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In South Africa access to essential drugs and vaccines is truly about
strengthening health systems, by focusing on four components, as spelt
out in the WHO Medicines Strategy 2000 - 2003, i.e.:
a) rational selection
b) affordable prices
c) sustainable financing
d) reliable supply systems.
Rational selection
In the field of immunisation just taking rational selection into account
the following problems hinder progress:
- lack of reliable information. We really do not have effective and
efficient health information systems established, let alone drug management
information systems. This makes the rational selection of essential
drugs a problem.
- Once a medicine has been selected we also need to look at how it is
being used - by prescribers, dispensers and the patients. In my province
we recently changed from subcutaneous BCG to intra-dermal BCG. We already
know of one case where a child, in a hospital, was given the intra-dermal
form of the drug via the subcutaneous route. Whilst the administration
of the vaccine did not cause the death of the child it certainly contributed
to it. Why do I give you this example? I want to illustrate what happens
when we do not integrate our systems when we implement programmes.
GAVI does allude to offering technical assistance, however my experience,
and I am sure that of many other Africans, is that technical support often
is dictated by the funding agency without actual consideration of what
the health care system is trying to achieve. In the example I provided,
the HRD section of my province trained trainers and nurses on how to administer
the intra-dermal BCG. We have a system where nurses are rotated in the
wards within the hospital. Obviously when the trained nurse was moved
out of this ward, the person who replaced her had not received the training
on the administration of the new product. She did what she was used to.
Now had we looked at the implementation of this vaccine from a systems
point of view rather than another vertical programme, we would have had
a proper human resource planning and training strategy in place which
would ensure that all staff at whatever level of function received proper
training and support at all times and the system should also be in a position
to address gaps, where these exist.
When technical support is offered, it is offered for a particular programme
or project. However people do not apply the principles learnt in the one
programme to other programmes and just understand that this is what I
must do for EPI. If the support is integrated into existing systems that
address human resource development(HRD), rather than just HRD for this
project it benefits far greater numbers as well as the system itself.
Affordable prices
SA pays high prices for its drugs, in general. I am not certain about
whether our vaccines are more expensive than other countries.
Sustainable financing
It is this government's policy that there will be free services for
pregnant women and children under 6. Therefore patients do not have to
pay for vaccines. However we are already starting to see stock outs of
many essential medicines due to limited finances at facility level. This
may have to do with poor management but has a lot to do with the prices
we pay. With GAVI new vaccines may be developed and introduced but at
what cost? And will our existing policies of free services be able to
cope with the increased costs? How will the initiative support our governments
in adhering to their constitution of free health care when the drugs required
become too expensive? Will the initiative provide technical support to
ensure that there will be sustainability that is not dependent on donor
funding or outside technical support?
My biggest issue with technical support is that it comes from outside
our countries with ex-pats who often do not understand the local situations,
or even if locals are used, they are paid salaries that our governments
cannot afford so they will also leave once donor funding has dried up.
When are locals going to actually possess the capacity required to develop,
implement and actually manage programmes/projects? Whilst I agree that
this is an issue for the government to deal with it is also very much
influenced by donors and technical agencies. You get the distinct impression
that our northern supporters view us as possessing really limited abilities,
and whilst there may be evidence to support this - we require to be more
creative in the manner we provide technical support.
Reliable supply systems
This issue is sometimes such a joke. We have been using polio vaccines
which come with vaccine vial monitors ( a real treat when we donot have
reliable cold chain maintenance). However we continue to dispense expired
polio, i.e. the vvm's (vaccine vial monitors)have expired, even when we
use private sector distribution systems.
In a country like SA with its many resources we still experience stock
outs due to a multitude of reasons - the most important being poor management.
With regard to public private interactions, in my view:
- PPIs are bad for us when ownership of the process is undertaken by
stakeholders not truly representative of our people and our governments,
where civil society is not truly represented and where vested interests
will continually dilute the picture in favour of the vested interest.
- Our government has a long way to go towards ensuring that access is
addressed through strengthening existing or new supply systems, ensuring
sustainable supply and rational selection and use. We should not just
emphasis affordable prices when we do not take the responsibility of
meeting the other aspects related to access, because when prices do
become affordable (in someone's eyes) then are we (government) in a
position to deliver?
- Integration of programmes is key, not just nationally but internationally
as well. One of the biggest problems we experience from an operational
point of view is that the international agencies, who often lead the
technical support, sometimes do not appear to be working together. The
final result will be countries receiving recommendations that are not
mutually beneficial. For eg. with the introduction of IMCI and the EDP
in SA, we found that IMCI guidelines and STGs produced through the DAP
did not necessarily concur resulting in many fights at the local level.
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