WORLD HEALTH ORGANIZATION
REGIONAL OFFICE FOR THE WESTERN PACIFIC BUREAU R~GIONAL DU PACIFIQUE OCCIDENTAL
•
ORGANISATION MONDIALE DE LA SANTE
REGIONAL COMMITTEE Thirty-eighth session Beijing 8-14 September 1987 Provisional agenda item 15
WPR/RC38/11 14 July 1987 ORIGINAL: ENGLISH
DRUG SUPPLY
~~NAGEMENT
IN THE SOU111 PACIFIC
Report bv the Regional Director
This document describes the outcome of the review carried out in accordance with resolution WPR/RC37 .R3 on drug supply management in the South Pacific, which requested the Regional Director to review national essential drugs programmes, to play an active role in coordinating technical cooperation in drug procurement and supply management, and to explore the possibility of establishing appropriate financial arrangements - to facilitate the procurement of essential drugs in the South Pacific.
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1•
INTRODUCTION
At its thirty-seventh session in 1986, the Regional Committee adopted resolution WPR/RC37.R3 on drug supply management in the South Pacific. The resolution, among other things, requested the Regional Director to review national essential drugs programmes, to play an active role in coordinating technical cooperation among countries in drug procurement and supply management, and to explore the possibility of establishing appropriate financial arrangements to facilitate the procurement of essential drugs in the South Pacific. Since April 1984, WHO has been implementing an intercountry project which aims at strengthening collaboration with governments in the South Pacific in improving national drug supply systems. The project consists mainly of the provision of advisory support to national officials engaged in drug supply management by the project's technical staff, a WHO pharmacist based in Apia, Samoa. Reviews of the drug procurement and supply management situation in the South Pacific have been conducted routinely as part of this project activity. In addition, the project has been exploring ways of strengthening technical cooperation among countries in this area. Regarding the possibility of financial arrangements to facilitate the procurement of essential drugs in the South Pacific, information has been collected on the experiences of UNICEF and other WHO regional offices. This information has been evaluated and the applicability of a few options for the South Pacific has been studied. A \.Jerking Group on Drug Supply Management in the South Pacific was convened in Manila on 7-10 July 1987 to further study these issues and to make recommendations to the Regional Director on future activity priorities. The Working Group was composed of seven members selected from countries in the South Pacific by virtue of their experience in drug supply management, and two experts from Australia and Japan. This paper summarizes the review and studies carried out by the Regional Director, including the outcome of the Working Group on Drug Supply Management in the South Pacific.
2.
CURRENT STATUS OF NATIONAL ESSENTIAL DRUGS PROGRAMME IN THE SOliTH PACIFIC
2.1
Drug policies and list of essential drugs
There are general indications that the concept of essential drugs has been well accepted, at least by the health authorities in
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the South Pacific. All Member States in the South Pacific (Cook Islands, Fiji, Kiribati, Papua New Guinea, Samoa, Solomon Islands, Tonga and Vanuatu) have national lists of selected drugs for their public health care sector. Though their names vary from country to country, these lists can be regarded as national essential drug lists. Papua New Guinea, for example, calls the list "Hedical Stores Catalogue". The first edition of the Nedical Stores Catalogue was issued in 1950, more than a quarter of a century before the start of the essential drugs programme in \illO. In many small countries, there is insufficient local expertise to review and update their drug lists. Furthermore, there is some resistance to the limited list, often from patients who have had drug therapy initiated overseas. In some countries, a sub-list has been developed providing the names of the drugs to be made available at community level. Despite the general acceptance of the essential drugs concept by health planners, the translation of this concept into actual programmes and their implementation varies among countries depending on many factors. For example, in some countries physicians, particularly those recruited from overseas on short-term contracts, may be unwilling to restrict their prescription of drugs to the essential drug list. 2.2 Procurement and supply
In most Member States in the South Pacific, the volume and coverage of drug supply in the private sector are much less significant than in the public sector. Governments purchase their drug requirements from the international market. Drugs are usually supplied through government health facilities free of charge, but a few countries try to recover part of the cost from patients by levying small charges. Although the WHO plan to establish a bulk purchasing scheme did not materialize, the general drug procu..rement situation in the South Pacific has improved as a result of informal cooperation among governments as well as increased competition among commercial suppliers. In the smaller countries information on suitable sources of drugs at reasonable prices is deficient. Funding limitations have not been regarded as a very serious constraint on drug procurement. However, some countries have experienced occasional difficulties due to shortages of funds, often as a result of devaluation of their currencies. Difficulties are also experienced in storage and distribution to the periphery owing to inadequate storage facilities, lack of expertise in stock management and limited means of transportation.
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In some countries where drugs are purchased through the government supply organization, inadequate liaison with the organization often results in procurement delays. There is a similar problem concerning relations with the Treasury. In this connection, supply arrangements in most countries need 't o be further improved to ensure more efficient management in terms of accountability. 2.3 Quality assurance
There is no drug quality control laboratory in the South Pacific. Means of assuring quality are therefore limited to the use of the WHO Certification Scheme on the Quality of Pharmaceutical Products moving in International Commerce, or bilateral arrangements for sample testing by foreign laboratories. Selection of reliable suppliers in practice constitutes a major strategy for assuring the quality of purchased drugs. For this purpose, some countries obtain manufacturers' assay certificates and rely on the reputation of, and past experience with, the suppliers. 2.4 Personnel
The shortage of adequately trained personnel is the most serious obstacle to the provision of pharmaceutical services in the South Pacific. Training within the South Pacific for pharmacy technicians is deficient owing to the lack of well qualified teaching staff, and overseas training for national pharmacists has not been very successful, partly because it has been difficult to attract suitable students. Foreign pharmacists will continue to fill the gap, but their recruitment often presents difficulties. 2.5 Successful models and factors contributing to success
Although it has not been possible to identify an ideal model of a national drug supply system, most countries have relatively successful essential drug procurement systems, in spite of the many constraints observed throughout the South Pacific. The acceptance and use of a restricted list of drugs are central to any essential drugs programme. Papua New Guinea's drug supply system, for example, has been functioning well since the first essential drug list was introduced in 1950. The essential drug list is revised periodically by a pharmaceutical advisory committee consisting of specialist medical officers and pharmacists. The concept of standard treatments, well-integrated into health and training programmes, is also a major factor contributing to the success of their system. Despite the lack of specialist medical officers, . Tonga's essential drug list is regularly updated because the chief pharmacist provides strong guidance and support to the drug committee.
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In the area of drug distribution, the use of imprest ordering systems for ordering from central medical stores, strictly defined stores procedures (which in some cases have beeen incorporated into a manual) and adequate supervision are identified as factors contributing to success. There are no entirely successful models of inventory control operated by the systems reviewed. Vanuatu's computerized inventory control would serve as a successful model, although it does require further development.
3.
SOUTH PACIFIC PHARMACEUTICAL PROJECT
3.1
Background
An attempt was made to establish a drug bulk procurement scheme for the South Pacific starting in 1978. It was, however, difficult to fulfil the requirements for such a scheme, which presupposed an agreement among the participants on (a) drug items and sources, (b) synchronization of procurement and financial cycles, (c) funding arrangements, including currencies. An efficient mechanism of communication and coordination and a strong political commitment were also considered essential. These conditions were not fully met in all cases despite a lot of preparatory activities, and the plan was subsequently transformed into an intercountry project, which started in 1984 to provide governments with advisory services through a \iliO pharmacist based in the South Pacific. 3.2 Activities undertaken
Through his visits, the \VHO pharmacist has been providing technical advice to the staff in charge of drug supply management in Cook Islands, Fiji, Kiribati, Samoa, Solomon Islands, Tonga, Vanuatu and a few other countries or areas. The recommendations presented in his reports cover such areas as national essential drug lists, management, personnel, procurement, storage and distribution. Three issues of an informal newsletter aimed at facilitating the exchange of information among countries in the area have been produced. Information on prices and sources of drugs has been distributed to the South Pacific countries. Hicrocomputers are now being introduced for use in inventory control. Preliminary studies are being made to exchange information on country experiences and to assess their usefulness.
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4.
FINANCIAL ARRANGEMENTS TO FACILITATE TIIE PROCUREMENT OF ESSENTIAL DRUGS IN THE SOUTH PACIFIC
Studies have been made by the Secretariat of existing financial arrangements for the procurement of essential drugs or of certain arrangements previously under consideration. These include UNICEF' s fund for procurement of essential drugs and vaccines, the revolving fund for essential drugs for Central America and Panama, and studies conducted by the WHO Regional Office for Africa. UNICEF's revolving fund aims at providing credit facilities for essential drug procurement by developing countries through the UNICEF Procurement and Assembly Centre (UNIPAC). Thanks to a donation from the Government of the Netherlands, the fund has recently been made available to five countries up to a total amount of US$3 .1 million. The beneficiaries include two countries in the South Pacific, which are entitled to draw up to US$250 000 and US$100 000 respectively. The revolving fund for Central America and Panama became operational last year, thanks to the contributions of the Governments of the Netherlands and Sweden. Administered by the Pan American Health Organization, the fund provides credit facilities and drug procurement services to seven countries in Central America. After careful examination of several procurement and funding options, the V.'HO Regional Office for Africa recommended the use of UNICEF's procurement and funding options. After a review of these experiences, three options have been identified: (1) retaining existing procurement arrangements with continued ~10 technical support; (2) seeking contributions from donors to enable countries to use the UNICEF revolving fund; and (3) seeking a donor whose contributions could be applied to establishing a revolving fund operated by the ~ID Regional Office for the Western Pacific on behalf of interested South Pacific countries. These options have been examined from various angles and in the light of experiences in other regions. While it is noted that existing arrangements are generally satisfactory, it is considered that insufficient information is at present available to determine whether options (2) or (3) would provide additional benefits. Consequently, it is be conducted with regard experience of two South credit·facility, and the for Central America and Organization. considered that more detailed studies should to potential savings, quality assurance, the Pacific countries in the use of the UNICEF operational experience of the revolving fund Panama organized by the Pan American Health
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It is also necessary to study how the various financial arrangements could produce the benefits of cost savings and improved supply management and quality assurance. In this connection, the need for governments to provide the information for the above studies is also emphasized.
5.
REX::OtfotENDATIONS
5.1
General
The following recommendations are not presented in any order of priority as problems and circumstances vary from country to country. ( 1) In order to ensure that national lists of essential drugs are kept up to date, national drug advisory committees should be set up where necessary and meet at regular intervals to revise the lists as necessary. Standard treatment manuals should be developed to promote the rational use of drugs in the prevention and treatment of disease. Drug procurement and supply systems should be reviewed from time to time with a view to streamlining working mechanisms wherever possible and improving efficiency. Proper inventory control is indispensable. There is clearly substantial scope for improvement in central medical schools and health care facilities at all levels, especially in the rural areas. Where applicable, guidelines should be established for general stores procedures, including record-keeping and information retrieval. It is important to ensure adequate storage facilities. Sufficient financial support must be mobilized in order to upgrade these facilities. The establishment of an adequate organizational structure defining the number and category of personnel required and their responsibilities is indispensable. Appropriate training programmes need to be established and implemented to ensure continued availability of required personnel. Greater emphasis should be placed on the quality of procured drugs. The use of the \VHO Certification Scheme and the manufacturer's certificate should be further explored. Arrangements need to be made for selected
(2)
(3)
(4)
(5)
(6)
(7)
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samples to be tested. Consideration should also be given to the establishment of a subregional laboratory for testing drugs. (8) Collaboration needs to be made available to South Pacific countries for the formulation or revision of necessary legislation. Adequate information support should be made available to drug supply services in order to improve their operation. Member States should be supported in their efforts to develop and implement activities in the above areas, including exchanges of information and experience. Regular intercountry meetings should be organized, subject to availability of funds.
(9) (10)
5.2
South Pacific pharmaceutical project
The following collaborative activities are proposed under the South Pacific pharmaceutical project: (1) (2) Provision of continuing advisory support to governments. Provision of support to quality assessment programmes by facilitating selection of samples for analysis and disseminating information. Promotion of procurement. information exchange relating to drug
(3) (4) (5) (6)
Promotion of technical cooperation among countries. Improvement of inventory control systems, including the use of microcomputers and standardization of software. Routine dissemination to other South Pacific countries of country visit reports by the project pharmacist, after clearance by the governments concerned in accordance with WHO procedures.
5.3
Financial arrangements
It is essential to provide adequate funding for the supply of essential drugs to meet the requirements of national health plans or policies and to satisfy the actual needs of health services. With regard to international financial arrangements, a detailed study should be undertaken of the Pan American Health Organization's revolving fund and of the experience of any South Pacific countries which may utilize the UNICEF credit facility, to determine whether alternative financial arrangements could be of benefit to South Pacific countries.