PROVIDA’S IMPACT ON IMPROVING ACCESS TO AND USE OF ESSENTIAL DRUGS IN POOR COMMUNITIES IN PERU

1. PROVIDA’S IMPACT ON IMPROVING ACCESS TO AND USE OF ESSENTIAL DRUGS IN POOR COMMUNITIES IN PERU JOSEFA CASTRO, PHARMACIST JORGE SOLARI, PHYSICIAN SERVICIO DE MEDICINAS PRO-VIDA

2. Problem Statement: The poor of Peru were confronted with high-cost medications, lack of supplies in government health facilities, and the promotion of the irrational use of drugs by health care providers. • Objectives: Increase access to essential drugs for poor communities, with their active participation. Promote the rational drugs use (RDU) among communities, health professionals, and the general public. Lower the costs of health care not only by lowering drug costs but also by lowering the cost of drug treatments through their rational use. Set an example for government institutions to include RDU as part of their health policies. • Intervention: A model was designed for grassroots pharmacies (GPs) in communities where government services were not available. The model includes training a health promoter elected by the community to be the head of the grassroots pharmacies and a professional health care adviser to the grassroots pharmacies . An essential list of generic drugs was developed to be supplied to the grassroots pharmacies at low cost (60% to 90% less than regular pharmacies). A methodology for providing health education to uneducated adults was also developed. In 1985, Provida started working as a nongovernmental organization based on this model. • Results: Provida’s model has been replicated by the Peruvian Health Ministry (PHM) and some other Latin American countries. grassroots pharmacies are recognized by Peruvian law as providers of pharmacy services of high quality. A 1996 study found 4,500 active grassroots pharmacies serving 2,600,000 community members. Medications had been provided to 1,200,000 people. The number of grassroots pharmacies has decreased since the government applied Provida’s model and expanded its health services. Around 10,000 health promoters and health professionals have been trained. Provida’s team periodically conducts research studies on drug use. Provida’s supply system is 100% auto-financed, while Provida’s administration as a whole is 85% auto-financed. For the past 17 years, Provida has put out a quarterly magazine that is independent of the pharmaceutical industry and contains reliable scientific information. Abstract

3. Servicio de Medicinas Pro-Vda, Pro-Vida, was created in July, 1985 as a non government organization by initiative of pastoral agents following a catholic church initiative to contribute to improving access to essential drugs for Peruvian poor people. • Pro-Vida promotes the rational drug use(RDU) to different target audiences: - Health care workers:health professionals health promoters(HP), among others. - MOH authorities and health official - General public Background

4. Poor people of Peru faced • High-cost medications • Under supply of drugs in government health facilities • Inadequate access to essential drugs, especially in rural areas • Health care providers prescribing and dispensing irrationally. Problems Addressed

5. Increase access to essential drugs for poor urban and rural communities. • Promoteactive participation of these communities in health care. • Promote rational druguse (RDU)among communities, health professionals, and the general public. • Lower the cost of health careby lowering the cost of drugs and drug treatments through their rational use. • Set an example for government institutions to include RDU as part of their health policies. Objectives

6. A model was designed for grassroots pharmacies in communities where government services were not available. It included: • A methodology created by Provida: training conducted by using educational techniques specially designed for uneducated adults. • Training materials to support training activities. • Training a health promoter (HP)elected by the community to be head of the grassroots pharmacies • Training a health care professional to give technical assistance to the HP in charge of the grassroots pharmacies • A limited list of essential drugs to be managed by HP • A rational system for supplying essential-quality drugs to the grassroots pharmacies at low cost (60% to 90% less than regular pharmacies). • A revolving fund for drugs raised by the community by means of loans from Provida as seed fund. Since 2001, HP are also being trained on community epidemiology to cover needs beyond grassroots pharmacies. Intervention Model for Grassroots Pharmacies

7. Characteristics of Pro-Vida’s methodology are: • To encourage active participation of the community with representatives in the local board. The grassroots pharmacies are a initiative of these local boards. • To introduce a strong awareness of the benefits of an RDU policy • To provide accessible educational material to the community in such a way that it be related to them • Constant updating of the training of the health promoters and the training material to fit the needs of the community • To extend the training and RDU education to healthworkers from public services, MOH and NGOs. • Thus, education efforts cover all levels from the general public to health professionals and policy makers. Methodology of the Intervention Model

8. Provida’s model has been replicated by the Peruvian Ministry of Health (PACFARM, a public supplying program) and some other Latin American countries. • Because of the good work that Grassroots pharmacies have done and as well as Pro-Vida’s lobbying have donne, they have been recognized by peruvian law as providers of pharmaceutical services of high quality in their communities (firsth level) • In the Health Act (Law) promulgated in july 1997, the Peruvian Ministry of Health has declared that: Government health care providers must follow a RDU policy. Drug supply must be managed through a generic drug list. Community participation in health care should be promoted Implications

9. A 1996 study found: • 4,500 active grassroots pharmacies serving 2,600,000 community members. • medications had been provided to 1,200,000 people. • around 10,000 health promoters and health professionals have been trained. • Pro-Vida’s team periodically conducts research studies on drug use. • Its supply system is 100% auto-financed, while provida’s administration as a whole is 85% auto-financed. • For the past 17 years, Provida has put out a quarterly magazine that is independent of the pharmaceutical industry containing reliable scientific information about RDU. Results

10. Beyond supplying low cost drugs to community pharmacies, Provida : • is now actively participating in the MOH tenders • has been able to reduce the price of antileshmaniasic drugs drastically, thus, bringing the cost of treatment down to 1/8th of the cost in 2003. • has obtained a 5 fold price decrease for antileishmania drugs • has increased the number of treatments obtained by supplying quality drugs at lower price • is contributing to improve efficiency of government funding OthersAchievements

11. Strong opposition from some laboratories and drug suppliers to the RDU policy • Lack of economic resources restricts the promotion of RDU. It is not easy to finance a drug bulletin that promote RDU. • A weak legal system hinders the promotion of generic drugs • The register process of drug needs technical improvement in order to strengthen RDU. • Withdrawal of health promoters from grassroots pharmacies due to personal economic needs. Limitations

12. Provida’s model has shown to be successful in: • improving use of drugs and • lowering the price of essential medicines for the poorest families in Peru. • By doing so, it is contributing to increase access to proper treatment. CONCLUSIONS

13. Continue to support communities in their efforts to have access to rational health treatments. Continue -and improve the logistics on -the supply of drugs to the Ministry of Health for treatments against: • Leishmaniasis (since December, 2003) • Malaria (since February, 2004) • VIH (currently in supplier selection process) • For tuberculosis (since February, 2004), joint work with the MOH and some others NGOs on prevention, education and organization of patients, their needs and rights (Global Fund Project ). Current and Future Work