Remediar – Mauricio Monsalvo, National Coordinator – Argentina
The national coordinator for Argentina’s ministry of health Plan Remediar discusses developing a professional management culture in the country’s public health centers, and the programs wider role in the public health system.
Would you begin by giving our readers a brief introduction to Plan Remediar, and the scope of your operations?
The main objective of Plan Remediar is to provide access to free medications to everyone in Argentina. When this program started, we purchased and supplied 21 different drugs to 2500 health centers, and in 2004 we extended our portfolio to 50 products and worked with 5000 health centers. Currently, we work with 7000 health centers, and we are planning to complete a Drug Reference Book for primary care level covering the 79 different medications we currently provide.
Today, Remediar finances, procures, stores and distributes these 79 drugs to primary healthcare facilities and public health centers across the country. We are also used as a public logistics operator by a variety of other ministry of health programs, so we distribute many more medications than just those that we procure. The entire range of medications and materials distributed is very wide, for example, we distribute HIV antiretroviral drugs on behalf of the national HIV/AIDS plan as well as our own medications for conditions such as hypertension or diabetes.
What are the biggest challenges for Remediar currently?
Managing the logistics of distribution and record keeping always is a huge challenge. Much remains to be done and many challenges lie ahead, like the development of our systems and information departments; once ready, they will help us to manage our operations much more efficiently. Another problem comes when the same drugs that we distribute are also acquired by other Health Programs within the ministry, as it increases competition substantially.
One of our main strengths lies on the fact that we do not outsource and privatize all of our logistics operations. Our distribution model does not rely on the established private commercial circuit and the pharmacy chain; meaning that we’re self dependant in many ways. We also reject the option of letting the state do everything for us. We have our own infrastructure, our own warehouses and means of transportation. This gives us a balanced point of view that allows us to make more efficient decisions regarding what services should be provided by the state and what we should outsource to the private sector. For example, we invest on drug reception and storage and then transport all the drugs to many Health Centers all around the country. We are some sort of hybrid between a warehouse, a drugstore and a distributor. The standard pharmaceutical chain goes like this: laboratory producer, drugstore, distributor, seller, and pharmacy. Our job is to make management decisions on “who makes what”, “what goes where”, and “who is monitoring, taking, moving, or delivering it”. It’s neither 100 percent private or 100 percent public.
Could you describe the tender process by which you assign contracts to manufacturers?
We go through an international public tender and a competitive process. First of all, we need to have a technical definition of the quality of any given medication that must be registered by then. Many international labs and companies from abroad can compete as long as the medication is not certified in Argentina. Again, we must set the minimum quality standards for every product and, finally, we base our final decision on quality-cost relationship.
After that, we start the contract signing process. More often than not, we will trust the more experienced labs and companies because their quality standards are very high compared to less experienced ones. Companies that have a higher productive and financial capacity also an edge over the smaller ones, as they are able to keep up with our high volume purchases more reliably, and since we don’t provide particularly flexible payment terms. We also operate on a “national preference” principle, which gives local companies higher priority by adding a 15 percent surcharge to all foreign bids; ie, a foreign provider has to undercut the best Argentinian offer by more than 15 percent. There have been a few South American companies that have won contracts by submitting very low bids, however they clearly didn’t do so for profits, but to help build a toehold in the Argentinian market.
How is Remediar working to improve the professionalism of the public health sector in Argentina?
The main priority of Plan Remediar is to ensure public health-care workers have access to a reliable drug supply. There is a lot of uncertainty for doctors working at primary health care centers, which are managed and funded at the provincial level, as supply and equipment deliveries are unreliable. Remediar serves as a national provider of essential medications to these centers that ensures they have them on hand, enabling doctors to administer medications immediately, which of course accelerates the patients response and is more likely to prevent further complications.
To answer the question related to professionalization, our country is undergoing an enormous personnel-training process; that includes physicians, health-care workers, and many others. We are also under an ambitious training program for inventory management that focuses on the storage of medicines, pharmacovigilance procedures, definition of demands, processing stock shortage conditions, inventory reconciliation procedures, forecasting future demand, and a few other areas. This new health center culture that we are fostering is very innovative for Argentina, as most government departments still don’t record what drugs they provide; until recently there was no proper registration of the drugs inside the health centers.
What variables do you use to monitor progress and set internal goals?
First of all, we use productivity indicators for primary health care centers. We also keep records of our stock and our prescriptions. So, all items posess that kind of information: stock and prescription. Normally, we will plan our stock two years in advance, and the procurement process takes about a year. All of our drug deliveries are done on a monthly basis, we keep a three month supply in our warehouse, and the centers keep a one month supply on hand to protect against potential delivery failures.
What medications and capabilities would you like to add to Plan Remediar in the future?
We have a few ideas and plans, but they are still in the development process, and won’t be introduced into our portfolio of medications for another five years. Some examples of the medicines that we’re planning to work with are CNS medications for mental health issues, and medications for non-transmittable diseases. We already have a couple lines of diabetes and hypertension medications but we would like to explore some other possibilities to give physicians more options to work with. Some of the other products in our pipeline include immunosuppressants for transplant patients.
I would also like to see Remediar expand its operations to the Argentinian provinces that we are not active in yet, there is still a significant portion of the population that we do not cover.
What would you change about this industry?
I hope that the health centers in Argentina improve the professionalism of their management make use of the skills we are helping them to develop through our educational programs. There have been some compliance problems within those institutions including many of the prescriptions (written for off label use, inappropriate dosage, incorrect indication, etc), and half of the Argentinian population doesn’t take full advantage of their medications because they don’t follow the directions of their prescriptions. A lot of resources are lost due to the lack of information and education provided to both physicians and patients; for every two million dollars invested, a million is lost for the reasons above. Let’s say someone is prescribed antibiotics, if they must take them for seven days, but only take them for four days, they may recover in the short term but because they didn’t follow the prescription properly, some of the infection might survive and return with a greater antibacterial resistance; this is something that most public health center patients have no understanding of, and that physicians do not adequately emphasize. Perhaps developing a culture of “adherence to the treatment” is our biggest challenge.
How did you make the leap from political sciences to epidemiology?
By accident! Within political science, there are many different branches, and some of them include aspects such as public health policy, which incorporates a macro-level of epidemiology. One of my political science professors worked in the medical branch of one of this government’s public departments. Before rose to my current position in this field, I did a masters degree on epidemiology to complement my political background. Working in this field, in the ministry of health, is very fulfilling as our work helps a lot of people and improves the health and life of individuals across the country.