Assessment of the Level of Adherance of Private Medical Clinics in Kampala to the Standards of Good Pharmacy Practice

7/26/2019 Assessment of the Level of Adherance of Private Medical Clinics in Kampala to the Standards of Good Pharmacy P

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MAKERERE UNIVERSITY

COLLEGE OF HEALTH SCIENCES

ASSESSMENT OF THE LEVEL OF ADHERANCE OF PRIVATE MEDICAL CLINICS

IN UGANDA TO THE STANDARDS OF GOOD PHARMACY PRACTICE

BY

KAMAKUNE CAROLYNN MURUNGI

(B.PHARM MAK)

A DISSERTATION SUBMITTED TO THE SCHOOL OF GRADUATE STUDIES IN

PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF MASTERS

OF SCIENCE IN PHARMACEUTICALS AND HEALTH

SUPPLIES MANAGEMENT DEGREE OF

MAKERERE UNIVERSITY

MAY 2014

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DECLARATION

I,Kamakune Carolynn Murungi, hereby affirm that this dissertation is original and has not been

submitted to any other institution for any other academic award. Appropriate references have

been cited where works from other authors have been used.

SI!A"#$%.............................................

&A"%.......................................................

"his dissertation has been submitted with approval of the following supervisors'

ASS(CIA"% )$(*%SS($ +(A! KA-A!( / )harm, MscComm )harm, MscClin%pid

and /ios0

.............................................................

)$(*%SS($ $IC1A$& (&(I A&(M% / )harm, Msc)harmcol, )1&0

................................................................

Copyright reserved by author2

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DEDICATION

"his study is dedicated to all the people and organisations whose work is committed to ensuring

that medicines are available, safe, and efficacious and used rationally by those that need them.

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ACKNOWLEDGEMENTS

*irst and foremost, I would like to thank the almighty od for giving me the grace, wisdom,

persistence and resilience for preparing and completing this work.

My supervisors' )rofessor $ichard (doi and Associate )rofessor Kalyango +oan' thank you so

much for letting me share your profound knowledge and wisdom and for always being available

whenever I needed you. od bless you.

My classmates and professional colleagues provided me with the 3eal and e4ternal drive to keep

pushing on until the end. *or this I am forever grateful.

And finally my family, my daughters Melinda and !icole5 thankyou for 6ust being you and my

husband for being understanding, caring and supportive during this tumultuous time of my life5 I

could not have asked for better.

"his study has been completed with the generous support of S#$% #ganda' the financial

assistance rendered covered the cost of travel to the districts, accommodation and data collection.

I am highly indebted to /irna "rap and &orthe Konradsen of S#$% #ganda for giving

constructive criticism right from concept development to the write up of the final report.

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TABLE OF CONTENTS

&%CA$A"I(!..............................................................................................................................i

&%&ICA"I(!.................................................................................................................................ii

ACK!(7%&%M%!"S...........................................................................................................iiiIS" (* "A/%S..........................................................................................................................vi

IS" (* A))%!&IC%S................................................................................................................vii

A//$%8IA"I(!S A!& AC$(!-MS.....................................................................................viii

()%$A"I(!A &%*I!I"I(!S'..................................................................................................i4

A/S"$AC"...................................................................................................................................4i

C1A)"%$ (!%'.............................................................................................................................9

9.: Introduction........................................................................................................................9

9.9 /ackground........................................................................................................................;

9.9.9 "he 1ealth System Structure...........................................................................................;

9.9.< 1ealth work force of #ganda..........................................................................................;

9.9.; $egulatory *ramework....................................................................................................=

9.< )roblem Statement.............................................................................................................>

9.; +ustification........................................................................................................................?

9.= Study (b6ectives.................................................................................................................@

C1A)"%$ "7(' I"%$A"#$% $%8I%7..................................................................................


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;. %thical Considerations......................................................................................................9@

C1A)"%$ *(#$' $%S#"S A!& *I!&I!S.........................................................................9

=.: Introduction......................................................................................................................9

=.9 Characteristics of private medical clinics.........................................................................9

=.< /ackground characteristics of the dispensing persons in the clinics................................

$%*%$%!C%S..............................................................................................................................;@

A))%!&IC%S...............................................................................................................................=9

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LIST OF TABLES

"able 9' Characteristics of ?: private medical clinics...................................................................9

"able ' )atient knowledge on medicines that they had received'................................................


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LIST OF APPENDICES

Appendi4 9' )atient Consent *orm................................................................................................=9

Appendi4

Appendi4 =' 1ealth Care )rovider Consent *orm.........................................................................=@

Appendi4 >' &ata Collection "ool.................................................................................................=

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ABBREVIATIONS AND ACRONYMS

*/( *aith /ased (rganisations

.).) ood )harmacy practice

1SS) 1ealth Sector Strategic )lan

M(1 Ministry of 1ealth

!&A !ational &rug Authority

!&) !ational &rug )olicy

!&)EA !ational &rug )olicy and Authority

!( !on overnmental (rganisation

!MS !ational Medical Stores

!)SS) !ational )harmaceutical Sector Strategic )lan

)1C )rimary 1ealth Care

)1) )rivate 1ealth )ractitioners

)!*) )rivate !ot *or )rofit organisations

S#$% Securing #gandaFs right to essential medicines

"CM) "raditional and Complimentary Medicine practitioners

#IA #ganda Investment Authority

#)MA #ganda )harmaceutical ManufacturersF Association

71(7orld 1ealth (rganisation

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OPERATIONAL DEFINITIONS

D!"#$%"!%&refers to the interpretation, evaluation, and implementation of a prescription drug

order including the preparation and delivery of a drug or device to a patient, or patientFs agent, in

a suitable container appropriately labelled for subseGuent administration to, or use by, a patient

College of respiratory therapists of (ntario,


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It is a vocation in which knowledge of some department of science or learning or the practice of

an art founded upon it is used in the service of others.

R*/!'%* D+& "$' reGuires that patients receive medications appropriate to their clinical needs,

in doses that meet their own individual reGuirements for an adeGuate period of time, and at the

lowest cost to them and their community 71(,


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ABSTRACT

AIM' "o assess the level of adherence of private medical clinics in #ganda to the standards of

good pharmacy practice in regard to dispensing, storage and stock management of medicines.

METHODS' A cross sectional survey of private medical clinics in three districts of #ganda was

done. It involved observation of dispensing practices, storage practices and stock management

practices in ?: randomly selected private medical clinics. "he person responsible for dispensing

of medicine in each clinic was interviewed using a semi structured Guestionnaire. In addition, ten

patients were asked a few Guestions regarding their medicine as they left the clinic. "he data was

entered using %pi data software and analysed using S)SS version


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CHAPTER ONE

1.0 I%/+'-/!'%

)rivate 1ealth practitioners play an important role in the delivery of health services and account

for about =?H of the total number of health facilities in #ganda. "hey have a large urban and

peri5urban presence and provide a wide range of services, mainly in primary and secondary care.

*ew provide tertiary services. Curative services are widely offered while preventive services are

more limited, with the e4ception of family planning, offered by @>H of )1) facilities Andrea et

al, 0.

Curative services in health care have two very important of components' prescribing and

dispensing of medications. )rescribing involves the selection of a particular therapy which may

or may not involve the use of medicines0 based on a diagnosis reached after careful consideration

of the patientFs history, physical e4amination and where necessary supporting

laboratoryacGuired diagnostic findings while dispensing. &ispensing on the other hand,

involves all the steps reGuired to ensure that the patient receives the correct type and Guantity of

medication as prescribed by an authori3ed prescriber andall relevant, practical information and

guidance necessary to ensure that the medicines is correctly used and stored by the patient

M(1,


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activities in #ganda, with dispensers performing the role of prescribers, and prescribers eGually

performing the dual role of prescribing and dispensing.

)erhaps because of the noted shortage of pharmacists in #ganda, anecdotal evidence suggests

that in spite of the e4isting regulations, other health care professionals such as' doctors, nurses,

and clinical officers dispense and prescribe medicines at the same time. "he combination of

prescribing and dispensing functions in one professional usually leads to overprescribing, as

there is a financial incentive to sell more or more e4pensive drugs. "hese two functions should

be separated as much as possible, e4cept in rural areas where there is insufficient market for

separate pharmacies. Such a measure usually meets with strong opposition by dispensing doctors

who may earn a considerable part of their income by selling drugs0 and by pharmacists who

may earn a considerable part of their income by selling drugs without prescription0. 71(,


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1.1 B*-5&+'%

1.1.1 T$ H$*/ S"/$, S/+-/+$

"he !ational 1ealth System in #ganda constitutes of all institutions, structures and actors whose

actions have the primary purpose of achieving and sustaining good health. It is made up of the

public and the private sectors M(1,


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dentists, pharmacists as well as laboratory personnel are e4tremely uneGually distributed

throughout the country and only serve a fraction of the population. It further indicates a heavy

urbanErural imbalance with most health workers being concentrated in the central region. "he

central region which hosts 0

"he !urses and Midwives Act 9? section ;>0

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"he Medical and &ental )ractitioners Statute 9? section ;


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practitioners from retailing of medicines without a valid license. 1owever, up to date no such

license is issued permitting medical practitioners to dispense medicines as part of the

professional services that they offer to their patients. In some other African countries like South

Africa and imbabwe, prescribers that dispense medicines are given additional training and also

issued with a license to operate 71(, 9@0. "his la4ity in enforcing the law in #ganda may

lead to la4 procedures for dispensing and stock management in these facilities and hence put

patientsF lives at risk. Inappropriate or incorrect dispensing can undo many of the benefits of the

health care system as all of the resources reGuired to bring a drug to the patient will be wasted if

dispensing does not ensure that the correct drug is given to the right patient in an effective

dosage and amount, with clear instruction, and in packaging that maintains the integrity of the

drug MS1, 9@0

)revious studies have focused on dispensing practices in pharmacies and drug shops Abula et

al.


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(ne of the goals of the #ganda national drug policy is to ensure that dispensing practices at all

levels in both the public and private sectors comply with recommended standards of good

practice M(1,


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CHAPTER TWO LITERATURE REVIEW

2.0 I%/+'-/!'%

A literature search was done in order to gain insight about the field of study and also to focus

and clarify the research Guestions. A number of articles and reviews were analy3ed for their

relevance to the study, however, there was very littleE scanty literature pertaining to good

pharmacy practices in private medical clinics. "herefore all articles on good pharmacy practice

regardless of the setting were included in the review and also reference lists from the articles

found were also used as a source for literature.

2.1R$"/" 3+', !/$+*/+$ "$*+-

"he results from the literature search will be discussed according to the following themes which

are in alignment with the specific study ob6ectives' good pharmacy practice, medicines

dispensing, medicines storage, and medicines stock management.

G'' #*+,*- #+*-/!-$

ood pharmacy practice ))0 has been defined differently by different authors'

"rap et al,


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studies reviewed had any relevance to good pharmacy practice in private medical facilities and

this provides further 6ustification for this study.

)rivate health facilities usually have poor adherence to the standards of ))' In Sri anka,

compliance to seven subsystems of good pharmacy practice was studied in ; private pharmacies

using observation checklists. It was found that' storage of drugs, maintenance of cold chain,

dispensing and documentation were comprehensively substandard in both the rural and urban

districts 7i6esinghe and Senevirante, drug sellers in both public

and private pharmacies in ao )&$ found that public pharmacies had lower mean scores for

availability of medicines and essential materials, and a higher percentage of antibiotics

dispensed, however, overall both public and private pharmacies performed sub optimally in

relation to various aspects of good pharmacy practice and rational drug use Syhakang et al,


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while in rural public health facilities in /angladesh it was


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accountability for medicines MS1,


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)oor storage conditions and practices generally enhance chemical degradation and may alter the

biopharmaceutical properties of most drugs thus rendering them ineffective Kayumba et al,9>

and /allereau et al, 9@0. (keke and amikanra, 9> demonstrated this using a cross sectional

study that evaluated the Guality of tetracycline capsules in !igeria.

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CHAPTER THREE METHODS

7.0 S/ D$"!&%

A cross sectional survey of medical clinics in three randomly selected districts of #ganda was

carried out. "he clinics were sampled from the ministry of 1ealth list of registered and licensed

private medical clinics. "his study was Guestionnaire based using prospective data collection

methods including observations and face to face interviews.

7.1 S/ S$//!%&

"he study was based in three districts of #ganda including' Kampala, ira and Mbarara. "hese

were purposively selected because they are a fair representation of the urban areas in #ganda

where medical clinics are most freGuently found.

#ganda is an agri5based landlocked country that has a total population of about ;=.9 million

people with Kampala district accounting for 9.@ million people. Mbarara has a population of

;,@:: people while ira has a population of 9:,?:: #/(S,


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7.7 S*,#$ S!>$ *% S$$-/!'%

"he sample si3e for this study was determined basing on 71( recommendations for

determining sample si3e of health facilities. *or basic cross sectional studies, 71( recommends

a sample si3e of ;: facilities with


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"en patient e4it interviews were conducted to assess patient knowledge of the medicines and also

to assess whether the packaging and labelling of medicines was done appropriately. (nly 9:

patients were included per facility so that the study can be feasible within the time available for

carrying out research for a postgraduate degree. 7here less than ten patients were seen at the

clinic then the principal investigator had to go back the ne4t day and interview more patients.

"he sampling strategy employed was a multi stage process with districts being purposively

selected at the first stage and health facilities randomly sampled at the second stage.

7.4 S/ V*+!*$"

"he indicators used herein are adopted from "rap


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acceptable storage practices acceptable encompasses storage of products off the floor,

away from direct atmospheric conditions0.

"he stock management indicators included' )ercentage of facilities with stock card

available for a basket of medicines, percentage availability for a basket of tracer drugs

and )ercentage of facilities with stock cards accurate for a basket of medicines accurate

defined as stock card balance eGuals physical count.

Also considered as a core indicatorJ in this study is the percentage of the surveyed

facilities where dispensing of medicines is done. "his information was collected to

determine the prevalence of dispensing of medicines in the clinics.

(ther variables included' staffing levels, professional Gualifications of dispensers andprescribers, opening hours of the medical clinic, and average number of patients seen per

day.

7.9 D*/* C'$-/!'% *% E%/+

A data collection tool that included indicators about rational dispensing, storage conditions and

stock management was used to collect data from the private medical clinics. "he tool was coded

and did not include the name of the patient, health facility or even the health worker.

At each private clinic, one dispensing health worker was interviewed using a semi structured

Guestionnaire. "hey were asked about how they store medicines and manage stock. An

observation checklist was filled to assess storage conditions for the medicines in the clinic. "his

data was collected by the principal investigator who also ensured that the Guestionnaires were

completely filled before leaving the private medical clinic.

"en patient e4it interviews were conducted at each clinic to determine the level of patient

knowledge of the dispensed drugs. &rug packages of these patients were also e4amined to see if

they were appropriately labeled with the patient name, drug name and strength and dose,

freGuency and duration.

*ive dispensing times were measured at each facility to determine the amount of time that the

dispenser spent on medication counseling and information. "he stop watch was started when the

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patient presented to the dispensing window, paused during packing of the medicines and started

when the dispenser is e4plaining to the patient how to take the medicine. "he average dispensing

time was then computed for each facility. "he data was entered using %pi data software version

;.9.

7.? S/ T''"

"he data collection tool used for this study was a semi structured Guestionnaire that included

multiple response Guestions, open ended Guestions and also observation checklists to evaluate

storage and stock management indicators.

"he Guestionnaire was interviewer administered to ensure complete and accurate data collection.

At the health facility' the Guestionnaire was administered to the dispensing health worker. "he

Guestionnaire was pre tested on five private medical facilities.

7.: D*/* M*%*&$,$%/ *% A%*"!"

All the data was checked for completeness, sorted and entered into the computer using

appropriate software packages. "he raw data was securely stored to maintain confidentiality.

&ata analysis was done using the Statistical package for social sciencesP S)SS0 software

version


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Informed consent was obtained from all the participants before they were recruited into the

study.

"he names of private health care facilities and the study participants were kept anonymous and

any other personal information obtained was kept confidential.

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CHAPTER FOUR RESULTS AND FINDINGS

4.0 I%/+'-/!'%

"his chapter presents the findings of the study in relation to the specific research ob6ectives

"he findings from the study will be presented in the following order'

Characteristics of the ?: medical clinics surveyed.

Characteristics of dispensing persons in the private medical clinics surveyed.

)) assessment for the clinics as regards dispensing indicators, storage indicators and

stock management indicators.

)revalence of dispensing in medical clinics and reasons given for dispensing of

medicines.

4.1 C*+*-/$+!"/!-" '3 #+!*/$ ,$!-* -!%!-"

T*$ 1 C*+*-/$+!"/!-" '3 ?0 #+!*/$ ,$!-* -!%!-"

V*+!*$ M$*"+$ V*$

Specialist services offered, n H0

&ental

(bstetrics and gynecology

)aediatrics

Maternity

aboratory

9 ;:H0

9: 9?.@H0

9< H0

>: ;.;H0(pening hours, n H0

: 5 hours

Q 9?hours

9@ Q 9, =,


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Medical doctor

Clinical officer

!urse

Midwife

(thers


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4.2 B*-5&+'% -*+*-/$+!"/!-" '3 /$ !"#$%"!%& #$+"'%" !% /$ -!%!-".

T*$ 2 C*+*-/$+!"/!-" '3 /$ ?0 !"#$%"!%& #$+"'%" !% /$ #+!*/$ ,$!-* -!%!-"

"+$$.

V*+!*$ M$*"+$ V*$"Age , median Min, Ma40 9, ?;07orking %4perience, median Min, Ma40 ; 9, ;@0

Se4, n H0

Male

*emale

9 ;9.@0

=9 ?.;0

Bualification, n H0

Certificate in health related course

&iploma in nursingEclinical medicine

raduate doctorEnurse

)aramedical Gualification

= 9.@0

@ 99.@0

; >.:0

9 9.@0

)osition of responsibility, n H0N

)rescriber

AdministratorEmanager

(wner

(thers

< ?.@0

>9 >.:0

9>.:0

@ 99.@0

= ?.@0

9;


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4.7 A$+$%-$ '3 #+!*/$ ,$!-* -!%!-" !% U&*%* /' /$ "/*%*+" '3 &'' #*+,*-

#+*-/!-$

An assessment of good pharmacy practice in the private medical clinics involved assessing three

aspects' dispensing, storage and stock management in the medical clinics. "he indicators used

therein attempt to measure three elements of good pharmacy practice which include' supply and

use of medicines, self care and influencing prescribing and dispensing.

4.7.1 D!"#$%"!%& I%!-*/'+" '3 /$ S+$$ C!%!-"

T*$ 7 D!"#$%"!%& !%!-*/'+" '3 /$ -!%!-" "+$$

I%!-*/'+ % ()

Appropriate packaging material available > ?.@0

SpatulaEspoon available =< @:.:0"ablet counting tray available ;;>>.:0

"ablets not counted by bare hands ;> >.;0

&ispensing eGuipment cleaned before use 9@ > ;.;0

)rivacy during dispensing ;9 >9.@0

1and washing facilities available =9 ?.;0&rinking water available ;< >;.;0

Clean cups available for use ;9 >9.@0

&ispensing log available and in use ;< >;.;0

"able ; above presents a summary of the dispensing indicators in the surveyed clinics. Almost

all the clinics had appropriate packaging materials ?.@H0 for the dispensed medicines and

chairs or benches ;.;H0 at the waiting area. Although ma6ority of the clinics had dispensing

eGuipment available @:H had a spatulaEspoon0, only about a Guarter of them


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*rom table = above' the measured overall mean dispensing time for the surveyed clinics was ;:.>

seconds S&


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"able ? above shows that ma6ority of patients @?H0 received medicine packs that were labeled

with name and doseL however, none received medicine packs labeled with the date and patient

name.

4.7.2 S/'+*&$ I%!-*/'+" '3 /$ S+$$ C!%!-"

T*$ : S/'+*&$ !%!-*/'+" 3'+ /$ "+$$ -!%!-"

A"#$-/ N,$+ (%) P$+-$%/*&$ ()

Medicines stored only on shelves >@ >.:

Medicines stored in a systematic manner either

alphabetic or in therapeutic categories

=? @?.@

!o bo4es directly on the floor => @>.:

A record for e4pired drugs is available ; >.:

&esignated area for e4pired drugs is available @ 99.@*%*(Nis adhered to =9.@

Medicines are protected from direct sunlight >@ >.:

!o signs of pestsErodents or any other harmful insects

seen

>@ >.:

*unctioning system for cold storage 9=


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A*!*!!/ '3 * "/'-5 ,*%*&$,$%/ ""/$,

T*$ @ P+!*/$ ,$!-* -!%!-" /*/ * * "/'-5 ,*%*&$,$%/ ""/$, !% #*-$

S/'-5 ,*%*&$,$%/ *"#$-/ N,$+ '3 -!%!-" (%) P$+-$%/*&$()

Stock card available : :Computeri3ed stock

management system

; >.:

Computeri3ed system

captured key information

9 9.@

"able shows that only >H of the clinics had a computeri3ed stock management system while

none of the clinics kept stock cards as a stock control tool.

T*$ 8 A*!*!!/ '3 /+*-$+ ,$!-!%$" !% ,$!-* -!%!-" '% /$ * '3 /$ "+$

M$!-!%$ N,$+ '3 -!%!-" P$+-$%/*&$

Artemether and lumefantrine


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*or this study' a clinic was categori3ed as a dispensing facility if it dispenses medicines to

patients regardless of the Guantities involved in addition to all the services that it provides to the

patients.

All the surveyed clinics reported that they dispensed medicines to their patients and therefore the

prevalence of medicines dispensing was found to be 9::H.

4.9 R$*"'%" 3'+ ,$!-!%$" !"#$%"!%& !% /$ #+!*/$ ,$!-* -!%!-"

"he reasons why private medical clinics held stockEdispensed medicines to their patients were

Guite varied but belonged to one or more of the following themes'

"o offer an all encompassingEcomprehensive service to their patients.

"o facilitate patient compliance and promote rational use of medicines.

Medicines are an essential component of medical care

*inancial incentives

T' '33$+ * -',#+$$%"!$ "$+!-$ /' /$!+ -!$%/"

"he dispensers said that they dispense medicines to their patients so that they get all the services

they need at one place. A nurse at one of the medical clinics in Mbarara aptly put it as' when

patients come here they want to find a laboratory, treatment room and also the medicine that

they need, basically they want to find everything they need in one place.

(thers kept medicine stock because patients e4pect them to find the drugs that they need when

they visit them. A nursing assistant in one of the clinics in ira put it like this' some patients

come here for treatment (diagnosis and medication administration) while others come

specifically to buy medicines, to just get a few doses of this medicine or the other.

T' 3*-!!/*/$ #*/!$%/ -',#!*%-$ *% #+','/$ +*/!'%* "$ '3 ,$!-!%$"

"he need to aid patient compliance to the medicines prescribed came out strongly. Some said

they dispense medicines to their patients because they want to be sure that their patients get the

right medicines for the right medical condition.

A doctor in Mbarara who was the clinic ownerEprescriber and dispenser had this to say'

sometimes when we send our patients to the pharmacies/drug shopsthe people they find there

just substitute the medicines that we would have prescribed with others in the event that they

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dont have the medicines that were prescribed without first consulting us. !o the patient fails to

respond to the treatment and they come back and tell you that "doctor the medicine you asked

me to take did not work and when you in#uire further you find that they were given something

totally different from what you prescribed.

M$!-!%$" *+$ *% $""$%/!* -',#'%$%/ '3 ,$!-* -*+$

Some responses were in agreement with the opinion that medicines constitute a very important

component of medical care. In fact for most of the dispensers interviewed' medical care came

down to dispensingEadministering of medications to the patients. $esponses to this effect

included' we give our patients medicine because it is part of treatment and how else can we

treat our patients without giving them medicine$

F!%*%-!* !%-$%/!$"

Some respondents implied that they dispensed medicines to their patients because of the

financial rewards associated with it.

"wo of the respondents interviewed said that they dispensed medicines to their patients because

they had to stave off competition from other dispensing clinics. A registered nurse who was a

clinic ownerEprescriber and dispenser in Mbarara district put it like this % "& keep medicines that &

dispense to my patients because if & dont have them then they will go and get them from other

clinics. &f & want to compete favorably with other clinics then & definitely have to dispense

medicines to my patients.

(ther reasons for dispensing of medicines in private medical clinics included' because they have

been prescribed by the prescriber, for emergency situations and because that is the business

policy. Interesting to note is the fact that none of the respondents said they dispensed medicines

because there was no nearby pharmacy or drug shop.

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CHAPTER FIVE DISCUSSION AND LIMITATIONS

9.0 I%/+'-/!'%

"his chapter aims to interpret and discuss the study findings in relation to what has been found in

literature. A summary of the findings will be presented first, followed by discussion of the

findings relative to the specific research ob6ectivesL finally the limitations of the study and how

they were overcome will be presented.

9.1 S,,*+ '3 /$ 5$ 3!%!%&"

Ma6ority of the clinics surveyed have been in operation for @ years or more, receive on average

9@ patients per day and are located about half a kilometer to the nearest pharmacy. "he

prevalence of dispensing by the private medical clinics was found to be 9::H.

An assessment of good pharmacy practice in the area of dispensing practices revealed that most

clinics had appropriate packaging materials but did not have regularly cleaned dispensing

eGuipment. "he dispensing time was e4tremely short ;: seconds0, patient knowledge and

medicine labeling was found to be suboptimal.

Storage practices of medicines were adeGuate for five out of the nine indicators assessed but

there was lack of a functional cold storage system in most clinics surveyed.

Stock management practices were found to be suboptimal in the clinics surveyed' none of the

clinics kept a stock card and only about >H had a computeri3ed stock management system.

Medicines availability was moderately good as all the medicines on the tracer list were found to

be available in ?:H or more of the clinics visited.

"he reasons for holding stock and medicines dispensing in the private medical clinics included'

to facilitate patient compliance, to offer a comprehensive service to their patients and because of

financial incentives.

9.2 D!"-""!'% '3 3!%!%&"

"his study is meant to serve as a baseline survey for policy makers, health care managers,

researchers and other relevant stakeholders. It was intended to Guantify the problems of

pharmacy practices in the private medical clinics and not to e4plore the factors responsible for

themL these could be taken on by a follow on study.

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"his study has shown that corrective action is urgently reGuired in the areas of' cadre of staff that

should be allowed to participate in medicines management in private medical clinics, dispensing

practices, storage practices and stock management practices in the private medical clinics.

!ursing assistants were most freGuently found to be in charge of storage ?9.@H0 and dispensing

of medicines in private medical clinics ?:H0. "his is in agreement with the findings from a

cross sectional study on ;?: private health care facilities in #ganda that also found that nursing

assistants were employed in ?:H of all the private health care facilities surveyed Mandelli et al,

0. iven the fact that this cadre of staff has been phased out in public health facilities

Ministry of )ublic Service,


43/70

favorablyJ may mean that there is a profit motive behind the need to dispense medicinesE keep

medicines as stock items. "rap et al,


44/70

Almost half of all the private clinics surveyed did not have dispensing eGuipment, and slightly

more than a Guarter cleaned the dispensing eGuipment before use. "he risk of cross

contamination of medicines therefore is very high. "his would be fatal in cases where a patient

receives medicine that was contaminated with another medicine to which he is sensitive.

ess than half of all the patients interviewed effectively recalled the reason =;.H0 for taking

their medicines and the length of the duration ;.9H0 for which to take their medicines. "hese

findings agree with the findings from /otswana where duration of treatment was recalled by less

than half of all the patients interviewed ==H0. AdeGuate patient knowledge of medicines

supplied is one of the important prereGuisites for patient compliance. "herefore correct use of

medicines maybe compromised by inadeGuate patient knowledge. /oonstra et al,


45/70

findings mirror the situation in Sudan where there was neither a manual nor a computeri3ed

stock management system in both the public and private sector %lamin et al,


46/70

CHAPTER SI RECOMMENDATIONS AND CONCLUSIONS

I%/+'-/!'%

"his aim of this chapter is to present recommendations for corrective action based on the study

findings and also give conclusions to the study findings'

?.1 C'%-"!'%"

"his study has given a snapshot view of the state of pharmacy services in level II private medical

clinics in #ganda. It has demonstrated that 9::H of the private medical clinics in the surveyed

districts dispense medicines to their patients and that availability of medicines was Guite good for

the medicines on the tracer list.

"he reasons for dispensing of medicines were Guite varied but were in agreement with the ones

found by other studies and included' to ensure that the patients get the right treatment, to meet

patientsF e4pectations, and for economic reasons' such as to be able to compete with other clinics

that were dispensing medicines to their patients.

An assessment of good pharmacy practice in the area of medicines dispensing revealed that'

dispensing in more than ?:H of all the clinics was done by inadeGuately Gualified staff nursing

assistants0, that dispensing time was e4tremely short half a minute0, there was no dispensing

eGuipment in most clinics, medicine labeling of dispensed medicines was poor, less than 9:H of

all the medicine packs e4amined had been labeled with patient name, date, strength and

Guantity0.

"he aspects of medicines storage that warrant the most attention were' the absence of a

functional system for cold storage in ma6ority of the clinics surveyed, absence of a designated

area for storage of e4pired medicines and non adherence to *irst %4piry *irst (utJ method of

medicine storage in more than half of all the clinics.

Stock management had the worst scores among all the three areas assessed' none of the clinics

surveyed had a manual stock management system stock card0 while only three clinics had a

computeri3ed stock management system.

"his study demonstrates that adherence to the standards of good pharmacy practice in the areas

of medicines dispensing, storage and stock management of medicine is not satisfactory and

34


47/70

therefore reGuires urgent corrective action to ensure that the ma4imum benefits are achieved

from the medicines used in the private for profit sector.

?.2 R$-',,$%*/!'%"

Standards should be set on the minimum cadre of health workers that are allowed to

provide pharmaceutical services in private medical clinics. "he pharmaceutical services e4pected to be provided by private medical clinics need to

be clearly defined by the relevant stakeholders. "here is need to develop and implement a system for carrying out )) inspections in

private medical clinics for the purpose of licensure of facilities that can provide a

satisfactory pharmaceutical service by the !ational &rug Authority. "he licensing system

needs to put in place a procedure for delicensingJ those private medical clinics that

donFt meet certain standards. All health workersEdispensers in private medical clinics need to receive basic training

appropriate to the level of pharmaceutical service that they are e4pected to provide.

Specific issues that should be addressed include' basic pharmacology and appropriate

medicines use.

$egular and freGuent supportive supervision should be provided to dispensers in private

medical clinics to uphold the standards of practice. "he government needs to allocate resources for training of more pharmacists and

pharmacy technicians in order to mitigate the shortage of adeGuately Gualified staff both

the private and public sectors.

!ational guidelines for )) for the different health care settings should be developed and

implemented by the relevant stakeholders. *urther research is needed to assess the effectiveness of regulatory action as well as to

define the most appropriate order of implementing the interventions.

*or these recommendations to work there are key success factors that need to be considered'

)olitical will' the government of #ganda needs to be convinced of the need and value

of a Guality pharmaceutical service in contributing to the overall health of the

population in order for it to allocate more funds to the training of pharmacists and

pharmacy technicians. "he public should be educated and empowered about the Guality of pharmaceutical

services they should demand from all healthcare facilities.

35


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36


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REFERENCES

Abood $.$. 90, R)hysician dispensing' issues of law, legislation and social policyF

'merican ournal of law and medicine,retrieved on .

/irna ", 1ansen %1, "rap $, Kahsay A, Simoyi ", (teba M(, $emedios 8, %verard M


50/70

&aniel Ko6o


51/70

Management Sciences for health


52/70

Markle 7, Melanie *, and $ay S


53/70

APPENDICES

A##$%! 1 P*/!$%/ C'%"$%/ F'+,

T!/$ '3 /$ "/' Assessment of the level of adherence of medical clinics in #ganda to the

standards of good pharmacy practice

P+#'"$ '3 /$ "/the study is intended to assess the level of adherence of medical clinics in

#ganda to the standards of good pharmacy practice specifically related to dispensing, storage

and stock management.

I am reGuesting you take part in this study.

S/ #+'-$+$-ou will be asked some Guestions regarding identity, duration and dosage of

the medicine you are taking.

C'%3!$%/!*!/' the information collected will only be used for research purposes. "he forms

will only have a number and will be stored securely with the principal investigator. -our name

will not appear anywhere on the Guestionnaires or even in the final report.

B$%$3!/"' "here are no immediate benefits to you but important recommendations from this

study will be communicated to the Ministry of 1ealth and all the other relevant stakeholders and

will be used to generate and implement policies which will contribute to rational use of drugs in

#ganda.

R!"5"' "here are no ma6or risks to you as you are only going to be asked to answer a few

Guestions.

Y'+ +!&/"' you are free to decline to participate in this study, or withdraw from it anytime and

this will not affect how you will be managed as a patient at this medical facility.

S/*/$,$%/ '3 -'%"$%/'

I have fully understood the purpose and nature of this study and hereby voluntarily choose to

participate as signed below'

..............................................................

41


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!ame of client

.............................................................

SignatureE thumbprint

...........................................................

!ame of investigator

............................................................

Signature

42


55/70

A##$%! 2 P*/!$%/ C'%"$%/ F'+, T+*%"*/$ I%/' R%*%5'+$= R5!&*

EKIHANDIIKO KYOKWIKIRIA OMURWAIRE KWETABA OMU KUCONDOOA

AYEKUNDIIRE

O,/6$ &6'5-'%''>* (kushwi6umaorurengo oruamarwariro garikukuratirira omu

nkoresa ehikire yFemiba3i omu #ganda, ahabwFokwenda kuhikiiri3a enkoresa yFemiba3i enungi.

E5!&$%$+6* 5'5-'%''>* (kucondoo3a oku, kugyendereire kushwi6uma oku

amarwariro garikukuratira enkoresa ehikire yFemiba3i omu #ganda, namunonga omu kugigaba,

okugibiika gye, hamwe nFokugireeberera kurungi ahi ebiikire.

!inkushaba ngu oikiri3e kwetaba omu kucondoo3a oku.

E%/6*>* '5-'%''>* !oi6a kubuu3ibwa ebibuu3o ebikwatiraine na byona

ebirikukukwataho, obwire obu oma3ire orikukoresa omuba3i hamwe nFekipimo kyagwo eki

orikumira.

O55,* $%**,* %bi oraagarukyemu nibii6a kwe6unisibwa omu kucondoo3a kwonka.

*oomu egi nei6a kuba eriho enamba yonka, kandi omuntu orikucondoo3a nei6a kugibiika gye.

%i3iina ryawe tiririkwi6a kugira ahi ryahandiikwa hoona, nangwa nFaha ripoota eyFahamuheru

tiririkwi6a kuteibwaho.

E!+%&! $!+**+&$, "ihariho birungi bingi ebyahonaaho ebi oraatungye kuruga omu

kucondoo3a oku, okwihaho ebishemereire kukorwa ebikuru ebiragambweho nibii6a

kumanyisibwa minisiture yFebyamagara hamwe nFebindi bitongore ebirikukwatwaho enshonga

egi. !abwanyima, ebirugiremu ebi, nibii6a kwe6unisibwa omu kutaho enkora ehikireL ekirai6e

kwongyera kusheme3a omuringo gwFokukoresamu emiba3i omu #ganda.

A5*! *5**5**"* 5* 5*+!, (kwetaba omu kucondoo3a oku tikurai6e kukureetera kabi

koona ahabwokushanga ngu noi6a kuba nooshabwa kugarukamu ebibuu3o ebiraakubuu3ibwe

byonka.

O&** 6*6$ (ine obugabe bwFokwanga kwetaba omu kucondoo3a oku nari obaasa

kukurugamu ahi oraayendere. Kwonka nFobu eki kyakubaho, tikirii3e kuhindura aha ku

ogabirwe nootunga obuheere3a obu oshemereire kutunga nkFomurwaire aha irwariro eri.

43


56/70

E!&*,' ',+6*!+$ *** %**>* 56!5!+!>* 56$/** ', 5-'%''>*

!aayetegyere3a gye ekigyendererwa nFomuringo gwFokucondoo3a oku, kandi naata omukono

aha kihandiiko eki, ekirikworeka ngu naikiri3a gye nyekundiire kukwetabamu

.......................................................

%i3iina ryForikucondoo3ibwaho

........................................................

(mukono gwForikucondoo3ibwaho

........................................................

%i3iiina ryForikucondoo3a

........................................................

(mukono gwForikucondoo3a

44


57/70

A##$%! 7 P*/!$%/ C'%"$%/ F'+, T+*%"*/$ T' L$*%&'

PWOM ME YEE OTWOO

N!%& 6! 56*% ,*%!giyo itere tere kit ame kilinike i #ganda lubu kede rwom me tic aber a

udi catto yen.

T$% 5'# ,$ 56*% ,*% kwan man tye me ngiyo itere tere kit ame kilinike i #ganda lubu kede

rwom me tic aber a udi catto yen tutwalere kop amako tic me pokko, kanno kede gwokko yen

aber.

Atye akwayi me bedo i kwan man.

K!/ *,$ 56*% ,*% *6'/ 5$$ obino penyi apeny mogo amako nying yat, kare itio kede yat

kede do6 me yat ame itye itic kede.

K'# ,$ !,%& ngec ducu ame obino rayo ni obino tic kede keken ka pi kwan man. )wom magi

bino bedo kede nama keken dok atel wi kwan man aye bino gwokko pwom magi aber tutwal.

!yingi pe obino coyo kakanoro keken ikom papula me apeny magi kadi ikom ripot me agiki

dong.

;*,! *$-' ginoro aber pe bino bedo atye piri cutu cutu ento ngec apire tek ayaa i kwan man

obino cwallo bot Minicitiri me -otkom kede dong 6o okene ame kwan man mako gi dok obino

tic kede me katto kede cik kede ketto cik magi i tic ame bino konyo i tic kede yen i #ganda iyore

opore.

;*,! *+$-'pe tye 6ami mogo areco atir atir abino nen ikomi pien obino penyi me gammo apeny

mogo anonok.

T6$+' %! itye agonya me kwero bedo i kwan man, nyo ya wekko oko kwan man icawa moro

keken dok man pe bino lokko kit ame obino tic kede ikomi acalo ibedo atwoo i ot yat man.

M'55' Y$$

Atyeko dong niang odoco tyen kop me kwan man kede kit ame abedo kede dok abongo dic aye

me bedo i kwan man acalo aketo cinga ping kan'

45


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.............................................................................................................

!ying akwan

.............................................................................................................

&wallo cingECapa Atwon Cingi

.............................................................................................................

!ying apeny peny

.............................................................................................................

Cinge (dwalo

46


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A##$%! 4 H$*/ C*+$ P+'!$+ C'%"$%/ F'+,

T!/$ '3 /$ "/' Assessment of the level of adherence of medical clinics to the standards of

good pharmacy practice.

P+#'"$ '3 /$ "/ the study is intended to observe dispensing, storage and stock

management practices in private medical clinics to identify areas where substantive

improvements can be realised after implementation of rational drug use strategies.

I am reGuesting you to be enrolled into this study

S/ #+'-$+$-ou will be asked to respond to some Guestions regarding staffing storage,

dispensing and stock management practices at your health facility.

C'%3!$%/!*!/' "he following procedures will be followed to keep your personal information

confidential' "he data collected about you or your medical clinic will be kept confidential' to

protect your privacy, your records will be kept under a code number rather than by name. -our

nameE health facility name and any other facts that point to you will not appear when the results

for this study are presented or published. "he information collected will only be used for

research purposes.

B$%$3!/"' "here are no immediate benefits to you but important recommendations from this

study will be communicated to the Ministry of 1ealth and all the other relevant stakeholders and

will be used to generate and implement policies which will improve rational use of drugs in

#ganda.

R!"5"' there are no ma6or risks to you as you are only going to be asked to answer a few

Guestions.

Y'+ +!&/"' your participation in this study is voluntaryL you are free to decline to take part in

this study if you do not want to. -ou can also withdraw from the study anytime without giving

any reason and without penalty.

S/*/$,$%/ '3 -'%"$%/'

47


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I have fully understood the purpose and nature of this study and hereby voluntarily choose to

participate as signed below'

..............................................................

!ame

.............................................................

SignatureE thumbprint

...........................................................

!ame of investigator

............................................................

Signature

48


61/70

A##$%! 9 D*/* C'$-/!'% T''

9. Code of health facility

. 7hat are the opening

hours of this clinic7e

?. 1ow many hours a day is

the clinic open tick one0

@. 1ow many years has the

clinic been operational

. 7hat is the average

number of patients that this

clinic receives per day

. 1ow far is the nearest

pharmacy to this clinic

kilometres0

9:. 7hat specialist services

are offered at this medical

clinic put a tick on all the

answers that apply0

A. &entist.......................................................

/. (bstetrician and gynecologist....................

C. )ediatricianWWWWWWWWWWWWWWWWW.

&. MaternityWWWWWWWWWWWWWWWWWW..

%. laboratoryWWWWWWWWWWWWWWWWWW..

*. others Specify...........................................

WWWWWWWWWWWWWWWWWWWWWWWWWW.

49

Week

Week

ends0 to 8hrs

9 to 16

17 to


62/70

.


9


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Clinical officer.......................................

!urse...................................................

Midwife...............................................

)harmacy technician............................

)harmacist.........................................

aboratory

technicianWWWWWWWWW..

(thers specify0..................................

..................................

9?. 7hat is the

highest

Gualification of the

people who

prescribe medicines

in this medical

clinic choose one0

A. Certificate in health related course.............

/. &iploma in nursingEclinical medicine...........

C. raduate doctor or nurse.............................

&. )ostgraduate medical degree..........

%. others specify..........................................

9@. /ased on the

professional

designations in

Guestion 9> above,

mention the main

person responsible

for performing the

following functions

related to medicines

A. Selecting the drugs to be stockedWWWWWWW..

WWWWWWWWWWWWWWWWWWWWWWWWWWWW..

/. )lacing and following up on drug

ordersWWWWWWWWWWWWWWWWWWWWWWWWW

C. $eceiving, storing and arranging the drugs on

shelves...............................................................

&. &ispensing the drugs to the patientsWWWWW..

51


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management

DISPENSING PERSON=PERSON INTERVIEWED

9. )osition of responsibility

tick all that apply0

A. ownerWWWWWWWWWWWWWWWWWWWW..

/. clinic administratorWWWWWWWWWWWWW

C. &ispenserWWWWWWWWWWWWWWWWWW..

&. prescriberWWWWWWWWWWWWWWWWW..

%. other specify0WWWWWWWWWWWWWWW.

9. Age


65/70

!o

. 7hy do you dispense

medicines to your patients

probes' convenience,

availability of drugs, patient

e4pectations0

A. /ecause they have been prescribed by the

doctorWWWWWWWWWWWWWWWWWWWWWW..

/. "o meet the patientsF e4pectationsWWWW

C. to offer the patients convenienceWWWW..

&. /ecause itFs the business policyWWWWW..

%. "here is no nearby pharmacyEdrug shopW


*. others specify0WWWWWWWWWWWWWWWW


.

WWWWWWWWWWWWWWWWWWWWWWWWWW


66/70

(bserve and record the dispensing time for > patients.

)atient number 9 < ; = > Average

&ispensing time in

seconds

28. P*-5*&!%& M*/$+!*

(bserve and verify the packaging material available and in use -esO9E!oO:0

9E:

a0 Are appropriate dispensing envelopes available

b0 Are appropriate clean containers i.e. bottles made specifically for

the purpose of dispensing liGuids and bottles that are not reused

available

70. D!"#$%"!%& $!#,$%/8erify that the dispensary has the following eGuipment in the dispensing area -esO9E!oO:0

%Guipment 9E:

a0 A spatula or spoon

b0 "ablet counting tray or similar

c0 "ablets not counted by bare hands

d0 raduated measuring cylinder

e0 Are the eGuipment for countingEmeasuring cleaned before use

71. S$+!-$" **!*$ */ /$ !"#$%"!%& *+$*

8erify that the dispensing areaEhealth facility has the following services -esO9E!oO:0

Services 9E:

a0 Chairs or bench to sit on in dispensing area

b0 Can privacy be achieved during dispensing (ther waiting patients

should be at least < metre away

c0 Are handwashing facilities available

d0 &rinking water to take tablets0 by patient in dispensing area

e0 Clean cups available to patients for taking water

f0 &ispensing log where all medicines dispensed are recorded

72. P*/!$%/ !%3'+,*/!'%

54


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Interview 9: patients and ask to see the medicines they have received and if possible their

prescription. Select one of the medicines to check patient knowledge of the following areas'

-esO9E !oO:0

P*/!$

%/ %'.

D'"$=

H'6

,-

/' /*5$

F+$= H'6 '3/$%

/' /*5$

D+*/!'%= '6 '%&

/' /*5$

D'$" #/. 5%'6 6

"=$ !" &$//!%& /$

/+$*/,$%/

9

?

@

9:

77. L*$!%& '3 !"#$%"$ ,$!-!%$"

Interview 9: patients and ask to see the medicines they have received. Select one and check for

labelling -O9E !O:0

Medicine no. Medicine

nameN

Strength Buantity &ate &ose )atient name

9

?

@

9:PART C STORAGE MANAGEMENT

-esO9 !oO:

55


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69/70

57


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PART D STOCK MANAGEMENT

;>. for the table below, use the following codes' -esO9, !oO:, %4piredO %, !ot

ApplicableO!A

N*,$'3,$!-!%$

#nitpack

itema

vailable'yesO9,

!oO:,

%4piredO%

S

/'-5-*+=0$&$+1''5*2*!0*10$

P"!-*0-'4%/'%$$2$+7,'%/"*%+$-'+$

.

I"/$-*+3!00$-'++$-/6!/%*,$"/+$%&/'"*&$

C'4%//$%4,1$+'3+4&"!%"/'-5*%-$-5

R$-'+/$

*2$+*&$,'%/0-'%"4,#/!'%

R$-'+/$%4,1$+'3*"'4/'3"/'-5!%/$0*"/?

I""/'-51''5!%

4"$HW!/$%/+$2$+,'%/H

I""/'-51''5-'++

$-/03!00$6!/AMC!%-04$

R$-'+/$!&$"/1*0*%-$'%*%3'+/$0*"/?

, ' % / " C ! + - 0 $ ! 3 ' 2 $ + " / ' - 5 $ ( A M C 9 )

9 ArtemetherEumefantrine

5

Documents

Assessment of the Level of Adherance of Private Medical Clinics in Kampala to the Standards of Good Pharmacy Practice