Motivación y satisfacción laboral

A few observations can be made about the implications of my findings for policy development in Cambodia. Firstly, both government and non-government respondents mention under the ‘Regulatory Frame’, that despite many official laws and policies being introduced since 1996 to strengthen the supply chain of pharmaceuticals, there remain gaps in the pharmaceutical regulatory framework, especially with regards to effective enforcement of these rules and regulations. The main reason put forth for this lack of enforcement is the stretched capacity – both human and financial - within the MoH. This lack of regulation, it is implied, may lead to exploitable gaps in the supply chain, driving the demand for medicines beyond the legitimate supply chain and heightening the risks of both substandard and falsified AMLs from reaching patients. Results suggest that most regulatory efforts have been in response to key focusing events – the initial evidence of poor-quality essential medicines, evidence of artemisinin resistance or media attention around a crisis linked to poor-quality health services in the Roka commune. Initiatives for systematic cooperation against poor-quality medicines, such as the IMC, have not been upheld over the long-term. Instead, government officials emphasize the success of one-off enforcement initiatives, such as the 2010 enforcement of the ban on oAMTs and crackdown on unlicensed pharmacy outlets. This shift of emphasis on unauthorised medicines suggests a lack of political interest towards the challenge of poor-quality medicines per se, and seems commensurate with the focus, from 2010 onwards, on less targeted efforts against falsified medicines and a stronger emphasis on efforts against oAMTs.

Both government and non-government respondents framed the issue of poor-quality medicines as a security concern, especially with regards to rising artemisinin resistance at the Thai- Cambodian border. Under the ‘Security Frame’, both categories of respondents concurred that the flow of MMPs across Cambodia’s borders contributes to the challenge of poor-quality medicines. The emphasis on migration and artemisinin resistance as a regional security threat, reflects the government’s emphasis on the role of the PPM scheme and the VMWs – to reach out to plantations and migrant workers and work to extend access to quality AMLs for these communities at risk. The geographical position of Cambodia as a hub for border development projects but also as the epicentre of artemisinin resistance, may therefore have shaped the priorities of the government, whose emphasis has been first and foremost on reducing resistance and working to control malaria in border areas. Government representatives argued that poor-quality medicines including AMLs are a greater problem in neighbouring countries, and that these may enter Cambodian borders only through MMPs, thereby shifting the blame for the circulation of poor-quality medicines away from the government. While both categories of respondents recognized the regional threat that the circulation of poor-quality medicines

represents, there was a notable reluctance among respondents regarding the feasibility of cross-border efforts. Once again, government representatives expressed scepticism towards the role of supra-national bodies such as ASEAN but praised instead, the ground-level initiatives with cross-border ties such as the VMW and the PPM initiative. As the government respondents interviewed also represent Cambodia in international for a, such as the ASEAN Pharmaceutical Product Working Group, this scepticism could explain the lack of emphasis towards regional harmonization of efforts for the regulation of medicines.

Among government respondents, the problem of poor-quality medicines was framed more as a medical concern. It was not framed as a criminal law issue, and the language used is predominantly clinical rather than legal. The ‘Medical Frame’ was the dominant frame among government-level policy actors interviewed, within which respondents refocused the issue of poor-quality medicines on the associated risks of artemisinin resistance and the need to strengthen efforts towards malaria elimination. This frame shift could be explained by the priorities set by the mandates of key donor organizations. Donor organizations may also emphasize technical approaches to dealing with poor-quality medicines, artemisinin resistance and to working towards malaria elimination, while avoiding the politically sensitive issue of poor-quality medicines. A common viewpoint among respondents was that Cambodia was a ‘step ahead’ of its neighbours in terms of malaria control efforts. Focusing on artemisinin resistance and malaria elimination, however, does not bode well for the case of other therapeutic categories of potentially poor-quality medicines that may be circulating in the country, and for general efforts to improve access to quality medicines.

Under the medical frame, government respondents also denied the problem of poor-quality medicines as a ‘Cambodian problem’, and shifted the responsibility for the issue to neighbouring nations and to the movement of migrant workers. Most government respondents deviated from the debate around ‘falsified’, ‘fake’ or ‘counterfeit medicines’, and re-centred the discussions around the problem of ‘substandard’ or ‘unauthorized’ medicines. The fact that ‘falsified’ was not a part of the local respondent’s discourse is not surprising in so far as it is not part of official definitions either. Instead, many respondents focused on ‘drug efficacy’, once again mirroring the main frame that emanate from the primary law and policies focused on the regulation of pharmaceuticals. Both in the legal documents available as well as in the discourse of government-level respondents, there tends to be an amalgam of definitions between falsified, substandard and unauthorized medicines. This amalgam of definitions is problematic, since these categories require distinct policy solutions and legal sanctions.

Non-government respondents, while validating the success of Cambodia’s efforts to enforce the ban on oAMTS, discussed the lack of transparency and corruption to explain that the official discourse should be interpreted with caution. Under the ‘political frame’, however, non-government respondents argued that the reported successes against poor-quality medicines, although validated by some recent evidence of lower rates of poor-quality oAMTs, might also be explained by a lack of transparency on data held by the DDF regarding the quality of other types of medicines. Non-government respondents emphasized that the sensitivity around the issue of poor-quality medicines means that some government officials were not willing to address the topic. This resonates with an apparent lack of political will to target the problem of poor-quality medicines especially the pharmaceutical crime of falsified medicines, as well as with the 2010 policy shift towards improving pharmacovigilance, drug efficacy rates and adverse drug reactions reporting; rather than focusing on cross-sectoral cooperation against the potential production, smuggling and distribution of criminally produced poor-quality medicines. Instances of corruption, especially with regards to the procurement budget, or in the form of vested interests in the pharmaceutical industry, respondents argued, still pose a problem for accessing quality medicines in general. The arguments put forth under the political frame seem commensurate with the shift incurred by the 2007 Amendment towards lighter penalties for the circulation of poor-quality medicines and, in particular, for officials acting as accomplices in such activities.

Non-government respondents also explained that weak enforcement of current regulations and political strife has an impact on the health system in general. Under the Health Systems Frame, they argued for the need to improve access to medicines through health systems strengthening and good governance. Non-government respondents pointed out that because of Cambodia’s tumultuous political past, the public health sector has been largely weakened. As a result, the private sector is still perceived among patients as a more trustworthy alternative. Government respondents agreed that the proliferation of unlicensed drug outlets is a challenge that only complicates the overall supply chain of medicines. This seems to correspond with the importance granted by government officials to the 2010 enforcement on the ban on oAMTs and the successful closure of unlicensed outlets. In the process of developing laws against the circulation of poor-quality AMLs, respondents alluded to the government’s intention to ban the sale of AMLs from the private sector altogether. This was presented as a source of policy controversy among policy makers, with some arguing that such a decision would impact access to medicines altogether, since a large proportion of the population still relies on the private sector for access to health and medicines. In this sense, respondents recognized the need to further incorporate the private sector under the regulation of the DDF to improve

access to quality AMLs, which is the purpose of the PPM program. The PPM program and PSI’s branded medicines were framed as an important initiative to improve access to quality AMLs through the licensed private sector – where most patients in Cambodia still seek treatment. The majority of respondents concurred that the patchy supply and distribution of pharmaceuticals and weak enforcement capacity (especially at the provincial level) of pharmaceutical regulations, still represent a challenge for access to essential medicines in general. Ultimately, non-government respondents conveyed that, while the availability of poor-quality antimalarials may indeed have reduced considerably since 2010, the problem is likely to persist for other substandard or falsified essential medicines.

Recent studies suggest that the presence of poor-quality medicines and especially of oAMTs has considerably reduced since 2010. However, poor-quality medicines in general remain a problem in Cambodia. Krech and colleagues (2014) report that failure rates have fallen from 7.4% in 2006 to 0.7 in 2011, but that poor-quality essential medicines can nevertheless still be found. Falsified lifesaving medicines like antibiotics are still found in community drug outlets, grocery stores, village shops as well as open markets (Khan, Okumura, et al. 2011; Yoshida et al. 2014; Krech et al. 2014; Lon et al. 2006; Phanouvong, Raymond, Krech, Dijiba, et al. 2013; ACTwatch Group & PSK 2014). The literature suggests that the supposed source of these poor-quality medicines lies in India, China or Thailand, labelled with names of (often bogus) companies such as VKP Pharmaceutical Co (Thailand), Brainy Pharmaceuticals or Guilin Pharmaceuticals (China) (Krech et al. 2014). Gaps remain therefore in Cambodia’s drug regulatory framework to address the threat of poor-quality medicines.