Implement models of sustainable drug supply (RDFs), including community co-management and cost sharing , in twenty-five selected commune and district facilities in four provinces:

　

　

　

　

　

　

　

　

　

　

　

　The table shows achievements against planned objectives/activities for both the core Essential Drugs for community Needs project as well as related projects impacting on progress towards overall project objectives.

　Achievements should be seen against the background of an ongoing health sector reform process focussing on the rebuilding of health services at the first level of care which is providing both opportunities and constraints to project progress.

　

Nineteen ninety-seven saw the implementation of the first official revenue raising schemes in health facilites. Seventeen health centers in the four target provinces introduced revenue raising schemes and formal community co-management through health center management committees and “feedback committees."　

　

An additional fifty-five health centers are now operational in the four provinces but without community comanagement of official revenue raising. These are expected to introduce these components by early 1998. Although all will be subject to quarterly monitoring, twenty-five will be closely monitored and evaluated over the next year as part of the government's effort to identify models of sustainable service delivery for national replication.

　

　An additional eighty functioning health centers without RDF/community financing schemes are expected to be in place countrywide by the end of 1997. Rapid replication of models developed through the project will therefore be possible in 1998.

　

　Although the first official revenue raising schemes have been operational for only several months, the Ministry of Health has already requested faster and wider implementation. It will be important to set up a solid mechanism for sharing results from the four provinces on an ongoing basis throughout 1998. A formal period of study at a limited number of facilities followed by replication of a model approach will not now be possible. Political pressure for expansion is already high.

　

　A sound foundation in areas of health service delivery, essential drug supply and financing policy, within the context of the broader district revitalization plan, will enable up to 150 facilities to introduce official revenue raising schemes by the end of 1998.

Objectives/Major Activitls 1997	Achievements
Operationalize 25 community co-managed pilot health centers in four provinces
Complete operational guidelines for pilot health centers implementing financing/RDF schemes covering co-management, fee setting, exemptions and use of funds	Completed following an inter-provincial workshop held in June; guidelines adopted by Ministry of Health for all other partners; componets of the guidelines are now being documented in detail as experience is gained
Prepare a health center operational manual for staff and a standard training course; conduct training for health center staff in service provision and drug supply and replenishment	NGO partner contracted to finalize an already developed training curriculum covering practice, theory and suppervision; staff (total 17) trained in 9 health centers in 4 provinces
Implement financing schemes in 25 health centers Community committee formation and community/health staff training program in 25 health centers	51 health centers now operational in pilot areas; 17 health centers initiated financing and full community co-management following elections; 25 centers with financing expected to be in place by early 1998; support given to ensure quality of committee meetings; no formal training program needed; additional schemes in non-pilot areas expect to begin end 1997
Train district management teams	Training course for district teams in pilot areas drafted and used in 3 districts in 1 province; additional effort in this area needed considering low capacity of health teams and major restructuring of health services at the district level; regular supervision by provincial teams established for all districts
Improve efficiency of drug replenishment
Finalize computerization of national inventory control	Completed: all CMS and drug quantification and reordering functions now fully computerized
Prepare projectins of financing needs for essential drugs and supplies for the 4 year period 1998-2001	Completed: donor pledges and government revenues estimated for the 4 year period
Supply essential drugs from CMS to all health facilities countrywide	100% of central, provincial, and district facilities, and 82% of commune facilities supplied by CMS
Implement request system for replenishment from CMS	Completed for 8 provinces
Write drug replenishment guidelines/manual	New drug supply strategy manual completed
Train district pharmacy staff of newly installed operational districts	8 training workshops held for 150 pharmacy staff; training modules revised to reflect new operational district supply strategies
Review private sector capacity and costs for transport to remote provinces	New negotiations with private transporters now in process for contracting out deliveries to 6 remote provinces
Improve drug use
Revise the national treatment guidelines manual novering all protocols	Draft finalized; completion expected December 1997
Conduct 6 prescribed in-service training workshops	Not carried out due to the extensive time required for treatment guidelines revision
Improve community self-medication practices
Design training program for private drug sellers focussing on antibiotic use, anti-diarrheal use and OR use; train 450 drug sellers in Phnom Penh	Completed: patient management flow charts, training videos and other course materials produced; 400 private sellers trained
Carry out a first evaluation survey 3 months after training is completed	Evaluation planned for December 1997
Design a public education program on self-medication	4 TV spots, 4 radio spots, calendars, posters, tee-shirts and drug seller giveaways designed and now being reproduced in time for campaign initiation at end 1997; community outreach component now being developed for poor urban communities in Phnom Penh and for future RDF pilot areas
Improve planning and monitoring
Tri-monthly supervision of all provinces by central supervision teams	All provinces supervised by pharmacist/physician teams
Tri-monthly supervision of all districts by provincial supervision teams	35% of districts and 100% of pilot districts supervised
Quarterly compilation of standard national and provincial program indicators	Completed for all quarters
Develop indicators for monitoring inpatient prescribing	Completed in September for use by monitoring teams by end 1997
Develop indicators for monitoring of RDF health centers	Completed but not yet officially adopted
Annual and six monthly project planning and review workshops	Completed as scheduled in January and June

　

　

　Reference is made to the document Operational Guidelines for Community Co-management and Financing in Health Centers in Pilot Areas, May 1997. This document attempts to link policy and implementation and has been adopted by the Ministry of Health.

　

　Community involvement: The approach adopted is to set up full community co-management mechanisms. A health center management committee comprising health staff and elected community representatives (equal representation) provides the forum for all decision making and communications. Meetings of the management committee every two months, using a structured agenda followed by a “feedback committee" meeting comprising a larger number of village representatives, has given good results. This arrangement has ensured a balance between the need for small groups to take decisions and the need for broad community representation, taking into consideration the limited time that community members can be expected to devote to these activities.

　

　Agreement on service problems and constraints, fees and exemptinos, and expenditures have been discussed. A formal contract for community health service providers is being advocated but has not yet been introduced.

　Concerns that the health authorities cannot meet financial obligations (allocation of national budget) have prevented progress in this area (see constraints).

　

　The best approaches for community involvement are now being documented for wider circulation.

　

　Fee setting and payment methods: Schemes introduced so far are based on health card payment for all users except those exempt or on additional fees for curative consultations and birth spacing services. This approach has been universally advocated by the management committees. Family card prepayment schemes have been overwhelmingly rejected, mainly due to the lack of confidence in health services rather than in a lack of ability to pre-pay.

　

　Fees set are low. This may be explained by the unwillingness of users to pay more for services until an observable improvement in quality and, in some extremely poor areas, by insufficient household income. It is anticipated that higher fees can be charged at a later date once service quality improves.

　

　The initial objective has therefore been to introduce transparent revenue raising schemes, with full community co-management as a first step with upward revision of fees at a later date. Scope for higher fee setting is possible in some districts and the testing of higher fee levels will be planned.

　

　Revenue raised: Looking at income and expenditure results for five health centers that have been in operation for at least six months, income has matched expenses for non-drug operational costs even considering that government budget allocations have largely not been received.

　

　For Health Center 5, the impact of essential "seed" drugs provided in April 1997 and the adaptation of the drugs to expected activities is shown by the significantly increased utilization and income.

　

　For Health Centers 1 and 2, improvements in main health indicators (extrapolated to one year) can be seen following the introduction of revenue raising.

　

　Drug replenishment system for pilot health centers: This is now based on replenishment from the public sector CMS. National inventory control is now fully computerized and CMS performance indicators are acceptable.

　Replenishment to the district level is functioning well. One hundred percent of all facilities now send stock reports for replenishment and a request system is being introduced. Specific record and report forms have been developed for the national supply system and countrywide stock management training and supervision is ongoing. Training for health center staff in replenishment from district stores has been completed in eight provinces, including the four provinces with pilot RDFs. All districts expect to receive training by the end of 1998.

　

　Pharmacy management indicators show some stock shortages directly related to national procurement delays.

　Essential drug procurement has recently been contracted out to a private procurement agency and performance is now being monitored.

　

　One constraint is the lack of suitable district storage facilities. The first operational district pharmacy store is now being constructed and others are planned for early 1998. Funding is not available for construction and is a constraint to full implementation of the new operational district supply system.

　

　Drugs are now priced and issued by CMS at actual purchase price. The recent computerization of CMS now allows profit to be made on issue (sales). A full RDF at the central level of CMS can now be put in place. For the initial pilots already in place, community charges are based on services provided and not related to actual drug prices.

　For pilot RDFs attempting to recover a higher level of costs, user payments for drugs will be introduced. This is expected to begin in 1998 but payment scales have not yet been discussed.

　

　Monitoring performance of RDFs: Ministry of Health provincial supervision teams are already in place.

　Supervision of pilot facilities is now carried out monthly by provincial and district authorities. At the central level, a Health Financing Task Force has formal responsibility for evaluation and monitoring of the pilots as well as any other future financing schemes. In addition, monitoring teams for drug supply and use are fully operational.

　

　Baseline surveys in the pilot areas, as well as the final indicator list for provinces to monitor and report to the Financing Task Force, are being planned for early 1998.

　

　Current reports being maintained include: patient treatment numbers and morbidity patterns; drug use, pharmacy stock data and replenishment requests; and monitoring reports generated from supervision visits by district and provincial health teams. All necessary drug and supplies stock records are already being maintained. A final accounting and reporting system is now being documented to ensure transparency at the local level. A financial reporting form is in place but has not been officially adopted; this records income and expenditures from all sources and carry-over balances. These basic records are already used as one component of health center management committee meetings and as one component of progress monitoring by the Ministry of Health and UNICEF.

　

　Pilot RDfs are in provinces supported by UNICEF provincial health advisors and close supervision and monitoring of health centers/RDFs can be guaranteed. In addition, UNICEF provides technical support to the essential drug program.

　

　There is now a need to introduce a clear monitoring and evaluation plan for the pilots, which has been recognized as a priority.

　

　

　No drugs have yet been requested from the Nippon Foundation. The first year of Nippon Foundation support to Cambodia was for the development of a financing policy and RDF operational guidelines, for strengthening essential drug supplies and to increasing the capacity of health teams. The second year of support, 1997, was for the implementation of RDFs in pilot areas as well as for further progress in the supporting components.

　

　Additional funding for essential drug "seed stocks" for pilot facilities will be sought in 1998.

　

　

　The latest National Drug Policy was officially adopted in February 1995.

　

　The Essential Drug List was last reviewed in July 1995 and will be amended at the end of 1997 following the updating of the National Treatment Guidelines.

　

　Comprehensive legislation on regulation of the pharmaceutical sector was updated in 1995.

　A new pharmacy law that regulates imports and the retail sale of pharmaceuticals was approved by the National Assembly in April 1996.

　

　Extensive guidelines for drug supply management have been developed since 1993. These were updated in 1997 to define drug supply procedures for operational districts including health centers and referral hospitals. These guidelines cover all aspects of the drug supply system. Procurement guidelines still need to be documented, particularly in light of recent private sector input into this area.

　

　Foreign currency availability is not a constraint. The major constraint is the low and inconsistent tax revenue base resulting in frequent treasury fund shortages for procurement and operational costs. Eighty percent of national revenues are derived from import duties. Customs revenues fell in the first half of 1997 to only 38% of the level collected in the corresponding period in 1996. Political instability has reduced private investment in Cambodia in 1997.

　

　Despite this fall in revenue the drug budget is maintained at a reasonable level covering 65% of the needs for 1998. Donor pledges have been received to cover the funding gap although this is being reviewed following suspension of aid by some donors.

　

　Projects are currently underway for improving implementation of the National Drug Policy:

　

　

　These interventions will all impact positively on the planned RDF implementation by ensuring the availability of drug and financial resources to pilot health centers and improving the capacity of the health system for implementation.

　

　An adequate regulatory mechanism for the pharmaceutical sector as a whole has been developing slowly. A legal framework has been developed but difficulty remains in enforcing private sector pharmaceutical laws. This must now be addressed if alternatives to public sector durg supply are to be considered.

　

　The National Financing Charter: Adopted by the Council of Ministers in April 1996, this outlines overall policy on cost recovery/cost sharing. The Charter allows full local management of revenues raised.

　

　Operational guidelines for pilot financing schemes under this project have been developed. The Charter allows the testing of wider financing schemes for central, provincial and district referral hospitals. Guidelines in these areas have not yet been developed although several schemes have recently been implemented with NGO support.

　

　

　Technical support is available to provincial and district health authorities from central MOH departments and provincially-based expatriate health advisors. Management, supervision and training programs have been developed for provincial/district teams countrywide. The pilot RDFs are in districts selected with such criteria as the strength of the provincial health team, the capacity of the district health team and the pesence of full-time support of expatriate UNICEF provincial health advisors.

　

　A training curriculum for health center staff was designed in 1997 (UNICEF/NGO) and is now used as the basis for health center clinical and managerial training in such areas as community co-management and financing. Another training curriculum for health center staff is being developed with Asian Development Bank support, but it does not meet the needs of the next eighteen months and at any rate will not be finalized until the end of 1998.

　

　Management skills training for newly designated operational district health teams is now being organized in the four project provinces. Discussions with a local training institution are underway.

　

　RDF supervision has been completely integrated into the overall supervision scheme of the province and the district.

　A horizontal approach has been adopted to implement the RDFs. Checklists have already been developed for current aspects of supervision, including quality of care assessment, pharmacy management and drug use. Financing and community co-management indicators have been defined for integration into the supervision scheme for RDFs but these have not yet been officially adopted.

　

　A formal monitoring and evaluation plan for the central Ministry of Health must now be developed.

　

　The limited capacity of district health teams is identified as a main constraint to implementation. A second constraint is that local health authorities find it difficult to access adequate national budget for supervision visits. External support is still needed for this activity.

　

　

　

　Official revenue raising schemes were implemented only in 1997 in relatively few health centers and the effects on national budget allocations are not yet seen.

　

　The national essential drug budget has been increased and maintained over the past three years despite government revenue difficulties but the operational cost budget allocation (excluding drugs), at around 40 % of the total health budget, is often not fully available.

　

　There is a possibility that operational budgets may be reduced if local revenue raising schemes expand but this has not been stated as an intention by the government.

　

　

　Unreliability of national budget availability for local operational costs: Health center allocations of riels 4.2 million per year (US＄1,200) are often only partially received. This has been a serious constraint to improving service quality but forms part of the rationale for local revenue raising.

　

　This is a long term constraint difficult to completely resolve due to limited tax revenues and the difficulty faced by provincial authorities in prioritizing allocations of available funds despite an agreed national health budget. Direct allocation of district development budgets to selected pilot districts (accelerated district development budgets or ADD) was implemented as a solution in 1996 and 1997 with initial success but even these arrangements have not been honored recently.

　

　One assumption is that organizing and increasing the capacity of communities may lead to improved budget allocation. In setting fees it is assumed that the government contribution for operational costs will be received and discussions are underway to secure this commitment from provincial governors and also to include the use of a user-provider contract.

　

　Weak essential drug procurement capacity: This was a serious constraint in 1995 and in 1996 but is now partially resolved by contracting out procurement functions to a private company. Efficiency of public procurement needs to further improve and alternative supply options considered in 1998 now that private supplier networks are expanding and strengthening. UNICEF assistance will be provided in this area in 1998.

　

　Time and human resource constraints: This is evident in efforts to organize community elections and committees where no committees exist and in areas where there is no community support program. Health sector staff therefore have to take the lead which is time intensive. In the pilot phase this can be done but may be difficult in an expansion phase.

　

　Political will for expansion before experiences are fully evaluated: The government is now fully committed to introducing official local revenue raising on a national scale. There is little experience of financing schemes outside of the pilots under this project which is only several months into implementation. Consequently, the introduction of official revenue raising before service quality improvements would be detrimental. It will be important for the project to increase emphasis on monitoring, evaluation and sharing of best practices in 1998.

　

　

　Technical and financial support to overcome constraints has been given by UNICEF/WHO to central government departments of the Ministries of Health and Finance and to provincial health authorities through expatriate advisors.

　

　This support has been in the areas of policy development and operational support.

　

　Financial support given by the Nippon Foundation has been used for planning and operational strengthening in critical areas. This includes support for essential drug supply, health center training, district supervision and community organization in pilot areas. Technical support will be sought from Tokyo University for an evaluation of pilots in 1998.

　

　

　Objectives and activities to be undertaken in 1998 will be officially adopted during a planning workshop in November 1997. A draft schedule of activities is now being prepared.