Indicators for monitoring and assessing pharmaceutical situation in countries

Indicators for monitoring and assessing

pharmaceutical situation in countries

2 -- (Monitoring & assessment - 04/21/23) WHO - EDM

Who can use the results from assessment and monitoring?

Countries

National policy-makers

Health facilities

International agencies

Professional groups, NGO, academia


Indicators for monitoring and assessing pharmaceutical situation

systematic data gathering

to compare facilities, districts, regions, countries

to measure trends


Core indicators to monitor national drug policy http://www.who.int/medicines/strategy/policy/indicators_intro.shtml

Level I indicators

(structure & process)

Level II indicators

(outcome)

Level III• WHO NDP indicators• Indicators for specific pharmaceutical

components:• How to investigate drug use in health facilities• Assessing regulatory capacity of countries•TRIPS, Drug pricing, Traditional medicines

Questionnaire

Systematic survey


Level I indicators

questionnaire (every 4 years with subset every two years) 1999 WDS questionnaire as template, consultations and

discussions with team, regional advisers, countries mostly structure and process indicators for countries country progress indicators for global tracking EDM database


Level I indicators

Covers key components of pharmaceutical system

National medicines/drug policy

Access

Legislation and Regulation, Quality control of pharmaceuticals

Essential drug list

Medicines supply system

Medicines financing, production*

Rational use of drugs

Intellectual property rights protection and marketing


Operational package on level II indicators designed as a practical tool:

to assess and monitor impact and outcome (systematic survey) to provide countries with feasible tool to monitor and assess

pharmaceutical situation to design a monitoring system and for regular monitoring of

NDPs Designed around practical/operational system of managing

resources (time, people and money) Step by step procedure

• administrative preparation (budget guideline, training schedules)

• technical requirements (training and field test, actual survey, analysis, reporting and identifying intervention


List of indicators

on availability, stockout, record keeping and expiry of key drugs conservation conditions and handling of medicines affordability (child and adult moderate pneumonia and option for

other disease condition drug dispensed, labelling, patients knowledge, cost of medicines Number of medicines prescribed, % antibiotics, % injection, ED

prescribed, drugs in generic name availability of EDL and STG drugs prescribed for diarrhea, pneumonia, ARI


Sampling Recommendations

Sample 6 regions/districts 30 public health facilities with pharmacy/dispensary 30 private pharmacies 6 warehouses

Option to add private facilities, mission clinics depending on health service mix or provider


Clustering in Drug Supply or Drug Use Data

Geographic Characteristics Administration and drug supply system Epidemiologic or socio-economic differences

Health Facility Characteristics Differences in management Peer norms and collective habits

Provider Characteristics Training, knowledge, clinical experience Economic incentives Industry pressure

Result: Effective sample size is reduced


Countries

AFRO: Cameroon, Chad, Ethiopia, Ghana, Kenya, Mali, Nigeria,

Rwanda, Senegal, Tanzania, Uganda

AMRO: Guatemala, Columbia (10 more countries)

EMRO: Iran, Oman

EURO: Bulgaria, Kyrgyzstan,

SEARO: Indonesia, Nepal

WPRO: China, Philippines, Malaysia


Monitoring if there is progress or none

Comparing 1995-2002 key indicators shows progress in some areas but that enhanced efforts needed in others

0%

20%

40%

60%

80%

100%

Availability of keydrugs

% of presc. drug inEDL

% presc. withinjection

Availability of keydrugs

% of presc. drug inEDL

% presc. withantibiotics

% patient withadequate

knowledge

% presc. withinjection

1995 2002

Bulgaria Philippines


Essential medicines are still not available and affordable to all

Access indicators

0%20%40%60%80%

100%

Guatemala Iran Philippines Bulgaria

Availability of key drugs

% drug dispensed

Affordability (cost to treat pneumonia/w eekly salary


Inappropriate use of antibiotics is a common problem

Antibiotic use 2002

0%

20%

40%

60%

80%

100%

Guatemala Iran Philippines Bulgaria

% presc. w ith antibiotics

Antibiotics for ARI

Pneumonia w ith > 1 antibiotics

Either amox,pen, cotrimox for pneumonia


Survey makes possible the comparison of public and private pharmacies

% Availability at public and private sector (2002)

0%

20%

40%

60%

80%

100%

Tanzania Mali Ghana

Public facility pharmacy

Private pharmacy


Comparing public and private pharmacies

Cost to treat moderate pneumonia in children as percentage of lowest weekly government salary

0%

2%

4%

6%

8%

10%

12%

Nigeria Tanzania

Public dispensary/pharmacy Private pharmacy


Summary Values

Mean vs. median Equivalent if data are normally distributed Mean weighted toward skewed values

Standard deviation vs. quartiles SDs more widely understood Quartiles better summary of skewed data

Need to detect wild data points Can be due to data errors or true outlier values Can substantially bias means and SDs Need to have standard screening procedures


Appropriate Standards for Indicators

Group norm Easy for region/facilities to relate to peers Norm might be wrong

Ideal values Logical values exist for some indicators Can be calculated empirically Should ideals be stated in manual?


Sampling and Analysis Issues

Small sample from more facilities Summary measure (mean/median, SD/quartiles) Appropriate standards for indicators Inter-country comparisons Changes over time Connecting results and interventions


Connecting Survey Results and Interventions


Household survey to measure access and use of medicines

currently one page survey instrument (13 questions) information covers the the following:

health seeking behaviour leading to use or non use of drugs if patients can afford, if they are available, where they are

available, if able to get the medicine, reason why not


Household survey to measure access and use of medicines

Field testing in conjunction with level II systematic survey WHO- HAI project in AFRO House hold survey for World Health Report

Development of questionnaire (one page with level II and option to expand with qualitative questions)

Sampling (recommended/appropriate sampling vs. resources)

Form a working group to further develop the manual and the process (questionnaire and sampling framework)


Lower income groups do not get all the medicines they need

How much of the medicine prescribed was obtained: Tanzania 2002

0%

20%

40%

60%

80%

100%

<$2 $2-$10 >$10

Weekly expenses

None

Some

All


Availability and affordability are the barrier to access

Why households did not obtain all the medicines Tanzania 2002

0%

20%

40%

60%

80%

100%

<$2 $2-$10 >$10

Weekly expenses

Other

Medicines not available

Price too high

Not enough money


The way forward on country monitoring

Evidence through systematic but feasible data collection process is necessary in policy making and activity implementation

Should demonstrate that in the long run regular monitoring is not difficult and can be done in a cost efficient manner

Portion of country support budget and project grants should be allotted to monitoring and evaluation using indicators

Information sharing: studies and results will be available in the web

Documents

Indicators for monitoring and assessing pharmaceutical situation in countries