日本財団図書館（電子図書館）　First International Meeting on Essential Drugs and Community Health systems

Conference Overview: Implications of Recent Experiences in
Implementing Revolving Drug Funds in Asia and Central America

Dr. Mohan Narula

Conference Context

　　Many developing countries in Africa, Asia and Latin America lack adequate supplies of the basic essential drugs listed in the Essential Drugs List (EDL) compiled by WHO. There are numerous reasons for this (and lack of finances due to budgetary constraints being the only reason despite governmental rhetoric to the contrary is by no means the case). Other reasons include: the attitudes and behavior of governments, prescribers and dispensers, consumers and the drug industry itself; poor management of national drug supply systems; wastage; and lack of long-term planning compounded by limited foreign exchange, to name just a few.

　　Equity is a controversial issue when it comes to user contributions to source funds for provision of and improvements in health care delivery, and it has been addressed to some extent earlier in this report. Indeed, it has been repeatedly emphasized as one of the underpinnings of primary health care, at least in terms of accessibility, availability and affordability, if not in terms of quality of care or in the range of services provided. Therefore equity in essential drugs¹ should include at least the following:

* access to necessary medicines for all people;

* prices which society and individuals can afford;

* priority on drugs that meet the real health needs of the majority of the population;

* fair distribution between rural and urban areas;

* assurances that the drugs are safe, effective, and of good quality, and that all prescribers are adequately trained;

* user access to objective information;

* real dialogue between consumers (patients) and prescribers;

* empowerment of consumers through education and training;

* community involvement and participation;

* development of drugs that meet the needs of developing countries;

* responsible manufacture and export;

* ethical promotion and marketing;

* the cessation of donations of “hazardous” or “ineffective” products.

　The World Bank in its World Development Report 1993,“Investing in Health,”lists the following groups of interventions as the components of any package of essential health services:

1. Services to ensure pregnancy-related care (prenatal, childbirth and post partum), and strengthened efforts to prevent most of the 500,000 maternal deaths occurring in developing countries;

2. Family planning services such as improved access, which would save 850,000 children from dying every year and eliminate 100,000 maternal deaths annually;

3. Tuberculosis (TB) control through drug therapy to reduce the annual mortality rate of two million, which makes TB the leading cause of death in adults;

4. Control of sexually transmitted diseases (STDs) which account for 250 million new cases of illness (sometimes fatal) annually;

5. Care of common serious illnesses in children, namely diarrhoeal diseases, acute respiratory illness (ARI), measles, malaria and acute malnutrition, which account for seven million deaths annually;

6. Other services, which may include:

△ treatment for minor infection and trauma, and hospital emergency care;

△ treatment for non-communicable diseases and conditions, such as hypertension, cervical cancer, some psychoses and cataracts, using low cost treatment protocols (i.e. aspirin for heart disease).

The above package would require the availability of basic drugs and thus defines the need for the provision of essential drugs within the context of equity.

　　Many governments in developing and some developed countries were, in the past (and some still now), politically committed to providing free health care as part of the primary health care goal of Health for All by the Year 2000. Economic realities and rising health care costs, however, led to the questioning of this commitment. Gradually but surely, the provision of free health care and free drugs at all levels of health care delivery became less and less possible. With shrinking government budgets for health, increasing costs for drugs and medical supplies, consumers' rising expectations, poor drug supply management systems in developing countries, and increased losses (due to damage, pilferage, poor quality drugs, etc.), many government and international health agencies started to look to communities to assist in providing resources for drugs and later maintain health care services.

　　As government health care services became more and more inadequate and irrelevant to the needs of local populations, as evidenced by increasingly acute and prolonged shortages of basic drugs, private sector production of drugs began to flourish, but the drugs were often of poor quality, improperly prescribed and costly. In an effort to address this situation, a number of initiatives involving community financing of drugs (with some level of co-management and oversight by community groups) were started. UNICEF, in response to these scattered but seemingly successful efforts, launched the Bamako Initiative, using the provision of drugs as an entry point to encourage communities to gradually take responsibility for effective operation of health care services in their areas, eventually using funds collected for community development.

　　The varied successes of the Bamako Initiative in African countries called attention to the possibility that some of the basic principles on which the Initiative was based could be applicable in devloping countries in Asia and Latin America. This awareness was reinforced by the emergence of cost-recovery as a feasible option to finance part of health services in developing countries suffering from dwindling government budgets as well as from more stringent but reduced funding by international donors. This prompted The Nippon Foundation (then known as the Sasakawa Foundation) to become involved in the setting up of revolving drug funds (RDFs) consistent and in cooperation with Bamako in a number of Asian and Central American countries. The Foundation's participation had three objectives:

1. that the RDFs would be self-sustaining after initial support:

2. that there would be a reliable drug replenishment mechanism in place to support the RDFs;

3. and that there would be sustained community participation in the monitoring and management of the RDFs.

Approach

　　The Nippon Foundation has a unique position as an NGO. It makes significant contributions to development projects (particularly in the area of health) in terms of technical support, financing and direct access to host governments. This, combined with the Foundation's non-political nature, allows its involvement to often act as a rallying point for other sectors and agencies with overlapping projects, prompting them to come together to accomplish goals and objectives.

　　Responding to requests from various governments, The Nippon Foundation provides funds for the purchase of seed stock, which is then distributed by the drug supply system of the host country's Ministry of Health (MOH) to peripheral health facilities, thereby initiating the process of establishing RDFs. To facilitate the setting up of these RDFs, UNICEF is provided with funds to help coordinate this effort as an extension of the Bamako Initiative and to strengthen health system activities in general.

　　Following the signing of documents of understanding, The Nippon Foundation provides the drugs requested by the MOH and UNICEF on an annual basis for an average of two years, subject to interim reviews. It also commits operational funds to UNICEF to facilitate training, the development of the policy and procedural components of the RDFs, and provide assistance to the MOH to create mechanisms to monitor and supervise these RDFs so as to ensure community participation in management and supervision, as well as to achieve sustainability in the stipulated period.

Need for the Conference

　　Through the Department of Health Policy & Planning of the Graduate School of International Health at the University of Tokyo, and also directly, The Nippon Foundation monitors progress of these projects employing a combination of on-site annual reviews supplemented by progress reports. Release of succeeding tranches for each project is contingent on the recommendations following these forms of feedback.

　　As part of this ongoing review process, and to harness the experiences of the various projects, The Nippon Foundation organized the International Conference on Essential Drugs and Community Health Systems with the technical support of the University of Tokyo's Department of Health Policy & Planning, which took place October 25-27, 1995 in Tokyo. The conference brought together ten participating countries to share experiences, review the approaches employed, discuss problems and constraints and make recommendations to the Foundation, participating international agencies and to one another. The conference was also attended by representatives from the World Health Organization's Drugs Action Programme, UNICEF's Bamako Initiative Management Unit, as well as from other agencies such as the World Bank, Japan International Cooperation Agency and UNICEF Tokyo.

Conference Overview

Conference Objectives

　The objectives of the conference were to

* review achievements,

* examine constraints,

* discuss issues arising from the implementation of the projects,

* explore possible expansion of support for RDFs,

* make recommendations to The Nippon Foundation and other partners.

Related areas such as national drug policies, which also include drug supply systems and essential drug lists, management capabilities of the health teams at the periphery, improving quality of care, rational drug use, community participation and operation of RDF/PHC committees at various levels, were also discussed.

Preliminary Synopsis Reports

　　The conference organizers required each participating country to submit a detailed report, as requested in a UNICEF HQ memo, as well as a synopsis of the detailed report to be presented at a plenary session. Issues, problems and constraints were extracted from these documents and compiled into a list of discussion topics that was made available to all participants prior to the working group sessions. Each synopsis report was to include six sections, according to the following format:

Key Objectives of The Nippon Foundation Supported Project

This section required participants to list the key objectives of the project that are directly supported by the Foundation, and those objectives of UNICEF and the Ministry of Health that may have significant impact on the performance of the project.

Achievements Against Objectives to Date

This section asked the participants to identify achievements against the objectives listed in the previous section, describing the achievements briefly, and sometimes using numbers for clarification or indication of very considerable progress. While the detailed report contained data and figures about the general health status and performance of the health system on the whole in each country, the aim of this section was to summarize only the achievements that directly met the stated project objectives. Therefore, numbers and figures were to be kept to the bare minimum, and included when as relevant to the objectives as possible.

Problems and Constraints Experienced During Implementation

Problems and constraints experienced in the conceptualization, planning, implementation and monitoring of the project were to be described here in chronological order, including the status of resolution. This section was designed to allow the participating countries to contrast and compare problems and constraints, to permit the conference organizers to collate and categorize these for discussion during the working group sessions, as well as to provide a comprehensive view of the challenges that lie ahead.

Issues that Need Discussion and Resolution

Here, Key issues (technical, managerial and resource related) that had emerged as a result of project implementation were to be listed, particularly those that would need to be addressed to sustain the implementation process and contribute to the strengthening of the overall health care delivery system of the country. Issues that had arisen because of the project extending into other areas were also to be included so that they could be collated and categorized and made available to participants during the working group discussions.

Future Plans

In this section, the participants were asked to discuss any future plans for the extension of the project into other relevant intersectoral areas as a result of implementation, and plans for the expansion of the project to other geographical areas of the country in the medium term with a view to possible future scalingup to the national level. Other sectors and agencies tha would need to become involved were also to be indicated. Some idea of the approximate costs for these plans were to be included as well if this was possible. This section was designed to provide the organizers and partners some idea of resource needs over the next couple of years, and the various directions the projects seemed to have taken as a result of implementation.

Recommendations to the Conference

In this section, participating countries and agencies were asked to list the key recommendations they would make to the conference as a result of their experiences.

These recommendations were to be specific and to include strategies to be employed (with a brief outline of the types of activities needed to be carried out to implement these recommendations). Also to be included, where appropriate, were assignment of responsibilities to institutions in terms of actual implementation or facilitation. These recommendations were also to be collated and categorized and provided to the working groups during their deliberations.

Conference Organization

　The conference could be seen as divided into three types of events:

1. ceremonial, which included the opening and closing sessions, and the welcome/Keynote address;

2. plenary, which included presentations of the synopsis reports, presentations by representatives of WHO and UNICEF, presentations by the working groups, and consolidation and endorsement of conference recommendations to organizers and partners;

3. working, which was comprised of small group sessions where problems, constraints, issues, and future plans were discussed with the aim to formulate/accept/modify recommendations that would be consolidate and endorsed during the final plenary session.

Working Group Sessions

　　The working groups covered broad areas such as national drug policy (essential drug lists, drug supply systems), rational drug use, guidelines and procedures for the operation of RDFs, the functioning and roles of PHC/RDF committees at various levels, management capabilities of the health teams at the periphery, quality of care, community participation, cost recovery, financial management and others that may be derived from the objectives and other sections of the synopsis reports.

　The working groups were formed to achieve the following aims:

* increase participation,

* focus on specific areas pertaining to the projects,

* promote the development of specific recommendations to include strategies and assignment of responsibilities,

* encourage richer exchange between countries and programs.

The specific objectives of the working groups were to:

1. review issues, constraints and problems related to the areas assigned to the group from previously received reports and handout; prioritize, very simply, the issues, constraints and problems that the group would like to address;

2. discuss these prioritized issues, constraints and problems using core questions provided in the handout;

3. formulate recommendations for these priority issues, constraints and problems according the provided format;

4. and present the recommendations and report of the working group at the plenary session.

The participants were divided into 4 groups covering the following areas:

Group I. Community Participation (including community mobilization, community education and PHC/RDF Committees, etc.);

Group II. Operations of RDFs and RDF committees (including guidelines and procedures for the RDFs, inventory management, accounting and financial management, etc.);

Group III. Drug Supply and Logistics (including national drug policies, essential drug lists, drug information systems, etc.);

Group IV. Management Capacity of Health Teams (including strengthening of ability at various levels to supervise, monitor, plan, implement, and coordinate activities, training to deliver quality health care, etc.).

　　Each group was given guidelines,² a set of questions, a list of issues, constraints and problems, and other handouts prepared by resource persons from WHO Drug Action Programme, regional offices and UNICEF. Summaries of the reports of each group are included separately in this report.

²See Appendix for the handout, “instruction for Formation of Working Groups,” given to each participant.

Conclusions from the Working Groups

　　A successful RDF project requires a number of components to be in place or at least be taken into consideration. These components are listed below with a brief explanation. The progress of the participating countries towards the setting up of a sustainable RDF, based on information provided in the country reports and during presentations, is plotted in a matrix format (see Table, p.16).

　Important components in setting up an RDF project are as follows:

1. A national drug policy, which should include legislation and regulation, regulatory control in terms drug registration and licensing, cost and price, prescribing and dispensing at different levels, drugs and pharmaceutical product selection, supply, quality assurance, revolving drug fund operation, manpower and development needs;

2. An essential drug list (EDL) and a clear mechanism to review and revise the EDL at regular intervals. The list should include drugs and pharmaceutical products for all levels of health care;

3. A national formulary which should provide information on drugs and pharmaceutical products along with dispensing and prescription information for each product;

4. Mechanisms to assess the financial resources available for drug and pharmaceutical supply, which should include methods for estimating the total quantities of drugs needed and their cost, and the forecasting of foreign exchange needs for drug purchases;

5. A drug and pharmaceutical products supply system, which should encompass procurement, storage and inventory, requisition, distribution, and record keeping and accounting at each level that health services are provided;

6. A drug information system to monitor and evaluate marketed drugs and products, adverse reactions and drug use;

7. Adequate management capacity of health teams at provincial, district and health facility levels to deliver relevant and good quality health care services;

8. Community participation, which should include community organization and management skills for effective co-management and supervision of the RDFs;

9. Supervision of RDFs and health services;

Table. Progress of the Various Projects as of October 1995, Derived from the Reports Provided¹

Country	Research & Development	Supervision of RDFs	National Drug Policy	Essential Drug List	National Formulary	Financial Resources
Vietnam	++	+++	+++	++++	+	+++
Nepal	+++	++		+++	++	+
Myanmar	++	+++	+++	++++	++++	++
Mongolia	+	++	++++	++++	++	+
Laos	++	++++	+++(?)	+++	++	+
Honduras	+	++(?)	+++(?)	++	++	++
Guatemala	+	++	++	++	+++	++
Peru	+	++	+++(?)	++	++	++
Ecuador	+	++	++	+++	+++	++

Country	Supply System	Drug Information System	Management Capacity	Community Participation	Ranking (Total+s)
Vietnam	+++	++	++	+++	2(27)
Nepal	+++	+++	++	++	3(24)
Myanmar	++	++	++	+++	2(27)
Mongolia	++	++	+++	+++	3(24)
Laos	++++	+++	+++	+++	1(28)
Honduras	++	++	++	++++	6(20)
Guatemala	+++	++	++	+++	4(22)
Peru	+++	++	+++	++	1(28)
Ecuador	+++	++	++	+++	5(23)

+	not included in the plan
++	has been included plan
+++	is being developed or revitalized
++++	is in place and operational
?	based on inadequate information

¹The grading and rankings are very subjective and are based only on reports submitted to the conference. The table will be revised whenever additional information becomes available.

10. Research and development capacity, which should consider, according to the specific health problems, interests and capacities of each country, fundamental research³ and health systems research.⁴

³In clinical trials of drugs and vaccines, pharmacological and toxicological studies, industrial research for the manufacturing sector, biotechnology, chemistry and molecular biology, immunology.

⁴To measure impact of national drug policies and accessibility to essential drugs, health economics, behavioral studies prescribing problems and different levels and the social and cultural aspects of drug use, self-medication and utilization of services.

　　Revolving drug funds at the community level strive to stimulate community participation in their management and to ensure that the funds do not get decapitalized. This depends greatly on community understanding of the concept of RDFs, and on the extent to which there is a sense of community ownership. An entrepreneurial spirit in the community is also an important ingredient. Examples of this are:

In Vietnam, because of the emerging market economy as a result of the Doi Moi reform process, the local entrepreneurial spirit has burgeoned and this has augured well for the success of RDFs. Twenty percent of the communes now have operating RDFs as a result of the RDF project. These drug funds so far (six months since their inception) have been maintained and many have grown, while the central government has decreed that salaries for at least three health workers per fund, at the commune level, be provided to improve supervision by the MOH.

Lao P. D. R and Myanmar also show signs that the RDF approach is consonant with the local entrepreneurial spirit generated by the movement towards market economies in these countries. The response of the governments to support this initiative from the highest level has also been appropriate and is a good indicator of the relevance of this approach to strengthening primary health care services.

It seems quite clear, at least from the experiences of these three countries, that RDFs tend to thrive in an environment where the local economy is vibrant and growing. Their sustainability in these cases can be attributed to the fact that communities are already participating in their own economic development as a practical issue rather than a political or ideological expression of a national policy.

　　The setting-up of an RDF requires a considerable increase in the basic management skills of both the health team and the community, as well as in their ability to co-manage the RDF. As seen in the country reports, the interaction of health teams and communities ranges from the health teams' managing the day-to-day operations while supervised by community-composed RDF committees, to local administration of the funds with day to day operations left to the MOH.

　　RDFs also stimulate the development or revision of a national drug policy and EDL. A number of countries⁵ have begun the review of their national drug policies and EDLs. RDFs also contribute to bringing about functional integration of health services provided at the operational level. There are a variety of ways that RDFs are implemented in various countries but there appears to be a number of shared concerns and issues common to the various RDF projects. These are:

1. Community participation occurs primarily through representation on RDF/PHC Committees, which in the majority of the countries are dominated by MOH or NGO staff.

2. Accounting and reporting formats are not standardized within countries and between different communities and districts, making the monitoring, supervision and comparison of progress difficult.

3. Many countries for some reason have not allocated the resources and limited access to foreign exchange necessary to the purchase of drugs. In some situations, countries just cannot afford to provide these funds. Quite often this is because all expenditures in the procurement and distribution of drugs are not meticulously justified, and working relationships with national planning and finance authorities are not close. Lack of adequate data further undermines attempts to justify such expenditure especially if it involves limited foreign exchange reserves.

4. The setting up RDFs in almost every country exposed basic weaknesses in the management system of the MOHs in particular and the central governments in general, particularly at the district and provincial levels. Also highlighted were the failings of the national accounting and financial management systems, especially in terms of effects on logistics management, which in turn directly impacts on the effective functioning of the RDFs.

5. RDF projects, generally, were implemented in response to The Nippon Foundation's initial commitment to providing drugs. Therefore, many project proposals lack clear project management frameworks for the implementation and regular monitoring of the projects.

6. Gaps between communities and health workers representing the MOH are wide, while interaction in more centralized countries is nominal and token. Communities and community organizations are expected to comply rather than participate despite the rhetoric to the contrary.

7. National health insurance is generally nominal and more often than not, inadequate and poorly managed. It can be speculated that, in some countries, these schemes are an attempt to camouflage free health care, since health insurance premiums are paid by the government with only part payment by government employees. Such schemes tend to cover only the formal sector and wage earners, excluding more vulnerable groups. Shortage of funds and delays in reimbursement are also quite common, thereby creating bottlenecks and contributing to stockouts. There is also a tendency for governments to get into large scale national health insurance schemes too soon, with detrimental effects, since the management infrastructure at operational levels is not yet robust enough to shoulder the additional burden of the meticulous management required for effective operation. A gradual phased approach (and this does not have to be on a pilot project basis) may provide the experience needed to strengthen management capacities at the peripheral levels before scaling up to regional or national levels.

8. National drug policies in many countries do not adequately address such areas as: legislation and regulation, regulatory control in terms of drug registration and licensing, cost and price, regulations on prescribing and dispensing at different levels, choice of drugs and pharmaceutical products, supply, quality assurance, revolving drug fund operation, manpower and development needs, patents, brand and generic names, appropriate drug use, self-medication, health education, monitoring and evaluation, identification of financial resources, research and development and technical cooperation between countries.

⁵Vitnam, Nepal, Myanmar, Laos, El Salvador, Honduras and Peru (based on reports provided).

　　The recommendations, developed and endorsed during the conference, address many of the issues and concerns raised above, but it must be recognized that if RDFs are to contribute to improvements in primary health care, the context in which RDFs are set up needs to be included in the development of project proposals right at the very start. This does not mean that a project needs to cater to the establishment of all these elements, listed previously as requirements for sustainable RDFs. It does mean, however, that these elements have to considered and linkages to progress made in these areas included in the planning and management frameworks, if one is to avoid the quick, short-lived success stories so welcomed by politicians and international donors. Setting up RDFs is a capacity building exercise that takes time if it is to become an integral part of a community, to be jointly managed and sustained.

　　The setting-up of RDFs in terms of guidelines and procedures may be accomplished within a relatively short time frame. Community participation, however, from the point of view of co-management and community supervision, as well as adequate management capacity at the various levels to allow cooperation between health teams and the community, takes a long time and must be included within the project time frame.

　　Another area that needs to be looked at is that of user contributions. User contributions in the form of various fees, cost recovery, community financing and different types of cost sharing are still seen as one of the main ways to finance health care services, especially in an environment of diminishing government spending in the health sector. There are a number of arguments that need to be carefully thought over if RDFs, one way of obtaining user contributions, are to be made sustainable in rural communities experiencing resource shortages despite the fact that households spend significant proportions of their income on private health care. Some of these considerations⁶ are listed as follows:

* User contributions may undermine political support for universal coverage of basic social services.

* User contributions require institutional capacity, decentralization and government support.

* User contributions are likely to result in a reduction in the utilization of services, particularly among the poor and vulnerable.

* Gender biases, seasonal variations and regional economic disparities may aggravate the impact of user contributions on equity.

* User contributions without exemptions could lead to greater inequity. Exemption schemes do not appear to have performed well and are costly to administer.

* While user contributions can promote a sense of ownership by the local community, co-management does not always guarantee greater efficiency, effectiveness or fairness.

* User contributions, as a method of resource mobilization, should not be overstated since contributions are generally limited to small scale inputs.

* There is a considerable difference between the ability to contribute and the willingness to pay. Therefore, willingness to pay should not be made the sole basis for assessing the viability of user contributions.

⁶UNICEF (1995), Internal Memorandum from Office of Social Policy and Analysis, “User Contributions towards Basic Social Services,” by Jan Vandemoortele.

Recommendations and Future Directions

　　The recommendations included elsewhere in this report accurately address many of the above issues and concerns, and also demonstrate the commitment of the participants and the agencies involved to support the institutionalization and sustainability of RDFs and to employ these to stimulate development of the other required components that are critical if primary health care services are to be strengthened and made more effective. The value of these recommendations, and indeed the whole conference, will depend on the extent to which these recommendations will be implemented.

　　Increased communication, more frequent reviews and evaluations, the development of mechanisms to share and exchange information gleaned from regular and ongoing monitoring of projects within and between countries, and the provision of ongoing technical assistance, must be encouraged and should become the hallmark of this cluster of projects. This way, experience is harnessed and the lessons learned can be disseminated to those whose decisions influence the delivery of health care services at the operational level. Adequate human, monetary and material resources must be targeted to achieve the above, and governments and agencies must respond with increased commitment to the setting-up of RDFs as a key strategy in strengthening primary health care delivery.