Financial sustainability is vital to the success of any bulletin. Money is needed for:
• human resources: payment for administrative staff, writers and editors;
• material resources: references, equipment, rent, phone and electricity charges;
• printing and distribution of the bulletin.
Financial resources vary greatly from country to country and between different regions or centres within a country. Developing countries usually have severe budgetary constraints and sources of funding are usually limited. It is important to carefully manage finances right from the start. Decisions on the size, appearance and the extent of circulation of a bulletin should be based on a realistic assessment of the financial resources available. It is best to start modestly, at least initially, and then slowly expand as the bulletin gets established and more resources become available.
Much can be achieved with a limited budget if there is a strong commitment and motivation at both individual and organizational levels. As an example, the production cost of the Nepal Drug and Therapeutics Letter, described above, is very modest. Seven hundred copies of the bulletin, produced every two months, cost around US$10. This cost is borne by the university teaching hospital.
Sources of funding
There is no simple answer to the question of how to finance a bulletin. Some say that whenever possible bulletins should try to generate their own income through paid subscriptions. Having a lot of small sponsors can support a much stronger and more independent editorial base than one or more main sponsors (e.g. through a bulk subscription arrangement). Relying on the sponsorship of individual readers means relying on people who share the views of the editorial team. Bulletins that depend on subscriptions expect their readers to be interested enough to pay for their information, and subscription renewals are indeed a sign of readers’ interest.
Most doctors and pharmacists are used to receiving promotional information from industry free of charge. Some bulletins who do not try to change this established custom choose a system of controlled circulation in which all or most health professionals receive their copy of the bulletin free. This may be possible with financing from the Ministry of Health, a consumer organization, a sick fund, a professional association or a non-governmental organization. Charging for a bulletin may discourage or diminish its use, especially in developing countries. It is not unusual for a bulletin that depends on subscriptions to reach only 10 - 20% of professionals whereas a bulletin distributed free to health professionals may reach 80 - 95%. Broad distribution of a free bulletin has the advantage that it may reach the 'not-yet-converted'. Readership surveys should be carried out, however, in an attempt to know to what extent a bulletin is being read (see Chapter 12). Bulk subscribers (e.g. governments, health authorities) will also need to be assured that the bulletin is worth paying for.
The choice of financing will also depend on how you can obtain funding with the maximum guarantee of maintaining your editorial independence. No interest group should be allowed to influence the choice of topics or the contents of a bulletin. Before accepting any external funding, the bulletin’s editors need to assess if there are any implications for the independence of the bulletin. The following could be considered.
In countries where national drug policies exist and are really implemented, it is very helpful for bulletins to try to be included and funded within the framework of such policies. Some bulletin editors might be as wary of government funding as of private industry. An important difference however is that the government normally represents the general public interest and does not promote the use of certain brand name drugs. By contrast, it might be in the interest of the government to reduce costs and therefore to promote use of the cheapest, but not necessarily the best, option. There are examples where drug bulletins published by government department have had ‘sensitive’ articles censored. A national government cannot be considered as one monolithic block, but as an umbrella for different sections, often with conflicting interests. Funding is best sought from a government department that is oriented towards public health and directly concerned with the aim of promoting rational drug use (for example, the department responsible for drug reimbursement or for the development of national health and drug policies); such a department is probably less likely to have conflicts of interest than, for example, the authorities in charge of industry development.
Institutions and non-governmental organizations
Depending on the local situation, funding for the bulletin could be secured from several other sources. These include local, national or international non-governmental organizations, universities, hospitals, professional organizations of doctors or pharmacists, health insurers, consumer organizations, donor agencies and charities.
The pharmaceutical industry
Pharmaceutical companies are never a good option to ask for funding. Sooner or later they will want to influence the contents of your bulletin. How will you write critically about a certain new drug if the company selling the drug is your main sponsor? Companies will often want a return on their investment, for instance by being named or by letting you print advertisements for their products. Concern about future funding can also lead to a less critical editorial policy or to silence on sensitive issues. A bulletin cannot be a member of ISDB if it receives funding from the pharmaceutical industry.
Case study: Boletin AIS-COIME*, Nicaragua
Under the Sandinista Government (1979 - 1990) there had been strict control of the supply of drugs and drug information. After the change of Government in 1990, one of the first actions taken by the new Ministry of Health was to ‘free’ the drug market and allow the importation of drugs without any requirement for registration. As a result of these changes the number of private pharmacies increased, pharmaceutical industry representatives renewed their activities and there was widespread advertising of drugs in newspapers, on television and on street posters.
To address some of these problems we started our bulletin. The first two editions were published in 1992 and they denounced the unethical practice of advertising unnecessary, inappropriate or unsafe drugs (e.g. antidiarrhoeal drugs, strychnine and vitamin A-based sexual and brain stimulants). These articles prompted a national campaign in the mass media and, at a television press conference, the Ministry of Health was forced to publicly support the control of drug advertising. Subsequently, offending street posters were withdrawn in the capital. This episode stimulated us to produce an independent source of information for the country.
It took us four years to get to the stage of publishing our bulletin regularly three times a year. We were able to achieve this by 1996 once we got financial support to employ a young physician full time to develop the different activities of our organization (AIS-Nicaragua), including information, training, advocacy, networking and research. Now five medical practitioners are working in AIS. We work together in a very small room (20m2) and have access to facilities such as a fax machine, photocopier, store, library and a meeting room, which we share with another NGO. The printing alone costs us US$1500. Most of the issues have been funded by European NGOs and some by the Pan American Health Organization office in Nicaragua. We are involved in all AIS activities, so only part of our time can be devoted to bulletin activities and the production process. However, we can call on a small group of physicians and nurses from different specialties in the Ministry of Health, NGOs or private practice to act as reviewers. We have a good working relationship and collaboration with the Ministry of Health drug information centre that provides us with information and reviews as needed, and also helps with the distribution of the bulletin. AIS is also an active member of the Interinstitutional Coordination for Access to Essential Medicines and the National Group for the Promotion of Evidence-Based Medicine. Participants from both networks take part in the article review process.
*AIS = Acción Internacional para la Salud (Health Action International)
COIME = Coordinadora Interinstitucional de Medicamentos Esenciales (Inter-institutional Coordination for Access to Essential Medicines)
Contributed by Benoit Marchand, Boletin AIS-COIME.