BY DR. INDERMOHAN NARULA, SPECIAL ADVISOR TO THE EDP COMMITTEE

　

　The Third International Meeting on Essential Drugs and Community Health Systems was held in Hanoi, Vietnam from 29 to 31 October 1997. Five countries participated, namely Cambodia, Laos, Mongolia, Myanmar and Vietnam. The main purpose of this meeting was to find ways and means to further develop sustainable revolving drug funds and community health systems in Asia, building on the experience of the RDF projects in the participating countries that have been supported so far by the Nippon Foundation.

　

　The objectives of the meeting were as follows:

　

　The meeting was composed of a mix of activities to maximize participation and exchange of experience. It began with a field visit, followed by plenary sessions for progress reports, the presentation of findings of the Vietnam RDF Project Study and the preparation of recommendations, and then by working group sessions for drafting outline country proposals.

　

　The objectives of the field visit were as follows:

　

　

　The field visit helped contextualize subsequent discussions by assisting the participants to formulate relevant questions, identify critical issues and concerns and relate these to their own countries and local situations. This contributed greatly to the discussions at the meeting, particularly regarding the need for additional resources and time. The field visit was well received by the participants and the MOH-Vietnam project team, and provided a suitable springboard for the discussions that ensued after the presentations of reports and study findings. The participants, donors and technical agency representatives were able to discuss what needed to be done in light of these issues and constraints and the similarity of these in other countries. There also emerged a deeper awareness of the issues and challenges facing countries and agencies in the institutionalization of RDFs and the development of community health systems, particularly from a poin of view of the mix of resources that will be required, including recognition for longer implementation time frames.

　The first session after the opening session was the presentation of the preliminary findings of the Vietnam Study, which was jointly done by the University of Tokyo's Department of Health Policy & Planning and Management Sciences for Health (MSH).

　During this presentation , a summary of the findings at the national and sub-national levels was presented, highlighting the catalytic and system development effect of the RDF Project. The shift in policy, both in terms of range and pace, was presented using a timeline analysis. What was observed was that prior to the setting up of the RDF Project, there had been a very gradual progress regarding policies for the development of the pharmaceutical sector, rational drug use, user charges, authorization of local use of locally generated funds, and for the further development of the regulation and control functions of the government. With the setting up and operation of RDFs, issues regarding availability, regulation, control and rational use of drugs were brought into the mainstream; issues related to the operation and effect of RDFs on services being provided at the commune level and the support required from the district level moved higher up on the Ministry of Health's action agenda; and the pace of policy development and reform within the MOH structure rapidly accelerated. Along with this increase in pace the MOH began to move more rapidly towards a PHC orientation. Key shifts were the institutionalization of user charges and outhorization of local use of RDF generated funds, and from a production focus to a control and regulation focus regarding the pharmaceutical sector.

　Preliminary information regarding the operation of RDFs was presented by a team from Management Sciences for Health. The aim of this part of the study was to test and evaluate key indicators of performance of RDFs and provide a baseline on several unmeasured characteristics. With regard to drug availability and pricing, the preliminary data showed that availability for selected tracer drugs was better in the private sector and that there was relatively little difference between the project and control RDFs. Prices at RDFs were a bit higher than at private outlets and a broad range of drugs was available. Improved utilization of CHCs could not be sufficiently established since the inception of the RDFs. However, there was evidence from other sources (World Bank) that utilization of CHCs has been showing a gradual increase. This could be due to a number of reasons such as improvement of services provided, the return of health care professionals to public service and provision of wages at the commune level. There was also the possibility that the availability of good quality (imported) drugs at the CHCs operating NF-supported RDFs may have contributed to increased utilization.

　The study in effect established a baseline for rational drug use. It was noted that practitioners in the study group were less likely to prescribe inappropriate antibiotic combinations, despite there being little difference between the study and comparison groups on standard indicators of average number of drugs prescribed per encounter, percent of antibiotics and percent of injectables prescribed. One explanation for this positive finding is that UNICEF included rational drug use training materials in the form of standard treatment guidelines in the training of CHC health workers in the project communes. There were also, relatively speaking, more supervisory visits to these project communes.

　Financially the RDFs in both groups showed mixed financial performance. A clear condusion could not be arrived at because the financial data required to build up a financial picture was not all obtainable for a variety of reasons. For purposes of assessing the performance, however, four key indicators were used, namely profitablility, solvency, liquidity and financial efficiency of operations and use of available capital. From those CHCs in the study group that provided a somewhat complete picture, five had positive signs and eleven had mixed signs. Three CHCs had too little data to draw any useful conclusion regarding their performance or potential for sustainability. In the comparison group, none of the CHCs had enough information, but from the data available, four CHCs had generally positive indicators. Thirteen showed mixed results with some positive signs and some danger signals suggesting that for sustainability, additional subsidization may be required at a later date, especially if these RDFs (both in the study and comparison groups) are not able to expand beyond their current sizes. Seven of the CHCs in the comparison group had very little data from which to draw any useful conclusion regarding performance and potential for sustainability.

　The overall conclusion of the study was that the implementation of the RDF Project had clearly stimulated the MOH to improve the management of the pharmaceutical sector through improved regulation and control and to employ RDFs as a potent entry point to development of health services and improvement of the quality of care at the commune and district levels. At the basic performance level, most of the RDFs reviewed in the study showed mixed signs in the areas of drug availability and pricing, improved utilization of health facilities, rational drug use and financial performance. That all the RDFs reviewed (especially in the study group) were functioning in terms of having drugs available and replenishing their stocks was remarkable.

　Recent Vietnamese government approval of the operation of RDFs and authorization of the levying of user charges and local use of these revenues were other indications of the viability of the RDF approach to reviving commune level health services. Recognizing the weakness at the operational level of RDFs, the government has decided that more attention will be directed towards providing clearer guidelines and procedures about what is expected from RDFs in terms of services, accountability and transparency.

　On the second day, the participating countries presented their reports on progress made against program objectives since the Yangon, Myanmar conference. Contents of reports included:

　

　

　These reports are included in these proceedings, and key progress, constraints and tasks have been summarized in an overview of the Nippon Foundation Essential Drugs Project.

　Following the reports, there was a general discussion on the contents of the reports and the directions that the projects and participating countries need to take to carry the processes forward. The issues of political commitment by the various governments and the support of UNICEF and other partners were explored. It became evident that all of the participating countries were ready to scale up their RDF projects. This was particularly the case with Vietnam and Myanmar. Laos had also obtained official approval to introduce user charges for durg purchases and was poised to start widespread training of health teams and local communities.

　It also became clear, with the excepion of Myanmar and to some extent Cambodia, that external support would still be required for the software components of the projects, namely for the development and strengthening of RDF guidelenes, the regularization of supervisory systems, the streamlining and development of financial and accounting systems, and the improvement of inventory keeping and rational drug use. The bulk of previous support was for purchasing essential drugs but such support would no longer be necessary, at least in Laos, Vietnam, and to a great extent, Cambodia. This would significantly reduce the external funds required. Myanmar, because of its unique political and foreign exchange situation would require additional commodity support for scaling up. All the participating countries and the Regional UNICEF Office also recognized the crucial role RDFs were beginning to play as a catalyst for and entry point to the development of health care services, especially at the commune levels. The importance of quality improvement and development and reform of national polices and practice regarding public and private pharmaceutical sectors was also highlighted. For RDFs learning from the Vietnam experience, special actions would be required to improve performance through improving supervision and, from a very early stage incorporating training for rational drug use, not only at the commune and health post levels, but at the district and provincial hospital levels also.

　Following the plenary discussion on reports and the future directions of the various country projects in view of the Vietnam Study findings, the participants were provided with guidelines for developing their country proposals for future support that the Nippon Foundation. It was required that these proposals be developed in draft form for presentation on the last day. These guidelines, with explanations provided (see appendix for guidelines), were presented to the participants. The purpose was to get each country group to work together to draft a country proposal that would describe: what has been done, what needs to be done, what are the constraints and how could these can be overcome, and what are the key areas in which support is required over the next couple of years to institutionalize RDFs.

　The participants met during the late afternoon of the second day and in the morning of the final day, after which each country made its presentation. These presentations are included in the latter half of the proceedings. Each presentation was discussed and clarifications sought. This was followed by a plenary discussion to make recommendations that would be endorsed by the meeting.

　During the final plenary and the closing ceremony, remarks were by the a managing trustee of the Nippon Foundation, Mr. Reizo Utagawa; the chairman of the Essential Drug Project Technical Advisory Committee to the Nippon Foundation, Professor Takusei Umenai; the UNICEF Country Representative to Myanmar, Dr. Juan Aguilar; the UNICEF Country Representative to Vietnam, Madame Rima Salah; and by the UNICEF Regional Health Advisor, Dr. Rudolf Knippenberg. Final comments were made by the Vice Minister of Health of Vietnam, Professor Le Van Truyen. There was a vote of thanks by the organizers.

　The conference ended on the note that much progress had been made. While there was still much to be done, the Nippon Foundation would consider each country proposal on a case by case basis for future support. Such support would not be automatic as the stipulated period for the project had come to an end with this international meeting.

　However, it was agreed in principle that the detailed findings from the Vietnam Study and an overview of the progress of the Essential Drugs Project would be prepared and then presented at a Round Table Conference to be held in Tokyo in the spring of 1998. The conference would possibly be hosted by the Nippon Foundation and conducted by the University of Tokyo with the support of UNICEF Tokyo and the UNICEF Regional Office in Bangkok. At this round table, the role of RDFs in the evolution of community health systems and in building capacity of health care delivery systems (putting people at the grassroots level first), would be proposed as an alternative framework, where RDFs are employed as entry points to developing health systems and improving local health security. Bilateral and multilateral donor agencies active in these participating countries, and regional development banks, would be invited to actively participate and perhaps make substantial commitments to support RDF initiatives, thus supplementing the support that may be provided by the Nippon Foundation in the next few years.