For some considerable time problems affecting national pharmaceutical services provision have been recognised. Those in the area of drug supplies management, particularly in the districts, have featured prominently in various reviews and reports relating to the pharmaceutical sector.
Specific problems noted include drug leakages, absence of proper stock management information and poor storage conditions.
Drug management training was an element of the Uganda Essential Drugs Support Programme 1991-1996 but adequate drug management systems are still not consistently in place.
Although such problems can be assumed to have existed prior to 1993, the introduction of local government reforms with the resulting decentralisation of health service delivery have exacerbated the situation because of uncertainty regarding roles and responsibilities in the area of drug management. However these reforms also provide an opportunity for improving drug management in the districts.
The Health Sector Strategic Plan 2000 defines procurement and management of drugs, medical supplies, and logistics as a key component of the integrated support systems element of the Plan. Major outputs identified are:
• an efficient and integrated procurement, distribution and storage system
• appropriate and adequate logistics
• efficient and effective drugs and medical supplies management system
The Joint Government/Development Partners Mission of November 1999 reviewed drug management and procurement from the perspective of the SWAp approach and observed that:
• despite efforts to establish an appropriate institutional framework for drug management the current system had weaknesses at all levels
• despite a reasonable per capita expenditure on drugs, the poorer segment of the population do not have adequate access to essential drugs
• the National Drug Policy had not been updated to take account of changing circumstances in the health sector
• decentralisation reforms had not taken into account the need to redesign the drug management system
• despite efforts to improve rational use of drugs, problems still persist with poly-pharmacy, over-prescribing and inappropriate self-medication
• despite an attempt to harmonise planning, procurement, storage and distribution of pharmaceuticals, this still remains a major problem in drug management
Key recommendations of the Joint Mission were
• the establishment of a Task Force on Drug Management with the responsibility of managing the transition and development towards a state of adequate functioning of the sector
• the establishment of a Commissioner for Pharmaceutical Services with adequate supporting human and other resources
The Task Force on Drug Management was subsequently established in late 1999 and functioned up to 2001. Its members included representatives of MoH Headquarters, MoH Districts, National Drug Authority, National Medical Stores, Pharmaceutical Society, Joint Medical Stores, the pharmaceutical private sector, the general public and health sector development partners. It was chaired by the Director of Health Services (Clinical and Community Health).
Its two main objectives were:
• to guide the process of reforming the pharmaceutical sector in general
• to establish a new system which can effectively secure access to essential drugs by the population within the concept of the new National Health Policy
Outputs expected from this Task Force were:
• a revised National Drug Policy
• an updated regulatory framework
• an adequate institutional framework for future drug management and a clear plan implementing necessary changes
• a proposal for the establishment of a Department of Pharmaceutical Services in the MoH with adequate technical and support staff
• a consolidated drug needs assessment
• a plan for essential resources for drug management
• a costed plan for the promotion of rational use of drugs
• a plan of action to address the drug leakage problem
• a plan for financing drug supply including the role of community schemes and cost recovery schemes
• a plan for harmonisation of drug procurement
A key activity related to the National Drug Policy output was to review the current National Drug Policy in a consultative process with relevant stakeholders.
According to WHO, a National Drug Policy is both a commitment to a goal and a guide for action. It expresses and prioritises the goals set by Government for the pharmaceutical sector and identifies the main strategies for attaining them. It provides a framework within which the activities of the pharmaceutical sector can be co-ordinated. It should include both the public and private sectors and the main actors in the pharmaceutical area.
The basis of any policy is a body of values, norms, standards and principles that guide decisions, strategies and actions. A drug policy is a global orientation with objectives and strategies to be undertaken to improve the national pharmaceutical sector and in particular the availability, accessibility and rational use of good quality essential drugs at affordable cost.
Following extensive planning the Task Force held a one-week National Drug Policy workshop in Jinja at the end of January 2000. The workshop was supported and assisted by WHO which sent three professional advisors (one from the AFRO Regional Office in Harare and two from the HQ in Geneva). One advisor participated with the Task Force secretariat in a week-long pre-workshop fact-finding and situation analysis exercise which included consultations with many of the key stakeholders and visits to 4 districts. Following extensive briefing the other two advisors participated in the workshop giving clear WHO guidance as to the most suitable approach for correct National Drug Policy formulation.
The workshop had presentations and intensive discussions on all areas of national pharmaceutical services and covered in detail all the main drug sector management issues which had been identified in the various reviews and reports. The successful outcome of the workshop was a working draft of the National Drug Policy. The Task Force further refined this in line with initial comments received from key stakeholders. The document was subsequently circulated to all stakeholders for further review and finalisation during a National Drug Policy Consensus Workshop which was held in Kampala in April 2000 as the final stage of the consultative process.
Following this workshop the agreed amendments and additions were incorporated into the final form of the document.
A peculiar feature of the previous National Drug Policy was that it was contained within the National Drug Policy and Authority Statute of 1993. This established the National Drug Authority as the national drug regulatory body with one of its functions the implementation of the Policy.
This proved to be a very difficult and impractical arrangement as:
• the policy was not comprehensive, simply consisting of a series of brief statements of intent
• no strategies were identified for implementation of the policy
• it was beyond the capacity of NDA to satisfactorily implement the policy in addition to its primary and increasingly demanding drug regulatory role
• the fact that the policy was enshrined in the statute meant that any amendment required would have to go through the complex and prolonged legal process involving ultimate approval by parliament. As policies are supposed to be dynamic management tools under constant review and capable of suitable amendment to respond to changing circumstances, this was obviously a major obstacle to implementation.
Thus one of the main recommendations of the Task Force workshop was that the National Drug Policy should be separated from the statute so that it can be used, implemented and amended as required.
This step will also represent the first stage in the preparation of a revised statute which is another key output expected of the Task Force. Considerable work has already been done on proposed revisions of other elements of the statute. It is expected that the end result of these changes will be a much improved and updated statute which will greatly strengthen the ability of the NDA to effectively implement the necessary regulatory controls for the pharmaceutical sector in Uganda.
The formal Ministry of Health adoption of this new NDP was followed by the development of a comprehensive, detailed 5-year National Drug Policy Implementation Plan (or National Pharmaceutical Master Plan).
The successful implementation of this will require major commitment and support of MoH and stakeholders in the pharmaceutical sector and significant and sustained financial and technical assistance from our development partners.
It is our sincere hope and expectation that the outcome will be significantly improved national pharmaceutical service provision and pharmaceutical care for each individual patient.
Dr Sam Zaramba
Director of Health Services (Clinical and Community Health)
Chairman, Task Force on Drug Management
Kampala, October 2002