Geneva Health Forum Archive

Browse and download abstracts, posters, documents and videos from past editions of the GHF

Global Redesign Initiative: New Architecture for Global Health Governance

Author(s): O. M. Raynaud*1, R. Samans2
Affiliation(s): 1Global Health and Healthcare sector, World Economic Forum, Geneva, Switzerland, Head, Global Redesign Initiative
Keywords: Global Health, Governance, policies, International Organisations, Architecture, cooperation
Background:

The Global Redesign Initiative (GRI) is an unprecedented multistakeholder dialogue that is developing recommendations for adapting the structures and systems of international cooperation to the challenges of the 21st century. The GRI was launched by the World Economic Forum in 2009 under the patronage of the governments of Qatar, Singapore and Switzerland

Methods:

A specific Council of International Health experts and leaders has been formed. It will meet in Dubai at the end of November 2009 and present its first recommendations in Davos in Janunary 2010. The council will work on the following aspects :
- The landscape of global agencies working in the international health arena is confusing. Coordination among them, standardized processes, information sharing and efforts to counter duplication need to be improved.
- Emphasis should be put on a macro approach, there is too much silo-thinking and too little focus on efficiency. Interaction between the different parts of the system takes place without identifying the goals of the interaction in the first place.
- Accountability of global health players is weak; it is not clear to whom they are accountable, for what and how they can be held accountable for actions as well as lack of actions.
- There are significant differences in terms of quality of governance in health-related areas globally. Particularly the development field was highlighted as lacking architecture and structure.

Results/Conclusions:

The recommendations of the Council will be presented and debated with Geneva Health Forum participants before final recommendations are made in a final report to be released at the time of a special intergovernmental and multistakeholder meeting in Doha, Qatar, in the spring of 2010.

Participatory Democracy: National Health Assembly of Thailand

Author(s): C. Kanchanachitra1
Affiliation(s): 1Mahidol University, Nakhon Pathom, Thailand
Keywords: Healthy participatory public policy process
Background:

Thailand has launched the first participatory process for healthy public policy at the national level under the “National Health Assembly” (NHA) in 2008 under the mandated by the Thai National Health Act 2007. The assembly comprises of three main groups including representatives from government or politicians; representatives from academic and expert groups; and representatives from civil societies. These three groups form the ‘triangle that moves the mountain’ principle proposed by Prof. Prawase Wasi that stipulated the importance of having all three groups collaborate in order to move the difficult policies.

Methods:

The process of the Thai NHA was adapted from the World Health Assembly in terms of intervention and adoption of the resolution. However, the Thai NHA was designed to be inclusive in terms of member attendance and agenda setting to be bottom up rather than top down approach. The agenda was proposed by constituencies to the National Health Assembly Organizing Committee (NHAOC), in which committee members also come from 3 groups. The Technical Subcommittee under the NHACO has convened meetings among partner / networks and constituencies to discuss on all agenda proposed and selected the top most important agenda based on pre-determined criteria that will be put forward for the Assembly. A total of 14 agenda (from 68 proposals) in 2008 and 11 agenda (from 115 proposals) in 2009 were proposed to the NHACO for approval. The technical working group for each agenda item was formulated to draft the background documents and resolution and convene meetings among constituencies concerned to receive the opinions from different groups. The resolutions and background documents were then submitted to the NHAOC for consideration and circulated to all constituencies for their opinions and the resolution and background documents were revised according to opinions received and submitted it to the NHAOC for final documents to be adopted at the NHA.The NHA in 2009 was comprised of 2,000 members from 180 constituencies, expert groups, international representatives and observers. Each constituency has equal speaking rights and the adoption of resolution is only by consensus. If agreement cannot be reached, a working group will be convened to find the consensus in the disagreement issues. The system has set for not putting on voting to pass the resolution.

Results/Conclusions:

These participatory processes have several benefits in terms of increasing awareness of the general public on health issues and raising the level of commitment at the local level to solve the problems themselves. In the process of proposing the agenda, people at the local level realized the health problems they faced and some interventions were implemented without waiting for the government to set the policy. It also builds capacity of people to analyze and collect data to understand the situation in their areas. However, many challenges remain especially on ensuring representation of the constituencies and in bringing resolutions adopted at the NHA to implementation.

GHIs and Health Workforce – The Importance of State Ownership and Actor Coordination: Field Perspectives from Burundi and South Africa

Author(s): J. Cailhol*1, T. Mathole1, A. Parsons1, T. Niyongabo2, D. Sanders1
Affiliation(s): 1School of Public Health, University of Western Cape, Bellville, South Africa, 2National Center for HIV Reference, Bujumbura, Burundi
Keywords: Global Health Initiatives, Human Resources for Health, Burundi, South Africa
Background:

Burundi and South Africa are virtually opposite countries: Burundi is a post conflict and poorly resourced country with a low HIV prevalence while post apartheid South Africa is a middle-income country with a high HIV prevalence. However, both countries experience a significant shortage of human resources for health (HRH), though affecting Burundi to a greater extent. Both countries have also in common 2 Global Health Initiatives (GHIs), PEPFAR and GFATM. In Burundi, the Permanent Executive Secretary of the National AIDS Council (PES-NAC) has been the principal GFATM recipient since 2003. Funds were not disbursed to the Ministry of Health, considered at that time unreliable. The PES-NAC sub-contracted NGOs to deliver HIV-related services and advised PEPFAR on its NGO implementation. In South Africa, GFATM funds have been provided through government health departments and PEPFAR has historically directly funded NGOs.

Methods: The impact of GHIs on HRH in Burundi and South Africa was assessed as part of the INCO-DEV “Experience of 5 African countries with GHIs” study (2006-2010) and as part of the WHO “Maximizing Positive Synergies between GHIs and health systems” study (2009). Qualitative data were collected from national-level and from 3 provinces inBurundi and in South Africa. National-level interview participants included key stakeholders from both government and donors’ institutions. In each province, key-informants were interviewed from a sample of facilities andNGOs. Thematic content analysis was used to analyse qualitative data and results were triangulated with documentanalysis and quantitative data from NGOs and facilities. We report here preliminary results on HRH. We focus onhow the employment of HRH for HIV activities was handled in Burundi, exploring its consequences and structural,organisational and contextual factors. We then discuss these results in relation to experiences in South Africa.
Results/Conclusions:

Burundi’s post-conflict context did not allow the state to manage GHI funding or to predict their effects on HRH. The public sector, perceived as unable to deliver services, was ignored and the focus placed on sub-contracting NGOs. The scarcity of HRH pushed NGOs to provide decent salaries to attract and retain HRH. This reduced coordination possibilities between NGOs and public sector. By contrast, South African health authorities seemed to exert strong leadership and ownership of GFATM and latterly PEPFAR funds, controlling HRH terms of employment and often coordinating NGO activities. However, the extent of such coordination and ownership depended on the capacity of local government. These countries’ experiences with GHIs could be explained by their backgrounds and show the importance of government organizational structures and ownership in HRH planning and management. A country’s capacity to negotiate and plan GHI activities may also be related to GHIs’ contributions to national health expenditure.

Access to ARVs in China: A Case Study

Author(s): Y. Hu*1, X. Wang2, P. Jia3
Affiliation(s): 1Legal consultant, China Access to Medicines Research Group, China Global Fund Wacth Initiative, 2International cooperation, State Food and Drug Administration, 3CEO, China Gobal Fund Watch Initiative, Beijing, China
Keywords: Access to medicines, ARV, patent, China
Background:

In the year of 2003, the Chinese government initiated the “four free and one care policy” to provide free antiretroviral medicines (ARVs) to HIV/AIDS patients who have not joined the basic medical insurance program. Five years later, though most of the first line ARVs provided by the government are locally produced, accessibility of ARVs in China remains a challenge in responding to the increasing drug resistance and need for advanced treatment regimen. First, the choice of medicines is still narrow, especially for newer ARVs. Second, though China is major supplier of active pharmaceutical ingredients (API), Chinese AIDS patients could not have access to generic version of some key ARVs due to patent and regulatory monopolies. Thirdly, nearly all newer ARV for second and third line treatment have been patented in China, and not available in an affordable manner. The paper aims to analyze the legal obstacles of scaling up ART in China with special focus on access to ARVs.

Results/Conclusions: THREE REVISIONS ON CHINESE PATENT LAW AND ITS RELEVANCE TO ACCESS TO MEDICINES
Chinese patent law was first issued in 1985 and completed its third revision in December 2008 with integrated and strengthened a number of flexibilities allowed by WTO TRIPS rules. These include strengthened the compulsory license clauses, introduced parallel importation and Bolar exceptions. However, none of the flexibilities has been put in practice so far in safeguarding access to ARVs.
CASE OF LAMIVUDINE(3TC): MULTIPLE REGULATORY MONOPOLIES
Though China is a major supplier of API of 3TC, the Chinese patients so far still have no access to generic 3TC. This is because there are a number of exclusive rights over 3TC. Patent together with regulatory exclusivities including drug administrative protection, new drug protection and data exclusivity seriously delayed the introduction of generic 3TC and its fixed-does-combination(FDC) in China.
CASE OF TDF AND AZT/3TC: PATENT- ABILITY QUESTIONS
Chinese patentability criteria allow new use or salt form of known compound and combination to be patented. Therefore,TDF as essential first and second line ARV is patented in China, although as a salt form of a known compound, its patent application in Brazil and India was rejected. Patenting TDF in China has a number of side effects. First, it delayed the full use of TDF for the government second line treatment program. Secondly, it hindered introduction of newer FDC containing TDF, e.g. both Atripla(TDF/EFV/FTC) and Truvada(TDF/FTC) are not registered in China. Broad patentability also enables GSK to maintain its monopoly over Combivir, a combination of 3TC and AZT, in China. While the same patent has been withdraw in India and Thailand because of civil society push and stricter patentability on combinations. WAYS FORWARD: A CONCLUDING REMARK   The various bodies of the Chinese government have started establishing a system on the use of TRIPS flexibilities on medicines through law revision and policy discussion.Civil society has been taking more proactive steps in advocating for better access to ARVs. But the actual practice of these flexibilities has not yet happened. Because of the lack of sufficient information, training and hands-on experiences, people would rather choose a reserved approach than taking more concrete action. To overcome the challenges, several measures need to be taken. Firstly, the government needs stronger political will and inter-sectional collaboration in working out a practical solution. Secondly, domestic empirical research and analysis are seriously lacking and there is a need for more involvement from the intellectuals,professionals, and practitioners. Thirdly, domestic industry should play a more visible role in both improving access to ARVs and enhancing quality standards of its production. Finally, a more coherent and professionalized civil society development would be critical for the future of access to ARVs advocacy in China.

African Partnership For Patient Safety in Cameroon: The Story So Far

Author(s): V. Djientcheu1
Affiliation(s): 1Department of Neurosurgery, Yaoundé Central Hospital, Yaoundé, Cameroon
Keywords: Hospitals, Patient Safety, Developing Countries, Cameroon, Africa
Background:

Safe effective care is a WHO priority. In May 2004, the WHO World Alliance was created to act as a major force for improvement internationally and to mobilize efforts to protect patients from adverse effects of care in health systems across the world. In Cameroon, momentum on patient safety has been gradually increasing. In September 2008, 27 African Health Ministers as well as their homologue Cameroonian signed their support for action on health care-associated infections at a special ceremony that was part of the WHO AFRO Regional Committee Meeting. Also in September 2008, a scientific day on hand hygiene took place at the Central Hospital of Yaoundé (CHY) and was transmitted through the Francophone African Network (RAFT). The expert lead of the First Global Patient Safety Challenge visited the 4 University Hospitals of Yaoundé, a district (Effoulan) and a Regional Hospital (Bafoussam) as proposed by the Minister of Public Health. All these events were critical to laying the foundation for APPS in Cameroon.

Methods:

In early 2008, the Central Hospital of Yaoundé (CHY) was designated as the Cameroonian first wave hospital to accompany the 5 other first wave hospitals in Africa (3 francophone and 3 Anglophone). The local focal point was appointed and participated in a workshop in Geneva in May 2009 to shape the programme with all other APPS focal points. The APPS programme was defined and the model of partnership working between CHY and Hôpitaux Universitaires de Genève (HUG) was adopted. The situational analysis was conducted in the CHY in June 2009. In October 2009, the Uganda Workshop allowed the CHY-HUG action plan to be finalized based on the situational analysis. The CHY-HUG action plan focused on hand hygiene and the control of health care associated infections, knowledge and learning on patient safety and the protection of health care personnel. The different members of the CHY APPS team were assigned to a specific task including continuous training (nurse), infection control (nurse), control of hospital waste (nurse), production of alcohol based hand rub (pharmacist), protection of health care personnel (nurse) and communication (CHY focal person). A member of the community was designated to develop the hospital-community interface on patient safety. Local implementation has already started with continuous training and sensitization of personnel. Two nurses will be trained on ABHR production in Mali in April 2010. Enquiries on health worker immunization status has also started.

Results/Conclusions:

Safe care will become a reality in the CHY through continuous learning and improvement in key action areas. The sustainability of this program will be achieved by ensuring mechanisms for the ongoing training of health professionals for infection control, continued sensitization and through integrating patient safety activities within the CHY care environment.

Consumer Rights and the Limits to Trust in an African Market for Essential Medicines: Regulatory Implications in Rural Tanzania

Author(s): P. G. M. Mujinja*1, M. Mackintosh2
Affiliation(s): 1Public Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania, 2Faculty of Social Sciences, The Open University, Milton Keynes, United Kingdom
Keywords: Consumer rights, consumer information, medicines, trust, Tanzania, dispensing, regulation
Background:

If access to medicines is obtained by a population largely through market exchange, then consumer rights become a key aspect of the right to health. In Tanzania, out-of-pocket payment is dominant; consumers thus rely on a market transaction for both access to treatment and for essential information concerning the proper use of medicines. In many cases, this is a drug seller in a small private shop.

Methods:

The results reported here are drawn from a survey of medicines dispensing and purchase in four rural districts of Tanzania, which formed part of a larger study of the supply chain of medicines to rural consumers. The rural survey included staff and customers at all types of non-governmental medicine outlets including NGO/FBO facilities and private shops and facilities; interviewees included prescribers, dispensers, shop and facility owners and managers, shop sellers and customers interviewed on exit. The wider study included stakeholder and policy interviews, also used here. The rural districts varied by income and pattern of facility ownership. All the selected medicine outlets’ were asked to provide price data for a selected list of 32 essential medicines from the National Essential Drug List. This paper draws particularly on the qualitative interviewing concerning dispensing practice and consumer information.

Results/Conclusions:

The results of this study show that there is very poor provision of information by sellers and dispensers to consumers of medicines. Consumers are shown to have poor knowledge of the types of information they require, and dispensers and sellers poor knowledge of the information that they should provide. Sellers and dispensers frequently offer diagnostic advice without training and dispense without prescription: interview questions concerning diagnostic knowledge showed a lack of basic knowledge of symptoms and treatments for common illnesses. The dangerous practice of dispensing part-doses was found to be widespread, and indeed normal. Consumers thus were putting misplaced trust in dispensers in a context of poor dispensing practice. NGO and faith-based facilities displayed somewhat better dispensing practice on average than the private shops and dispensaries, but still failed to protect consumers. Furthermore, both consumers and sellers had little knowledge of consumers’ rights to information and protection, and the less educated the consumer, the less they were likely to have asked for medicine information of any kind. Regulation of transactions was poor and failed to protect the consumer, and there was virtually no knowledge of means of redress. The paper notes the efforts made so far in Tanzania to improve rural dispensing practice. In discussing the findings, the paper argues however for a shift of emphasis in research on medicines markets from exploration of sources of trust to a much stronger focus on methods of strengthening the implementation of consumer rights. It proposes a clearer incorporation of consumer rights in medicines markets into efforts progressively to implement the right to health; and argues that a strengthening of civil society and NGO activity in promoting consumers’ rights – moving the source of consumers’ information away from sole reliance on the drug purchase transaction itself – is essential to promote better consumer protection and the appropriate use of medicines.

Exploring the Effects of Drug Detailing on Village Doctors in Chakaria, Bangladesh

Author(s): M. Rahman*1, S. Agarwal1, S. Tuddenham1, H. Peto1, M. Iqbal2, A. Bhuiya2, D. Peters1
Affiliation(s): 1International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States, 2Social and Behavioural Sciences Unit, ICDDR,B, Dhaka, Bangladesh
Keywords: Drug detailer, medical representative, informal provider, developing country, village doctor
Background:

Informally trained village doctors supply the majority of healthcare services to the rural poor in many developing countries. Little is known about factors influencing drug prescribing practices of village doctors, although medical representatives (MRs) who promote pharmaceutical sales may play an important role. This study explores the relationship between MRs and village doctors in rural Bangladesh.

Methods:

This study was conducted in 9 unions and 1 township of Chakaria, a rural sub-district of Bangladesh. Focus Group Discussions and In-depth Interviews were conducted among village doctors and MRs, along with a quantitative survey including questions about demographics, education, and practice perceptions. Data analysis was performed using Grounded Theory for qualitative data and bivariate statistical tests for quantitative data.

Results/Conclusions:

Village doctors identify MRs as primary sources of pharmaceutical information. Village doctors base drug prescription decisions on disease type and severity, pharmaceutical company reputations, credit availability, and incentives offered by MRs. MRs have a higher average socio-economic status than village doctors with a difference in median monthly expenditure of 5000 taka ($72) (p<0.001). MRs are better educated with 98% having bachelor’s degrees whereas 84% of village doctors have twelfth grade education or less (p<0.001). MRs exert a strong influence on prescribing practices of village doctors in rural Bangladesh. Improvements in the safety and quality of healthcare delivered to the rural poor in Bangladesh and similar informal provider-based health markets will require regulations and educational initiatives to reduce inappropriate incentives and improve medical information conveyed by MRs to village doctors.

The Underground Healthcare Market: The Case of Rural Medical Practitioners in India

Author(s): S. K. Mondal*1, B. Kanjilal2
Affiliation(s): 1Research, Indian Institute of Health Management Research, Kolkata, 2Indian Institute of Health Management Research, India
Keywords: Healthcare Market, Rural Medical Practitioners, India
Background:

The Rural Medical Practitioners (RMP), who practice modern medicine without any formal training or legal sanction, have gained a dominant presence as a first point of contact in the Indian rural health care market. Recent studies have confirmed their popularity among rural poor due to their easy availability and low cost of treatment. Their rapid and unregulated spread raises several questions regarding its potential impact on Indian health market: how rationally they use the drugs and medicines? To what extent their proliferation is safe and useful in the context of rural health services? How does it affect the health outcome of rural population? What should be the policy response to deal with these prominent but underground providers in the rural health care market? This study examines the above pertinent questions and attempts to find out the potentiality of the market in the context of rural health care services in West Bengal, India.

Methods:

The study is based on primary data sets, collected by the Indian Institute of Health Management Research (IIHMR) from the rural areas of two districts of West Bengal, India, during January to March 2009. Data related to health seeking behavior were collected from 1140 households. In addition, about 200 RMPs were randomly selected, tracked, and interviewed to understand their knowledge and practices. Specifically, data were collected on their education and social background, practice details, basic knowledge about the symptom of some common diseases and treatment, referral practices, average number of patient served by them, and so on. An analytical framework is proposed to analyze the dynamics of this market using concepts of new institutional economics, such as transaction cost and trust. The quantitative data were analysis was done using simple statistical methods.

Results/Conclusions:

A little more than 60 percent of ailing persons in the selected rural areas were found to have sought treatment from the RMPs. Low transaction cost and trust were the two most important determinants of the high demand of RMP services. On average, a RMP client had to travel less than a quarter of the distance travelled by a user of government facilities for treatment. The out of pocket expenses incurred by a user of RMP services was also significantly less than users of formal health facilities. The factors coupled with low entry barrier to this underground market have made the RMPs a dominant market player with huge potential of benefits and harms. On the one hand, they meet the minimum need of population where formal sector is nearly absent; on the other, their unregulated practices generate three substantial risks which manifest in their (1) irrational use of drugs, (2) increasing engagement in surgical interventions and abortion, and (3) gradual penetration in inpatient care market.

UNITAId’s Medicines Patent Pool Initiative

Author(s): E. T. Hoen1
Affiliation(s): 1UNITAID, Geneva 27, Switzerland
Keywords:

UNITAID is a financing mechanism set up in 2006 as a way of securing sustainable financing of treatments for AIDS, TB and malaria primarily through a tax on airline tickets. UNITAID seeks to have a lasting impact on markets - essentially, by reducing prices and increasing production. UNITAID also plans to play a role in ensuring the development of paediatric formulations for AIDS drugs or fixed-dose combinations where they do not exist. UNITAID spends over 100 million USD on the purchase of AIDS medicines annuallyThe implementation of the World Trade Organization’s TRIPS Agreement is leading to more widespread patenting of new medicines in countries that traditionally have been important producers of generic essential medicines. One example is India where product patenting did not exist until 2005. This enabled many generic manufacturers to develop and produce and sell less costly versions of medicines thereby introducing competition in the market.

Background:

This is now changing and as a result, unless action is taken, generic versions of new medicines will only become available after the 20 year patent term has expired. When medicines are patented they are in general more expensive. For example, treating a patient for one year with the most affordable improved first-line regimen for HIV, as recommended by the World Health Organization (WHO), today costs between US$ 613 and 1 033, using originator products. This represents at least an eight-fold increase from the price of the older regimen, which stands at US$ 80 and is widely available as a generic. Patents may also stand in the way of the development of fixed-dose combinations or formulations for paediatric use of which the patents on the different components are held by different companies. Therefore in July 2008, the UNITAID board decided to establish a medicines patent pool to deal with both access and innovation issues related to the medicines patents. A patent pool would enable others, such as generic industries, to obtain a license to the patents to develop, produce and sell AIDS medicines in developing countries at low cost in exchange for the payment of a royalty to remunerate the patent holders.

Methods:

The medicines patent pool offers a one stop shop for all parties involved and will provide the confidence in being able to market, which is a prerequisite for generic producers to invest in the development of generic AIDS medications. The medicines patent pool is a voluntary initiative and its success will depend on the willingness of both the patent holders, mostly pharmaceutical companies and the generic companies to cooperate. There is a growing interest in patent pools in the pharmaceutical sector. For example on 13 February 2009 GSK announced a patent pool for neglected tropical diseases.
The UNITAID Patent Pool Initiative has the potential to provide benefits to all: pharmaceutical companies are remunerated for making licenses available; generic companies are able to access the licenses to needed patents more easily and quickly; and patients in developing countries get faster access to improved, more affordable and better adapted treatments.

Availability and Use of Essential Drugs in PhC Facilities in Bangladesh: Fulfilling Outcome Objectives of the National Drug Policy?

Author(s): S. M. Ahmed*1, Q. S. Isalm1
Affiliation(s): 1Research and Evaluation Division, BRAC, Dhaka, Bangladesh
Keywords: Essential drugs, rational use of drugs, drug policy 1982, BRAC, Bangladesh
Background:

A baseline survey done in 1994 by WHO at some public sector PHC facilities in rural areas of Bangladesh found the availability and use of essential drugs very low and irrational, and over-prescribing common. Evidence exists that the situation has deteriorated over the years. This study aimed to explore how far the outcome objectives of the National Drug Policy of 1982 in terms of availability, affordability, and rational use of essential drugs have been achieved from a representative sample of public and private sectors PHC facilities in rural and urban areas of Bangladesh.

Methods:

This study was designed as a facility-based cross-sectional study which can be easily implemented “by individuals without special training or access to many resources”. The study covered a representative sample of Upazila (sub-district) health complexes, UHCs (n=30) and Drug shops (n=30) in the rural areas, and a sample of urban clinics (n=20) in the capital for observation, exit interview and mini-market survey to collect relevant data

Results/Conclusions:

Average consulting (120 seconds) and dispensing (60 seconds) time in the UHCs appeared to have increased from 1994, but only marginally so. The proportion of drugs dispensed out of those prescribed was much higher in the UHCs (76%) compared to the urban clinics (44%). None of the drugs dispensed from any of the facility was labeled properly (name, generic name of drug and dosage) though an improvement in knowledge of correct dosage since 1994 (measured by self-reporting) was observed in case of UHCs (from 57% in 1994 to 73% in this study). Polypharmacy was on rise (from 5% in 1994 to 33%) in the UHCs and on an average the number of drugs prescribed per encounter with patients in the UHCs (2.2) was higher than in 1994 (1.4). In case of drug shops and urban clinics, this was even higher (46-61%). In 44% of encounters in the UHCs and urban clinics, an antibiotic was prescribed which rose to 60% in case of drug shops where providers like untrained village doctors and semi-qualified medical assistants attended patients. Only 47% of the UHCs and 55% of the urban clinics had a copy of the Essential Drug List (EDL). In more than 60% of the encounters in the UHCs and the urban clinics, drugs were prescribed from the (EDL) while the proportion was only 44% in case of drug shops. Deterioration was observed in the availability of essential drugs for treatment of common illnesses. Only 6% of the UHCs and 15% of the urban clinics had at least 15 of the 20 drugs from the reference list prepared for this study. The anarchy prevailing in the drugs market is well amplified by the wide variation found in the price of drugs based upon brands sometimes the differences being as high as 500%. There has been deterioration in rational use of drugs over time especially in rural Bangladesh. Polypharmacy is alarmingly on increase including misuse and overuse of antibiotics, especially at the rural drug shops and the urban clinics. Generic prescribing is almost non-existing. Consulting and dispensing time is too short for any meaningful communication to take place between patient and provider(s). The retail prices of key essential drugs vary widely depending upon brands and is a barrier to reaching the poor with quality medicine at low cost.