In general, in can be concluded that the VHVs and VDFs play a limited role in the provision of drugs in Thai villages. Their contribution to appropriate use of drugs by consumers is very small indeed. The abundance and easy availability of drugs in the villages are an extremely unsuitable environment for the enhancement of appropriate drug use by consumers. The wide availability of prescription drugs reflects the serious defects of the drug regulation system of the country in this respect.
RQ 1: Which Village Drug Provision Profiles (VDPP), including the relevant activities of BHS and private sources of drugs, prevail in the villages of Thailand?
The prevalent situation in the villages is one of availability of a wide range of drugs from various sources. It is a situation of abundance, easy availability due to a variety of outlets, and hardly any restrictions. 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 joint activities in a cooperative or merged with a grocery, not part of the newly introduced CCPHC). Drug peddlers visit almost all villages, mainly during agricultural peak periods, selling drugs ranging from OTC and prescription drugs to herbs and YaChud (mixed bags containing various drugs, including prescription drugs). 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 an outlet for antibiotics and intravenous solutions.
In each village OTC drugs, prescription drugs and traditional medicines are available. On average 42 drugs (measured by the number of brand names) were available per village. Eighty-two per cent of available drugs were modern pharmaceuticals, 20% of which were prescription drugs. Among the prescription drugs antibiotics with 54% formed the largest proportion, followed by anti-inflammatory drugs (11%), antidiarrhoeals (11%) and YaChud (10%).
RQ 2: How are these VDPPs differentiated by socio-economic and cultural area characteristics?
No marked provincial or regional difference in the presence of drug sources at the village level has been found. The prevalent situation of drugs and drug source 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 found to be a decisive differentiating factor. The bigger villages are found to have more drug outlets, specifically a large number of groceries, and sell a wider range of drugs than the smaller ones. This reflects the situation in which various drug sources respond to the drug use demand in a context where restrictions are rarely 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 but where drugs are easily available.
RQ 3: What is the current status/performance and relative importance of VDFs and VHVs distributing drugs in the villages?
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 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 kept the narrowest range of drugs of all available village drug outlets it has a very low sales volume and is, consequently, difficult to maintain. In fact, many of the single VDFs still considered functioning have a very sleepy existence. VDF cum groceries, i.e mergers of a VDF with a grocery shop for reasons of survival, 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.
RQ 4: What is the relative importance of various sources of drug distribution in the drug consumption pattern of the village population?
A household drug use survey in ten villages with a functioning single VDF, including 644 tracer illness episodes where medicines were obtained from one of the aforementioned outlets, resulted in the following picture. In the majority (45%) of the 644 episodes medicines 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 found to be resorted to only seldom 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.
RQ 5: How do, respectively, BHS staff, VHVs and villagers perceive the provision of drugs by VHVs, VDFs, groceries and other sources?
The drug provision role of the VDF is, in principle, perceived by both BHS staff and villagers rather positively: it contributes to the supply of cheap, good quality, and easily accessible drugs. In practice, it is usual for the BHS staff to think about the VDF as an important health-policy-related activity that must be kept surviving and mentioning in the reports. For villagers, specifically in Chiangrai, VDF were frequently perceived as a source of drugs that suit children (i.e. paracetamol syrup, chlorpheniramine syrup). For adults, VDF drugs were perceived as having weaker and slower curing effect. Complaints about a VDF came more often from its caretakers than others. Many VHVs or VHCs who had been looking after a VDF for years were bored, felt frustrated and wanted others to help them take care of the VDF.
No negative feelings against the drug providing role of sources such as grocery shops and injectionists were mentioned by villagers. In contrast, many villagers questioned why grocery drug sale was illegal as many drugs sold at groceries were allowed to be produced and advertized by the government authorities. They perceived the existence of these sources and the wide range of drugs as a normal condition: they are part of the community’s everyday life. Some BHS staff had a more critical view towards these drug sources. Yet almost all of them chose to keep a peaceful relationship with these drug providers as it was much better for their work that requires cooperation with all villagers.
RQ 6: What is the range of drugs VHVs and other sources distribute and where are they obtained?
The single VDF, as well as the CCPHC distributes a very limited range of drugs. The analysis of source of drugs used in household self-medication reveals drugs acquired from the single VDF or CCPHC were mostly analgesics, antihistamines and anti-cough drugs. These drugs were obtained from Government Pharmaceutical Organization (GPO) through district health facilities (i.e. district hospital).
The VDF grocery, similar to any grocery shop, distributes a full range of drugs, including (dangerous) prescription drugs, and many traditional drugs. Drugs are partly obtained from GPO, but mostly in the commercial market.
Many drug peddlers supply traditional drugs. Yet some distribute prescription drugs and some common pharmaceuticals. They frequently obtain drugs from local drug manufacturers in the province and sometimes from drugstores in provincial and district towns.
Private clinics normally provide a wide range of drugs including injectables. Injectionists distribute a relatively narrower range but always injectables, especially antibiotics, vitamins and antipyretics. Their major source of drugs are drugstores in provincial and district towns.
RQ 7: Within the total range of activities of village cooperative stores what is the relative importance of distributing drugs?
Normally, village cooperative stores are operated similarly to grocery shops. Various commodities are sold in order to respond to the client’s demands and drugs are one item among many. The relative importance of the drugs distribution activity in this context can not be distinguished from other selling activities. The fundamental VDF task to be a provider of essential drugs for the community cannot be expected to be carried out properly in case of the cooperative stores.
RQ 8: What is the relative importance of distribution of drugs in the daily activities of, respectively, VHVs who are involved and those who are not involved in the management of VDFs?
VHVs only are involved in the distribution of drugs in the context of a VDF or a CCPHC. In case they run a single VDF, drug distribution will cover only a very small proportion of their activities. If they run a VDF cum grocery, sale of drugs is an important activity, amidst sale of other commodities. On their participation in the activities at a CCPHC nothing much can as yet be said.
RQ 9: How are the payment of VHV services and the operation of the VDF arranged?
Generally, the VHVs and VHCs are not paid for their activities. Most of their duties in the community are voluntarily done at the request and under supervision of the health center staff (i.e. child weighing). For those who are responsible for the VDF, they may be given some money derived from the net profit of drug sales each year. Yet this is usually a very small amount. For the VHV/VHC who take part in the CCPHC, a certain small amount of money (i.e. 50 Bahts/month) is provided as a per diem for those who attend supervisory meetings.
The single VDF is expected to be managed by a committee appointed by the community with the VHV/VHC as most active members. Yet, in reality, half of this VDF type are run by a VHV or VHC solely.
VDF grocery has two forms. One is the village cooperative store or multi-purpose fund which is usually developed from the integration of many small and single-purpose PHC funds. Management is similar to that of the single VDF, but due to the larger turnover, payment for the manager is more. The other is a VDF that evolves to do business in a similar way as a grocery shop or the VDF that is looked after by a grocer.
RQ 10: Do VDFs make special allowances for poor villagers?
It is advised by the MoPH to the operational VDFs to arrange a part of their net drugs sale profit to provide special allowances for the poor in the village. Yet, in reality, the majority of VDFs had a very low sale volume (about 40% of single VDF had sale volume of less than 100 Bahts a month). This means that in practice no special allowances can be made.
RQ 11: What (practical) problems occur in the operation of VDFs?
There are problems at different levels:
1. The VDF operates in an environment characterized by abundance of easily available drugs. It does not, in other words, address a felt need based on scarcity.
2. It is increasingly difficult to recruit VHVs, as providing unpaid services to other villagers is not an appealing proposition. Besides, the prevailing model of VHV addressing simple health complaints is not well suited to a situation where in the village morbidity pattern accidents, AIDS, work-related diseases and chronic complaints take a prominent position.
3. The prevailing drug use culture of villagers emphasizes drugs which are defined by them to be efficacious. In practice, this implies a strong emphasis on antibiotics and other prescription drugs, YaChud and injectables. The VDFs stock of drugs and the VHV’s mode of administering a medication do not fit these preferences at all.
RQ 12: Do the VHVs issue the correct dosage of drug for the appropriate length of time for the symptoms diagnosed, according to a defined standard?
Drugs from a VDF are mostly obtained on the basis of villagers’ self-prescription. People come to buy drugs at the VDF, like they go to any grocery store, with the preconceived notions of what drugs (brand names) they want. Data from observation at grocery shops disclosed that customers normally asked for drugs by mentioning brand names. Many even walked through the back of the shops and picked up drugs themselves. These practices are also common at the VDF. If the VHVs do prescribe for some of their clients, correct or incorrect issuing of drugs is not a point as only a few common drugs are frequently obtained from the VDF (i.e. paracetamol, paracetamol syrup, brown mixture, antihistamine) and they are widely known by villagers.
RQ 13: What advice do VHVs and other providers offer to their customers concerning use of drugs?
Some VHVs and other VDF care takers, sometimes, gave advice to their clients about drug use. Their advice usually concerned dangers of YaChud and side effects of Ya-song (a packet of aspirin and caffeine) which they were taught about by health center staff. Yet, most of them complained that their advice was hardly if at all followed by villagers.
Advice on appropriate use of drugs from other sources such as grocery shops, injectionists, and private clinics, has not been systematically investigated, but is expected not to be given.
RQ 14: Do/Did the BHS provide support to the VHVs to strengthen their capacity to enhance rational drug use by consumers?
In areas where VDFs are functional, BHS staff were found to have a supportive role towards the VDFs. However, most of the supporting activities were supply of drugs, regular supervisory visits, and periodical auditing visits. These activities are very important for the VDFs to sustain. However, they did not directly relate to the enhancement of rational drug use by consumers.