日本財団図書館（電子図書館）　Second International Meeting on Essential Drugus and Community Health Systems

COUNTRY REPORTS

CAMBODIA COUNTRY REPORT

The Essential Drugs for Community Needs Project planned to initiate ten RDFs by the end of 1996. As of September 1996, no RDFs were yet functioning. Fifteen RDFs are expected to be functioning by the close of March 1997. Forty are expected to be functioning by the end of 1997.

I. Overall Goals and Objectives

○Raise health status of population by improving access to essential drugs and promoting their proper use

○Develop models of sustainable drug supply in twenty-five pilot commune and district health facilities in four provinces by end of 1997

○Ensure availability of essential drugs at functioning health facilities nationwide while using currently available resources and promoting rational use through training at different levels

II. Specific Objectives

○Further develop essential drug supply system and improve drug use to ensure capacity to respond to planned RDF drug supply needs

○Further develop capacity of central, provincial and district health teams to plan and manage activities

○Finalize development and official adoption of health financing policy, enabling introduction of official revenue raising which includes RDF pilot testing

○Conduct baseline costing studies in pilot health centers

○Develop operational guidelines and handbooks for RDF operations, covering such topics as revenue raising, use of funds and community co-management

○Set up new pilot health facilities

○Organize community representation in pilot villages

○Carry out community-based study on self-medication and use of private pharmacies for planning public awareness program and drug seller training programs

III. Achievement against Specific Objectives/Activities

○Seven health centers ready to commence RDFs in early 1997 when final RDF national guidelines and proposals are completed. Additional fifteen expected to be ready by March 1997, and a total of forty (target was twenty-five) by end of 1997

Specific Objective/Activity		Achievement
1. Operationalize ten pilot health centers in four provinces
Map location of new health centers and referral hospitals according to new operational district policy guidelines; initiate construction, procure equipment and reassign government staff; adapt drug supply needs		Completed mapping in all twenty-one provinces; constructed, staffed, and equipped twelve new centers in four target provinces; adapted drug supplies. More than thirty additional new health centers operational through NGO initiatives
Prepare health center operational manual and standard training course for staff; conduct training for health center staff in service provision, drug supply and replenishment		Completed manual and trained staff in eight largest health centers in target provinces; developed and initiated training course, but course not yet adopted as national standard
2. Strengthen skills of fifteen district management teams in four provinces
Strengthen skills by specific training in operational district plans, management, and drug supply; supplement training with regular supervision by provincial management team		Established regular, good quality supervision for all districts; held specific training workshops for management teams in all fifteen districts
3. Strengthen capacity of communities for co-management in pilot districts of four target provinces
In districts with input from community support programs and projects, organize sensitization workshops for provincial and district decision makers; hold village elections to form community committees and develop first village action plans		Formed three committees in two districts; regular meetings being held, but not yet focused on health service provision
In pilot districts which do not have input from community support programs or projects, document optimum strategy for community organization		Drafted discussion paper for review
Prepare monitoring plan for selected pilot RDF/cost recovery health centers		Scheduled for completion by end 1996
4. Ensure essential drug supply for all health facilities countrywide; adapt supply and replenishment system to pilot districts
Define new drug supply system for operational districts, including record and report forms and revised standard drug lists by level		Completed June 1996
Initiate new system of drug supply for health centers and referral hospitals in pilot operational districts		Implemented first operational districts July 1996
Implement request system for replenishment from CMS		Completed for five provinces
Supply essential drugs and health supplies for all health facilities countrywide		100% of central, 100% of provincial, 100% of district and of 82% commune facilities supplied by CMS
Decentralize provincial pharmacy planning		Commenced August 1996 after national workshop was held and provincial action plans were prepared
Prepare projections of financing needs for essential drugs and supplies for 1997 through 2001		Completed March 1996
Improve inventory practices at national level by full computerization at CMS		To commence November 1996
Introduce revolving fund at national CMS for recovery of operational costs from the national budget		Implemented March 1996
5. Improve drug use
Write standard prescriber training module		Planned for November 1996
Hold one national and sixteen provincial workshops on rational drug use/standard treatment guidelines		Taking place September 1996 through January 1997
6. Improve monitoring of drug supply and drug use
Conduct trimonthly supervision visits to all provinces by central supervision teams		100% of provinces supervised by Pharmacist/Physician Teams
Conduct trimonthly supervision visits to all districts by provincial supervision teams		46% of districts; 100% of pilot districts supervised
Compile standard program indicators at national and provincial levels on a quarterly basis		Commenced first quarter of 1996
Set national targets for the year 2000 (pharmacy management and drug use indicators)		Targets set July 1996
7. Improve community self-medication practices
Carry out baseline drug survey in Phnom Penh; prepare drug seller training program and public awareness program		Completed survey and now analyzing results; training program to commence December 1996
8. Introduce RDF/community financing in four health centers in four pilot districts
Write and adopt document for National Financing Policy (Financing Charter)		Developed, officially adopted Charter April 1996
Allocate increase of national budget resources to pilot districts		Allocated additional budget for accelerated district development, though funds not available until mid-year
Carry out costing studies at selected health centers to determine resource needs and income and expenditure patterns		Completed studies in three facilities using methodology developed by MOH
Prepare guidelines and manual for implementation of community co-management and co-financing, covering such topics as accounting, fee setting, exemptions and use of funds		Due to commence December 1996
Prepare final proposals for implementation of RDF/cost recovery schemes in four provinces		Due for completion January 1997
Form Ministry of Health Task Force and a working sub-committee on financing (HESC) to oversee project progress in introducing community financing		Task force and sub-committee formed and operational

IV. Problems Encountered

○There has been a lack of national policy in the areas of financing, RDFs and community co-management, which has delayed implementation by three months

○The arrival of adequate financial resources for the rehabilitation of pilot health centers has been delayed; large financial inputs from development banks for the building health centers will not be available until 1997. A number of pilot district centers have been built using alternative funding.

○The national budget available for local operational costs in peripheral health centers has been unreliable. District development budgets have been directly allocated to selected pilot districts as a solution.

○There was a lack of formal structures through which village communities could be organized. To ensure full involvement, the Community Action for Social Development Programme initiated community elections and organizations in two districts where RDFs are to start.

○The weakness of essential drug procurement capacity and the complexity of financial regulations resulted in low disbursement of the national drug budget and some stock shortages. This has been partially resolved by contracting procurement functions to a private company.

V. Future Plans

○Objectives and activities to be undertaken in 1997 to be officially adopted during a planning workshop in November 1996

○Activities to be monitored by the Ministry of Health Financing Task Force and Pharmacy Department and the UNICEF Project Officer

○See table

Table. 1997 Activity Plan of RDF Project in Cambodia

Main Activities		1997
		1	2	3	4
1.Operationalize Community Co-Managed Health Centers
	Provision of essential drugs	○	○	○	○
	RDF operational guidelines completion	○
	Health center staff in-service training program	○		○
	RDF implmentation	○	○	○	○

2.Strengthen Skills of District Management Teams
	District management team in-service training program	○		○

3.Strengthen Community Capacity for Co- Management
	Community sensitization and committee formation	○	○		○
	Committee-health staff training program	○		○

4.Improve Efficiency of Drug Replenishment
	CMS support,logistics	○	○	○	○
	Central，provincial senior pharmacy saff development			○
	Pharmacy-staff in-service training progrram	○	○	○	○
	Sustsinabie supply study	○

5.Improve Drug Use
	Treatment guidselines, handbooks	○		○
	Prescriber in-service training program	○	○	○	○

6.Improve Planning and Monitoring
	Workshop planning	○			○
	Monitoring indicators develoment	○
	Provincial,district supervision	○	○	○	○
	Regional RDF/community financing study visit		○

７．Enhance Public Awareness
	Surveys of community Drug use in pilot districts	○
	Consumer promotinal material	○	○		○
	Drug seller training program	○		○