These are outlined in the Project Plan of Action, which is divided into four main milestones of specific activities and corresponds to the main goals of the project:

　

　

　Strategies for reaching objectives

　

　In all aimags, project monitoring groups were established consisting of the head of the Social Policy Department of the aimag governor's office, its health officer, the head of the aimagemimpex (drug company), sum governors, and sum health managers.

　

　Based on the guidelines developed by the MOHSW, councils on revolving drug funds were established in all sums, each comprising the sum governor, sum doctor, pharmacist, bag governors, bag feldshers (medical assistants) and representatives from the community.

　

　Sum councils on revolving drug funds have regular meetings at the end of each month and discuss the use of the funds, sales and income. Bag governors then inform the communities about the results of the meeting, the topics discussed, and the decisions made at bag community meetings.

　

　Special bulletins issued at the sum level that regularly review the status of the revolving drug funds are posted at RDF sites.

　

　Community people are very motivated to support revolving drug funds and health services at the sum level. In some sums, people contribute livestock to the RDFs on average of one sheep, goat or cow per family. Bulletins are issued that include details of these contributions. Companies and local small scale industries also make contributions to the drug funds.

　

　At the bag level, which is the lowest level, people are beginning to generate their own resources and establish health funds for the purpose of purchasing motorbikes for feldshers and jeeps for sum hospitals.

　

　In Gobi Aimag, the local sum governors' offices have allocated funds (Tug 20,000 to 200,000) to the bag level for drug purchases, using the same management and financial procedures as at the sum level.

　

　Extensive training of health volunteers has been conducted in twelve selected sums, each one having about twenty health volunteers. Each health volunteer is responsible for fifteen to twenty households. These health volunteers are the PHC message distributors at the grass roots level. The training of trainers of health volunteers has been conducted at the central and aimag levels. These trainers will conduct training in the sums of their respective aimags.

　

　The women's NGOs at the sum level are actively participating in the health care education of the population.

　

　The survey conducted by the Health Management and Information Center has shown that most of the respondents are well aware of community participation and are involved in the management and decision making of revolving drug funds. A prevailing segment of those involved in the survey accept the fact that activities related to RDFs are carried out with community participation.

　Since 1995, all ninety-nine sums have received the seed drugs (worth five to ten million tugriks) donated by the Nippon Foundation for the establishment of revolving drug funds. RDFs sell the drugs from pharmacies directly to outpatients and inpatients, and through bag feldshers to people at the grass roots. Bag feldshers usually obtain every month drugs worth 30,000-60,000 tugriks from the RDFs. After selling 60% of the drugs, a feldsher returns for replenishment, at which time he/she deposits the money from drugs sold.

　

　At the sum level, an RDF places an order with aimagemimpex (aimag drug company) for the next month, based on the drugs sold at sum and bag levels, and takes delivery of drugs regularly every one or two months.

　

　Sum level revolving drug funds obtain drugs from the aimag level drug company at 10 to 15% discounts. This increases the income of the funds. However, sums prefer to get drugs from Ulaanbaatar drug companies and pharmaceutical factories that give 25% discounts which are much higher than aimag branch discounts.

　With the assistance of a US Peace Corps volunteer, an accounting system has been developed for RDFs. As only twelve sums were operating RDFs previously, this system was not very widely used. In the recent period, the RDFs have been using the usual forms issued by Mongolemimpex for their local branches. As all the sums of the six selected aimags have now established revolving drug funds, it is becoming important to use the new accounting system. The training of trainers has taken place in Ulaanbaatar and is planned for all aimags in November and December this year. Before aimag training sessions, financial report forms will be printed and distributed to all sum RDFs. The accounting system was introduced to the participants of the 2nd International Meeting on Essential Drugs and Community Health Service in Myanmar last year.

　

　This system includes the following reports:

　

　

　All RDF financial reports will be kept at sum RDF and aimag RDF management units, which are usually located at public health centers (PHCs). PHC directors are the aimag project managers.

　In 1991, the Ministry of Health began shaping the Mongolian National Essential Drug Policy with the support of WHO. Based on the WHO model, Mongolia's essential drug policy was developed.

　

　The First Conference on National Drug Policy and Essential Drugs was held in 1992. The main objective of the national drug policy was to provide the population with safe, effective, high quality drugs at reasonable prices, and to improve drug management and rational use of drugs. A new drug policy has been designed and approved, including the establishment of a Drug and Bio-Preparation Council to be in charge of registration and other regulatory matters, and the creation of essential drugs lists based on WHO recommendations for different levels of public health facilities.

　

　The essential drug lists were revised in 1993 and comprised some 225 drug items for central-, 207 for aimag-, 136 for sum-, and thirty-seven for bag levels. The lists were reviewed in 1994 and expanded to comprise 240 drug items for the central level. The lists were again revised in 1996 and expanded to deem 265 drug items as essential based on the Health Minister's Decree No.A/231.

　

　A draft of the pharmaceutical law to regulate the import, manufacture, distribution and sale of drugs was submitted to the Parliament. It will be discussed during this autumn session. Quality assurance activities are being carried out by the National Center for Control of Drug and Bio-Preparation under the supervision of the Ministry of Health and Social Welfare.

　

　In keeping with international accounting standards, the revised accounting system has been introduced, computerized and coded. Due to this system all bookkeeping and accounting systems have been changed accordingly. Training on international accounting standards has been conducted for accountants at all levels.

　

　Until 1997 all income from donor-assisted drugs was centralized for the state budget. According to the government decree issued under No.333 this year, income from all sold drugs and pharmaceutical equipment assisted by donors will be kept at the Central Revolving Drug Fund established within Mongolemimpex. This greatly increases the importing capacity of the Mongolemimpex. The government does not allocate any funds for drug importing. Since the beginning of this year, a total of US$2.9 million worth drugs have been imported from abroad. At present, Mongolemimpex company the amount of US$200,000 for purchase of the drugs on the basis of agreements.

　

　Since 1991, the Ministry of Health and Social Welfare in cooperation with WHO has been implementing a five-year program on essential drugs and vaccination. Within the framework of this program:

　

　

　In order to improve the structure of the drug supply agency, the Minister of Health and Social Welfare and the chairperson of the State Property Committee jointly issued Decree No.01/01, according to which pharmacies and branches of Mongolemimpex located at hospitals are now under the respective hospital's authority at all levels.

　This activity has positive effects for the decentralization process, but it may also bring some negative results. For example, at the grass roots level, there may appear a shortage of professionals and professional management.

　During the last four years of implementation, the main focus has been given to the capacity building of local and community leaders and health personnel in terms of management of the project and RDFs, community participation, drug management, rational use of drugs, and RDF accounting systems, etc. All sum governors and health managers have been involved in this training.

　

　Local project managers at all six aimags, including sum doctors and some sum governors, attended overseas training. Four groups (a total of twenty-nine people) participated in overseas training on management of community-based health services.

　

　Besides training within the framework of the project, local leaders are attending other health training sessions conducted in cooperation with WHO, UNFPA, World Vision International and others.

　

　The Ministry of Health and Social Welfare and the Health Management and Information Center, in cooperation with WHO, are implementing small scale projects on health service management. Sum governors and sum doctors are involved in this training. Training on health management has been conducted in Ovorhangai, Dundgovi and Bulgan aimags and this training will be conducted in other aimags according to a special schedule. We are discussing linking the Community and Health Project, particularly RDFs, with this training, which is very important in terms of integration and maximization of efficiencies and impact.

　The Community and Health Project was developed based on the experiences of other countries where community initiatives propelled change for improvement of rural health services. The activities of the project are well designed to meet the specific needs of Mongolian rural health services. As time passes, it is becoming more evident that the revolving drug funds experience in its present performance is quite appropriate for Mongolia's particular situation.

　At a meeting with governors of the selected aimags participating in the Community and Health Project, Dr. Zorig, Minister of Health and Social Welfare, expressed his commitment to supporting RDFs and to expanding them to all sums of the country. The minister issued a decree on the establishment of the Health Revolving Fund at the sum level. However, there are still some areas that need improvement and revision:

　

　

　In order to revitalize the public health care system within the framework of the basic health care system, the Myanmar CCS projects aim to ensure that:

　

	Objective	Achievement
1.	Decentralize revolving drug funds	Revolving drug funds have been decentralized. The pricing of drugs, selection and quantification of requirements are carried out by locally managed supervisory committees. Recovered funds are submitted to the central bank account and then the central replenishment committee does what is necessary for procurement by calling tenders from FDA registered firms. Decentralization is on its way except for procurement.
2.	Encourage local production of essential drugs	The Myanmar Pharmaceutical Factory, the sole manufacturer of essential drugs in the country, has improved itself to meet the GMP standard, but production capacity does not meet national demand.
3.	Strengthen the existing accounting and financing mechanism in line with community cost sharing	Financial management modules for various levels of health facilities have been developed and field tested in 3 townships. With the experience gained from the field testing, they are being re-edited and will be distributed to all levels of health care for a better accounting and financing mechanism.
4.	Build capacity for rational use of drugs	Training is being conducted on an ongoing basis.
5.	Negotiate with foreign drug firms for standardization of prices	Negotiations with foreign drug importers have been carried out in accordance with consumers' rights concerning pricing. Foreign drug importers have also agreed to support the MOH's CCS scheme by supplying drugs at bulk price and at prices lower than they charge private drug retailers.

　

　In Myanmar 3,577 RDF clinics have been established which are mainly manned by midwives. All of them are functioning with various levels of success. The community is involved in financial management and in advocating RDF concepts to the rural populace. As for the replenishment system, required drugs are requested by township medical officers at the local level but purchasing is still centralized. Purchasing is done through a tender system from FDA registered firms and the stock is received at the CMSD. The CMSD in turn distributes the drugs to the townships. Township medical officers and the stores in charge receive the drugs, enter them into the inventories at the townships, and then distribute to health assistants and midwives concerned at the grass roots level.

　In its first donation, the Nippon Foundation contributed US$1.7 million worth of essential drugs. From these US$700,000 worth of drugs were provided to various disease control campaigns. Only US$1.02 million worth of drugs were used for establishing RDFs at the PHC level. In the second consignment, the Nippon Foundation assisted with US$1.7 million worth of drugs which were all used for RDFs. Starting from 1994 November to date, Myanmar has recovered 46 million kyats from RDFs.

　The central level distributes to the townships, for information, basic unit prices according to UNIPAC and Belgium price lists (in US$). The actual pricing at the community level is done by the township health supervisory committee, which is composed of community leaders, local Law and Order Restoration Council members, NGOs, health staff, etc. Local medical retailers play a major role in drug pricing as the township health department aims to price drugs at levels below local current market rates. After the pricing mechanism is done at the township level, midwives and health assistants use it as a standard in RDF clinics.

　Financial reports are first scrutinized at the rural level by the village health committee, and when compiled are sent to the township level. The township health supervisory committee monitors them and reports are sent to the Department of Health monthly.

　Supervisory reports concerning field supervision, monitoring, and continuing education activities are sent to the TMO and the DOH monthly.

　

　The National List of Essential Drugs has been adopted and intermediate lists of essential drugs have also been developed for various levels of health care since 1989. The national list was updated in 1994. A national formulary known as the Myanmar National Formulary (MNF) has been developed since 1989. Revision and updating the national formulary as well as the National List of Essential Drugs was done during the reporting period.

　The National Drug Policy has been in force since 1989 and the National Drug Laws since 1992. Although the National Drug Policy has not been reviewed and revised, the National Drug Laws have been properly enforced recently and the pharmaceutical sector has been complying according to the laws.

　Enforcement of the existing National Drugs Laws has enhanced the implementation framework the National Drug Policy. In the pharmaceutical sector, because of this enforcement, private drug dealers have stopped marketing unregistered drugs. The RDF project benefits from this program since it requires that RDFs procure only registered drugs in their own localities thereby enhancing decentralization.

　

　In early 1996, a committee was formed at the central level for the replenishment of essential drugs for townships practicing community cost sharing. The committee receives the revolving funds from various townships concerned together with their requisition of drugs. The committee calls tenders from FDA-registered importers and procures the required drugs for the townships using their own respective funds. The CMSD purchases the drugs from the local importers and supplies them to all these townships. The MOH has encouraged local production of essential drugs with proper logistical management in collaboration with the CMSD and other foreign pharmaceutical manufacturers.

　The supervisory committees at the grass root levels are using 90% of recovered funds for drug replenishment and 10% as locally managed funds for the purpose of strengthening or upgrading health facilities and services.

　

　The budget for the procurement of drugs for the public sector in fiscal year 1996-97 was 79.2 million kyats and the amount of foreign exchange available during the same period was US$218,914.16 for the procurement of drugs.

　

　Primary health care services in the project areas are being strengthened by the provision of essential drugs donated by the Nippon Foundation, and the health care providers at grass roots levels are improving their managerial capabilities concerning financial and drug management.

　Continuing education is being provided on rational use of drugs. Training concentrates mainly on use of standard treatment guidelines at the township level in every monthly payday meeting. The central team, during monitoring and supervision tours, also provides continuing education in this area. Annual review meetings are being held at the township, state and divisional and central levels regularly to monitor achievements.

　Supervision teams are being formed at the state and divisional level. Deputy state/divisional health directors or training team leaders are assigned as focal persons to monitor project activities with the aim of achieving 80% coverage. During supervision tours they meet community committees and share views and experiences.

　Health care providers are still weak in financial management, and continuing education is being given through providing financial management modules for various levels of health care. As prescription audits were being carried out regularly, it was observed that midwives and health assistants need additional training in rational prescribing. Continuing education concerning rational use of drugs is being conducted monthly in the townships.

　The MOH has circulated a directive to put up billboards in all hospitals across the country that state: “This hospital gives free treatment to the poor. To those who can afford, it practices CCS." According to this directive, health staffs are giving exemptions to those who cannot afford to pay.

　

　Health care providers at rural health sub-centers keep track of monthly progress and by the 25th of each month, report their progress to the rural health center where health assistants compile the monthly rural health center report. The monthly rural health center report is submitted to the TMO's office during the monthly payday meeting. The TMOs' office compiles the reports of various RHCs in the township and sends the progress report to the central level and a copy to the state and divisional level. The central level compiles all the township reports and submits the monthly achievements to the MOH.

　Townships, states and divisions, and the central level monitor these reports and if any discrepancies are observed, the reports are sent back to the reporting units concerned for verification. The central and state/divisional levels monitor these reports in terms of morbidity pattern versus drug consumption and number of treatment episodes versus cash recovered.

　

　The national budget for health was 2,812.2 millions kyats in 1995-96, which represented 7.03% of the total national budget. Compared to the previous year, the proportion has increased and when the actual numerals are observed, it can be clearly seen that the health budget is well on the increasing trend.

　

　The total recurrent health expenditure by type of services shown in the following table does not vary much over a three year period.

　

　Although not related to the RDF program, the overall budget level for the MOH (including primary health care activities, drugs and medical supplies, etc.) from the mof is increasing yearly as the country experiences overall development, including health sector development. The increasing trend is in the positive direction as the quality of health services has improved. The government is planning to reallocate funds from townships successfully implementing RDFs to the least developed and border areas in the near future.

　

　Community participation and financial management is still weak in some project areas. Although decentralization has been achieved down to the grass roots level in project management, it is still limited in drug replenishment. Grass roots level health care providers still need the advice and expertise of central personnel in the procurement of the drugs. Local production of essential drugs is outside the control of the MOH as the sole pharmaceutical plant in Myanmar is under the control of a different ministry. Planning local production of essential drugs is multi-sectoral. At present local production does not meet the demands of the communities. In spite of continuing training, irrationality still remains in some localities due to lack of behavioral change in terms of rational use of drugs in both provides and consumers.

　

　Long standing problems

　

　The inflation rate in Myanmar is fluctuating and it is an impediment to the replenishment of drugs. It is resistant to resolution as it depends on the country's economy.

　

　Advocacy meetings and training have been given to one representative from every village in the project area. Financial management training has also been given to community treasurers from every village. Supplementary funding for the project channeled through UNICEF has facilitated these training activities. Community empowerment has been strengthened through the training of voluntary heath workers. Community participation has been achieved in the sense that communities are now involved in financial management

　Local committees, including community members, have been formed. These committees decide pricing, selection and quantification of drugs for procurement at the grass roots levels.

　Focal persons are being assigned in states and divisions who will go on monitoring and supervision tours. A regular reporting methodology has been developed.

　Concerning current inflation rates, the project plans to have shorter replenishment cycles to combat the problem. The Food and Drug Administration has issued directives concerning the sales of non-registered drugs in Myanmar. At the moment, the pharmaceutical market in Myanmar provides only registered drugs produced with GMP standards. Discussions and negotiations have been carried out with pharmaceutical manufacturers from different countries for the local production of essential drugs. Unicef Myanmar fully supports the Community Health Management and Financing Project through the utilization of the supplementary funds assisted by the Nippon Foundation. An assistant program officer has been assigned full-time to assist the project by UNICEF. The Nippon Foundation has channeled through UNICEF US＄1.2 million as supplementary funds for project implementation. It has shown its concern for the status of the project by sending evaluation teams. It plays a vital role in winning political commitment to community cost sharing. The Department of Health Policy and Planning, University of Tokyo, plays a vital role in the evaluation process of the project. Professors visited Myanmar and shared knowledge and experiences in solving problems. In June 1997, technical sessions with Professor Narula were of great benefit for the MOH. The University of Tokyo emphasized the importance of the country's political commitment towards CCS and in detail looked into the status of the implementation of the project assisted by the Nippon Foundation.

　

　The project's objectives for the years 1998-2000 are as follows. In order to strengthen primary health care within the framework of the health care system, the Myanmar CCS projects are to ensure that the people can obtain essential drugs at all times at affordable prices, and that the drugs reaching patients are safe, effective, of good quality and rationally prescribed. These objectives are subdivided into four sub-objectives:

　

　

　

　The project intend s to cover at least 80% of the country by the year 2000. In that context, the project intends to expand its activities at the rate of forty-three townships per year till the year 2000 until a total of 261 townships are covered, which represents 80% of the whole country. The cost of EDS for each township per year is estimated to be US＄25,000 assuming an inflation rate of around 10% per annum. Thus, the cost of ED for expansion will be US＄1.2 million for 1998, US＄1.3 in 1999 and US＄1.4 in 2000. The rationale for expanding the CCS scheme to these townsihps is to strengthen primary health care activities and to offer wide availability of ED at the grass roots level.

　

　

　Building local capacity in ED production

　

　An operational study is being planned to assess the magnitude of the local capacity of ED production. A consultant will be retained for this study, a protocol developed and the study implemented. From the outcome of this study which will reflect the existing situation, strategies will be drawn to increase ED production capacity. The study will also find ways and means to introduce measures to enhance ED imports by the private sector. The MOH is considering exempting registration fees for drugs on the National List of Essential Drugs. At present, the MEDP, CHMF, CMSD, and UNDP/HDI-E projects are practicing CCS based on the essential drugs concept and rendering wide availability of essential drugs in the country. The MOH now plans to introduce in an integrated manner a uniformed approach under one umbrella.

　

　

　Upgrading the drug supply management system

　

　The drug supply management system needs to be upgraded. For this, the following support activities hav ebeen planned:

　

1. Operational study on the existing system

　The existing system of drug supply management needs to be critically assessed. A consultant knowledgeable in logistics and who has good experience with the operations of CMSD will be assigned for this purpose. An assignment protocol will be developed and th eactual study implemented. (An honorarium of US＄3,000 has been estimated) From the outcome of this study, strategies will be drawn while considering possible collaboration with private and public sectors to improve the supply management system

　

2. Regular in-service training

　For systematic drug management, regular in-service training of health workers has been planned to improve their skills. Regular refresher courses to be held annually for the existing 132 townships have been planned up to the year 2000. In-service training courses have been planned for the forty-three new townships to be brought into the project each year. The trainers will be TMOS and personnel in charge of the drug stores. The estimated cost for regular in-service training is 160,000 kyats in 1998.

　

　Improving physical structure of storage facilities

　

　At present, storage facilities at the grass roots level do not comply with the standards laid down by WHO/DAP.

They need to be upgraded.

　As Myanmar is a tropical country, temperature and humidity are not favorable for the storage of drugs, especially volatile compounds, vaccines etc. Ventilators and air conditioners are planned to be installed in these facilities. For improving storage facilities, the cost is estimated to be US＄180,000 in 1998 and US＄43,000 in each year of 1999 and 2000.

　

　

　In the future, townships at the grass roots level will be responsible for the selection and quantification of their essential drugs needs. Therefore, capacity building to enable local personnel to perform these tasks has been planned. Training sessions will be organized for the 132 townships for this purpose. A total of 384,000 kyats has been earmarked. Measures to improve regional capacity in monitoring and supervision of RDF activities have been planned. They include office automation for monitoring in fourteen states and divisions. A total of 8.4 million kyats has been earmarked. Financial management also is an underlying constraint in RDF activities, and health workers are in need of training in this area. Financial management training is planned to be held in 175 townships which will require funds amounting to 855,000 kyats in 1998. Refresher courses and regular courses for new townships are also planned for 1999, which will require funds amounting to 10.03 million kyats. In the year 2000 such courses will be repeated in existing and new townships, which will require funds of around 12.74 million kyats. As health providers need incentives, it is under consideration to introduce consultation fees at public health facilities where CCS is being practiced.

　

　

　Mobilizing voluntary health workers for CCS (community empowerment)

　

　In Myanmar, primary health care services are being delivered at th egrass roots level through basic health staff and voluntary health workers (VHWs). The MOH has planned a scheme to involve VHWs in RDFs. One hundred sixty VHWs in three townships have been targeted to be trained for this purpose and for better coverage. A total of 150,000 kyats has been earmarked for training in 1998. This activity will be expanded to another eighty townships in 1999 and an estimated cost of 360,000 kyats has been earmarked. Depending on the level of success, the process will continue in another 150 townships at an estimated cost of 810,000 kyats. In Myanmar, as village health units are manned by VHWs, empowering them will be of great benefit to the community. In mobilizing VHWs, it is planned that community leaders and community representatives be assigned for monitoring and supervision. A community volunteer or representative from these villages will be trained for proper planning, monitoring, supervision, and financial management of RDFs. Local NGOs usually participate in such activities. The cost of empowering VHWs is estimated to be 510,000 kyats in 1998, 120,000 kyats in 1999 and 270,000 kyats in the year 2000.

　

　

　Training newly appointed and transferred health workers

　

　For newly appointed and transferred health workers who have never been exposed to the essential drugs concept, local training on rational use of drugs and comunity cost sharing has been planned.

　

　Training of private practitioners

　

　Although public health workers are practicing the rational use of drugs and essential drugs concept, private practitioners do not know the ED concepts and do not comply with rational use of drugs. Training in this area has been planned for the private sector, including private drug dealers.

		Activities	Target date	Estimated cost (US＄)
1.	Introduce CCS scheme at all levels of public primary health care facilities in 80% of townsihps in the country
	i.	54% covered (total 175 townships)	12/98	1,182,500
	ii.	67.3% covered (total 218 townships)	12/99	1,300,750
	iii.	80.56% covered (total 261 townships)	12/00	1,430,825
2.	Improve availability of essential drugs in the country
	i.	Build local capacity in essential drugs production (MPF, private sector, etc.)
	ii.	Consolidate different CCS projects (i.e. MEDP, CHMF, CMSD and UNDP)
		-Introduce uniform approach/methods	12/98
		-Create 1 umbrella body for CCS	12/99
	iii.	Operationalize study on local capacity	06/98
	iv.	Increase MPF's production capacity (MOH increase its order)	12/98
	v.	Increase MPF's ED production capacity	12/00
	vi.	Strengthen FDA activities to control private sector (as per FDA, PPA)
	vii.	Introduce favorable measures to private sector for ED import
	viii.	For 70 to 80 items, give import tax exemption	12/98
	ix.	Make exemption for registration fees	12/98
	x.	Control unregistered drugs in close collaboration with other government law enforcement sectors (FDA, PPA)
3.	Improve drug procurement, storage and distribution system at all levels
	i.	Upgrade CMSD's supply management system
	ii.	Operationalize study on existing system and produce strategy in due consideration of possible collaboration with private sectors and other public sectors	06/98	3,000
	iii.	Give regular, in-service training to health workers on systematic drug management	12/00	1,627,000
	iv.	Improve physical structures of drug storage facilities at twonship and lower levels	12/98 12/99 12/00	175,000 43,000 43,000
4.	Strengthen comprehensive decentralization process of public sector's health service management (i.e. planning, monitoring, supervision, financial control and evaluation)
	i.	Strengthen ongoing decentralization of PHC management
	ii.	Make townships responsible for selection and quantification of essential drugs	1997-2000	384,000
	iii.	Continuously build regional capacity in monitoring and supervision of CCS (including provision of equipment such as computers, fax machines, etc.)	1997-2000
	iv.	Train all health workers involved in CCS on financial management
		-175 townsihps	12/98	8,550,000
		-43 townships	12/99	10,028,000
		-43 townships	12/00	12,738,000
	v.	Introduce consultation fees at public health facilities where CCS is practiced (cf. cooperative clinics)	12/98
5.	Increase community participation in health service management
	i.	Mobilize AMWs/CHWs for CCS
		-3 townships	12/98	153,000
		-80 townships	12/99	360,000
		-150 townships	12/00	810,000
	ii.	Strengthen community capacity for planning, supervision, and financial management (train selected/volunteer community members on these subjects)
		-3 townships	12/98	51,000
		-80 twonships	12/99	120,000
		-150 twonships	12/00	270,000
6.	Improve quality of health service providers (public and private service providers, including drug sellers)
	i.	Train newly appointed/transferred health workers on CCS and RUD	1998-2000
	ii.	Train private sector providers on RUD	1998-2000
	iii.	Train public medical doctors on RUD	1998-2000
	iv.	Train public health workers (including pharmacists) and community members (of CCS twonships) on RUD	1998-2000

　Some Remarks on the Management of Revolving Drug Funds in Vietnam During Recent Years

　

　By the end of the 1980s, due to economic inflation, the health sector was fraught with many difficulties. Restriction of health performance and low utillzation was experienced by commune health centers (CHCs) due to drug shortages. CHCs mainly provided preventive services. Meanwhile, the private health sector had not yet considerably contributed anything, except some traditional health care.

　Since 1986, the economic reform has been in place. Economic status, especially in rural areas, has improved. However, the management of production teams, which mainly provided community health finance, also loosened. Commune health workers (CHWs) did not receive their salaries on time. Village health workers nearly quit work because they were not paid by the production teams. There was a serious shortage of drugs at CHCs during this period.

　The performance of CHCs deteriorated the most. At that moment, the Bamako Initiative was introduced in three districts, then expanded to six districts. According to 1991 baseline statistical information (when the project was not yet developed), in Me Linh District (Vinh Phu Province), the value of drug funds per capita was only fourteen VNDs a year. This figure rose to 300 VNDs per capita in 1995. According to the 1995 survey conducted by the departments of planning in six districts,^* the value of drug funds per capita rose to 450 VNDs. RDF drug funds accounted for 9.9% of the total budget of CHCs. This shows that the first contribution of the project was to give, at the right moment, a hand to districts in improving the severe drug shortage situation.

　

　The CHC drug shortage was relieved due to the legalization of private medical and pharmaceutical practice by the government. During this period, it can also be said that there were very few localities where drugs for the treatment of common diseases were insufficient. At the same time, the RDFs continued to expand due to the insufficiency of funds for drug procurement. The project not only aimed at directly supplementing funds for drug procurement. It also aimed at attracting the population to access services at CHCs, at mobilizing community contributions for upgrading CHCs (through marking up drug purchases), and at improving participation of district people's committees in district health performance, supporting CHC activities and in RDF management. In 1995-1996, the situation concerning management and drug utilization changed complexly. The transition from drug insufficiency to movement in the opposite direction with involvement of the private sector in the pharmaceutical supply system occurred fairly quickly. At the same time, the health sector was not prepared for fine-tuning and controlling the deviations in drug management at the grass roots level and for retraining health staff. Thus, the side effects of “drug sufficiency" without proper control capability in terms of rational use and prescriptions became more and more evident and dangerous for users. Recent MOH surveys (thirty-two communes in sixteen districts in eight provinces) show the following:

　

　

　In addition to the above mentioned contributions, the results of the study on the situation of RDF management in six districts and 2000 households that were directly interviewed in 1995 sohwed other sizable benefits brought by the project:

　

Encouraged sick persons to utilize CHCs

　

　In general, 20% to 30% of people came to seek care at CHCs while in two surveyed districts (Thach Ha and Yen Phong), this percentage was 50%. Sick children also sought care at CHCs in those districts: 58.5% of ARI children and 42.5% children with diarrhea sought care at CHCs as opposed to 15% to 20% respectively in the total population. The percentage of people who came to CHCs to purchase drugs was also high (64%).

　

Reduced self-medication

　

　Only approximately 20% of sick cases used self-medication, considerably lower than the overall figure (about 40% to 60%).

　

Increased antenatal check-ups

　

　The number of pregnant women seeking antenatal care at CHCs was high, with 2.7 antenatal check-ups per pregnant woman on average. Overall, this figure for mothers, by the time of delivery, was 1.3 check-ups. The percentage of deliveries at RDF CHCs was also fairly high (78.9%), while in other localities this accounted for only 50% to 60%. From 1995, 95.2% of children under five have been provided with vitamin A by the CHCs.

　

Increased drug purchases

　

　In the two years 1994 and 1995 only, RDF funds in six districts increased 23%. The profit value of drug purchases in 1995 was 220 VNDs per capita per year on average, a 14.7% increase over 1994. Drug consumption per capita per year in communes with RDFs rose one and a half to two times the general figure.

　

Incentives for health staff

　

　A sizeable share of RDF profit was used for incentives for health staff at the grass roots level. The percentage of profit used for CHWs (to vitalize and sustain those teams) was 37.6%, while the share for health staff of CHCs was 11.8% of the total value of RDF profits. In districts where RDFs were surveyed, an average of 10 to 80 VNDs per capita was used for exempting the poor and people of certain social groups.

　

Improved management

　

　One considerable contribution of the project was that relations between district and commune levels were more regular and close and thereby strengthened. The quality of the reporting system was fairly good in communes with RDFs. To demonstrate this conclusion, two report data sets of CHCs and households were compared for consistency. For instance, 46% of children under five were given ORS (two packages per child on average) compared to 42.5% based on survey data. The percentage of deliveries at CHCs reported was 73.6%, while this result based on households surveyed was 78.9%. Mothers having had three antenatal check-ups or more accounted for 71.2% of mothers, while a similar percentage of mothers in the survey had had 2.7 antenatal check-ups by the time of delivery.

　

Drug fund retention

　

　Revolving drug funds were so far being maintained and were continuing to increase in most localities. In five surveyed districts, the level of seed stock value increased from 11 to 71 million VNDs per district, or 44 million VND in total, though in some districts the value of seed stock was not yet recovered (despite four revolving cycles). This was mainly due to non-payable population debts (6.3%) and the requirement of commune people's committees to give donations to the poor as subsidies for drug costs. Another reason was that the regulation that 50% of RDF profits be used for replenishing the drug budget was not assured.

　To be sure, there were some irrational points. Compared to the situations in other poor countries such as those in Africa, however, the RDF project in Vietnam has in fact brought initial benefits: the restriction of drug sohrtages and the promotion of health performance at the grass roots level; motivation of community participation and local government leadership in the health sector; and boosting district level to CHC level activities.

　

　Given the strong benefits of the RDF project, particularly on the community side, its effectiveness still does not correspond to fund levels and the efforts made by health staff at the grass roots level. There are many subjective and objective reasons and avoidable and inevitable difficulties, mainly in project management and coordination, reaching from grass roots and district levels through provincial levels up to the MOH Steering Committee. To strengthen the cost effectiveness of the project in the future, there is a need to concretely discuss previous shortcomings, to make projections for the sustainability of the project, and to plan future actions.

　We shall also review project management from the grass roots level, up through the district/provincial level, to the MOH Steering Committee.

　

Project management at the grass roots level

　

　Management was examined in two areas: specialization and accounting. In terms of specialization, problems began right after the receipt of seed stock. Most complaints were about the incompatibility of some items of seed stock with treatment demands in some localities. For instance, nistatin was expensive and being received in large amounts so that it could not be sold. Ergomethrin was also received in large quantity though the demand for it at the commune level was low. There were not a few complaints about drug prices being set at similar or higher levels than those in the market, especially in rural areas where most inhabitants could only afford lower prices. A recent poll of the opinions of 200 households about drug prices at CHCs with RDFs showed that only 31.6% considered CHC drug prices lower than those in the market. The same proportion thought the prices were equal or higher.

　Regarding drug quality at CHCs, 21.1% of the people thought that CHC drugs were better than drugs on the market. The remaining thought that the quality was equal. People's attitudes to the CHCs show that there is a need to study the demands of communities before determining which drugs to procure.

　Drug procurement was usually undertaken after the stock-out of items and was decided by CHCs. According to the 1997 study, the decision was usually made by the persons in charge of drugs, mostly nurses. Only 47.7% of communes had discussions before major decisions were made. Stock replenishment was done at least one or two times per month, but only 27.7% of communes made decisions based on groups of people at monthly meetings, but even these were in fact based on local consumption levels and according to the principle of “procure any item whenever it runs out." Drugs have become uncontrollable commodities. Regarding replenishment, many problems arose. In general, most decisions (40.4% of the cases) had to do with the quantity of drugs to be procured, with far less attention to the kinds of drugs (29.8% of the cases).

　Price setting is an issue that must soon be addressed because high demand drugs should be sold at lower premiums than “luxury" drugs that are in lower demand. Only 17% of CHCs have held meetings that discussed drug prices. However, of these CHCs, 74.5% answered "yes" to the question, “Are the kinds of drugs to be procured based on disease patterns?" To the question, “Are the kinds of drugs to be procured based on based consumption?" the proportion of affirmative responses was 83%. In fact, there was a tendency to procure antibiotics which made up 42% of the total cost for drug procurement, with non-essential drugs taking up only 25.4% of costs. Thus, the problem is not that facilities do not know how to estimate drugs for replenishing, but how to direct procurement decisions to be primarily based on disease patterns. The answer perhaps should be answered by district supervisory teams going for training in the provinces.

　For the purpose of quality control and directing communes' decision on disease-based drug procurement, there should be regulations that drugs be procured from district pharmacy outlets. Fifty-three point two percent of communes procured drugs from other sources. There are many reasons, but the meaning is clear: the districts find it difficult to control the communes. In other words, the quality of drugs at the commune level is not controlled by the district level after drugs stocked from district pharmacy outlets run out.

　In terms of RDF management and use of profits, in principle people's committees should have signed contracts with district health centers on management aspects, but in fact they trusted CHCs to self-manage and report to them. Sometimes, the only requirement was to forward the share of profit to commune finance committees. Some committees were completely self-managing and had established their own drug outlets, hiring people to sell drugs. Both cases are unacceptable.

　Current profit management and price setting can vary considerably from commune to commune, even within one district. The share of profit used for replenishing RDFs in some communes is not quaranteed, and was 14% on average. Thus, if an RDF revolves only one and a half to two times per year, that would be only enough to recover cost escalation, spoilage and drug expirations. This situation is more severe in disadvantaged communes with high levels of personal debt or where more social groups require “support" from people committees. We can say that current drug management is in a state of laissez-faire. Looking at household surveys in two districts and at commune health center reports, it is apparent that there is a discrepancy between the reported household drug expenditure at CHCs and that reported by the CHCs, themselves. Sixty percent of the sick reported purchasing drugs from CHCs while the turnover of drugs was reported to equal 6.3% of household expenditure. This situation was observed not only in the two surveyed districts but elsewhere as well. Even if the project were well managed, there would be no way to improve such fund deficits or low revolving cycles in its current state.

　

Project management the district level

　

　After receiving drugs at the district level, the people's committees established steering committees of which the directors of district health centers were the executive members. After drugs were distributed to communes, districts had nearly no responsibility for management, but only waited for CHC reports which mainly covered revolving cycles and drug fund retention. Council meetings usually attempted to address problems such as fund deficit, spoilage of drugs, expiry of drugs, drugs that should be sold at discount, and so on. In short, discussions covered administrative and management aspects rather than specific details of management. Dstrict health centers knew that too many drugs were not on the EDL and about antibiotic and non-essential drug overutilization at CHCs, but there was no mention of these in reports. A few districts, though, did guide communes on drug procurement in terms of quantity and type.

　It is possible to say that management problems at the commune level ware mainly due to the lack of supervision from the districts and the fact that information was not provided on time. Annual evaluation was undertaken mainly on administrative and financial performance. It is believed that through supportive supervision on focus points, district management can be boosted and the situation at the commune level improved. For this reason, in 1997, the RDF project produced a manual on health supervision at the grass roots level and trained TOTs at the provincial level. Training for the district level is now being prepared at the district level.

　

Roles of province health bureaus and the MOH Steering Committee

　

　Recently, project management has been able to achieve much in the reporting system and in supervision between provincial health bureaus and districts, or between the MOH and provinces. However, it takes time to innovate work habits, not only to better organize the reporting system but also to directly support districts and communes. First and foremost is to focus on retraining health staff on management, maintenance and use of drugs. A good monitoring system is needed to regularly screen mistakes, note the special strengths of health staff in different districts and communes in order to share important experiences, and produce solutions for the whole project. It is necessary to identify regulations for authorized portions of non-essential drugs and sources for drug procurement so that they can be better supervised at the district level by provincial health bureaus.

　Regarding the remaining problems, each of the localities should set their own priorities, but first and foremost efforts should be made over the whole project to undertake these tasks.

　

　The above were the main conclusions. Results from surveys can be found in the following references: