System and market failures: The unavailability of magnesium sulphate for the treatment of eclampsia and pre-eclampsia in Mozambique and Zimbabwe

Abstract

Ensuring the availability of effective drugs for priority health problems remains a key public health issue in many African countries.1 Market deficiencies in ensuring drug development for "neglected" diseases affecting developing countries are well described,2 3 w1 and several global initiatives are attempting to tackle this.4 w2 Even when low cost, effective treatments exist, however, drug availability for many common health problems remains poor in many settings, limiting progress towards achieving the millennium development goals.5 One such health problem is the management of pre-eclampsia and eclampsia, important causes of maternal and infant morbidity and mortality. Over 63 000 women die annually after eclamptic convulsions, with 99% of these deaths occurring in low and middle income countries.6 7 w3 Evidence is strong for the effectiveness of magnesium sulphate in treating and preventing eclampsia.8-10 w4 w5 Magnesium sulphate costs $0.35 (£0.19; 0.29) per ampoule (40 ml of 10% magnesium sulphate; Central Medical Stores, Mozambique, April 2005) and has appeared on the World Health Organization's essential medicines list since 1996.11 It is of great concern that this effective and low cost drug is still unavailable in many countries.12 13 w6 w7 We describe problems with the registration, approval, acquisition, and distribution of magnesium sulphate, and hence its availability to clinicians, in Mozambique and Zimbabwe, two countries with high maternal mortality ratios (table).14-16 We draw on a range of sources, including a bibliographical review of policies concerning magnesium sulphate over the past 25 years and qualitative data collected as part of a case study of policy making and procurement for magnesium sulphate in the two countries (box 1),17 to argue that drug availability has been affected by system and market failures.