DANIEL SEKYERE MARFO*

* Daniel Sekyere Marfo is Chief Pharmacist, Bank of Ghana Clinic, Accra, Ghana.

THE adoption of the top-up system of drug supply has led to an improvement in drug supply management at the Bank of Ghana Clinic in Accra. As a result a small project that started with injectables has now been extended to other items with equal success.

The Bank of Ghana Clinic is a fairly small quasi-Government outpatient health facility. It was established in June 1988, mainly to provide quality health care (in terms of economy, efficiency, effectiveness and equity) for the Bank’s staff and their dependants. It is also open to a small group of non entitled but authorised paying patients - mostly expatriates and tourists. The clinic’s professional staff is made up of two doctors, one pharmacist, three pharmacy technicians, 10 nurses, one medical laboratory technologist, three medical laboratory technicians and a part-time physiotherapist.

The clinic is organized on a “functional unit” basis with medical consulting, nursing, pharmacy, medical laboratory and support units. It is funded entirely by annual budgetary allocations from the Bank of Ghana. Treatment, including drugs, is free for all members of staff and their dependants. Patients receive drugs of proven efficacy, purchased from reliable sources. They are counselled against abuse and misuse, and possible or expected adverse effects of drug therapy. They are also encouraged to complete the full course of treatment, to follow instructions correctly and to refrain from sharing drugs with colleagues, relations or friends. Additional written instructions and labels are provided to ensure adherence to treatment, successful outcome and patient safety. The pharmacy unit, which dispenses about 17,000 prescriptions per annum, is also responsible for managing medical stocks at the health facility, including selection, sourcing, procurement, storage and distribution through the system.

With the exception of injectables, all other dosage forms are supplied to patients directly on prescription from the pharmacy, as described earlier. Injectables are first supplied to the injection room, where they are managed by the nursing staff.

PROBLEMS OF RATIONAL SUPPLY AND USE

The rational use of drugs is a prerequisite for good health delivery. The impact of drug use on the health of a population does not only depend on availability, affordability or accessibility, but even more importantly on the rational use of drugs at clinic level. This is particularly true in situations of relative plenty, in other words where pharmaceuticals are generally available, affordable (at no cost at all to users) and accessible. Sometimes health workers in such situations are overwhelmed by the variety and quantity of drugs available, and the result is excessive and unnecessary expenditure on drug supply.

IMPLEMENTING A TOP-UP SYSTEM OF INJECTABLES

Essentially a top-up system is based on real need and involves the replenishment of running stock with quantities equal to those used (see Box). Meetings are held between the pharmacy unit and the nursing unit to discuss the issues involved in the supply of injectables.

Initially a survey was carried out to determine the actual weekly consumption pattern of all injectable items supplied to the nursing unit. Recordings in the nursing books were extracted and analysed, with a safety margin of 10%.

This information was used to agree on maximum weekly stockholdings. Review meetings were also planned.

New weekly injection supply forms were designed to provide data on quantity used, top-up quantity and expiry dates.

Since September 1996, at the beginning of each working week, the difference between the current stock and the maximum agreed stocks has been provided as replenishment. The nursing staff fill in the current stock levels and send the forms to the pharmacy. A pharmacy technician sends the week’s supply to the injection room where he or she assists in updating records of stock levels and expiry dates.

MEASURING SUCCESS

A comparative study of the value of stock requests before and after the institution of the top-up system (changed in September 1996) was carried out. The 13 most commonly used drugs were selected for study. Stock requests for the 13 drugs over a period of four months before and after September 1996 were recorded and analysed. The results indicated a general trend of over-stocking before the top-up system was introduced illustrated by an average 46.8% reduction in nursing requests after it began. The other obvious advantage is a notable reduction in inventory value. The success of the initial trial led to the extension of the new system to the supply of dressings and other sundries, followed by drug procurement. Currently procurement is largely on a replenishment basis.

Over-stocking is prevalent in most government funded medical stores. It is our belief that a main cause lies in structures and procedures; the success achieved with the top-up system has substantiated our conviction. However, the outcome of the trial could have been different if the pharmacy unit had decided to “go it alone” in the effort to change the old style of supplying injections to the nursing unit. The involvement of the nursing unit, as the major in-house customers of pharmacy services, was crucial. The top-up system of drug supply has proved to be very useful if well managed. The pharmacy can have better control over running stock. Drug needs’ estimation can be more accurate and thus funds and needs can be better matched for greater efficiency.

Pharmacy technician, Margaret Fianko-Sakyi (right), discussing a point with Nurse Stella Opoku during one of the weekly meetings at the Bank of Ghana Clinic. These meetings are vital to the success of the Clinic’s drug management system

Photo: D. Sekyere Marfo

Drug budgets and therefore real expenditure can be reduced by the adoption of the top-up system of drug supply on an even wider scale.