Transcript Impact of the Essential Drugs Programme at the

Abstract
Impact of the Essential Drugs Programme at the Primary Health Care Level in South Africa
Hela M, Zeeman H, Department of Health South Africa; Auton MS, South Africa Drug Action
Programme, World Health; Organisation; Sallet J-P, Management Sciences for Health; Summers
R, School of Pharmacy, Medunsa; Eagles P, School of Pharmacy, University of Western Cape
Problem Statement: Prior to the establishment of a democratically elected and internationally
recognized government in 1994, drugs were not available to all South Africans due to the structured
inequalities and inaccessibility caused by apartheid.
Objectives: To determine the impact of the Essential Drugs Programme (EDP) at the primary
health care (PHC) level in South Africa.
Design: Synchronized cross-sectional surveys in the 9 provinces and 6 metropolitan areas using
prospective and retrospective sampling methods combined into a national data set and compared with
baseline results.
Intervention: The comprehensive EDP was established to support the implementation of the 1996
National Drug Policy, which has the goal of ensuring an adequate and reliable supply of safe, cost
effective drugs of acceptable quality for all citizens of South Africa as well as rational use of drugs by
prescribers, dispensers, and consumers.
Outcome Measures: 202 indicators covering facility infrastructure, human resources, inventory
management, financial management; drug use, patient knowledge, and patient care.
Conclusions: The EDP was found to be widely implemented, although there are areas identified for
improvement. The national report highlights recommendations for action at the national level and for
individual provinces and metropolitan areas.
Introduction/background
• 80% of the population depends on public sector health care services
• Great inter-provincial and intra-provincial inequities.
• Equitable distribution of public health care resources and increased
provision of primary health care, particularly for currently
disadvantaged groups represent major challenges
• The goal of the 1996 National Drug Policy is to ensure an adequate
and reliable supply of safe, cost effective drugs of acceptable quality
to all citizens of South Africa and rational use of drugs by
prescribers, dispensers and consumers.
• Provincial baseline surveys were carried out between 1996 and
1998
• Follow up surveys in all 9 provinces and 6 metros were carried out
simultaneously in 2003
Objective
The aim of these surveys was to determine the impact of
the Essential Drugs Programme at Primary Health Care
level in South Africa, as a follow up to previous provincial
baseline studies
Methodology
• Between February and April 2003, 15 surveys were carried out in the 9
provinces and 6 metropolitan areas - a total of 239 primary health care
facilities and outpatient departments of district hospitals
• Methodology, sample size determination and Data Collection
Instruments were based and adapted from the WHO publication: “How
to investigate drug use in health facilities”
• Sample selection was performed as follows: 20 primary health care
facilities from each province, and 10 from each metro, stratified by
districts were randomly selected. The aim was for the sample to consist
of 20% out patients (gateway) at district hospitals or community health
centres and 80% primary health care clinics
• Data were verified at the provincial/metro level and then combined into
a national data set
• Where possible, these findings were compared with the findings of
provincial baseline surveys that were carried out between 1996 and
1998
Results: Availability of key drugs
•
•
An average 82% of the basket of key drugs were found to be available at
facilities; there is no notable change since the baseline survey
69% of facilities were found to have greater than 75% of the key drugs
available, however 6% of the facilities had half or less of the key drugs
available
Availability of Key Drugs - distribution by facilities
100%
75%
% of Facilities
Recommendation
• Investigate why 6% of
the facilities had half or
less of the key drugs
available and develop
interventions
69%
50%
25%
25%
1%
5%
0%
0-25%
>25-50%
>50-75%
% of Key Drugs Available
>75%
Prescribing according to the National EDL
• 90% of all prescribed items were found to be in accordance with
the National EDL, a substantial improvement from the baseline
surveys (65%)
Prescribing according to the EDL
100%
90%
75%
65%
50%
25%
W P
P
C
-C
t
N
at
io
n
Ba al
se
l in
e
W
C
W
N
C
P
U
N
M
P
LP
b
-D
KZ
N
KZ
N
P
G
FS
PEk
G
PJb
G
PTs
G
EC
P
P
-M
a
0%
EC
% of Prescribed Items from EDL (Average)
Recommendation
• As part of the launch
of the 3rd PHC EDL
in 2004, provinces
and metros reflecting
sub-optimal
compliance with
aspects of the EDP
should be targeted
for more intensive
prescriber education
initiatives.
Injection prescribing
•
5% patients were prescribed an injection, which is a marked decrease from
11% in the baseline surveys
•
The proportion of patients receiving injections ranged from 1% to 11% between
provinces/metros: a difference factor of 11
Recommendation
Investigate the
25%
11%
5%
-C
t
Na
ti o
na
Ba
l
se
l in
e
W
PC
W
CP
NW
P
NC
M
PU
LP
PEk
G
PJb
G
PTs
KZ
N
KZ
NDb
0%
P
interventions
G
prescribing and develop
50%
G
proportion of injection
FS
differences in the
75%
EC
EC P
PM
a
reasons for the marked
% of Prescriptions with an Injection
•
Injection Prescribing
100%
Patient knowledge
•
88% of patients knew how to take all of their drugs (i.e. how many tablets and
when to take them)
In 7% of facilities, half or fewer of the patients knew how to take their drugs
Recommendations
• Investigate why in 7% of
facilities 50% or fewer of
the patients knew how to
take their drugs and
develop interventions;
the list of facilities for
the investigation can
be obtained from the
source data
• Counselling at dispensing
point to be strengthened
Patient Knowledge - distribution by facilities
100%
82%
75%
% of Facilities
•
50%
25%
11%
5%
2%
0%
0-25%
>25-50%
>50-75%
>75%
% of Patients that Knew How to Take their Medicines - Range
Inventory compliance with provincial formularies
• 96% of drugs found on the shelves were found to be from the applicable
provincial formulary
Recommendation - Investigate which drugs are from provincial formularies but
not from the National EDL and whether there are commonalities between
provinces/metros, so that these drugs can be considered for inclusion in the
EDL.
Accuracy of stock records
• In 50% of cases, the physical stock count was found not to match with the stock
records; there has been no notable change since the baseline surveys (48%)
Recommendation - Investigate why interventions to improve inventory
management are not effective. Ensure that Drug Supply Management Norms
and Standards and SOPs for Stock Control are used in all facilities.
Cold chain indicators
• 75% of facilities were found to be recording the vaccine fridge temperature
twice a day; this is a considerable improvement from the baseline surveys
(25%)
Recommendation - Cold chain training and supervision needs to be
continued and further improved to capitalise on progress made.
Security
• Inadequate security and adherence to key policies
Recommendation - Security measures should be improved at facilities.
Conclusions
The EDP was found to be widely implemented, although there are areas
identified for improvement. There are recommendations for action at the
national level and for individual provinces and metropolitan areas.
Summary of key recommendations
Inventory Management
• Investigate which drugs are on provincial formularies but not on the
National EDL so that they can be considered for inclusion in the EDL
• Investigate why 6% facilities had poor availability of key drugs and
develop interventions.
• Investigate new interventions to address poor inventory management
• The Drug Supply Management Norms and Standards and SOPs
should be implemented and supervision strengthened.
·
Prescribing Practice, drug use and patient satisfaction
• Investigate reasons for the marked differences between
provinces/metros in the average number of items prescribed,
proportion of antibiotics prescribed, proportion of injections
prescribed and develop interventions.
• Target facilities where patient counselling on how to take
medication was weak.
• Investigate why labelling in 80% of facilities did not comply with the
minimum legal requirements and take remedial action.
Human resource management
• Strengthen pharmaceutical supervision by district pharmacists.
• Ensure ongoing training is provided to staff responsible for drug
supply management and prescribing.
Financial management
• Strengthen mechanisms to improve the financial management and
accountability at facilities.
Additional recommendations to those in the previous sections
• Provincial and metro PTCs should investigate the marked
differences between provinces/metros on drug use and supply
management identified in this report. PTCs should continue
coordinating monitoring and evaluation of rational drug use and
contributing to the EDL selection process.
• The training of pharmacist assistants should be prioritised.
• Attention should be given to recruitment and retention of personnel.