Lignes directrices de l’accès et leurs indicateurs
The EPN Access to Essential Medicines guidelines do not address issues beyond the control of church health services (CHSs), such as foreign exchange rates, storage outside the CHS system, patient poverty, number of pharmaceutical staff (for example, pharmacists available), and patient information from other sources (for example, advertising). Nor do the guidelines address issues that are beyond the remit of EPN to assist CHSs, such as access to transport, construction of stores, the CHS system in its entirety, the expansion of CHSs to serve larger populations, and the health service of a country in general. These areas are recognized as being important but are nonetheless beyond the remit of this particular project.
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The guideline approach
Three factors are fundamental to this approach:
- The initial baseline study for each country that reveals the current level of compliance on each of the specific guidelines and provides an impact assessment tool.
- The development of country-specific plans, owned by EPN members, to increase compliance in a specific country.
- The transfer of knowledge to members in other countries to increase their capacity to carry out such work.
The impact of individual guidelines is cumulative and there is no specific prioritization within them. However, for access to be maximized, it is believed that all the specifics detailed by the guidelines need to be in place. Each country will have its own pattern of compliance and the importance of interventions will depend on country specifics. It is believed that, as countries are at different levels of compliance, the priority for intervention to increase compliance should reflect local circumstances and not an external priority list. Thus, in any particular country, a small intervention may 'top up' a particular guideline activity and therefore may be prioritized over a large intervention targeting another recommended guideline from start-up to compliance. For example:
- If 70% of hospitals with over 50 beds have working DTC committees then an intervention targeted on those 30% without committees may be prioritized over work to support the implementation of local community involvement in 100% of hospitals with more than 50 beds.
- A particular country could decide that work to get tax exemptions extended to CHSs would have a greater immediate impact than training hospital 'owners'.
The key to developing country-specific plans is the results from the baseline survey. These results will not only allow impact evaluation and monitoring but also provide information for decision making.
Guidelines and their indicators
- Compliance with best practices for drug storage and management.
- Presence of check list for good storage conditions
- Percentage of stock outs
- % of expired medicines (in relation to average inventory value)
- Service level (% fulfilment of requested demands)
- Presence and use of bin or stock cards
- Regular calculation of minimum and maximum stock
- Presence of annual audit/inventory reports of drug store
- Presence of SOPs (procurement, receiving, issuing)
- Regular monitoring reports.
- Compliance with rational use of medicines guidelines.
- No more than two indicators to be used from WHO guidelines for each of:
- Prescribing
- Dispensing
- Facility
- Patient care.
- Functioning medical supply system.
- Structures—warehouse and stores
- Essential Drugs List (EDL) stocked
- Meets CHS needs for supply, cost, and delivery
- Low levels of wastage
- Availability of stock records
- Availability of standard operating procedures and evidence of implementation
- Procedure manuals or guidance for personnel and financial activities.
- Functioning Drug and Therapeutics Committees (DTC) in hospitals.
- Membership defined
- ToR in place
- Regular meeting
- Date of last meeting
- Drug list adapted to needs
- Standard treatment guidelines in evidence
- All 'owners' with maximum understanding or roles, best practice, and management information.
- Revolving drug fund concept: Understanding of concept and implementation of methods of increasing access for the poorest
- Rational use of medicines concept
- Essential drugs concept
- Management of HIV/AIDS—related demands
- Awareness of health and drug production in country
- Costing mechanisms for pharmaceutical services
- Sustainability of CHS concepts
- Strategic planning.
- Implementation of standard operating procedures for procurement.
- Availability of SOP procurement document
- Self-assessment results of SOP audit.
- Improvement in access to medicines for a facility, passed on to patients.
- Affordable prices
- Prices compared to other facilities
- Independent pharmacy budget
- List of exemptions.
- Quality assurance policy in place and implemented.
- Structure in place to ensure compliance to registration standards
- Frequency of regulatory authority visits
- Written standard operating procedures
- Access to and usage of a quality control laboratory
- Compliance with national regulatory authority standards (or an appropriate alternative, such as WHO).
- Pricing policies in place and operationalized.
- Documented pricing policy (formula and accounting process, and accounting for windfalls)
- Price list
- Implementation evidence.
- Government subsidies extended.
- % trained personnel (pharmaceutical)
- % salaries paid by government
- % national health budget that goes to CHS for medicines (subsidised medicines received)
- Government contribution to infrastructure development.
- Pro-poor ethic in evidence.
- Exemption policy
- Promotion of insurance schemes
- Differential pricing
- Advocacy activities
- For provision/subsidies for the poor.
- Tax exemptions available to CHSs.
- Documentation of existing taxes (current government tax policy)
- List of current exemptions
- Documentation (application letters, acceptances and rejections).
- Transparency mechanisms in place in support of 'Health for All'.
- Audited reports available
- Annual reports available
- Collective planning (annual, strategic) mechanism in place
- Policy on monitoring and evaluation written and implemented
- Organogram (professional profile)
- Staff recruitment policies written and implemented.
- Effective community involvement system in place.
- Evidence of system
- Evidence of topics raised and actions resulting from the system
- Awareness levels of the local community of system.
- Cross-facility information sharing.
- Evidence of information collected
- Evidence of information passed to other facilities, the government systems national drugs policy, and national health management information systems and within hierarchies.
- Compliance with drug donations guidelines.
- Selection of three indicators from guidelines.
- Mechanism in place to allow for representation at regional and national levels in relevant debates.
- Selection of three indicators appropriate for the local debate environment.
- At least one pharmaceutically trained person per facility.
- Quantification of drug needs
- Drugstore management
- Quality assurance
- Rational use of medicines
- Unit costing
- Record and data management
- Appropriate financial management.
- Access to key pharmaceutical information.
- Available in the pharmacy area:
- Essential Drugs List
- National (or WHO) formulary
- Standard treatment guidelines
- New and obsolete drugs list
- Registered drugs list
- Local production manuals.
- Available in the facility:
- National drugs policy
- DTC/PTC guidelines
- WHO essential medicines publications
- International medicines pricing indicators
- Rational use of medicines information
- Reports from CHSs on pharmaceuticals
- Managing drug supply manuals.
- Regular assessment of pharmaceutical unit work.
- Annual reports of unit evaluation.
- Church leaders' awareness of key messages.
- Comparison to baseline in three selected areas appropriate to the local environment.
- Pharmaceutical function represented at all levels of discussion.
- Minuted discussions at various levels
- Interview results.
- Disaster preparedness procedures in place (e.g., earthquake, flood, influx of refugees, conflict).
- Documentary evidence
- Review data of three selected indicators.
Access guidelines baseline research
Activities for Phase 1 of the EPN Access to Essential Medicines project are:
- To support the development of the project and draw up and prioritize a list of guidelines and indicators for those guidelines to be used in the project.
- To carry out a baseline survey of existing compliance with the EPN guidelines, initially in six countries, Malawi, Ghana, Uganda, Togo, Cameroon, and Tanzania (see below for the survey tools) .
- To present results to members and partners in-country and to a wider audience.
Baseline survey
A baseline survey is the measurement of key indicators before any intervention is started. The guidelines will be used as indicators. The survey results are required in order to set realistic targets, measure change, and make comparisons.
The baseline survey has been prioritized over a situation analysis because the programme has already identified indicators. Measuring the starting point for these indicators produces a situation analysis that covers those aspects that the programme can itself influence.
The purpose of the baseline survey is therefore to provide the required starting point information to allow the development of the country-specific design and management processes for maximizing access to essential medicines.
In addition to supplying required information and a reusable methodology, three further benefits have been identified for this work:
- It sets the tone and draws out realistic timeframes and potential impacts, and involves people and organizations from the beginning.
- It will improve decision making around programme and policy objectives, priorities, and allocation of resources, improve methodologies, and maintain the relevance of interventions.
- The knowledge, outputs, and capacities gained in performing the work will also be relevant to the collaboration partners’ respective ongoing programmes of work.
The baseline survey methodology should also realize other more general benefits such as:
- Reinforcing country-specific accountability and ownership
- Facilitating institutional and individual lesson learning
- Fostering team building
- Strengthening partnerships
- Promoting understanding among stakeholders
- Increasing the likelihood of defining SMART objectives
- Informing project-related decisions
- Providing the starting point for further monitoring, evaluation, and impact assessment work.
Stakeholder participation and ownership is a particularly crucial part of the overall project and the baseline survey gives the country-specific EPN members group and the CHSs an exciting initial opportunity to increase co-operation, participation, and local ownership.
Furthermore, Phase 1 will:
- Increase the development of knowledge and skills, from project design to context analysis
- Begin to create social change by allowing for the promotion of, defence of, or opposition to specific programmes, actions, or policies.
Baseline methodology
The methodology used to carry out the baseline survey has been successfully applied by a number of international agencies, including DFID and IFRC. This has also proved useful in EPN’s own Drug Supply Organization Study where, by forming an overall team consisting of a consultant from each country, the work was carried out with in-country knowledge as well as capacity raising. Using an international consultant to lead the team provides for training of the in-country consultants, assures the quality of results, and brings international analysis and communications to the project. Although team members only carry out the work in their own country, their shared experience not only provides mutual support but a replicable methodology for other countries.
This replicable methodology reduces costs for further countries as the baseline manual can be followed in the future.
- Preparation:
- Six countries will be chosen for the initial work (Malawi, Ghana, Uganda, Togo, Cameroon, and Tanzania).
- A country team member will be identified in each country.
- Draft baseline manual will be prepared, including tools such as subject-specific surveys, etc.
- Baseline survey training for each of the six in-country team members (three-day meeting).
- Second draft of manual confirmed following the meeting
- In each country, the following activities will take place:
- Central editing and review of country reports.
- Drawing together an overall report.
- Baseline reporting and lesson learning regional meeting.
- Finalization of baseline report with lessons learnt.
Communication of results
- Country-specific report dissemination to key stakeholders in country.
- Promotion of web accessible version of the report.
- Overall analysis and drawing together of the report for dissemination to donors and international audiences.
Malawi Access baseline survey
Executive summary of baseline survey research in Malawi
In Malawi, in May 2005, researchers from five countries were trained in the use of the baseline survey tools for the EPN Access to Medicines project (in order to carry out work in Cameroon, Ghana, Malawi, Togo, and Tanzania), and undertook fieldwork to complete the baseline survey for Malawi.
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The EPN Guidelines project is part of the EPN programme entitled ‘Maximizing access to essential medicines for church health services and their clients’. The first phase of the project identifies the baseline in each EPN guideline area and feeds this information back to an in-country group that can then decide which EPN guidelines should be prioritized and what further work should be undertaken.
This summary of results provides the baseline for compliance with EPN guidelines in Malawi, and is drawn from the results of the tools used. Wherever possible, results are simply scaled up to cover all church health services (CHSs) in Malawi—this means that the compliance indicator is not a quantifiable certainty but is simply an indication of the level of compliance. A zero value shows that no facility was found that complied with that EPN guideline—it is possible that a facility does exist, but was not surveyed. Thus, a zero value only indicates a very low number of compliant facilities. A ‘no’ value indicates that something on a national scale does not exist.
The guided self-assessment workshops provided an indication of the priorities perceived by CHSs, in terms of which aspects of their challenges were perceived as having the greatest impact on increasing access. These priorities are indicated with an ‘X’ to the far left of Figure 1 (below).
Figure 1. Baseline EPN guideline compliance in Malawi
Overall conclusions
Based on the results of the guided self-assessment workshops, it is clear that the dominant trend for church health facilities is a worsening of their situation or, at best, little change. Informal discussions indicate that the departure of missionary health staff, the continuing brain drain, and the increasing poverty of a population frequently facing famine, all contribute to this situation.
However, the workshops also produced indications that there was a willingness to change, as well as recognition of the need to change. There were also important examples of success and improvement, in particular areas, in particular facilities. However, while one facility might be able to implement a particular SOP, a different facility would fail to implement in that particular area but succeed in another. These examples indicate that many solutions to church health service problems in Malawi do indeed lie within Malawi, and that the capturing of these experiences and the passing on of these approaches within the country could itself successfully increase access to health care through church health services.
Church health services (CHS) in Malawi provide approximately 37% of the available health care. All CHS hospitals and a proportion of clinics were given the opportunity to respond to the survey, with a total of 60 facilities contacted. A 58% response rate (35 facilities responded) was achieved for the survey. It is believed that the results are valid for general trends, but it is recognized that a higher response rate would provide a more accurate picture, particularly for clinics. Such problems were considered during the analysis of the results. All 10 planned guided self-assessment workshops were carried out, as were the 10 focus groups. Common results across these activities have been scaled up to inform the overall analysis.
The Christian Health Association of Malawi (CHAM) reports that the church health care facilities in Malawi number 33 hospitals and 132 clinics at the time of research. The government pays all health personnel salaries in CHSs and some allowances such as housing and transport. Government health facilities offer free health care (including consultation and medications), while the CHSs charge. In many areas, the CHS is the sole provider of health care.
Three issues emerged relating to the methodology.
- First, straightforward questions such as ‘do you implement rational use of medicines guidelines’ often provoked a positive response (taken literally, what ‘rational’ person would say no?) However, on examination of responses to further ‘test questions’ in the survey, it became clear that the answer was actually ‘no’.
- Second, despite a request to complete the survey during a management committee meeting or to have the most senior staff member complete it, this often did not happen—as indicated by the high number of ‘don’t know’ or incomplete responses.
- Third, the institutions responded very positively to the EPN visits (despite some organizational problems). The workshop and focus group participants were all excited about being asked and also about the process of asking. The survey process, on the other hand, indicates the need for training on teamwork for the institutions.
The issue of direct and indirect EPN Guideline impact
A clear entry point is when a need for intervention meets the capacity to intervene. The issue of indirect, but still important, impacts needs to be part of the analysis of a response to CHS-identified needs and problems. For example, while EPN cannot do anything directly about increasing institutional resources, the implementation of some of the EPN guidelines would indirectly increase resource availability:
- EPN Guidelines
- Pricing policies in place and operationalized.
- Compliance with drug donations guidelines.
- Implementation of standard operating procedures for procurement.
- Access to credit (for some patients).
- Indirect impacts
- Improved financial stability, income, and resource availability and efficiency in some areas.
- Reduced likelihood of closure.
- Reduced theft (of pharmaceuticals).
Indirect impacts would also contribute to the improvement of quality of care in relation to, for example:
- Improved skills—in a number of areas, particularly pharmaceutical-related.
- Reduced staff turnover and brain drain, through increased staff commitment and motivation, particularly in pharmaceutical-related areas.
- Improved training, MIS systems, and the simplification of a wide range of procedures.
As identified through force field analysis in the workshops, increased resources would produce the biggest lift, and improved management would reduce the biggest constraint. The force field analysis shows a direct relationship between these areas. However, while human resources provide the second biggest lift, only the staff training aspect was identified as a crucial constraint—these two areas are only partly linked and indicate that increased training would be the priority area of the human resource challenge.
Two further aspects were identified as constraints and had no matching lifting aspects—client poverty and government politics and policies. While both of these issues are important and EPN guidelines would indicate that the relationship with government could be improved, the issue of client poverty itself is beyond the bounds of the EPN guidelines and indeed the work of EPN.
An analysis of the problem tree exercise allows us to match EPN guidelines to problem solving. See the report for more details.
Potential priorities
There appears to be an issue of understanding of pharmaceutical terminology, particularly where certain terms that have particular pharmaceutical meanings are being interpreted literally, such as ‘rational use of medicines’. The survey showed that many people answered ‘yes’ to the question ‘does your facility comply with rational use of medicines practices’, when their answers to other ‘test questions’ showed the answer to be ‘no’.
In nearly all EPN guideline areas there is at least one hospital that indicates it has implemented the EPN guideline. This means that a significant impact could be achieved through networking efforts and sharing local examples, rather than only through external guidance.
The EPN guidelines can also be linked to leading problems through the force field analysis. Below are four issues identified as areas where greatest positive change could be achieved, partnered with a corresponding EPN guideline.
- While it is extremely difficult to do anything directly about increasing institutional resources, the implementation of some of the EPN guidelines could indirectly increase resource availability.
- Pricing policies in place and operationalized.
- Compliance with drug donations guidelines.
- Implementation of standard operating procedures for procurement.
- The inclusion of further EPN guidelines in the work would directly respond to the hospital-based recognition for improved management.
- Compliance with best practices for drug storage and management.
- Functioning Drug and Therapeutics Committees (DTC) in hospitals.
- All ‘owners’ with maximum understanding of roles, best practice, and management information, understanding of revolving fund concept and implementation of methods of increasing access for the poorest.
- Quality assurance policy in place and implemented.
- Transparency mechanisms in place in support of ‘Health for All’.
- Pharmaceutical function represented at all levels of discussion.
- Disaster preparedness procedures in place.
- The particular importance of training of human resources would be reflected in the need to train staff as part of the above EPN guidelines and to support the implementation of other EPN guidelines, for example:
- Compliance with rational use of medicines ‘guidelines’.
- At least one pharmaceutically trained person per facility.
- Access to key pharmaceutical information.
- Regular assessment of pharmaceutical unit work.
- The identification of government policies and politics could be addressed in part by the implementation of EPN guidelines, for example:
- Effective community involvement system in place.
- Cross-institutional information sharing, including provision of information to national drugs policy and national health management information systems.
- Mechanism in place to allow for representation at regional and national levels in relevant debates.
- Church leaders’ awareness of key messages.
Access research feedback and next steps, Blantyre, Malawi
A three-day meeting was held in Blantyre, Malawi (13th–15th March 2006) in order to return the results of the maximizing access to essential medicines baseline study (carried out by EPN in May 2005) and to look at ways forward.
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The participants included doctors and hospital administrators, pharmacists, and pharmaceutical technicians. Also present were representatives of:
- MSH
- Government of Malawi Medicines and Poisons Board
- UNICEF
- CHAM (Christian Health Association of Malawi).
Facilitation and agenda
Facilitation was led by Heather Budge-Reid (consultant) under the guidance of Dr Eva Ombaka (Coordinator of EPN). Some adjustments were made to the original timetable as the workshop progressed: first, in response to the daily evaluation responses; and second, in response to the speed with which the group progressed.
A fully participative and appreciative enquiry approach was used during the process, partly based on VIPP (Visualization in Participatory Programmes), a manual prepared by UNICEF Bangladesh.
Meeting objectives
As an icebreaker and an introduction to participative techniques, the group was asked to:
- Brainstorm possible personal objectives for the meeting
- Sort these into common groups
- Prioritize their importance.
The results were:
- The way forward
- Return of results
- Skills enhancement
- Pharmaceutical issues learning
- Knowledge of EPN.
These objectives and prioritization were then fed into the monitoring and evaluation mechanism.
Please see the report for more details on M&E.
Ideas generated
At the request of EPN, the specific ideas generated at the entry point identification stage of the process are listed here. This is not a full list, as other ideas were introduced later in the group discussions around future activities, but it is believed that there is a value in capturing them here. Where similar ideas were proposed, they have not been repeated.
The main output of the workshop (a proposal for future action) is available separately from this report in the form of a project document.
- Share a pharmacist between nearby hospitals.
- More coordination between units.
- Link into district hospitals more.
- Work more with the government drug and poisons board.
- (Poor inventory system). Improve drug management by use of stock cards, training of staff, and setting of minimum and maximum levels.
- Open more health posts.
- Use more home-based care teams to overcome distance problems.
- Work with village health committees to reduce the impact of distance.
- Establish more outreach clinics to reduce the impact of distance.
- Increase the number of qualified staff.
- Monthly feedback and supervision.
- Train people in good storage practice.
- Lobby to lower entry requirements so that assistants can be upgraded to pharmaceutical technicians.
- Increased in-service training at all levels.
- Secure scholarships from government and donors.
- Government and CHAM should exchange pharmaceutical technicians – secondment.
- Government should post pharmaceutical technicians to CHAM hospitals.
- Introduce an allowance for pharmacists like the doctors get.
- Pharmacists need to be a higher priority for hospital management.
- Offer upgrading courses for pharmaceutical technicians.
- Pharmaceutical technicians should be offered a place on the new government-run course after working in a CHAM unit for two years.
- CHAM should lobby the government for a progressive grading system for staff, as per the government hospitals.
- Salary increase.
- Top-up salaries and staff loans.
- Training in customer care.
- Help improve recruitment policies, e.g., must see identification, chase up references, etc.
- Exchange visits to pharmaceutical best practice faith-based hospitals inside and outside the country.
- We need to work out a way to increase staff commitment and change attitudes.
- Increase access to training of the lower cadre of pharmaceutical assistants, with full pharmacists as teachers/sponsors/coaches.
- All DTCs to have a terms of reference.
- Train members in DTC functions.
- Strengthen DTCs.
- CHAM should supervise DTCs, as well as pharmacies, on a monthly basis.
- Introduce monitoring and evaluation policies and implement them in hospitals and clinics.
- Provide standard SOPs on all issues.
- Centralize procurement.
- Use a procurement team in each hospital covering drugs, supplies, and everything else for the hospital.
- Help in procurement of equipment, e.g., tablet counting trays, counters, etc.
- Help provide storage conditions – anti-burglar bars, sturdy shelves, cooling systems, refrigerators.
- CHAM to buy in bulk and negotiate with IDA.
- Lobby on Central Medical Stores and their problems.
- Develop a CHAM drug supply organization.
- Support the development of service agreements and their inclusion of pharmaceutical issues.
- Collect consumption figures from each CHAM unit and then give feedback.
- Need a consultant with each hospital to set up the systems and train for a limited period.
- CHAM should contract someone to help computerize systems across CHAM units.
- Adapt the government procurement programme and software so that it is not so reporting orientated.
- Lobby on tax system.
- We need to be getting publications from WHO and EPN, etc.
Uganda Access baseline survey
Ghana Access baseline survey
Executive summary of baseline survey research in Ghana
Research for the ‘EPN guidelines’ baseline survey was carried out in Ghana in August–October 2005. This report of results provides the baseline for compliance with the ‘EPN guidelines’ in Ghana, and respondents represent over 2,545 beds and 694,500 outpatients. It is a statistically sound report for Catholic health services in the southern and central regions of Ghana (only 8% of respondents are from northern facilities).
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The northern region of Ghana is known to have greater problems in health care provision – however, the only assumption we can make for this region is that positive results found in the other regions will be lower in the north, and therefore, if there is a problem in the other regions, this problem will be greater in the north.
Faith-based health services in Ghana provide approximately 40% of the available health care. The Christian Health Association of Ghana (CHAG) reports that the church health care facilities in Ghana number 56 hospitals and 83 clinics at the time of research (CHAG does not distinguish between clinics and health posts).
Table 1 Faith-based health care in Ghana, by faith
| Faith | Percentage of health care in Ghana |
Catholic | 27% |
Other Christian churches | 11% |
Muslim | 1-2% |
Thirty-four hospitals (including all 32 Catholic hospitals) and 30 of the 66 Catholic clinics were given the opportunity to respond to the self-assessment survey, with a total of 64 facilities contacted. A 41% response rate (26 facilities responded) was achieved for the survey.
If it is assumed that Catholic health services are representative of faith-based health services in Ghana, then these results can be scaled up to present a picture of church health services across Ghana.
Figure 1 Baseline EPN guideline compliance in Ghana
Overall conclusions
Taking into account the results from all the tools used, the overall trend for church health services in Ghana appears to be one of improvement. Good results were seen in a number of areas:
- Government support of the church health services (although it seems that some facilities are not taking up the opportunity of having salaries paid).
- Information sharing and representation opportunities indicate that there is a good degree of integration between the government and church health services.
- Good community involvement (although this could be improved at some hospitals where there is an interesting link between lack of community involvement and a perception of poor staff–patient relations and nepotism). Where community links are strong, links to church leaders are also strong.
- A functioning drug supply system is in existence.
- Relatively high levels (compared with other African countries) of pharmacists, pharmaceutical technicians, and pharmaceutical assistants per hospital.
On the more worrying side, the baseline does not cover the North of the country (an area understood to face bigger problems in health and health services) and there appeared to be problems for a number of ‘guidelines’ even in the southern and central areas.
- Only 50% of hospitals have a functioning DTC.
- A large number of hospitals accept medicines donations, but there is almost no adherence to drug donation guidelines.
- There is relatively low level of implementation of standard operating procedures, and while the main drug supply organizations do use SOPs, this is not reflected in the health services.
- There appears to be almost no training of hospital board members in the issues and possibilities of their decision-making.
- Health facilities themselves identified poor management and staff training as key problem areas that affect services. Lack of financial resources acted as a cause and an effect of these problems and thus a vicious circle is identified, whereby a lack of funds prevents a facility from improving itself in order to improve revenues and funding.