Academic journal article Bulletin of the World Health Organization

Threats Posed by Stockpiles of Expired Pharmaceuticals in Low- and Middle-Income Countries: A Ugandan perspective/Menaces Representees Par Les Stocks De Produits Pharmaceutiques Perimes Dans Les Pays a Revenu Faible et Intermediaire: Exemple De l'Ouganda/Amenazas Que Suponen Las Reservas De Medicamentos Caducados En Paises Con Ingresos Bajos Y Medios: Una Perspectiva De Uganda

Academic journal article Bulletin of the World Health Organization

Threats Posed by Stockpiles of Expired Pharmaceuticals in Low- and Middle-Income Countries: A Ugandan perspective/Menaces Representees Par Les Stocks De Produits Pharmaceutiques Perimes Dans Les Pays a Revenu Faible et Intermediaire: Exemple De l'Ouganda/Amenazas Que Suponen Las Reservas De Medicamentos Caducados En Paises Con Ingresos Bajos Y Medios: Una Perspectiva De Uganda

Article excerpt

Introduction

In many low-income countries, and some middle-income countries, the government's budget for the health sector is too small to finance the national health system adequately. In Uganda, for example, the expenditure on health in 2014 was only 12 United States dollars (US$) per capita, i.e. about 35% of the value recommended by the World Health Organization (WHO), and the expenditure on pharmaceuticals was just US$2.40 per capita. (1) Such poor financing means that access to pharmaceuticals, like many other health sector priorities, has to be compromised. Many health systems have no choice but to rely, at least in part, on drug donations from high-income countries and vertical supplies from development agencies. (2,3) During civil emergencies and periods of severe political instability, health systems may have to rely almost entirely on drug donations. (2)

Unfortunately, donated pharmaceuticals often mismatch the pharmaceuticals that are needed. International guidelines require that drug donations are responsive to the health needs of the recipient country and that the drugs involved have a shelf-life of at least one year on arrival. (4) However, drugs that are already past their expiry dates have often been dumped in low--or middleincome countries (5-9) and many past donations have been so large or so unwanted that they could not be used entirely before their expiry dates (Table 1).

Stockpiles of expired pharmaceuticals may also build up as a result of poor forecasts of future demand. Efficient stocking may be made difficult by deficiencies in the management of a supply chain or by poor coordination between a national supply system and the development partners or special programmes offering to supply pharmaceticals. (10) In most low- and middle-income countries, the supply of pharmaceuticals is centralized and one state agency is entrusted with the procurement, storage and distribution of pharmaceuticals to all public health facilities. (3,11) The network of public health facilities in any given country is often so expansive and complex that it is impossible for a single agency to respond effectively to the unique demands of each client. In Uganda in 2016, one central agency--the National Medical Store--was entrusted with supplying all pharmaceuticals to the country's two national referral hospitals, 14 regional referral hospitals, 144 district hospitals, 197 county health centres. 1289 sub-country health centres and 2941 parish health centres. (12) Unfortunately, few of these health facilities have staff members with the skills needed to manage pharmaceutical inventories or forecast future pharmaceutical needs effectively. In 2010, only 31 pharmacists were employed in Uganda's public-sector health system. (11,12) Structural and technical dysfunction in the management of a pharmaceutical supply chain can promote the accumulation of large quantities of expired pharmaceuticals in central stores and health facilities. In some low- and middle-income countries, including Uganda, civic observers and government oversight agencies have raised concern over the high incidence of expiry of stocked pharmaceuticals in the public supply system. (13-19) The disposal of expired pharmaceuticals may also be a very slow process. In Uganda's national medical store and public-sector health facilities, for example, such pharmaceuticals were found to be held for a mean of six years. (18)

In the absence of their timely and safe disposal, expired pharmaceuticals may be simply dumped--with the risk of environmental pollution--or repackaged for the counterfeit market. Toxicity from environmental exposure to pharmaceuticals has been reported in fish (20) and vultures. (21) If antibiotics are dumped, exposure to subtherapeutic concentrations of the drugs may lead to the selection of drug-resistant soil bacteria, which may then infect humans (22,23) and even pass on their resistance genes to bacteria that are human pathogens. …

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