• Availability of key drug in health facilities
* The availability of drugs is dependent on a proper scheduled procurement of drugs supply. Health facilities should adhere strictly to properly scheduled procurement cycles and make reviews of these cycles regularly.
* The personnel involved in drugs/pharmaceuticals supply should be trained in managing drug supplies.
* Adequate funding should be set for drugs.
Quantification of SP should be done immediately to save it from expiry and hence, save money. The distribution of this drug in the kit should be revisited to avoid further piling up.
• Stock-out duration
Stock levels should be properly determined so as to avoid stock-out of essential drugs.
Introducing reporting system on drug availability to all health facilities and hospitals and regional pharmacists to supervise these activities.
Training for stock management to the pharmaceutical personnel.
• Affordability of key drugs in health facilities.
The affordability of key drugs in health facilities is influenced by the economic, status of the community. Since the majority of Tanzanians live in poverty, strategies to alleviating poverty among Tanzanian communities should be developed so as to raise the people’s purchasing power and eventually increase the affordability of key drugs.
• Adequacy of drug storage
The adequacy of drug storage has been found out, by this survey, to be 9 out of 11 points and 7 out of 11 points rating scale for warehouses and public pharmacy stores respectively. Since poor or inadequate storage conditions have negative effects on the quality of drugs, efforts should be made to ensure that the storage conditions are face-lifted to comply with the required standards.
• Patient knowledge
In order to enhance the patient knowledge on dispensed drugs.
Qualified pharmaceutical staff should be recruited and deployed appropriately in the pharmaceutical sector.
The existing pharmacy staff should be trained in good dispensing practice.
• Tracer cases treated according to STGs
The use of antibiotics for non-pneumonic ARI is high according to results obtained from this study. Further to it, there is a deviation from the standard of using one first-line antibiotic, that is, more than one antibiotics are used in treating mild/acute pneumonia.
In order to avoid the recurrence of this situation:
The STG should be reviewed to specify the demarcation of use of antibiotics in non-pneumonic ARI basing on the severity of the diseases.
Continuing education to prescribers and dispensers (especially on rational use of drugs) should be provided regularly.
Laboratory services should be strengthened to support the rational prescribing practice.
• Adherence to recommended treatment guidelines in treating diarrhoea in children.
The study has revealed an indiscriminate use of antibiotics in treating diarrhoea in children averaging 44%. This is a high non-adherence trend of practice. The contributing factors for this situation might be the lack of supportive laboratory services for discriminating the infective from non-infective diarrhoea and pressure of work on the part of prescribers.
It is therefore strongly recommended to strengthen the laboratory investigation services so as to enhance the rational prescribing practice.
Good prescribing practices through continuing education
• Adequate labeled drugs
The study indicates that 24% of drugs dispensed were not adequately labeled. The responsibilities for adequately labeling of dispensed drugs lies on the dispenser. This then confirms the need to having trained pharmaceutical staff in health facilities and dispensing practice for non-pharmaceutical staff doing dispensing activities.
• Average number of drugs per encounter
The smaller the number of drugs per prescription, the better is the situation for this indicator. The result, from the survey is 1.8 that is quite good and the trend shows improvement with years. However, there is still room for improvement to bring the figure further down. In order to achieve even a lower figure:
The preventive services, which include improvement and raising the standards of general sanitation, should be strengthened.
Continuing education to prescribers on rational drug prescribing should be provided.
Again, laboratory services should be strengthened so as to prevent short-gun-therapy tendencies practiced by some prescribers.
• Percentage of prescribed drugs dispensed
The study results indicate that 10-20% in three regions and 53% of the prescribed drugs were out of stock. The main cause of this situation has been attributed to insufficient drug distribution patterns in the drug supply/delivery system and insufficient funding especially for district hospitals.
It is therefore recommended that, the distribution and drug supply management system be strengthened and the NDP should have a strategic plan on this aspect.
Funding should be improved for drugs.
• Number of patients receiving antibiotics in one encounter
The use of antibiotics in one encounter is still high and stands, according to results of this study; at 42% and that it has remained so for almost 10 years. In order to reduce the over-usage of antibiotics:
Preventive services should be strengthened at community level.
Laboratory services should be strengthened and prescribers use them for diagnosis
Continuing education to prescribers be provided
Health education should be provided to the public to reduce the tendencies for self-medication.
Research should be carried out for the purpose of seeking alternative ways of handling the opportunistic infections especially in HIV/AIDS cases.
An antibiotic resistance-monitoring center should be established.
Education to the public on the use of antibiotics should be improved.
• Percentage of patients receiving injections
The results show a tremendous improvement, from 35% down to 10% in the past 10-year’s period. Nevertheless, there is still room to reducing the figure further down to only the absolutely necessary injections. It is therefore recommended that continuing education be provided to prescribers on various options available leading to cutting down the use of injections to patients.
• Prescribing according to EDL
The results are excellent on this indicator, that is, 98.5% adherence to prescribing according to EDL
This trend should be encouraged and maintained.
• Percentage of expired drugs
Regular inspections by the Pharmacy Board need to be carried out to public health facilities so as to curb the laxity exhibited on this aspect by the pharmacy staff in these facilities.
Supervision by PSU should be implemented using the regional and district pharmacists.
FEFO principle should be encouraged to all staff responsible for drug storage
• Guidelines availability
Supervise and implement the use of National drug list and Guidelines. The Ministry of Health should ensure that STGs and/or NEDL are available in all health facilities and accessible to all health personnel. There is a need for supportive supervision in the pharmaceutical sector for maximum use of these guideline and policies.
GENERAL RECOMMENDATIONS
There are a number of interventions, which could be used to improve pharmaceutical sector in Tanzania and promote quality of health services provided. These include training of pharmaceutical personnel and prescribers; implementation of NDP and guidelines: presence of up-to-date pharmaceutical Master plan, targeted continuing education and research. In order to execute the various components of the pharmaceutical sector and achieve the objectives of the NDP, the following way forward is recommended: -
• Encourage councils to recruit and deploy qualified pharmaceutical staff in the pharmaceutical sector.
Shortage of qualified workers in pharmaceutical sector is found in many council health facilities. However, it is noted that councils are not giving due weight on recruiting and deploying qualified pharmaceutical personnel.
• Ensure the pharmaceutical Master plan is revised and/or updated.
The present pharmaceutical sector master plan has been in place since 1991. There have been a number of policies and institutional changes which need to be revised. In this regard, the Ministry of Health is urged to review and update the Pharmaceutical sector master plan.
• Conduct a baseline survey using Level 111 core indicators in order to establish more details facing the Tanzania pharmaceutical Sector.
Establish mechanisms to monitor and assess the performance of pharmaceutical personnel.
Promote and stimulate health consumers’ knowledge about proper use of drugs.
Investigate factors associated with presence of expired drugs in health facilities.
Develop tools for assessing and monitoring drugs availability, accessibility and rational use.
A study should be done to see what is the mark-up for pricing of pharmaceuticals in Tanzania and if mechanisms could be instituted to effect drug pricing.
REFERENCES
• Grand A, Hogerzeil HV and HaaijerRuskamp FM: Intervention research in rational use of drugs: a review; Health Policy and Planning 14(2) 89 - 102; 1999.
• WHO, How to investigate drug use in health facilities: Selected drug use indicators. World Health Organization: Geneva, 1993 (WHO/DAP/93.1)
• Laing RO, Hogerzeil HV, and Ross-Degnan D Ten recommendation to improve use of medicine in developing countries. Health Policy and Planning 18(1): 13 - 20; 2001.
• Lates J and Shiyandja N Third National Survey on the Use of Drugs in Namibia’s Public Health Institutions including Monitoring, the Implementation of the National Drug Policy; 2001
• Malele RSR, Senya SS. A prospective survey of prescribing habits in the OPD of Muhimbli Medical Hospital, Dar es Salaam Tanzania (1992).
• Managing drug Supply 2nd Edition (revised and expanded) 1997 Management Sciences for Health, Boston USA.
• Masselle AY and Nsimba SED Comparison of Drug Utilisation in Public and Private Primary Health Care Clinics in Tanzania; 2001
• Masselle AY, Nsimba SE and Rimoy G Prescribing habits in church-owned primary health care facilities in Dar es Salaam and other Tanzanian coast regions; 1997
• Masselle AY, Ofori - Adjei, D., Laing RO. A study of prescribing patterns with special reference to Drug Use Indicators in Dar es Salaam region, Tanga; 1993
• Muella SH, Mushi Ak, and Ribera JM; The paradox of the cost and affordability of traditional and government health services in Tanzania. Health policy and Planning 15 (3) 296 - 302: 2000.
• Ross-Degnan D. Laing RO, Quick JD, et al A Strategy for Promoting Improved Pharmaceutical Use: The International Network for Rational Use of Drugs. Social Science and Medicine, 1992; 35(11): 1329-1341
• Standard Treatment Guidelines (STG) and the National Essential Drug List for Tanzania; MOH 2nd Edition; 1997.
• The Tanzania National Drug Policy. MOH, 1991.
• WHO Guidelines for National Drug Policies. Geneva. WHO, 1998
