Whether or not a public sector supply system operates with cost-recovery, decentralized drug budgets, “cash-and-carry” or other systems, it should be well designed and given sufficient human and financial resources to be run properly. The performance of the distribution system defines whether or not patients will receive the essential drugs they need.
As mentioned above, the best systems are probably based on a combination of public and private management. For example, the transport of drugs and supplies can often be done better by private transport companies. In all cases, distribution and storage should be monitored to ensure the quality of drugs at all levels of the distribution network.
Availability of essential drugs in rural areas depends heavily on the distribution system within the districts. In several countries, such as Kenya, Uganda and the United Republic of Tanzania, monthly ration kits have been used. However, they are inflexible and involve higher direct costs. They can also lead to surpluses and shortages of some drugs. If the necessary managerial and administrative structures are in place this “push” system should be changed into a “pull” system on the basis of lists of essential drugs and supplies for rural facilities. A simple requisition system includes the use of a maximum stock at the rural facility (usually set at three months’ consumption) towards which monthly orders are placed by rural staff.
In most countries the majority of the population is serviced by private-sector drug supply systems, which include private wholesalers, distributors, pharmacists and informal drug sellers. Although growing in most countries, in developing countries the private sector is still concentrated mainly in urban areas and usually fails to serve rural areas fully. When developing a national drug policy it is important to take this sector into account, since it can play a role in maximizing access to health care.
Motivating the private sector to cover less profitable areas of the country may need a system of incentives, such as government subsidies, public or “people’s” pharmacies, or franchising. Another approach to increasing access through the private sector is by a programme of training in prescribing for drug sellers (see under rational use). This may require legal changes.