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2a. Access: Impact of Interventions to Improve Availability of Quality Medicines in LMIC
Can ADDO Accomplishments Be Sustained? The Tanzania Experience Six Years Later
1Management Sciences for Health, United States of America; 2Tanzania Food and Drug Authority (TFDA), Tanzania
Problem Statement: In 2003–2004, the accredited drug dispensing outlet (ADDO) program was piloted in Tanzania’s rural Ruvuma region, which had few pharmaceutical services. The program focused on training and supervision to improve dispensing practices at retail outlets and regulatory enforcement to assure quality. The pilot evaluation showed improved access to affordable quality medicines and pharmaceutical services, particularly related to managing common conditions, such as malaria. However, a major question has been the sustainability of these improvements.
Objective: To determine if ADDOs in Ruvuma have maintained the availability of quality products and services and profitability seven years after implementation.
Design: A quantitative data collection through a price and availability survey and a mystery shopper exercise (five-year-old child with simple uncomplicated malaria). The results were compared with the ADDO pilot results from 2002 and 2004.
Setting: 30 randomly selected ADDOs from Ruvuma that had opened during the original pilot and were still operating in 2010.
Outcome measures: Percentage availability and median prices of tracer products, percentage of unregistered products available, and indicators on dispensing services for malaria.
Results: Average availability of select antibiotics in Ruvuma in 2010 was 70% compared with 77% at endline in 2004 and 45% in 2002. No unregistered products were found in 2010 compared to 2% in 2004. The average median price for a market basket of antibiotics compared with the International Price Guide showed virtually no difference between 2004 and 2010 (+15% compared with +16%). The percent of encounters where malaria cases were treated according to national standard treatment guideline rose to 63% in 2010 compared to 24% in 2004 and 6% in 2002. In terms of dispensing practices, the percentage of mystery shopper encounters where the drug seller: (1) asked about symptoms—rose from 48% in 2004 to 53% in 2010; (2) asked about other medicines the child took—decreased from 54% in 2004 to 43% in 2010; gave instructions for taking medicines—increased from 60% in 2004 to 77% in 2010; and recommended a referral to a doctor or clinic—decreased from 52% in 2004 to 27% in 2010.
Conclusions: With minimal additional training and supportive supervision since the pilot, the 2010 assessment showed that overall, the quality of dispensing services in Ruvuma ADDOs has actually improved since 2004. Declines in referral for simple malaria indicate ADDO dispensers’ increased ability and confidence to manage simple malaria. Median prices compared to the International Price Guide increased 1% between 2002 and 2010.
Funding Source: Management Sciences for Health/East African Drug Seller Initiative funded by a grant from the Bill & Melinda Gates Foundation
SMS for Life: A Pilot Project to Reduce or Eliminate Stock-outs and Improve Access to Malaria Medicine at the Remote Health Facility Level, Using Innovative SMS, Internet, and Mapping Technologies
1Novartis Pharmaceuticals AG, Switzerland, Switzerland; 2IBM (UK) Ltd, MP9, PO Box 31, Birmingham Rd, Warwick, CV34 5JL, UK; 3National Malaria Control Program, Ministry of Health & Social Welfare, Ocean Road - NIMR Offices, Box 9083, Dar-es-Salaam, Tanzania; 4Lindi District Council, P.O. Box 328, Lindi, Tanzania
Problem statement: Maintaining adequate supplies of antimalarial medicines at the health facility level in rural sub-Saharan Africa is a major barrier to effective management of the disease. Lack of visibility of antimalarial stock levels at the health facility level is an important contributor to this problem.
Objectives: To demonstrate that visibility of weekly stock levels of key antimalarial medicines at the health facility level will promote action to eliminate and/or reduce stock-outs and to demonstrate that a state-of-the-art data gathering infrastructure can be made available via simple tools such as SMS and mobile telephones, the Internet, and Google mapping in remote locations in sub-Saharan Africa
Design: A 21-week pilot study, “SMS for Life,” was undertaken during 2009–10 in three districts of rural Tanzania, involving 129 health facilities, covering a total population of 1.2 million. The pilot project was undertaken through a collaborative partnership of public and private institutions, consisting of the Tanzanian Ministry of Health and Social Welfare, the Roll Back Malaria Partnership, Novartis Pharma AG, Vodafone Global Enterprise, and IBM. Each partner funded its own activities. SMS for Life used mobile telephones, SMS messages, and electronic mapping technology to facilitate provision of comprehensive and accurate weekly stock counts from all health facilities to each district management team. The system covered stocks of the four different dosage packs of artemether-lumefantrine (AL) and quinine injectable. Results were evaluated using various methods including interrupted time series analysis.
Results: Stock count data were provided in 95% of cases, on average. A high response rate (≥93%) was maintained throughout the pilot. The error rate for composition of SMS responses averaged 7.5% throughout the study; almost all errors were corrected and messages re-sent. Data accuracy, based on surveillance visits to 90% of participating health facilities, was 94%. District stock reports were accessed on average once a day. The proportion of health facilities with no stock of one or more antimalarial medicines (i.e., any of the four dosages of AL or quinine injectable) fell from 78% at week 1 to 26% at week 21. The proportion of health facilities with no stock of any dose form of ACT fell from 26% to 1%. In Lindi Rural district, stock-outs were eliminated by week 8 with virtually no stock-outs thereafter. During the study, AL stocks increased by 64% and quinine stock increased 36% across the three districts.
Conclusions: The SMS for Life pilot provided visibility of antimalarial stock levels to support more efficient stock management using simple and widely available SMS technology. The SMS for Life system has the potential to alleviate restricted availability of antimalarial drugs or other medicines in rural or under-resourced areas. Country-wide implementation (ca. 4,500 health facilities) of SMS for Life is ongoing in Tanzania with a scheduled completion date of October 2011. New pilots with slightly different scope were initiated in Ghana and Kenya July and August 2011, respectively.
Funding source(s): Each of the partners of the pilot project provided the funding of their respective contributions.
Piloting the Use of Mobile Short Messaging Systems (SMSs) to Improve Access to Medicines: Experiences from Kenya
Management Sciences for Health/ Strengthening Pharmaceutical Systems (MSH/SPS) Program, Nairobi, Kenya
Problem statement: Accurate and timely information on medicine consumption and use is necessary to inform national forecasting and procurement. However, in Kenya, reporting on medicines consumption from rural health facilities is very poor, and when reports are received, they are often delayed and incomplete. This results in stock-outs and hence limits access to medicines.
Objective: The intervention objective was to determine the effectiveness of using SMS to improve medicine consumption data reporting.
Setting: Rural primary health care facilities in Thika, Muranga South and Kiambu districts
Intervention: SPS program worked with district health management teams (DHMTs) in 4 districts to pilot primary health care facilities’ use of SMSs to report medicines consumption. The pilot targeted monthly reporting for priority public health programs—antiretroviral, antituberculosis, and selected malaria and family planning medicines. Health facilities sent information on medicine consumption via SMS, using phones linked to a central server and computers at district health information offices. The system logged SMS transmission details including the sender, source facility, district, and date of data receipt. The software also enabled synchronization and aggregation of data at central and district levels and notification of facilities in case of delay or absence. In addition SPS helped train DHMT and facility staff and provided technical assistance for monthly DHMT data review meetings and direct financial support for the costs of SMSs.
Outcome measures: Number of health facilities reporting using SMSs; accuracy, timeliness, and completeness of data received
Results: Within 6 months after the intervention, 176 rural facilities representing over 80% of rural health facilities in the 3 districts were using SMSs to send medicine consumption data. Reporting rates using the SMSs had reached 100% for sites that provided antiretroviral treatment and for all facilities with laboratories. Review of the systems showed improved quality, timeliness, and completeness of data received from the reporting sites. Access to this information also strengthened DHMTs’ management role because they had data to inform basic decisions such as redistribution of stock from overstocked to understocked facilities.
Conclusion: This pilot demonstrated the feasibility and effectiveness of using simple SMS mobile technology to report medicine consumption data for improved medicine quantification and availability. Although set-up and maintenance costs may hinder scale-up efforts particularly in the public sector because of resource constraints, public-private partnerships can be used to support such innovations.
Funding source: PEPFAR
Educational Intervention to Combat Counterfeit Medicines in Selected Areas in the Philippines
1National Drug Information Center, Philippines; 2University of the Philippines Manila
Problem statement: The continued proliferation of counterfeit medicines has been a public concern for the Philippines. It was estimated that almost 10% of the available medicines in the Philippines are counterfeit.
Objective: To determine the effects of an educational intervention on the knowledge and behavior of consumers on counterfeit medicines
Design: This was an intervention study that involved drug sellers and consumers.
Setting: The study was done in 2007 in three areas in the Philippines: the national capital city, a provincial city, and 2 rural municipalities in a province.
Study population: The study population consisted of clients from randomly selected drug stores and neighborhood grocery stores, using a 3-stage systematic sampling design.
Intervention: The intervention consisted of development and distribution of a brochure and poster on counterfeit medicines and orientation-training for drug sellers on the meaning of messages in the brochure and poster.
Outcome measure(s): The outcome measures consisted of the difference in the proportion of consumers, before and after the intervention, who were aware of the existence of counterfeit medicines, who inspected medicines for signs of being counterfeit during purchase, who inquired from the drug sellers about counterfeit medicines during purchase, and who received advice or information material on counterfeit medicines from the drug seller. Post-intervention measurement was done one to two months after the intervention.
Results: Responses were taken from 667 consumers before intervention, and 708 after intervention. On baseline, 92.7% of respondents were aware of existence of counterfeit medicines (compared with 99.6% post-intervention), 66.3% inspected drugs for signs of being counterfeit (versus 64.4% post-intervention), 10.0% inquired from the drug seller about counterfeit medicines during purchase (vs. 23.3% post-intervention), and 5.2% received advice or information on counterfeit medicines from the drug seller (vs. 37.0% post-intervention).
Conclusions: The intervention showed improvement in the increase in awareness of the existence of counterfeit medicines and interest in inquiring about counterfeit medicines among the respondents. Likewise, there was a reported increase in proactive interaction by the drug sellers in terms of sharing advice or information materials on counterfeit medicines. There was no change in the proportion of consumers who inspected drugs for signs of being counterfeit during the purchase.
Funding source(s): World Health Organization, Western Pacific Regional Office
Increasing Access to Quality Essential Medicines and Services Provided by Drug Shops in Uganda Through Accreditation and Regulation
1Management Sciences for Health, Uganda; 2National Drug Authority
Problem Statement: Most people in rural areas of Uganda often turn to local drug shops for their medicines and health care advice. These shops may be unlicensed, have staff that are untrained, and sell medicines that may be of uncertain quality or that they are not allowed to dispense. Regulatory inspection and supportive supervision are infrequent.
Objectives: To transform existing Class C drug shops into well regulated Accredited Drug Shops (ADS), so that people living in rural communities have access to quality medicines and pharmaceutical services.
Design: A quantitative and qualitative pre- and post-intervention design in Kibaale district, with Mpigi district as the control. We collected baseline (2008) and endline data (2010) using drug shop audits and interviews with owners and shop attendants and measured quality of pharmaceutical services using a mystery shopper scenario (malaria in a 5-year-old child).
Setting and Study Population: 45 Class C Drug Shops in Kibaale district; 43 in Mpigi district
Intervention: NDA developed standards for premises, personnel, record keeping, and dispensing practices; and established a list of prescription medicines that can be legally dispensed by ADS. Local monitors and supportive supervision teams from the district were trained and empowered to supplement NDA’s routine inspections. Drug shop attendants received training in good dispensing practices and how to handle common medical problems, patient communication, and referrals. Owners also received business skills training and guidance on obtaining loans from microfinance institutions.
Outcome measures: Percentages related to indicators of medicines availability, price change, and service quality.
Results: Endline results from Kibaale indicate improvement in service quality and dispensing practices. For example, availability of injectables, which are illegal in all drug shops, dropped from 61% to 0% in ADS compared to the control district, where availability remained unchanged at 35% (p < 0.05). In addition, the percentage of mystery shopper encounters where the drug seller enquired about prior medicines given to the child rose from 31% to 64% in Kibaale compared to a much smaller increase (from 40% to 43%) in Mpigi (p = 0.136) . The legal availability of essential prescription-only medicines has also improved (e.g., availability of essential antibiotics in Kibaale increased from 57% to 84% compared to Mpigi where their illegal availability remained unchanged at 64% [p < 0.05]). Medicine prices have not changed on average, despite concerns that costs might rise in ADS because of the expenses associated with meeting new regulatory standards.
Conclusions: Results indicate that the accreditation of Class C drug shops has improved access to legally available products and quality services in retail drug outlets that serve populations living in rural areas in Uganda.
Study Funding: Management Sciences for Health/East African Drug Seller Initiative, funded by a grant from the Bill & Melinda Gates Foundation