E-drug: Decentralizing Pharmaceutical Services (cont)
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Dear E-druggers,
South Africa is about to enter into an interesting phase of health
reforms where access to health services and real dynamics of the
pharmaceutical services and the industry are at play. In Zambia, we
decentralized the public health commodities budget (essential drugs,
laboratory and other medical supplies) to district level. The budget
allocation is based on per capita. The District Health Boards get
paper budgets or "virtual" paper money. They order their essential
drugs and medical supply requirements against their budget allocation
from a given essential list. Any other item required outside the list
would be obtained from other sources using cost sharing or recovery
and emergency funds.
The system has not worked quite well for various reasons. Some of
these include: 1) Limited stocks at the central warehouse, 2)
restocking that is resource based rather than need, 3) limited
capacity to prioritize facility needs based on pharmacoeconomics and
public health concepts. 4) There is limited competence to
functionalize the concept. 5) Inappropriate procurement practices
both at central and district levels; and many others.
Lessons learnt from expenditure of emergency and cost recovery funds
has been encouraging. Some of the mitigating factors are compelling
some stakeholders to contemplate the possibility of decentralizing
the funds to district level. However, the experiences are very
limited and the amounts at hand are very little. In addition, Health
Boards are not allowed to spend above given figures by the contractor
(Central Health Board). In some cases institutions do under spend due
to various reasons too. Drugs are expensive and if bought in little
amounts do not have a visible impact on the health service delivery.
Inadequate pharmacy outlets (if any) in the remote districts is
another limiting factor, etc.
Decentralization of money would put the staff at the mercy of the
industry. Most of the institutions do not have pharmaceutically
trained cadres. In addition, to be frank, it is common knowledge that
civil servants are very much under paid in our country. They will not
miss the window of opportunity to assist the industry to maximize the
costs.
The issue of incurring high costs by referring patients has been
taken care of in Zambia. The system here demands that the referring
institution must meet the costs incurred by the higher referral
level. Hence, in some cases it is the patients who suffer most when
the lower level is unwilling to incur any further costs from the
referral hospitals.
There are many lessons that could be learnt from the Zambia health
reforms. For South Africa, I would recommend that before the system
is introduced make sure there is a good program of district capacity
building and ensure availability of pharmaceutically trained health
personnel. These may assist to improve availability, access and
equity of access to pharmaceuticals, particularly the remote and
disadvantaged communities.
Oliver Hazemba
Lusaka, Zambia
ohazemba@zamnet.zm
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