A WHO survey package to facilitate monitoring and assessment of country pharmaceutical situations was further developed in 2002. It provides a cost-effective means of determining availability of essential medicines, the safety, efficacy and quality of those medicines, and whether they are used rationally. So it can help countries pinpoint the strengths and weaknesses of their pharmaceutical sector and prioritize areas for intervention. Follow-up surveys can be undertaken to assess the impact of interventions and to monitor pharmaceutical trends over time. Common use of the package will facilitate comparisons between facilities, districts/regions and countries. By the end of 2002, the package had been field-tested in 16 countries, representing all six WHO regions.
Looking at access and rational use
Use of the package in Bulgaria and the Philippines not surprisingly yielded different performances for the key indicators. Although Bulgaria does not yet have a national drug policy (NDP) in place, a pharmaceutical programme is included in its national health plan. This is reflected in the availability of key essential medicines, which is high, and which has increased since 1995. However, further efforts are required in rational medicines use, given that less than 50% of medicines prescribed are on Bulgaria's essential medicines list.
In the Philippines, availability of key medicines in rural health facilities has gone down - possibly due to decentralization of health services. Prescription of medicines on the essential medicines list has also declined. Worryingly, the percentage of patients being prescribed antibiotics has increased to over 50%, although other prescribing practices have improved. Training and continuing education in rational medicines should therefore remain a focus of support provided by government to provinces and towns.
Looking at access indicators for four countries - Bulgaria, Guatemala, Iran and the Philippines - it can be seen that availability of key medicines and dispensing do not concur. This suggests that prescribing of nonessential medicines may be occurring.
The affordability of essential medicines varies widely in the four countries surveyed, while prescribing data indicate that key medicines are not available in sufficient quantity
Field-testing in Africa
In Africa, field-testing of the monitoring package was carried out in Ghana, Mali, Nigeria, Tanzania and Uganda by newly-appointed national programme officers (NPOs) working with their Ministry of Health (MoH) counterparts. The package was particularly welcomed by MoH staff given that previous pharmaceutical situation surveys had generally been carried out by external consultants. In carrying out the surveys with the NPOs, MoH policy-makers and health officials could appreciate firsthand the impacts - good or bad - of pharmaceutical decisions they have made. Results of these surveys are now guiding implementation and or modification of NDPs.
Comparing 1995 and 2002 indicators for Bulgaria and the Philippines shows progress in some areas but that enhanced efforts needed in others
For most of the countries, the role of the private sector in providing health care and medicines is increasing. So including private pharmacies and drugs outlets in the surveys was very important. In so doing, the surveys made possible the comparison of the availability and affordability of medicines in the public and private sectors.
The monitoring package includes a one-page questionnaire for carrying out a household survey. The questionnaire covers: health-seeking behaviour and whether it leads to use or non-use of medicines; whether needed medicines are available and affordable; and, if used, whether they are used rationally. Household surveys are key to measuring access to medicines since it is only through these that we can obtain information to determine whether households can obtain all the medicines they need and how much they can afford to pay for them.
In Tanzania, use of the household survey showed that households are most likely to self-medicate and use public health facilities, and that use of public health facilities is not confined to lower economic groups. Nevertheless, it was seen that many households, especially those in the lowest economic groups, are unable to obtain all the prescribed medicines that they need. More than 50% of the lowest economic group could not obtain all the medicines that it needed. Access to medicines was observed to be limited primarily by lack of income for purchasing medicines, high prices of medicines and/or unavailability.
Such information can be used by policy-makers to design policies, programmes and interventions to meet essential medicines needs.
Tanzania 2002: what percentage of the medicine prescribed was obtained by households within 5 kilometre radius of public facilities and public private pharmacies
Tanzania 2002: why households - within 5 kilometre radius of public facilities and public private pharmacies - did not obtain all the medicines they required
Copies of the monitoring package can be requested from: email@example.com. The package will also be posted on the WHO Essential Drugs and Medicines Policy website at: http://www.who.int/medicines/strategy/policy/indicators_op.shtml