University of the Philippines, Manila The effect of an educational intervention on the drug purchasing practices of local government officials in a decentralized setting   Isidro C Sia M.D., Ph.D.*, Cristina E. Torres, Ph.D.†, Noel R. Juban, M.D., M.S.‡   * Department of Pharmacology, College of Medicine, University of the Philippines Manila † Department of Social Sciences and Philosophy, College of Arts and Sciences, University of the Philippines Manila ‡ Department of Clinical Epidemiology, College of Medicine, University of the Philippines, Manila  

Background The advent of decentralization has given greater responsibility to local leaders for decision-making & resource allocation. Devolution in the Philippines involved the transfer of responsibility & resources from the national to the local government units (LGUs) who now have to deal with the burden of apportioning scant resources for multiple local programs. It is widely perceived that funds available for health and drugs after devolution has been substantially reduced. Given the limited resources & urgent need for provision of other basic social services it becomes important that municipalities efficiently purchase appropriate & sufficient drugs to address the health requirements of the people.

Objectives The aim of this study is to improve the drug purchasing practices of local officials using an educational intervention focusing on the principles of rational drug use. We hypothesize that the intervention will increase health budgets for drug purchases and bring about a corresponding increase in the purchase of essential drugs. Methods Subjects & Setting: Ten municipalities/cities were chosen at random from the provinces of Laguna (intervention) & Batangas (control). Potential participants were recruited my mail and included the mayor or representative, mayor’s executive staff including the local planning & development officer, budget officer, accountant, municipal/city health officer & staff, barangay officials.

Intervention The intervention was pre-tested & included two components: 1. Interactive discussion (IGD) addressing purchasing procedures at the municipal level, including budgeting guidelines and procedures, purchasing procedures and actual practices being followed in each community. 2. Short lecture-discussion, distribution of materials and IGD addressing legislation and guidelines for drug use and purchasing. Topics were; national drug purchase guidelines; Executive Order 49; Generics Act of 1988 (Republic Act 6675); Philippine National Drug Formulary (PNDF); essential drugs for rural health units; principles of drug supply management; rational drug use principles; drug use guidelines for common illnesses; & drug use guidelines for community health workers, pharmacies & home use. The intervention was conducted 10 times, in each intervention municipality or city, & coincided with regular executive meetings. Each session lasted between 1.5 & two hours.

Intervention Province Results Table 1. Number and Class of Participating Local Government Units Intervention Province Control Province 1 City 9 Municipalities 1 - 1st Class 2 - 4th Class 6 - 5th Class 2 - 1st Class 1 - 2nd Class 1 - 4th Class 5 - 5th Class

* Mann- Whitney Rank Test at alpha = .05 Table 2. Average Baseline Total, Health and Drug Budgets and Ranks per Group Averages Intervention Control P – value* Total Budget 62.5 57.3 0.7623 Rank 10.9 10.1 Health Budget 3.95 2.88 0.2720 11.95 9.05 Health over Total 7.71 7.84 0.8798 Drug Budget 0.68 0.61 0.7043 Drug over Health 22.92 18.08 0.7624 * Mann- Whitney Rank Test at alpha = .05

Table 3. Comparison of health and drug budgets pre- and post-intervention Averages Intervention Control P-value Health Budget 2000 2001 % change 67.21 81.4 14.19 64.24 72.23 8.05 0.6501 Drug Budget 12.31 11.30 - 1.02 11.14 14.29 3.15 0.4497 Drug to Health 22.92 14.49 - 8.43 18.08 19.50 1.51 0.1736

Table 4. Comparison of purchase of essential and non-essential drugs pre- and post-intervention Control P-value Essential 2000 2001 % change 88.58 91.99 4.26 82.52 84.21 2.89 0.5453 Non-Essential 11.42 8.01 - 11.75 17.48 15.80 9.47

Conclusions One time intervention may not be sufficient to bring change. There seems to be a greater impact among LGUs with less resources than the rich LGUs.. There was noted increase in the health budget and per capita health expenditure in the intervention LGUs. 4. There was a decrease in the purchase of non- essential drugs in the intervention LGUs compared with the control LGUs..

Recommendations Reinforcements may be done in educating the heads Of LGUs regarding rational drug purchasing and use. Involvement of the village leaders should be encouraged since they have to work with lesser budgets and are the most in contact with the people. In depth analysis of the processes done by the different LGUs to identify which systems works for whom.