Baseline Survey f the Pharmaceutical Sectr in Tanzania 2002
Table f Cntents Baseline Survey f the Pharmaceutical Sectr in Tanzania 2002...1 Acrnymys...1 Acknwledgements...1 Executive summary...2 Intrductin...4 Sampling...7 Ethical cnsideratin...9 Data cllectin...9 Main study results...11 Specific recmmendatins...19 List f annexes...23 Annex 1 Survey frm 1a: Central/district warehuse...23 Annex 2 Survey frm 1b: Public health facility pharmacy...24 Annex 3 Survey frm 2a: Central/district warehuse...25 Annex 4 Survey frm 2b: Public health facility pharmacy...26 Annex 5 Survey frm 3a: Central/district warehuse: Strage Checklist...26 Annex 6 Survey frm 3b: Public health facility pharmacy: Strage Checklist...27 Annex 7 Survey frm 4a: Public health facility pharmacy...27 Annex 8 Survey frm 4b: Private pharmacy...28 Annex 9 Survey frm 5: Private pharmacy...28 Annex 10 Survey frm 6: Public health facility: Ratinal drug use Prescribing indicatr frm...29 Annex 11 Survey frm 7: Public health facility: Ratinal drug use Patient care frm...30 Annex 12 Survey frm 8: Public health facility: STG...31 Annex 13 Survey frm 9: Public health facility: Treatment f diarrhea, ARI, and pneumnia...32 Annex 14 Survey frm 9 (cnt.): Public health facility: Treatment f ther tracer diseases...33 Annex 15 Survey frm 10: Husehld access and use f medicines...33 Annex 16 Cmments n the frms...35 i
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Baseline Survey f the Pharmaceutical Sectr in Tanzania 2002 UNITED REPUBLIC OF TANZANIA Published by Ministry Of Health In Cllabratin with Wrld Health Organizatin Acrnymys ARI Acute Respiratry Infectins EDL Essential Drugs List EDM Essential Drugs and Medicine Plicy EDP Essential Drugs Prgramme HSR Health Sectr Refrms INRUD Internatinal Netwrk fr Ratinal Use f Drugs MH Ministry f Health NDP Natinal Drug Plicy NEDLIT Natinal Essential Drugs List f Tanzania NGO Nn Gvernmental Organisatin OPD Out Patient Department ORS Oral Rehydratin Salts STG Standard Treatment Guidelines URTI Upper Respiratry Tract Infectins WHO Wrld Health Organisatin FEFO First Expiry First Out PSU Pharmaceutical Supplies Unit SP Sulphadxine 500mg/Pyrimethamine 25mg Acknwledgements The Ministry f Health wuld like t express its gratitude t the Wrld Health Organizatin whse financial supprt made it pssible t cnduct this survey and indeed the reprt write up. The ministry wuld als like t thank Rse Shija WHO EDM Natinal Prfessinal Officer, Helen Tata WHO EDM/DAP, WHO Geneva and Simna Chrliet, the WHO/EDM cnsultant, Bamak Mali fr their technical supprt. 1
Needless t mentin the clse cperatin and guidance frm the Reginal Medical Officers and Reginal Pharmacists f Mwanza, Dar es Salaam, Mbeya and Kilimanjar Regins during data cllectin. The Ministry f Health wuld like t acknwledge the valuable wrk f the fllwing research team wh devted their time t cnduct this survey: 1. Jseph S. Muhume Chief Pharmacist Ministry f Health 2. Rainalds S.R. Malele Senir Lecturer Faculty f Phamacy MUCHS 3. Emmanuel Mauga Senir Tutr, Directr IAHS 4. Dennis J. Mazali Envirnmental Health Officer/Tutr Schl f Hygiene MUCHS 5. Mildred Kinyawa Senir Pharmacist, Head, Schl f Pharmacy MUCHS 6. Henry Irunde Pharmacist Public Health Specialist Pharmacy Bard 7. Yuze G. Mlavwasi Senir Pharmacist Muhimbili Natinal Hspital 8. Danstan Hyplite Pharmacist Public Health Specialist Pharmacy Bard Finally the Ministry f Health wishes t greatly acknwledge the Principal Investigatr, Dr. Rainalds Malele tgether with Emmanuel Mauga and Dennis J. Mazali fr the preparatin f this survey reprt. Executive summary A survey n mnitring and assessing the pharmaceutical sectr in Tanzania was carried ut s as t knw whether r nt the ppulatin has access t essential drugs that are f gd quality, efficacius and are being used prperly. The survey als aimed at generating current infrmatin n the pharmaceutical situatin in Tanzania. The infrmatin s gathered will frm a basis fr the review f the Natinal Drug Plicy (NDP) f 1991 and the Pharmaceutical Master Plan f 1992 2000. This survey was carried ut in Octber Nvember 2002 invlving fur purpsely selected gegraphical areas, ie Mwanza, Kilimanjar, Mbeya and the capital city, Dar es Salaam. Frm the fur areas a ttal f 20 public health facilities were randmly selected (five frm each study area). Arund each f the health facilities visited, 15 husehlds and ne private pharmacy/drug utlet were surveyed. Since the survey fcused n mnitring and assessing the access, quality and ratinal use f medicines, the WHO level II cre indicatrs were used. Face t face interviews, exit interviews plus retrspective recrd data were used t cllect the required infrmatin. A summary f key results f this survey reprt is as fllws: Indicatr Results Stckut duratin f 28 days 75% Affrdability f key drugs fr children 51% Affrdability fr adults 86% Patient knwledge n dispensed drugs 80% The use f antibitic fr nn pneumnia ARI 90% The average prescriptin f mre than ne antibitic 6% Adequate labeling f drugs 76% Average number f drugs per encunter 1.8 N. f Patients receiving antibitics per encunter 42% Percentage f patients receiving injectin 14% Prescribing accrding t EDL 98.5% 2
Percentage f expired drugs in health facilities 13% It has been nted in this survey that there are mre areas f the pharmaceutical sectr in Tanzania which have shwn imprvement than thse which raise cncern f every stakehlder f the sectr. The evidence fr this deductin is based upn the indicatrs which have shwn psitive results and these are: Availability f key drugs in health facilities Stck ut duratin Affrdability f key drugs in health facilities Adequacy f drug strage Patient knwledge Adequately labeled drugs Average number f drugs per encunter Percentage f prescribed drugs dispensed Patients receiving injectins Prescribing accrding t EDL Percentage f expired drugs The areas f cncern as evidenced by thse indicatrs which, shwed negative trends are: Tracer cases treated accrding t STGs Adherence t recmmended treatment guidelines in treating diarrhea in children Number f patients receiving antibitics in ne encunter and Availability f Guidelines, STG, EDL etc. On the basis f the abve results, the fllwing cnclusins and recmmendatins have been drawn: The availability f/and access t key drugs has imprved in primary health facilities hwever, there is still rm fr the situatin t be even better especially n the area f apprpriate drug supply management Ratinal Use f Drugs is imprving and again, effrts shuld be made t further raising the standards and sustain them accrdingly Adherence t prescribing accrding t EDL is excellent and need t be encuraged and sustained/maintained Adherence t STG is lw and the situatin has sme areas whse pr status has remained s fr abut ten (10) years! The peple cncerned shuld institute crrective measures. The typical example here is the ver usage f antibitics. Prescribers and dispensers need further training and cntinuing educatin especially n areas f Ratinal Use f Drugs and Management f Drug Supply Preventive services need t be strengthened t imprve the general sanitatin in the cmmunity The labratry services need t be strengthened s as t supprt ratinal prescribing f drugs The availability f STG, EDL and ther Natinal Guidelines is unacceptably lw, effrts t imprve the situatin shuld be made which shuld include munting f inspectin exercises t health facilities fr this purpse. The general analysis f the survey data shws a cnsiderable imprvement in the perfrmance f the pharmaceutical sectr. The majr recmmendatin is that, thse indicatrs which, depicted unfavurable results shuld be addressed with new strategies f a revised NDP and the Pharmaceutical Master Plan. 3
Intrductin 1. Tanzania Cuntry Prfile Ppulatin 34.5 millin Urban: Rural 26 : 74 GNP/Capita $260 Per capita health expenditure Pharmaceutical annual expenditure per capita public+private Allcated public expenditure per capita Pharm Agriculture $9 $ 2 $1.30 (02/03) 46% f GDP Annual Inflatin 5% Literacy 62% Dependency rati 104% Ttal fertility 6.5 4
Infant mrtality 102 <5 mrtality 154 Maternal mrtality 530 Life expectancy 51 Access t health facilities 93% (1 hr) Ppulatin/health facility 7,431 Immunizatin cverage 83% Annual malaria deaths >100,000 Pr/least pr ratis Health indicatrs 1.7 Health interventins 0.62 Ppulatin living with HIV 9.4% 2. Backgrund Infrmatin The verall bjective f the Natinal Health Plicy is t imprve the health and well being f all Tanzanians with a fcus n thse mst at risk and t encurage the health system t be mre respnsive t the needs f the ppulatin, which stands at a ttal f 34,568,609 peple (Mainland: 33,584,078 and Zanzibar: 984,531)(census 2002). The Natinal Health Plicy alng with its underlying Natinal Drug Plicy (NDP) and the Health Sectr Refrm (HSR) clearly spell ut the gvernment respnsibility fr ensuring that Tanzanians have equitable access and utilizatin f health services ffered by public, private and NGO institutins thrugh the public private partnership phenmenn. Inspite f the prgress made since independence and the recent favurable ecnmic grwth realized s far, the Tanzania s scial indicatrs, which include health, are still belw the acceptable levels. The causes that have resulted in the current unfavurable situatin include, amngst thers: Shrtfalls in the annual health sectr budget allcatins Increased demand fr health care due t expanding ppulatin and changing disease patterns Increased csts f essential health care inputs e.g. persnnel emluments, drugs, equipment and medical supplies. Increased mrbidity and mrtality due t HIV/AIDS In respnse t a number f prblems encuntered in the pharmaceutical sectr, the gvernment f Tanzania thrugh its Ministry f Health has taken several steps in an attempt t imprve the situatin. In 1991 it endrsed the first Natinal Drug Plicy (NDP), which serves as the basis upn which future planning f pharmaceutical sectr is carried ut. A master plan fr the pharmaceutical sectr 1992 2000 was develped frm the NDP clearly indicating the bjectives, strategies, time frames and the budget required t achieve develpment in varius key areas f the pharmaceutical sectr. The gvernment further established cmplementary/alternative financing mechanisms/ptins t alleviate the prblems namely: User Fees (Cst sharing/drug Capitalizatin) Cmmunity Health Fund The Natinal Health Insurance Scheme The main bjective f these develpments is t ensure that the mst needed drugs and medical supplies f gd quality are made available in health facilities at all times with special emphasis n rural health facilities. 5
Mnitring and assessing the pharmaceutical situatin in Tanzania, like in any ther cuntry, is imprtant s as t knw whether r nt the ppulatin has access t essential drugs that are f gd quality, efficacius and are being used ratinally. Since the pharmaceutical sectr is cmplex, a systematic methd f gathering data is very imprtant t assess if the abve bjectives are met. There are multiple, crss cutting factrs that can influence the achievement f these bjectives and a variety f strategies t achieve them that can be implemented and adpted by a particular cuntry. The Internatinal Netwrk fr Ratinal Use f Drugs (INRUD) in cllabratin with the Wrld Health Organizatin (WHO) has develped cre indicatrs fr mnitring natinal drug plicies that can be used t systematically assess, evaluate and mnitr the frmulatin and implementatin f varius strategies and cmpnents f the pharmaceutical system. The indicatr based methd f assessing the pharmaceutical situatin can be useful fr varius grups and parties invlved in the prvisin f pharmaceuticals. The methd can clarify the respnsibilities f varius players in the pharmaceutical system and assess their cntributins t attaining key bjectives. Indicatrs can prvide plicy makers and managers with a clear picture f natinal and institutinal prblems s that they can reassess their strategies and pririties. Results can be used as a guide t priritize and strengthen pharmaceutical system cmpnents and strategies t achieve maximum impact r t synchrnize plicies. The cre indicatrs have been gruped int three levels. Gruping mnitring indicatrs by level has the fllwing advantages: Suits the different purpse f thse interested in infrmatin n the cuntry s pharmaceutical situatin: Rapid assessment f key pharmaceutical cmpnents. Mnitring utcme and achievement f key bjectives f the pharmaceutical plicy. In depth assessment f specific system cmpnents. Prvides practical methds fr regularly mnitring NDPs and their cmpnents Encurages regular reprting and exchange f pharmaceutical infrmatin amng facilities, districts, regins, gvernment and nn gvernment agencies within cuntries as well as internatinal rganizatin. Rapid assessment, Level I indicatrs are intended t get infrmatin n the existing infrastructure and key prcesses in each cmpnent f the pharmaceutical sectr. Level II indicatrs prvide systematic data t describe the degree f attainment f the NDP bjectives access, quality and ratinal use. Access is measured in terms f availability and affrdability f essential drugs especially t the pr and in the public sectr. Measuring the actual quality f the drugs invlve testing drug samples and can be expensive. Ratinal use is measured by examining patterns f drug use and the implementatin f key strategies such as STGs and EDLs. Level III indicatrs such as thse in the WHO manual n Indicatrs fr Mnitring Natinal Drug Plicies can be used t assess in mre detail the cuntry s NDP prgramme and the implementatin f each cmpnent f the pharmaceutical system. Cuntries implementing natinal drug plicies can use this as baseline assessment and fllw up studies can be cnducted depending n needs and capabilities fr extensive assessment. Fllwing the fact that the gvernment has invested substantially in ensuring that peple have access t essential drugs and medical supplies f gd quality and that the drugs are being used prperly. This study has adpted the use f level II cre indicatrs which measure access t drugs and medical supplies by the ppulatin, matters n quality f drugs and matters n ratinal use f drugs. The WHO recmmends that activities t strengthen the pharmaceutical sectrs are rganised under the umbrella f a rehearsal drug plicy 6
(WHO, 1998). OBJECTIVES OF THE STUDY T assess the cuntry capacity such as availability infrastructure, lgistic and human resurces t implement the varius elements f NDP. T mnitr the prcess and strategies used in the implementatin f varius cmpnents f the pharmaceutical sectr t see if they achieve the bjectives f NDP and the Pharmaceutical Master Plan. T cllect baseline infrmatin n the pharmaceutical sectr in Tanzania frm the facility t the central levels, this will prvide a clear picture f the current situatin s as t reassess the strategies and pririties t be used during the planned revisin f the NDP. Study Design And Methdlgy The study was bth prspective and retrspective crss sectinal survey invlving twenty randmly selected health facilities and three hundred husehlds. Study ppulatin The study ppulatin was drawn frm clients and wrkers f public health facilities treating utpatients and with pharmacy/drug units. Als, frm private pharmacies, drugs warehuse and husehlds arund the health facilities. Sampling The survey was cnducted in Tanzania mainland, which is divided int 21 administrative regins. It is further divided int 121 districts. Each district is subdivided int divisins, wards, villages and hamlets. Fr a situatinal analysis in a cuntry, a minimum f 4 gegraphical areas was selected and the capital city is usually included. The ther three gegraphical regins were purpsely selected t represent the different gegraphical, demgraphic and sci ecnmic situatins in the cuntry. The 4 gegraphical areas selected were: Dar es Salaam Mbeya Kilimanjar and Mwanza. In each regin ne district was randmly selected. Frm these 4 identified districts, 20 public health facilities were randmly selected within 10 kilmetres distance frm the different districts. These frmed the basis (reference pints) fr selecting private utlets and a ttal f fur Znal MSD warehuses were included ne frm each regin which cater t general ut patients and have a pharmacy r a drug dispensing unit. Arund each health facility 15 husehlds were randmly selected frm a ttal number f husehlds frm the same area making a sample size f 300 husehlds in ttal; 20 private utlets were als randmly selected. The ttal number f husehld arund each health facilities was selected. 7
Table 1: The sample f survey units Figure 1: Sampling and selectin prcess Regins Districts Health Facilities Pharmacies Warehuses Husehlds Dar es Salaam Temeke 5 5 1 75 Mbeya Urban 5 5 1 75 Kilimanjar Hai 5 5 1 75 Mwanza Nyamagana 5 5 1 75 Ttal 4 4 20 20 4 300 Table 2: Classificatin f Health Facilities Regin District Name f Health Facility Status Dar es Salaam Temeke Munincipality Temeke Hspital Buza Mji Mwema Chekeni Mwasnga Nunge Health Centre Dispensary Dispensary Dispensary Mbeya Urban Mbeya Reginal Hspital Igawil Mwansekwa Kiwanja Mpaka Itende Health Centre Dispensary Health Centre Dispensary Kilimanjar Hai Hai District Hspital Nrnga Ngarenairbi Dispensary Dispensary 8
Masama KIA Health Centre Dispensary Mwanza Nyamagana Sekture Reginal Hspital Rumagila Sakwa Igma Buhngwa Dispensary Dispensary Dispensary Dispensary Ttal 4 4 20 Ethical cnsideratin Ethical cnsideratins were adhered t thrughut while cnducting this study. Permissin was sught befrehand frm the reginal and district authrities t wrk in their areas. Mrever, a number f ethical issued were als cnsidered fr example all infrmatin cllected were treated cnfidentially, cnsent was sught and freedm f participatin r pting ut was prvided. At the same time all data cllectrs were given intrductry letters t shw t the heads f facilities, warehuses, private pharmacies and ten cell leaders. Pre testing: The tls fr data cllectin were pre tested in Kinndni Dar es Salaam regin. The aim f pre testing was t assess the applicability f the tls in the Tanzania situatin. Relevant deletins and additins were effected n the final tls and methdlgy. (See annex 16) Data cllectin Face t face interview methd with sme exit interviews, plus retrspective recrd data sampling were used t cllect infrmatin. These methds used the standardized tls develped by the WHO, mainly t measure the degree f attainment f the strategic pharmaceutical bjectives f imprved access, quality and ratinal use. Access was measured in terms f availability and affrdability f key drugs, which are used t treat the tp 10 diseases as recmmended by the MH Tanzania. These are: Malaria URTI Diarrhea Wrms Pneumnia Eye infectin Fungal Allergies Pain Anaemia The key drugs t treat the abve tp ten diseases include: 9 Amxycillin 250mg tablets r capsules Aspirin 300mg tablets Chlrpheniramine 4mg tablets
C trimxazle 400/80mg tablets Ferrus salts 200mg Flic acid 5mg tablets Mebendazle 100mg tablets Oral rehydratin salts (ORS) Paracetaml 500mg tablets Pvidne idine Prcaine penicillin 4mu injectin Quinine injectin 600mg/2ml Sulfadxine pyrimethamine 500/25mg tablets Tetracycline eye intment 1% Whitfield intment (benzic acid cmpund) Quality, n the ther hand, was assessed by adequacy f handling and strage f drugs. Finally, ratinal use was measured by examining patterns f drug use, and the implementatin f key strategies such as STGs and EDLs. Surveys were cnducted t measure the indicatrs as fllws:? Public health facilities were used t gather infrmatin abut: % f expired drugs. Availability f key drugs. Stck ut duratin. Adequacy strage. Affrdability f key drugs (Treating Pneumnia withut hspitalizatin). Average number f drugs per prescriptin. % f patients receiving injectins. % f drugs in EDL. % f patients receiving antibitics. % f drugs dispensed. % f drugs with adequate label. % f patients wh knw hw t take drugs. Availability f STG fr cmmn lcal cnditins. Availability f EDL at the facility and ther relevant materials. % f tracer cases treated using recmmended treatment guideline (STG).? Private retail utlets t assess: % f expired drugs. Availability f key drugs. Stck ut duratin. Adequate strage. Affrdability f key drugs (Treating pneumnia withut Hspitalizatin). % f expired key drugs Availability f key drugs.? Husehld arund each health facility was cnducted t assess: Husehld access and use f medicines. Befre implementing the survey, the tp ten diseases in Tanzania were listed and the key drugs t manage them were als identified. These key drugs were listed n the survey frms 1a, 1b, 2a and 2b (Annexes 1 4). Likewise, drugs and preparatin fr standard treatment f pneumnia were identified and listed n survey frm 4. Altgether ten (10) survey frms were used fr mnitring and assessing the pharmaceutical situatin in Tanzania. (Frms: survey frms 1a 10 in annexes). 10
Main study results Public health facilities results 1. Availability f key drugs in health facilities Figure 2 belw shws availability f key drugs fr treating the tp ten diseases. 87.28% f key drugs are available in the znal warehuses. In tw regins the availability is abve 90%. 2. Stck ut duratin Figure 2: Availability f key drugs fr treating tp ten diseases In this study it was fund ut that the average stck ut duratin fr all essential drugs is 28 days (Median 21.2, Maximum days 67.1, and Minimum days 3). 3. Affrdability f key drugs in health facilities In this study it has been revealed that n average 51% and 86% f the lwest daily gvernment salary was spent t purchase drugs frm private pharmacies fr children and adult patients respectively. 4. Adequacy f drug strage The average adequacy f strage was fund t be 9 fr Znal warehuses and 7 fr public pharmacies. This rating is ut f an 11 ranking scale indicatr. 5. Patient Knwledge The result indicates that the average patient knwledge abut dispensed drugs was 80%. 5. Tracer cases treated accrding t STGs Figure 3: belw shws the use f antibitics fr nn pneumnia ARI is ver 90% in three regins and 66% in ne regin. 11
Figure 3: Percentage f antibitic use in health facilities fr treating nn pneumnic ARI The results in Figure 4 belw shw that in three regins the use f mre than ne antibitic fr treating mild/acute pneumnia is belw 6%. It is high in ne regin, abut 42%. In this particular case Amxycillin was prescribed cncmitantly with C trimxazle, where the latter is nt indicated. Figure Percentage f patients receiving mre than ne antibitic t treat mild/acute pneumnia 6. Adherence t recmmended treatment guidelines in treating Diarrhea in children Figure 5 belw shws the adherence t recmmended treatment fr diarrhea in children. The trend in all the surveyed areas shws a high nn adherence by the indiscriminate use f antibitics f abut 44% n average. Hwever, ORS is prescribed n average f 82% f the cases. There are imprtant differences amng regins (Dar es Salaam, 82%; Mbeya, 80%; Kilimanjar, 70% and Mwanza, 96%) 12
Figure 5: Adherence t recmmended treatment guidelines in treating Diarrhea in children 7. Adequately labelled drugs The result indicates that n average 76% f drugs were labelled adequately. 8. Average number f drugs per encunter The results shw that the average number f drugs per encunter is 1.8. 9. Percentage prescribed drugs dispensed The results shw that in the three regins, it is high and indeed frm 80% nwards, the highest being abut 90% (Figure 6 belw). The lwest being 47% frm ne f the regins. Figure 6: Percentage f drugs dispensed t patients 10. Number f patients receiving antibitics in ne encunter The results shw that 42% f patients were prescribed antibitics. 11. Percentage f patients receiving injectins The number f patients receiving injectins in the health facilities visited was 14%. 13
12. Prescribing accrding t EDL The results shw an average adherence f 98.5%. 13. Percentage f expired drugs There were n drugs in the private facilities shelves with dates beynd expiry date. Hwever, in public facilities 13% f key drugs were expired. 14. Guidelines Availability Only five (5) facilities ut f 20 had the natinal STGs in their premises. Husehld survey results Three hundred husehld heads were asked t reprt n a recent illness. Out f these husehlds surveyed (patient cases) 43% (129) were males and 57% (171) were females. Frty nine percent (49%) (147) f the patients had their ages ranging frm 16 54 years and 15% (45) were 55 years f age and abve and the rest were children under 16. The majrity f thse interviewed, 78% (234) had Primary schl educatin fllwed by 8% (24) wh had secndary schl educatin, vcatinal r University level and the rest had n educatin. Ninety percent (90%) f thse with secndary educatin were frm Dar es Salaam regin. The disease cases that were encuntered are summarized in Table 3: Table 3: Diseases frequently cnsulted at health facilities. Diseases Frequencies Diarrhea 24 Cugh 50 Fever 123 Others* 155 * Sme patients had mre than ne disease cnditin Under thers, the diseases, which were frequently encuntered, culd be categrised int the fllwing grups: Injury, Malaria, Flu, hypertensin and gynaeclgical prblems. Just less than half f the ppulatin surveyed 38% (114) cnsulted public health facilities fr their medical cases as shwn in Table 4 belw. Hwever, quite a gd percentage (19%) f the ppulatin went fr alternative cmplementary therapies like traditinal medicine. Where cnsultatin was sught, 77% f all cases medicatin was prescribed, while nly 23% medicatin was nt prescribed. Fr thse cases where medicines were prescribed, 79% received/bught all prescribed drugs frm the facilities while 12% gt part f the prescribed drugs and 9% did nt get any drugs. The main reasn fr nt getting all the drugs fr sme patients include frm amngst thers, affrdability due t high prices fr the drugs especially in private facilities. The ther reasn is cntributed by stck ut duratin Table 4: Frequencies f health services sught Health Services Frequencies Percentage Cnsulted Traditinal healer 69 19 Cnsulted Public Health Clinic/hspital 142 38 Cnsulted Private Health Clinic/hspital 32 9 14
Cnsulted pharmacists 15 4 Cnsulted drug seller 12 3 Sught advise frm friends/neighbur/family 18 5 Bught medicine withut cnsultatin 10 3 Used medicine left frm anther illness 4 1 Did nthing 68 18 Ttal 370 100 DISCUSSION OF RESULTS ACCESS Availability f key drugs in health facilities Seventy five percent (75%) f key drugs were available in the Znal warehuses. In tw regins the availability was abve 90%. Physical availability f key drugs in all health facilities especially in public sectr facilities is expected t be 100%. Availability f key drugs t treat cmmn health prblems, in this case the tp ten diseases in public health facilities and supply depts gives a clear picture f drugs availability t cmmunities. Drugs availability is a sub cre indicatr under accessibility. Other sub cre indicatrs under accessibility are stck ut duratin in health facilities and central/reginal stres, percentage f drugs dispensed t patients and affrdability f key drugs in facilities and private retail utlets. The tw cities, Dar es Salaam and Mwanza shw a slightly lwer availability f key drugs. The reasns fr this trend are: There is a direct crrelatin with the ppulatin served. The cities have the highest number f peple cmpared t the ther municipalities (Census, 2002). In cities many peple can affrd the cst f treatment cmpared t municipalities (urban and rural) due t trade and business envirnment surrunding the cities. Trust f heath service is higher in cities where there is a cncentratin f highly trained health persnnel. There are many supprting services e.g. Transprt system t facilitate access t health facilities. This survey has nted with cncern the ver supply f SP drugs in all the public health facilities visited. This prblem will cntinue fr smetime if immediate measures are nt taken since, every mnth there is a supply f 12 X 500 tablets in each facility. Mrever, advcacy n the use f SP in treating Malaria has nt been well received by the cmmunity, needless t mentin the cmpunding side effects f this drug. Furthermre, the dsage regimen fr Malaria f 3 tablets fr adults and 1½ fr children have bviusly cntributed t the bserved piling up f this drug in all public health facilities. Ntwithstanding, the lng expiry f this drug (5 years) the current supply cupled by the slw mving will definitely have a net psitive utcme n the ver availability f this drug. Stck ut duratin 15 Presence f essential drugs at all times in health facilities is an imprtant factr in prvisin f quality health care. The histrical availability f key drugs t treat cmmn health prblems shws an adequate lgistic system that ensures essential drugs remain in stck at all times. The current situatins f 28 days stck ut duratin gives an indicatin that ne f the key drugs is nt available fr abut a mnth in health facilities. This stck ut duratin has partly been influenced by late supply f quinine t the health facilities due t change in plicy in Malaria cases management. In additin drugs such as amxicillin caps, C trimxazle 400/80mg tablets and Chlraphenicl have cntributed substantially t this situatin. Due t
their smetimes unnecessary ver prescriptin such as in the cases f diarrhea in children (see figure 4). Affrdability f key drugs in health facilities The percentage btained frm this study (51% fr children and 86% fr adults) may have been influenced by the chice f tracer drug which in this case was the antibitic, Amxicillin and which was expensive. The cst f treatment using this drug was pegged against the lwest gvernment salary (TShs. 1,500/= per day). The ther cntributing factr is the pricing mechanism perating, which is under free market frces. In this pricing system, it is pssible t have different prices fr the same drug within the same lcality. In the public health facilities children belw 5 years were suppsed t be n free medical services, hwever, this were nt cnsistent because lcal gvernments have their wn perating mechanisms fr exemptin. Adequacy f drug strage Presence f dusts, prtectin against direct sunlight, drugs stred n flr, prvisin f temperature mnitring charts and facilities t mnitr rm temperature are cmmn prblems encuntered in the pharmacies. Accrding t the results the standard f the strage area was fund t be very gd fr warehuses (9 ut f 11 rating scale) and abve adequate (7 ut f 11 rating scale) fr the public pharmacies. Prper strage f drugs is an imprtant factr in ensuring that quality f drugs is maintained either in warehuses r stre pharmacies f health facilities and central/reginal stres thus the public pharmacy stres need t imprve the strage cnditins. RATIONAL DRUG USE Patient Knwledge Patients shuld have adequate knwledge abut the dispensed drugs. In this case patient knwledge was measured by exit interview where a patient was required t restate crrectly the instructins n hw t use each drug dispensed. The persn dispensing the drugs thrugh verbal and written instructins imparts this knwledge nrmally. It is the respnsibility f the persn dispensing the drugs t ensure that the patients have adequate knwledge abut the dispensed drugs befre the patient leaves the dispensing windw/rm. The patient knwledge abut dispensed drugs, which was 80%, is indeed a gd achievement. Hwever, the 20% gap is still substantial since, it pses a risk fr inapprpriate use f the dispensed drugs. The remedy t this situatin again is t ensure that: The dispensing staff members are trained n gd dispensing practice. The staffing levels are adequate. Tracer cases treated accrding t STGs The ideal situatin is t have the lwest pssible percentage use f antibitics fr Nn pneumnic ARI. Figure 3 results abve f ver 90% in three regins and 66% in ne regin are n the higher side. This might be due t: Lack f supprtive labratry services t distinguish severity f ARIs may lead prescribers t pt fr shrt gun therapies. Lack f clinical skills t diagnse ARI. Lack f cntinuing educatin n disease management. Accrding t the Standard Treatment Guideline the first line drug treatment is C trimxazle and the alternative is Prcaine penicillin r Amxycillin. 16
The results in Figure 4 abve shw that in three regins the use f mre than ne antibitic is belw 6%. It is high in ne regin, abut 42%. In this particular case Amxycillin is prescribed cncmitantly with C trimxazle. All in all the deviatin frm this indicatr shuld be avided, cntinuing educatin t prescribers and strengthening labratry services are crucial in imprving the situatin. Adherence t recmmended treatment guidelines in treating Diarrhea in children The recmmended treatment fr diarrheal cases that are nn infective is by the use f ORS nly. The trend in all the surveyed areas shws a high nn adherence by the indiscriminate use f antibitics f abut 44% n average. ORS is prescribed in 82% f the cases. There are hwever imprtant differences amng regins. Likewise, the use f antispasmdic (Hysine butylbrmide) in this case is als indiscriminate. Adequately labelled drugs The results indicate that 76% f drugs were adequately labelled. Similar study cnducted in Dar es Salaam and Cast regin shw that 87% f drugs dispensed were adequately labelled (Massele et al, 2001). In Namibia a similar survey shwed a 67% f the same (Lates et al, 2001). The remaining 24% f the drugs, which were nt adequately labelled, is substantial enugh t pse danger in use f the dispensed drugs. If drugs are t be used prperly, the persn carrying ut dispensing shuld label them apprpriately. Apprpriately r adequately labelling f drugs fr this study was defined t include name f the drug, hw t take it and strength (see annex 16). The reasns fr having prly labelled/unlabelled drugs are mstly due t: Negligence n the imprtance f labelling frm the dispensing staff. Pressure f wrk. Understaffing f qualified dispensers. Pr practicing f untrained dispensing persnnel. Mst f the dispensers had n pharmaceutical backgrund. Imprper labelling f drugs leads t their imprper use. Prlnged misuse f drugs such as antibitics and antimalarials may naturally lead t favuring the survival f micrbes that develp resistance. Average number f drugs per encunter The results shw that the average number f drugs per encunter is 1.8. The smaller the number f drugs per prescriptin the better the prescribing habits and hence ratinal use f drugs. One des nt get a drug every time he/she visits the dctr, hwever this figure f 1.8 is slightly imprved frm previus nes f mid 1990 s when it was 2.2 (Malele, et al, 1992; Massele et al, 1997; Massele, 1993). This current trend cmpares very well with ther develping cuntries such as Zimbabwe (1.7) Malawi (1.7), Guetemala (1.4) and Yemen (1.5) (Rss Degnan et al, 1992). Percentage f prescribed drugs dispensed The ideal situatin is t have 100% prescribed drugs dispensed. This study shws a perfrmance ranging frm 80% 90% in three regins and a 47% in ne f the regins (Mwanza) as seen in Figure 6 abve. Sme f the reasns fr this deviatin may include: The infrastructure and distance frm prts f entry i.e Dar es salaam influences the distributin pattern f drugs/pharmaceuticals and thus the availability. Drug management systems are inadequate Purchasing pwer frm the patient side was lw. Number f patients receiving antibitics in ne encunter 17
The results shw that 42% f patients were prescribed antibitics which cmpared t previusly result f 39% 1993 (Massele et al); 51% f Namibia 1993 (Lates et al.) This shws that the trend has nw been at this level fr almst 10 years in Tanzania. There have been mves t reduce the ver use f antibitics mainly, t cut dwn n csts and ffset the grwing resistance. Trpical cuntries seem nt t have much chice n this especially with trpical infectins, and nw the pprtunistic diseases resulting frm HIV/AIDS infectins. The blanket treatment and/r self medicatin appraches fr nn specific childhd diseases and fr mild nn bacterial infectin e.g. ARI are sme f the factrs, which cntribute t this high percentage (veruse) f antibitics. Percentage f patients receiving injectins The 14% injectin use perfrmance has greatly imprved ver the past 10 years when the injectin use std at 35% (Massele et al, 1993, 1997 & 2001). HIV/AIDS campaigns are sme f the factrs, which have recently cntributed t the fall in use f injectin. Als many injectins were frm the use f chlrquine. A shift t SP has had an impact n this indicatr. There is still rm fr imprvement n use f injectin cutting it dwn t less than this current bservatin since, injectin treatment apprach is expensive. Prescribing accrding t EDL The results shw an average adherence f 98.5%, which is very gd indeed. Expected adherence, hwever, wuld have been 100%. This perfrmance culd have been due t inclusin f the Essential drug cncept in training/curriculum, plicy emphasis and indeed streamlining and making available the key (essential) drugs in all health facilities. This situatin is a psitive cntributin f the Natinal Essential Drugs prgram. The shrtfall f 1.5% culd be due t special requested drugs fr certain medical cases which are nt in NEDLIT. Percentage f expired drugs There were n drugs in the private facilities shelves with dates beynd expiry date. Hwever, in public facilities 13% f key drugs were expired. One f the reasns fr having expired drugs in public health facilities is because these facilities are nt subjected t regular inspectins which, in turn gives laxity in perfrmance. Als, fr the kit system sme drugs are nt needed in sme health facilities leading t piling up and finally expiring Guidelines Availability This study has revealed that nly five (5) health facilities ut f 20 had the natinal STGs in their premises. The bserved situatin is an alarming ne, especially when these guidelines are required as wrking tls and suppsedly freely distributed t all public facilities. Hwever, the ther guidelines fr examples, malaria, and TB treatment and reprductive health were available in health facilities. A mechanism shuld be instituted t ensure that private facilities have access t the same. Timely revisin f STG and prper mechanism fr disseminatin and distributin shuld be instituted fr all health facilities. Husehlds survey Frm the husehld survey it was fund ut that mre females (57%) were sick cmpared t males (43%). The results als revealed the utilisatin f healthcare services f 38%. This the utilisatin is still very lw, belw 50% given the substantial investment in the healthcare prvisin by the gvernment and partners. 18
Sme f the factrs cntributing t this trend include: Ecnmical reasns (Affrdability) Figure 7: Health seeking behaviur Self medicatin Seeking such services frm Traditinal healers. This is mainly dne t ffset the therwise expensive mdern healthcare services Sci cultural reasns This is especially the case with STIs, which carry a stigma n the patient and hence influence the health seeking behaviur which in turn checks the utilisatin f healthcare services. Hwever when these prviders are cmbined as a public/private mix, it is fund that mre peple (54%) seek help frm prfessinal health prviders. Specific recmmendatins Availability f key drug in health facilities * The availability f drugs is dependent n a prper scheduled prcurement f drugs supply. Health facilities shuld adhere strictly t prperly scheduled prcurement cycles and make reviews f these cycles regularly. * The persnnel invlved in drugs/pharmaceuticals supply shuld be trained in managing drug supplies. * Adequate funding shuld be set fr drugs. Quantificatin f SP shuld be dne immediately t save it frm expiry and hence, save mney. The distributin f this drug in the kit shuld be revisited t avid further piling up. Stck ut duratin Stck levels shuld be prperly determined s as t avid stck ut f essential drugs. Intrducing reprting system n drug availability t all health facilities and hspitals and reginal pharmacists t supervise these activities. Training fr stck management t the pharmaceutical persnnel. 19
Affrdability f key drugs in health facilities. The affrdability f key drugs in health facilities is influenced by the ecnmic, status f the cmmunity. Since the majrity f Tanzanians live in pverty, strategies t alleviating pverty amng Tanzanian cmmunities shuld be develped s as t raise the peple s purchasing pwer and eventually increase the affrdability f key drugs. Adequacy f drug strage The adequacy f drug strage has been fund ut, by this survey, t be 9 ut f 11 pints and 7 ut f 11 pints rating scale fr warehuses and public pharmacy stres respectively. Since pr r inadequate strage cnditins have negative effects n the quality f drugs, effrts shuld be made t ensure that the strage cnditins are face lifted t cmply with the required standards. Patient knwledge In rder t enhance the patient knwledge n dispensed drugs. Qualified pharmaceutical staff shuld be recruited and deplyed apprpriately in the pharmaceutical sectr. The existing pharmacy staff shuld be trained in gd dispensing practice. Tracer cases treated accrding t STGs The use f antibitics fr nn pneumnic ARI is high accrding t results btained frm this study. Further t it, there is a deviatin frm the standard f using ne first line antibitic, that is, mre than ne antibitics are used in treating mild/acute pneumnia. In rder t avid the recurrence f this situatin: The STG shuld be reviewed t specify the demarcatin f use f antibitics in nn pneumnic ARI basing n the severity f the diseases. Cntinuing educatin t prescribers and dispensers (especially n ratinal use f drugs) shuld be prvided regularly. Labratry services shuld be strengthened t supprt the ratinal prescribing practice. Adherence t recmmended treatment guidelines in treating diarrhea in children. The study has revealed an indiscriminate use f antibitics in treating diarrhea in children averaging 44%. This is a high nn adherence trend f practice. The cntributing factrs fr this situatin might be the lack f supprtive labratry services fr discriminating the infective frm nn infective diarrhea and pressure f wrk n the part f prescribers. It is therefre strngly recmmended t strengthen the labratry investigatin services s as t enhance the ratinal prescribing practice. Gd prescribing practices thrugh cntinuing educatin Adequate labeled drugs The study indicates that 24% f drugs dispensed were nt adequately labeled. The respnsibilities fr adequately labeling f dispensed drugs lies n the dispenser. This then 20
cnfirms the need t having trained pharmaceutical staff in health facilities and dispensing practice fr nn pharmaceutical staff ding dispensing activities. Average number f drugs per encunter The smaller the number f drugs per prescriptin, the better is the situatin fr this indicatr. The result, frm the survey is 1.8 that is quite gd and the trend shws imprvement with years. Hwever, there is still rm fr imprvement t bring the figure further dwn. In rder t achieve even a lwer figure: The preventive services, which include imprvement and raising the standards f general sanitatin, shuld be strengthened. Cntinuing educatin t prescribers n ratinal drug prescribing shuld be prvided. Again, labratry services shuld be strengthened s as t prevent shrt gun therapy tendencies practiced by sme prescribers. Percentage f prescribed drugs dispensed The study results indicate that 10 20% in three regins and 53% f the prescribed drugs were ut f stck. The main cause f this situatin has been attributed t insufficient drug distributin patterns in the drug supply/delivery system and insufficient funding especially fr district hspitals. It is therefre recmmended that, the distributin and drug supply management system be strengthened and the NDP shuld have a strategic plan n this aspect. Funding shuld be imprved fr drugs. Number f patients receiving antibitics in ne encunter The use f antibitics in ne encunter is still high and stands, accrding t results f this study; at 42% and that it has remained s fr almst 10 years. In rder t reduce the ver usage f antibitics: Preventive services shuld be strengthened at cmmunity level. Labratry services shuld be strengthened and prescribers use them fr diagnsis Cntinuing educatin t prescribers be prvided Health educatin shuld be prvided t the public t reduce the tendencies fr self medicatin. Research shuld be carried ut fr the purpse f seeking alternative ways f handling the pprtunistic infectins especially in HIV/AIDS cases. An antibitic resistance mnitring center shuld be established. Educatin t the public n the use f antibitics shuld be imprved. Percentage f patients receiving injectins The results shw a tremendus imprvement, frm 35% dwn t 10% in the past 10 year s perid. Nevertheless, there is still rm t reducing the figure further dwn t nly the abslutely necessary injectins. It is therefre recmmended that cntinuing educatin be prvided t prescribers n varius ptins available leading t cutting dwn the use f injectins t patients. Prescribing accrding t EDL The results are excellent n this indicatr, that is, 98.5% adherence t prescribing accrding t EDL 21
This trend shuld be encuraged and maintained. Percentage f expired drugs Regular inspectins by the Pharmacy Bard need t be carried ut t public health facilities s as t curb the laxity exhibited n this aspect by the pharmacy staff in these facilities. Supervisin by PSU shuld be implemented using the reginal and district pharmacists. FEFO principle shuld be encuraged t all staff respnsible fr drug strage Guidelines availability Supervise and implement the use f Natinal drug list and Guidelines. The Ministry f Health shuld ensure that STGs and/r NEDL are available in all health facilities and accessible t all health persnnel. There is a need fr supprtive supervisin in the pharmaceutical sectr fr maximum use f these guideline and plicies. GENERAL RECOMMENDATIONS There are a number f interventins, which culd be used t imprve pharmaceutical sectr in Tanzania and prmte quality f health services prvided. These include training f pharmaceutical persnnel and prescribers; implementatin f NDP and guidelines: presence f up t date pharmaceutical Master plan, targeted cntinuing educatin and research. In rder t execute the varius cmpnents f the pharmaceutical sectr and achieve the bjectives f the NDP, the fllwing way frward is recmmended: Encurage cuncils t recruit and deply qualified pharmaceutical staff in the pharmaceutical sectr. Shrtage f qualified wrkers in pharmaceutical sectr is fund in many cuncil health facilities. Hwever, it is nted that cuncils are nt giving due weight n recruiting and deplying qualified pharmaceutical persnnel. Ensure the pharmaceutical Master plan is revised and/r updated. The present pharmaceutical sectr master plan has been in place since 1991. There have been a number f plicies and institutinal changes which need t be revised. In this regard, the Ministry f Health is urged t review and update the Pharmaceutical sectr master plan. Cnduct a baseline survey using Level 111 cre indicatrs in rder t establish mre details facing the Tanzania pharmaceutical Sectr. Establish mechanisms t mnitr and assess the perfrmance f pharmaceutical persnnel. Prmte and stimulate health cnsumers knwledge abut prper use f drugs. Investigate factrs assciated with presence f expired drugs in health facilities. Develp tls fr assessing and mnitring drugs availability, accessibility and ratinal use. A study shuld be dne t see what is the mark up fr pricing f pharmaceuticals in Tanzania and if mechanisms culd be instituted t effect drug pricing. REFERENCES 22
Grand A, Hgerzeil HV and HaaijerRuskamp FM: Interventin research in ratinal use f drugs: a review; Health Plicy and Planning 14(2) 89 102; 1999. WHO, Hw t investigate drug use in health facilities: Selected drug use indicatrs. Wrld Health Organizatin: Geneva, 1993 (WHO/DAP/93.1) Laing RO, Hgerzeil HV, and Rss Degnan D Ten recmmendatin t imprve use f medicine in develping cuntries. Health Plicy and Planning 18(1): 13 20; 2001. Lates J and Shiyandja N Third Natinal Survey n the Use f Drugs in Namibia s Public Health Institutins including Mnitring, the Implementatin f the Natinal Drug Plicy; 2001 Malele RSR, Senya SS. A prspective survey f prescribing habits in the OPD f Muhimbli Medical Hspital, Dar es Salaam Tanzania (1992). Managing drug Supply 2nd Editin (revised and expanded) 1997 Management Sciences fr Health, Bstn USA. Masselle AY and Nsimba SED Cmparisn f Drug Utilisatin in Public and Private Primary Health Care Clinics in Tanzania; 2001 Masselle AY, Nsimba SE and Rimy G Prescribing habits in church wned primary health care facilities in Dar es Salaam and ther Tanzanian cast regins; 1997 Masselle AY, Ofri Adjei, D., Laing RO. A study f prescribing patterns with special reference t Drug Use Indicatrs in Dar es Salaam regin, Tanga; 1993 Muella SH, Mushi Ak, and Ribera JM; The paradx f the cst and affrdability f traditinal and gvernment health services in Tanzania. Health plicy and Planning 15 (3) 296 302: 2000. Rss Degnan D. Laing RO, Quick JD, et al A Strategy fr Prmting Imprved Pharmaceutical Use: The Internatinal Netwrk fr Ratinal Use f Drugs. Scial Science and Medicine, 1992; 35(11): 1329 1341 Standard Treatment Guidelines (STG) and the Natinal Essential Drug List fr Tanzania; MOH 2nd Editin; 1997. The Tanzania Natinal Drug Plicy. MOH, 1991. WHO Guidelines fr Natinal Drug Plicies. Geneva. WHO, 1998 List f annexes Annex 1 Survey frm 1a: Central/district warehuse Indicatr: % f expired drugs Availability f key drugs Facility Lcatin Date Investigatr Key drugs in stck t treat cmmn cnditins [A] Amxycillin 250mg tablets r capsules Aspirin 300mg tablets In stck [B] Yes=1, N=0 Drugs in stck that have expired [C] Yes=1, N=0 23
Chlrpheniramine 4mg tablets C trimxazle 400/80mg tablets Ferrus salts 200mg Flic acid 5mg tablets Mebendazle 100mg tablets Oral rehydratin salts (ORS) Paracetaml 500mg tablets Pvidne idine Prcaine penicillin 4mu injectin Quinine injectin 600mg/2ml Sulfadxine pyrimethamine500/25mg tablets Tetracycline eye intment 1% Whitfield intment (benzic acid cmpund) Ttal n. f key drugs [A 1 ]= [B 1 ]= [C 1 ]= % in stck in this facility [B 2 ]= % f expired drugs [C 2 ]= Annex 2 Survey frm 1b: Public health facility pharmacy Indicatr: % f expired drugs Availability f key drugs Facility Lcatin Date Investigatr Key drugs in stck t treat cmmn cnditins [A] amxicillin tablets r capsules aspirin tablets chlrpheniramine tablets c trimxazle tablets ferrus salts flic acid tablets mebendazle tablets ral rehydratin salts (ORS) paracetaml tablets pvidne idine prcaine penicillin injectin In stck [B] Yes=1, N=0 Drugs in stck that have expired [C] Yes=1, N=0 24