Improving Access and Use of Medicines through Private Sector Initiatives: A case for an Essential

Medicines Franchise in Ghana

Eghan Kwesi, Mensah D, Idun J, Staley,R. Marsden,A. Arhinful,K. Ofori-

Adjei,D. Dodoo A.

ABSTRACTProblem Statement: Licensed Chemical Shops (LCS) and non-prescription drug outlets account for over 66% of total community drug outlet visits in Ghana. These practioners however lack the ability to recognise and appropriately manage simple ailments. Their drug procurement activities are resource–heavy and inefficient, resulting in high prices to consumers, while regulatory and supervisory visits by the legal regulator are irregular and limited. To address these issues, Strategies to Enhance Access to Medicines (SEAM) established a working relationship with the Ghana Social Marketing Foundation Enterprise Limited (GSMFEL) as its implementing partner to operate a franchise. Objectives: The franchise provides a structured approach technique through technical training to LCS for recognising simple ailments; provide commercial skills to assist selected LCS operators to run sustainable enterprises; develop a group purchasing program accompanied by systematic distribution practices for a network (franchise) of LCS; and provide effective and regular supervision to enhance quality of service delivery. Design: Pre- and post-intervention design. Setting and Population: Seventy-nine rural to peri-urban based LCS serving a population of about 500,000 were franchised based on pre-identified criteria including minimum educational status; catchment area; and absence of a local pharmacy shop. Intervention: Following multi-stakeholder meetings, local experts developed, field tested and harmonised training manuals for a modular training programme for franchisees. Simultaneously, a centrally coordinated logistics and supply system was initiated to supply all products for the franchisees by the franchisor. Nationwide and regional baseline assessments were carried out before the interventions. Post-intervention regional assessments are planned for October 2004 and March 2005. Outcome Measures: Pre and post training knowlegde assessment;availability of tracer drugs; stocking and supply of insecticide treated nets; proportion of symptoms properly responded to; and number of referrals to health facilities. Results: Findings will report changes in the above indicators following the intervention. These would include availability of tracer drugs, stocking and supply of insecticide treated bed nets and percentage changes in response to presenting illnesses according to the taught protocols including referral to appropriate public health facilities.

BackgroundDemographics source: 2000 census data

Population: 19 Million

Sex Male: 49.5%Female: 50.5%

Locality Rural: 56.2 %Urban: 43.8%

Growth Rate: 2.7%

PopulationDensity:

79.3 pers/sq.km

PHARMACIES 1028CHEMICAL SELLER 7000

Maternal Mortality Rate: 214Life Expectancy: 58

HIV Prevalence: 3.8%

Ghana is a tropical country situated in the West Coast of Africa and located between latitudes 4 ˚ & 11˚ North of the equator

Economic IndicatorsGNI per capita $340Inflation Rate 2003 23.6%Per Capita Health Spending

$8

Background The Strategies for Enhancing Access to Medicines

(SEAM) Program was established in 2002 with a trinity of country-level public-private initiatives to improve access to essential medicines and commodities. The three (3) components are:

• Establishing a franchise of chemical seller shops that provide essential medicines and health supplies;

• Improving pharmaceutical supply and promoting more appropriate use of medicines in the Mission sector (Catholic) of Ghana; and

• Strengthening the Pharmacy Council’s capacity to regulate chemical seller shops in Ghana

Problem Statement

Almost sixty –six (66%)1 of Ghanaians visit the Licensed Chemical Seller ( LCS) as their first point of call when accessing health care services. Yet most have little or no healthcare background. Additionally LCS are small individually run operations with high overheads. This had lead to

• Poor quality service provision by LCS• Resource- heavy and inefficient operations

leading to high prices.• Additionally there exist a low level of regulatory

and supervisory visit from the authorities

Objective Questions

The problems raises two questions• Can we enhance the access to medicines

and improve rational use of medicines by private sector initiatives?

• Specifically, can the above objectives be achieved through an essential medicines franchise in a sub-Saharan African country with limited resources?

Intervention • An Essential Medicines Franchise network – branded as CAREshops was

set up in the Volta Region as a pilot The Volta Region, with its 1.6 m people , is served by only 621(8.8%) and 17(1.5%) of the National 7000 LCS and 1028 Pharmacies 2

• A Structured modular training programme was implemented for the accredited CAREshop Managers. This was over a 10 week period with 2 week breaks in between modules.

• A group purchasing program and a logistically sound distribution network was established by GSMFEL CAREshop Franchisor

• Regular monthly supervisory and mentoring visits were conducted with the CAREshop

• Periodic impact assessment of programwas is undertaken through - Review of Records, - Drug Availability and Affordability surveys, - Mystery shopping and Field observations .

1. MSH baseline Survey 2000 Ghana 2. Pharmacy Council 2002

.

Methodology & Outcome Measures

• Based on the training needs assessment a Pre and post training knowledge assessment was conducted.

• Data was collected on the availability of tracer drugs in CAREshops

• Level of stocking and supply of insecticide treated nets– a key indicator in relation to contemporary initiatives in malaria control were and prevention in CAREshops were measured

Results 1- Improvement in knowledge of CAREshop operators

The number of LCS obtaining a 60% basic score before and after training was measured This tool will be reapplied in Oct 2004and Jan 2005

Training Assessment

77 76

31 35

9886

67 72

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40

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ilmen

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core

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0 before

after

RESULT 2Tracer Drug Availability CAREshop Franchise

Tracer Drugs Allowed to Stock VR N=66 All RegionsFranchise Jan

2004 N= 79

Acetylsalicylic acid tabs 300mg 100.0% 99.6% 100%

Aluminium Hydroxide 500mg 89.4% 80.4% 98%

Amodiaquine 200mg 22.7% 20.0% 34%

Chloramphenicol Eye Ointment 27.3% 30.8% 45%

Chloroquine Tab 150mg 97.0% 94.4% 100%

Chlorpheniramine 4mg Tab 78.8% 68.8% 100%

Condoms 97.0% 94.4% 100%

Ferrous Sulphate/Fumarate 200mg Tab 62.1% 56.4% 98%

Ibuprofen 200mg Tab 86.4% 76.4% 100%

Oral Rehydration Salt 89.4% 92.4% 100%

Paracetamol tab 500mg 100.0% 96.8% 100%

Secure 86.4% 84.0% 90%

Sulfadoxine/Pyrimethamine tab 500mg/25mg 68.2% 63.2% 100%

Treated Bednets 3.0% 1.6% 7%

Average % for Tracer Drugs 70.0 67.3 83.7%

Availability of 15 tracer drugs (franchise to non franchise :70% to 83% Availability of ITN (franchise to non franchise : 3% to 7%

Discussion• Measurable improvement noted in medicine supply and use by

CAREshops especially through the established group purchasing and distribution system

• Increase in knowledge and practice level of Franchise Chemical Sellers observed

• Observations of the current interventions also show that working with the private sector requires an understanding of the motivations of private sector providers

These motivations include, but in most cases are not limited to– financial benefits– image enhancement– increased skill and competence leading to increased

commitment to proper sale and supply of medicines

Conclusion

• Private sector initiatives can improve access to medicines

• Franchising of essential medicine suppliers provides opportunity for training, improvement in service delivery and cost of reduction in supply chain

• Regular monitoring and an understanding of the motivation private sector providers is essential for success

Next Steps ….. Conclude and Implement Access dimensions for evaluation Evaluation to measure the CAREshop Program impact on * Quality of Dispensing (communication and

counseling) * Quality of Stocked products * Appropriateness of Recommendations * Affordabilty and availabilty of essential medicines * Acceptabilty /satisfaction with the CAREshop outlets Assess the enablers and constraints of the franchise program

implementation Post intervention regional assessment planned for October 2004

and March 2005