Indicators for Monitoring National Drug Policies
(1999; 250 pages) [French] View the PDF document
Table of Contents
View the documentACKNOWLEDGEMENTS
Open this folder and view contentsCHAPTER I: Introduction
Open this folder and view contentsCHAPTER II: Development of the manual
Open this folder and view contentsCHAPTER III: Model lists of indicators
Open this folder and view contentsCHAPTER IV: Methodology for indicator calculation
Close this folderCHAPTER V: Detailed presentation of indicators
View the documentStructural indicators
View the documentProcess indicators
View the documentOutcome Indicators
Open this folder and view contentsANNEX 1: Data collection forms
View the documentANNEX 2: Glossary
View the documentANNEX 3: Table of random numbers
View the documentBACK COVER
 

Outcome Indicators

These 10 indicators provide quantitative information on the achievement of four major objectives of national drug policy: availability of essential drugs, affordability of essential drugs, quality of drugs and rational use of drugs. The indicators measure the degree to which these objectives are being attained. This manual assumes that if good results are achieved on the structural and process indicators, then the outcome indicators should also show positive results or improvement over time. If the outcome indicators provide evidence of significant problems, when the process indicators show good results, then decision-makers should undertake a careful analysis of the problems in order to identify causal factors and revise strategies accordingly.

These outcome indicators are measured by a percentage or a figure based on information available at the central level and/or obtained through surveys. The indicators can be used for assisting national and international decision-makers in measuring the results of policies, and in evaluating drug policies and implementation strategies. Indeed, they allow comparison between the situation at the time the indicator is used and the situation a few years before or an ideal situation, and therefore provide information on the progress achieved. They can also be used in comparing the pharmaceutical policies of different countries.

Based on field experience with the manual, data for the outcome indicators can be collected at the same time as data for the process indicators. For most indicators, special surveys may be necessary. These surveys can be organized to collect data for several process and outcome indicators at the same time (see Chapter IV) and can take up to six weeks. Model sampling procedures, data collection forms for the field work and a model summary form (Summary Form 4) are provided in Chapter IV and Annex 1. In this chapter, each indicator is described as follows: definition; use; description; sources and methods of data collection and indicator calculation; and limitations.

Availability of essential drugs

Indicator OT1:

Number of drugs from a basket of drugs available in a sample of remote health facilities, out of total number of drugs in the same basket.

Use: To assess the attainment of one of the objectives of the national drug policy, which is to make essential drugs available for the whole population. The fact that patients can find some of the most essential drugs even in the most remote health facilities is a good indicator of the success of the national drug policy. This indicator can also be used for monitoring the effectiveness of the distribution system (see indicator PR29).

Description: Remote health facility is defined as a facility which is situated at a distance of more than 100 km from a town of 100,000 inhabitants and outside the main road system; however, the definition can be adapted to each country. An example of a basket of drugs is provided in Chapter IV (see page 59). It can be adapted to the country's context. The indicator has been designed mainly for measuring the effects of the drug policy in the public sector.

Sources and methods of data collection and indicator calculation: The numerator is obtained by counting the number of drugs in the drug basket available the day of the visit to each remote health facility and by adding the result at each remote health facility included in the survey sample. The denominator is the number of drugs contained in the drug basket multiplied by the number of remote health facilities surveyed. If, for example, the sample of remote health facilities is 20, and the basket of drugs contains 10 drugs, the denominator will be 200. Data for the numerator should be collected through a survey of remote health facilities. A model for sampling health facilities is provided in Chapter IV and a data collection form in Annex 1 (see Data Collection Form 4). The indicator is obtained by simple calculation:

Example: 82% of the drugs contained in the drug basket were available the day of the survey in remote health facilities.

Limitations: In certain countries, drugs are delivered as kits every three to four months and are sold quite rapidly to patients. The facility may then remain without drugs for a time. The temptation could be to select the periods when drugs are available for the surveys. Supervisors should be aware of such possible bias.

Availability of essential drugs

Indicator OT2:

Number of drugs at the lowest price from a basket of drugs, out of total number of drugs in the same basket.

Use: To assess the fact that patients can find the most essential drugs at affordable prices in the private sector is a good indicator of the success of the national drug policy. The indicator therefore measures the capacity of the private sector to provide essential drugs at the most affordable price for patients. It measures at the same time both availability and affordability of a basket of essential drugs.

Description: In the private sector, drugs including essential drugs, are usually available under brand names at a cost which is often not affordable for the majority of patients. Experience shows that in most private drug outlets each product is usually available under different brand names and even under generic names at different prices. This indicator looks at the availability of some essential drugs at the lowest price in the private sector. An example of a basket of drugs is provided in Chapter IV (see page 59). It can be adapted to the country's context. The indicator should be calculated in the private sector and the rate should be as near as possible to 100%.

Sources and methods of data collection and indicator calculation: The numerator is obtained by adding the number of drugs from the basket available at the lowest price the day of the visit to each private drug outlet. The lowest price should correspond to the cheapest price of a product under brand or generic name, available in private drug outlets in a given country. The denominator is the number of drugs contained in the drug basket multiplied by the number of drug outlets surveyed. If, for example, the sample of private drug outlets is 20, and the basket of drugs contains 10 drugs, the denominator will be 200. Data for the numerator should be collected through a survey of private drug outlets. A model for sampling private drug outlets is provided in Chapter IV and a data collection form in Annex 1 (see Data Collection Form 1). The indicator is obtained by simple calculation:

Example: 40% of the drugs contained in the drug basket were available at the lowest price the day of the survey in private outlets.

Affordability of essential drugs

Indicator OT3:

Average retail price of standard treatment of pneumonia, out of the average retail price of a basket of food.

Use: To assess the affordability, in both the public and private sectors, of the treatment for one of the most common diseases. If a national drug policy is to be successful, the cost of the treatment of the most common diseases should be such that it will not compete with the basic food needs of the household. This indicator compares the price of a standard treatment with the price of a basket of food. The cost of the standard treatment of a common disease would also give a good idea of how much people will need to spend on their health.

Description: The standard treatment is defined as the one proposed by the ministry of health in the official national therapeutic guide. If there is no such official standard treatment, academic specialists can provide one. However, it is important that the chosen one remains the same for comparisons within the country over a period of years. The retail price is the price paid by the patient for all the drugs included in the standard treatment. This price can differ from one drug outlet to another and if the drugs are sold under brand or generic names. This is why an average price is needed. A basket of food should be defined by the monitoring unit with the support of the department in charge of the price index in the ministry of finance. Experience shows that it can be based on about 10 basic products used every day by households. The basket should correspond to an average-size household's consumption during a period of one week. The average size of households differs according to the country, but the figure can be easily obtained from the ministry of finance.

Sources and methods of data collection and indicator calculation: The numerator is obtained by adding the price paid for the standard treatment in each drug outlet and dividing it by the number of drug outlets in the sample. The denominator is obtained by adding the price of the selected basic products and dividing it by the number of stores surveyed. Data for the numerator should be collected through a survey in drug outlets. A model for sampling drug outlets is provided in Chapter IV and data collection forms are provided in Annex 1 (see Data Collection Forms 1 and 2). Data collectors should go to the drug outlet with a prescription written in INN. Data needed for the denominator are normally available from a quick survey among 10 stores/markets. The indicator is obtained by simple calculation:

Example: The average retail price of standard treatment of pneumonia represents 80% of the average retail price of a basket of food.

Affordability of essential drugs

Indicator OT4:

Value of a basket of drugs, out of the value of the same basket with the cheapest drugs.

Use: To assess the attainment of one of the objectives of a national drug policy, which is to make essential drugs affordable for the whole population. This objective is valid for both the public and the private sectors but is normally easier to implement in the public sector. This indicator will measure to what extent this objective is attained in the private sector, where essential drugs are usually available under brand names but at a cost which is often not affordable to the majority of patients.

Description: In the private sector, drugs including essential drugs are usually available under brand names at a cost which is often not affordable to the majority of patients. Experience shows that in most private drug outlets each product is usually available under different brand names and even under generic names at different prices. This indicator looks at the difference between the value of a basket of drugs based on prices obtained in a sample of private drug outlets and the value of a basket of drugs at the cheapest price for the same drugs. The cheapest drugs are defined as the ones proposed at the lowest price to the consumer and the retail level. If the national drug policy provides incentives for the private sector to limit the price of drugs, the difference between numerator and denominator would decrease. The indicator is calculated on a basket of drugs which takes into account the level of consumption of each of the drugs in the basket; an example of a basket of drugs is provided in Chapter IV (see page 59). It can be adapted to the country's context. The method for calculating the value of such a basket is provided in Chapter IV (see page 60). The indicator should be calculated in the private sector and the rate should be as near as possible to 100%.

Sources and methods of data collection and indicator calculation: The numerator is the same as in indicators PR30 and PR32. The data needed for the numerator derive from a survey in a sample of private drug outlets. A model for sampling drug outlets is provided in Chapter IV and a data collection form is provided in Annex 1 (see Data Collection Form 1). For the denominator, the cheapest price for each drug in the basket sold in the private sector should be identified by the monitoring unit through a quick survey in a sample of 10 drug outlets. The indicator is obtained by simple calculation:

Example: The value of a basket of drugs in the drug outlets surveyed is 150% of the value of the same basket with the cheapest drugs; this means that consumers pay 50% more than if they were sold drugs at the cheapest price.

Quality of drugs

Indicator OT5:

Number of drugs/batches that failed quality control testing, out of the total number of drugs/batches surveyed.

Use: To assess the attainment of one of the major objectives of any national drug policy, which is to provide drugs of quality anywhere in the country. The fact that patients can find drugs of quality in any health facility or drug outlet is a good indicator of the success of the national drug policy and the effectiveness of its quality assurance system.

Description: In a system where drugs/batches are routinely collected and tested (see indicators PR4 and PR5), the indicator can be calculated on the basis of the results of these tests. In other cases, where controls are carried out only on the basis of suspicion, or even not carried out at all, the data for the indicator should be obtained from a survey. This survey should be done in the public as well as the private sector. The rate should be close to 0%.

Sources and methods of data collection and indicator calculation: The data needed for the numerator derive from the reports of the quality control laboratory for the drugs collected during a survey in a sample of drug outlets. A model for sampling drug outlets is provided in Chapter IV and data collection forms are provided in Annex 1 (see Data Collection Forms 1 and 2). The figure for the denominator is decided during the design of the survey by the monitoring unit, according to country capability and resources. The drugs chosen for quality control should be among the ones in the basket of drugs. An example of a basket of drugs is provided in Chapter IV (see page 59). The indicator is obtained by simple calculation:

Example: 10% of the drugs surveyed failed quality control testing.

Limitations: One limitation on obtaining data for the numerator easily is linked to the presence or the absence of a reliable quality control laboratory at country level. In the absence of such a laboratory, samples should be sent to foreign laboratories. A second limitation could be the cost of the tests within or outside the country. The ministry of health's financial resources will often be the determining factor in deciding on the size of the denominator.

Quality of drugs

Indicator OT6:

Number of drugs beyond the expiry date, out of the total number of drugs surveyed.

Use: To assess the attainment of one of the objectives of a national drug policy, which is to provide drugs of quality anywhere in the country. The fact that patients can find drugs within the expiry date in any health facility or drug outlet is a good indicator of the success of the national drug policy and the effectiveness of its quality system.

Description: Every drug has an expiry date which is normally clearly stated on the label. In certain countries, expiry dates are given in codes. In this case, the monitoring unit should provide the data collectors with the necessary information on the codes. The indicator should be used in the public and the private sectors. The rate should be close to 0%.

Sources and methods of data collection and indicator calculation: The data needed for the numerator derive from a survey in a sample of drug outlets. A model for sampling drug outlets is provided in Chapter IV and data collection forms are provided in Annex 1 (see Data Collection Forms 1 and 2). The figure for the denominator is decided during the design of the survey by the monitoring unit, according to country capability and resources. The drugs chosen should be the ones in the basket of drugs. An example of a basket of drugs is provided in Chapter IV (see page 59). The indicator is obtained by simple calculation:

Example: 10% of the drugs surveyed were beyond the expiry date.

Rational use of drugs

Indicator OT7:

Average number of drugs per prescription.

Use: To assess the attainment of one of the major objectives of any national drug policy, which is the rational use of drugs. The fact that the number of drugs per prescription is low can be considered a good indicator of drug use. Although there is no global standard on the number of drugs per prescription, it is agreed that an average of more than two drugs per prescription will probably reflect a problem in prescribing practices.

Description: The prescriptions to be considered for indicator calculation are the ones given to outpatients. Combination drugs should be counted as one. The drugs to be counted are the ones on the prescription, regardless of whether the patient actually received them. The indicator can be applied in the public and the private sectors, as prescribing practices should be improved in both sectors. Results can be presented separately.

Sources and methods of data collection and indicator calculation: The data derive from a survey of prescriptions in a sample of drug outlets. A model for sampling drug outlets is provided in Chapter IV and data collection forms are provided in Annex 1 (see Data Collection Forms 1 and 2). The indicator is calculated by dividing the total number of different drugs prescribed by the number of prescriptions surveyed (see Chapter IV).

Example: The average number of drugs per prescription is 2.5 in the public sector.

Rational use of drugs

Indicator OT8:

Number of prescriptions with at least one injection, out of the total number of prescriptions surveyed.

Use: To assess the attainment of one of the major objectives of any national drug policy, which is the rational use of drugs. The indicator measures the overall level of use of a type of drug therapy (injections), which should be used only when oral therapy is not possible.

Description: Injections should not be used just for any condition, although this is often the case. Scientific evidence shows that in developing countries oral therapy is easier to manage, has fewer side-effects for the patients (risk of local infections as well as transmission of HIV and hepatitis-B virus with badly sterilized material) and is less expensive in most cases. Immunizations are not to be counted as injections. The prescriptions to be considered for indicator calculation are the ones given to outpatients. The indicator can be applied in the public and in the private sectors, as prescribing practices should be improved in both sectors. Although there is no global standard on the "ideal" number of injections, it is agreed that the result is a good one when the figure obtained is low. Norms should be decided at the national level, taking into account morbidities and training of health personnel. These norms need to be revised regularly.

Sources and methods of data collection and indicator calculation: The numerator is obtained by adding the number of prescriptions with at least one injection in a sample of drug outlets. Data needed for both numerator and denominator should be collected through a survey in a sample of drug outlets (see Chapter IV and Annex 4). A model for sampling drug outlets is provided in Chapter IV and data collection forms are provided in Annex 1 (see Data Collection Forms 1 and 2). The indicator is obtained by simple calculation:

Example: 50% of prescriptions in the private sector contained at least one injection.

Rational use of drugs

Indicator OT9:

Number of children under five with diarrhoea receiving antidiarrhoeal drugs, out of the total number of children under five with diarrhoea surveyed.

Use: To assess the attainment of one of the major objectives of any national drug policy, which is the rational use of drugs. The indicator measures the quality of care and rational drug use for an important health condition where clear standards of pharmaceutical treatment exist, namely always to prescribe ORS and never to prescribe an antidiarrhoeal drug.

Description: This indicator is very useful where clear guidelines exist, e.g. all children with diarrhoea should receive ORS and no antidiarrhoeal drugs.

Sources and methods of data collection and indicator calculation: The data needed for the indicator derive from a survey in a sample of health facilities in the public sector. A model for sampling health facilities is provided in Chapter IV and a data collection form in Annex 1 (see Data Collection Form 3). To facilitate the work of the data collectors, a list of the antidiarrhoeal drugs sold in the country but not recommended for this morbidity could be prepared by the monitoring team (note: ORS are not considered as antidiarrhoeal drugs). Alternatively, Data Collection Form 3 (Annex 1) could be used in such a way that data collectors note down all drugs which have been prescribed for five cases of diarrhoea in children under five. Calculation and analysis can then be done at central level by the monitoring unit. For this indicator, in certain cases, prescriptions can be sampled retrospectively, i.e. by drawing random prescriptions from historical medical records. This should be done only if data are complete and reliable. The indicator is obtained by simple calculation:

Example: 47% of children with diarrhoea receive an antidiarrhoeal drug.

Limitations: This indicator is one of the most valuable measures of quality of care, but problems exist in terms of defining the severity of the health problem and in obtaining enough prescriptions with this specific problem during the course of the survey.

Rational use of drugs

Indicator OT10:

Number of drugs from the national essential drugs list among the 50 best selling drugs (EDL), out of the 50 best selling drugs in the private sector.

Use: To assess the impact of the national drug policy on drug consumption. As the essential drugs list should cover the main therapeutic needs, most of the top selling drugs should be from the list. The indicator is important, as it shows whether the efforts of the national authority to influence prescribers and consumers to use essential drugs are successful or not.

Description: The indicator covers the 50 best selling drugs: ethical or OTC under brand name or generic name. It should be calculated for one year. The higher the rate, the better the result, as it means that most of the 50 best selling drugs are essential drugs.

Sources and methods of data collection and indicator calculation: The numerator derives from the analysis of the 50 best selling drugs. "Best selling drugs" can be defined according to the quantities sold in value or in number of units. Countries may calculate the two or decide to calculate only one of them for reasons such as lack of data. It is important to note what has been decided, in order to be able to measure it identically in the future. As the indicator is measuring rational use of drugs, the number of units sold will provide better information on real consumption and use. The list of "best selling drugs" is normally available from the main wholesalers and sometimes is recorded by the national drug authority. The national EDL and a cross-reference index are needed for identifying drugs from the EDL. The indicator is obtained by simple calculation:

Example: 75% of the 50 best selling drugs are from the EDL.

 

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