Background

This study is based on the recognition, by the Action Programme on Essential Drugs and the Special Programme for Research and Training in Tropical Diseases, of the increasing importance in a number of countries of nongovernmental organizations (NGOs) in drug distribution and supply. These NGOs distribute a substantial proportion of drugs (more than 20%) and play an important role in health provision in general.

The increasing role of NGOs as distributors has also been recognized by the Organisation for Economic Cooperation and Development/Development Assistance Committee (OECD/DAC), the United Nations (UN), and by several donor countries involved in development assistance. Reform of the UN, changes in donor attitudes towards NGOs, and decentralization in many countries have further strengthened the role of NGOs in drug distribution and supply. The increasing importance of NGOs can be seen at country level, where several NGOs are participating more frequently in policy formulation and strategic definition of goals.

This study focuses on:

• the different World Health Organization headquarters (WHO/HQ) programmes involved in drug distribution and supply;

• international NGOs involved in drug distribution and supply;

• the drug distribution and supply situation in Central and East Africa, specifically, Kenya, Malawi and Uganda.

Aim and objectives of the study

The aim of the study was to analyse the importance of NGOs in drug distribution and supply from port to district, and to collect evidence to support the argument that a more proactive WHO policy on collaboration with NGOs working in drug distribution and supply is needed.

The specific objectives were to:

• develop a list of WHO programmes/divisions working in drug distribution and supply;

• develop an inventory of NGOs involved in drug distribution and supply (including which countries they are working in and what they are doing);

• analyse the collaborative experience of NGOs, Ministries of Health (MoHs) and WHO programmes in drug distribution and supply;

• translate this experience into recommendations for future WHO policy and programme implementation in the field of drug distribution and supply.

Findings

The study showed that collaboration between WHO programmes and NGOs is strongest when issues such as norm-setting, formulation of treatment regimes, production of guidelines and coordination are addressed, and weaker when issues such as financing and procurement are the main focus. This accords with the finding that many WHO/HQ programmes perceive their job as primarily normative and their priorities as standard setting, regulation and coordination.

Interaction is also relatively marked in the area of distribution and dispensing. This is related to the fact that WHO programmes see NGOs as effective in these areas (even though NGOs have been assessed as distributing less than 5% of all drugs globally). The study found too that attitudes towards NGOs are more positive when a programme is collaborating with numerous NGOs on an informal basis, as opposed to collaborating with only a few NGOs who are in official relations with WHO.

The correlation between the number of NGOs in informal relations with a programme and a positive attitude towards NGOs can partly be explained by four factors:

• that programme's particular area of work or the medical treatment regime that it recommends;

• the way in which programme activities are financed;

• the presence of programme workers at country level;

• the positive personal attitude of programme staff towards NGOs and a tradition within the programme of working with NGOs.

Interviews with WHO/HQ programmes showed that collaboration with NGOs is based on the following four assumptions:

• that agreements and knowledge accumulated at WHO/HQ level flow down to NGOs operating at the international, regional and national level;

• that WHO/HQ programmes request involvement of NGOs at country level as required;

• that WHO country offices involve NGOs in their work; that NGOs and MoHs are interested in and have the capacity to undertake collaboration with WHO.

However, these assumptions do not necessarily reflect reality. The main findings at WHO/HQ were that:

• few programmes have an established overview of the NGOs with which they collaborate;

• only one-third of the NGOs that collaborate with WHO programmes in drug distribution and supply are in official relations with WHO;

• only a few WHO programmes - including those working in countries and regions where NGOs are highly important - have an established and explicit policy on collaboration with NGOs.

Interaction between WHO and NGOs thus tends to be based on personal contacts and has a low degree of sustainability. These factors, and the absence of an officer addressing NGO work in the majority of programmes, somewhat contradicts the assumption that agreements and knowledge accumulated at WHO/HQ level flow down to NGOs at international, regional and national level, and that WHO/HQ programmes request the involvement of NGOs at country level. These assumptions would be more likely to reflect reality if programmes had an explicit programme policy on NGOs, a network overview^a of the NGOs with which they work and an officer responsible for addressing these issues.

^a A network overview is a list of NGOs with which the programme has collaborated, either officially or informally, during the past two to three years.

In fact, most NGOs questioned doubted whether a downflow of information occurs. They also questioned whether WHO programmes involve NGOs at country level. Information collected during the country studies conducted in Kenya, Malawi and Uganda indicated that agreements and knowledge accumulated at international level do not necessarily flow down to country level. Indeed, several NGOs have called for WHO to support the formation of coalitions at country level so that WHO can more effectively use what many NGOs see as WHO's comparative advantage: good contact with governments and MoHs. This is in line with study findings indicating that WHO programmes and WHO country offices focus extensively on MoHs and only to a limited extent on NGOs.

The study indicated that practical collaboration and involvement of NGOs in drug distribution and supply at country level are best handled by the relevant national WHO/country office, with minor responsibility assigned to WHO/HQ programmes. But it was found that WHO country offices do not necessarily involve NGOs in drug distribution and supply activities, and little effort has been made by WHO to initiate interaction between NGOs, MoHs and WHO in this area.

The study showed that developing a list of specific WHO programmes working in drug distribution and supply would be possible. However, developing a complete inventory of the NGOs involved in drug distribution and supply would not be, since not all individual WHO programmes have an overview of the NGOs working in drug supply and distribution in their particular area.

In each of the countries studied it is anticipated that NGOs will become even more important in terms of drug supply and distribution, due to ongoing decentralization, demands from donors to increase NGO involvement in drug distribution and supply, and financial constraints. In all three countries, national drug distribution systems and NGO distribution systems are dependent on external funding. This situation could exacerbate competition between the different stakeholders involved in drug distribution and supply.

Recommendations

Specific recommendations for WHO programmes, WHO country offices and NGOs are outlined below.

WHO/HQ programmes

Based on the study and conclusions, it is recommended that each WHO programme:

• establishes an evidence-based overview of the importance of NGOs in drug distribution and supply in its area of work;

• establishes a network overview of the NGOs with which it interacts, thereby creating transparency inside the programme and between programmes;

• develops an explicit policy on NGO collaboration including: guidelines for informal collaboration; information about what NGOs can expect from the programme; and a list of criteria that NGOs must meet in order to establish informal relations with the programme;

• establishes mechanisms to collect and document experiences of working with NGOs;

• addresses involvement of NGOs in country-level work as a part of programme policy;

• helps countries to establish overviews of the NGOs involved in drug distribution and supply at national level.

WHO country offices

It is recommended that the WHO country offices in the African region:

• establish policies on how to involve NGOs in drug distribution and supply;

• use WHO as a link between MoHs, national drug programmes and NGOs;

• support MoHs in involving NGOs in drug distribution and supply to a larger extent;

• establish mechanisms together with MoHs to collect and document experiences of working with NGOs.

NGOs

The NGOs in countries should:

• form coalitions of NGOs involved in drug distribution and supply in order to create partners for national drug programmes and WHO;

• define their role in drug distribution and supply.

Further research

Further research is recommended to:

• identify NGOs in Asia, Europe, South America and West Africa and initiate research on the work they undertake, for comparative purposes;

• analyse the experiences of other UN agencies concerning collaboration with NGOs in drug distribution and supply.