agreed to the following ideal criteria when selecting STD drugs:
Note: Table 1 lists drugs that can be selected for STD treatment based on these criteria.)
Efficacy is the critical factor when choosing among available regimens. Ideally, treatment for STDs should offer at least a 95 percent cure rate. Unfortunately, low-cost antibiotics and chemotherapeutic agents such as tetracycline and penicillin that once provided high cure rates often no longer do so, in part because of illogical therapeutic use and self-medication, which induce the development of drug resistance.
Most resistance to STD drugs has developed in the organisms that cause gonorrhea 7 and chancroid.8 In Neisseria gonorrhoeae, chromosomal resistance involves penicillin and other therapeutic agents (tetracycline, spectinomycin, erythromycin, thiamphenicol and cephalosporins) and plasmid-mediated resistance affects penicillin and tetracycline. There is growing evidence of decreasing sensitivity of N. gonorrhoeae to quinolones in travelers from southeast Asia and from central Africa. 9 Haemophilus ducreyi, which causes chancroid, has also developed resistance to antibiotics. Plasmid-mediated resistance has been found against ampicillin, sulfonamide, tetracycline, chloramphenicol and streptomycin. (For the current WHO recommendations, see Chapter 8.)
The reasons for the emergence of antibiotic resistance are numerous and complex. They include the practice of self-treatment, repeated episodes of gonorrhea and incomplete use of anti-chlamydial cotherapy in those infected with both gonorrhea and chlamydia.10 The emergence of new forms of resistance can be unpredictable (e.g., plasmid-mediated tetracycline resistance), and the ease and extent of international travel mean that such problems can spread rapidly.
It is important to identify changes in the local epidemiology of resistant organisms on an ongoing basis. Likewise, selection of STD drugs for individual countries should be based on well-designed epidemiological studies conducted regularly in the populations that frequently use STD services.
For example, in a sample of 50 patients with uncomplicated gonorrhea at the outpatient department of a central hospital, in vitro tests demonstrate 42 cases of resistance to co-trimoxazole. Thus, an alternative regimen should be defined using one of the following drugs: ciprofloxacin, ceftriaxone, cefixime, spectinomycin or kanamycin. The choice should be guided by the criteria mentioned above. In many developing countries the treatment cost will be the decisive factor.
Gonococcal infection is prevalent in many areas. The drug chosen to treat syndromes in which gonorrhea is present (e.g., urethral discharge, vaginal discharge and lower abdominal pain) can have a major impact on the total cost. Gonococcal strains worldwide now show high levels of resistance to many common and sometimes newer antibiotics. As a result, WHO recommends quinolones and third generation cephalosporins as first line treatment. Because of cost, often they are not practical and programs frequently choose less expensive alternatives that may be less effective. Clearly, there is a trade-off between increased access to a less effective drug and limited access to a very effective drug. The impact of these alternatives on the population prevalence of STDs is unknown.
Judged on their current usefulness, below is a categorization of STD drugs used to treat gonorrhea (CDC/WHO recommendations).
Universally, no longer useful:
- Penicillins
- Tetracyclines
Useful with varying degrees of efficacy:
- Kanamycin
- Spectinomycin
- Ampicillin/clavulinic acid/probenecid
- Trimethoprim/sulfamethoxazole
- Thiamphenicol
Highly effective in most parts of the world:
- 3rd generation cephalosporins (cefixime, ceftriaxone)
- Fluoroquinolones (ciprofloxacin, norfloxacin)*
(*Note: emerging resistance to fluoroquinolones is being seen in southeast Asia.)
Choosing more appropriate drugs to respond to drug resistance requires adjustments in procurement procedures: identifying new suppliers, adapting to new purchasing conditions and planning for the impact on lead time (the time interval needed to complete the procurement cycle). In order to avoid shortages because of lack of financial resources, especially at the end of a fiscal year, managers must know the cost implications of changing therapies, evaluate the alternatives and reconcile needs with available budgets.
Quantification
The cost of drugs used for treating STDs is a serious impediment to their procurement in many countries. Acute shortages occur not only because of lack of funding but also because of inappropriate management practices. Managers must be able to quantify their drug needs in order to estimate costs, reconcile financial requirements with available budgets, and plan orders in advance so that unit and freight costs can be minimized. Quantifying needs is therefore a critical step in the process of supplying drugs for STD treatment and requires the input of expert clinicians, pharmacists, administrators and financial officers.
Most drug requirements can be quantified by using either existing data on consumption of the drugs during previous procurement cycles or morbidity data in the population.1 Unfortunately, drug consumption data are not appropriate for estimating requirements for STD treatment because most of the antibiotics are not used exclusively for STDs. Instead, a method called "the patient morbidity standard treatment method" (PMSTM) is recommended. According to this method, estimated need is obtained by multiplying the expected number of cases of each STD by the total quantity of each drug specified for the corresponding average standard treatment. If a drug is used for more than one STD, the respective totals are added together to obtain the total quantity required.
When done by hand, these calculations can become cumbersome. Computerized spreadsheets or available software specifically designed for that purpose can help.12
Three sets of data must be merged to quantify the drugs needed for STD treatment during a time period and to determine their estimated cost: (1) a list of drugs with their unit prices; (2) average drug quantities required for the treatment of every condition (classified either as a syndrome or as a diagnosis); and (3) epidemiological data (prevalence or absolute numbers). These three classes of data are indicated by bolded frames in Figure 2, which shows a simplified algorithm for estimating drug needs.
The drug catalog
The drug catalog should list the drugs used for the treatment of STDs that are registered in the country. This list can be easily established by the national Essential Drug Program from the catalog of the Central Medical Store.
The unit price of the drug (the price of 1 tablet or of 1 vial) should be equivalent to the cost insurance and packing (CIP)price to get the unit on the shelf, and not the free on board (FOB) price where the seller bears all the cost up to the point of placing the drug onboard a commercial carrier at the point of the product's origin. In certain countries, the difference between the CIP and the FOB prices can be more than 30 percent.
The standard regimen
The standard regimen lists the average quantities of the drug(s) needed for the treatment of a syndrome or an STD. The practical way of preparing that list is to invite three or four STD experts in the country, a pharmacist with procurement experience and administrators to reach a consensus on drugs and average regimens usually required in adults or children. This consensus ensures the credibility of the quantification and forms the basis for national STD treatment guidelines.
Estimating prevalence of STDs
Collecting data to identify prevalence of STDs is difficult. Morbidity data are usually incomplete, inaccurate or unavailable. Six strategies are proposed to facilitate morbidity assessment. They are not mutually exclusive and it is a good idea to compare and reconcile figures obtained from several sources.
1. Collecting epidemiological data at national level:
In most countries, morbidity data recorded in health facilities are consolidated at national or regional levels for epidemiological and planning purposes. Considerable time and effort can be saved if these data can be used to estimate the number of treatment episodes for every STD. When the strategy for management of patients with STDs is based on a syndromic diagnosis (see Chapter 8), data may be more reliable since syndromes are more often recorded than specific STD diagnoses established by laboratory tests.
2. Collecting data from health institutions:
Health institutions selected for data collection should be representative of the institutions on which people rely for STD treatment. Although specialized STD clinics in urban areas may keep good records, they may be less representative than the private practices of doctors; and they may not represent the situation in rural areas. The lack of laboratory support in nonspecialized peripheral units demands that data be reorganized according to syndromes (e.g., urethral discharge or genital ulcer).
3. Metanalysis:
A metanalysis combines the results of independent studies (usually drawn from the published literature) and synthesizes summaries and conclusions that may be used to evaluate prevalence, therapeutic effectiveness and interventions.13,14 A significant amount of information on STD epidemiology is available and can be used for such a metanalysis.
For example, a literature search on STD epidemiological data in selected countries was carried out on Medline in 1993 using three key words–STD, epidemiology and a country name. As a result, four publications for Thailand, sixteen for Kenya, seven for Zimbabwe and five for Brazil were identified. Each publication quotes prevalence data on STDs and is a good source of information for quantification purposes.
4. Prospective sample survey:
If no data are available, then a prospective survey (a survey or study that goes forward in time and follows a group of persons or the records of a group of health facilities) can be carried out to measure STD prevalence. A prospective sample survey can be tailored precisely to meet the data requirements necessary for the calculation. But this requires time and resources.15
5. Estimating prevalence:
When statistical data are not available and it is not feasible to carry out sample surveys, STD prevalence and reinfection rates can be estimated based on experienced clinical judgments. Among the methods for reaching consensus, the Delphi Approach16,17 and the nominal group process, 18 which have been widely used in social sciences, can be applied for estimating STD prevalence. Both methods encompass a process to reach a consensus of opinion between members of a panel.
6. Projecting epidemiological data:
Whatever method of data collection is used to estimate prevalence, the results will indicate the number of treatment episodes in the past, whereas the desired outcome is to quantify drug requirements for future procurement cycles. If the rate of increase (or decrease) in STD prevalence is known or can be estimated, the estimates of the number of treatment episodes can be adjusted upward (or downward) to allow for expected changes.
The easiest way to make projections of future treatment episodes is to calculate the percentage increase between two previous periods and apply the percentage to the next period, as shown in Figure 3.
Analyzing cumulative cost
Analyzing cumulative cost is an important step in the quantification process. A drug may account for a significant part of the total recurrent costs because its unit price is very high or because of the quantity needed. Sometimes both unit price and volume are significant.
Usually a small percentage of the total number of drugs ordered during a period of time accounts for a large percentage of total expenditures. Managers need to identify these drugs so they can reconcile estimated costs with their budgets and reach an acceptable compromise between therapeutic needs and financial constraints.
A simple case study (Appendix 1) shows how to carry out a cumulative cost analysis. If the analysis shows that a few drugs account for most of the total drug costs, these results can be used to determine whether the drugs are necessary or if they can be replaced with cheaper and just as effective alternatives.
Procurement
Procedures for procuring drugs to treat STDs use the same techniques and rules guiding procurement of other drugs.19 This section describes different options for procuring drugs, including drugs for STD treatment.
National procurement
Central medical stores, in cooperation with national finance departments, purchase drugs used for STD treatment, following the procurement procedures established in the national drug policy. Low-price procurement, below the United Nations Children's Fund (UNICEF) Supply Division price, is usually achieved through international open tenders for generic products. (A tender is a procedure by which competing bids are made for an advertised or published purchase order.) Prices of branded products under patent protection, which are usually higher, can be negotiated directly with the manufacturer.
Local production
Manufacturing antibiotics requires complex operations and relatively heavy fixed asset investments. Only a few developing countries (like China, India, Thailand) have the level of technology and knowhow to produce antibiotics of good quality at a competitive cost.
Procurement from agency
Several nonprofit organizations such as the UNICEF Packing and Assembly Center (UNIPAC), the International Dispensary Association, the World Health Organization and the Pan American Health Organization procure essential drugs for sale at affordable prices to nonprofit institutions in developing countries. The advantage of using these procurement services are their expertise, low cost and reliability for quality assurance.
Joint drug procurement
Several countries have established joint procurement schemes to reduce procurement costs. Economies of scale, overhead sharing and higher volumes allow lower operational costs and cheaper prices. The Comité Maghrébin d'Achats en Commun in Northern Africa and the Eastern Caribbean Service are examples of successful joint drug procurement.
Whatever the method used, the efficiency of procurement procedures depends heavily on the ability of pharmaceutical services to:
Storage
Drugs for STDs are mostly antibiotics that are very sensitive to light and temperature. Proper storage is of paramount importance. When drugs are stored under especially unfavorable conditions (i.e., inadequate protection from sunlight, moisture and heat), they may lose their potency. This increases the risk of resistance or even toxicity such as in the case of tetracycline.
An STD drug should not be used beyond the expiration date printed on the container, after which time the manufacturer will not guarantee the drug's potency, purity, uniformity or bioavailability (i.e., the rate of the product's absorption from the specific dose form). Loss of potency should never be compensated for by an increase in dosage, because of the serious risk of overdosage and toxicity.
The following tabulation shows storage conditions that should be observed for drugs for STDs:
Distribution
Distribution, the process of moving STD drugs from a central point (e.g., a central medical store) to an STD patient, involves administrative procedures as well as transport, storage and user facilities.
The majority of drugs used in STD treatment are also commonly prescribed to treat other infections. Antibiotics, an expensive and scarce commodity in developing countries, are in great demand. If antibiotics for STD were indiscriminately distributed to peripheral health institutions, there would be no possibility of limiting their use to STD infections, because of a chronic shortage and ethical considerations.
Therefore, the challenge is to ensure that drugs for STDs are actually used for that purpose. This can be achieved by a verticalization of STD services through which activities are carried out by a trained staff in specific STD prevention and care, and STD drugs are exclusively distributed.
However, verticalization is not compatible with the structure of health care services in most cases. Health centers in developing countries satisfy the demand of 80 to 90 percent of the population living in rural and periurban areas. It is estimated that 10 percent or more of their daily workload may be related to STD and their complications.20
Therefore, health problems posed by sexually transmitted infections must be addressed within the framework of existing primary health care services rather than through the establishment of specialized STD clinics. Although these STD clinics may be effective, they are usually expensive and reach only small segments of the population. Two distribution strategies may solve this dilemma.
Distribution strategies
a. STD kits:
Kits are sealed containers with standard volumes of a designated range of medical supplies for dispatch to peripheral health units. Their use requires accurate estimate of quantities required for all sectors and appropriate selection of drugs. Drug kits have the advantage of controlling pilferage, reducing waste and facilitating distribution. On the other hand, they introduce some rigidity into the system, which may not allow adequate response when demand for drugs used to treat STDs at peripheral level is fluctuating between procurement cycles. Kits for STD drugs could be an effective method of supplying units through the usual distribution channels and of promoting integration of STD prevention into the existing health care delivery system.
b. Syndrome selective packaging:
Like STD drug kits, syndrome selective packaging (SSP) provides a package of standardized STD treatment. But SSP targets the ultimate user–the patient. SSP kits are sealed packs containing the full treatment course for a syndrome. For example, an SSP kit for genital ulcer might contain 20 condoms, an injection of 2.4 MU of benzathine penicillin to be administered by a health worker, one tablet of ciprofloxacin, an instruction leaflet and a partner referral card. Although packing them may prove relatively expensive, SSP kits are worth considering, particularly for social marketing of STD drugs. SSP kits require that personnel responsible for their distribution be adequately trained in their use and also in patient counseling.
Rational Prescribing
Antibiotics, popular drugs among patients and prescribers, are often used inadequately. A study carried out by WHO in three African countries revealed that 27.3 percent of ambulatory patients and 51.7 percent of hospitalized patients received antibiotics; more than 30 percent of these prescriptions used injectable forms, and there was a lack of proper clinical examination and diagnosis.21
Prescribing is a very complex process in which the prescriber is influenced by the following: the disease (severity); the patient (age, sex, sociocultural factors); the prescriber's access to drug information, his or her working conditions (diagnostic, facilities, referral system, income) and professional skills; and the level of the availability and accessibility of drugs determined by the national drug policy.22
There are several techniques to evaluate STD drug use practices and assess the influence of these factors: in-depth interviews (prescribers and patients), focus group discussions, observations and the use of surrogate patients. Based on the result of studies using these techniques, managerial, educational or regulatory interventions can be implemented.23 Figure 4 shows a process to improve prescribing practices.
Patient Compliance
Lack of adherence to treatment is a universal problem. A study in Canada showed that 37 percent of TB patients were non-compliant with anti-TB drugs.24 Factors contributing to adherence encompass communication between doctor and patient (on treatment rationale, disease, drug efficacy, adverse reactions), suitability of drugs, physician error and drug efficacy.25 There are several patterns of patients who request medical advice but do not follow it:
Those who are motivated but lack knowledge
Those who are knowledgeable but insufficiently motivated
Those who are unable to adhere to treatment because of external constraints
Those who decide against the recommendations
Patient adherence to treatment and the prescribing behaviors of health care providers are linked. They should always be examined together as part of quality of care assessment. It is difficult to improve adherence to treatment because of the intricacy of the above factors and the variety of situations. The bottom line however is very simple: doctors must communicate better with their patients before asking them to better adhere to treatment (see Chapter 10). The strategy for improving adherence includes prescriber education, patient counseling, regimen simplification and, if possible, a constant adherence monitoring.
Allocating Adequate Funding
Funding is a critical (if not the most critical) factor in the success of STD care and prevention programs. For instance, treatment cost of one episode of urethral discharge would reach around US$ 2.7 with the use of cefixime 400 mg in a single dose and doxycycline 100 mg twice daily for seven days. In comparison, the average public drug expenditure per capita per year does not exceed one dollar in many African countries.
Reconciling Budgets and Needs
As indicated earlier, reconciling budgets and needs is one of the steps of the quantification process. In a calculation of drug cost, some items have a greater influence on the final result than others. It is useful to identify these items so they can be subjected to special scrutiny, such as therapeutic rationale, pertinence, existence of less expensive alternatives, etc.
Techniques for doing this are called sensitivity analysis. To identify the drugs that are most costly, doing a cumulative cost analysis is recommended as shown in Appendix 1. If budgets cannot be increased, cheaper alternatives can be chosen, regimens can be changed and cheaper sources of procurement can be identified.
Increasing, Reallocating Budgets; Seeking External Support
When needs exceed the available budget, it may be possible to increase funding or to reallocate funds from one budget line to another. However, many developing countries have found it difficult to meet recurrent health costs from their own budgets because of the status of their national economies and other budget priorities for development or defense. Donor support is another option for increasing funding for STD drugs. However, donors are reluctant to support recurrent costs, particularly for drugs, because of the risk of diversion and therefore of uncontrollable inflation of expenditure.26 The following standards for project design should reduce donor apprehension:
Recovering Costs
Another approach to matching funds with needs is to introduce innovative funding mechanisms in which patients are directly or indirectly charged for the services they receive from health care institutions.
Direct User Charges
Cost-recovery, cost-sharing
Many developing countries have implemented user charges for health services as a way to generate financial support to the health sector.27 Payment at time of illness can be based on cost-recovery (when the patient pays the total cost of the service, including consultation fees and drugs) or on cost-sharing (when the patient pays a fraction of the cost). Payment can be made for each visit to a health institution, per episode of illness or for consultation and/or drugs separately.
When designing user charges, it is important to consider the impact on equity and efficiency. If poverty-stricken people are more price-sensitive than those who have more money, then user charges would reduce the use of STD services by the former. Implementing user charges only for STD drugs in the public sector would also single out STD treatment procedures and patients. Not only might this be unacceptable to patients, it also might induce discrimination against people suffering from STDs and HIV/AIDS.
The effectiveness of user charges depends on people's willingness and ability to pay. Perceived quality of service is one of the most important determinants of people's willingness to pay, and experience has shown that cost-recovery schemes may have a negative impact on health status if not carefully designed and implemented.28,29
Social marketing
The use of commercial marketing techniques to address social or public health problems is another way of recovering some or all of the cost of STD drugs.30 It is also an attractive way to increase the acceptability and accessibility of STD prevention and treatment for target groups.
Social marketing requires thorough market research, promotion, and sale of services and products (usually at subsidized prices) at locations and times that are convenient for the target audience. Only a fraction of the infected population (especially among women) seeks appropriate treatment for an STD from an accredited source for a variety of reasons, including social and cultural perceptions of STD and lack of access to efficient, high-quality services. Thus, social marketing should be an attractive way to increase the acceptability and accessibility of STD prevention and treatment for target groups, especially for those who do not seek treatment.
Social marketing has been widely used in condom distribution.31 Using this approach for other aspects of STD prevention is more complex because it entails a mix of tangible (drug therapy) and intangible products (diagnosis, education, partner referral). Dissociating certain components of this product mix–such as selling drugs without training prescribers in syndromic diagnosis, and without educating patients about treatment compliance and partner referral–could result in irrational use, wastage and drug resistance.
Therefore, social marketing should focus not only on drugs but, more comprehensively, on the control of STDs. Social marketing of drugs for the treatment of STDs is likely to be difficult to implement. However, experience in other domains shows that because of its positive impact on sustainability and self-sufficiency, it is an avenue worth exploring.32 This approach was piloted in Cameroon under the name of Mstop (see Chapter 13 for full discussion).
Long-term sustainability of direct user charges depends on foreign currency availability. It is necessary for revenues raised in local currency to be converted into foreign currency to procure either finished products or raw material on the international market.
Indirect User Charges
Indirect financing mechanisms for drug purchase are usually derived from taxes, mutual funds or insurance schemes. These mechanisms are difficult to extend to unemployed people who constitute the majority of the population in many countries, and are not easy to implement in view of their social, administrative and economic implications.33
Conclusion
Common STDs represent a significant burden in many societies and rank among the top ten most important health problems in developing countries. Their prevention requires that effective drugs be available at all times and that adequate information and education be provided to patients. Because of the high prices of effective drugs, the supply of drugs for the treatment of STDs requires a compromise between therapeutic requirements, financial constraints and the orientation of national drug policies.
The three key components of a strategy to ensure adequate supply are increasing efficiency in pharmaceutical services, allocating adequate funding after a careful estimate of needs, and implementing user charges and other cost-recovery mechanisms. Innovative distribution strategies or mechanisms, such as social marketing, have to be carefully designed in order to gain acceptance and minimize the risk of encouraging further development of drug resistance.
Appendix 1
References
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- Urban GL, Hauser JR. Design and marketing of new products. Englewood, New Jersey: Prentice Hall, 1980:135.
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- Over M, Piot P. Health sector priorities review. HIV infection and sexually transmitted diseases. Washington, DC: The World Bank, Population, Health and Nutrition Division, 1991; HSPR-26.
- Prescription des antibiotiques dans trois pays d'Afrique de l'Ouest, Mauritanie, Niger et S‚n‚gal. Geneva: World Health Organization, 1993.
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- Laing R. Changing prescriber drug behaviour. Africa Health 1994:11—14.
- Wright EC. Non compliance-or how many aunts has Mathilda. Lancet 1993;342:909—913.
- Homedes N, Ugalde A. Patients' compliance with medical treatments in the third world. What do we know? Health Policy Plan 1993 8(4):291—314.
- Abel-Smith B, Creese A, eds. Recurrent costs in the health sector–problems and policy option in three countries. Geneva: World Health Organization, 1989.
- Waddington C, Thomas M. Recurrent costs in the health sector of developing countries. International Journal of Health Planning and Management 1972;3(3).
- Mc Pake B, Hanson K, Mills A. Experience to date in implementing the Bamako initiative: a review and five country case studies. London: London School of Hygiene and Tropical Medicine, Department of Public Health and Policy, 1990.
- Moses S, Mali F, Bradley JE et al. Impact of user fees on attendance at a referral centre for sexually transmitted diseases in Kenya. Lancet 1992;340:463—466.
- Kotler P, Roberto EL. Social marketing: strategies for changing public behaviour. New York: The Free Press, 1989:401.
- Condom social marketing as an AIDS prevention strategy. Unpublished report. World Health Organization, October 1991.
- Fourth generation social marketing reduces donor costs for administration, distribution, and commodities. Washington, DC: SOMARCII, 1993; highlights no 1.
- Planning and implementing health insurance in developing countries: guidelines and case studies. Geneva: World Health Organization, 1993.
