Transcript Indicators for monitoring and assessing pharmaceutical situation in

Indicators for monitoring and
assessing pharmaceutical
situation in countries
Who can use the results from
assessment and monitoring?
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Countries
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National policy-makers
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Health facilities
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International agencies
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Professional groups, NGO, academia
2 -- (Monitoring & assessment - 4/6/2016)
WHO - EDM
Indicators for monitoring and
assessing pharmaceutical situation
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systematic data gathering
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to compare facilities, districts, regions, countries
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to measure trends
3 -- (Monitoring & assessment - 4/6/2016)
WHO - EDM
Core indicators to monitor national drug
policy
http://www.who.int/medicines/strategy/policy/indicators_intro.shtml
Level I
indicators
 Questionnaire
(structure & process)
Level II
indicators
(outcome)
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4 -- (Monitoring & assessment - 4/6/2016)
 Systematic survey
Level III
WHO NDP indicators
Indicators for specific pharmaceutical components:
• How to investigate drug use in health facilities
• Assessing regulatory capacity of countries
•TRIPS, Drug pricing, Traditional medicines
WHO - EDM
Level I indicators
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questionnaire (every 4 years with subset every two years)
1999 WDS questionnaire as template, consultations and
discussions with team, regional advisers, countries
mostly structure and process indicators for countries
country progress indicators for global tracking
EDM database
5 -- (Monitoring & assessment - 4/6/2016)
WHO - EDM
Level I indicators
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Covers key components of pharmaceutical system
National medicines/drug policy
Access
Legislation and Regulation, Quality control of pharmaceuticals
Essential drug list
Medicines supply system
Medicines financing, production*
Rational use of drugs
Intellectual property rights protection and marketing
6 -- (Monitoring & assessment - 4/6/2016)
WHO - EDM
Operational package on level II indicators
designed as a practical tool:
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to assess and monitor impact and outcome (systematic survey)
to provide countries with feasible tool to monitor and assess
pharmaceutical situation
to design a monitoring system and for regular monitoring of
NDPs
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Designed around practical/operational system of managing
resources (time, people and money)
Step by step procedure
• administrative preparation (budget guideline, training schedules)
• technical requirements (training and field test, actual survey,
analysis, reporting and identifying intervention
7 -- (Monitoring & assessment - 4/6/2016)
WHO - EDM
List of indicators
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on availability, stockout, record keeping and expiry of key drugs
conservation conditions and handling of medicines
affordability (child and adult moderate pneumonia and option for
other disease condition
drug dispensed, labelling, patients knowledge, cost of medicines
Number of medicines prescribed, % antibiotics, % injection, ED
prescribed, drugs in generic name
availability of EDL and STG
drugs prescribed for diarrhea, pneumonia, ARI
8 -- (Monitoring & assessment - 4/6/2016)
WHO - EDM
Sampling Recommendations
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Sample
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6 regions/districts
30 public health facilities with pharmacy/dispensary
30 private pharmacies
6 warehouses
Option to add private facilities, mission clinics depending
on health service mix or provider
9 -- (Monitoring & assessment - 4/6/2016)
WHO - EDM
Clustering in Drug Supply or Drug Use Data
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Geographic Characteristics
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Health Facility Characteristics
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Administration and drug supply system
Epidemiologic or socio-economic differences
Differences in management
Peer norms and collective habits
Provider Characteristics
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Training, knowledge, clinical experience
Economic incentives
Industry pressure
Result: Effective sample size is reduced
10 -- (Monitoring & assessment - 4/6/2016)
WHO - EDM
Countries
AFRO: Cameroon, Chad, Ethiopia, Ghana, Kenya, Mali, Nigeria,
Rwanda, Senegal, Tanzania, Uganda
AMRO: Guatemala, Columbia (10 more countries)
EMRO: Iran, Oman
EURO: Bulgaria, Kyrgyzstan,
SEARO: Indonesia, Nepal
WPRO: China, Philippines, Malaysia
11 -- (Monitoring & assessment - 4/6/2016)
WHO - EDM
Monitoring if there is progress or none
Comparing 1995-2002 key indicators shows progress in some
areas but that enhanced efforts needed in others
Bulgaria
Philippines
100%
80%
60%
40%
20%
0%
Availabilit y of key %of presc. drug in
drugs
EDL
%presc. wit h
injection
Availabilit y of key %of presc. drug in
drugs
EDL
1995
12 -- (Monitoring & assessment - 4/6/2016)
%presc. wit h
ant ibiot ics
2002
WHO - EDM
%pat ient wit h
adequat e
knowledge
%presc. wit h
injection
Essential medicines are still not
available and affordable to all
Access indicators
100%
80%
60%
40%
20%
0%
Guatemala
Iran
Philippines
Bulgaria
Availability of key drugs
% drug dispensed
Affordability (cost to treat pneumonia/w eekly salary
13 -- (Monitoring & assessment - 4/6/2016)
WHO - EDM
Inappropriate use of antibiotics is a
common problem
Antibiotic use 2002
100%
80%
60%
40%
20%
0%
Guatemala
Iran
Philippines
Bulgaria
% presc. w ith antibiotics
Antibiotics for ARI
Pneumonia w ith > 1 antibiotics
Either amox,pen, cotrimox for pneumonia
14 -- (Monitoring & assessment - 4/6/2016)
WHO - EDM
Survey makes possible the comparison
of public and private pharmacies
% Availability at public and private sector (2002)
100%
80%
60%
Public facility pharmacy
40%
Private pharmacy
20%
0%
Tanzania
15 -- (Monitoring & assessment - 4/6/2016)
Mali
Ghana
WHO - EDM
Comparing public and private pharmacies
Cost to treat moderate pneumonia in children as
percentage of lowest weekly government salary
12%
10%
8%
6%
4%
2%
0%
Nigeria
Public dispensary/pharmacy
16 -- (Monitoring & assessment - 4/6/2016)
Tanzania
Private pharmacy
WHO - EDM
Summary Values
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Mean vs. median
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Standard deviation vs. quartiles
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Equivalent if data are normally distributed
Mean weighted toward skewed values
SDs more widely understood
Quartiles better summary of skewed data
Need to detect wild data points
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Can be due to data errors or true outlier values
Can substantially bias means and SDs
Need to have standard screening procedures
17 -- (Monitoring & assessment - 4/6/2016)
WHO - EDM
Appropriate Standards for Indicators
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Group norm
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Easy for region/facilities to relate to peers
Norm might be wrong
Ideal values
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Logical values exist for some indicators
Can be calculated empirically
Should ideals be stated in manual?
18 -- (Monitoring & assessment - 4/6/2016)
WHO - EDM
Sampling and Analysis Issues
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Small sample from more facilities
Summary measure (mean/median, SD/quartiles)
Appropriate standards for indicators
Inter-country comparisons
Changes over time
Connecting results and interventions
19 -- (Monitoring & assessment - 4/6/2016)
WHO - EDM
Connecting Survey Results and Interventions
20 -- (Monitoring & assessment - 4/6/2016)
WHO - EDM
Household survey to measure access and
use of medicines
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currently one page survey instrument (13 questions)
information covers the the following:
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health seeking behaviour leading to use or non use of drugs
if patients can afford, if they are available, where they are
available, if able to get the medicine, reason why not
21 -- (Monitoring & assessment - 4/6/2016)
WHO - EDM
Household survey to measure access and
use of medicines
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Field testing
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in conjunction with level II systematic survey
WHO- HAI project in AFRO
House hold survey for World Health Report
Development of questionnaire (one page with level II and
option to expand with qualitative questions)
Sampling (recommended/appropriate sampling vs.
resources)
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Form a working group to further develop the manual and the
process (questionnaire and sampling framework)
22 -- (Monitoring & assessment - 4/6/2016)
WHO - EDM
Lower income groups do not get all the
medicines they need
How much of the medicine prescribed was
obtained: Tanzania 2002
100%
80%
None
60%
Some
40%
All
20%
0%
<$2
$2-$10
>$10
Weekly expenses
23 -- (Monitoring & assessment - 4/6/2016)
WHO - EDM
Availability and affordability are the
barrier to access
Why households did not obtain all the medicines
Tanzania 2002
100%
80%
Other
60%
Medicines not available
40%
Price too high
20%
Not enough money
0%
<$2
$2-$10
>$10
Weekly expenses
24 -- (Monitoring & assessment - 4/6/2016)
WHO - EDM
The way forward on country monitoring
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Evidence through systematic but feasible data collection
process is necessary in policy making and activity
implementation
Should demonstrate that in the long run regular monitoring is not
difficult and can be done in a cost efficient manner
Portion of country support budget and project grants should be
allotted to monitoring and evaluation using indicators
Information sharing: studies and results will be available in the
web
25 -- (Monitoring & assessment - 4/6/2016)
WHO - EDM