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Infrastructure and supplies


Developing the infrastructure of a HS means assuring that there are enough health facilities, within proper reach of the population. They should be well-equipped and well-maintained. If physical access is problematic, this means either building new facilities or improving the roads or means of transport, which will require collaboration with other sectors. A usual target for physical access is a primary care facility within 5 km or one hour’s walk. For the first referral level, a hospital that offers surgery, obstetric surgery, internal medicine and paediatrics, a common target is one hospital per 100 000 people - but this is only a very rough rule of thumb. In order to plan the availability of health services in a particular area, a coverage plan should be developed. This coverage plan should also consider the private facilities in the area and the health seeking patterns of people and, if needed, involve negotiation with the populations as important stakeholders.

Supply of drugs

We will focus on the supply of drugs, because drugs are a crucial commodity in the HS and to ensure appropriate supply and use of those is a major challenge to many HSs. However, what is said about drugs applies also to other medical supplies and technologies that are needed in the HS. HS challenges with drugs can be classified among five groups: poor availability and supply; poor quality; poor financial access to drugs and poor prescription/use. Since drugs are commodities with a generally high demand, it is a product that is mainly produced and distributed via the market sector, in which for-profit companies have a strong dominance. However, there are strong market failures, such as the oligopolies of big pharmaceutical companies and the strong information asymmetry between client and pharmacist and others. If we want to ensure access to quality drugs for all people in the HS, we need strong regulation to channel and control market forces. In order to ensure this, the following functions are important: developing national policies, standards, guidelines and regulations; affordability of drugs; quality assurance; logistic systems and support for rational use (Laing et al. 2001).

National policies address the list of essential medicines, where drugs should be available in the HS, guidelines about the prescription of medicines. Rules and regulations for procurement and distribution need to be developed and enforced. Since many drugs are sold in the PFP-sector, regulation should extend to those pharmacies, clinics and drug outlets. In order to steer provider behaviour, other incentives such as education and training and financial rewards have been tried, but the limited success of most initiatives illustrate the difficulty.
The availability of medicines depends on the procurement and distribution system. Although in theory, a central supply system with an aggregation of orders at different levels results in efficiency gains, the reality shows that there are many potential weak links at different levels that can weaken the functioning of the total chain, such as stock management, haphazard ordering systems and slow distribution. Although a wide variety of supply chains leads to fragmentation and lack of overview, a limited number of parallel channels for supply is likely to guarantee continuous supply of drugs better that one single system. There are often other supply systems, e.g. for particular programmes or subsectors, that may function better or that may be used as a fallback. Besides such centralised systems, a great share of drugs is distributed via private wholesale firms, who supply many different customers. Besides being expensive, the origin and quality of their drugs is not always reliable if regulation and control is deficient. 
Ensuring financial access entails adequate information on prices, the capacity to follow (or fight) international trade agreements and capacity to set and negotiate prices at national level in the case of large procurement orders. This capacity influences the availability and access to medicines in the public sector. In the commercial sector the prices vary enormously.
To ensure the quality of drugs, most countries have drug regulatory authorities, who control the registration and quality of nationally produced and imported drugs. The two major problems with quality are counterfeit and substandard drugs. To ensure quality throughout the whole supply chain, one needs to identify reliable producers, procurers and suppliers. The WHO has set up a pre-qualification system to identify producers, but the list has been limited to drugs for malaria, tuberculosis and HIV/AIDS. To identify reliable suppliers among private-for-profit providers, franchise chains and like mechanisms are sometimes developed.
The first steps in rationalising drug use are the development of an essential drug list and the development of treatment guidelines. Pre-service and in-service training of providers for rational drugs use is necessary, but not sufficient. At local and provider levels, systems of control, support and supervision should be built in to enforce and stimulate provider behaviour to rational prescription. One can think of audits, drug monitoring committees and regular meetings between the pharmaceutical and medical staff. On the demand side, awareness can be increased, with the help of consumer organisations and public education about the existence and risks of the irrational use of drugs.
These functions are strongly interlinked and measures to improve the situation will need to involve actions in all fields. For instance, the set-up of a revolving drug fund starts from the need to ensure availability of drugs. Such a revolving mechanism is only affordable and thus sustainable if it is combined with rational prescription. To work well, it requires a functioning supply system (Unger et al. 1990).
There are few indicators to assess whether HSs perform well in ensuring proper infrastructure and supplies. An example of an indicator for pharmaceutical access is the percentage of facilities that have all tracer medicines and commodities in stock (at the day of visit, over the last three months) and the ratio of median local medicine price to international reference price (median price ratio) for a core list of drugs (World Health Organisation 2008b).