HAI NEWS

Wishing our readers a happy and fruitful 1999.

Quality of Healthcare

By Kiran Sagoo and Dr. K Bala

Introduction

The health service of the 90s has seen the emergence of the terms "quality of healthcare and "continuous quality development". This emergence is due to various reasons. In 1984, thirty-two countries in Europe adopted the WHO's programme, "Health for All in the year 2000". Among the targets identified to enable these countries to achieve their goal, was the subject of continuous quality development. Realising the importance of quality in the field of healthcare, much attention has been placed on improving the existing healthcare standards. Patients are also becoming increasingly aware of the quality of healthcare services and demand not only good quality, but also insist on continuous improvement. With these demands being put forward at a time of budgetary constraints, there is an urgent necessity to re-examine healthcare practices and procedures in order to improve quality within the framework of existing resources.

Dedicated to Professor Bibile, one of the pioneers of quality healthcare in Sri Lanka, a national workshop on Quality of Healthcare was held in Kandy, Sri Lanka. This workshop was held from the 18th to 20th of September 1998. Participants to this workshop included non-governmental organisations, Ministry of Health personnel, pharmacists, doctors, academicians and medical students. Ways of improving healthcare in Sri Lanka were discussed and explored. The organisers of this workshop were Consumers International Regional Office for Asia and the Pacific, Action for Rational Drugs in Asia (ARDA) - Sri Lanka partners, in collaboration with the Ministry of Health and Indigenous Medicine.

What is Quality of Healthcare?

In his welcoming address, Prof. K. Weerasuriya, Professor of Pharmacology, University of Colombo, pointed out that this workshop was a step in the series of a long journey. Much work lay ahead in the mission to improve quality of healthcare.

The components of high quality healthcare can be described as:

- A high degree of professional excellence

- Efficient use of resources

- Minimal risk to patients

- High degree of patient satisfaction

- Final health impact

Quality of healthcare also involves the sensible use of resources, and direct health-related activities such as diagnosis, treatment and nursing. The service functions of waiting time, catering and staff behaviour must also be included in the concept of quality of healthcare. "It must be noted that quality of healthcare is not a static phenomenon. Quality can always be improved," stated Dr. Balasubramaniam, Pharmaceutical and Health Adviser of Consumers International. Therefore, it is essential that a national policy focus on quality development as a dynamic process.

Continuous Quality Development

Healthcare consists of many components. Activities directly related to health are health promotion, diseases prevention, treatment and rehabilitation. Others include services involved in establishing, running and maintaining healthcare institutions. It is important to assess and evaluate the quality of care in each of these services. All these aspects of healthcare can be divided into three distinct components, which are the structure, process and outcome.

The structure refers to the organisational settings of care which includes the building, staff and their qualifications, economic conditions, management, personnel, equipment, facilities and information system. Activities carried out to deliver preventive, promotional, diagnostic, therapeutic, rehabilitative and information services to patients fall under the 'process' component. This component also includes staff behaviour. While a good structure and process are crucial for quality, on their own, they will not ensure a good outcome. The outcome is dependent on the effects of the care given to the patient. Factors such as patient satisfaction, mortality rates, complications arising and recovery targets have a strong influence on the final outcome. Medical technology, since it is a component of both structure and process, and also determines the final outcome, has an essential role to play.

Appropriate Use of Medical Technology

The principal reasons behind introducing new technologies are their technical advantage, impact on health, cost effectiveness and acceptability to the patients and healthcare providers. The relationship between medical technology and quality of healthcare can be seen in terms of utilisation, outcome and costs.

Appropriate utilisation produces high quality of care at an acceptable cost. However in all countries, there is an over and/or under utilisation of medical technology. The large variations between and within countries in the utilisation of medical technologies are due to varying economic conditions and political commitments of different governments. Differing criteria for appropriate use in countries also result in these differences. Thus, it is important that every country carry out a technology assessment to provide an objective approach to the selection of technologies.

It is relevant to note that in The Netherlands, the hospital licensing law gives the government the authority to control the number and location of high technology services. About fifteen services are controlled under this "Article 18" programme which includes open heart surgery, all organ transplants, renal dialysis, MRI scanning, clinical genetics services, intensive care and radiotherapy. This programme helps to ensure the effective distribution of services throughout the country and adequate volumes to ensure quality outcomes.

Patients and the Community

Mr Lucien Rajakarunanayake, convenor of the movement for social democracy, emphasised the importance of placing the patient first in considering quality of healthcare. As patients and the community as a whole are the beneficiaries of healthcare services, their experiences of care received adds valuable input in improving quality. Thus, strengthening the influence of patients on healthcare is an important part of continuous quality development. It is crucial that managers and healthcare providers at all levels create opportunities to involve patients, patient's organisations and the population in the process and listen to their definition of their needs, problems and expectations for the quality of healthcare.

Healthcare Providers

Quality of care is strongly dependent on the work carried out by healthcare providers. The concept of continuous quality development must form a permanent and integral part of the daily routine of all care providers. They must recognise that the ultimate objective of their efforts is not only to meet a moral obligation but also to improve their job satisfaction.

It is important that healthcare providers have a better understanding of the patients' needs in order to effectively serve them. Continuing contact with the patient is necessary to obtain feedback that can help the quality of services to improve. The needs of the patient must also be fully understood in a holistic sense, and not merely the part of the anatomy that is being treated.

Medical ethics also plays an important role in the provision of quality of healthcare to the patients. Physicians must uphold the interest of the patients at all times. Rational use of drugs must be enforced. Physicians must also play the leading role in educating the patient of the importance of generic drugs.

To achieve the desired level of quality, it was suggested by Mr Rajakarunanayake that perhaps there should be a reassessment of the manner in which selections are made to the professions in healthcare, particularly medicine and nursing. It is not in the best interest of the people to make selection for training purely on the marks scored in examinations. A continuous assessment should be made of a student's interest in caring for the needy and participation in charity work.

A biggest contribution towards the concept of quality of care would be a change of attitudes. Health workers need to realise the impact of their actions on the patient and take pride in their work. One of the central principles of quality of care, is that it can be better promoted by strengthening health workers' opportunities for self-assessment and self-regulation than by imposing means of control and punitive measures.

The Public Sector

Long waiting times are a serious problem in the public sector. This is due to an over-utilisation of the tertiary hospitals and under-utilisation of the peripheral hospitals. A solution to overcoming this problem would be establishing a proper referral system.

Back referral to the medical officer in the periphery should be encouraged. It is also necessary that a fast tracking reception point be established. First contact should be to assess and recognise patients who need immediate and/or special attention.

Over-utilisation of wards in the hospitals is a major problem that reduces the quality of care. This is mainly caused by the postponement of surgical operations due to the absence of various officers, sub-unit failures, administrative delay and medico-legal problems. Patients also contribute to the problem due to their misconception of seeking super specialities and not using peripheral services. Regularising and closely monitoring hospital procedures will assist in overcoming this problem. Patient education is also important.

The Way Ahead

The workshop acknowledged the need for reform in both the public and private sectors. Issues of concern in the private sector that were raised were the high cost of treatment, government doctors doing part-time private practice and quacks practising as doctors.

Proposals to overcome these include:

- Regulation of fees for consultation and services

- Phase out government doctors doing private practice

- Encourage more full-time private general practitioners. Training incentives should be given to enable doctors start independent practice.

- Enforce strict laws to register practitioners of all systems of medicine with the local authority

- Co-ordinating body of all medical councils to monitor practices of their respective members

The participants recommended that a Health Ministry official should be delegated the task of setting up structures and mechanisms towards continuous quality development. This official should work in close collaboration with all the stake-holders including health NGOs, associations of health professionals, and community organisations. Finding ways and means on how the available resources can be better and more effectively spent will go a long way in improving the quality of healthcare.

Europe

NGOs meet with WHO staff

On 9^th October, HAI co-ordinated the first NGO Pharmaceutical Roundtable between international health NGOs and WHO's Director General Dr Gro Harlem Brundtland and senior staff members. At the meeting, the NGO representatives gave their views on key drug issues including equity and access, independent drug information, drug promotion and the impact of globalisation and trade agreements on health.

The main outcomes included:

· WHO acknowledged the need to strengthen its support for and collaboration with NGOs at the national level.

· This meeting contributed to WHO's efforts to define and further develop processes for collaborating with NGOs and others.

· No decision was made on the structure of future meetings, but Dr. Michael Scholtz, Executive Director for WHO's Health Technology and Drugs cluster, promised to devise a strategy for working with NGOs in the future.

Both sides left the meeting in agreement that this had been an important step in repairing, redefining, and reinvigorating NGO contributions to and collaboration with WHO. (81/98)

The Netherlands

Dutch working group on drug donations

"What isn't good enough for us, isn't good enough for people in developing countries" writes the Dutch Minister of Health in the foreword of a new publication promoting appropriate drug donations from The Netherlands. Guidelines for Drug Donations from The Netherlands [Richtlijnen voor geneesmiddelendonaties vanuit Nederland] is based on the inter-agency Guidelines for Drug Donations issued by WHO in 1996. The publication was developed by members of the Dutch Working Group on Drug Donations and has received the support of the Dutch government, the Dutch pharmaceutical industry, and international NGOs such as the Red Cross.

The complete guidelines can be accessed from the Internet at the following address: http://www.wemos.nl/donaties. For more information about the guidelines, contact: Mark Raijmakers, Wemos, Postbus 1693, 1000 BR, Amsterdam, The Netherlands, Tel: (+31-20) 468 8388, Fax: (+31-20) 468 6008 or e-mail: wemos@wemos.nl (82/98)

Asia

Malaysia

A dream turning to reality

5^th November marked a special day. A day when CI ROAP's vision of over ten years took its first step of becoming a reality. For five days, a preparatory planning meeting for the People's Health Assembly took place in Penang. This meeting brought together a group of experts from Asia & the Pacific, Europe, Africa and Latin America to discuss various aspects of the assembly.

The event tentatively fixed for November/December 2000 will consist of a five-day assembly, and pre- and post-assembly activities. It will bring together people's movements, government representatives and multi-lateral agencies. The major objective of the assembly will be to put People's health in People's hands based on the 1978 Alma Ata Declaration of Health for All by the year 2000. (83/98)

Pakistan

Workshop on journalism and health

In September, The Network of Associations for Rational Use of Medication in Pakistan organised a three-day workshop for journalists to raise awareness on the importance of health reporting. According to The Network, health stories in Pakistan, if properly covered, could cause more impact on the public than the usual political and crime reporting. The main focus of the workshop was on the growing influence of industry on people's health.

The workshop also focused on the debate about essential drugs. Though Pakistan has an essential drugs list, thousands of drugs flood the market, due to poor implementation of the list. Lack of political will and vested interest have been stated as the two main reasons for the non-implementation of the essential drug list. It is important for people to understand the issues affecting their health. Only then can improvements in the nation's health take place. (84/98)

A step forward In October, a special working group of the WHO Executive Board (EB) met to formulate a new draft text on the resolution on Revised Drug Strategy (see HAI News lead article, June 98 for details). Zafar Mirza, co-ordinator of The Network of Associations for Rational Use of Medication in Pakistan (The Network) spoke on behalf of HAI at a technical briefing on access to essential drugs. In his remarks, he emphasised the need for public health interests to be placed above trade. He also recommended ways for national governments and the WHO to pursue public health goals in a globalised economy. The Executive Board's working group approved a new draft text on the Revised Drug Strategy. While the draft reflects compromise, it is quite promising. The text gives a broad mandate to WHO to advise Member States on the implications of international trade agreements and for the first time acknowledges that drug promotion causes problems in both developed and developing countries. The special working group will present the draft text to the Executive Board in January 1999.

Sri Lanka

Prescribe generics

The Study Group of Food and Drugs, Faculty of Medicine, University of Galle has initiated a programme to provide objective information on essential drugs to health professionals, medical students and the general public.

The first leaflet is on paracetamol and contains its pharmacological actions, indications, cautions, side effects and dosage. Relevant details on acute overdose including mechanisms of toxicity; susceptibility to toxicity, clinical features, biochemical and haemotological abnormalities and treatment are given. Retail prices of a single tablet of the generic and six brand named preparations are also given.

Name	Price in Sri Lankan Rupee &Cents (US$1=Rs.65)
Paracetamol	0.23

Brands

Fepanil	0.70
Setamol	0.70
Eurodopa	0.85
Paramol	0.90
Calpol	1.00
Panadol	1.25

[The editors congratulate the undergraduate medical students of the University of Galle for their innovative work.] (85/98)

Liver toxicity

The Japanese Ministry of Health reported in an adverse drug reaction bulletin that 57 cases of liver dysfunction including two deaths have occurred in patients being treated with the new diabetes drug acarbose (Precose).

Acarbose is a drug approved by the US Food and Drug Administration (FDA), for treatment of non-insulin-dependent diabetes mellitus (NIDDM). NIDDM is also known as type II, adult, or maturity-onset diabetes.

Acarbose works by slowing or preventing the absorption of sugars into the blood stream by blocking enzymes from the pancreas and the gastrointestinal tract that break down sugars. About one-half of the total energy supply in a typical diet comes from carbohydrates. The most important carbohydrate in a diet is starch. Starch is a long chain of single sugars that cannot be absorbed into the blood unless they are first broken down by enzymes into sugars.

The FDA-approved professional product information for acarbose states that in long term clinical trials lasting up to one year, 15 per cent of those taking acarbose had changes in their tests for liver function versus 7 per cent of those taking an inactive pill or placebo, thus indicating a possibility of liver toxicity.

Anyone using acarbose should have their liver function regularly monitored. Diet and exercise are the initial forms of treatment for NIDDM. Dietary restriction and weight loss are essential in overweight diabetics. (Worst Pills Best Pills News, USA, Vol. 4, No. 6, Jun 98) (87/98)

Generics: 60 percent of English scripts

In 1997, sixty per cent of all prescriptions in England were written generically. This is an increase of two percentage points over 1996 and a continuation of the trend seen over the past ten years.

According to the latest UK Department of Health figures, forty-nine per cent of prescriptions were dispensed generically, a rise of three points over 1996.

The number of items prescribed generically for the six leading therapeutic areas were as follows:

Therapeutic category	Percentage prescribed generically	Percentage change over 1996
Respiratory	48 per cent	+5 per cent
Infections	84 per cent	+3 per cent
Cardiovascular	74 per cent	+3 per cent
Endocrine	56 per cent	+3 per cent
CNS	78 per cent	+2 per cent
Gastro-intestinal	56 per cent	+2 per cent

500 million prescription items were dispensed in England in 1997 - a 3 per cent increase over 1996. They had a net ingredient cost (NIC) of British Pounds 4,367 million, up 9 per cent in 1996, with the average NIC per item costing 9 pounds. This is an increase of 5.7 per cent (2.9 per cent in real terms). Elderly people received the most prescriptions. In 1997, they faced a 5 per cent increase, which amounts to 224 million items.

The NIC for prescriptions was 785 pounds in 1997, 713 pounds in 1996 and 413 pounds in 1987. The average NIC per prescription was 12 pounds in 1997, 11 pounds in 1996 and 5 pounds in 1987. Eighty-five per cent of prescription items were free to patients last year and the number of free items increased by 3 per cent to 388 million. (SCRIP No. 2355, UK, Jul 24, 98) (88/98)

Life expectancy falls in Europe

Laying the blame squarely on poverty, unemployment, homelessness, excessive drinking, smoking and on health reforms that are too reliant on market forces, the World Health Report 1998 reveals that Europe's overall health is deteriorating for the first time in 50 years.

The reason for the fall is the social and economic upheaval in the newly independent states of the former Soviet Union and the countries of central and eastern Europe. On an average, a child born in the newly independent states can expect to live 11 years less than a child born in the European Union.

Re-emerging infectious diseases (such as malaria, diphtheria, tuberculosis), sexually transmitted diseases (such as syphilis and HIV/AIDS), and lifestyle mediated diseases (such as cancer, cardiovascular disease, and illnesses related to alcohol and tobacco) take a heavy toll. As the social safety net of the welfare state dissolves, extreme poverty affecting 120 million of Europe's 870 million people, homelessness, and other social and environmental factors also undermine health.

However, the report states that even among the 15 countries of the European Union, there is little room for complacency as rising unemployment and the expanding divide between rich and poor have resulted in health problems. Although infectious diseases such as tuberculosis and diphtheria have so far been confined mainly to countries in the east of the region, there is a risk that they will spread to western Europe. (BMJ, UK, 317:767, Sept 98) (89/98)

Performance of the EDP

The essential drug programme (EDP) was introduced in Burkina Faso in 1993. Prior to the introduction of the programme, patients obtained services in health centres free of charge, but had to buy the prescribed drugs in private pharmacies. With the introduction of the programme, village pharmacies have been set up in health centres. An essential drug list and treatment guidelines have been published, nurses had received refresher courses on essential drugs, and drug vendors had been trained on four week courses to sell the drugs in the new village pharmacies.

A study was conducted to determine how successful the implementation of the programme had been. It consisted of non-participant observation in the health centre and village pharmacy, and of household interviews with the patient. The study took place in the districts of Tougan, Nouna and Solenzo. The programme was implemented in the districts of Nouna and Solenzo in March 1993, and was fully implemented in Tougan by May 1995. The findings were as follows:

Overall, 82 per cent of the drugs prescribed in the health centres were dispensed at the village pharmacy. The remaining 18 per cent were either bought elsewhere or were not bought at all. A lack of resources was the major reason why drugs prescribed were not bought. The high rate of purchases in the village pharmacies as opposed to very few in the private market proves that patients accepted the programme extremely well.

Unavailability of prescribed drugs occurred in 5.9 per cent of cases; most of the missing drugs did not belong to the essential drug list; 1.3 per cent of the drugs dispensed at village pharmacies were sold without prescription.

There were significant differences between the different districts. Drugs purchased at the village pharmacies' of Nouna, Solenzo and Tougan stood at 87.4 per cent, 86.1 per cent and 62.2 per cent respectively. A drug being unavailable when a patient required it stood at 5.9 per cent for Nouna, 2.0 per cent for Solenzo and 19.0 per cent for Tougan. Dispensing without prescription occurred in 35.7 per cent of cases in Nouna, 9.3 per cent in Solenzo and as high as 54.7 per cent in Tougan. The performance in the district of Tougan was not as good as in the other two districts. This may be due to the later implementation of the essential drug programme in Tougan.

Patients could recall the prescribed dosage in 68.3 per cent of cases. In cases dealing with children under five compliance occurred in only 40.3 per cent of cases. Compliance in general seems to be independent from common socio-cultural factors. One reason for non-compliance may be illiteracy of the patient, inappropriate drug labels and pills looking alike. Further research is certainly needed in this area. (Health Policy and Planning, UK, 13(2) 159-166, 1998) (90/98)

Financial crisis increases child mortality

Countries reeling under the global financial crisis are having to cut back on children's vaccinations or delay plans for protecting children with newer vaccines. Government cuts in vaccination budgets have resulted in difficulties and delays in countries obtaining enough vaccines for their children. In some countries, local currencies have collapsed and budgets set for vaccines priced in foreign currency can no longer be met.

As reported by the CVI* Executive Secretary Bjorn Melgaard, "We are very worried about the situation in countries that rely on foreign aid or on foreign exchange to buy vaccines and run their vaccination programmes. Clearly, Asian and African countries have been hit badly by the crisis. But some big Latin American countries are also threatened. It would be tragic if our long-term efforts over the past 20 years to set up an efficient system that is bringing vaccines to the vast majority of the world's children were to suffer as a result of a hopefully short-term financial crisis."

However even without the financial crisis, many children are not getting the vaccines they need. CVI estimates that four million children are still dying every year from infections that can be prevented by existing vaccines. Of these four million, two million are dying because they are not getting vaccines that were developed and licensed many years ago against measles, tetanus, rubella and yellow fever.

The gap between the rich and the poor have been blamed for these needless gaps. With the financial crisis, the gap is growing. The lives of these four million children could be saved, if at least two conditions are met.

- All governments must put and keep vaccines and vaccination among their top priorities and stop spending on less cost-effective things, like high-tech hospitals.

- The world must double the US$10 billion it is spending annually on all aspects of vaccinations, from research and development to delivery. Currently US$ 1.80 per person is being spent on vaccines, compared to US$139 per person being spent on military equipment. (WHO Press Release WHO/83, Nov 10, 98)

*The 'Consultative Group' of the Children's Vaccine Initiative (CVI) is a worldwide coalition of organisations from the public and private sector. The Consultative Group was set up in 1990, to ensure that children everywhere are getting all the vaccines they need to protect themselves against life-threatening infections. The group meets every two years to review progress and thrash out roadblocks in achieving the CVI. (91/98)

Mifepristone for medical abortion

About 100,000-145,000 unwanted pregnancies each day, or about 36 to 53 million a year, end in induced (surgical) abortion. Estimates suggest that more than half of these abortions are performed under unsafe conditions and result in more than 70,000 deaths per year, almost all in developing countries.

Despite the availability of medical abortion with mifepristone in some countries in Europe and in China for over ten years, this has not resulted in worldwide access to safer abortion. The conference organised by The Population Council and the Wellcome Trust, recognised the need to assess research and development activity in drug-induced abortion. There was unanimous agreement that mifepristone has "come of age" for use in early medical abortion, with agreement on accepted practices and a recognition that it is appropriate for use in resource-poor environments. There was full consensus that medical abortion is a viable alternative to surgical abortion for early pregnancy termination.

It is important that manufacturers, distributors, and research agencies set up an international centralised registry to monitor adverse reactions to this drug. To avert the development of a black market, it is also important that manufacturers of mifepristone relax their controls on the introduction and licensing of the product to ensure the widest possible access and the lowest price. (Science, Vol. 281, Jul 24, 98) (92/98)

[Editors note: Medical abortion is defined as the use of drugs to terminate pregnancy.]

Competition from generic drugs

The pharmaceutical market has become increasingly competitive since the early 1980s, in part because of the dramatic growth of the drug industry. Forty-three per cent of the prescription drugs sold in the United States as measured in total countable units, such as tablets and capsules, were generic. Twelve years earlier, this figure was just 19 per cent. As generic drugs cost less than their equivalent brand-names, they have played an important role in holding down national spending on prescription drugs from what it would otherwise have been. Considering only sales through pharmacies, the Congressional Budget Office (CBO) estimates that by substituting generic for brand-name drugs, purchasers saved roughly US$8 billion to US$10 billion in 1994 at retail prices.

Three factors are behind the dramatic rise in sales of generic drugs that has made those savings possible. First, the Drug Price Competition and Patent Term Restoration Act of 1984 - commonly known as the Hatch-Waxman Act - made it easier and less costly for manufacturers to enter the market for generic, non-antibiotic drugs. Second, by 1980, most states had passed drug-product substitution laws that allowed pharmacists to dispense a generic drug even when the prescription called for a brand-name drug. And third, some government health programs, such as Medicaid, and many private health insurance plans have actively promoted such generic substitution.

(source: http://www.cbo.gov/showdoc.cfm?index=655&sequence=1)(93/98)

Drug Info On-Line The following useful information is now available on-line: Essential Drugs List WHO's Tenth Model List of Essential Drugs is now available on-line. To see the full text, visit: http://www.who.int/dmp/edl-10.htm An alphabetical listing of the drugs on the list can be obtained from: http://www.who.int/dmp/edlabclist.htm FDA-approved drugs Drug products approved by the US Food and Drug Administration (FDA) are available at the FDA's website. To search for 1998 drug approvals, see http://www.fda.gov/cder/approval/index.htm. The "Orange Book" which allows readers to search drug products by active ingredient, proprietary name, applicant holder and applicant number, is also available on-line. The database includes prescription-only drugs, over-the-counter medicines, biological products and discontinued products. To find the Orange Book, visit http://www.accessdata.fda.gov/ob/.htm

· ...and our rice pots are empty. The Social Cost of the Economic Crisis, published by Consumers International Regional Office for Asia and the Pacific (CI ROAP), 1998, 397 pp. US$20.00.

More than a year has passed since the crisis hit the Asian region. While much attention has been placed on the economic aspects of the crisis, the social aspect of the crisis has been neglected. This book aims on bridging this gap by highlighting the social costs faced by society. Based on a series of articles, which have been divided into appropriate sections, the book provides an overview on the causal factors of the crisis, updated insights and the social costs. Coming from a wide a range of backgrounds, contributors include individuals from the consumer movement, non- governmental organisations, the government sector, academicians and multi-lateral agencies.

Poverty is a major public health issue. The crisis has caused a rise in poverty levels, which is resulting in deteriorating health standards. Two articles in the book focus on the impact of the crisis on health. Providing a broad base on the economic and social factors, which will eventually affect the health of the people, this book will be valuable to those involved in the field of health and social development.

Available from: Consumers International Regional Office for Asia and the Pacific, PO Box 1045, 10460 Penang, Malaysia.

· Blaming the Brain: The truth about drugs and mental health, by Elliot S. Valenstein, Free Press, 1998, 292 pp (hardcover price US$25).

In the last fifty years, psychopharmacology has led to a revolution in how we think about depression and schizophrenia: the development of successful drug treatments has popularised the view that these diseases are due to biochemical abnormalities of the brain which can in principle and often in practice be corrected by drugs. But when the history of the science is carefully traced and the experimental and clinical evidence examined, as it is in this book, this view becomes untenable. The story grippingly illustrates how readily a seductive concept can be swallowed by vast numbers of doctors, including psychiatrists, and many of their patients - especially when pharmaceutical companies promote it heavily. Valenstein writes clearly, without being too technical. The title of the book aptly underlines what was going on: impersonal biochemistry got the blame for mental illness - it's nobody's fault. The result has been an over-reliance on psychotropic drugs, and unrealistic expectations from their use. The book brings us back to reality, and provides an excellent broad background for Charles Medawar's The Antidepressant Web. (Review by Dr Andrew Herxheimer)

· Health for All… Today?, special commemorative magazine for the 125th Anniversary of the Colombo Medical School, 1996, 122 pp.

This magazine was produced by Students Involved in Rational Health Action (SIRHA) to commemorate the 125^th Anniversary of the Colombo Medical School. Focusing on Sri Lanka, the publication consists of a variety of articles on health services, medical education and pharmaceuticals. Writers come from the medical and science field, and have a strong interest in social medicine.

Articles bound to evoke wide interest include David Werner's article on the future of primary healthcare and the article on health for all Sri Lankans - now. Emphasis has also been given to the issue of nutrition. Articles under the pharmaceuticals section will be useful to those working on drug-related issues. Topics include drug quality assurance, reducing drug costs, analysis of drug prices, essential drugs, registration, and the importance of labeling.

This publication will certainly be very useful to those wanting to know more about the Sri Lankan health scene. Both layman and professionals will benefit from the source of information in this magazine.

Available from: SIRHA, Faculty of Medicine, PO Box 271, Colombo, Sri Lanka.

· Regional Health Report 1998, published by WHO, Regional Office for South-East Asia, New Delhi, 1998, 80 pp.

This regional report by the World Health Organisation regional office for South-East Asia focuses on women living in Bangladesh, Bhutan, DPR Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka and Thailand. The report recognises that women's health programmes in the region have focused almost entirely on the health conditions and risks faced by women during their reproductive years. However it is now recognised that besides childbearing, women are vulnerable to a wide spectrum of health risks throughout their lives.

A demographic, socioeconomic and cultural profile of women is given. This is followed by a lifespan perspective, which addresses the health issues of women, right from conception and birth, throughout the reproductive years and into old age. Issues addressed include nutritional status, the burden of communicable and noncommunicable diseases, work related problems, substance abuse, mental health and violence. A chapter is devoted to other interconnected factors such as poverty and education that affects health and the quality of life. While seeking to position women's health issues within the wider perspective of overall development, this report seeks to convey a feeling of optimism that women in the region will achieve their fundamental right to health and well-being.

Available from: WHO Regional Office for South-East Asia, World Health House, Indraprastha Estate, New Delhi 110 002, India.

Production: Lin Min Min

HAI News is produced six times a year by the Regional Office for Asia and the Pacific of Consumers International (CI). For more information about the publication or to subscribe, contact HAI-Asia.

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