The Provision of Pharmaceuticals by Appropriate Technology

Author(s): P. Dunnill
Source: Proceedings of the Royal Society of London. Series B, Biological Sciences, Vol. 209, No.
1174, More Technologies for Rural Health (Jul. 28, 1980), pp. 153-157
Published by: The Royal Society
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Proc. R. Soc. Lond. B 209, 153-157 (1980)
Printed in Great Britain

DRUG SUPPLIES, MANAGEMENT AND MANUFACTURING

FOR LOCAL NEEDS

The provision of pharmaceuticalsby appropriatetechnology

BY P. DUNNILL
Department of Chemical and Biochemical Engineering,
University College London, Torrington Place, London WCIE 7JE, U.K.

The provision of drugs is of much lower importance to poor communities

than other health measures. However, partly because of the present
imperfections of such measures, drugs are needed and methods of
reducing their end cost and increasing their effectiveness are important,
particularly for the poor rural patient. The field is acutely influenced
by social, ethical and political forces but there are direct technical
questions which those most in need are not in a position to answer.
These have to do with the extent to which drug compounding can be
decentralized and the availability of equipment and of manuals on
simple handling techniques.

INTRODUCTION
Several provisos apply to any consideration of the technical problems of providing
drugs to rural communities. The first proviso, that nutritious food, clean water,
good sewage treatment and vaccination are far more important than drugs, cannot
be overstressed. However, even when adequate food, water and sewage treatment
are available there is still a need for drugs. A second proviso is critical. Probably
no other products are as affected by social, ethical, political and commercial
pressures as are drugs: sensible compromises between governments, companies
and doctors are therefore of crucial importance (Lall i974; Speight I975; Anon.
I975; Agarwal 1978). This aspect will be dismissed without discussion only because
it is the subject of a separate paper (Yudkin, this symposium).
Many governments and independent organizations in less developed countries
will have to continue to import some finished drugs. They gain much more
favourable terms by participating in the bulk purchasing schemes organized by
a number of non-profit agencies (Evans I977). However, it seems probable that
such schemes will not be a total solution. Less developed countries show an under-
standable desire to gain greater independence in the provision of drugs and to
save even more foreign exchange than they can by bulk purchase of finished drugs.
Once these provisos are accepted, the technical question of how finished drugs
can be manufactured for poor rural communities can next be approached.
I first examined this question as a biochemical engineer in the early 1970s. It
[ 153 ]

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154 P. Dunnill (Discussion Meeting)
was expected initially that the establishment of locally owned drug manufacturing
plants, modest in scale by European standards, but still involving investments of
several hundreds of thousands of pounds sterling, would be the best way forward.
Discussions since then with people controlling such industrial projects in less
developed countries have suggested considerable caution (Dunnill 1977).

PROBLEMS OF DRUG MANUFACTURE IN LESS DEVELOPED COUNTRIES

Those less developed countries that have attempted to produce basic chemicals
for pharmaceutical manufacture have experienced great difficulty in consistently
maintaining very demanding pharmacopoeia standards (Handoussa 1974). When
they have failed it has been necessary to buy erratically on the world market
with unfavourable terms and serious delay. At first sight, fermentation to produce
antibiotics should be less affected by the quality of the carbohydrate feedstock,
but in practice, substitution of local nutrients has been found to require very
prolonged trials and is often unsatisfactory owing to wide fluctuations in quality.
Efficient manufacture requires basic services. For example, seven-day fermenta-
tions and intensive quality control demand stable electricity supplies and good
servicing of equipment. Often these are not available. Finally there is an acute
shortage of skilled personnel. Fifteen years of teaching postgraduate biochemical
engineers from less developed countries suggests to me that the situation will
change only slowly and that graduating students will continue to face great
frustrations when they return to their countries of origin.
Some of these problems can be met by involving foreign companies but the
difficult compromises mentioned earlier then have to be faced in an acute form.
Agencies such as O.E.C.D. (Cilingiroglu i975) and UNIDO (UNIDO I976, 1978;
Dunnill I978) have an important role in this sector but one can safely conclude
that the development of industrial manufacture of drugs by chemical processes
in less developed countries will be a slow and rather painful business. When it is
established it will be centralized and in urban areas remote from most rural
communities. Past experience suggests that its products will be used mostly in
these urban areas.
Are there alternatives to centralized production? Two suggest themselves. The
first is to use local indigenous medicines. It certainly makes sense to encourage
their use where they have a well proven action or where their position in the local
culture gives them a psychological impact for good or where the tendency to
turn needlessly to potent drugs such as antibiotics and multivitamins is something
to be avoided (Werner 1978). However, there are serious conditions that require
modern drugs.
One may therefore ask what technical contributions can be made to bring
these drugs more cheaply and effectively to rural communities? The best reference
point would seem to be the local pharmacy often attached to some form of clinic
in which medical auxiliaries are already employed (Elliott I975). Depending on

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 Provision of pharmaceuticals by appropriate technology 1_55
the skill of the pharmacist or pharmaceutical auxiliary and the facilities, these
pharmacies do some compounding to make finished drugs and undertake drug
packaging. The simplest facility is a very basic pharmacy limited to dispensing;
the most sophisticated has the kind of equipment shown in table 1, which repre-
sents an investment beyond local resources. This equipment and a facility to

TABLE 1. SMALL PROCESSING FACILITY IN AFRICA

100 litre kettles and electric stirrers

motor driven filter
hand-operated bottle filler
hand-operated capping machine
steel sieves for granulation
drum-type powder blender
single punch tabletting machine
small capsule-filling machine

house it was provided by an international missionary hospital organization and

produces 40 finished drugs but does no chemical synthesis. The drugs go to a
number of clinics and other hospitals run by the same organization. One can ask,
'What limits the efficiency of these operations and the growth of more such
facilities manned by indigenous staff?' A number of restrictions are mentioned
widely in letters from field workers. These are not immediately concerned with
the act of compounding drugs but must be noted because they largely determine
the chances of effectively treating patients.
As at the more sophisticated level, the shortage of trained people is always
acute and the problem can be aggravated by restrictive attitudes of local qualified
staff concerned to preserve their status. A similar attitude tends to mean that
resources for pharmaceutical work are poor, even dangerous, in relation to any
sterile handling. The quality of drugs, however produced, is often nullified by
poor storage (Wickremasinghe & Bibile I97I) or poor transportation, or poor
packaging, or simply owing to patient illiteracy (Bratt I978). Some of these
problems are susceptible to outside technical help and are receiving it, as with the
W.H.O. work on cold storage (Lloyd I979).

LOCAL COMPOUNDING OF DRUGS

There are direct problems associated with the compounding of drugs by physical
and mechanical operations. First, there is only an advantage in compounding
precursors into finished drugs if the product can be cheaper than bought finished
drugs, allowing for the salary or other benefit to the local compounder. In some
cases this is manifestly so. Preparation of a rehydration mixture from readily
available materials will be cheaper than purchasing foreign-made sachets. With
more complex materials such as antibiotics, purchase of bulk powder and related
excipients will only give savings over the finished drug price if the same policy

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156 P. Dunnill (Discussion Meeting)
of coordinated bulk purchase can be organized. While there seems no doubt that
such purchase can be arranged, pioneers of this approach may have to pay as
much as the cost of finished drugs bought in bulk because of their limited pur-
chasing power and will need financial assistance.
A second problem is that small-scale compounding equipment is less and less
used in developed countries that have large centralized manufacturing facilities.
The extension of factory regulations to hospitals is reducing their incentive to
undertake small-scale manufacture. There is thus a vanishing market for small-
scale and particularly manually operated compounding equipment. Some com-
panies retain one or two particular machines which have found a role in develop-
ment work, and there are countries such as India where the market for small
equipment is able to support a good deal of fabrication. However, the expatriate
pharmacist or especially the indigenous compounder working in, for example,
rural Africa is in no position to trace, let alone judge the effectiveness of, particular
equipment. Reduction in small-scale formulation and compounding in developed
countries also means that publication of information on techniques has dwindled
and the number of people with expertise is growing very small.
There are a number of actions which could be taken to assist those in the field.
Creation of a guide to equipment is one such contribution. To include some
assessment of equipment requires a network of contacts who make use of such
items. Quite often it will be just as useful to draw upon the experience of field
workers to suggest alternatives to commercial equipment and table 2 lists a few
that have appeared in their correspondence. These alternatives are not always
ideal; however, the field workers who have found them express obvious delight
that by these means they can circumvent the months of delay or total unavail-
ability of conventional supplies.
TABLE 2. ALTERNATIVES TO COMMERCIAL EQUIPMENT

restaurant-type mixers

locally made: cabinet dryers

tablet counters
packaging: newspaper end of rolls
sealable polythene film
car windows for ointment tables

Manuals on the use of small-scale equipment can be built up partly on the

basis of published information. However, much of this is now rather dated and
for this reason it has to be supplemented by ideas from those still engaged in
small-scale formulation and compounding.
A third objective is one not easily pursued by an individual. The negotiation
of supplies of precursors is usually only entered into when there is a genuine
prospect of sales. For this reason it is the kind of activity best undertaken by a
non-profit agency already dealing with drugs.

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 Provision of pharmaceuticals by appropriate technology 157
Installing further facilities to encompass more physical and mechanical com-
pounding of precursers in local, rural, pharmacies appears to be a worthwhile
objective and can be aided by the provision of suitable technical information.

REFERENCES (Dunnill)
Agarwal, A. 1978 Drugs and the third world. Earthscan Press Briefing Document no. 10.
London: Earthscan.
Anon. 1975 Report of the committee on drugs and pharmaceutical industry. Delhi: Ministry of
Petroleum and Chemicals, Government of India.
Bratt, J. 1978 Pictorial prescription labels. Educ. Broadcasting int., September, pp. 143-148.
Cilingiroglu, A. 1975 Transfer of technologyfor pharmaceutical chemicals. London: H.M.S.O.
O.E.C.D.
Dunnill, P. 1977 The provision of drugs by appropriate technology. Appropriate Technol. 4
(2), 16-17.
Dunnill, P. 1978 The provision of drugs by appropriate technology. UNIDO Irt. Forum on
Appropriate Technol, New Delhi, 20-30 Nov. 1978, ID/WG 282/45.
Elliott, K. 1975 2he training of auxiliaries in health care: an annotated bibliography. London:
Intermediate Technology Publications.
Evans, B. 1977 A new life for old equipment. Wld Med. 12 (7), 82-86.
Handoussa, H. A. 1974 The pharmaceutical industry in Egypt. Ph.D. thesis. London Uni-
versity.
Lall, S. 1974 International pharmaceutical industry and less developed countries. Econ.
politic. wkly 9, 1949-1958.
Lloyd, J. S. 1979 Improving the cold chain. III. Progress report, January 1978/March 1979.
EPI/CC/79. 1. Geneva: World Health Organization.
Speight, A. N. P. 1975 Cost-effectiveness and drug therapy. Trop. Doctor 5, 89-92.
UNIDO 1976 Industrial Development Abstracts cumulative index. 05001-07000, New York:
United Nations.
UNIDO 1978 Documents list. Cumulative list for the period I January 1967 - 31 December
1977. New York: United Nations.
Werner, D. 1978 Wherethereis no doctor.P.O. Box 1692, Palo Alto, California: The Hesperian
Foundation.
Wickremasinghe, M. P. & Bibile, S. 1971 The management of pharmaceuticals in Ceylon.
Report to the Prime Minister.

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