"Equitable access to essential medicines is the goal - it is the people's right."
GGM uses a bottom-up approach in implementation of project and policy development. While a 3-step approach gives a framework to the project, each stage can be adapted to suit the specific country situation.
Phase I: National assessment of transparency and potential vulnerability to corruption of the following 8 functions of the pharmaceutical sector: registration of medicines, control of medicine promotion, inspection of establishments, control of clinical trials, licensing of establishments, selection of essential medicines, procurement of medicines, and distribution of medicines. WHO's standardised assessment methodology collects qualitative information on structural indicators; quantification is then used to define the level of transparency for each function.
Phase II: Development of a national GGM programme including components such as: an ethical framework and code of conduct, regulations and administrative procedures, collaboration mechanisms with other good governance and anti-corruption initiatives, whistle-blowing mechanisms, sanctions for reprehensible acts, and a GGM implementing task force.
This process is based on experience with promoting good governance in various countries, which shows that efforts to end corruption need a coordinated application of two basic strategies: 1) a "discipline approach,” which is "top-down" and based on legislative reforms; and 2) a "values approach," which involves promoting institutional integrity through moral values and ethical principles and attempting to motivate ethical conduct by public servants. The results of the assessment in Phase I - identifying the loopholes in the systems - will help countries in applying the first approach (adjusting its laws and administrative structures and procedures in terms of medicines regulation and supply). A national policy document that establishes moral values and ethical principles to motivate ethical conduct should be developed in consultation with key stakeholders, such as Ministry of Health officials, the private pharmaceutical sector, the Ministry of Finance, civil society organisations (CSOs), and academia. According to WHO, this generates a sense of ownership and personal identification, essential for creating the intrinsic motivation for public servants to act ethically.
Phase III: Implementing the national GGM programme, which is envisioned as a fully integrated institutional learning process centring around facilitating the application of new administrative procedures for increased transparency/accountability and the development of leadership capabilities. "It is vital that national GGM frameworks should not become documents developed by a few key actors at central level." This process requires the systematic training of government officials and health professionals so that civil servants may personally identify with and commit to the framework. A training package is being developed that will focus on developing good governance skills such as consultation, conflict resolution, moral reasoning, and consensus-building.
Access to Medicines.
The project currently operates in 19 countries covering all WHO regions. The focus is on consolidating efforts in the participating countries and on extending the project to new interested countries. The selection of new countries and activities is based on requests by governments and in collaboration with WHO Regional Offices.
According to WHO, more than US$4.4 trillion is spent on health services worldwide each year. Transparency International (TI) estimates that 10 to 25% of global public health procurement spending is siphoned off and stolen. Furthermore, spending within the pharmaceutical sector (with its US$600 billion-plus global market value) accounts for up to 50% of total health spending in some developing countries. The high market value of products means they are a magnet for theft, corruption, and unethical practices. According to TI, in some countries up to two-thirds of all hospital medicines are "lost" through corruption and fraud. WHO states that waste of public resources reduces government capacity to provide access to good-quality essential medicines, corrupt pharmaceutical practices are detrimental to national health budgets, and inefficiency and lack of transparency reduce the credibility of public institutions and erode public/donor confidence in governments.
Scientific and strategic partners: Leslie Dan Faculty of Pharmacy, University of Toronto, Canada; Medicines Transparency Alliance (MeTA); Núr University in Bolivia; Transparency International; and the World Bank. Donors: Australian Government's overseas aid program (AusAID), German Federal Ministry for Economic Cooperation and Development (BMZ), and the Department for International Development of the UK government (DFID).
GEMI is designed to complement the work of an existing programme, the Community-based Health Planning and Services project, initiated by the Ghanaian government, which exempts children from all fees for essential medical care. This programme posts nurses to rural communities where they provide basic curative and preventative health, as well as door-to-door maternal and child health visits, and community health talks. The nurses keep in contact with a doctor from the region via a two-way radio. According to organisers, while the project has been successful in increasing access to health care, it has created an unsustainable demand for pharmaceuticals.
The GEMI project, by investigating solutions for providing essential medicines, as well as providing information for new mothers and instruction for healthy deliveries and care of newborns, hopes to fill this demand. Trained researchers routinely monitor and track drug inventories at district facilities using hand-held devices that permit the accurate collection and recording of data in a timely fashion. The project also purchases essential drugs and distributes them to the various districts. In future, organisers plan to conduct a district-wide household survey on the availability and affordability of health care and on women's accurate health knowledge and health-seeking behaviours.
Health, Women, Maternal Health
The health of mothers and children remains more precarious in rural areas of Ghana than in cities and towns. Infant mortality is 70 deaths per 1000 live births in rural areas compared with 50 deaths per 1000 live births in the country overall. Pregnant women and young children in rural areas are especially vulnerable to preventable and treatable diseases. Malaria alone accounts for 25% of Ghana's child mortality.
Ghana Health Service, Population Council, Community-based Health Planning and Services project.
Working Group on Access to Essential Medicines, Health Action International (HAI) Africa (Leach), UN Millennium Project (Paluzzi), Medical Research Council Programme on AIDS - Uganda (Munderi)
This document describes the need to increase the availability, affordability, and appropriate use of medicines in developing countries.
UN Millennium Project website on March 20 2009.
Through the project, communities analyse their health priorities and elect representatives to health committees to coordinate action on these priorities. Campaigns launched on the priorities selected by the communities have included: promoting iodized salt; brucellosis prevention; promoting vegetable gardening; reducing alcohol abuse; access to treatment of reproductive tract infections; and addressing cardiovascular diseases, anaemia, hypertension, and tobacco consumption. For example, the iodized salt promotion campaign enabled communities to check the salt sold in their villages with simple test kits. It achieved a coverage rate of iodized salt in 98% of households. As of November 2008, a total of 807 villages have set up their own village health committee.
In 1999 the Swiss Agency for Development and Cooperation (SDC) started to support other donors in the health sector through the Kyrgyz-Swiss Health Reform Support Project. Initially, the geographic focus of the project was on Naryn oblast which is the largest and poorest in Kyrgyzstan. A qualitative assessment of people's health priorities revealed brucellosis, anaemia, hypertension, cold/influenza, reproductive tract infections (RTI), and dental diseases as the most prevalent. Nutrition, clean drinking water, hygiene and access to drugs were identified as the most important health needs in Naryn oblast.
During phase II, health promotion became the main focus of the project through the development of a community centred health promotion strategy for rural areas, called Community Action for Health. Phases III and IV saw the expansion of the project to the rest of the country of Kyrgyzstan. The project is currently (March 2009) in phase V.
Swiss Red Cross, United States Agency for International Development (USAID), Swedish International Development Agency (SIDA), and the Ministry of Health in Kyrgyzstan.
Community Action for Health website, Kyrgyz-Swiss-Swedish Health Project (KYSS) summary on the Swiss Agency for Development and Cooperation (SDC) website, "Kyrgyz Health Project: A Precedent-setting SDC-devised Project," and "Healthcare for Remote Regions - An SDC Project in Kyrgyzstan Sets the Standard" [PDF].
Launched in February/March 2009, this campaign is a call to action for African governments to meet their obligations to provide essential medicines by increasing the national budgetary allocation for the purchase of these medicines and by ensuring efficiency and transparency in the procurement, supply, and distribution of medicines. "Stop Stock-outs" is an initiative of Health Action International (HAI) Africa, Oxfam, the Open Society Institute (OSI) and a number of African partners - who together will be working in Kenya, Malawi, Madagascar, Uganda, and Zambia.
This advocacy campaign uses in-person events and information and communication technology (ICT) to demand action to eliminate "stock-outs", the term used when a pharmacy (in a medical store or health facility) temporarily has no medicine on the shelf. "Stop the Stock-outs" is calling on governments and health departments to end stock-outs now by: providing financial and operational autonomy to the national medicines procurement and supply agency; ensuring that civil society is represented on the board of this agency; ending corruption in the medicine supply chain to stop theft and diversion of essential medicines; providing a dedicated budget line for essential medicines; living up to commitments to spend 15% of national budgets on health care; and providing free essential medicines at all public health institutions.
Much of the emphasis of the campaign is on transparency and accountability in the supply chain, facilitated by ensuring that district health management teams are participatory and that monitoring of availability (and price) of medicines at health facilities is carried out. Having and sharing information about the duration which the medicine is off the shelves can - it is thought - fuel advocacy for 100% availability of essential medicines.
In addition to face-to-face exchanges that will be held throughout Stop Stock-outs, the interactive campaign website is a place where advocacy can be sparked and sustained. It carries regular features and updates on the campaign and its events, features case studies from members of the campaign community, hosts regular discussions on issues surrounding the campaign for essential medicines for all, disseminates the campaign statement, and includes a resource centre with downloadable materials to support spin-off activities.
"Access to essential medicines is a human right and a cornerstone of an effective primary health care system." - Stop Stock-outs
WHO defines essential medicines as "those that satisfy the priority health care needs of the population....Essential medicines are intended to be available within the context of functioning health systems at all times, in adequate amounts, in the appropriate dosage forms, with assured quality, and at a price the individual and the community can afford." At the World Health Assembly in 1977, governments made a commitment to ensure these essential medicines are available in public health facilities. Yet organisers say that today, over 30 years later, public health facilities in Africa have in stock only about half of a core set of medicines used to treat common diseases such as malaria, pneumonia, diarrhoea, HIV, tuberculosis (TB), diabetes, and hypertension – all of which are among the highest causes of death in Africa. Stock-outs disproportionately affect the poor, and this is exacerbated in rural areas.
HAI Africa, Oxfam, and OSI. Country Partners: Kenya: Kenya Access Treatment Movement (KATAM), Kenya Hospices and Palliative Care Association (KEPHCA), Ecumenical Pharmaceutical Network (EPN), Consumer Information Network (CIN) – Kenya. Malawi: Malawi Health Equity Network (MHEN). Madagascar: Sambatra Izay Salama (SISAL). Uganda: Coalition for Health Promotion and Social Development (HEPS), National Forum of PLHA Networks in Uganda (NAFOPHANU), Action Group for Health Human Rights and HIV/AIDS (AGHA). Zambia: Treatment Advocacy and Literacy Campaign (TALC), Network of Zambian People Living with HIV/AIDS (NZP+).
The campaign focused on the related issues of low availability of medicines, leakage of medicines, and poor management. According to organisers, studies have shown a low availability of medicines in public health facilities, as well as large quantities of medicines intended for public facilities being leaked into the private market where they can fetch a higher price. The organisation also noted that poor governance and corruption stem from poor management, and lead to problems going unnoticed or unreported.
The campaign therefore sought to introduce a way of increasing the accountability of health providers to the consumers and the communities that they are supposed to serve. According to ACCU, consumers generally lack the organisation and power to discipline other actors by voicing criticism or choosing a different health care provider. This campaign therefore sought to strengthen social accountability understood as an “approach towards building accountability that relies on civic engagement where ordinary citizens and civil society organisations participate directly or indirectly in exacting accountability. It is a broad range of actions and mechanisms that citizens, communities and CSOs and independent media can use to hold public officials and servants accountable."
The 2007 Anti-Corruption Week was therefore designed to increase people's awareness of the existing problems and their health rights, and to inform people about what channels are available for complaints and for seeking redress. Most of all, the activities were aimed at three concrete outputs: expose concrete cases of corruption in the distribution of medicines, form community groups for future monitoring, and ensure concrete commitments from local leaders. During the campaign, names and contacts of individuals, who were keen to volunteer to monitor local service delivery in the health sector, were collected. The volunteers, who became part of a community group, are then responsible for holding local leaders accountable. They are tasked with ensuring that an increased number of corruption cases related to medicines are indeed investigated by authorities and not ignored or left unresolved as has been the case. To create awareness and establish commitment and support, the campaign engaged in a broad range of activities which included public processions, debates, community-based drama such as forum theatre, and print and broadcast media.
Health, Corruption, Governance
The organisation states that in 1999, medicine leakage rates were as high as 73%. In addition, inadequate monitoring and supervision, as well as a lack of corrective action, affect the management and the quality of health service delivery. The organisation therefore recommended increased community oversight in health service provision.
According to ACCU, already one week after the week-long campaign results were evident. On January 14 2008, the Daily Monitor reported that 3 health workers from Gulu referral hospital were arrested. They had stolen medicine for 72 million Uganda Shilling. Again 3 days later on January 17, the New Vision and Daily Monitor both ran a story about 10 doctors and nurses who were arrested in central Uganda.
Following the 2007 campaign, MS-Danish Association for International Cooperation secured further funds to ensure that the campaign was sustained throughout 2008. During 2008 ACCU and the regional coalitions worked hand in hand to address the corruption in the health sector. Key demands were identified and included the demand that government health workers should be barred from owning clinics or drug shops since it is a clear that government drugs end up in those shops, and that the government must brand all essential drugs with a "NOT FOR SALE" label.
MS-Danish Association for International Cooperation - Uganda and Anti-Corruption Coalition Uganda (ACCU)
MS-Uganda website on March 12 2009.
True Vision Ghana is a non-governmental organisation that works in Northern Ghana to promote the rights of children affected by HIV/AIDS, reduce the impact of the disease, reduce related stigma, and p
True Vision Ghana provides services through three main programmes: education and training, care and aid, and economic empowerment. The education and training programme works with health care workers and young people to support HIV/AIDS education and youth empowerment. Specifically, the programme trains Ghanaian healthcare workers to volunteer in underprivileged communities and support HIV/AIDS education initiatives. This includes providing HIV/AIDS classes focusing on risks and preventative measures, as well as malaria and other health topics; facilitating sex education classes and clubs in primary and junior secondary schools, as well as training youth leaders to run them; and providing a monthly youth-run radio programme on HIV/AIDS issues. According to the organisers, educating youth and empowering them to talk about HIV/AIDS issues without fear of being judged, is the key to lowering rates of HIV/AIDS in the future.
The care and aid programme focuses on providing food, access to antiretrovirals and the national health insurance programme, and school fees and supplies to people living with HIV and vulnerable children. The organisation's economic empowerment programme works to provide micro-financing and support to women affected by HIV/AIDS.
HIV/AIDS, Children, Youth
According to True Vision, once they receive more funding and donations, the number of children in the care and aid programme will be expanded, as will the number of communities involved in health and sex education. Currently, the organisation works in 6 communities in Northern Ghana. The organisation hopes that within a 5-year period the various programmes in the communities will become self-sustaining and will only require occasional visits and support from True Vision Ghana. This will better enable the organisation to work with other communities in the region.
True Vision Ghana website on March 12 2009.