Group II. Operations of RDFs and RDF Committees
| Dashdavaagiin Bolormaa |
|
Alejandro Aguinaga Recuenco |
| Arwind R. Diwan |
|
Snivourast Sramany |
| Christine Dricot-d' Ans |
|
Mario Tavera |
| Margaretha Helling-Borda |
|
Takusei Umenai |
| J.R. Kestler Castellanos |
|
Sham Raj Upreti |
Prioritized Issues, Constraints and Problems
To identify and prioritize issues, constraints and problems, the members of the group have reviewed the countries' experiences one by one, with regard to the settingup and functioning of RDFs (See Table, p.86).
Taking into account the different social, political and cultural environments, it was acknowledged that the main constraints and problems may vary substantially from one country to another. However, the group was able to identify issues common to all countries, and categorize them into two main groups.
A. Issues Linked to Political Will and Commitment
Political will is not always translated into strong policies and guidelines clear enough to enable satisfactory operationalization of RDFs. The “political will” needs to be “quantified” and its contents must be reflected at the community level, where a clear understanding does not always exist on what RDFs are and how RDF committees will operate. Balance is needed between central policies, regulations and structures, and community action and autonomy. Sometimes, due to vague policy statements and weak guidelines, the community's role is not clearly defined, and therefore, the community is not involved fully.
B. Managerial Issues
They very much depend on political commitment, policies and strategies and are numerous and of different magnitudes. Prioritizing among them, the group identified the following points:
1. The replenishment of drugs (which drug, at which level, by whom, etc.);
2. The contribution and integration of different health financing systems along with RDFs;
3. The community ownership of funds collected, and, therefore, the community decision on their use;
4. The financial handling of the money, and the need for transparency and accountability;
5. The need to ensure good quality services to compete with a flourishing private sector;
6. The workload of health workers and their need to receive incentives.
Table. Lessons Leaned from Country Experiences with Regard to the
Functioning and Operating of RDFs |
| Country |
Political Commitment |
Central Level Role |
Community
Role |
Strength |
Issues |
| Mongolia |
-Agreement (MOH & MOF)to combat chronic shortage of ED, and to provide equitable access to them
-Agreement with insurance company
-Govnt. decree to officialize combination of insurance and users charge
-Build integrated financial system covering different drug sources |
-Buy ED
-Ensure training in diagnosis and treatment of 139 diseases |
Village-level committee to cover:
-1-2 medical doctors for treatment
-1 pharmacist in charge of RDF
-1accountant/administrator
-experience to date: 1 month |
-Very good net human resources, well deployed at each level
-Unique logistics system of drug storage and distribution
-Centralization of all donations and external support |
-Economy still in transition
-Irrational use of drugs |
| Nepal |
-Agreement to unify drug schemes and support one project (Community Drugs Programme) in 5 districts and endorsement to go nationwide in 5 years
-Establishment of clear directives and broad guideline
-Existence of intersectoral Steering Committee and Task Force at central and district levels
-Food and Drug Administration strengthened considerably
-Selection of drugs or level of care decided |
-Gives seed drugs to community
-District level ensures joint training of health workers and community members on managerial aspects
-Training in standard case management treatments for health care workers |
-Receives seed drugs
-Own funds collected from sales
-Financial handling and decisions on local purchase of drugs and incentives to be given health workers
-Experience to date: 1.5 years |
-Community
-based project
-Joint Committee of health workers and community members |
-Guidelines for standard treatment to be refined and adapted
-Lack of good accounting mechanisms for health workers and community members
-Increased workload of health workers
-Drug replenishment -Need for operational research |
| Laos |
-National Drug Policy, covering 13 elements including community participation, using 20% revenues
-Creation of National and Provincial Steering Committee at ministerial level
-Decree for preparation of standard treatments |
-Will soon ensure in training on rational use of drugs and standard treatments
-Conducted workshops with NGOs to explain policies and standardize implementation |
-Will manage 20% of revenues
-Experience to date: about to start |
-45% use of locally produced drugs
-NGOs and local organizations closely working together (complementarity) |
|
| Peru |
-Decision to take prime responsibility and buy low cost, good quality generic drugs for 3,800 PHC centers (out of 4,000)which had no ED supply before
-Establishment of norm to use 80% of for replenishment and 20% for PHC revitalization, inclusive of incentives for health workers
-Investment of US$4 mil. in ED and US$1 mil. in training, technical support, infrastructure |
-Organize 32 intermediate units for ED replenishment Conduct rational/provincial workshops for managerial aspects
-Conduct training to strengthen rational use and symptomatic treatment
-Flexibility at sub-regional level to adapt ED lists and prices (according to epidemiological patterns and local context) |
-Free use of the 20% of revenues by co -management committee, for i.e. upgrading of facilities, health workers incentives, exemptions for poor, transport
-Experience to date: 3 years prior to national program, 1 year national program |
-Tradition of community participation (esp. women) and revolving funds
-Strong emphasis on transparency in accountability |
-Health reform, core central regulations needed
-Irrational prescribing
-People cannot afford to pay in very poor areas, leading to management difficulties |
| Guatemala |
-Firm political commitment to establish essential drugs list (despite severe pressure from private sector)
-Allocation of funds directly to communities for ED (covering 82% of community needs) |
-Ensure progressive training (at least 3 months) before drug delivery to community level
-Identify priority diseases according to 7 main causes of mortality/morbidity, and give appropriate training -Maintain/sustain use of traditional medicines |
-Full autonomy to buy drugs
-Experience to date: 1.5 years in 4 provinces |
-Community action recognized and promoted
-Long tradition of community involvement (90% women) |
-Community role to be further clarified and strengthened towards sustainability
-Poor acceptance of generic drugs by private sector and medical professionals |
Recommendations
The exchange of experiences among the members of the group was very fruitful. Suiting the different socio-economic environments and taking local specificity into account, different RDF systems or mixes of systems have been established. Strategies and mechanisms to implement them may vary widely.
However, the group was able to formulate a set of global recommendations which are applicable to every country, no matter what its socio-economic and political context may be. They are as follows:
1. Continued and continuous political will
The already existing political will has to be reviewed periodically in order to make sure of maintaining and sustaining equitable access and use of primary health care services. The group strongly recommends clear statements on the choice of essential drugs and the constitution of RDFs. The national budget allocation for essential drugs must be well defined and increased.
2. Normative role of the central level
The aim of health services is not to use drugs as a regular commodity but to deliver appropriate health services on prevention and care. It is the central level's responsibility to elaborate guidelines, procedures and regulations, and to set up mechanisms to operationalize successful pilot projects, to be followed by national implementation.
3. Community ownership and participation
Clear delegation to the community is crucial. The community's participation in the responsibility and management of the funds collected should be endorsed at the policy level. Communities should be entitled to manage the revenues of the RDFs and receive a fair share of the revenues from the sale of drugs.
4. Support of technical groups
Intersectional task forces and support groups at central and intermediate levels must be established to ensure:
- Standardization of the operation of RDFs,
- Monitoring and supervision,
- Dissemination of information.
5. Regular, continuous training of both health workers and communities
The supply of drugs and technical and managerial training must go together, and the process must involve both providers and users (partnership in health care).
6. Monitoring by regulatory authorities
The role of government structures (like Drug Administration) in inspecting, controlling and monitoring drugs and their prescribing, sale and usage must be enhanced.
7. Review of drug selection and guides for priority diseases
Drug selection, priority diseases and standard treatment guides for better diagnosis and treatment, etc., must be reviewed for improving quality of services.
8. Workload problem of multi-faceted health workers
The workload of health workers as “multi-managers” has to be solved; a balance must be found to accommodate their multiple roles.
9. Need for operational research
More and better studies must be conducted on community perception of RDFs and health services acceptance, family expenditures, and performance of health workers with regard to technical and managerial aspects of RDFs, including monitoring of prescriptions and the use of essential drugs. It is important to feed the findings from operational research back into the system.
All these recommendations are intended for policymakers at different levels, with support from international organizations and donors.
