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Many developing nations have developed national drug policies, a concept that has been actively promoted by the WHO. For example, the national drug policy for Indonesia〔World Health Organization (1990) Review of the drug program in Indonesia. Report of a WHO mission 16 October-3 November 1989. ''DAP''. 90(11): 1-36.〕 drawn up in 1983 had the following objectives: *To ensure the availability of drugs according to the needs of the population. *To improve the distribution of drugs in order to make them accessible to the whole population. *To ensure efficacy, safety quality and validity of marketed drugs and to promote proper, rational and efficient use. *To protect the public from misuse and abuse. *To develop the national pharmaceutical potential towards the achievements of self-reliance in drugs and in support of national economic growth. To achieve these objectives in Indonesia, the following changes were implemented: *A national list of essential drugs was established and implemented in all public sector institutions. The list is revised periodically. *A ministerial decree in 1989 required that drugs in public sector institutions be prescribed generically and that Pharmacy and Therapeutics committees be established in all hospitals. *District hospitals and health centers have to procure their drugs based on the essential drugs list. *Most drugs are supplied by three government-owned companies. *Training modules have been developed for drug management and rational drug use and these have been rolled out to relevant personnel. *The central drug laboratory and provincial quality control laboratories have been strengthened. *A major teaching hospital has developed a program on rational drug use, developing a hospital formulary, guidelines for rational diagnosis and treatment guidelines for the rational use of antibiotics. *Generic drugs have been available at affordable costs to low-income groups. ==Encouraging rational prescribing== One of the first challenges is to promote and develop rational prescribing, and a number of international initiatives exist in this area. WHO has actively promoted rational drug use as one of the major elements in its Drug Action Programme. In its publication ''A Guide to Good Prescribing''〔de Vries TPG, Henning RH, Hogerzeil HV, Fresle DA (1994) Guide to good precribing. ''WHO/DAP''. 11: 1-108〕 the process is outlined as: *define the patient's problem *specify the therapeutic objectives *verify whether your personal treatment choice is suitable for this patient *start the treatment *give information, instructions and warnings *monitor (stop) the treatment. The emphasis is on developing a logical approach, and it allows for clinicians to develop personal choices in medicines (a personal formulary) which they may use regularly. The program seeks to promote appraisal of evidence in terms of proven efficacy and safety from controlled clinical trial data, and adequate consideration of quality, cost and choice of competitor drugs by choosing the item that has been most thoroughly investigated, has favorable pharmacokinetic properties and is reliably produced locally. The avoidance of combination drugs is also encouraged. The routine and irrational use of injections should also be challenged. One study undertaken in Indonesia found that nearly 50% of infants and children and 75% of the patients aged five years or over visiting government health centers received one or more injections.〔Management Sciences for Health (1998) ''Health Center Prescribing and Child Survival in East Java and West Kalimantan, Indonesia. Child survival pharmaceuticals in Indonesia. Part II''. Report of the Ministry of Health and Management Sciences for Health.〕 The highest use of injections was for skin disorders, musculoskeletal problems and nutritional deficiencies. Injections, as well as being used inappropriately, are often administered by untrained personnel; these include drug sellers who have no understanding of clean or aseptic techniques. Another group active in this area is the International Network for the Rational Use of Drugs (INRUD).() This organization, established in 1989, exists to promote rational drug use in developing countries. As well as producing training programs and publications, the group is undertaking research in a number of member countries, focused primarily on changing behavior to improve drug use. One of the most useful publications from this group is entitled ''Managing Drug Supply''.〔Management Sciences in Health (1997) ''Managing Drug Supply: the selection, procurement, distribution, and use of pharmaceuticals''. Kumarian Press. Connecticut.〕 It covers most of the drug supply processes and is built up from research and experience in many developing countries. There a number of case studies described, many of which have general application for pharmacists working in developing countries. In all the talk of rational drug use, the impact of the pharmaceutical industry cannot be ignored, with its many incentive schemes for doctors and pharmacy staff who dispense, advise or encourage use of particular products. These issues have been highlighted in a study of pharmaceutical sales representative (medreps) in Mumbai.〔Kamat VR, Nichter M (1997) Monitoring product movement: an ethnographic study of the pharmaceutical sales representatives in Bombay, India. In: Bennett S, McPake B, Mills A (eds) ''Private Health Providers in Developing Countries: serving the public interest?'' Zed Books, London & New Jersey.〕 This was an observational study of medreps' interactions with pharmacies, covering a range of neighborhoods containing a wide mix of social classes. It is estimated that there are approximately 5000 medreps in Mumbai, roughly one for every four doctors in the city. Their salaries vary according to the employing organization, with the multinationals paying the highest salaries. The majority work to performanace-related incentives. One medrep stated "There are a lot of companies, a lot of competition, a lot of pressure to sell, sell! Medicine in India is all about incentives to doctors to buy your medicines, incentives for us to sell more medicines. Even the patient wants an incentive to buy from this shop or that shop. Everywhere there is a scheme, that's business, that's medicine in India.' The whole system is geared to winning over confidence and getting results in terms of sales; this is often achieved by means of gifts or invitations to symposia to persuade doctors to prescribe. With the launch of new and expensive antibiotics worldwide, the pressure to sell with little regard to the national essential drug lists or rational prescribing. One medrep noted that this was not a business for those overly concerned with morality. Such a statement is a sad reflection on parts of the pharmaceutical industry, which has an important role to play in the development of the health of a nation. It seems likely that short-term gains are made at the expense of increasing problems such as antibiotic resistance. The only alternatives are to ensure practitioners have the skills to appraise medicine promotion activities or to more stringently control pharmaceutical promotional activities. 抄文引用元・出典: フリー百科事典『 ウィキペディア（Wikipedia）』 ■ウィキペディアで「Evidence-based pharmacy in developing countries」の詳細全文を読む スポンサード リンク
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