Medicine management
Access to medicines
Access to essential medicines is part of the right to the highest attainable standard of health. But in Dodoma, essential medicines are often beyond the reach of most households.
To alleviate this situation, we are working to improve medicine management, and this means addressing the supply chain as well as the use of medicines. Lack of access to medicines is a problem, but access is of little advantage if the medicines are not used correctly.
Although the emphasis of the HPSS project focuses on the aspects of health promotion and health financing, “health system strengthening” is not complete without strengthening the management and use of essential medicines. The project’s efforts to make additional financial resources available through community heath funds and to encourage health promotion activities in the community may not be successful if the quality of health services offered is perceived to be poor.
Improving the flow of funds to health facilities does not directly translate into proportional improvements in the services provided. The quality of these health services crucially depends on the availability and use of essential medicines and supplies.
A situation analysis and health facility survey revealed complex and systemic weaknesses of the whole supply chain at all levels including aspects of financing, human resources, health information, governance, supply and record keeping skills, bureaucratic procedures and service delivery as well as issues with Medical Stores Department (MSD) leading to significant stock-outs of medicines at facility level.
Improving supply of medicines at health facility level is considered imperative as enrolment into the newly structured CHF system will depend on enhanced quality of service delivery, often equated by the community with availability of medicines.
The regional HPSS project can only influence certain aspects of this system to strengthen medicine management and enable better availability of medicines. Through partnerships, we seek to build on the strengths that exist and bolster weak areas through training programs and coaching, new management and supply chain design concepts and awareness building.
Access to medicines
Access to essential medicines is part of the right to the highest attainable standard of health. But in Dodoma, essential medicines are often beyond the reach of most households.
To alleviate this situation, we are working to improve medicine management, and this means addressing the supply chain as well as the use of medicines. Lack of access to medicines is a problem, but access is of little advantage if the medicines are not used correctly.
Medicine Management - A Situation Analysis
A significant body of literature on the pharmaceutical sector in Tanzania is available, including recent assessments, surveys and consultations commissioned by the Minister of Health, Community Development, Gender, Elders and Children (MoHGDEC)and WHO and conducted by various consultancy groups. Numerous recommendations have been made; many of these recommendations are yet to be implemented.
Our initial assessment of medicine management in the Dodoma region in 2011 showed there are important strengths already in place. A National Medicine Policy (NMP), Standard Treatment Guidelines (STG), the Integrated Logistic System (ILS), administrative and governing structures and infrastructure (health facilities and roads) are in place.
A systemic approach to strengthening the supply chain
As one of the building blocks of the health system, medicines are crucial for the functioning of health care delivery. Availability of medicines supports and motivates health workers in their clinical work, gives people confidence in the public health system and most of all it allows patients to be treated and to get better. Availability of medicines is often equated with good quality of care even though other factors are equally important such as waiting time, empathy, compassion, good diagnostics and functional medical equipment, evidence based therapeutics and affordability of care. In the larger spirit of universal health coverage in Tanzania, medicines availability at health facilities will encourage the population to enroll in the community health fund (CHF).
Read more: A systemic approach to strengthening the supply chain
Health workers - the backbone for improving access to medicines
A general crisis of the health workforce in Tanzania is reflected in critical shortages of pharmacy staff at all levels of the public health system in Dodoma.
The situation analysis in 2011 showed that only 5 health facilities, notably hospitals employed a trained pharmacist, 7 facilities a pharmacy technician and 2 facilities a pharmacy assistant in 247 facilities surveyed. In 94% of health facilities medicines management is done by non-pharmaceutically trained cadres comprising nurses, medical attendants or clinical officers whose main task is clinical care of patients.
Read more: Health workers - the backbone for improving access to medicines
ILS training
Equipping medical staff with supply management skills
The national medicines supply system is organized around the Integrated Logistics System ILS. The ILS which gradually replaced the kit system in Tanzania comprises the process and procedure of ordering and receiving medicines from MSD through the requisition system. Using the ILS system, medicines are ordered based on forecasted quantity needs. To request supplies, a health facility employee fills out a Report and Request form (R&R form).
Our HPSS situation analysis showed that weaknesses leading to inadequate supply of medicines partly stem from inefficient use of this system. To name just a few of the problems: in the majority of health facilities, non-pharmaceutical staff such as nurses or clinical officers, with no training in ILS procedures, submitted R&R forms. These health workers’ primary responsibility naturally is to provide clinical healthcare to patients; hence, supply logistics was not a high priority. Filling out R&R forms could at times take up to one week of work. Some facilities resorted to simply copying forms from the previous quarter. In other cases, items were requested until the facility budget was exhausted, but no efforts were made to reconcile needs and budget. Once forms were submitted, there was inadequate review of the forms at the district and MSD levels, weak guidelines and deficient communication regarding available funds and supplies. In addition, delays in delivery and low order fulfilment at MSD compounded the situation.
All of this leads to stock outs at health facility level.
The HPSS situation analysis also revealed that the only ILS training for pharmaceutical staff was in 2005. Since then, there had not been a refresher or repeat course, despite staff rotations in facilities.
Therefore we developed a comprehensive ILS training program with the goal to build capacity of health workers in medicines supply management and the ILS.
Training workshops for the Integrated Logistic System (ILS) were conducted in February and March 2012. Over 300 people attended the workshops, which were designed for the Regional Health Management Team, Council Health Management Teams, pharmacists and health care workers from dispensaries, health centres and hospitals. The zonal MSD manager was invited to allow direct communication with health workers.
The impact of the training workshops was assessed through pre- and post-testing to evaluate skills in practical exercises. This allowed identifying best performing participants and those requiring further mentoring. The average increase in performance was 60 per cent.
Peer Coaching
The learning impact of a single training course needs to be sustained with follow-up activities to support implementation and transfer of skills into daily activities. The concept of cascade coaching for face-to-face peer mentoring was discussed, endorsed and workplans designed for implementation.
Coaching is defined as a one-to-one activity whereby a coach attempts to induce change in a coachee to boost his/her performance in a particular sector. Coaching and mentoring is often used in an exchangeable way. Coaching primarily is a supportive tool and its role has evolved from correcting deficiencies to facilitating learning and moving people from poor to good performance. Generally coaching is a one-to-one intervention to shape and deliver a learning program and to support colleagues in their professional work. It is an ongoing relationship.
The objectives of the cascade coaching are the following:
- To sustainably strengthen supply management of medicines at health facility (HF) level
- To sustain knowledge, skills gain and motivation after the ILS training
- To engage internal human resources and capacity and to create ownership of activity, embedded in district organization
- To encourage active participation of health workers in improving quality of care, building on the experience of existing cascade supervision.
Potential coaches in each district were identified based on their supply management performance, their capacity and willingness to mentor colleagues and by recommendation of respective DMOs. Workplans for each district were elaborated by the district coaches in collaboration with district pharmacists. The workplans include methodology of coaching and a scheduled activity plan per cascade node and month.
Cascade coaching started in July 2013 after training new coaches on ILS management supply and coaching skills.
Complementing MSD Supply with a Prime Vendor System
It has become evident that alternative strategies to improve availability to medicines in the HF of Dodoma region are needed. The supply gap of approximately 40% needs to be filled by other means as efficiency of MSD cannot be influenced by the HPSS project in a significant way. While MSD will remain the backbone for medicines supply to the public sector, Dodoma region together with the HPSS project decided to tackle the problem of out of stocks of medicines with a PPP approach.
The supply gap will be complemented by medicines from other sources financed with complementary funds. Health facilities and districts have funds available that are earmarked for the purchase of supplementary medicines. These medicines will be paid from regular sources of complementary funds available such as CHF, NHIF, user fees and basket funds. So far, purchase of supplementary medicines has, however, been very fragmented and uncoordinated and has not taken advantage of economies of scale.
A concept for possible scenarios with a Prime Vendor (PV) was discussed and endorsed by the districts. The PV concept comprises an approach that could alleviate supply availability problems by implementing a complementary supply system, involving the private sector. The new regional Prime Vendor (PV) system is a unique public private partnership (PPP) with the objective to supplement medicines supplies of Medical Stores Department (MSD) with supplies from a single vendor in a pooled regional approach.
After a comprehensive and transparent prequalification and procurement process by the regional authorities, a supplier was selected based on Applicable Procurement Regulations. During an official launch on September 2014 graced by with the guest of honor the deputy Minister of Health and the Swiss Ambassador, the 1st contract between the regional authorities of Dodoma and the selected Prime Vendor was signed.
This has been the starting point for the implementation of a system that is expected to fill the gap in medicines availability, in collaboration and partnership with MSD as the main supplier of medicines to public health facilities. The region will also closely collaborate with TFDA, the Pharmacy Council and the Pharmaceutical Services Section of the MoHCDGEC.
A comprehensive and user friendly handbook with Standard Operating Procedures for health facilities and districts was developed to operationalize the PV system. All actors have been called upon to adhere to the operational principles and purchase supplementary medicines from their regional PV.
Next to reducing stock outs of medicines, good clinical practice including correct prescribing and use of medicines based on the national Standard Treatment Guidelines will be a prerequisite for better health outcomes. Providing more medicines in the supply system may increase the opportunity for leakage and misappropriation. Therefore; RHMT and CHMT should conduct regular supportive supervision and auditing to improve medicine accountability.
For more information regarding JAZIA prime vendor system, please visit: https://www.jaziaprimevendor.or.tz/
Supportive supervision to improve medicines management
WHO defines supervision - a managerial activity- as the "overall range of measures to ensure that personnel carry out their activities effectively and become more competent at their work". It also aims at giving health workers job satisfaction. Supervision ensures that health workers carry out their activities effectively and become more competent and motivated at their work. Nevertheless, supervision is often weak despite being a critical district activity to increase quality of care. Although highly recommended, itis rarely conducted as a planned activity due to lack of transportation means, fuel, financial resources, as well as inadequate training of supervisors in supervisory skills.
Supportive supervision in Dodoma region is carried out by the Council Health Management Teams (CHTM). However tools and procedures are weak and limited by available resources. Using short checklists enables teams to provide guidance on the technical aspects of services which should result in improving quality of health care. Checklists help organize the work of supervision to make it regular and reliable.
The currently used supervision checklists of districts in Dodoma region were analyzed for items and questions resp. indicators referring to medicines management. Findings revealed that supervision checklists for medicines are either absent or of poor quality. Questions do not cover relevant aspects of medicines management, are poorly structured and cannot be measured or validated against standards.
During a workshop the various district supervision checklists were discussed and a new, improved and harmonized list was developed. Together with harmonization and an enhanced process of supportive supervision in the whole region the supervision checklist has been implemented.
Medicines and financial audits followed by appropriate actions
Medicines being a lucrative commodity, numerous loopholes in the supply chain exist for intransparent activities bypassing regulations. Unfortunately leakage of medicines at various junctures of the supply chain is not uncommon. Accountability of actors and concerned communities is critical as is effective supervision and auditing.
We started a medicines and financial audit process in a few districts and found that the majority of health facilities had discrepancies in medicines stocks and/or user-fee collection. Record keeping was found to be one of the key challenges at health facilities. Quantities of medicines not accounted for were converted into cash and health care workers were informed of the amount of medicines and funds not accounted for. These losses had to be refunded by health facility in charges which resulted in significant improvement of reporting, documenting and funds collected. This audit methodology coupled with sanctions taken will be replicated in other districts and institutionalized.
Rational use of medicines to improve quality of therapy
Lack of access to medicines is a major problem in any health system, but access is of little advantage if the medicines are not used correctly. The availability of essential medicines, equipment and supplies, together with rational use by prescribers, dispensers and patients are two important indicators for the quality of health care services. Irrational use of medicines is a serious global problem that is wasteful and harmful.
To improve the use of medicines, we need a two-pronged approach: on the community end, we address perceptions and behaviours; on the health provider’s side, we address the professional knowledge, skills and practices needed for effective use of medicines through rational prescribing and dispensing.
A baseline study on medicine use - also called rational use of medicines study (RUM), based on WHO/INRUD standard methodology – was conducted in 2012 serving to explore the current situation and to identify potential areas for planning interventions.
Of the 270 public facilities in the six districts of Dodoma, a random sample of 120 facilities was included. Pharmacy graduates from St John’s University in Dodoma were trained and questionnaires were pilot tested. A total of 3510 encounters were collected and recorded retrospectively and 1397 encounters were collected and recorded prospectively.
Among many findings requiring attention, the most critical is the high use of antibiotics (66%). A similarly serious finding is the low availability of key medicines in the visited health facilities that prevents appropriate prescribing and use of medicines.
This comprehensive study allowed an insight in the use of medicines in Dodoma region. It can be used to understand gaps and define priority activities for further investigation and action. It can also be used baseline for measuring the impact of interventions.
A concurrent study explored adherence to national Standard Treatment Guidelines (STG). We focused on the quality of pharmacotherapy exploring the medicines prescribed for a given diagnosis. In total diagnoses of 2’886 patient cases were recorded and analysed. The results are worrisome as complete adherence to STG was found in only 31% cases and wrong treatment was found in 30% of diagnoses. About one third of cases received at least the correct medicine but additional unnecessary or wrong medicines. We are planning interventions focusing on the main diseases to improve pharmacotherapy as this affects availability of medicines and ultimately health outcomes.