Providing medical goods and services
In addition to issues concerning human and financial resources, strengthening health systems in developing countries involves providing quality delivery of health goods and services. This includes improving supply and distribution systems for drugs and vaccines, constructing or rehabilitating health infrastructure, general healthcare organization, hospital reforms and contractualizing public-private partnerships.
The issues in providing medical goods and services
Lack of access to quality drugs
The availability of cheap essential drugs is one of the Millennium Development Goals. Access to essential generic drugs has improved over the past twenty years but many problems do still remain. Half of Africa’s population still does not have access to drugs. Africa’s share of the drugs market has deeply deteriorated since the 1970s and remains marginal (1% of the global market for 12% of the total population).
The black market for drugs has grown sharply over the past 15 years (representing 60% of drug sales in some cases) due to the widespread practice of self-medication and high-cost, low quality services. Real counterfeit markets have sprung up everywhere multiplying both individual and collective risks. In addition, many countries are still dogged by problems of management and misappropriation, even though the public supply and distribution sector has generally improved performance thanks to the creation of national purchase and distribution centers with independent status.
Finally, less than 10% of resources for research target South diseases which, however, make up 90% of global health problems. Over the past 30 years 1 556 new products have been marketed but only 21 of them concern diseases mainly affecting South countries.
Various initiatives have been launched to improve access for South populations to quality low-cost drugs. The marketing of generic drugs (from Brazil and India) led to a sharp reduction in the price of antiretroviral drugs and the sale of some drugs at near-generic prices by some of the big pharmaceutical laboratories. The right of developing countries to use compulsory licences for manufacturing or importing generic drugs, one of the Doha principles, forms part of the World Trade Organization 2005 TRIPS agreements (trade-related aspects of intellectual property rights).
However, access for countries and populations to new patented molecules, particularly second line drugs to treat HIV/AIDS or malaria, remains very limited and dependent on international financing instruments. Yet these new drugs are necessary due to increasing drug resistance. The international drug purchase facility (UNITAID), supported by France and other countries, has the specific goal of scaling up and securizing financing allocated to purchasing dugs and tests for HIV/AIDS, tuberculosis and malaria. This should lead to a broader supply and price cuts.
Several initiatives have also been developing in research. The mechanism which commits to vaccine purchases proposed by Italy (advance market commitment) aims to create a market whose stability (thanks to donor contributions) would boost private research investment and speed up the introduction of new vaccines. Finally, some actors (private foundations, bilateral or multilateral partners), in partnership with the World Health Organization (WHO) support research and development for new molecules to fight against diseased neglected by the pharmaceutical industry.
Low use of public health services and non-regulated private sector development
Shortcomings in public services have led to sharp growth in lucrative private healthcare delivery. Patients, including the poorest (sometimes with heavy sacrifices for the household), turn towards “formal” private services when they exist and are affordable, or to traditional medicine and the “informal” sector where the personnel often has public status, varying levels of qualifications, and practise privately. According to the WHO only a third or a quarter of the population in poor countries use public health centers.
In Least Developed Countries (LDCs) “formal” private delivery is mainly concentrated in urban areas. In Middle Income Countries (MICs) it is often predominant and is the healthcare service the most used by middle or upper classes. However, the quality of private healthcare often varies enormously and both the best and worst quality can be found. Market regulation is a difficulty for both the State and professional organizations. Its integration into a global healthcare service delivery with complementary public and private sector delivery is also an issue. Public-private partnerships are still very recent and national health authorities have not yet let go of the model of one type of healthcare for everyone.
AFD actions aim to improve supply and distribution systems for drugs and vaccines, health infrastructure (rehabilitation / construction and equipment) as well as general healthcare organization (hospital reforms, contractualization, public-private partnerships etc.). Interventions to improve goods and service delivery have a specific “niche logic” focus or aim to complement other strategies.
Drugs and vaccines
In 2006 AFD entered into partnership with the DNDi Foundation for neglected diseases, in particular concerning the development phase for new artemisinin-based combination therapies for malaria. If both parties are satisfied with this partnership, AFD would like to continue it in 2008 and is also willing, through concessional loans, to support industrial partners in Africa and Asia who accept to manufacture combinations following DNDI principles (manufacturing non-patented generics sold at cost price to the public sector and international solidarity organizations). Such principles have been accepted by the French laboratory Sanofi Aventis for manufacturing in Africa.
Pharmaceutical industry support can, more generally, also concern high-impact drugs and vaccines as may be the case, for instance, with the manufacturing of the yellow fever vaccine by the Institut Pasteur in Dakar.
Improving delivery and reforming organization and management
AFD interventions to improve technical platforms (infrastructure and equipment) for public hospitals in LDCs are extremely selective and particularly aim to strengthen priority services which are essential to the implementation of other strategic axes it supports in the country. In every case, these interventions also include developing new incentives for service providers to improve the general governance within hospitals as well as the management methods in force. The small number of hospital reform projects initiated by French cooperation in target intervention countries are conducted from this angle.
Whenever possible AFD projects seek to support decentralization processes underway in many African countries and strengthen the capacities of local authorities to manage health infrastructure now under their responsibility.
Partnerships with the private sector are developed so that the latter participate in the public health service or in the management of health services. For instance, in Cameroon the health C2D supports the policy of partnership and contractualization with the denominational private sector. These partnerships are developed in particular in health services in towns within an urban health logic. In the Central African Republic for instance, where public infrastructure management is extremely deficient, the Ministry of Health has accepted to delegate health center management in Bangui to a private employers’ organization within the framework of an AFD financed project.
In MICs support to the modernization of public and private delivery is financed by loans. Concessionality applies to the profit and non-profit making private sector which participates in a public service mission with requested investments meeting priority public health issues. Finally, AFD seeks to support public-private partnerships in health in countries expressing interest in this new management method (South Africa, Kenya etc.)