In all three countries, NGOs play a major role in drug distribution and supply, especially in more rural areas. In these areas-which tend to lack a strong private sector and where there is little MoH presence-NGOs are the main suppliers of drugs and providers of health services. In each country, the NGOs involved in drug distribution and supply are mainly national mission-based NGOs. A few international NGOs, but of less significance, also operate. The Mission for Essential Drugs and Supplies (MEDS) in Kenya, the Christian Medical Association for Malawi (CHAM) in Malawi, and the Joint Medical Stores (JMS) in Uganda are all affiliated to international networks, but highly independent in their activities.

NGOs are expected to become more important in drug distribution and supply in these countries, owing to:

• ongoing decentralization of the public health systems;
• difficult economic situations (especially in Kenya and Malawi);
• demands from donors for more NGO involvement in drug distribution and supply.

^a Donors are phasing out their funding of public distribution systems in Uganda and reducing their funding in Malawi.

In the three countries studied, continued need for donor funding of public distribution systems and, to a lesser extent, for missionary-based systems underlines the issue of sustainability regarding NGO activities in drug distribution and supply. Both public systems and NGO systems depend on external funding. Therefore, none of them can claim to be financially sustainable, although JMS in Uganda is 75% self-financed, and similar figures apply to MEDS in Kenya and CHAM in Malawi. In all three countries, the lack of government resources is leading to competition between the different stakeholders involved in drug distribution and supply.

In Malawi, the MoH&P is sceptical about NGOs. It believes they lack professional capacity and that they are unwilling to be regulated. Such an attitude understandably affects the collaboration between the ministry and NGOs. This sceptical attitude towards NGOs on the part of the MoH is also seen, to a degree, in Kenya. Moreover, in all three countries, policy in drug distribution and supply has been developed without much NGO involvement.

Yet country studies revealed that NGOs are interested in collaborating more closely with WHO and MoHs in drug distribution and supply. They showed too that NGOs are prepared to work under some kinds of regulations (even though these could restrict their activities), provided their autonomy could be guaranteed. In all three countries, NGOs would like the national drug programmes to adopt a more proactive approach towards working with them, and urged WHO to use its comparative advantages to create better links between NGOs and MoHs. A more proactive WHO approach towards NGOs would presumably cause MoHs to focus more on NGOs.