PROFESSOR TAKUSEI UMENAI, CHAIRMAN OF THE EDP COMMITTEE

　

　During the third conference on essential drugs and community health systems, revolving drug fund projects in Cambodia, Laos, Mongolia, Myanmar, and Vietnam were reviewed. Implementation of these RDf projects is being carried out by the national ministries of health with support from the Nippon Foundation and technical support from the University of Tokyo (Department of Health Policy & Planning, Graduate School of International Health) and UNICEF.

　The conference focused primarily on progress so far, including accomplishment of the recommendations made during the previous two conferences. Emphasis was also placed on demonstrating that, while each country was at a different level in the implementation and scaling-up of its RDF project, enough progress had been made for each country to be able to continue the process with very much less support than previously required. The study carried out in Vietnam showed that the relative success of its RDF project had been and still is a potent stimulus for significant policy and organizational changes within the MOH at all levels of the health care delivery system. In other countries the RDF projects also appear to have served a similar purpose, but to a lesser extent.

　Revolving drugs funds have shown to have considerable impact on increasing the availability of essential drugs in communities and remote areas that hitherto did not have access to such drugs. The experience of operating RDFs also highlighted the importance of promoting rational drug use, ensuring equity through a combination of appropriate user charges and exemptions, strengthening the pharmaceutical sector from a quality assurance and replenishment logistics perspective, and not impeding the development of the private pharmaceutical sector while maintaining adequate regulation and control over quality and price.

　At the level of primary health care, RDFs, at least in the participating Asian countries, have contributed to a shift in the orientation of health care service delivery, that is from a socialist PHC and Alma-Ata orientation to a more free market orientation. RDFs have also raised the importance of the concept of community health security within the primary aim of making health services affordable.

　At the economic level, especially in rural communities where RDFs are operational, cost recovery management, income generation, and priority setting in the allocation and use of locally generated and other community resources, have been introduced within the health sector, setting the stage for increasing interaction between community organizations and the formal health sector.

　RDFs are also beginning to have a political impact at the community level. While evidence is mainly anecdotal, it nevertheless indicates another area where RDFs could begin to impinge on the development of the community and create an enabling environment for local empowerment. Managing and monitoring RDFs require supervision and control not possible from the central level. They then fall within the scope of district health teams, further promoting decentralization. Consequently, an increasing capacity is required at the local level to manage community revenues and the operation of community development funds. Managing and monitoring RDFs also appear to promote the emergence of appropriate community based administrative units to oversee the work of service sector agencies, public or private.

　What is probably the single most important effect is that RDFs could set the stage for the development of a group awareness or cognition that would remarkably enhance community participation, promote system development orientation at various levels of health care delivery, and promote increasing levels of collective decision making within local governance units through the use of consultation and problem solving skills.

　Successful RDFs therefore require a number of underpinnings. At the political level, there is need for opening up the health sector to allow more private initiative through the adoption of a free market approach and the promotion of decentralization along with delegation of requisite authority. At the economic level, there is need for adoption of the policy of user charges, for facilitation of legitimate and regulated private practice to improve penetration and coverage of health care services, and for the development of the pharmaceutical sector both public and private. At the health ministry level, the aim of government agencies needs to shift from a production focus to a regulatory and control focus with the promotion of rational drug use targeting the provider, the consumer and the pharmaceutical industry. At the pharmaceutical sector level, there is need to develop sustainable replenishment and distribution systems to allow for increased local purchasing with appropriate regulation and control to ensure quality of drugs and fair prices. At the community level, there is need to ensure that the operation of an RDF is locally controlled (the community collaborating with local health center staff), that the community owns the RDF, and that there are clear procedures supported by national policies and adequate supervision at all levels to ensure accountability and transparency.

　As seen in Vietnam, and to some extent in other countries such as laos, Myanmar and Cambodia, the provision of Nippon Foundation support has lead to significant development of the health sector. There appears to be sufficient evidence that for the RDFs to become institutionalized, additional support from a variety of other sources may be required for another cycle of three years. Continued technical and implementation support would encourage the futher development of the health sector in the directions mentioned earlier and ensure that gains made over the last three years will not lapse. Collaboration and support, should it continue, should be technically focused and targeted to achieve improved access to affordable, acceptable quality essential drugs and the strengthening of primary health care.