Workshop on Ensuring Access to Priority Medicines for Mothers and Children, Manila, Philippines, 15 to 17 August 2011 : report

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Meeting Report

Workshop on Ensuring Access to Priority Medicines for Mothers and Children

15-1 7 August 201 I Manila, Philippines

western Pacific ~egion.

Report series number: RS/2011/GE/47(PHL)

English only

WORKSHOP ON ENSURING ACCESS TO PFUORITY MEDICINES FOR MOTHERS AND CHILDREN

Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Manila, Philippines 15 to 17 August 201 1

Not for sale Printed and distributed by: World Health Organization Western Pacific Regional Office Manila, Philippines

World Health Organization weitern Pacific Region

NOTE

The views expressed in this report are those of the participants on the Workshop on Ensuring Access to Priority Medicines for Mothers and Children and do not necessarily reflect the policy of the World Health Organization.

This report has been prepared by the World Health Organization Regional Office for the Western Pacific for governments of Member States in the Region and for those who participated in the Workshop on Ensuring Access to Priority Medicines for Mothers and Children, 15-17 August 201 1, Manila, Philippines.

CONTENTS SUMMARY.................................................. 1.

2.

.. . ...................... ............. . .1 INTRODUCTION ......................................... ...,..,.*... ..,.. . ... . ,... . .. . . . .4 ...........................4 1.1 Background information ........................................ . . ............. . . . . . .. .. ....................4 1.2 Objectives ....................., 1.3 Participants ...................................................................... , ....................4 1.4 Organization and content of the workshop .................................... ..,............5 1.5 Opening session ................................................................... ,. . . . .. . . .. 5 PROCEEDINGS........... ..................... ....................... ........ * 5 ,. . .

2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 3.

Introduction to the consultation .............................................,....,..............,..,. 5 Maternal and child health in the Western Pacific Region (Dr Marianna Trias)6 Improving service delivery for maternal and child health (Ms Laura Hawken) 6 Intervention packages for maternal and child health (Dr Ardi Kaptiningsih . ............. .................................. 7 and Dr Emmalita Maiialac) ........,...,.,.,... , Priority medicines for mothers and children ( B Krisantha Weerasuriya)..... 8 Financing options for maternal and child health services (Dr Chris James) .... 8 Country presentations - delivery of MCH services and challenges for access, availability and quality of priority medicines ......... .... . .............. .10 Improving access, availability and rational use of priority medicines .......................... .. +..........16 for mothers and children...............,.... Barriers to and options for improving access to priority medicines 22 at national, sub national, facilities and community levels ...............................

CONCLUSIONS AND RECOMMENDATIONS ....................... . .. ..2 5 3.1 Conclusions ..............................,........................................,................,....... 25 3.2 Recommendations.........................,..... ... .. . ...... . . . . ...................26

. . ., .

ANNEXES: LIST OF PARTICIPANTS, OBSERVERS AND SECRETARIAT

SUMMARY OF PRIORITY FOLLOW UP ACTIONS IDENTIFIED BY THE WORKSHOP PARTICIPANTS Keywords: Drugs, Essential - supply and distribution / Pharmaceutical preparations - supply and distribution / Maternal health services 1 Child health services

SUMMARY

The Workshop on Ensuring Access to Priority Medicines for Mothers and Children was held in Manila, Philippines, from 15 to 17 August 20 11. The objectives of the workshop were: to review the current status of service delivery for maternal and child health as (1) related to access to priority medicines for mothers and children; to analyse the existing fmancing and supply system for essential medicines and (2) to identify bottlenecks for access to priority medicines for mothers and children; and to defme country-specific feasible options and next steps to improve access to (3) and use of priority medicines for mothers and children at national and subnationaVdistrictlevels. The 27 participants i n the workshop came from Cambodia, China, Lao People's Democratic Republic, Mongolia, Papua New Guinea, Philippines and Viet Nam. There were also representatives kern partner organization UNFPA, observers and a WHO secretariat from the Western Pacific Regional Office, WHO country off~ces in Cambodia, China, Laos, South Pacific, Viet Nam, Philippines, Papua New Guinea, and WHO Headquarters (Annex 1). The programme consisted of plenary presentations and discussions together with group work to define country-feasible optinns and next steps to improve access to and use of priority medicines for mothers and c h ldren at national and subnational/districtlevels. Participants of the Workshap on Ensuring Access to Priority Medicines for Mothers and Children dscussed the services delivery of maternal and child health inQfferent counhes, especially on the access and availability of the medicines in different levels of health facilities. The bottlenecks for access, availability, quality as well as proper usage by providers and consumers were reviewed and practical options for improvements were proposed.

Partiwts also discussedthe progress mid challen~w of the Millennium Development Goals 4 (Pedr~chg ddilmorklity) a d and [Jmpmvhg matend health). There is indeed notable pjgiw in some o d w despite ~ M S Wmgw S in other countries. Follow up actions at different levels of services delivery werepmpsed tb improve access and availability of the .. priority medicines, from selections, pricing, and &tsdmng the pmamment, i n general. The hiporhrm of supply and management as part of the essential me&~fnes monitoring and supervision and the need for effective back up system for supply and for proper usage is underlined. There is a need for a mechanism for exchange of information, sharing of experiences and collaboration to cross fertilize the success to other countries in need.

Following were the recommendations:

WHO, UNFPA and partners WHO and UNFPA should closely collaborate to follow up the joint assessment (1) and to provide technical support in improving the logistics supply distribution and monitoring of priority medicines for mothers and children. WHO, UNFPA and partners should facilitate effective intercountry exchange of (2) experiences, cross fertilization, and collaboration in relation to access to priority medicines and the achievement of health outcome to reduce mortality. WHO, UNFPA and partners should collaborate to devise a mechanism for (3) locating available stocks and rapid delivery of resupply of the priority medicines for emergency care such as oxytocin. WHO should facilitate, advocate and provide technical support for improving (4) the availability and production of quality paediatric formulation. (5)

WHO should facilitate the documentation and publication of success in ensuring access to the priority medicines and the progress towards the achievement of the Millennium Development Goals.

Member States: a translation of Priority Medicines for Mothers and Children 201 1 should be (1) made available in the local language; a (national) workplan for improving access and availability to priority medicines (2) through the existing delivery system should be devised, if possible as part of the bigger national strategy on maternal and child health. Proper advocacies and training of providers should be part of the plan. The plan should also include ways of ensuring access in remote places. The implementation of the action plan can be started in a particular area, e.g. provinces or districts, and scale up with a step wise approach; adequate financing of essential medicines for mothers and children should be (3) ensured by inserting the priority medicines, as published in WHO'S list as "Priority medicines for mothers and children 201 1",on the list of reimbursable items of national health insurance schemes. Costing of standard treatment courses for health problems facing mothers and children, should be based on the Priority medicines" list and on WHO'S standardized costing methodologies; relevant follow up actions should be initiated within six months to one year at (4) the national and subnational levels to address the bottle neck for access and availability of priority medicines for mothers and children; (5)

the implementation for monitoring and back up support for the availability, supply management and use of priority medicines should be developed and initiated; and a pilot area for implementation should be identified. A baseline on availability and affordability of the medicines can serve as an evidence for advocacy and a basis for

measuring progress. Track availability of a small set of selected medicines from the list "Priority Medicines for Mothers and Children 20 11"

(6) effective mechanism for intercountry cross fertilization and collaboration in ensuring access to priority medicines and achievement of health outcome should be pursued to reduce child and maternal mortality. Document success stories towards the achievement of millennium Development Goals and share with other countries.

1. INTRODUCTION

The Workshop on Ensuring Access to Priority Medicines for Mothers and Children was held in Manila, Philippines, fiom 15 to 17 August 20 11. 1.1 Background information

Universal access to good quality essential medicines for childhood illnesses and maternal health is one of the critical elements to improve service delivery for achieving Millennium Development Goals 4 (to reduce child mortality) and 5 (to improve maternal health). Yet lack of access to essential medicines for maternal and child health remains a major challenge in many developing countries and areas in the Western Pacific Region. This will inevitably constrain efforts to reduce mortality and improve the health of children and mothers. Recently, the United Nations Population Fund, the United Nations Children's Fund and WHO launched the global list of Priority Medicines for Mothers and Children 201 1. This list aims to help countries and partners select and make available those medicines that will have the biggest impact on reducing maternal, newborn and child morbidity and mortality. Improving access to these medieines is a priority for the Western Pacific Region. This workshop, involving responsible officers fiom high burden countries, will identify bottlenecks in the medicine financing and supply system in the overall context of health service delivery for women and children at the national and subnational levels, and will identify feasible options for improvement. 1.2 Obiectives The objectives of the workshop were: to review the current status of service delivery for maternal and child health as (1) related to access to priority medicines for mothers and children; to analyze the existing financing and supply system for essential medicines and (2) to identify bottlenecks for access to priority medicines for mothers and children; and to define country-specific feasible options and next steps to improve access to (3) and use of priority medicines for mothers and children at national and subnationalldistrict levels. 1.3 Participants

The 27 participants in the workshop came fiom Cambodia, China, Lao People's Democratic Republic, Mongolia, Papua New Guinea, Philippines and Viet Nam. There were also representatives fiom partner organization UNFPA, observers and a WHO secretariat from the Western Pacific Regional Office, WHO country office in Cambodia, China, Laos, South Pacific, Viet Nam, Philippines, Papua New Guinea, and WHO Headquarters (Annex 1).

1.4

Organization and content of the workshop

The workshop elected Dr Lahui Geita from Papua New Guinea as Chairperson, Dr Lamphone Syhakhang from Lao People's Democratic Republic as Vice-chairperson and Ms Angelina del Mundo from the Philippines as Rapporteur. The workshop timetable is in Annex 2. The participants were provided with background and discussion papers related to the subjects, and a complete set of all country presentations, in hardcopy as well as on USB, with all the workshop presentations in Powerpoint@ format. 1.5 Opening session

Dr Hans Troedsson, Director, Programme Management, WHO Western Pacific Region, delivered the opening address on behalf of Dr Shin Young-soo, WHO Regional Director for the Western Pacific Region. Dr Troedsson referred to Millennium Development Goal (MDG) 4 that calls for a reduction in child mortality and MDG 5 that seeks a reduction in maternal mortality. He emphasized that there are three key factors for achieving MDGs 4 and 5. These are: (1) appropriate health care seeking behaviour, (2) availability of qualified and skilled health workers and birth attendants, and (3) access to essential medcines. A l l three are important, though this workshop will focus an the third element. He underscored that priority medicines for mothers and children should always be available at all levels of health care facilities. Henceforth, the bottlenecks relative to access to a core set of critical and life-saving medicines for mothers and children ought to be identified and addressed. He firthemore warned that it can be tempting to design "perfect" solutions that are too complex to be implemented; instead, the focus should be on what is feasible, practical and doable. Finally, he noted that attending the workshop is not an objective in its own right, and that the success of this workshop will be measured by how much increase in access will be achieved. ]

2. PROCEEDINGS

2.1

Introduction to the consultation

Dr Santoso Budiono explained the objectives of the consultation.The methodology would be in the form of plenary presentations and discussions together with group work to identify bottlenecks and challenges and options for improving access to priority medicines for mothers and children. The output would include recommendations for follow up action, both at national levels and sub-national levels, to improve access to priority medicines for mothers and children.

2.2

Maternal and child health in the Western Pacific Region (Dr Marianna Trias)

Significant progress has been made towards MDG 4 (reduce child mortality) and MDG 5 (improve maternal health) in the Western Pacific Region. The overall under-five mortality rate has declined by 50% and maternal mortality ratio by almost 60% between 1990 and 2008, though geographical and geographical inequities exist. In 2008,527 000 children under five still died - often due to neonatal conditions (prematurity, asphyxia and severe infections) and major communicable diseases (postneonatal pneumonia, diarrhoea and malaria). More than 50% of the 13 000 maternal deaths were due to haemorrhage and hypertension. Although cost-effective maternal and child health interventions exist along with technical guidelines for their implementation, huge coverage gaps persist along the continuum of care. For example, in four countries with the highest under-five mortality, only 40% to 65% of children under five with suspected pneumonia received appropriate antibiotics, whle oral rehydration therapy (ORT) coverage for diarrhoea varied from as low as 15% to around 60%. Furthermore, quality of care remained an issue particularly in antibiotic prescriptions. In a responsive health system, care is provided along the continuum of care across the life-course and all levels of care, and proven evidence-based interventions are delivered as packages in an integrated manner, and supported by appropriate policies and country-led health plans. Improving equity and reaching universal access to maternal and child health services are important goals for the Region, which requires higher investments in health and reducing out-of-pocket payments and other barriers to maternal and child health services. Skilled health workers with the necessary infrastructure, drugs, equipment and regulations play a major role. Collaborative approach to maternal and child health (MCH) and health systems strengthening including improving access to priority medicines is necessary as better health requires coherent policies and efficient planning and organization of fmancial and human resources.

2.3

Improving. service delivery for maternal and child health (Ms Laura Hawken)

In order to improve service delivery, it is important to take a whole system approach, for all components or building blocks of the health system (leadership and governance; health care financing; health workforce; medical products and technologies; information and research; and service delivery) are interconnected. The weakest part of the system will determine its output; thus, all parts should be balanced and coordinated. Similarly, values of health as a human right, participation, quality and equity are all important in relation to health system design and objectives of accessibility, affordability, acceptability and accountability. A service delivery model outlines: a

how the community enters and interacts with the health system; what types of facilities and services are available at each level; when facilities or services are open, e.g. 24 hours per day, 7 days-perweek;

the number and mix of staff at each level, what they can and should do, and how they work together; the referral system and the controls on access to higher level, specialist and expensive services, including the incentives to providers and patients to comply; the linkages between levels of service, e.g. communication, transport, supervision, specialist visiting, financial linkages; and the role of non-state providers and how they interact with state services to support reaching national and local health goals. These aspects were discussed in relation to the service packages for MCH, service management and scaling up services. Strategies and plans for scaling up services may include the use of feasible, integrated packages that have potential for being delivered universally. 2.4

Intervention packages for maternal and child health (DrArdi Kaptiningsih and Dr Emmalita Mafialac)

Dr Ardi Kaptiningsih, Regional Adviser for Making Pregnancy Safer~Women and Reproductive Health, and Dr Emmalita Maiialac, Medical Officer for Child and Adolescent Health presented the Packages of interventionsfor family planning, safe abortion care, maternal, newborn and child health. The intervention packages for MCH across the continuum of care were described. The adequacy, accessibility and good quality of the interventions are crucial. The interventions need to be adapted according to country needs and delivered in an enabling environment, and in consideration of the prevailing socioeconomic milieu and relevant socio-economic interventions. The guiding principles in delivering the interventions include universal access with a special attention to the needs of underserved and vulnerable groups; address inequity, gender and cultural sensitivity and human rights; integration of health services and women and community participation. The presentation moved on to the specific packages of interventions for family planning, safe abortiodpost-abortion care; pregnancy, childbirth and postpartum care; newborn, infant and child care. For each intervention package, elaborations were made on the components of services, benefits and indicators used. Further, components of services at various levels, namely at home and community, primary care and referral facility, were explained. Medicines that are lifesaving at crucial life stages are covered in a subsequent presentation on priority medicines for mothers and children.

2.5

Priority medicines for mothers and children (Dr Krisantha Weerasuriya)

The Priority Medicines List for mothers and children was developed from the WHO Model List of Essential Medicines - it is a subset that will have biggest impact on reducing maternal, newborn and child morbidity and mortality. It addresses the Millennium Development Goal 4 (Reduce Child Mortality) and 5 (Improve Maternal Health). The number of medicines relevant to each of the countries varies (depending on the disease pattern) but is around 25. The challenge is to have these medicines available 24 hours per day, seven days per week, 52 weeks per year. The medicines are ones that health care workers are familiar with: oxytocin, magnesium sulphate, ampicillin injections, amoxicillin dispersible tablets, Oral Rehydration Salts and Zinc tablets are some examples from the list. The reasons for these medicines not being available runs right throughout the chain - the medicine may not be in the National Essential Medicines List, may not be registered in the country, may not have suppliers carrying the product, may not have been ordered although being available in the Central Medical Store - and when available in the health care facility, may not be used. The questions that should be asked are: 1) Are the priority medicines are in national treatment guidelines and essential medicines lists? 2) Is there is asupplier of a quality product? 3) Are the priority medicines licensed? 4) Are the priority medicines being supplied? 5) Do the health professionals know how to use the priority medicines? and 6) Is there consumer demand for medicines such as ORS and zinc tablets? The answers to these questions will provide information to tackle the issue of the availability priority medicines for mothers and children. 2.6 Financin~ options for maternal and child health services (Dr Chris James)

Millions of people around the world still cannot use needed health services because they are unavailable or are too expensive. Millions more suffer financial ruin each year because they must pay for the health services they use at the time they receive them. There are three fundamental health financing challenges countries must address if they are to move closer to universal coverage whereby all people can use services without the risk of financial ruin. These are: (1) Raising sufficient funds for health to ensure the provision of priority maternal and child health (MCH) medicines and other commodities. The main options are to increase the priority given to health in government budget allocations (for countries where the current priority to health is relatively low); to raise revenues more efficiently (for example by minimizing tax evasion); to find new or more diversified sources of revenue, such as 'sin' taxes on tobacco, alcohol and unhealthy foodstuffs, or specific levies on large profitable companies and tourists; and more, and more predictable, external funds for health (for lowincome countries).

(23 Minimizing the reliance on direct out-of-pocket payments implies that priority MCH commodities are provided for free or low cost at the point of use. This requires increased prepayment and risk pooling through taxes and/or social health insurance. Reducing or eliminating charges in government health facilities is another policy option, and specific attention should be given to the poor and vulnerable. At the same time it is important to note that universal coverage is difficult unless contributions are compulsory.

best use of availabIe rtwurms requires that public budgets and/or health (3) M d d n ~ insurance subsidize the m o s t cost-effective MCH commodities. Essential packages of care, web as the Partmrship for Maternal, Newborn & &iId Health essential pacIrage, can help &Be this priorithationpmem. Efikiency m afsa possible through other supplwide policies. Tbh involves increasing the use of generic medicines, reducing prices th-mgh better procurement puIicies, improving supply chain management, and reducing jnapproprkh use of cmmudities by modifving the incentives f a d by Wt.providets. Discussion During the ensuing discussions, the following issues were raised:

In the past, due to consistent advocacy, the utilization of ORS has been a success (nearly 90% utilization rate). However, with the introduction of zinc, which needs to be utilized together with ORS, utilization of ORS has dropped to between 50%-60%. So there is a need to adapt the advocacy: where zinc is available, it should be used together with the ORS. However, where zinc is not available, the use of ORS alone should continue to be encouraged. The existence of perverse incentives for prescribers, such as doctors in hospitals (in some countries) who receive payments for prescribing certain medicines, can increase costs dramatically.

?hm of the "Oat of Pocket Expenses" by patients and government expenditure on drugs is high. A high propdon of tbese drugs are used irrationally, often leading to additional cost of managing dmg m ~ ~ . Cost-containment is equally important in ensuring cost-effective use of resources, and should be considered as critical for sustainable financing or health insurance coverage. The lack of controls on type and the prices of medicines that are reimbursed may lead to cost escalation and high expenditures for the health insurance. It is therefore important to d y z e the e x p e n d i k on and the tamumptio~ of mediohes at the facility level. High promprices i n d by hospitals axe secondzuy to inefficient procurement system. hefeicimt pmcmaeht systems a n d m M o m we l of mdcines increase costs to b~s~,Mdh&fh servkes. fncreases i n~ dwill limit the i health insurance ~ capacity to inmeme the b r d t h ofiEs coverage and the extent of the benefits that it can provide. Furthermore, the importance of increasing the focus on pre-service training was raised. The availabiliiy of competent human resources is a pre-condition to enable the MOH to staff the health system wifh p v i h tbat are q b l e of responding, timely and efficiently, to the nl.Rbs af&e ptimb and ofputting into practice national health policies and strategies. It shouldbe recognized that v d d systems fomshg on9 particular disease contribute to the fragmentation of the health care system. Finally, the need to involve men in MCH programs was stressed; it is of paramount importance for the success of any MCH interventions.

2.7

Countw mesenlatiom - deliCambodia

of MCXI services and challmm for access,

availability and quality of priority medicines

In Cambodia, the leading causes for maternal mortality are haemorrhage during or after delivery, pre-eclampsia, infection, unsafe abortion and obstructive labour. The main causes of under five mortality are respiratory infections, diarrhoea, premature birth, neonatal infections and asphyxia. Maternal and child health services are delivered at community level, where traditional birth attendants are the main provider of services (though MoH is discouraging delivery sewices at this level), at the primary care level (Health Centers), where midwives and nurses are the main service providers, and at referral level. The latter refers to district hospitals, provincial hospitals or national hospital. Physicians, midwives and nurses are the main providers of services at this level. Some of the priority medicines for mothers and children have not been included in the Essential Medicines List (EML). Compliance with Standard Treatment Guidelines (STGs) is ensured through training, supervision and by supplying only those medicines in the EML and STGs. MCH medicines are procured, along with other essential medicines, through centralized procurement. From the central store, they are distributed to district stores, from where facilities collect their orders. They are provided fiee of charge to patients. Generally, priority medicines for MCH are available in Cambodia. Supply chain challenges include late delivery of orders, inadequate quantity supplied and stock management issues. .Comments and discussion: It was noted that Cambodia has made good progress regarding the availability of zinc tablets. This was attributed to two main factors: the training on health professionals on rational use and proper medicine management. The zinc tablets come from donation and it is recommended that donor should not'only donate medicines but also provide supplementary fund for training the prescribers. The importance of monitoring medicine supply and use was mentioned; Cambodia has quite an extensive monitoring system that works well (see also under 4.4). 2.7.2 China

The leading causes for maternal death in China are obstetric haemorrhage, pregnancyinduced hypertension syndrome, heart disease, amnionic fluid embolism, pneumonia. The leading causes for under five death in China are: preterm or low birth weight, pneumonia, birth asphyxia, congenital heart disease, accidental asphyxia. There are three levels of service delivery for maternal and child health: community level (village), primary care level (township) and referral level (countyldistrict and above).

The main medicines used for maternal and child health in the country are amoxicillin\Cefuroximekithromycin\anti-TBobroxol. There is no formal list of maternal and child medicines. Most of maternal and child medicines are registered in China and included in the 2009 National Essential Medicine List (NEML) for primary level. (1)

Standard treatment guidelines and rational use of medicines

Nearly all standard treatment guidelines (STGs) for maternal/child health are available. For ensuring the compliance with STGs, the training and supervision are applied and in addition, the Standard prescription for children is being developed. (2) Medicines supply system

In China, a decentralized procurement mechanism is applied for the essential medicines with MCH medicine included. Each province is responsible for the procurement of the essential medicine for the health facilities in its own region. (3)

Availability of medicines The maternavchild health medicines generally available at the primary care level (public sector) and first referral level (public sector) The MCH medicine that is frequently not available is Erythromycin

(4)

Funding for medicines The Health Insurance, Public expenditure and out-of-pocket payment consist of funding source for MCH medicines Some medicines are free-of-charge, such as anti-TBMnti-AIDS\Vaccine

(5)

Achievements and challenges:

The key achievements regarding ensuring access to matemallchild health medicines: the issuance of NEML including the necessary medicines for matemallchild health. The fast track registration mechanism is in place for children's medicines. Comments and discussion: Reference was made to the ongoing hospital reform in China, which is very successful; hospitals see many outpatients and sell medicines. However, the question was raised whether that creates challenges for following STGs and promoting rational use of medicines. To address this, several aspects will need to be considered, such as regulating the behaviour of prescribers to ensure rational prescription and educating consumers to not demand medicines that do not have clear value. It was also suggested that perhaps more outpatients should be directed to the primary facilities where medicines are free and services very good.

Lao People's Democratic Republic According to Census in 2005, the Maternal Mortality Rate and the Under Five Mortality Rate of Laos are 405 per 100 000 live births and 98 per 1000 live births respectively. Data on leading causes of death are not available. Maternal and child health service are provided at community, primary care and referral level. Maternal health service includes non-pregnancy RH care, pregnancy care, intrapartum care and post natal care, while child health services includes new born and under five cares. Most medicines used for mothers and children are in the National Essential Medicines List and registered. The medicine list and guideline on treatment and care specific for mothers and children exist. Medicines for mothers and children are quantified based on past consumption and the medicines are procured and supplied through the provincial health authority using tendering or price negotiations. Most medicines for mothers and chldren are available at primary health care, and referral level. However, there are some medicines which are not frequently available such as magnesium sulphate, oxytocin, benzathyl penicillin and zinc. Medicines are funded through health care facility revolving find, initiatively started by government fund or donors. The main achievements include the availability of a national essential medicine list, a guideline on treatment and care for mothers and children and the availability of a training guideline on treatment and care. Besides the achievements, there are some main challenges, such as, uncontrolled prices of medicines, no specific national essential medicine list for MCH services, irrational uses of medicines and insufficient drug supply at different level of facilities. Comments and discussion: The importance of monitoring procurement prices, and sharing this information, was mentioned. Prices are monitored at province and hospital level, but only in certain pilot provinces. Efforts are underway to harmonize procurement systems. Suggestions were made about integrating supply systems and pooling procurement, to achieve economies of scale. However, if the budget is insufficient to purchase a large volume of medicines, then there is no point. Moreover, nationwide pooled or centralized procurement requires sufficient storage space and staff that is capable of handling this. Thus, instead, Laos is pooling procurement at the provincial level, not at the national level. 2.7.4 Mongolia

Health service delivery is organized under three levels based on the administrative structure of the country: national, aimag and soum levels. Primary health care services are provided by health care workers and feldshers in soum and bagh and by general practitioners in urban family clinics. The Government of Mongolia has placed a high priority on achieving MDGs 4 and 5. There are a number of government policies, legislation and programmes on maternal and child health such as the National Strategy for Reducing the Maternal Mortality Rate (MMR) 2005-20 10 and the National Strategy for Maternal and Newborn's health 20 11-2015.

The MDG target for the under-five year mortality rate (2 1.0 by 2015) is on track. Vaccination of measles for child less than one year is 99%. The National Programme for Children 2002-2010 was ratified in 2002 by Government Resolution No. 245. The priorities are: improvement of fetal and newborn care; nationwide implementation of IMCI; promotion of breastfeeding practice; immunization for vulnerable and unregistered children; increase capacity building of human resources for child health and eexpand adolescent friendly health service. A number of standards and guidelines are in place to guide and facilitate quality child care services. The MMR has declined steadily from 200 (1990) to 49.9 (2008). A reverse trend was observed for MMR in 2009 (81.9) and then it declined again in 2010 (45.5). The sustainability is a challenge due to a number of factors such as: lack of modem equipment for early detection and treatment of the cornpIications of pregnancy, childbirth and postpartum period, congenital abnormalities; and lack of health professionals in rural areas. Most priority medicines for mothers and children are included in the national essential medicines list and they are registered. A joint assessment of availability, accessibility of life-saving maternal medicines was carried out in 2009 by UNFPA, WHO and the government. Overstocks or stockouts of some medicines (like ergometrine, oxytocin, metronidazole, ampicillin) was observed in some sites. Overall the storage conditions at both public and private facilities and pharmacies are good. However, inappropriate condition of oxytocin was observed in some places (issue is the labelling construction which is in English). Medicines procurement is decentralized. Most oxytocin and all ergometrine is provided by UNFPA. Estimating or forecasting requirements for RH essential medicines needs to be improved at all levels. Future plans include: to improve availability of essential equipment and medicines according to structural and operational standards of each health facility, to allocate appropriate funds for MCH services, and to strengthen human resource capacity for MCH service delivery. Comments and discussion: Inappropriate storage, for instance of oxytocin, is caused by lack of clear instructions and labels in a foreign language which is understood. Now, it is required that all medicines instructions should be in Mongolian or Russian languages. Other countries can learn from Mongolia's experience in reducing MMR. The main factors that contributed to the decline of maternal mortality rate ( M M R ) ,hfant mortality rate (IMR) and child mortality rate (CMR) were strong government commitment, an enabling legal and policy environment, an increased budget allocation and dedicated human resources. The translation of WHO guidelines and training materials, the referral strategy (developed in 2000) and the fact that an essential medicine policy was in place have also contributed. But all this was underpinned by government commitment. It is challenging to delive~ care to a hpersed rural population. In Mongolia, two weeks before delivery, pregnant women are expected go to a maternal care home and wait there; once delivery starts, they are taken to a nearby hospital. In Mongolia, there has not been much resistance to these "delivery houses", since people know the risks of home delivery.

Facilitating factors are the relatively high level of education of the population, and the fact that maternal and child services are provided for free. 2.7.5 Papua New Guinea

Papua New Guinea has the highest MMR amongst the countries participating in the workshop: 7331100 000 (DHS 2006). The main causes of mortality are postpartum haemorrhage, sepsis, malaria and anaemia. Papua New Guinea can learn from Mongolia, which has achieved a significant reduction in maternal mortality. For example, with support from UNICEF, waiting houses for pregnant women are being tried out on a small scale, to gain experience and test acceptability. MCH medicines are not registered. The regulatory system is weak and drug registration is very slow. However, the national medicines regulatory authority can prioritize and fast track the registration of MCH medicines in the future. Papua New Guinea has a challenging geography which, together with a weak supply chain, contributes to low availability of critical MCH medicines. Oxytocics are distributed and stored without temperature-monitoring, which may compromise efficacy. There is an obstacle in sharing fridges with the expanded programme on immunization (EPI) as there is great fear of health workers confusing different drugs. However, MCH and EPI programme managers will discuss further about sharing the limited resources. Also, at the regional level, MCH and EPI programmes are convening to seek collaboration. Paediatric formulations of TB drugs run out quickly and it is difficult to use adult doses for children. More attention should be given to TB drugs for children. Comments and discussion:

In addition to the issue of storage of oxytocin in "EPI fridges", there are other products where cooperation between the EPI and MCH programmes would be desirable, such as hepatitis vaccine and maternallneonatal tetanus] Like Mongolia, Papua New Guinea has a dispersed rural population and a challenging geography; collaboration between the two countries in for example the area of drug supply could be explored. 2.7.6 Philippines

With the rate the country is going (maternal mortality rate changed from 209 per 100 000 live births in 1990 to 162 in 2006, NDHS), it is unlikely that the MDG target for MMR in the Philippines (52 by 2015) will be reached. However programs to rapidly reduce MMR, such as Maternal, New Born, Child Health and Nutrition Strategy (MNCHN), are already underway. Leading causes of maternal deaths include post-partum hemorrhage, pregnancy-related hypertension, infection, and dystocia. '

Under-five mortality rate is 34 per 1000 live births (NDHS, 2008). This is attributed to the following lead causes: neonatal death, pneumonia, NCD, diarrhea, injury, meningitis, and other infections. There is little improvement in child mortality despite changes implemented. Specifically neonatal mortality is caused by prematurity, pneumonia/sepsis, asphyxia, and

congenital abnormality (CHERG, 2008). NMR and IMR are 17 and 9.3 per 1000 live births respectively (NDHS, 2008). MCH services are provided at the: (1) community level (trained volunteer health workers); (2) primary level (rural health unit staff); and (3) referral facility (district and provincial hospitals, specialty hospitals or medical centers). Standard treatment protocols are followed with special emphasis on rational drug use (such as IMCI, WHO). Medical treatment is governed by the List of Essential Women's Health and Safe Motherhood and Child Suryival Drugs and Supplies complied by both DOH and PhilHealth, and the PHL National Drug Formulary (PNDF). All drugs included at the PNDF are registered with DOH Food and Drug Adminrstration. W h l e the majority of medicines is obtained out-of-pocket, the government procures a part of the total essential drug requirement based on budget and priority (20% in 2010 and 75% in 201 1 for the MCH programme). All local government health facilities are required to have appropriate essential medicines at aU levels.

The supports MDG 4 and 5 through policies such as the Formula One for health and the Aquino Health Agenda, although political issues, financial matters, and availability of skilled professionals still threatens its sustainability. The country plans to improve access to healthcare through implementing new legislations, reforms in logistics management, optimization and creation of treatment guidelines, and strengthening the government programs. Comments and discussion: Misoprostol is not on the essential medicines list in the Philippines since abortion is illegal and oxytocin is considered safer for non-abortion purposes. Viet Narn A steady decline in MMR is observed in Viet Nam, from 130 per 100 000 live births (1992) to 69 (2009). Although disparities between mountainous and plane regions are large, with an obsemed MMR of 41 1 in Cao Bang compared to 45 in Binh Duong (2000-2001 data). Leading causes of maternal mortaiity are haemorrhage, ecIampsia, infection, abortion, ectopic, and uterus rupture. There is substantial reduction of child mortality, with a significant disparity between rural and urban deaths. Neonatd rnortaIity accounts for 57% of under-five year old deaths. Other leading causes include: pneumonia, darrhea, accidents, measles, and HIVIAIDS. MCH services are provided at commune level and district/provinciallevel through home-based maternal and child care and district/provincial hospitals, respectively. Medicines used for MCH are included in the current 5th list of essential drugs of Vid N m (MOH, 2005) and a standard treatment guideline for diarrhea in children is in existence (MOH, 2009). Additionally, there are plans to update both the EML and treatment guidehes to strengthen the country's MCH policy. Local pharmaceutical manufacturers supply basic medicines in Viet Nam (49% of demand), while specialized drugs are imported. The drug distribution network is developed

and covers almost a l l areas of the country including remote areas. Medicine expenditure is mainly out-of-pocket with only 18% of total health expenditure funded by the government (National Health Account, 2008). Challenges in infrastructure and resources have been identified. And in addition to legislation and policy development, the country also plans to improve the quality of MCH care through capacity and skill improvement for health care providers. Comments and discussion: It was suggested that the therapy in provincial level should be monitored to ensure rational prescription and use. 2.8 Improving access. avaiIability and rational use of priority medcines for mothers and children

Framework for improving access to medicines (Ms Karin Timmermans) From a public health perspective, the overarching objective in the area of pharmaceuticals is to ensure equitable access to good quality essential medicines and to ensure their rational use by providers and consumers, in order to improve health outcomes. While the main focus of this presentation is access, ensuring quality and rational use are equally important. Moreover, there are linkages between the strategies to ensure access, quality and rational use. Access to medicines depends on: Rational selection. Selection of a limited number of essential medicines is the basis for optimizing supply, financing and use. Selection should be evidencebased and take cost-effectiveness into account. The EML and STGs should be harmonized, and essential medicines should be registered. +

Adequate and sustainableJinancing. Available b d s should be spent on costeffective products. Public financing for MCH medicines may have to be increased. Affordable prices can be achieved by using measures such as reducing taxes, tariffs and margins. Regressive mark-ups or fxed dispensing fees can reduce prices as well as perverse incentives. The use of INN (international nonproprietary names) or generic names'lluring procurement enables competition, which can drive prices down. Alternatively, prices could be negotiated based on reference prices etc. It may also be important to make price information public and comparable.

r

Reliable supply systems. There are two significant challenges related to medicines supply. Firstly, in many countries, multiple 'vertical' supply systems for medicines co-exist. Yet there is no dedicated supply system for MCH medicines. The unintended result is insufficient attention for and supply of MCH medicines. Secondly, several countries have decentralized medicines supply systems, which results in a loss of economies of scale. Nevertheless,

other factors such as access to market intelligence and up-to date price information, and a reliable payment record also are important factors in obtaining good prices; thus, even in a decentralized system it is possible to obtain reasonable prices. Attention was drawn to the importance of proper quantification, procurement procedures that give due attention to product quality, storage, inventory control and distribution. Systems for emergency supply and redistribution of excess stock may need to be put in place. In addition, there is a need for a comprehensive generic policy, policies to manage conflicts of interest as well as regular monitoring and evaluation to identify and address problems in a timely manner.

Comments and discussion: Procurement and supply management systems should be tailored to country's situation and needs; there is no one-size-fits-all solution. In,terms of procurement, not only the quality and price should be considered, but also the performance of suppliers; for example if suppliers fail to deliver on time, cost could be enormous. It can be challenging to get prescribers to prescribe rationally. Some governments have put in place systems of financial rewards (in the United Kingdom, savings will flow back to the prescriber's practice) or punishments (Germany: if physicians surpass their allocated prescription budget, they will be asked to reimburse the surplus) to increase compliance with STGs. Efficient procurement, supply and management (Dr Socorro Escalante) Procurement, supply and management of essential medicines directly affect health outcomes because they impact on the availability and affordability of medicines that combat diseases and save lives. The goal of efficient procurement therefore is to ensure that: Essential medicines are at all times available in health facilities Are of assured quality, procured from reliable sources and at competitive prices Provided to the intended patients in a timely and appropriate manner The evidence collected fkom various WHO studies undertaken in several &can countries show that the average availability of essential medicines is consistently low, most especially for ORS and zinc. The latest survey in Viet Nam covering 29 selected medicines for mothers and children showed a mean availability of 13.6%. When procurement systems are inefficient, the same medicines may be obtained fiom different suppliers at hfferent prices. This can result in wasting government resources and may needlessly complicate the supply management system.

A comprehensive assessment of procurement and supply systems should cover all levels (from manufacturing or import to delivery at health facilities), and should consider the following: Get an overall view of the supply system. This involves an assessment of the (1) overall availability of essential medicines in the country. When the availability is low, the government must conduct national advocacy to improve the availability of medicines and may encourage local production of generic medicines. Secure the public sector supply. The availability of MCH medicines is (2) consistently low in the public sector. It is important that the government should ensure an adequate supply system in the public sector. This is critical, as the public health facilities usually are the first point of contact, especially for poor patients. Reduce regulatory and policy barriers. Some interventions to address this (3) include: a) facilitate registration of priority medicines for mothers and children; b) ensure their inclusion in the EML; 3) ensure their inclusion in the re-imbursement list; and 4) make these medicines a priority for entitlements. Address operational barriers: good planning, quantification and transparent and accountable procurement systems can ensure the availability of medicines at the facility level. Drug and therapeutic committees must be involved in the selection and provide technical support in the efficient utilization of medicines. (4)

Countries may consider the establishment of a National Medicines Facility (NMF) that rationalizes, oversees and supports local govements and health facilities in medicines procurement. Specifically, a NMF shall: a) conduct a national tendering system or provide support to health authorities and facilities to conduct tendering; b) outsource procurement of medicines which have very low availability and high prices from international and local sources; c) prequalify and accredit suppliers to ensure quality assurance in procurement; and d) monitor and disseminate medicines prices. Comments and discussion: Ensuring quality of the medicines procured and supplied is of utmost importance. Strategies to ensure quality include purchasing from preselected/prequalified suppliers, or purchasing prequalified products. Nevertheless, all medicines need to be registered at the national Medicines Regulatory Authority, including imported andlor prequalified medicines. It is also important to encourage regular sampling for quality testing,,and to make the results publicly available; among others, this can enhance confidence in the procurement system and in the medicines supplied. 2.8.3 Rational use of priority medicines for mothers and children (Dr Budiono Santoso)

,

The relevance of promoting rational use of medicines in improving access to essential medicines for mothers and children towards improved health outcome was illustrated. Without rational use, improving access to essential medicines will not bring about impact on health outcome. The presentation started with the d e f ~ t i o n of rational use as defined by WHO Conference of Experts in 1985. Rational use of drugs requires that patients receive medicines appropriate to their clinical needs, in doses that meet their individual requirements,

for an adequate period of time and at the lowest cost for them and their community. Some specific examples of irrational use of medicines, affecting mothers and children were provided. Overuse of antimicrobials and injections are common examples of irrational use of medicines. While progress in reducing the over use and misuse of injectable products has been observed over the years, such success has not been demonstrated in'dealing with the over use of antimicrobials. The presentation also highlighted some indicators of usage from the WHO Medicines 201 1 databases, including the use of antibiotics and oral rehydration therapy in acute diarrhoeas, the use of antibiotics in non pneumonia and pneumonia acute respiratory infections. The data basically show that indeed irrational use of medicines is stdl commonly encountered in health facilities jeopardising the quahty of medical care and wasting resources for health in many developing countries. Specific challenges in promoting rational use, particularly in the region, were the fact that in many countries medicines sales have been used for revenue generation and for incentives to the providers. The major proportion of medicines expenditure is fiom the patient and paid out of their pocket. This poses serious barriers for promoting rational use of medicines. After explaining the common factors influencing the use of medicines, which include those deriving from providers themselves, fiom the social and cultural environment, fiom the work group, from the work place environment, and fiom the information, strategies for promoting rational use of medicines were highlighted. The strategies include the educational intervention, behavioural intervention, managerial intervention, financing intervention and regulatory intervention. The nature of these interventions was explained and examples were presented. Some specific targeted interventions which had been implemented in some countries in the Asia Pacific region, were presented, including the interactive group discussion (IGD) - a behavioural intervention (implemented in Indonesia and China), monitoring training and planning (MTP) intervention (implemented in Indonesia, Laos and Cambodia), a small group active learning for consumers (Indonesia) and a small group intervention to improve rational use of medicines in acute diarrhoea (Indonesia). The presentation proposed that efforts to promote rational use of medicines for mothers and children should focus on thase interventions that have a direct impact on health outcomes, such as the lack of use of oraI rehydration in acute dmrhoea, the use of antimicrobials in children, inappropfiate use of uterine stimulants etc. It was concluded that monitoring of ' medicines use and availabihty in health facilities, and providing back up support for supervision and for resupply, is extremely important for improving rational use of medicines. Furthermore, a combination of Merent interventions is needed, as a single intervention alone rarely works. Comments and discussion: The presentation was followed by a discussion on the role of regulation vs. education. Examples of regulatory interventions include the withdrawal of artemisinin monotherapy from the market in Viet Nam and the ban on the sale of TB drugs in the private sector in Cambodia. It was also noted that scaling up of interventions to promote rational use of medicines is not always easy.

Monitoring and supervision of medicines management and use in health facilities in 2.8.4 Cambodia (Mr William Mfuko) Cambodia has implemented a "supervision and monitoring" program for more than 16 years, since 1995. Implementation was initially supported by WHO and UNICEF. Supervision and monitoring activities were intensified in 2007, when several other partners, including the GF (HSS grants), the Health Sector Support (HSSP) program and KfW (Germany Development Bank) joined hands to support the program. The main objective has been, and continues to be, to improve and ensure the availability of essential medicines in health facilities at all times, through the regular collection of data for selected drug management indicators. Among others, agreed indicators include the number or the proportion of facilities: with accurate inventory records; found with sufficient stock levels; found with overstocks; that experienced stock out and stock out rates; with expired medicines; that stocked medicines that are not in the National Essential Medicines List (NEML). Monitoring and supervision visits to collect data on these indicators and to provide the needed support are conducted by either a team from central level (the DDF), provincial (PHD) or district (OD). NGOs supporting drug supply management in Cambodia also participate in the program. During these visits, previously trained pharmaceutical staff working in health facilities stores are interviewed and assessed on their ability to manage health commodities in their respective stores. Appropriate hands-on support is given as needed where short-fall or under performance is observed. Results presented in the form of graphical trend analysis were shared with the participants for each of the indicators monitored. Drug management indicators showed notable achievements, including increased availability of essential medicines during the last 3-4 years of the project. Currently the availability of essential medicines in health facilities in Cambodia is nearly 98% (or 2% stock out rates). Cambodia's experience shows that regular and timely monitoring and support supervision visits to health facilities' pharmacy stores have the potential of improving drug supply management and, most importantly, of reducing the level of stock out and consequently improving the availability of and access to essential medicines. However, this outcome can only be achieved with sustainable sources of finding for the purchase of essential medicines, efficient procurement and distribution procedures. W H O W survey on access, availability and affordability of priority medicines for 2.8.5 mothers and children (Dr Richard Laing;)

MDG target 8E aims to provide access to affordable essential drugs in developing countries. Data from HAUWHO surveys conducted in 50 countries show insufficient availability of the most affordable versions of selected essential medicines: their availability varied from 28-42% in the public sector. Low public sector availability could be due to lack of resources or under-budgeting, to inaccurate forecasting or inefficient procurement and distribution, or to low demand for slow-moving products. High private sector prices could furthermore be due to high manufacturer's selling prices or high import costs or taxes and tariffs and /or high mark-ups. The policy options to address these problems include measures to improve procurement efficiency, or to ensure adequate, equitable, and sustainable financing, through health

insurance systems that cover essential medicines. There is also a need to prioritize the medicine budget, i.e. target widespread access to priority medicines for mothers and children. A key policy action to improve access would be to facilitate and promote generic use through preferential registration procedures (e.g. fast-tracking, lower fees), by ensuring the quality of generic products, and by permitting generic substitution and providing incentives for the dispensing of generics. In addition, there is a need to educate doctors and consumers on the quality, availability and acceptability of generic medicines. Additional policy initiatives to separate prescribing and dispensing as well as controlling import, wholesale a d o r retail mark-ups through regressive mark-up schemes may also be necessary. There is also a need to provide tax exemptions for medicines. Where there is little competition, it may be necessary to consider regulating prices. For patented medicines it may be necessary to use the flexibilities of trade agreements to introduce generics while a patent is in force and to promote differential pricing schemes whereby prices are lowered, in line with the purchasing power of governments and households in poorer countries. However, one should be cautious about introducing price controls for generic medicines when competition exists. The W H O M pricing policy papers available at h m : //WWW. haiweb. org/medicineprices/ may be a useful resource. Comments and discussion: There was some discussion on bioavailability and bio-equivalence. It was pointed out that bioavailability studies are not needed for vast majority of essential medicines. WHO has specified which essential medicines require bioavailability studies (technical report series).

If originator companies break the rules regarding advertising and promotion, e.g. if they make false statements that a generic product is not bioequivalent or is of lower quality, they should be fined. 2.8.6 UNFPA-WHO Collaborative Initiative to Review the Current Status of Access to a Core Set of Critical Life Saving MaternayRH Medicines in Asia Pacific Countries @r Kabir Ahmed and Mr Peter Zinck) UNFPA and WHO conducted a joint review of access to selected, life-saving maternal and reproductive health medicines in Lao PDR (2008), Mongolia (2009), Philippines(2009), Solomon Islands (20 10) and Vanuatu (2009). The main objectives were to: obtain a 'snapshot' of the current status of access, supply and rational use; develop a harmonized approach for performing rapid assessments of critical maternall reproductive health medicines; guide institutional support and capacity building in commodity security; and

suggest ways forward for consideration by the governments and key stakeholders. The studies were conducted based on a toll developed by a core team from UNFPA and WHO. Document review, key informant interviews and consultations with key stakeholders were used, as well as visits to warehouses, health facilities, pharmacies at central, regional, district level and below. Public, private and nongovernmental organization sectors were included. The studies were not based on representative samples; thus, the findings cannot be generalized. Nevertheless, they do provide valuable insights and are useful for raising awareness. The findings also supplement the findings of other studies and surveys. It was found that, though the key medicines for maternal and reproductive health were mostly available, there were nevertheless incidences of stock out or overstock, due to inadequate knowledge of and guidelines on quantification, procurement andlor storage. Other issues that surfaced included the fact that the essential medicines list was outdated, absence of STGs, or a mismatch between STGs and the medicines that are actually available. In some instances, unregistered or expired medicines were in stock. It was also found that while prescribers knowledge is usually good at teaching facilities and academic institutions, there is a gap between knowledge and practice; thus, ultimately irrational use of medicines occurs at all levels. Inadequate dispensing skills were also observed. Wide variation in prices, donordependent supply chains and lack of quality control facilities pose further challenges. Finally, the maintenance of equipment (such as the fridge) may pose challenges. Proposals to address this include in-service training, supportive supervision, strengthening of capacities for storekeeping and inventory management, forecasting, procurement and supply management. Ways need to be found to make these topics more interesting, especially for staff in health facilities. It also would be useful to harmonize approaches among UN agencies. Comments and discussion: The joint assessments brought to light that at times products are being stuck at central level. This may need to be looked into further; it is suggested that UNFPA and WHO can jointly do some follow-up work on this. There has been a instance of adverse reactions to oxytocin related to a quality problem. This resulted in the withdrawal of the product. Such instances highlight the need to have resupply/emergency supply systems in place. The "one UN" process could help to improve coordination between UN agencies. 2.9

Barriers to and options for improving access to prioritv medicines at national, sub national, facilities and community levels

The first part of this session consisted of group work; individual country groups identified country-specific feasible options and possible next steps to improve access to MCH medicines. A summary of the priority follow up actions can be found in Annex 3.

S.ribqumtIy, the proposed fallow up actions were presented and discussed. Issues

raised -these pmmtatim (either by the presenting country itself or by other pdcipaats) are s m m x k d helow. Questions and discussion about Viet Narn Many plans are for the mid- to long-term. For immediate action, already existing clinical guidelines can be collated together to form a national standard treatment guideline. Another area of immediate focus should be to ensure that medicines are available in the health centres. It is critical to strengthen clinicians' declaration of conflict of interest. It is common in Asia that influential clinicians are often supported by pharmaceuticalcompanies, It would be a good idea to adopt what US and Italy have done t o control drrrgpromotimin the private sector. In the US, all payments made to doctors need ta be reported by the phmmceutical companies. Italy levies 5% tax on all marketing activities and the money generated are used for research in neglected diseases and generic medicines. Reimbursement of a l l medicines by the national insurance scheme drains the budget and is not sustainable. However, reimbursement costs for MCH services and medicines are low. Increase in reimbursement rate for MCH would stimulate increased utilization of services. It is costly ta cany oat quality testing of drugs, however, the information is not shared. As Global Fund publikes qqlitycontrol results on their website, sharing information would enhance b quality of dmgs. Questions and discussion about the Philippines The Philippines already has guidelines and benchmarks for the use of MCH medicines in place. A list of essential MCH medicines exists, as an annex to the relevant treatment guidelines. Some MCH medicines are included in the medicines provided by the botika &ranggay, for example OR8 and certain antibiotics are included. The intention is to expand t b range, but there is a temporary moratorium, for some of these botikas were found to operate outside tbeir l i m e . Previously, different strengths of oxytocin were available, this has been standardized; currently only 10 l U should be available. Previously, midwives were not allowed to use oxytocin, to protect them from being sued in case of unexpected side effects that they cannot handle. Now there is an administrative order that allows them to administer oxytocin, but there should be a doctor in reasonably near distance. This is however mainly an issue in the private sector. Questions and discussion about Papua New Guinea Public-private partnership should be encouraged. For-profit sector is not very big but faith-based organizations are very active providing half the health care services in the country.

Though private sector is profit-driven, some private organizations are interested in promoting the public good. Intervention studies in other countries can be benchmarked to promote ORS sales and free distribution of family planning commodities through private outlets. Papua New Guinea is interested in canying out pricing survey. Faith-based organizations (FBOs) can be included as a third sector. The experience from East African countries is that FBOs procure medicines at low public prices, however sell at a private sector price making a big profit. Quality control of medicines is a major concern. Though most vertical programs procure from WHO-prequalified suppliers, general supplies are procured from developing countries with weak regulation. Absence of quality testing lab makes it difficult to filter substandard medicines entering the country. Questions and discussion about Lao People's Democratic Republic Procurement is decentralized in Laos. The government is trying to centralize the system as the decentralization has led to problems of inconsistent quality of drugs and varying prices across the country. Centralized system already exists for certain vertical program commodities such as contraceptives and vaccines. Though centralization cannot be done at once, MCH commodities could be prioritized. Vertical programs have a parallel supply chain. It would not be encouraged that MCH set up another parallel system. Hence, it was suggested that strengthening one standardized guideline on supply chain management would be useful. However, SOPSalready exist in Laos. The document itself is not e n ~ u g h to ensure compliance without monitoring activities. Countries are encouraged to run drug use surveys. Laos has carried out one in 2005 and plans to do level 1 1survey this year. Laos expressed an interest in exploring the use of regular monitoring (MTP), as in Cambodia. Questions and discussion about China One challenge in China is the under-utilization of primary facilities; patients have a tendency to go for "the best doctor". The question was raised how useful it is to have a separate list of MCH medicines. Would it be better to have them in the regular EML? Perhaps it is usehl to have the separate list ready and advocate for including those medicines in EML once the next revision is due. 1.e. a separate list is not an end in itself (but a means to make progress). It was noted that some countries (e.g. Cambodia) have an EML which has a section where the medicines are listed per program; this makes it easy for each programme to review "their" part once revision is due. The process for updating the WHO Model List of Essential Medicines was changed from selection by a committee of experts to a process based on applications and evidence.

It is important that treatment guidelines are formally endorsed by MOH and widely distributed, including by uploading on websites. Questions and discussion and Cambodia Cambodia raised the question whether macronutrients for the treatment of malnutrition could be included in EML. Inclusion of macranuirients in WHO model list is unlikely. By contrast, micronutrients are part of WHO model list as they have pharmaceutical standards which do not exist for macronutrients. However, it could be tried through WHO model list application process. Inclusion in the WHO model list can have a great impact on availability of certain medicines. For example, inclusion of fixed dose combination therapy for TB increased its market share to 90%. Common use of multi-dose injectables in Cambodia causes risk of contamination. Single dose is preferred, however, manufacturing cost of a multi-dose vial are often lower than or not too different fi-om single dose. Hence, it may be more economical to use multidose vial for single usage.

3. CONCLUSIONS AND RECOMMENDATIONS

3.1

Conclusions

Participants of the Workshop on Enslrring Access to PrioriQ Medicine$ far Mothers and Children discussed the services deliverg.of maternal and childhealth indifferent countries, especially on the access and a-iby of the medicines in &f"t levels of health facilities. The bottlenecks for access, availability, quality as well as proper usage by providers and consumers were reviewed and practical options for improvements were proposed.

Pdcipauts also discussedthe progress and challenges of the Millennium Development Goals 4 (Awing child morbdity) and 5 (improving maternal health). There are indeed notable p r o w in some c&a despite smiaus challenges in other countries. Follow up actions at diEaent levels of senices delivery were proposed to improve access and madability of the priority medicines, k m selections, pricing, financing and streamlining the procurement, supply and management as part of the essential medicines in general. The importance of monitoring and supervision and the need for effective back up system for supply and for proper usage is underlined. There is a need for a mechanism for exchange of information, sharing of experiences and collaboration to cross fertilize the success to other countries in need.

3.2

Recommendations

WHO, UNFPA and partners WHO and UNFPA should closely collaborate to follow up the joint assessment (1) and to provide technical support in improving the logistics supply distribution and monitoring of priority medicines for mothers and children. WHO, UNFPA and partners should facilitate effective intercountry exchange of experiences, cross fertilization, and collaboration in relation to access to priority medicines and the achievement of health outcome to reduce mortality. (2)

WHO, UNFPA and partners should collaborate to devise a mechanism for (3) locating available stocks and rapid delivery of resupply of the priority medicines for emergency care such as oxytocin. WHO should facilitate, advocate and provide technical support for improving the availability and production of quality paediatric formulation. (4)

WHO should facilitate the documentation and publication of success in ensuring (5) access to the priority medicines and the progress towards the achievement of the Millennium Development Goals. Member States: a translation of Priority Medicines for Mothers and Children 201 1 should be (1) made available in the local language,. a (national) workplan for improving access and availability to priority medicines (2) through the existing delivery system should be devised, if possible as part of the bigger national strategy on maternal and child health. Proper advocacies and training of providers should be part of the plan. The plan should also include ways of ensuring access in remote places. The implementation of the action plan can be started in a particular area, e.g. provinces or districts, and scale up with a step wise approach. adequate financing of essential medicines for mothers and children should be (3) ensured by inserting the priority medicines, as published in WHO's list as "Priority medicines for mothers and children 201 I", on the list of reimbursable items of national health insurance schemes. Costing of standard treatment courses for health problems facing mothers and children, should be based on the Priority medicines" list and on WHO's standardized costing methodologies. relevant'follow up actions should be initiated within six months to one year at (4) the national and subnational levels to address the bottle neck for access and availability of priority medicines for mothers and children. the implementation for monitoring and back up support for the availability, (5) supply management and use of priority medicines should be developed and initiated; and a pilot area for implementation should be identified. A baseline on availability and affordability of the medicines can serve as an evidence for advocacy and a basis for

measuring progress. Track availability of a small set of selected medicines from the list "Priority Medicines for Mothers and Children 20 11" effective mechanism for intercowtry cross fertilization and collaboration in (6) ensuring access to priority medicines and achievement of health outcome should be pursued to reduce child and maternal mortality. Document success stories towards the achievement of millennium Development Goals and share with other countries.

ANNEX 1 LIST OF PARTICIPANTS, OBSERVERS, AND SECRETARIAT 1. PARTICIPANTS

CAMBODIA

Mrs Oudam Roath, Chief, Essential Drug Bureau, Department of Drugs and Food, Ministry of Health No.93 B, Street 360, Sangkat Boeung Keng Kang III, Khan Chamkarrqorn, Phnom Penh. Tel.: + 855-23-880969; 855-12803485. Fax: + 855-23-880696. E-mail: oudam-r@online.com.kh; oudamr@gmail.com Professor Chheang Sena, Deputy Director, Kampong Cham Provincial Health Department, #4 Village 7, Preah Kosamak Street, Kampong Cham Quarter, Kampong Cham Town Kamvong. Cham Province. Tel.: + 855-12 787170. Fax: + 855-42-941 800. E-mail: sena-chheang@yahoo.fr Dr Sam Vanrithy, Chief, Out-Patient Department, National Maternal and Child Health Center, 15B, Street 146 Sangkat Depot II, Khann Tuol Kok, Phnom Penh. Tel.: + 855-11-966999. Fax: .: + 855-11-966999. E-mail: somvanrithy@gmail.com

J Phary, Chief, Pharmacy Department, National Mrs & Pediatric Hospital, #I00 Blvd. Russian, Tuk Laak I, Tuol Kork. Tel.: + 855-16 676392. Fax: + 855-16 676392 E-mail: limphary@yahoo.com CEIINA, PEOPLE'S REPUBLIC OF Dr Sane Li, Deputy Director, Department of Maternal and Children 'Health, and Community I-IeaIth, Ministry of Health #I Nanlu, Xizhimenwai 100044, Beiiing. Tel.: (8610) 68792308. Fax: (86 10) 687-92321. E-mail: songlimoh@126.com Ms & Jiying, Officer, Division of Essential Medicine System Department of Drug Policy and Essential Mehcine, Ministry of Health, #1 Nanlu, Xizhimenwai 100044, Beiiing. Tel.: (8610) 687-92603. Fax: (8610) 687-928 19. E-mail: tujy@moh.gov.cn Mr Jia Liming, Director, Department of Drug Policy and Essential Medicines, Bureau of Public Health of Jiangxi Province, No.69 Beijing West Road, Jiangxi Province, Nanchanq. Tel.: 0791-6283136. Fax: 0791-6256240 E-mail: jialiming097@yahoo.corn.cn

LAO PEOPLE'S DEMOCRATIC REPUBLIC

Dr Lamphone Svhakhang, Head of Food and Drug Department Ministry of Health, Simeuang Road, Vientiane. Tel: +856-21 243657. Fax: +856-21 214015. E-mail: Syhakhangl@ yahoo.com /drug@laotel.com

Annex 1 Ms Manila Phimmasv, Deputy Head, Hospital Pharmacy Section, Champasak Provincial Hospital, Champasak Province. Tel.: +856-31-212-18. Fax: +856-31-252928. E-mail: manilaqenny@yahoo.com Dr Manisone Oudom, Head of Planning Division, Maternal and Child Health Centre, Nongboun Road, Xaysettha District Vientiane. Tel.: 856.21.45219 (20). Fax: 856.21.45219. E-mail: omanisone@yahoo.com.uk Dr Keovilayvanh Phoumsavanh, Deputy Chief, Maternal and Child Health Division, Savannakhet Provincial Health Department, Road No.9, Kavsone District. Tel.: 856 41 212098. Fax: 856 41 212098. E-mail: keo00 13@yahoo.com

MONGOLIA

Dr Yadamsuren Buvaniarnal, Officer-in-charge, Maternal Health Care, Ministry of Health, P.O. Box 491627, Ulaanbaatar. Tel.: 976 99190750. Fax: 976 51 263652 Ms Choijoo Amq'arnal, Officer, Department of Pharmaceuticals and Medical Devices, Ministry of Health 210648 Zasgiin gazriin VIII bair, Olympiin gudamj 2, Sukhbaatar duureg, Ulaanbaatar. Tel.: 976 51-263786. Fax: 976 11 323541. E-mail: amarjargal~ch@yahoo.com Dr Dashdamba Amaraa, Officer of Pharmaceutical Health Department, Health Department, Murun sum, Khuvsml Province. Tel.: 976 01382 24005. Fax: 976 01382 22214. E-mail: amara-emgazar@yahoo.com Dr Khavchig Alimantuva, Doctor-in-charge, Pharmacy, Health Department, Jargalant sum, Khovd Province. Tel.: 976-143222381 ; 976-93222586. Fax: 976-0143222675. E-mail: ch.alimantuya@yahoo.com

PAPUA NEW GUINEA

Mr Vali Principal Advisor Pharmaceuticals, Department of ~ e a l t hP.O. , Box 807, Wainani. Tel.: 675-301 3888. Fax: 675-323 1631. E-mail: vali-karo@health.gov.pg

m, m,

Mr Elari Senior Purchasing Officer, Department of Health, P.O. Box 807. Waigani. Tel.: 675-301 3880. Fax: 675-323 1631. E-mail: elari-kou@health.gov.pg Dr Lahui Geita, Technical Advisor, Maternal Health, Department of Health, P.O. Box 807, Waiaani. Tel.: 675-301 3719 I 71614601. Fax: 675-323 1910. E-mail: lgeita@cbsc.org.pg

Annex 1

Dr James Amini, Chief Paediatrician, Port Moresby General Hospital, Private Mail Bag #I, Boroko, NCD. Tel.: 675-324 8200 176826548. PHILIPPINES Dr Irene I?. F d a s , Medical Officer N, National Center for Pharmaceutical Access, and Management (NCPAM), 3F, Bldg. 15, Department of Health, San Lazaro Compound, Manila. Tel.: (63) 7402792. Fax: (632) 7402792. E-mail: ireneffarinasmd@yahoo.com Ms Angelina A. del Mundo, Director ID, Administrative Service, Department of Health, San Lazaro Compound, Manila. Tel.: (632) 71 1-6712. Fax: (632) 711-6712. E-mail: pangga3 1@hotmail.com Dr Francisca P. Cuevas, Municipal Health Officer, Pateros Health Department, Pateros, Metro Manila. Tel.: 632 6413256. Fax: 632 6413256. E-mail: anchitperez@yahoo.com Director I I I , National Center for Dr Honorata Disease Prevention and Control, Department of Health San Lazaro Compound, Manila. Tel.: (632) 7 11-9956. Fax: (632) 711-7846. E-mail: honoratacatibog@yahoo.com VIET NAM, SOCIALIST REPUBLIC OF

my

Thi Bich Ha, Officer, Medical Service Dr Admithbatiw, Ministry of Health, 138A Gang Vo Street $a Dmh, Wa Noi. Td: 844 273 2273 ( 1 7 0 3 ) . Fax: 844 273 2094.%mail: bich)tatrcb@gmail.eom Mr Van Truong, Vice Chair of Pharmaceutical Management Bureau, Department of Health, Tay-Son Street Ha Noi. Tel.: 0912-156-198 I 04-437337193. E-mail: uongxuantruong@yahoo.com

Dr Nnuven Mai Huong, Officer, Maternal and Child Health Department, Ministry of Health, 138A Giang Vo Street Ba Dinh, Ha Noi. Tel.: 843 823 3802 E-mail: maihuongrh@yahoo.com Dr Hoang Thanh Mai, Specialist on Drug Information Management, Drug Administration of Viet Nam, 138A, Giang Vo Ban Dinh, Ha Noi. Tel.: 844 382 358 12. Fax: 844 38234758. E-mail: dav@netnam.vn

Annex 1 2. OBSERVERS Dr Joyce Ducusin, Officer-in-charge, Division Chief, Family Health Office, National Center for Disease Prevention and Control, Department of Health, 2/F, Building 14, San Lazaro Compound, Rizal Avenue, Sta. Cruz, Manila, Philippines. Tel.: 632 743 8301 local 172611728. Fax: 632 71 1 7846. E-mail: juducusin@yahoo.com Dr Anthony Calibo, Supervising Health Program Officer, Family Health Office, National Center for Disease Prevention and Control, Department of Health, 2/F, Building 14, San Lazaro Compound, Rizal Avenue, Sta. Cruz, Manila. Tel.: 632 6517800 local 1726, 1728, 1729. Fax: 632 71 1 7846. E-mail: acalibomd@yahoo.com 3. SECRETARIAT

Dr Budiono Santoso (Responsible Officer), Team Leader, Essential Medicines and Technologies, World Health Organization, Western Pacific Regional Office, P.O. Box 2932, United Nations Avenue, 1000 Manila, Philippines. Tel.: +632 528 9846. Fax: +632 521 1036 E-mail: santosob@wpro.who.int (Co-Responsible Officer), Team Leader, Dr Marianna Maternal, Child Health and Nutrition, World Health Organization, Western Pacific Regional Office, P.O. Box 2932, United Nations Avenue, 1000 Manila, Philippines. Tel.: +632 528 9868. Fax: +632 521 1036. E-mail: triasj@wpro.who.int Dr Ardi Kaptininasih, Regional Adviser (Making Pregnancy Safer), World Health Organization, Western Pacific Regional Office, P.O. Box 2932, United Nations Avenue, 1000 Manila, Philippines, Tel.: +632 528 9876. Fax: +632 521 1036. E-mail: kaptiningsiha@wpro.who.int Ms Karin Tirnmermans, Senior Technical Officer (Intellectual Property RightsITrade and Health), Essential Medicines and Technologies, World Health Organization, Western Pacific Regional Office, P.O. Box 2932, United Nations Avenue, 1000 Manila, Philippines. Tel.: 1-632 528 9026. Fax: +632 521 1036. E-mail: timmermansc@wpro.who.int Dr Emmalita Maalac, Medical Officer, Child Health, World Health Organization, Western Pacific Regional Office, P.O. Box 2932, United Nations Avenue, 1000 Manila, Philippines. Tel.: +632 528 987 1. Fax: +632 521 1036. E-mail: manalace@wpro.who.int

Annex 1

i3r Q K h Jms$Macroecmdst,H& FinsrvGing Wmld Wed& OrgpiWi414 Western PaeIfic R e g i d OBm, P.0. Bm.2932,U;nitedN&uns Aveme, 1000 Mda,P-i. Tel.: -hS32 528 9849; Fax: +632 521 1036. E-mail: jamesc@wpro.who.int Ms Laura Hawken, Technical Officer, Health Services Development, World Health Organization, Western Pacific Regional Office, P.O. Box 2932, United Nations Avenue, 1000 Manila, Philippines. Tel.: +632 528 9086. Fax: +632 521 1036. E-mail: hawkenl@wpro.who.int

*

WHOICOUNTRY OFFICE

Ms Vanchinsuren Lkhauadorj, Technical Officer in Pharmaceuticals, World Health Organization, ZRve14, Zprovkht Elma One, Downtmn 3 0 33 m e i r y Suvzt; f -0: Box 113, Piji. TeL: 4-679323 4100 (Gaml)/'6B323 4125 (IXmt) Fag 4-679323 4177/323 4156. E-mail: lkhagvadorjv@wpro.who.int -.

~

~

Dr Socorro Escalante, Technical Officer in

F h x W e ~ t h hWorld , Real& Organization, 63 Tran HMg Dao Stme& Hoan IUemDistrict, Ha Noi, Sod&tB@bJlc ofViatNam. Tel.: +844 94337536. Fax: +8449433740. E-mail: escalantes@wpro.who.int Mr William Clement Mfuko. Technical Officer (Essential Medicines), World Health Organization, No. 177-179 corner Pasteur (51) and 254, Phnom Penh, Cambodia. Tel: (855) 23 216610. Fax: (855) 23 21621 1. E-mail: mfikow@wpro.who.int Dr Huang Baobin, National Professional Officer, Essential Drugs and Medrcines, World Health Organization, 40 1, Dongwai Diplomatic Office Building, 23, Dongzhmenwai Dajie, Chaoyang District, Beiiing 1000600, China. Fax: +86I 0-6532-2359, E-mad: huangb@wpro.who.int Ms Uhjin K_lm. Technical Officer, Essential Medicines and Technologies, World Health Organization, 4th Floor, AOPI Centre, W aigani Drive, Port Moresbv, Papua New Guinea Td.: 4675 325 7827. Fax: i-675 325 0568. E-mail: kimu@wpro .\vho.int

Mrs Sengphet Phonmhachaah, Technical Officer (NPO) Essential Drugs and Medicines, World Health Organization 125 Saphanthong Road, Unit 5, Ban Saphangthongtai, Sisattanak District, Vientiane, Lao PeopIes Democratic Republic. Tel.: (856) 21 353902. Fax: (856) 21 353905. E-mail: phongphanchanhs@wpro.who.int

Annex 1 Dr Laura Guarenti, Technical Officer (Reproductive, Maternal and Child Health), World Health Organization, 4th Floor, AOPI Centre, Waigani Drive, Port Moresbv Papua New Guinea. Tel.: +675 325 7827. Fax: +675 325 0568. E-mail: guarentil@wpro.who.int Dr Howard Sobel, Medical Officer, Maternal and Child Health, World Health Organization, No. 177-179 corner Pasteur (5 1) and 254, Phnom Penh, Cambodia. Tel: (855) 23 216610. Fax: (855) 23 216211. E-mail: sobelh@wpro.who.int Dr Robert Scherpbier, Medical Officer, Maternal and Child Health, World Health Organization, 401, Dongwai Diplomatic Office Building, 23, Dongzhimenwai Dajie, Chaoyang District, Beiiina 1000600, China. Fax: +8610-6532-2359. E-mail: scherpbierr@wpro.who.int Ms Alahn Khounnasene, Technical Assistant, MNCH Programme, World Health Organization, 125 Saphanthong Road, Unit 5, Ban Saphangthongtai, Sisattanak District, Vientiane, Lao Peoples Democratic Republic. Tel.: (856) 21 81847. Fax: (856) 21 353905. E-mail: khounnasenea@wpro.who.int Dr Richard Ogilvie Laing, Medical Officer, Medicines Information and Evidence for Policy, Health Systems Financing, World Health Organization, 20, Avenue Appia CH-1211 Geneva 27, Switzerland. Tel: +41-22-791-4533. E-mail: laingr@who.int Dr Krisantha Weerasuriva, Medical Officer, Medicines Access and Rational Use, World Health Organization, 20, Avenue Appia, CH-1211 Geneva 27, Switzerland. Tel: +41-22-79 1-2357. E-mail: weerasuriyak@who.int

UNFPA

Dr Kabir Ahmed, Technical Adviser, United Nations Population Fund, 605 Third Avenue, New York, New York 10158, United States of America. Tel.: 1-212-297-5199. Fax: 1-212-297-4953. E-mail: kahmed@unfpa.org Mr Peter Zinck, Health Systems / RHCS Specialist, United Nations Population Fund, Office for the Pacific, PMB, Suva, Fiji. Tel.: +679 330 8022. E-mail: zinck@unQa.org

ANNEX 2 WORKSHOP ON ENSURING ACCESS TO PRIORITY MEDICINES FOR MOTHERS AND CHILDREN 15 to 17 August 2011, Manila, Philippines TIMETABLE Time 08:OO Registration Monday, 15 August 2011 Time 08:OO Tuesday, 16 August 2011 10. Improving access, availability and rational use of priority medicines for mothers and children Framework for improving access (Karin Timmermans) Efficient procurement, supply and management (Socono Escalanfe) Coffee break Time 08:OO Wednesday, 17 August 2011 Plenary presentations & discussions Barriers and options for improving access to priority medicines - national, sub national, facilities and community levels.

WPRIDHSIEMT(04)201Illb

08:30

1.

Opening ceremony

Coffee break 09:30 2.

09:30 1 O : O O

09:30 10:OO 12. Follow up plan

Coffee break

Introduction of the workshop (Budiono Santoso) Maternal and chitd health n the Western Pacific Region (Marianna Trias) improving sewice dellvery for maternal and child health (Laura Iiawken)

3.

Rational use of priority medicines for mothers and children (Budiono Santoso) Monitoring and supervision of medicines management and use in health facilities Cambodia case (William Mfuko) WHOlHAl survey on access, availability and affordability of priority medicines for mothers and children (Richard Laing) UNFPANVHO joint assessment on availability and affordability of priority medicines for mothers - PIC perspectives (Peter Zinck) UNFPA-WHO initiative to review the current status of access to a core set of critical life saving maternallRH medicines in selected countries (Kabir Ahmed) Discussions

National level Subnational level (province, district) Facilities Community levels

4.

5, Intervention packages for maternal and child health (Ardi Kapfiningsih, Emma Mairdac) 6.

Pnority med~c~nes far mothers and children (Krisaniha Weerasuriya) Financing options for matornat and child health services (Chris James)

Discussions

7.

Discussions

f2:30 13:30 8.

LUNCH BREAK Country presentations - delivery of MCH services and challenges for access, availability and quality of priority medicines. Coffee break 9. Country presentations - brief overview on access to priority medicines for mothers and children. 13:30 Group work - barriers to and options for improving access to priority medicines - national, sub national, facilities and community levels. Coffee break (Cant.) Group work - barriers to and options for improving access to priority medicines -national, sub national, facilities and community levels.

13.

Conclusion and recommendations

75:OO

15:OO

15:30

14.

Closing session

17:OO 7:30

Cocktails -

ANNEX 3

PRIORITY FOLLOW UP ACTIONS IDENTIFIED BY WORKSHOP PARTICIPANTS National level Prepare a separate list of priority medicines for MCH. Include additional priority medicines for mothers and children, including F75,F 100 and BPI 00 for treatment of acute malnutrition, in the national EML. MoWGovt to look for alternative sources of funding for contraceptive commodities after 2012. Conduct storage needs assessment and seek funding for identified gaps. Continue to promote Public-Private Mix Strategy.

] Sub-national level CAMBODIA Continue the utilization of existing back-up systems, such as stock transfers and supplementary orders, to meet program scale-up needs. Continue the expansion of the MTP approach to improve rational drug use. Strengthen DTCs at all referral hospitals. Continue to promote Public-Private Mix Strategy. Continue training and implementation of drug management guidelines.

1 Facility Strengthen reporting of medicines use. Continue training and implementation of drug management guidelines.

] Community Strengthen Village Health Volunteers groups,

Compare the WHO Priority list with the Chinese EML, identify gaps and consider inclusion of "missing" medicines in Chinese EML. Set up database on supply management and use of medicines for maternal and children health Apply fast track registration for pediatric dosage forms. Increase government investment for the provision of MCH medicines. Integrate the 3 separate insurance systems.

CHINA Implementation of Health Reform Policy. Increase government investment for the provision of MCH medicines. Integrate the 3 separate insurance systems Set up an integrated information system (including health facilities) for collecting the information on medicine requirements efficiently and transparently.

I

Develop guidelines for prescription audits and education. Cut the link between prescription and income; compensation should be provided by government. Conduct performance evaluation with comprehensive indicators, such as rational prescription, patient satisfaction.

Capacity building for human resources Retention of qualified health professionals

Annex 3

Develop a clear policy on procurement for :*. Involve technical staff in forecasting MCH medicines. medicine requirements. Develop a detailed plan to implement the Improve storage conditions. policy of free health services for mothers Strengthen the role and and children. responsibility of pharmacist and logistic staff. Include pediatric formulations in the EML. Facilitate registration of needed MCH Train health providers on rational medicines. prescription. Use MTP for improvement of Disseminate the EML for MCH to all rational use of medicines. health facilities. Disseminate the EML for MCH Centralize procurement for essential medicines. medicines to all health facilities. Introduce Unified logistic system for supplying medicines including MCH medicines. Provide guideline on storage of essential medicines for all levels. Train health providers on rational prescription. Use MTP for improvement of rational use of medicines. -~enew reproductiveEealth programme; Renew national programme for children's health. Price assessment of essential medicine.

Provide drug information to patients when dispensing drugs. Only registered medicines should be procured (selfmanagement by pharmacists at all levels).

Educate the community on the rational use of medicines.

I

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--

'1

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Conduct refresher training for service providers.

Annex 3

1* I

i

National Quantification study,. Increase manpower number & skills. i:

I

Establish provGcial transit stores to strengthen supply chain. Increase and training of appropriate manpower.

Capacity building: - Supportive supervision.

. .

a

Capacity building -of commdity health workers. Supportive supervision. Advocacy for increased utilization 1 access to essential basic health services Close follow-up and monitoring of clients Functional community health teams

. -

-

1)

1

0

Assured fiunding support by 'incorporatingas budget line item Financial risk protection by expanding PhilHealth benefits Universal coverage of PhilHealtli enrolment and increased utilization thru social marketing and information dissemination Increase hctionality of health facilities Assist CHD regional offices in operationalization of universal health care (UHC) -- - . -

I

-Alignmentof priorities with the Aquino Health Agenda through localization of national policies and guidelines.

-'

Effective implementation of identified prioritized national programs 4 Sustainability mechanism in place

1

1

.. .

,

'I*

''

I

, . .

%

- ~ e v e l - ahational o~ strategy for access to prioritjmedicines for mothers and children and incorporate it in the national reproductive strategy; develop an EML for MCH as a component. Advocate for improving access to essential medicines for mothers and children. Prioritize MCH medicines in the policy for local pharmaceutical production Develop national treatment guidelines for children. - - -

Review operational procedures for procurement and supply of medicines. Strengthen post-marketing surveillance Develop local level capacity for medicines management.

Strengthen drug therapeutic committees and drug information units to provide independent information on medicines. Introduce prescription audits and utilization analysis for medicines.

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