Transcript Specific aims of regular public sector surveys

REVIEW OF PUBLIC SECTOR INDICATOR STUDIES IN ZIMBABWE—WHO IS PAYING ATTENTION?
Tisocki K, Ndhlovu CE, Simoyi T, Wilson E, Goredema, National Drug and Therapeutic Advisory Committee, Zimbabwe
Problem Statement: Zimbabwe has developed and implemented a national essential drug program since the country gained its
independence. Regular pharmaceutical indicator studies have been used to assess the performance of this program for the last two
decades. A previous study from Zimbabwe, presented at ICIUM 1997, evaluated the usefulness of such studies to managers of the
Zimbabwe Essential Drugs Program. Recent health sector reforms and adverse political and economic conditions have dramatically
altered the management and implementation of the program, however; follow-up study was needed.
Objectives: To review the results of public sector surveys conducted in the last five years (in 1998, 2000, and 2001) and assess the
extent to which recommendations made from the surveys have been followed by the relevant policy makers and decision makers.
Design: Descriptive, cross-sectional studies based on World Health Organization (WHO) indicators methodology and conducted in
randomly selected facilities.
Setting: Public sector health facilities at all levels of care.
Outcome Measures: Information collected was compared to previous years’ results to assess trends. The surveys aimed at
assessing the availability of essential medicines, drug management processes, and the rational use of medicines. Nationally
established targets were used for comparison, and evaluation of performance was measured by the various WHO indicators for
prescribing, patient care, and facilities.
Results: Overall drug availability has been declining, though some improvements were observed for specific items, such as TB
drugs and vaccines, at certain levels of the public health care system. Overall adherence to standard treatment guidelines for
indicator diseases has also been declining, with just 49% overall adherence measured in 2001. The Drug Management Supervisory
Program, which was recommended to strengthen decentralized drug management activities, appears to be poorly implemented, as
indicated by the low number of annual visits by supervisors.
Conclusions: Regular pharmaceutical surveys can provide a clear picture of existing performance and certain problems of the
pharmaceutical system. In the last three years, significant changes in the donor support structures and availability of funds, as well
as changes in the economic climate of the country and the managerial capacities of the Ministry of Health, have occurred. As a
result, in the current situation it is often difficult to implement recommendations arising from these routine pharmaceutical surveys.
There is a need for introducing other sensitive, rapid evaluation tools that can assist decision makers in dealing with nearemergency situations as well as in conducting more in-depth studies to identify fundamental causes of problems and barriers, which
can allow decision makers, in turn, to strengthen their capacity to effectively plan appropriate interventions.
BACKGROUND AND SETTINGS

Zimbabwe has started an essential drug program in the early
1980s

Since 1986 regular surveys were conducted to monitor and
evaluate the impact of the Zimbabwe Essential Drug program.

The results of the survey in the past have provided important
information to the managers of ZEDAP at Ministry of Health.

Major changes have occurred in the last 5 years;

Decentralisation has shifted decision making on drug management towards the
district and local authority level.

The Central Medical Stores has been replaced by the parastatal National
Pharmaceutical Company (Natpharm)

Long standing donor support of ZEDAP by Danida ended

Adverse economic conditions created chronic shortages of financial and human
resources in the health sector both at central and local level

The chronic shortages of foreign currency has lead to serious shortages of
essential drugs and other medical supplies

Rapidly rising inflation and unemployment has lead to increasing poverty and food
insecurity

heavy burden of HIV/AIDS and communicable diseases places high demands on
the health sector
OBJECTIVES

Objectives


To review current trends in implementation of the National
Drug policy in relation to availability, management and
rational use of drugs in Zimbabwe.
Specific aims of regular public sector surveys:

Monitor drug availability in relation to VEN, stock
management systems and drug procurement

Monitor rational drug use by measuring adherence to
standard treatment guidelines

Evaluate the implementation of essential drug programme
by making comparisons to results of past surveys

Provide recommendations for future interventions and
strategies
METHODS
Survey methodology:
 Design: descriptive, cross
sectional study, utilizing
time series analysis with no
controls for comparison.
 Settings: Randomly
selected health facilities
from all levels of public
health sector facilities
 What is surveyed?

Indicators developed to
measure every point of the
drug management cycle
Selection
Procurement
Management
Quality assurance
Monitoring & Evaluation
Rational Use
Storage and
distribution
RESULTS
Proportion of Health Facilities by range of
availability 1998 to 2001
Proportion of facilities
within the range (%)
100
1998
2000
80
2001
60
40
20
0
<40%
40-60% 61-80%
81-90%
Range of availaibility
>90
RESULTS
Availability of VEN items
90
Availability %
80
70
1998
60
2000
2001
50
40
V=Vital
Should be 100%
30
20
E= Essential
Should be >80%
10
0
Vital
Essential
VEN category
Necessary
N=Necessary
Should be >40%
DRUG MANAGEMENT
Selected Indicators
1998
2000
2001
Total stock management score#
43.3
39.3
44.8
% of drugs expired
2.8%
5.5%
9%
% of facilities managed by
Drug management Supervisor
52%
75%
70%
Average No. of annual visits by
Drug management Supervisor
0.5
0.7
0.8
#
Total Stock Management Score is calculated on the basis of average
 correct use of stock cards
 Correct se of stock book
 Correct minimum stock
ADHERENCE TO STANDARD TREATMENT
GUIDELINES BY MARKER DISEASES
90
80
70
60
50
1998
2000
40
30
2001
20
10
0
diarrhoea
ARI in
under 5's
Urethral
discharge
in M
Genital
Ulcers in
M&F
RECOMMENDATIONS & BARRIERS

Strengthen procedures for
procurement from private
sector using local Health
Sector Funds

High inflation rapidly eroded buying
power of allocated resources resulting in
recurrent essential drug shortages

Strengthen Drug
Management Supervision
and training.

Pharmacists, nurses have left the public
sector in large numbers. Critical shortage
of manpower present country-wide

Improve drug availability
and supply performance of
NatPharm stores

Even though significant restructuring and
re-organsiation has taken place at
Natpharm, the chronic shortage of foreign
currency and fuel severely limits capacity
to deliver needed drugs


Improve patient care and
review of STG and establish
Hospital Drug and
Therapeutic Committees that
should assist with
implementation of STGs
Already mentioned shortage of manpower
and shortage of essential drugs severely
limits training and promotion of rational
use of drugs
DISCUSSION & SUMMARY



Conduct of regular drug management surveys in the public sector continues to
provide valuable information on the performance of the essential drug program
However, as the survey provides only a snapshot picture of the two weeks survey
period current dramatic fluctuations in drug availability may not be captured.
Access to treatment with essential medicines have been dramatically declining in
the past 4 years due to



high inflation eroded purchasing power of local funds allocated through decentralized
health structures as well as patient’s ability to pay form essential medicines
critical manpower shortages in public sector health facilities
rapid changes in donor support and allocation of donor funds

There is a need for introducing other sensitive, rapid evaluation tools that
can assist decision makers in dealing with near-emergency situations.

It is important to conduct more in-depth studies to identify fundamental
causes of problems and barriers for example in cases of declining
adherence to STGs.

Essential drug program implementation needs to be urgently
strengthened at all levels to deliver basic health care to patients whose
vulnerability rapidly increasing due to existing adverse economic
conditions.