Survey form 1: Public health facility pharmacy and central/district warehouse
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% of expired drugs |
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Indicator: |
Availability of key drug |
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Facility |
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Date |
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Location |
____________ |
Investigator |
____________ |
Key drugs in stock to treat common conditions
[A] |
In stock
[B]
Yes=1, No=0 |
Drugs in stock that have expired
[C]
Yes=1 No=0 |
ORS |
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Cotrimoxazole |
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Chloroquine or Sulphadoxine/pyrimethamine |
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Iron tablets |
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Folic Acid |
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Mebendazole |
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Chloramphenicol eye ointment/drops |
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Iodine |
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Benzyl/salicylic acid |
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Paracetamol tablets |
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Amoxycillin syrup |
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Vitamin A |
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Total no. of key drugs [A1]= |
[B1]= |
[C1]= |
% in stock in this facility [B2]= |
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% of expired drugs [C2]= |
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Notes:
[A] List of 10-15 key drugs previously identified at national level must be printed before starting the survey. The process is described on page 21. Add the total number of key drugs [A1].
[B] Mark 1 if stock is available (even if only one dosage form is available). Mark 0 if the drug is not physically available. Add the total at the bottom. [B1]
[B2] 
[C] For all drugs in stock, check if expired or not. Add all the “Yes” answers [C1]
[C2] 
Survey form 2: Private pharmacy
Indicator: |
% of expired drugs |
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Facility |
____________ |
Date |
____________ |
Location |
____________ |
Investigator |
____________ |
Key drugs in stock to treat common conditions
[A] |
Drugs in stock that have expired
[B]
Yes=1 No=0 |
ORS |
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Cotrimoxazole |
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Chloroquine or Sulphadoxine/pyrimethamine |
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Iron tablets |
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Folic Acid |
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Mebendazole |
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Chloramphenicol eye ointment/drops |
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Iodine |
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Benzyl/salicylic acid |
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Paracetamol tablets |
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Amoxycillin syrup |
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Vitamin A |
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Total no. of key drugs[A1]= % of expired drugs [B2]= |
[B1]= |
Notes:
[A] List of 10-15 key drugs previously identified at national level must be printed before the survey. The process is described on page 21. Add the total number of key drugs[A1].
[B] Check if expired or not. If any of the strengths has an expiry problem the answer for the drug should be “Yes”.
[B1] Add all the “Yes” answers.
[B2] 
Survey form 3: Public facility pharmacy/central district warehouse
Indicator: |
Stockout duration |
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Facility |
____________ |
Date |
____________ |
Location |
____________ |
Investigator |
____________ |
Key drugs
[A] |
No. of days out of stock
[B] |
No. of review
[C] |
Equivalent no. of days/year
(D)=B × 365/C |
ORS |
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Cotrimoxazole |
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Chloroquine or Sulphadoxine/pyrimethamine |
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Iron tablets |
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Folic Acid |
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Mebendazole |
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Chloramphenicol eye ointment/drops |
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Iodine |
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Benzyl/salicylic acid |
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Paracetamol tablets |
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Amoxycillin syrup |
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Vitamin A |
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[A1]= Total no of key drugs (sum of A)= |
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[D1]=Sum of D
[E] = Average number of stock out days=[D1/A1] |
[D1]= [E]= |
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Notes:
[A] List of 10-15 key drugs previously identified must already be printed in [A]. (see page 21). Review the stock cards of the key essential drugs listed.
[B] Go through the stockcards covering the review period. Add the number of days that each of the key essential drugs are not available or marked “0” on the stockcard. A drug is considered in stock if it or its equivalent is available in either generic or branded form.
Indicate in (B) the total number of days.
[C] The review should cover a six month to one year period. If this is not possible then indicate the number of days covered by the review.
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Example:
Key drugs
[A] |
No. of days out of stock
[B] |
Number of days covered by the review)
[C] |
Equivalent no. of days/year
B × 365/C=(D) |
Amoxycillin |
58 |
120 days |
58 × 365/120= 176 |
Cotrimoxazole |
90 |
6 months |
90 × 365/180=182 |
Paracetamol |
30 |
1 year |
30 × 365/365=30 |
A1= 3 keydrugs |
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[A1]= Total no of key drugs =3 |
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[E]= Average number of stock out days [D1/A1]= |
129 days |
Survey form 4: Private drug outlet and public health facility pharmacy
Indicator: |
Affordability of key drugs (treating pneumonia without hospitalisation) |
Facility |
____________ |
Date |
____________ |
Location |
____________ |
Investigator |
____________ |
Drug/INN |
Preparation |
Unit price (inj. vial, tablet, or capsule) |
No. of units needed to complete treatment |
Total cost U$ |
E/G × 100= |
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Local |
U$ |
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[A] |
[B] |
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[C] |
[D] |
[E] |
[F] |
Crystalline penicillin injection |
1 mega unit vial |
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20 |
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Amoxicillin |
125mg/5ml (syrup or suspension). |
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20 |
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Cotrimoxazole |
(200mg sulfamethoxazole +40mg trimethoprim /5ml (syrup or suspension). |
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10 |
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[G]=Lowest government salary in a week/5 working days 1,375 or 11.3 USD |
[H]= F with lowest value |
Notes:
Get the prices of drugs listed in the above table. Choose the lowest priced product/brand.
Identify other preparations only when necessary or if the above are not available.
If there are other preparations these should be written in columns [A] & [B] before starting the survey.
(see page 21-Identifying drugs to treat children w/ pneumonia as outpatient).
[B] Only one preparation will be used for each drug.
[C] The field worker will indicate the unit price in local currency & in US$
[D] Before starting the field test, check the STG to determine the number of units needed for the duration of treatment. Print this number on the form for each drug listed.
[E] = Total cost of treatment = C x D. Only one drug (antibiotic) should be used to calculate cost of treatment and not a combination of drugs
[F] = % of treatment cost (per drug) to lowest government salary for one week = E/G x 100
[G] = Get the one week equivalent salary from the daily or monthly lowest salary of government worker/public servant
[H] = F with the lowest value will be used as the % treatment cost/salary of the facility.
Survey form 5: Checklist for storage area in public pharmacy/warehouse
Indicator: |
Adequate storage |
Facility |
____________ |
Date |
____________ |
Location |
____________ |
Investigator |
____________ |
Checklist |
Storage |
Pharmacy |
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(check the box if Yes) |
Are there locks which are working in the storage area |
Ο |
Ο |
Storage and shelves area are clean (no dust and litter) |
Ο |
Ο |
No evidence of pests seen in the area |
Ο |
Ο |
There is a roof/ceiling |
Ο |
Ο |
There are windows that can be opened or there are air vents |
Ο |
Ο |
No direct sunlight should enter the area, glass window pane painted white, or with curtains/blinds to protect against sunrays |
Ο |
Ο |
Area free from moisture (leaking drains and taps).
Drugs should not be stored directly on the floor |
Ο |
Ο |
There is a separate storage and dispensing area for issuing drugs |
Ο |
Ο |
Drugs are sorted in systematic way (alphabetical, first expiry-first out) |
Ο |
Ο |
There is stock record system |
Ο |
Ο |
There is a cold storage with temperature chart |
Ο |
Ο |
Rating for the facility: [A]+ [B]/2, if only one exists just use [A] or [B] = |
[A]= |
[B]= |
Facility storage |
Rating (check) |
Equivalent rating for quality of drugs |
Poor |
0-3 |
Ο |
Quality may be poor |
Not adequate |
4-5 |
Ο |
Quality may be doubtful |
Moderately adequate |
6-7 |
Ο |
Acceptable quality |
Adequate |
8-10 |
Ο |
Acceptable quality |
More than adequate |
11 |
Ο |
Good quality |
Survey form 6: Rational drug use - Prescribing indicator form (public health facility)
Indicator: |
average number of drugs % injection use |
% antibiotic use |
% drugs in EDL |
Facility |
____________ |
Date |
____________ |
Location |
____________ |
Investigator |
____________ |
Seq. Patient No |
Type (R/P) |
Date of Rx |
N° drugs |
Antib |
Injec. |
No. of Drugs on EDL |
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[A] |
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[B] |
(0=no, 1= yes)
[C] |
(0=no,1=yes)
[D] |
[E] |
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Total |
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B* = |
C* = |
D* = |
E* = |
Average |
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B** |
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Percentage |
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C*/No. of cases × 100 = |
D*/No. of cases × 100 = |
E*/B* × 100 = |
Notes:
[A] Select 30 outpatient patient seen within 6 months- one year period from the records (R = retrospective)/those being treated (P = prospective). Sample of cases can be a combination of P and R. (See page 20: Select patient encounters)
[B] Count number of drugs prescribed for each case. (B* = Total no. of drugs)
Count as 1 a drug given in different preparation (ex: paracetamol tablet and injection two brands of similar chemical entity/INN/generic name will be counted as 1 also
[B**] Average No. of drus prescribed = B*/Number of cases
[C] Indicate 0 if no antibiotic is prescribed and 1 if one or more type of antibiotic is given. (C*= Total of cases with antibiotics)
[D] 0 if no injection and 1 if it was given. (D* = Total of cases with injection)
[E] From the number of drug prescribed for the case, count those included in the EDL (E* = total number of drugs listed in EDL)
Survey form 7: Rational drug use - Patient care form (public health facility)
Indicators: |
% of drugs dispensed |
% of patients who knows how to take drugs |
% drugs with adequate label |
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Facility |
____________ |
Date |
____________ |
Location |
____________ |
Investigator |
____________ |
Seq. N° |
Number of drug prescribed [A] |
N° of drugs dispensed
[B] |
N° of adequately labelled
[C] |
Knows dosage *
(0=no, 1= yes) [D] |
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Count |
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All 1= |
Total |
Total B= |
Total C= |
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Average |
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Percentage |
% dispensed = Total B/No prescribed × 100=____ |
% w/adequate level = Total C/Total B × 100 = |
% of patient who know = All 1/cases asked × 100 =____ |
Notes:
[A] Interview 30 patients leaving the dispensing area/pharmacy (See page 21: Prospective sampling)
[B] Check how many drugs (chemical entity/INN/generic) were given to each patient.
[C] Check which are adequately labelled (name of drug, dosage and duration plus any additional criteria specified by country). A drug is adequately labelled only if all criteria are met.
[D] Ask patient if he/she knows how to take the drug. If patient can correctly give the name of all drugs or state what the drugs are for and how they should be taken.
(0) If the patient cannot give the name of even one drugs or state what the drugs are for or does not know how to take one of the drugs given.
Survey form 8: STG at public health facility
Indicators: |
Availability of STG for common local conditions |
Availability of Essential Drug List (EDL) at the facility |
Facility |
____________ |
Date |
____________ |
Location |
____________ |
Investigator |
____________ |
Standard treatment guidelines available at facility |
(Yes/No) |
National STG |
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STG for URTI |
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STG for Diarrhoea |
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STG for Pneumonia |
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Malaria |
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Tuberculosis |
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Others: |
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EDL available at the facility |
(Yes/No) |
National EDL |
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Provincial/District |
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Primary EDL |
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Others: |
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STG is available in this facility |
Yes No |
EDL is available in this facility |
Yes No |
Notes:
The facility is considered to have STG if any of the above is available provided the STG was developed by an independent group and the document is not associated to promote pharmaceutical products.
2. Before the survey, the latest most updated version of EDL must be identified. The facility is considered to have EDL if one of the above is available.
Survey form 9: Treatment of diarrhoea, ARI, and pneumonia at public health facility
Indicators: |
% tracer case treated using recommended treatment |
Facility |
____________ |
Date |
____________ |
Location |
____________ |
Investigator |
____________ |
Notes: Select at random 30 patients (diarrhea, ARI & pneumonia). Choose only single disease encounters. Always write 1 or 0 for all drugs enumerated.
For assessment (level 1, 2) write A/ B/ C/ D/E on the appropriate spaces. Add total.
Diseases/Drug prescribed |
Cases (1=yes/ 0=no) |
Total yes (1)/ cases × 100 |
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1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
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Diarrhoea in Children |
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ORS |
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Antibiotic |
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Antidiarrheal |
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Antispasmodic |
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Other drugs given |
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Level I assessment (A/B) |
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A=___/B=___ |
Level 1 assessment: |
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A = appropriate = (all criteria: ORS 1, antibiotic 0, antidiarrhoeal 0, antispasmodic 0, other drug 0) |
B = not appropriate =(one or all criteria: ORS 0, antibiotic 1, antidiarrheal 1, antispasmodic 1, other drug 1) |
Non-pneumoni- acute respiratory tract infection (ARI) |
Antibiotic prescribed |
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Level 1 assessment (A/B) |
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A=___/B=___ |
Antipyretic/analgesic |
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Cough and/or cold drugs |
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Other drugs given |
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Level 2 assessment (C/D) |
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C=___/D=___ |
Level 1 assessment: |
Level 2 assessment: only if level 1 is A |
A= appropriate(antibiotic 0) |
C= appropriate (all criteria: antipyretic/analgesic 1 or 0, cough/cold 1 or 0, other drug 0) |
B= not appropriate(antibiotic 1) |
D= not appropriate (other drug 1) |
Pneumonia |
Crystalline Penicillin inj. |
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Amoxicillin |
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Cotrimoxazole |
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Number of other types of antibiotics: |
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0 |
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1 |
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>1 |
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Level 1 assessment(A/B/C) |
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A___,B___,C__ |
Antipyretic/analgesic |
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Cough and/or cold drugs |
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Other drugs given |
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Level 2 assessment(D/E) |
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D=___/E=__ |
Level 1 assessment |
Level 2 assessment: only if level 1 is A |
A = appropriate = (only one: procaine penicillin or amoxicillin or cotrimoxazole is 1, number of other types of antibiotic 0.)
B= not certain = if none of procaine penicillin or amoxicillin or cotrimoxazole was prescribed, then number of other types of antibiotic can be 0 or 1. (the other antibiotic may be appropriate or not)
C = not appropriate = (any combination of procaine penicillin, amoxicillin, cotrimoxazole and other type of antibiotics. It means > 1 type of antibiotic given in the case. |
D = appropriate = (all criteria: antipyretic/analgesic 1 or 0, cough/cold 1 or 0, other drug 0)
E= not appropriate (other drugs 1) |
Access and use of medicines |
Have you or any members of the household been ill in the last two weeks? (exclude hospital admission)
Yes No |
Sex and age of person who has been ill |
Male
Female
Age: _____ year(s) |
What were the person’s symptoms? (mark one or more) |
Diarrhoea
Cough
Fever
Others (symptoms or diagnosis) |
What was done for the person? (use numbers to indicate the order of actions taken) |
____ Consulted traditional healer |
____ Sought advice from friend/neighbour/family |
____ Consulted public health clinic/hospital |
____ Bought medicine without consultation |
____ Consulted private health clinic/hospital |
____ Used medicine left from another illness |
____ Consulted pharmacist |
____ Did nothing |
____ Consulted drug seller |
(If no one was consulted, skip to question 9) |
Was medication prescribed?
Yes No |
Which medicines were bought?
All Some None |
If not all, why not? (mark one or more) |
Price was too high |
Traditional healer did not have all the medicines |
Did not have enough money |
Public pharmacy did not have all the medicines |
Not able to borrow enough money |
Private pharmacy did not have all the medicines |
Too many medicines were prescribed |
Drug seller did not have all the medicines |
Did not believe all the medicines were needed |
Already had some of the medicines at home |
Started to feel better |
Other |
No time to get all the medicines |
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How much of the prescribed medicine was taken?
All Some None |
What medicines were used? (include traditional medicines) |
Amount spent (write 0 if free) |
Mark an X through the source as numbered (1 - 9) |
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Local |
US$ |
(1) Traditional healer
(2) Public health centre/hospital
(3) Private health centre/hospital
(4) Public pharmacy
(5) Private pharmacy |
(6) Local store/marketplace
(7) Friends/neighbours/family
(8) Medicines already owned
(9) Other |
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(1) |
(2) |
(3) |
(4) |
(5) |
(6) |
(7) |
(8) |
(9) |
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(1) |
(2) |
(3) |
(4) |
(5) |
(6) |
(7) |
(8) |
(9) |
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(1) |
(2) |
(3) |
(4) |
(5) |
(6) |
(7) |
(8) |
(9) |
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(1) |
(2) |
(3) |
(4) |
(5) |
(6) |
(7) |
(8) |
(9) |
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(1) |
(2) |
(3) |
(4) |
(5) |
(6) |
(7) |
(8) |
(9) |
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(1) |
(2) |
(3) |
(4) |
(5) |
(6) |
(7) |
(8) |
(9) |
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(1) |
(2) |
(3) |
(4) |
(5) |
(6) |
(7) |
(8) |
(9) |
Estimated family weekly income OR total household expenses last week
Local ____________________ US$ ____________________ |
