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The State of Medicine Quality in the Mekong Sub-Region

 | 
Sauwakon Ratanawijitrasin
, 
Souly Phanouvong

3 - Medicine Quality as Reflected in the Five Country Study

Texte intégral

1The analysis to be presented in the sections below covers two levels: country and region. The regional analysis relies on the combined data of test results from all five countries. Where aggregation of data is required in the examination and comparison of results from different countries, we take into account the comparability of the data. Furthermore, because the samples used for the tests were not collected randomly, and came from the border provinces of these countries, which were areas known to have deeper problems in medicine quality and were often targeted for investigation and enforcement, the degrees of the problem revealed in this analysis do not represent national or regional averages. In addition, because the quality testing takes time from sample collection to final analysis, the test results inevitably reflect quality of samples from previous times, rather than the current situation. In this case, the analysis generated from this study may serve as reference points to which data from new monitoring efforts can compare longitudinally to see if the quality situation has improved or deteriorated.

2For any results from a monitoring study, the fact that quality problems exist at all should send a signal or sound an alarm on the need for intervention. This is because, ideally, no medicine should fail the scrutiny for quality.

3In this analysis, a medicine at any level of quality that fails to ensure patient safety is considered a failed product. Thus, the two categories – substandard and counterfeit medicines – are both failed products. Neither of them meets the legal requirements on quality.

3.1 - Medicine Quality: the Overall Picture

4When the results of all the medicine samples collected from all the survey rounds from these five countries are combined, the percentage of samples that did not pass quality testing range from 3.3% in Lao PDR to 15.5% in Cambodia, with an average failure rate of 8.1% for the region.

5Figure 12 presents the percentage of medicine quality failure from each of the countries.

Figure 12: Percentage of samples failing quality testing by country

Figure 12: Percentage of samples failing quality testing by country

Note: The number above each bar chart indicates the number of poor-quality (substandard as well as counterfeit) samples from each country. Note that the total number of samples collected from each country varies.

3.2 - Medicine Quality Trends at Country Level

6The quality failure rate found in each country represents the overall multi-year monitoring results. Three out of the five countries – Cambodia, Lao PDR and Vietnam – sampled in different years. Data from Thailand is only available for one year in this database. Furthermore, in regards to the samples collected from Yunnan Province in China for three years, the number of samples tested each year is too small to allow for any meaningful analysis in trends. Thus, we looked at changes over time only in Cambodia, Lao PDR, and Vietnam.

7Among the countries surveyed, Cambodia has the most complete set of data. Figure 13 depicts the relative rates of samples that passed and failed quality testing over the years. The total number of samples per year is shown on each of the bar charts to allow the readers to judge the relative weight of the data from different years. High failure rates occurred during 2002 and 2003, at 28.3% and 29.4%, respectively. There was then a general downward trend, except for a jump to 30% in 2006.

8Products with relatively high failure rates were the anti-malarials – artesunate tablets and chloroquine tablets – with almost 60% of the samples failing quality tests. These high anti-malarial failure frequencies caused the rise in overall failures in 2006.

Figure 13: Quality of medicines samples collected in Cambodia between 2002-2008 showing the proportion of products that passed and failed quality testing

Figure 13: Quality of medicines samples collected in Cambodia between 2002-2008 showing the proportion of products that passed and failed quality testing

Note: The number in the dark grey section on each bar chart indicates the number of poor-quality (substandard as well as counterfeit) samples tested each year in Cambodia.

9In Lao PDR, samples were collected between 2003 and 2008, except in 2005. Thus, the data is available for five years only. The findings from Lao PDR show a general improvement trend in quality. The highest failure rate among the surveys in Lao PDR was 20.7% in 2003, but this fell by half the following year, and subsequently tapered to 0-2%.

Figure 14: Quality of medicines samples collected in Lao PDR between 2003-2008 showing the proportion of products that passed and failed quality testing

Figure 14: Quality of medicines samples collected in Lao PDR between 2003-2008 showing the proportion of products that passed and failed quality testing

Note: The number in the dark grey section on each bar chart indicates the number of poor-quality (substandard as well as counterfeit) samples tested by year in Lao PDR.

10In contrast to the findings in Cambodia and Lao PDR, the frequency of medicines failing quality testing in Vietnam was relatively low and stable at 4-6% from 2004 to 2008.

Figure 15: Quality of medicines samples collected in Vietnam between 2004-2008 showing the proportion of products that passed and failed quality testing

Figure 15: Quality of medicines samples collected in Vietnam between 2004-2008 showing the proportion of products that passed and failed quality testing

Note: The number in the dark grey section on each bar chart indicates the number of poor-quality (substandard as well as counterfeit) samples tested by year in Vietnam.

3.3 - Quality of Medicines by Therapeutic Group

11In the many studies on medicine quality in the Mekong Subregion, the main medicines of interest have primarily been anti-microbials. This study follows the same focus. Of more than 3,000 samples collected, only six items belonged to categories that are not anti-microbials. Hence, the analysis here focuses only on anti-microbial medicines as they are the main targets. Medicines in four anti-microbial therapeutic categories were sampled and tested: anti-malarials, antibiotics, anti-tuberculosis medicines, and anti-retrovirals.

Figure 16: Quality of four categories of anti-microbial medicines samples collected and tested in the region (2003-2008)

Figure 16: Quality of four categories of anti-microbial medicines samples collected and tested in the region (2003-2008)

Note: The number in the dark grey section on each bar chart indicates the number of poor-quality (substandard as well as counterfeit) samples by therapeutic group.

12With a 12% failure rate, anti-malarial medicine is the most problematic group among the four. Antibiotics, of which 6% did not pass quality testing, came second. Failed anti-tuberculosis medicines rated at 1.4%, while all the anti-retroviral medicines for the treatment of HIV were found to meet quality standards.

13Because of such a wide variation among the quality of these different medicine groups, it is interesting to learn more about the explanations behind such differences. Except for antibiotics, many countries manage the other three groups of anti-microbials in vertical programmes. Theoretically, the government should be in a position to ensure that the medicines distributed and dispensed are of good quality. Otherwise, all the efforts made to exert direct control of the treatment of these serious infectious diseases would be in vain. The fact that more than 10% of anti-malarial drugs that are circulating are of poor quality demands that investigations be made into the workings of drug distribution and its context in the region. Further analysis is made on each of the different medicine groups and country to identify problem areas.

3.3.1 - Anti-malarial medicines

14This data suggests that the problem is most severe in Cambodia – where 20% of the anti-malarials failed to pass the tests, followed by Lao PDR at 10%. In the other three countries, the rates were around 7%.

Figure 17: Quality of anti-malarials collected by country

Figure 17: Quality of anti-malarials collected by country

Note: The number in the dark grey section on each bar chart indicates the number of poor-quality (substandard as well as counterfeit) samples by country.

15In Cambodia, the type of anti-malarial medicines that did not pass quality testing included artesunate, chloroquine, mefloquine, and quinine solid dosage forms. The most problematic drug was quinine with only 37% of the samples passing the tests. Of the rest of the samples, about 3% were substandard and as high as 60% were identified as counterfeits, based on the country's legal definition.

16The failure rates of anti-malarials from Lao PDR were also alarming, with 17% of chloroquine and 13% of artesunate not passing. The failure rate for this whole group in Lao PDR was 10%.

Figure 18: Inspectors of the Food and Drug Department of Lao PDR inspect retail pharmacy outlets as part of the monotherapies ban policy implementation in Lao PDR

Figure 18: Inspectors of the Food and Drug Department of Lao PDR inspect retail pharmacy outlets as part of the monotherapies ban policy implementation in Lao PDR

Photo: S. Phanouvong

  • 6 Despite the countries in Mekong subregion have banned the artesunate solid dosage form monotherapy (...)

17Among the samples from Yunnan Province in China, the most problematic anti-malarial was artesunate (in tablet form) with a worrisome 17% failure rate, although the sample was small. The overall rate for this anti-infective group was 7%. Artesunate, a key component of artemisinin-based combination therapy (ACT), is one of the most efficacious medicines for treating P. falciparum malaria. In 2009-2010, due to the increasing concern of prolonged parasite clearance time and resistant malaria to artemesinin monotherapy in the region, especially in the ‘hot spot’ malaria zone along the Thai-Cambodian border areas, artesunate solid dosage form as monotherapy was banned by most countries in the Mekong Subregion6.

18In Thailand, substandard artesunate, chloroquine, and quinine were found, with relatively, yet still problematic, lower failure rates of 4%, 17%, and 6%, respectively.

19In Vietnam, the item with the highest failure rates was quinine (13%), followed by chloroquine and artesunate (9% and 3%).

20That older, less effective, anti-malarial medicines are widely available throughout the border areas of these countries suggests that they are bought and used by people in these areas. Although it is not known which dosage regimens are actually used by those who buy medicines to treat themselves, the appropriateness of medicine use is questionable. With great efforts made at the global, regional and national levels to devise the best ACT treatment regimens for malaria, the reality in the field is significantly different from what policy-makers intended. To effectively control the spread of the malaria epidemic, policy implementation requires no less attention than policy formulation.

21This study also suggests that many anti-malarial medicines were substandard and that the quality level is considerably lower than in other categories of anti-microbials that were monitored. The threats from poor quality medicines are multi-fold. First, they do not cure and might cause harm to the patients. Second, patients taking bad medicines are led to believe that treatment is being made and defer seeking appropriate care. Third, there is a great risk in the development of the parasite’s resistance strains.

22The incidence of malaria in the Mekong Subregion is still relatively high, and drug resistant strains of malarial parasites first arose in this area. High rates of poor quality medicines to treat the disease and the inappropriate treatment regimens used constitute a serious cause for concern to public health, and demands serious call for intervention.

3.3.2 - Antibiotics

23The majority of the antibiotics tested were from Lao PDR (717 samples). No antibiotics were collected from China for this study; and only tetracycline was collected from Thailand. Hence, the numbers presented in Figure 19 are not entirely amenable for cross-country comparison.

Figure 19: Quality of antibiotics collected and tested by country

Figure 19: Quality of antibiotics collected and tested by country

Note: The number in the dark grey section on each bar chart indicates the number of poor-quality (substandard as well as counterfeit) antibiotic samples by country.

24In Cambodia, the antibiotic with the highest failure rate was tetracycline – only 81% passed quality tests. About 11% were substandard and 7% were found to be counterfeit products. Another antibiotic with serious poor quality issues was ampicillin, of which 16% were substandard.

25In Thailand, only tetracycline samples were collected, and 3% were substandard. For Lao PDR and Vietnam, tetracycline and ampicillin had the highest failure rates compared to other medicines.

3.3.3 - Anti-tuberculosis medicines

26Of the three countries from which samples of anti-TB medicines were collected, it was found that some samples from Cambodia did not pass the test. They contained low doses of isonizid and rifampicin.

Figure 20: Quality of anti-TB medicines collected and tested by country

Figure 20: Quality of anti-TB medicines collected and tested by country

Note: The number in the dark grey section on each bar chart indicates the number of poor-quality (substandard as well as counterfeit) anti-TB samples by country.

3.3.4 - Anti-retroviral medicines (ARVs)

27Anti-Retroviral medicines were collected only in Cambodia and Vietnam. All of the ARV samples passed the tests.

Figure 21: Quality of ARVs collected and tested by country

Figure 21: Quality of ARVs collected and tested by country

3.4 - Counterfeit Medicines7

  • 7 Refer to definitions of counterfeit medicines in Annex I

28Of the pharmaceutical products collected in the various rounds of surveys, 99 (2.7%) samples were identified as counterfeit medicines. The vast majority of the counterfeit products identified came from Cambodia ; and all of them were detected between 2001 and 2004. Of the other relatively few counterfeit samples (5 out of 99), 4 came from Lao PDR, and 1 from Yunnan Province (China). The number is too small to allow any meaningful analysis. Therefore, we decided to focus on the situation in Cambodia.

Figure 22: Counterfeit medicines by country

Figure 22: Counterfeit medicines by country

Note: The y-axis indicates the percentages of counterfeit medicines. The number above each bar chart indicates the number of counterfeit samples from each country. Note that the total number of samples collected from each country varies.

Figure 23: Counterfeit medicines found in Cambodia between 2005-2008

Figure 23: Counterfeit medicines found in Cambodia between 2005-2008

Photo: M. Boravann

Table 3: Counterfeit medicines identified in the five countries during 2002-2008

Table 3: Counterfeit medicines identified in the five countries during 2002-2008

3.4.1-Types of counterfeit medicines

29A staggering 60 counterfeit samples were quinine, constituting 60% of the quinine samples collected and 64% of all the counterfeits identified. The second target with the largest percentage of fake medicines was artesunate, of which 9% of the samples were counterfeit. This was followed by 7% for tetracycline, 4% for mefloquine, and 0.6% (1 sample) for chloroquine.

Table 4: Counterfeit medicines identified in Cambodia

Medicine

Number of samples collected and tested

Number of counterfeit

Percentage of counterfeit

Quinine

100

60

60%

Artesunate

172

16

9.3%

Tetracycline

203

14

6.9%

Mefloquine

71

3

4.2%

Chloroquine

155

1

0.6%

30Many of the counterfeit quinine tablets and tetracycline capsules were labelled as manufactured by a company named Brainy Pharmaceutical. Although the country of manufacturing was not shown, the label texts appeared in both English and Thai.

Table 5: Examples of counterfeit quinine identified in Cambodia with information regarding active ingredients, trade-name and manufacturer as stated on the packaging

Trade name

Stated manufacturer

Site

Number of samples

Quinine

Brainy Pharmaceutical

Clinic
Street Vendor
Retail Drug Outlets
Unknown

2
1
1
9

Quinine

UNKNOWN

Retail Drug Outlets
Unknown

2
3

Quinine sulfate

Brainy Pharmaceutical

Pharmacy
Unknown

5
2

31However, this name does not appear in the list of pharmaceutical businesses licensed by the Thai Food and Drug Administration. It is likely to be a counterfeiting company. Other counterfeit medicines were purported to be manufactured by companies in different countries, for example: Australia, Belgium and China.

32Of the five counterfeit medicines detected, four were anti-malarials. With the increasing failure rates of artemisinin-based therapy, the findings of these counterfeit anti-malarials underline serious concerns over the increasing possibilities of drug resistance.

Table 6: Examples of counterfeit artesunate identified in Cambodia with information regarding active ingredients, trade name and manufacturer as stated on the packaging

Trade name

Manufacturer’s name as claimed on label

Origin of sample

Number of samples

Artesunate

Guilin Pharmaceutical Works

Pharmacy
Unknown

1
6

Arinate

[missing manufacturer name, labeled as made in Belgium]

Unknown

1

Artesunate

Central Pharmaceutical Factory No.2, Dopharma

Street Vendor

1

Table 7: Examples of counterfeit mefloquine identified in Cambodia with information regarding active ingredients, trade name and manufacturer as stated on the packaging

Trade-name

Manufacturer’s name as claimed on label

Origin of sample

Number of samples

Mefloquine

Gateway Pharmaceuticals
Panlaboratories Ply Ltd
Australia

Pharmacy

1

Table 8: Examples of counterfeit tetracycline identified in Cambodia with information regarding active ingredients, trade name and manufacturer as stated on the packaging

Trade-name

Manufacturer’s name as claimed on label

Origin of sample

Number of samples

Tetra-250

Brainy Pharmaceutical

Retail Drug Outlets
Pharmacy

1
2

Tetracycline

Brainy Pharmaceutical

Clinic
Pharmacy
Street Vendor

1
1
4

Tetraclor

Chemephand Medical (Thailand)

Pharmacy

1

3.4.2 - Source as provincial sites

33Counterfeit samples were detected in all the provinces from which medicine samples were collected between 2002 and 2004. In Cambodia, the monitored provinces include Battambang, Pailin, Preah Vihear, and Pursat.

Table 9: Number and percentage of counterfeit medicines in Cambodia identified by province and year

Table 9: Number and percentage of counterfeit medicines in Cambodia identified by province and year

34The number of counterfeits found appeared to decrease each year, and no counterfeit samples were reported from 2005 to 2008. When surveys expanded after 2004 to a number of additional provinces, such as Kampong Cham, Koh Kong, Ratanakiri, and Stung Treng, no counterfeits were reported from these provinces.

3.4.3 - Distribution channels: mainly street vendors and pharmacies?

35Because the distribution channels from which 54 out of the 99 samples identified as counterfeits were not recorded, the data in this analysis should not be considered definitive. However, this data, as incomplete as it is, remains useful in suggesting potential problematic areas for counterfeit products. In addition, the analysis here serves to provide an analytical framework for investigating problems at the final stage of flow through which counterfeit medicines reach the hands of consumers.

36Of the counterfeits with ‘known’ sources, the majority were collected from street vendors (37.8%) and pharmacies (35.6%). Retail drug outlets and clinics were the other two types of distribution channels with a share greater than 10%. No counterfeits were found among the samples collected from health centres, distributors, national health programme warehouses, and malaria clinics.

Figure 24: Percentage of counterfeit medicines from each distribution channel out of total counterfeit samples found in the countries surveyed

Figure 24: Percentage of counterfeit medicines from each distribution channel out of total counterfeit samples found in the countries surveyed

3.5 - Quality of Medicines and Consumer’ Risk

37Because counterfeit and substandard medicines constitute real threats to the consumer health, the chance of buying a pharmaceutical product that does not meet quality standards can be considered as the ‘risk’ that a consumer faces in a place where a medicine is dispensed. Therefore, any distribution channel where counterfeit and substandard medicines are found is not performing its role in providing quality-assured medicines, and is a place where patient safety might be at risk.

38In the analysis below, the data is analysed in light of the risk to consumers when they acquire medicine from different distribution settings. The data include all the medicine samples that did not pass the quality scrutiny. The percentages were calculated based on the number of samples collected from each respective channel.

3.5.1 - What is the risk a consumer may face when acquiring a medicine from various sources?

39Pharmacies are the channel from which all the countries surveyed had samples collected. The risks to consumer when acquiring medicines from a pharmacy at a border province in Cambodia and Thailand are 12% and 11% respectively. In Lao PDR, such risk, which was found to be 3% in this study, was the lowest in the group.

40From this dataset, the risks of getting low quality medicines from hospitals in the border area stand at 6% for Thailand, and 1% for Lao PDR. No substandard or counterfeit medicines were identified in hospitals in the other three countries. Among the clinics in the three countries (Cambodia, Lao PDR, and Yunnan Province in China) where medicines were collected, the risks were high in both Cambodia (17%) and Yunnan Province in China (15%). Even in the government sector, a medicine quality problem was still identified. Substandard medicines were discovered in malaria clinics in Thailand and Yunnan, China. In addition, they were also found in a national programme warehouse in Yunnan.

Figure 25: Consumers’ risk of receiving bad medicines from pharmacies at the border provinces in each of the countries

Figure 25: Consumers’ risk of receiving bad medicines from pharmacies at the border provinces in each of the countries

Note: Number above on each bar chart indicates the percentage of poor-quality (substandard as well as counterfeit) samples from each country. Note that the total number of samples collected from each country varies.

Figure 26: Consumers’ risk of receiving bad medicines from hospitals in the border provinces in each of the countries

Figure 26: Consumers’ risk of receiving bad medicines from hospitals in the border provinces in each of the countries

Note: The number above on each bar chart indicates the percentage of poor-quality (substandard as well as counterfeit) samples from each country. Note that the total number of samples collected from each country varies.

Figure 27: Consumers’ risk of receiving bad medicines from clinics in the border provinces in each of the countries

Figure 27: Consumers’ risk of receiving bad medicines from clinics in the border provinces in each of the countries

Note: The number above on each bar chart indicates the percentage of poor-quality (substandard as well as counterfeit) samples from each country. Note that the total number of samples collected from each country varies.

Figure 28: Consumers’ risk of receiving bad medicines from malaria clinics in the border provinces in each of the countries

Figure 28: Consumers’ risk of receiving bad medicines from malaria clinics in the border provinces in each of the countries

Note: The number above on each bar chart indicates the percentage of poor-quality (substandard as well as counterfeit) samples from each country. Note that the total number of samples collected from each country varies.

3.5.2 - Comparative consumer risks

41From another angle, a consumer in the Mekong Subregion should have information regarding his or her own risk when acquiring medicine from different types of settings in each of the countries. Each of the following charts provides a graphical display of the percentages of medicines that did not meet quality standards – both substandard and counterfeit – from the various distribution channels in border areas. Because the charts for different countries are put on the same scale, the values from the different graphs are comparable.

42Among the five countries under this multiple-year study, the highest risk for a consumer to obtain poor quality medicines was in Cambodia. With the exception of the hospital, the risk that a consumer in Cambodia might receive medicine with questionable quality was high for all distribution channels as all were greater than 10%. Retail drug outlets and street vendors, with the percentages of problem medicines higher than 30%, were particularly troublesome. Comparatively, a consumer in Yunnan Province, China, was exposed to a lower risk of bad quality medicines. However, low quality medicines were still available from pharmacies, clinics, and malaria clinics. A consumer in Lao PDR might find him or herself relatively safer getting medicines from clinics than pharmacies in the border areas. Pharmacies were also a risk in the border provinces in Thailand and Vietnam.

Figure 29: Consumers’ risk of receiving poor quality medicines from various distribution channels in the border provinces of Cambodia

Figure 29: Consumers’ risk of receiving poor quality medicines from various distribution channels in the border provinces of Cambodia

Note: The number indicates percentage

Figure 30: Consumers’ risk of receiving poor quality medicines from various distribution channels in the border counties of Yunnan Province

Figure 30: Consumers’ risk of receiving poor quality medicines from various distribution channels in the border counties of Yunnan Province

Note: the number indicates percentage

Figure 31: Consumers’ risk of receiving poor quality medicines from various distribution channels in the border provinces of Lao PDR

Figure 31: Consumers’ risk of receiving poor quality medicines from various distribution channels in the border provinces of Lao PDR

Note: the number indicates percentage

Figure 32: Consumers’ risk of receiving poor quality medicines from various distribution channels in the border provinces of Thailand

Figure 32: Consumers’ risk of receiving poor quality medicines from various distribution channels in the border provinces of Thailand

Note: the number indicates percentage

Figure 33: Consumers’ risk of receiving poor quality medicines from various distribution channels in the border provinces of Vietnam

Figure 33: Consumers’ risk of receiving poor quality medicines from various distribution channels in the border provinces of Vietnam

Note: the number indicates percentage

Notes

6 Despite the countries in Mekong subregion have banned the artesunate solid dosage form monotherapy, recent year sample collection rounds from the PQM-supported medicines quality monitoring activities suggested that artesunate tablets have been founds in private sector although in very limited frequency and quantity.

7 Refer to definitions of counterfeit medicines in Annex I

Table des illustrations

Titre Figure 12: Percentage of samples failing quality testing by country
Légende Note: The number above each bar chart indicates the number of poor-quality (substandard as well as counterfeit) samples from each country. Note that the total number of samples collected from each country varies.
URL http://books.openedition.org/irasec/docannexe/image/1208/img-1.jpg
Fichier image/jpeg, 59k
Titre Figure 13: Quality of medicines samples collected in Cambodia between 2002-2008 showing the proportion of products that passed and failed quality testing
Légende Note: The number in the dark grey section on each bar chart indicates the number of poor-quality (substandard as well as counterfeit) samples tested each year in Cambodia.
URL http://books.openedition.org/irasec/docannexe/image/1208/img-2.jpg
Fichier image/jpeg, 88k
Titre Figure 14: Quality of medicines samples collected in Lao PDR between 2003-2008 showing the proportion of products that passed and failed quality testing
Légende Note: The number in the dark grey section on each bar chart indicates the number of poor-quality (substandard as well as counterfeit) samples tested by year in Lao PDR.
URL http://books.openedition.org/irasec/docannexe/image/1208/img-3.jpg
Fichier image/jpeg, 83k
Titre Figure 15: Quality of medicines samples collected in Vietnam between 2004-2008 showing the proportion of products that passed and failed quality testing
Légende Note: The number in the dark grey section on each bar chart indicates the number of poor-quality (substandard as well as counterfeit) samples tested by year in Vietnam.
URL http://books.openedition.org/irasec/docannexe/image/1208/img-4.jpg
Fichier image/jpeg, 78k
Titre Figure 16: Quality of four categories of anti-microbial medicines samples collected and tested in the region (2003-2008)
Légende Note: The number in the dark grey section on each bar chart indicates the number of poor-quality (substandard as well as counterfeit) samples by therapeutic group.
URL http://books.openedition.org/irasec/docannexe/image/1208/img-5.jpg
Fichier image/jpeg, 85k
Titre Figure 17: Quality of anti-malarials collected by country
Légende Note: The number in the dark grey section on each bar chart indicates the number of poor-quality (substandard as well as counterfeit) samples by country.
URL http://books.openedition.org/irasec/docannexe/image/1208/img-6.jpg
Fichier image/jpeg, 72k
Titre Figure 18: Inspectors of the Food and Drug Department of Lao PDR inspect retail pharmacy outlets as part of the monotherapies ban policy implementation in Lao PDR
Légende Photo: S. Phanouvong
URL http://books.openedition.org/irasec/docannexe/image/1208/img-7.jpg
Fichier image/jpeg, 107k
Titre Figure 19: Quality of antibiotics collected and tested by country
Légende Note: The number in the dark grey section on each bar chart indicates the number of poor-quality (substandard as well as counterfeit) antibiotic samples by country.
URL http://books.openedition.org/irasec/docannexe/image/1208/img-8.jpg
Fichier image/jpeg, 79k
Titre Figure 20: Quality of anti-TB medicines collected and tested by country
Légende Note: The number in the dark grey section on each bar chart indicates the number of poor-quality (substandard as well as counterfeit) anti-TB samples by country.
URL http://books.openedition.org/irasec/docannexe/image/1208/img-9.jpg
Fichier image/jpeg, 74k
Titre Figure 21: Quality of ARVs collected and tested by country
URL http://books.openedition.org/irasec/docannexe/image/1208/img-10.jpg
Fichier image/jpeg, 61k
Titre Figure 22: Counterfeit medicines by country
Légende Note: The y-axis indicates the percentages of counterfeit medicines. The number above each bar chart indicates the number of counterfeit samples from each country. Note that the total number of samples collected from each country varies.
URL http://books.openedition.org/irasec/docannexe/image/1208/img-11.jpg
Fichier image/jpeg, 83k
Titre Figure 23: Counterfeit medicines found in Cambodia between 2005-2008
Légende Photo: M. Boravann
URL http://books.openedition.org/irasec/docannexe/image/1208/img-12.jpg
Fichier image/jpeg, 95k
Titre Table 3: Counterfeit medicines identified in the five countries during 2002-2008
URL http://books.openedition.org/irasec/docannexe/image/1208/img-13.jpg
Fichier image/jpeg, 140k
Titre Table 9: Number and percentage of counterfeit medicines in Cambodia identified by province and year
URL http://books.openedition.org/irasec/docannexe/image/1208/img-14.jpg
Fichier image/jpeg, 162k
Titre Figure 24: Percentage of counterfeit medicines from each distribution channel out of total counterfeit samples found in the countries surveyed
URL http://books.openedition.org/irasec/docannexe/image/1208/img-15.jpg
Fichier image/jpeg, 78k
Titre Figure 25: Consumers’ risk of receiving bad medicines from pharmacies at the border provinces in each of the countries
Légende Note: Number above on each bar chart indicates the percentage of poor-quality (substandard as well as counterfeit) samples from each country. Note that the total number of samples collected from each country varies.
URL http://books.openedition.org/irasec/docannexe/image/1208/img-16.jpg
Fichier image/jpeg, 57k
Titre Figure 26: Consumers’ risk of receiving bad medicines from hospitals in the border provinces in each of the countries
Légende Note: The number above on each bar chart indicates the percentage of poor-quality (substandard as well as counterfeit) samples from each country. Note that the total number of samples collected from each country varies.
URL http://books.openedition.org/irasec/docannexe/image/1208/img-17.jpg
Fichier image/jpeg, 53k
Titre Figure 27: Consumers’ risk of receiving bad medicines from clinics in the border provinces in each of the countries
Légende Note: The number above on each bar chart indicates the percentage of poor-quality (substandard as well as counterfeit) samples from each country. Note that the total number of samples collected from each country varies.
URL http://books.openedition.org/irasec/docannexe/image/1208/img-18.jpg
Fichier image/jpeg, 54k
Titre Figure 28: Consumers’ risk of receiving bad medicines from malaria clinics in the border provinces in each of the countries
Légende Note: The number above on each bar chart indicates the percentage of poor-quality (substandard as well as counterfeit) samples from each country. Note that the total number of samples collected from each country varies.
URL http://books.openedition.org/irasec/docannexe/image/1208/img-19.jpg
Fichier image/jpeg, 53k
Titre Figure 29: Consumers’ risk of receiving poor quality medicines from various distribution channels in the border provinces of Cambodia
Légende Note: The number indicates percentage
URL http://books.openedition.org/irasec/docannexe/image/1208/img-20.jpg
Fichier image/jpeg, 83k
Titre Figure 30: Consumers’ risk of receiving poor quality medicines from various distribution channels in the border counties of Yunnan Province
Légende Note: the number indicates percentage
URL http://books.openedition.org/irasec/docannexe/image/1208/img-21.jpg
Fichier image/jpeg, 87k
Titre Figure 31: Consumers’ risk of receiving poor quality medicines from various distribution channels in the border provinces of Lao PDR
Légende Note: the number indicates percentage
URL http://books.openedition.org/irasec/docannexe/image/1208/img-22.jpg
Fichier image/jpeg, 83k
Titre Figure 32: Consumers’ risk of receiving poor quality medicines from various distribution channels in the border provinces of Thailand
Légende Note: the number indicates percentage
URL http://books.openedition.org/irasec/docannexe/image/1208/img-23.jpg
Fichier image/jpeg, 83k
Titre Figure 33: Consumers’ risk of receiving poor quality medicines from various distribution channels in the border provinces of Vietnam
Légende Note: the number indicates percentage
URL http://books.openedition.org/irasec/docannexe/image/1208/img-24.jpg
Fichier image/jpeg, 85k

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