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ACCESS TO AND RATIONAL USE OF
MEDICINES AT THE
HOUSEHOLD LEVEL
Federal Ministry of Health
© 2010 Federal Ministry of Health, Nigeria
All rights reserved. No part of this publication may be reproduced, stored in
retrieval system or transmitted in any form or by any means, electronic, mechanical,
photocopying, recording and/or otherwise, without prior written permission of the
Federal Ministry of Health, Nigeria.
ISBN 978-978-49531-3-9
For all enquiries or comments, write to the publishers:
The Honourable Minister,
Federal Ministry of Health,
Federal Secretariat Complex,
Shehu Shagari Way,
P.M.B. 080 Garki,
Abuja,
Nigeria
Printed in Nigeria
i
TABLE OF CONTENTS
TABLE OF CONTENTS..................................................................................................................ii
ACKNOWLEDGEMENTS............................................................................................................iii
LIST OF ABBREVIATIONS..........................................................................................................iv
EXECUTIVE SUMMARY..............................................................................................................1
METHODOLOGY...........................................................................................................................3Study purpose and objectives ......................................................................................................3Study area.....................................................................................................................................4Study design.................................................................................................................................4Sampling procedures....................................................................................................................4Training of data collectors and pretesting of survey instruments................................................7Data collection.............................................................................................................................8Data analysis................................................................................................................................8Ethical considerations..................................................................................................................8
RESULTS.........................................................................................................................................8Characteristics of households/respondents..................................................................................9Access........................................................................................................................................16Rational use of medicines..........................................................................................................21
DISCUSSIONS..............................................................................................................................25Sociodemographic characteristics..............................................................................................25Access........................................................................................................................................25Rational use of medicines..........................................................................................................26Limitations.................................................................................................................................27
CONCLUSION AND RECOMMENDATIONS...........................................................................28
ii
ACKNOWLEDGEMENTS
The Federal Ministry of Health is grateful to Prof. Babatunde Osotimehin, the Honourable
Minister of Health and Mr. J. E. B. Adagadzu, the Acting Head, Food and Drug Services
Department for their contribution to the project.
The Ministry also appreciates the continued support of the World Health Organization in
Nigeria in the pharmaceutical sector. We are particularly grateful to Dr. Peter Eriki, the WHO
Representative in Nigeria, Dr. Edelisa Carandang, Technical Officer, WHO Geneva, Dr. Ogori
Taylor, the Essential Drugs and Medicine Policy (EDM) Advisor for Nigeria and Dr. Olaokun
Soyinka, Health Promotion Advisor for Nigeria for their commitment to the realisation of the
project. We wish to thank the European Commission for their financial contribution to the
project.
The contributions of Mrs. Catherine Vialle-Valentin from Harvard Medical School, Boston and
Mrs. Oluwatosin Ayo-Ajayi are also acknowledged. Mrs. Bridget Okala is appreciated for
coordinating activities at the Federal Ministry of Health level. The contributions of the
Pharmacists in Food and Drug Services Department who collected data are gratefully
acknowledged.
iii
LIST OF ABBREVIATIONS
iv
ACT Artemisinin Combination Therapy
CHEWS Community Health Extension Workers
GMP Good Manufacturing Practice
HMO Health Maintenance Organisation
MDCN Medical and Dental Council of Nigeria
NAFDAC National Agency for Food and Drug Regulation and Control
NGO Non-governmental Organisation
NHIS National Health Insurance Scheme
NMCN Nursing and Midwifery Council of Nigeria
NRA National Regulatory Authorities
OTC Over the Counter
PHC Primary Health Care
PCN Pharmacists’ Council of Nigeria
PMS Patent Medicine Shop
TBA Traditional Birth Attendant
USD United States of America Dollars
WHO World Health Organisation
EXECUTIVE SUMMARY
The main objective of the National Medicines Policy is to make available at all times and in all
sectors of the health care system, adequate supplies of medicines which are effective,
affordable, safe and of good quality; and also to promote rational use of medicines. The
objective of this study was to assess the extent to which the population has access to medicines
required to treat acute and chronic illnesses.
One state from the 6 geopolitical zones of the country was randomly sampled. Six
reference health facilities were chosen from both urban and rural areas. Households were
surveyed at less than 5km, between 5-10km and more than 10km from the reference facilities.
ne thousand and eighty (1080) households using the newly
revised WHO household survey tool.
� The results show there is good access to health care facilities as less than 2% of
households travel more than 1 hour to the nearest health facility in the public and
private sectors to obtain care. The most accessible health facilities were the public
hospital, the drug seller and the health centre in descending order of accessibility.
� Most households pay for medicines out of pocket as fewer than one out of every 5
households claimed to have obtained medicines free or supported by any form of
health insurance.
� Most households did not consider availability of medicines to be a hindrance to the
treatment of acute illness in members. However, they rated availability in both public
and private facilities low, with public facilities being the more affected.
each of
Interviews were conducted in o
Key Findings
Access
1
� Affordability of medicines constituted a barrier to access to medicines to about half of
households and the same proportion claimed to have borrowed or sold assets to be
able to pay for their medicines. About one out of every 3 chronically ill patient did not
take medicines because they could not afford them. The majority of chronically ill
patients (76%) did not have up to 30 days supply of medicine
� Most household members with acute illness sought care outside the home. In about
two thirds of cases, doctors prescribed for those with acute illnesses while drug sellers
prescribed for 13% and pharmacists for 7%. Almost all of them took medicines to treat
the acute illness.
� While most medicines found at the household were dispensed using adequate primary
packaging materials only half were adequately labelled with medicine name, dosage
instructions and expiry dates.
o The Nigerian health system needs to be re-engineered to ensure that different levels of
health care play the role for which they were established. The PHC needs to be
revitalised to ensure greater utilisation for care.
o Since drug sellers were shown to be important pharmaceutical care providers in the
community, they need to be adequately regulated and their capacity strengthened to
ensure that they provide adequate care. Of particular importance is the labelling of
medicines which needs to be standardised and enforced.
o Interventions to increase affordability of medicines especially for the chronically ill
should be devised by the government. Such interventions may include,
Increasing health insurance coverage for the populace especially for the poor
and the chronically ill
Ensuring greater access to medicines by exploring mechanisms such as
providing free medicines to the poor and chronically ill, monitoring the price
of medicines and developing and implementing a pricing policy
Rational Use of Medicines
Recommendations
2
METHODOLOGY
Study purpose and objectives
Figure 1: Map of Nigeria
Information on access and rational use of medicines are usually obtained from healthcare
facilities and retail outlets; however little information is available from end users of medicines.
This survey therefore aims to obtain accurate information from the end users on how they
obtain and use medicines. Results from the study are intended to serve as a basis for strategic
planning and implementation of programmes by policy makers; either in the short term or long
term, so that an enabling environment can be created and people empowered and motivated
to seek healthcare and use medicines for their acute or chronic illnesses
3
The following are the objectives of the study:
O To make recommendations for improvement in access to and rational use of medicines
Nigeria is located on the West Coast of Africa and has a landmass of 923,678 square
kilometres. It is divided into six geopolitical zones, which comprises 36 states and a Federal
Capital Territory. The states are further divided into 774 Local Government Areas (LGAs).
The 2006 census indicates that Nigeria has a population of about 140 million with a life
expectancy of about 48 years. There are over 250 ethnic group of which the predominant ones
are the Hausa-Fulani, Yoruba and Ibo in the north, southwest and southeast respectively. The
official language is English, but over 250 other languages are spoken.
It was a cross-sectional, descriptive time delimited study aimed to determine access and
rational use of medicines in households in Nigeria using the newly revised WHO Household
survey tool.
A multistage sampling technique was used to select the study population. Nigeria is divided
into six geopolitical zones each comprising between five to seven states and each state further
divided into LGAs.
O To determine the sociodemographic characteristics of the surveyed households
O To determine the various geographical and financial barriers to access to medicines in
the public and private sectors
O To determine the level of rational prescribing, dispensing and use of medicines at the
household level.
Study area
Study design
Sampling procedures
4
Selection of Reference Healthcare Facility
TABLE 1: SAMPLED HEALTH FACILITIES
One state was randomly selected from each of the six geopolitical zones. Six LGAs comprising
three rural and three urban LGAs were randomly selected from a list of LGAs in each of the six
selected states.
A reference central point, which is a secondary healthcare institution (general hospital) was
identified in each of the LGAs. Any selected LGA which does not have a secondary healthcare
facility was replaced with another randomly selected LGA..
The table below shows reference healthcare facilities selected from each of the six geopolitical
zones of the country.
5
Geopolitical
Zone
Sampled State Identified Reference Healthcare
Facility/LGAGeneral Hospital, Illela
General Hospital, Bodinga
UDUTH, Wamako
Maryam Abacha Hospital
Sokoto Specialist Hospital
Northwest Sokoto
General Hospital, Rabah
General Hospital, Share
General Hospital, Offa
General Hospital, Omuaran
General Hospital, Lafiagi
Ajikobi Cottage Hospital
Northcentral Kwara
Civil Service Hospital, Ilorin
Federal Medical Centre, Jalingo
Cottage Hospital
Cottage Hospital, Mutun Byiu
Cottage Hospital, Ardokola
General Hospital, Zing
Northeast Taraba
General Hospital, Wukari
Selection of Households
Thirty (30) households divided into six (6) clusters were selected at a given distance from the
reference healthcare facility in each LGA. This consists of two (2) clusters of five (5) households
each selected within 5km radius from the facility, ten (10) households (2 clusters) between 5km
and 10km and another ten (10) households (2 clusters) more than 10km from the reference
healthcare facility. Each cluster of household per given distance was selected from different
directions from the reference facility.
With the secondary healthcare facility as the central reference point, a household per cluster in
which an appropriate household informant was present was chosen for the interview.
Depending on the population density of an area, subsequent households were selected per
cluster skipping between appropriate numbers of households before the next interview was
conducted. If an appropriate household informant was not present at the time of conducting
the interview, a later time was re-scheduled. However, households that declined participation
were replaced with another household.
6
General Hospital, Epe
General Hospital, Badagry
General Hospital, Orile-Agege
General Hospital, Ajeromi
General Hospital, Somolu
Southwest Lagos
General Hospital, Isolo
General Hospital, Ebonyi
General Hospital, Amachi
General Hospital, Itim Afikpo
General Hospital, Owutu
General Hospital, Ishiagu
Southeast Ebonyi
Comprehensive Health Centre
Central Hospital, Ughelli North
Central Hospital, Warri
Govt. Hospital, Ibusa
General Hospital, Otujeremi
General Hospital, Bomadi
Southsouth Delta
General Hospital, Okwe
Selection of Household Informants
Data collectors
Training of data collectors and pretesting of survey instruments
The household informant or an appropriate substitute who met at least three of the following
criteria listed below were selected.
� Main health care decision maker
� Most knowledgeable about health of household members
� Most knowledgeable about health expenditures of the household
� Most knowledgeable about health utilization by household members
� Designated care giver for sick household members
Twelve (12) pharmacists drawn from the Federal Ministry of Health were trained and used as
supervisors for the collection of data in the six geopolitical zones of the country. They in turn
recruited and trained twelve pharmacists in each of the sampled states. Each of the teams was
supported by the Community Development Committee representative who helped them gain
easy access to households.
A two-day training for supervisors was conducted in Abuja, the Federal Capital Territory. The
training provided background information on the survey as well as data gathering (using the
questionnaire) and data entry (using the epidata software) techniques. Qualities required of
enumerators were also highlighted.
The trainees pretested the data collection instrument with their own families and neighbours.
Experiences, observations made and lessons learnt were discussed on the second day of the
training. The culture and predominant language spoken was taken into consideration when
drafting supervisors to each geopolitical zone.
7
The supervisors in turn trained the recruited enumerators in the selected states. Training lasted
one day using methods such as lectures, demonstration, discussion and role play. Emphasis
was laid on skills required for asking questions on sensitive issues such as amount spent on
household expenditure, types of illness, taking cultural factors into consideration. Pre-testing
of the instrument was done on the same day among the participants and clarifications on the
tools were made. Training also continued in the field as supervisors were present to provide
support throughout the period of data collection.
Data collection was done by a team of two enumerators per 30 households and spanned a
period of two days. Interviews were scheduled on Sundays and Saturdays in order to increase
the possibility of meeting household informants. Revisits were made where the household
informant was absent.
The data obtained were manually sorted, verified, coded and entered into the computer for
statistical analysis using the Epidata software. Data was presented using descriptive statistics
(means, percentages) charts and graph.
Consent was sought and approval obtained from the Ministry of Health of each of the selected
states and the community leader prior to the commencement of the study. Furthermore,
informed consent was obtained from the head of each household before conducting the
interview. Consent was verbal and not written. Written consent may have created a barrier to
the study due to cultural peculiarities. Verbal consent was therefore regarded as sufficient.
A total of one thousand and eighty (1080) respondents from households located at specified
distances from reference healthcare facilities were interviewed from the predetermined
locations
Data collection
Data analysis
Ethical considerations
RESULTS
.
8
Characteristics of Households/Respondents
Table 2: Household income bands
Demographic Information
Socioeconomic Information
The results of the survey showed the median number of persons in the households was 7 with
half of interviewed households having between 5 and 10 people living in them. Almost all the
households had children aged 12 years and below and 72% of households had at least one
child under 5. Most of the respondents were males (61%) and were between 25 and 50 years of
age (69%). One out of every 5 respondents had no formal education.
The majority of the households had a source of livelihood; the main income earners being
either traders/artisans (36%) or civil servants (32%). Only about (13%) of households did not
have anyone who earned income.
Sampled households had a median of 5 rooms; with half of these having between 3 and 7
rooms. Seventy four percent (74%) of the households had electricity, 55% had toilets not
shared with neighbours and 22% had tap water.
The main assets owned were radio (91%), mobile telephones (70%), house/land (68%).
Among those which had electricity, 82% had television and very few had computer (11%) or
air conditioner (10%).
9
Income bands Per capita expenditure % of respondents Number
A <1997 22.1 237
B 1997 – 3295 26.0 279
C 3296 – 4950 21.5 231
D 4951 – 9697 24.1 259
E > 9697 6.2 67
Table 3: Socioeconomic information of households
Figure 2: Age distribution of respondents
10
Percentage of Respondents by Age
<25 years
3%
26-50years
69%
>50
28%
Indicator Value
Median number of members per HH 7
Percentage of households with children 90.8
% female respondents 39.2
Median number of rooms per HH 5
% HH with the following:
Electricity
Running water
Own toilet
74.4
54.7
22.3
% HH with no one earning money 12.6
Figure 3: Educational attainment of respondents
Figure 4 : Occupation of respondents
11
Figure 5: Percentage of households with certain assets
Health Expenditure Indicators
Table 4: Health Expenditure indicator
The results show that 8.9% of households have monthly medicine expenditures that represent
more than 20% of their total expenditures. It also reveals that medicines account for 3.5% of
total household expenditure; with about 2,600 naira being spent on medicines per person on
an annual basis.
12
Indicator Percentage/
Median
% HH whose monthly medicine expenditures represent at least > 20% of
total expenditures
8.9
Median household medicine expenditures as % of total expenditures 3.5%
Median household medicine expenditures as % of non-food expenditures 12.7%
Median household medicine expenditures as % of total health
expenditures
100%
Median annualized health expenditures per person (Naira)
Medicine
Hospital
Other health expenditures
Health insurance expenditure
Total health expenditure
2600
2888
1381
2437
3250
Median HH medicine expenditures for a reported illness as a % of total
expenditures
Acute illness
Chronic illness
3%
1%
Morbidity Characteristics of Households
Table 5: Illness Characteristics of Household
Fifty seven percent (57%) of households interviewed reported at least one episode of acute
illness while 27% reported at least one chronic illness. Seventeen percent (17%) of households
had members who had both acute and chronic diseases in the period under investigation.
The main acute illnesses reported include fever and headaches (77%), acute respiratory tract
infections (ARI) (39%), and 68% of these were regarded as either very serious or somewhat
serious.
The main chronic illnesses reported include hypertension, (32%), arthritis or chronic body
pain (32%), ulcer or chronic stomach pain (20%), diabetes (12%) and asthma, wheezing or
chronic difficulty breathing (11%). The median age of household members with chronic illness
was 50 years, and half of those with chronic illness were between 36 and 60 years old
13
Indicator Percentage/Median
% HH reporting no illnesses 32.8
% HH reporting at least one acute and one chronic illness 29.9
% HH reporting at least one acute illness 56.9
% HH reporting at least one chronic illness 27.3
Median number of acute illnesses per HH 1
Median number of chronic illnesses per HH 1
Median age with acute illness
Years
Months
4
6
Median age with chronic illness 50
% females with acute illness 48.2
% females with chronic illness 43.5
Figure 6: Percentage of household members with acute illnesses by category of symptoms
Figure 7: Perceived severity of acute illness
14
Perceived Severity of Acute Illnesses
Not serious
32%
Somewhat
serious
47%
Very serious
21%
Figure 8 : Percentage of household members with chronic diseases
Medicine Financing
Table 6: Medicine financing indicators
Access
The survey shows that very few respondents (17%) claimed to obtain free medicines from
public healthcare facilities or had at least partial insurance coverage for the medicine used for
either acute (7%) or chronic (4%) illness. About one third would usually obtain credit from
pharmacies.
15
Indicator Percentage/Median
% respondents who can get free medicines at public health care
facility 16.6
% respondents who say they can get credit from the private
pharmacy
28.5
% HH with at least partial insurance coverage for at least one
medicine
Acute illness
Chronic illness
6.6
4.0
Geographical Accessibility
Table 7: Geographical accessibility indicators
Figure 9: Respondents who traveled more than one hour to reach the closest facility
Only 11% of respondents regarded distance of the facility from which medicines can be
obtained as a hindrance to adhering to prescribed medications and only 2% of respondents
have to travel more than one hour to reach any healthcare facility closest to them. Nearly a
quarter of those with chronic illnesses reported not taking prescribed medicines because the
place where medicines can be obtained was too far away. Most respondents considered the
location (70%) and opening hours (74%) of their public healthcare facility as convenient.
16
Indicator Percentage/Median
% respondents who say that prescribed medicines were not
taken “because the place where medicines can be obtained was
too far away”
Any illness
Acute illness
Chronic illness
10.6
3.4
23.3
% respondents who agree that the location of their public
healthcare facility is convenient.
69.6
% respondents who agree that opening hours of their public
healthcare facility are convenient
74.4
Figure 10: Respondents who traveled more than one hour to reach the facility used for
treatment of acute illness
Availability
Less than 10% of the respondents who had either an acute or chronic illness attributed non-
adherence to their prescribed medication to non availability at healthcare facility. More
respondents agreed that medicines are available at their pharmacy (52%) than their public
healthcare facility (37%).
The median number of medicines kept at home was three and one quarter of the medicines at
home were kept for future use. Forty two percent (42%) of households with children did not
have any medicines at home. About 30% of households with chronically ill members did not
have prescribed medications.
Of the medicines kept in households, analgesics (31%), multivitamins and supplements (22%)
antibiotics (12%) and anti-malarials (10%) were most frequently seen. Of the classes of
medicines seen in households paracetamol (analgesic), metronidazole, ampicillin/cloxacillin
and cotrimoxazole (antibiotics) and chloroquine (antimalarial) were most prevalent.
17
Table 8: Availability of Medicines in Healthcare Facilities in both Public and Private Sectors
Table 9: Availability of Medicines at the Household Level
Figure 11: Medicines kept at home
18
Indicator Percentage/
Median
Median number of medicines at home 3
% HH with no medicines at home 43.0
% HH who have children and have no medicines at home 41.9
% HH who have children <5 year and have no medicines at home 42.4
% HH who do not have at home the medicines prescribed to a chronically ill
HH member
29.2
% HH classes of medicines kept for future use 24.8
Indicator Percentage
% respondents who say that prescribed medicines were not taken “because
medicines were not available at the healthcare facility”
Any illness type
Acute illness
Chronic illness
7.3
4.6
11.6
% respondents who agree that medicines are available at their public
health care facility
36.7
% respondents who agree that medicines are available at their pharmacy 51.8
Figure 12 : Analgesics kept at home
Figure 13: Antibiotics kept at home
19
Figure 14: Antimalarial kept at home
Affordability
Table 10: Medicine affordability indicators
Fifty four percent (54%) of respondents claimed to be able to afford to buy the medicines they
need. About fifty percent agreed that medicines are more expensive at private pharmacies than
public healthcare facilities and 46% had to borrow money or sell things to pay for medicines.
Although very few (15%) mentioned non-affordability as reason for not adhering with
prescribed medication for their illnesses, it was more of a hindrance to those who were
chronically ill (28%) than those who had acute illness (7%). They however agreed that better
insurance coverage would increase their use of medicines.
20
Indicator Percentage
% respondents who agree medicines are more expensive at private pharmacies 48.9
% respondents who can usually afford to buy medicines they need 53.8
% respondents who have had to borrow money or sell things to pay for
medicines
46.3
% respondents who say that prescribed medicines were not taken “because HH
cannot afford medicines”
All illnesses
Acute illness
Chronic illness
14.6
6.9
27.9
% respondents who agree that better insurance coverage would increase their
use of medicines.
49.5
Rational Use of Medicines
The survey showed that majority of household members who had acute illness sought
healthcare from the public hospital (45%), drug seller (29%), private pharmacy (14%) and
public healthcare/dispensary (11%). Sixty percent (60%) of medicines used for acute illness
were prescribed by doctors, 13% by drug sellers, 7% by pharmacists and 5% by community
health officers. About one out of every ten respondents who had an acute illness was treated
with injections and up to 8% of respondents who had acute illnesses practiced self-
medication.
Medicines used for acute illness were mostly procured from public hospital (35%), drug seller
(24%), private pharmacy (17%), public health centre/dispensary (8%) and private/NGO
hospital (8%). Most of these were dispensed using adequate primary packaging (80%); but
only 52% were adequately labelled with the name of the medicine, dosage instruction and
expiration date.
Almost all household members who had a serious acute illness and sought care outside took
some medicine (98%); however 10% did not take all prescribed medicines because of
previous side effects.
Among household members who were chronically ill only 5% were never told to take
medicines. Majority (84%) claimed to take their medicines regularly. The main reasons cited
by those who did not take recommended medicines regularly were more related to
acceptability (78%) than previous experience of side effects (16%). Seventy six percent (76%)
of household members with chronic illness usually obtained less than 30 days supply of
medicines.
Sixty percent (60%) of households regarded the quality of services delivered either at their
public healthcare facility or by their private provider as being good.
21
Figure 11: Quality of Care Indicators
Figure 12: Rational Use of Medicines Indicators
22
Indicator Percentage/
Median
Number/
Interquartile range
(25%-75%)
% of acute illnesses treated with injections 11.5
% HH medicines with adequate label 51.9
% HH medicines with adequate primary packaging 80.1
% HH with a chronically ill person who was never
told to take medicines
5.4 (16) 16
% HH who usually obtain less than 30 days of
medicines for a member with chronic illness
100 (279) 279
% respondents who agree that quality of services at
their public healthcare facility is good
59.5 (643) 643
% respondents who agree that quality of services
delivered by their private provider is good
57.0 (616) 616
% respondents who agree that brand name medicines
are better than generics
47.3 (511) 511
% respondents who agree that imported medicines
are of better quality than locally manufactured
medicines
43.6 (471) 471
Indicator Percentage Number
% HH reporting a serious acute illness who
sought care outside but did not take any
medicine
2.3
% HH reporting a serious acute illness who
sought care outside but did not take all
prescribed medicines
10.9 14
% HH with a chronically ill person who does
not take recommended medicines regularly
15.7 43
%Respondents who said prescribed medicines
were not taken for a reason related to
acceptability
Chronic illness
76.7
33
%Respondents who said prescribed medicines
were not taken because of previous side effects
Acute illness
Chronic illness
10.3
16.3
9
7
Figure 15: Source of care for acute illness episode
Figure 16: Prescribed of medicines for acute illness episode
23
Figure 17: Source of medicines for acute illness
24
DISCUSSIONS
Household characteristics
Socioeconomic indices
Sociodemographic Characteristics
Access
The majority of respondents were men which is consistent with results obtained from the latest
Nigeria Demographic and Health Survey (2003 NDHS) in which decision making in
households was dominated by husbands.
The number of persons living in a household found in this survey is higher (7) than obtained in
the 2003 NDHS (5). This might be a reflection of the method of determining the number of
people living in a household. In this survey the main concern was estimating the financial
burden of households in relation to their ability to have access to medicines. Thus, members of
the household who were not present but who shared resources of the household were
included in the study. For example, children who were living in boarding schools who are
wholly taken on charge by the household were counted as members. On the other hand, the
2003 NDHS measured only members of the household who were present during the survey.
The study revealed that Nigeria has achieved geographical access to health facilities to the
populace as only about 2% of respondents had to travel more than 1 hour to the nearest health
facility. The fact that a majority of respondents sought help for acute illnesses in public
hospitals rather than primary health care centres or dispensaries shows a departure from the
norm in which primary health care centres are meant to serve as the first port of call before
being referred to hospitals. This gives an indication of a non functional primary health care
system. Some studies have shown that most of the PHC lacked medicines and were non
functional.
In the private sector, the drug seller was shown to be the most accessible medicine provider.
Indeed they are available in rural areas which may not be attractive to the pharmacist. The
1
25
challenge is to ensure adequate regulation and capacity building such that they are able to
provide good quality medicines as well as adequate health care counselling to the populace.
The study shows that most patients are still paying for medicines out of pocket as only 16%
reported receiving medicines free from facilities. About one out of every 5 patients reported to
having access to credit facilities in private pharmacy and half of the population had to borrow
money or sell their belongings to pay for medicines used for their illnesses. These are
indications that medicine affordability is a problem to the population, and the chronically ill
were more affected than those with acute illness as most of them (76%) were not able to obtain
30 days' supply of medicines. This can be expected considering the socioeconomic profile of
sampled households, which consists mainly of low and middle income group earners. Thus,
management of chronic illnesses would pose a challenge to most people. Other studies have
demonstrated that cost of medicines in Nigeria is quite prohibitive and would constitute a
barrier to care especially for patients with chronic illnesses .
The government needs to formulate policies and provide interventions to ensure that
medicines are affordable to its citizens. Wider coverage of the National Health Insurance
Scheme (NHIS), formulation, enforcement of a pricing policy for medicines and procurement
of some key essential medicines are some interventions which will improve access to
medicines.
The results show that the most used prescribers are doctors and drug sellers. This confirms that
respondents usually sought care outside the home either in hospitals in the public sector or
with drug sellers in the private sector. This accentuates the fact that the Nigerian health system
needs re-engineering to ensure that different facilities play the role for which they were
established.
Most of the household medicines were properly dispensed using adequate primary packaging
materials; however only half of dispensed medicines were adequately labelled with the name
2
Rational Use of Medicines
26
of the medicine, dosage instruction and expiration date. Since a good number of households
kept medicines for future use, adequate labelling is therefore very important. The results are
congruent with previous studies which show inadequate labelling to be the norm in health
facilities.
The results also indicate that only 10% of acute illnesses were treated with injections. This
shows an improvement in the frequency of use of injections as previous studies showed a high
rate of injection usage . This may be attributed to the change in antimalaria treatment policy
from the use of chloroquine to ACTs which are mostly used in the oral dosage form. It is not
clear how much the populace has embraced the ACT policy as more than half of the
households interviewed had chloroquine available in their homes. The cost of ACTs compared
to chloroquine may be at the heart of this preference.
This is an indicator based assessment which is meant to give an overview of the pharmaceutical
sector in order to determine appropriate interventions required to improve the system. In-depth
studies would be required to understand specific issues in the system.
The proportion of respondents who did not have any education may have been overestimated
due to the fact that in a country with significant proportion of Muslims, Quranic education was
not taken into account. Thus, any person not having the western form of education was
deemed not to have any education. Future assessments should take this type of education into
consideration.
It is doubtful if respondents could appropriately distinguish between primary health care
facilities and hospitals as the local languages refer to all health facilities as “hospitals”. It will be
important in the Nigerian survey to ensure that the two types of facilities are adequately
distinguished using local nomenclatures.
3
Limitations
2FMOH (2005). Prices people pay for Medicines in Nigeria. Published by the Federal Ministry of Health in collaboration with the World
Health Organization, EC & DFID
27
CONCLUSION AND RECOMMENDATIONS
O The results show that despite high accessibility of primary health facilities, the
hospitals are the main source of care and medicines for respondents for both acute and
chronicillnesses. There is therefore need to re-engineer the Nigerian health system to
ensure that different levels of health care play the role for which they were established.
O Drug sellers were important pharmaceutical care providers in the community. In order
to ensure that they provide adequate care to the populace, there is need for them to be
adequately regulated and their capacity built as primary care givers. Of particular
importance is the issue of labelling of medicines which needs to be standardised and
enforced.
O While medicines are geographically available, they are unaffordable to most persons
especially to those with chronic illnesses as a majority could not procure their
monthly medicine supplies. Interventions which will ensure increased access to
medicines especially for the chronically ill should be devised by the government. Such
interventions may include, formulating a pricing policy to reduce prices, providing
free medicines to those with chronic illness and increasing health insurance coverage
especially for the majority of the population who are currently uninsured due to the
limited implementation of the current policy.
28
3FMOH (2002). . Published by the Federal Ministry of Health in collaboration with
the World Health OrganizationBaseline survey of the Nigeria Pharmaceutical Sector