Getting the right medicines into the hands of patients on the front lines of emergency situations is no easy task. Elly Earls meets experts from the organisations doing it right to find out the importance of planning and collaboration.
While the industry has still not found a way to entirely eliminate wastage in emergency situations or longer-term humanitarian crises, the situation has improved markedly over the last two decades. This is largely down to the fact that the guidelines, vetting processes, and training and dispensing practices followed by leading organisations have been developed so thoroughly that they hold strong even in the
most catastrophic scenarios.
Collaboration: crucial to success
Ensuring that the right medicines reach the front lines in emergency situations or pandemics, and that they are safe and effective for use, involves incredible complexities. Drugs need to be delivered well in advance of their expiration date, in the right numbers, for each particular crisis, and often need to travel in specific, temperature-controlled conditions. These conditions must also be maintained when the drugs arrive at their destination, and they must be dispensed to patients by well-trained staff so that they are ultimately used effectively.
With so many stakeholders involved – from the pharmaceutical companies that manufacture the drugs to the logistics companies and forwarders delivering the product, and, finally, the NGOs working on the ground – collaboration between all parties is crucial to success. And it’s something that has hugely improved across the industry over the past two decades.
The Partnership for Quality Medical Donations (PQMD), a global alliance formed in 1996 to develop and champion high standards in medical supply and service donation, has played a huge part in these improvements.
"In 1996-97, there was a great outpouring of support and help for various disasters around the world, but it was without guidelines, meaning that companies were practically just dumping pharmaceutical and medical devices into disaster situations, creating even more havoc," says the organisation’s executive director, Elizabeth Ashbourne.
PQMD was created to coordinate the actions of global pharmaceutical companies, global NGOs and governments in times of crisis, and to ensure that their efforts were being carried out within a specific set of guidelines so that the products being delivered to emergency situations were used effectively, rather than wasted.
"Our organisation really focuses on making sure that all of those stakeholders are engaged in any kind of work we do," Ashbourne stresses, adding that the aim of PQMD’s guidelines is to ensure that every product is taken care of from production, through shipping and distribution, right to the end user. "We really take care of the products all the way through the cycle."
Important guidelines include determining the following factors prior to item donation:
- whether the product being sent matches the expressed need and is appropriate for treating the affected population
- whether the recipient has the proper storage facilities for the product, including adequate space, lighting, fire protection, shelving, dispensary/security and climate control
- whether the recipient has appropriately trained medical professionals for the prescribing, handling and dispensing
Additionally, no expired product should ever be shipped, and every product being considered for donation should be reviewed and approved by the recipient prior to shipping, including quantities to be received and expiry dating. "Nothing is done without tremendous supervision and oversight," Ashbourne emphasises. PQMD’s guidelines are also updated every year.
On top of PQMD’s efforts to improve collaboration across the industry, the UN has developed a cluster system, including ‘health clusters’ overseen by WHO, designed to coordinate the efforts of different stakeholders in humanitarian crises to avoid duplication and wastage. "The organisations that are involved in a health cluster meet sometimes daily, if it is required, and this is critical," Ashbourne says.
Overcoming challenges on the ground
One humanitarian organisation involved in PQMD and the UN health clusters is AmeriCares, which delivers over $500 million in quality medicine and relief supplies to more than 90 countries every year. The organisation’s vice-president of corporate relations, Geoff Kneisel, believes there are two keys to success in emergency scenarios: planning and communication.
At AmeriCares, which has been operating for more than 35 years, not only are the processes in place to vet the partners, but the organisation also works with incredibly stringent communication guidelines, and communication continues throughout the entire process of building an aid shipment.
"The amount of time and effort AmeriCares puts into ensuring that the match between resource and need is the best it can be is quite significant," Kneisel says, adding that the team declines over half the products it is offered because they are not likely to be a good match with humanitarian needs.
"There is a whole multifaceted department of the organisation involved in the decision-making process, and we work closely with the clinicians we’re serving and our partner organisations to understand the needs [of each situation], encouraging them to communicate honestly about what it is we have to offer."
Processes are also in place to ensure that once the product arrives on the ground, it is used properly by the patient and not wasted at the final hurdle.
"One of the early topics of conversation when vetting a partner is to ensure the labelling of the products will not lessen safety at all – so there are additional considerations on top of the manufacturer-provided guidelines, to give more local context about where the pharmaceutical is going to be administered and consumed," Kneisel explains. "The reliability and availability of temperature-sensitive conditions for certain products is also something we need to be sure of upfront, and just how reliable that last mile is in the local supply chain."
At times, this means getting down to the ‘nitty gritty’ little details. "The Haiti earthquake was a great example for us," Kneisel recalls. "It was utter chaos; following the earthquake, planes were landing on the tarmac as aid just piled up along the sides of the runway, so we realised we had to take the extra steps to get the pharmaceuticals into the hands of the clinicians. The volume of aid we sent was large, but the deliveries we were making were very small and done by hand to make sure the right products were going to the right places."
It is equally critical to ensure that members of staff on the ground are giving the correct guidance to the ultimate consumer, the patient – something Ramon Spatini Bernardo, section pharmacist at global NGO Médecins Sans Frontières (MSF), is keen to stress.
"We are constantly in contact with patients; we work with and support them, and when we are dispensing, we give them recommendations in line with our clinical guidelines," he says. "It’s crucial to train your staff in good dispensing practices, which means explaining how to use the drug, how much to take and the duration of the treatment."
Of course, in refugee situations, with patients on the move, things get even more challenging. "It’s very difficult to follow them, so you have to be present in the different countries and have knowledge about the pharmaceutical market in each country. This allows you to support them and avoid them not having access to the same medicines they were using before," says Spatini Bernardo.
Around Greece, for example, MSF is present in Italy, Serbia and Macedonia, and is therefore well positioned to support the growing number of refugees moving through the region. "We have knowledge of the pharmaceutical markets, and different sections of MSF are present; our pharmacists, working at the headquarters, have also taken many field visits to support [the refugees]."
Similarly, while AmeriCares does not have the global presence of staff members on the ground that MSF does, the organisation’s partnerships with vetted organisations mean its presence is still felt in over 90 countries.
Improvements under way
Unfortunately, in some countries, such as Syria, it is simply not possible to achieve the level of coordination necessary to ensure quality medical donations reach patients and are properly used.
"We manage to get medicines in via donation or imported from procurement centres in Turkey, and we do some local purchasing, but inside the country it’s a challenge, because they don’t have access to constant power supply. It’s a big issue," says Spatini Bernardo. "Even the regulatory agencies are not enforcing regulation in the rebel zones, so in Syria, the situation has deteriorated a lot."
That said, Spatini Bernardo has seen improvement in neighbouring countries. "Support from regulatory agencies within some countries is improving. It’s very slow, but they are improving. People are being trained by WHO: they go to work for some years at WHO, learn a lot, go back to their countries and improve a little."
Overall, the guidelines and support available to stakeholders involved in emergency medical donations have improved hugely over the past 20 years, resulting in a situation today where duplication of effort and wastage – while still occurrences – are much less frequent than before.
The combination of PQMD’s guidelines and the UN health cluster system, plus years of experience developing effective systems within individual NGOs, means patients in emergency situations are more likely than ever before to receive the right drugs and the right advice.