Ecuador
I. Background
The Central Medical Procurement and Distribution Agency (CEMEIM) is the only public organization promoting the use of essential generic drugs. In 1994, its drug budget amounted to US$2.5 million, a mere 1% of the total drug market estimated by WHO to be at US$250 million, which belies the general weakness of the government essential drug program. In response, the Ministry of Health, in collaboration with the World Bank and USAID is now conducting a policy revision of the national essential drugs management system.
The MOH, UNICEF and WHO-PAHO are developing and piloting a self-sustainable community managed essential drug system in the framework of the Bamako Initiative as part of the general policy revision. In concordance with the National Health Reform, currently being carried out by the National Health Council, the Project's main objective is to increase the general accessibility of health services. The first stage of implementation in three health areas (taking place August, 1995 to February, 1996) will be followed by expansion into three other areas in the second stage.
II. Purpose
To pilot a self-sustaining theoretical model aimed at strengthening public health services and improving the health condition of the population through community participation
III. General Objective
To assure that the majority of the population has access to basic health services
IV. Specific Objectives
□To promote consumer confidence in the public health system, through quality improvement of service delivery and increased delegation of decision making power to health districts
□To promote joint management of the health services with active community participation
□To encourage households to change habits that are harmful to health
V. Achievements Against Objectives to Date (see Table)
VI. Problems and Constraints
During the first half of 1995, the Project suffered considerable delays due to the following factors:
□Because the current Minister of Health assumed office in November, 1994, the top management structure of the ministry underwent reorganization through the end of the year.
□The armed conflict with Peru paralyzed the country from January through March, 1995, and maintained a high level of tension through June. Regular working activities were not reinitiated by the government until July.
□Ecuador is at present undergoing a process of modernization which has significantly reduced the number of government employees. The resignation of several middle management officers from the Ministry of Health caused considerable institutional delays.
□To cover the costs of the border conflict with Peru, resources were reallocated. As a result, public expenditure in the health sector was reduced, causing delays in salary payments, thereby producing nationwide strikes.
| Table. Achievements Against Objectives to Date (Ecuador) |
| A. Human Resource Development |
| 1. Design PHC training modules for public health personnel (Mds, nurses, and 150 staff) to include: |
1. Training modules prepared, with the exception of the areas concerned with community participation and co-financing. |
| a. Basic epidemiology |
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| b. PHC approach: community participation and co-financing |
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| c. Use of generic drugs and therapeutic standards |
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| 2. Design health volunteers curricula and training materials for both urban and rural areas |
2. Will take place in second half of this year |
| 3. Train 500 health volunteers |
3. Will take place in second half of this year |
| 4. Develop training modules and train at least 50 traditional birth attendants |
4. Training modules produced. Courses to take place in the second half of this year |
| 5. Train 50 fund administrators |
5. 63 persons from the health sector and from the communities trained |
| 6. Train at least 80 pharmacy staff in management |
6. 63 persons (26 health official and 37 community members) trained |
| B. Quality Improvement of Basic Health Service Delivery |
| 1. Review roles and functions of health personnel |
1. Ongoing; results will be ready by February, 1996 |
| 2. Review selection criteria, roles and functions of health volunteers in urban and rural areas |
2. Will take place in the second half of this year |
| 3. Standardize classification of main pathologies |
3. Completed |
| 4. Disseminate and monitor the use of existing WHO-PAHO therapeutic protocols and generic drug guidelines for major pathologies |
4. Training in therapeutic standards was carried out; follow-up to take place in second half of this year |
| 5. Provide minor medical equipment and consumables to health centers, volunteers and traditional birth attendants |
5. Will be distributed when available |
| 6. Strengthen referral system at all levels |
6. On-going |
| C. Ethnically Sensitive Community Mobilization and Participation |
| 1. Community awareness campaigns, utilizing NGOs, schools, churches, etc. |
1. Accomplished |
| 2. Creating/empowering PHC Committees and especially management committees |
2. Accomplished |
| 3. Elect health volunteers |
3. Will be accomplished in the second half of this year |
| 4. Establish links with traditional health practitioners |
4. Will be accomplished in the second half of this year |
| D. Promotion of Collaboration between Health and Other Social Sectors |
| 1. Identify relevant government and non-government organizations operating at the district level |
1. Accomplished |
| 2. Organize meetings to develop intersectoral mechanisms |
2. On-going |
| E. Monitoring |
| 1. Design KAP-epidemiological survey based on Bamako model to be conducted at the beginning and end of project |
1. Assessment of services and health situation of area was conducted with local staff participation. Participatory assessment was preferred to originally planned survey since it contributes to the theoretical-practical training of health staff and community members and leaders |
| 2. Conduct cost-benefit analysis of basic health services |
2. Will be carried out in January-February, 1996 |
| 3. Set up sentinel system to define epidemiological profiles at health center and district levels to determine pharmaceutical needs and health practices |
3. Existing surveillance system will be strengthened to this end. Will be considered part of theoretical-practical training of health staff and community members and leaders |
| 4. Review methodology of epidemiological data collection |
4. On-going |
| 5. Establish tools and criteria for monitoring health activities and programs at all peripheral levels |
5. On-going |
| F. Promotion of the Use of Generic Drugs |
| 1. Information campaign utilizing media and advertising |
1. Will be initiated once drugs arrive in country |
| 2. Promote generic drugs at community pharmacy level |
2. Will be initiated once drugs arrive in country |
| 3. Community mobilization |
|
| G. Establishment of Drug Management Policies and Facilities (Distribution and Storage) |
| 1. Conduct financial analysis to determine indicative drug re-sale price with a view to self-sustainable program |
1. On-going |
| 2. Set up accounting and banking system for funds administration and drugs replenishment at central and peripheral levels |
2. On-going |
| 3. Identify storage facilities at central and peripheral levels |
3. On-going |
| 4. Set up drug distribution services |
4. On-going |
| 5. Set up monitoring system |
5. On-going |
| H. Adoption of Cost Recovery Schemes in at least 40 community-Managed Health Services and Pharmacies |
| 1. Assist communities to |
1. On-going |
| a. Establish criteria for cost recovery |
|
| b. Establish criteria for identifying social cases |
|
| c. Set up ID system for different categories of social cases |
|
| d. Set up mechanisms for monitoring costs |
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| e. Identify social priorities for the use of community funds |
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Since July, 1995, the Ministry of Health, with support from UNICEF, has shown determination to implement project activities at both central and peripheral levels, with strong efforts to make up for lost time. Similarly, health reform received new impetus in the second half of the year when the Bamako Initiative was reclassified by the MOH as a “Reform Showcase Project,” and its implementation granted maximum priority.
VII. Issues that Need Discussion and Resolution
Project implementation is now well underway. Ecuador would like to learn from the experiences of other countries with respect to the following:
Key Technical Issues
□Nature and scope of health reform processes
□Strategies to meet health service demands according to demographic, epidemiological and economic-social risk factors
□Prescriptions using generic drugs, and whether the issue necessitates legal reform
□Registration requirements of imported drugs
Key Managerial Issues
□Management policies at the health district level
□Coordination processes among health institutions within the same district
□Decentralization processes and autonomous management within a health district
□Policy recommendations for improving quality of care provided by public health services
Key Resource Issues
□Policies recommendations for the redistribution of public resource to health districts according to the nature and magnitude of health problems and services
□Mechanisms for cost recovery schemes
VIII. Future Plans
By August, 1996, the Project will be in full swing in six health districts and initiated in six others. Political and administrative elections will take place between May and June; the first six project areas will form the basis of negotiations with new authorities for the expansion of the Project, perhaps to the nationwide level. Beginning in March, 1996, Reform Showcase Projects will be reviewed. At that time, a national proposal based on empirical evidence will be formulated, which will include the following: quality management in the provision of health services, incentives for health personnel, cost recovery schemes, community participation processes, and community pharmacies.
IX. Recommendations
The exchange of experiences among countries implementing Bamako or other like projects should be promoted.
