JANUARY 1983 - VOLUME 4 - NUMBER 1
Mozambique: Healthcare Without the Companies
by Joseph Hanlon
MAPUTO - Governments across the world are trying to discipline pharmaceutical multinationals that have flooded markets with unsafe, poorly tested and unnecessary drugs.
One developing country that has been particularly successful in revamping drug policy to suit its health needs is the fledgling East African nation of Mozambique.
Drug prices are plummeting in Mozambique. Aspirin, vitamins and many antibiotics now cost less than one-third of what they did just three years ago. Useless and dangerous drugs have disappeared from the shelves. And for the first time, basic medicines are now available in remote corners of the country.
This is the result of a revolution in drugs policy. A restricted drugs list, similar to the World Health Organization (WHO) essential drugs list of 200, is now in force. Importing is done in bulk with competitive bids. Rigid new regulations cover the dispensing of medicines. And an education campaign is transforming the way doctors and nurses prescribe.
A sparsely populated country of 12 million people, Mozambique was a Portuguese colony until the present ruling party, Frelimo, won a ten-yearlong war in 1975.
In colonial times health care was available only to the privileged minority in the cities who could afford it. And under Portuguese rule, there were virtually no restrictions on importing, advertising, and sales.
The multinational pharmaceutical companies took full advantage of this. Drugs were on sale in Mozambique which were banned in Europe. Drug salespeople and glossy advertising literature promoted many drugs as cure-alls, even though they were licensed for only a few illnesses in Europe because it was well known that they were ineffective or dangerous in other circumstances.
Now the picture is very different.
Health care was seen as a symbol of colonial oppression and Frelimo made its reform a top priority, particularly because Mozambique's new president, Samora Machel, had been a nurse in colonial hospitals.
Within a month of independence, the health industry was nationalized, and all private practice banned. The Ministry of Health then set up a Pharmaceuticals Commission. "Good medicine at the lowest price" was and is the motto, says Carlos Marzagao, a member of the Commission.
The commission carefully studies scientific journals to pick out the most effective drugs and those with the fewest side effects. Then it looks at lists of drug prices. Where two drugs are equally effective, it chooses the cheaper one.
In 1977, the commission published a list of 430 medicines. Then in 1980 it issued a revised list of only 343 drugs. Only drugs on this list can be prescribed.
Drugs are identified by the "generic" or chemical names, and trade names are not used. In addition, the Commission excluded expensive formulations of drugs on the list. Syrups, children's preparations, and suppositories cost five to 30 times as much as tablets or capsules of the same drug. A child's 100 mg aspirin costs more than an adult 500 mg tablet, so it is much cheaper to cut adult tablets into quarters for children.
The next step was to have one company import all drugs for Mozambique in bulk, instead of twenty private companies importing small lots of medicines.
In 1977 the state import company Medimoc was set up, and in 1979 private importing ended. Each year, Medimoc publishes a list of the drugs it plans to import, and asks pharmaceutical companies to quote prices.
Last year, more than 200 companies bid. And the range in prices is dramatic.
Consider chloroquine, for malaria phrophylaxis and treatment, which is now Medimoc's single largest purchase. Last year the prices offered for chloroquine ranged from $32 per thousand tablets down to $8 per thousand. Some prices have fallen to one tenth of what they were at independence.
The price savings are passed on to the consumer. About two-thirds of the drugs are distributed directly through the health service, where prescription fees range from nothing up to Medimoc's bulk import price, depending on the drug and patient's income. The other third are distributed through shops. Prices are fixed at double the import price, to allow both a tax and a profit margin for the shop.
In rural areas, more than 300 shops are now licensed to sell a range of non-prescription medicines such as chloroquine, aspirin, and drugs for ear and skin infections and intestinal worms.
But major problems remain. One of the biggest is to reform the prescribing habits of nurses and other health workers who were trained in colonial times, and who learned about drugs entirely from drug salespeople. There are recycling courses and meetings, and doctors are expected to supervise the prescribing habits of the health workers.
Diarrhea treatment has been a special target for retraining because diarrhea is one of the biggest killers of children and also one of the biggest wastes of drugs.
Research has shown clearly that even severe diarrhea eventually stops by itself, and that antibiotics have no effect. But dehydration can kill, and the best treatment is rehydration. For all but the most severely ill children, it is sufficient that they drink water with glucose, salt, and potassium added.
In Mozambique and in many other countries, pharmacies stock inexpensive packets of "rehydration salts" which contain all the things needed to be mixed with water for a child with diarrhea.
The effect of the education campaign has been dramatic. A World Health Organization evaluation team visited Mozambique in March, and went to randomly picked rural health posts. They found nearly all used oral rehydration.
Mozambique has taken two additional steps to insure mass health care. First, it decided that even the short list of 343 drugs should not be prescribed by every health worker.
Only certified doctors can use the whole list. Medical technicians with nine years schooling and three years training are allowed half the list; medical agents with six years primary school and two years training are allowed one third of the list: while the rural health workers who have only four years of primary school and a six month course have a drugs list not much longer than the non-prescription list sold in shops.
Second, the Pharmaceuticals Commission last year published a "Therapeutic Guide." It lists each drug, with the illnesses for which it can be used, the dose, side effects, and warnings about situations where it should not be used. Suggested treatment schemes are given for many illnesses.
And with an eye to Mozambique's limited budget, the guide tries to reduce the unnecessary use of expensive drugs. Notes next to some expensive items say "exceptional use only." After each vitamin is a list of foods which can be used instead of an expensive vitamin pill.
A restricted drug list, the use of generic names, and limitations on prescribing are all sharply opposed by the multinational pharmaceutical companies, because it cuts deeply into their profits.
In other countries that have tried this, such as Tanzania and Sri Lanka, the multinationals were able to mobilize doctors to oppose their loss of the "freedom to prescribe" useless, expensive, brand-name drugs. And in Mozambique they did try. Having failed, many doctors fled . . ..
But the doctors who stayed after independence, and the more than 100 doctors who have since come to help, support the restricted drugs list.
Mozambique's drug policy demonstrates that a Third World country can meet the health needs of its people without relying on multinational drug companies. Health care in Mozambique is no longer delivered to a privileged minority. As the World Health Organization evaluation in March noted, most rural health posts do have the basic drugs for servicing the rural peasantry.
Mozambique's success is all the more spectacular given the fact that the country is spending the same amount of money on drug imports today as it did 10 years ago; about $1 a person. But Mozambique under Machel is buying a lot more drugs for its money, simply by not wasting money o n useless and dangerous drugs, on fancy packets, and on well known trade names.
Joseph Hanlon is a journalist who lives in Maputo, Mozambique. His article was edited from a report he wrote for Health Action International, an informal network of consumer, health and development groups working on pharmaceutical issues.