This study aims to analyze the role of CHWs in drug distribution at the village level. Emphasis is on the implications of such a role for the enhancement of rational drug use by consumers and for the attainment of the total range of CHWs activities. Specific research questions are directed at the relative importance of CHWs in drug provision, in comparison to other drug sources available to villagers. Both quantitative and qualitative methods of data collection are used in this study, including: 1) mailed questionnaire survey; 2) rapid appraisal survey of Village Drug Fund (VDF) and other drug sources in the village; 3) field-visits; 4) village case studies.
It can be concluded, in general, that the VHVs (Village Health Volunteers) and VDFs (Village Drug Funds) play an extremely limited role in the provision of drugs in Thai villages. Their contribution toward appropriate use of drugs by consumers is limited. The prevalent situation in the villages is one of availability of a wide range of drugs from various sources. The common outlets include: groceries, Village Drug Funds (VDF), drug peddlers, private clinics, and injectionists. Groceries, of which there are, on average, four per village, are the most common source of drugs. Functioning VDFs were found in roughly half of the villages, the majority of which are single VDFs (i.e. not combined with other activities in a cooperative or merged with a grocery, not part of the newly introduced CCPHC), Drug peddlers visit almost all villages, selling drugs ranging from OTC and prescription drugs to herbs and “Ya-Chud” (mixed bags containing various drugs, including prescription drugs). Their visits increase during agricultural peak periods. Clinics which are run privately by government health center staff and hospital nurses are particularly, but not only, important for provision of injectables. Injectionists are a source of antibiotics and intravenous solutions. This abundance and easy availability of drugs in the villages constitutes an extremely unsuitable environment for the enhancement of appropriate drug use by consumers.
In each village OTC drugs, prescription drugs and traditional medicines were available. On an average 42 drugs (measured by the number of brand names) were available per village. Eighty-two per cent of available drugs were modern pharmaceutical, 20% of which were prescription only drugs. Among the prescription drugs antibiotics with 54% formed the largest proportion, followed by anti-inflammatory drugs (11%), anti-diarrhoeals (11%) and “Ya-Chud” (10%).
No marked provincial or regional difference in the presence of drug sources at the village level has been found. The situation of drugs and drug sources in the majority of villages is quite similar: a wide range of drugs from various sources. However, village size (measured by the number of households) is a decisive differentiating factor. The bigger villages which have more drug outlets, specifically a large number of groceries, sell a wider range of drugs, than the smaller ones. This reflects the situation in which various drug sources respond to the demand in a context where restrictions are hardly implemented. The presence of other types of drug sources i.e. private clinics and drug peddlers also reflects the demand side. Private clinics of health center staffs and district hospital nurses are always located in the populated villages. Injectionists, on the contrary, are likely to be present in areas that are peripheral and relatively socio-economically backward.
If VHVs (village health workers with curative and preventive tasks which include distribution of drugs) are involved in distributing drugs in the villages, they do so in the context of the village drug funds (VDF). Three major forms of VDF were found: single VDF (the majority), VDF cum grocery, and the newly introduced Community Center for Primary Health Care (CCPHC). Drugs available at the single VDF are mostly OTC drugs produced by the Government Pharmaceutical Organization (GPO). Because the single VDF usually keeps the narrowest range of drugs of all available village drug outlets it has a very low sale volume and is, consequently, difficult to sustain. In fact, many of the single VDFs still considered to be functioning have a very sleepy existence, VDF cum groceries, i.e mergers of a VDF with a grocery shop, are run commercially and respond to the community demand for a wide variety of drugs. It was found that medicines kept in stock by VDF cum groceries included about 20% prescription drugs. Hence, the VDF loses its role as provider of essential drugs to the villagers and in due course, de facto, disappears.
In addition, drugs from the VDF played a very limited role in actual household drug use. From the household drug use survey in ten villages with a functioning single VDF, including 644 tracer illness episodes, it was found that in the majority (45%) of the 644 episodes the medicines used were purchased from grocery shops. Drugs from VDFs were acquired in only 12% of episodes and in a very selective manner; more frequently for cough and cold and fever and headache but much less frequently for diarrhoea, stomach-ache, and muscle pain. Household stocks of drugs played an important role in the villages of Chiangrai in the North, Health centers, district hospitals and private clinics were relatively important sources of drugs for episodes of severe diarrhoea and cough and cold. Drugstores in town, traditional practitioners, and injectionists were seldom resorted to for these kinds of common illnesses. However, in case of serious and chronic work-related complaints, besides groceries, injectionists and private clinics were frequently resorted to.
In areas where many VDFs are functional, the basic health service (BHS) staff has a supportive role toward the VDFs. The supporting activities are supply of drugs, regular supervisory visits, and periodical auditing visits. These activities are very important for the sustainability of VDFs. However, they do not directly relate to the enhancement of rational drug use by consumers.
On the basis of these findings, the research team proposed three main recommendations to the Thai MoPH. First, Thailand should urgently formulate and implement a policy that directly addresses the promotion of rational drug use by consumers at all levels. Such a policy should place very serious emphasis on the appropriate use of drugs in self-medication. The enforcement of regulations and strict control of distribution of, particularly, prescription drugs as well as other accompanying measures, constitute decisive actions. Second, education of the public toward appropriate use of drugs must be implemented. It should address the causes of inappropriate drug use by consumers and take people’s drug use culture into consideration. A participatory approach is recommended for developing effective education measures. Third, under the prevailing socio-economic conditions in the rural areas the present village community health worker scheme is difficult to sustain. It is, therefore, recommended that the government study ways to develop community level primary health care which is better adjusted to the perceived-needs and professionally defined health requirements of village populations.
An additional recommendation to nongovernmental organizations in the field of health is to form a decentralized consumer organization which can monitor the situation of drug provision and consumption at the village level.