A BASELINE SURVEY OF THE PHARMACEUTICAL SECTORIN TANZANIA

R. Shija1, R.Malele2 ,

1. WHO, Tanzania 2. Muhimbili University Collage of Health Sciences, Tanzania

ABSTRACTA cross sectional survey on monitoring and assessing the pharmaceutical sector in Tanzania was carried out so as to know whether or not the population has access to essential drugs that are of good quality, efficacious and are being used properly. The survey also aimed at generating current information on the pharmaceutical situation in Tanzania. To achieve this, the WHO level II core indicators were used. The survey was carried out in 2002 involving four randomly selected geographical areas namely, Mwanza, Kilimanjaro, Mbeya and Dar es Salaam. From the four areas a total of 20 public health facilities were selected (five from each study area). Around each of the health facilities visited, 15 households (making a total of 300), and one private pharmacy/drug outlet were surveyed. Face to face interviews, exit interviews plus retrospective record data sampling methods were used in data collection.Some of the key results of this survey include; 87% of key drugs to treat the top 10 diseases were available; on average 51% and 86% of the lowest daily government salary was spent to purchase medicines from the private pharmacies for children and adults respectively; the average stock out duration for medicines in the public health facilities was 28 days; prescribing according to the Essential Medicine List was 98.5%; patient knowledge on dispensed drugs was 80% and number of patients receiving antibiotics and injections per encounter were 42% and 14% respectively.The general analysis of the survey data shows some improvement in the performance of some indicators of the pharmaceutical sector. The major recommendation is that, those indicators which, depicted unfavourable results should be addressed with new strategies of a revised National Drug Policy and the Pharmaceutical Master Plan.

Indicators for TanzaniaPopulation34.5 millionUrban : Rural26 : 74GNP/Capita$260 Per capita health expenditure$9Pharmaceutical annual expenditure per capita public+private$ 2Allocated public expenditure per capita-Pharm$1.30 (02/03)Agriculture 46% of GDPAnnual Inflation5%

Literacy62% Dependency ratio104%Total fertility6.5Infant mortality102100,000

1. WHO Tanzania

Introduction and BackgroundThe overall objective of the National Health Policy is to improve the health and well being of all Tanzanians with a focus on those most at risk and to encourage the health system to be more responsive to the need of the population.

Inspite of the progress made since independence and the recent favourable economic growth realized so far, the Tanzanias health indicators are still below the acceptable levels due to, amongst others: Shortfalls in the annual health sector budget allocations Increased demand for health care due to expanding population and changing disease patternsIncreased costs of essential health care inputs e.g. personnel emoluments, drugs, equipment and medical supplies.

Tanzania has taken several steps in an attempt to improve the situation. In 1991 it endorsed the first National Drug Policy (NDP), whose overall objective was to make available to all Tanzanians at all times the essential medicines which are of quality, proven effectiveness and acceptable safety at a price that the individual and community can afford. The NDP also serves as a basis upon which future planning of the pharmaceutical sector is carried out. A master plan for 1992 2000 was developed indicating the objectives, strategies, time frames and the budget required to achieve development in various key areas of the pharmaceutical sector.

Introduction and Background (2)Monitoring and assessing the pharmaceutical situation in Tanzania, like in any other country, is important so as to know whether or not the population has access to essential drugs that are of good quality, efficacious and are being used rationally.

The International Network for Rational Use of Drugs (INRUD) in collaboration with the World Health Organization (WHO) has developed core indicators for monitoring national drug policies that can be used to systematically assess, evaluate and monitor the formulation and implementation of various strategies and components of the pharmaceutical system.

This study adopted the use of level II core indicators which measure access to drugs and medical supplies by the population, quality of drugs and rational use of drugs.

ObjectivesTo assess the country capacity such as availability, infrastructure, logistic and human resources to improve access and rational drug use.

To monitor the process and strategies used in the implementation of various components of the pharmaceutical sector to see if they achieve the objectives of NDP and the Pharmaceutical Master Plan.

To collect baseline information on the pharmaceutical sector in Tanzania from the facility to the central level.

MethodologyStudy DesignProspective and retrospective cross-sectional survey

Survey Area4 regions ie Dar es salaam, Kilimanjaro, Mwanza and Mbeya Facilities per regionRandomly selected 5 health facilities, 5 pharmacies1 Medical warehouse75 Households.

The study populationClients and workers of, drugs warehouse and households around the health facilities Tanzania

ResultsAvailability of key drugs in health facilities for treating the top ten diseases shows that on the average 87.28% of key drugs are available in the zonal warehouses.

Results (2)Stock-out durationThe average stock-out duration for all essential drugs is 28 days (Median 21.2, Maximum 67.1 days, Minimum 3 days).

Affordability of key drugs in health facilities On average 51% and 86% of the lowest daily government salary was spent to purchase drugs from private pharmacies for children and adult patients respectively

Adequacy of drug storage The average adequacy of storage was found to be 9 for Zonal warehouses and 7 for public pharmacies. This rating is out of an 11 ranking scale indicator.

Patient KnowledgeThe average patient knowledge about dispensed drugs was 80%

Percentage prescribed drugs dispensedThree out of the four regions had between 80% and 90% of the prescribed drugs dispensed. One region had very low results ie 47%.

Results (3)The adherence to recommended treatment for diarrhoea in children.

On the average 44% prescriptions contained antibiotics. However, ORS was prescribed on average of 82% of the cases. There are important differences among regions (Dar es Salaam, 82%; Mbeya, 80%; Kilimanjaro, 70% and Mwanza, 96%)

Results (4)Number of patients receiving antibiotics 42% of patients were prescribed antibiotics compared to 39% reported in 1999.Percentage of patients receiving injectionsThe number of patients receiving injections was 14% compared to 35% reported in 1993.

Adequately labelled drugsOn average 76% of drugs were labelled adequately. A similar study conducted in Dar es salaam and Coast in 2001 showed 87%Average number of drugs per encounter The average number of drugs per encounter is 1.8 compared to 2.2 found in 1992.Percentage of expired drugsThere were no drugs in the private facilities shelves with dates beyond expiry dates. However, in public facilities 13% of key drugs were expired. Guidelines AvailabilityOnly five (5) facilities out of 20 had Standard Treatment Guidelines in their premises But 98.5% prescriptions were according to Essential Medicine List

Results (5)

Households surveyAt Public facility77% of all cases medication was prescribed.79% of above received prescribed medicines at the facility, 12% got part of prescribed medicines and 9% did not get any.

Lower income groups do not get all the medicines they need do not get all the medicines they need

Chart4

0.440.240.32

0.740.160.11

0.830.150.02

All

Some

None

Weekly expenses

How much of the medicine prescribed was obtained: Tanzania 2002

Chart1

0.280.110.140.120.35

0.640.140.050.10.07

0.540.170.070.120.1

Public facility

Private facility

Traditional healer

Pharmacy/ Drug seller

Self care, no care

care seeking by weekly expenses: Tanzania 2002

Sheet1

Care seeking by weekly expenses

$10

Public facility28%64%54%

Private facility11%14%17%

Traditional healer14%5%7%

Pharmacy/ Drug seller12%10%12%

Self care, no care35%7%10%

Medicines obtained by weekly expenses

$10

All44%74%83%

Some24%16%15%

None32%11%2%

Reasons why household did not obtain medicines by weekly expenses

$10

Not enough money24%13%12%

Price too high12%8%12%

Medicines not available41%72%70%

Other24%8%6%

Public facility dispensing /pharmacy

Sheet1

All

Some

None

Weekly expenses

How much of the medicine prescribed was obtained: Tanzania 2002

Sheet2

Not enough money

Price too high

Medicines not available

Other

weekly expenses

Why house did not obtain medicines by weekly expenses

Sheet3

Public facility

Private facility

Traditional healer

Pharmacy/ Drug seller

Self care, no care

Weekly expenses

Care seeking behaviour of households: Tanzania 2002

%Availability of key drugs

TanzaniaNigeriaMaliGhanaUgandaAverage

Public facility pharmacy87%46%87%74%66%72%

Public warehouse93%58%79%83%45%72%

Private pharmacy85%80%78%81%

TanzaniaMaliGhanaAverage

Public facility pharmacy87%87%74%

Public warehouse93%79%83%

Private pharmacy85%80%78%

TanzaniaMaliGhanaAverage

Public facility pharmacy87877483

Public warehouse93798385

Private pharmacy85807881

TanzaniaMaliGhana

Public facility pharmacy87%87%74%

Private pharmacy85%80%78%

000

000

000

000

000

000

Public facility pharmacy

Public warehouse

Private pharmacy

000

000

000

000

Public facility pharmacy

Public warehouse

Private pharmacy

%Availability of key drugs

00

00

00

Public facility pharmacy

Private pharmacy

% Availability at public and private sector

Conclusions / recommendationsAccessAvailability needs to be improved by:Further strengthening of the Medical Store Department and its zonal warehousesScheduled procurement cycles should be adhered to by Districts and health facilitiesIncreased budget funding for medicines Continuing education in drug management for all pharmaceutical staff in health facilitiesConstant monitoring of drug useaffordability is low especially for private facilitiesInterventions to look at pricing mechanisms of pharmaceuticals

Rational Drug UsePatient knowledge on drugs/labelling /antibiotic and injections misuseRevision and wide distribution of Standard Treatment Guidelines and EMLcontinuing education for prescribers and dispensers on rational drug use and good dispensingIEC on proper use of medicines to the community