Monitoring and Assessing Pharmaceutical Policies

Mr Enrico Cinnella WHO/EMP, Geneva 18 November 2009

Outline of the Presentation

 Introduction  Level I  Level II  Facility Survey  Household Survey

Why countries measure?

  As a baseline to inform decisions  Priority Setting To check how well (or badly) you are performing

1. Assess and Monitor 3. Implement 2. Plan

Knowing the situation Country A

RATIONAL USE

Last update of EML: 2009 Last update of STGs: 2008 Antiobiotics sold over the counter: NO

QUALITY CONTROL

System in place for quality control: Samples tested for post marketing surveillance: NO System in place for ADR:

NO NO

100%

See how well you are doing

Median availability basket of key medicines, public , private & mission sectors 2004-8

75% 50% 25% Private median Public median Mission Linear (Private median) Linear (Public median) Linear (Mission) 0% Apr-04 Oct-04 Apr-05 Oct-05 Apr-06 Oct-06 Apr-07 Oct-07 Apr-08 Oct-08

Who can use the results ?

 Countries - focus action, prioritize, measure achievement   International agencies  to assess the structure and capability of countries, assess the progress, accomplishment and impact of aid Professional groups, NGOs and academia  to focus advocacy activities and information campaigns  Health facilities to be aware of institutional problems & improve situations

Pharmaceutical indicators

     Variables that measure situations and change Numerical ( numbers, percentage, or averages) Binomials (yes” and “no)” Useful tools to track the performance of particular aspects or activities of the pharmaceutical system Linked to an important input, process, or outcome

The WHO System

Level I

•

Questionnaire/rapid assessment/checklist

•

Arrays achievement & weaknessess, illustrate sectoral approaches Level II

•

Comprehensive monitoring of pharmaceutical strategy outcome and impact

•

Measures attainment of objectives Level III

•

More detailed indicators for monitoring and evaluating specific areas/components

Questionnaire (Health Officials)

Level I

Core structure & process indicators Systematic survey

Level II

Core outcome/impact indicators & household survey

Level III

Indicator tools for specific components of the pharmaceutical sector ● ● ●

Pricing Human Resources ● ● Traditional medicine Assessing regulatory capacity Procurement and Supply

LEVEL I

Level I

Core structure & process indicators

Level II

Core outcome/impact indicators & household survey

Level III

Indicator tools for specific components of the pharmaceutical sector ● ● ●

Pricing Human Resources ● ● Traditional medicine Assessing regulatory capacity Procurement and Supply

Level I- A Global Survey

 Questionnaires sent to MoH officials every four years (1999, 2003 and 2007). Mostly yes/no question.

 Responses collected and compiled into a global database and global report.

Level I- What does it cover?

 Policies and Structures in 6 areas:  Medicines Policies  Regulation     Procurement and Supply Financing Production and Trade Rational Use

Advantages of the level I

   Little Financial and HR Investment.

Number of countries covered (156 in 2007).

Allows  An overview of the global situation   Comparisons across regions Comparisons across time

The Global situation in 2007

Official NMP document updated within the last 5 years

Have we made progress?

Standard Treatment Guidelines 2003-7 High income Middle income Low income 0% 20% 40% 60% 24/30 7/13 52/69 31/53 80% 100% 42/47 35/52 2007 2003

Limitations of WHO Level I

 Data quality  Ownership of the data  Does not tell anything about outcomes and impact

The SADC experience

   Assessment of Pharmaceutical situation in 15 countries Tools similar to level I, but including indicators from other surveys Main changes in the process:    Tool prefilled (more speed, less effort and duplication).

Data quality- official endorsement.

Data ownership- data used to build Profiles to be shared with countries. Countries will have all their information in a single document.

Level II

Level I

Core structure & process indicators

Level II

Core outcome/impact indicators & household survey

Level III

Indicator tools for specific components of the pharmaceutical sector ● ● ●

Pricing Human Resources ● ● Traditional medicine Assessing regulatory capacity Procurement and Supply

Level I vs Level II

LEVEL I LEVEL II

    Single Questionnaire Little Investment Policies and Structures Based on EMP's strategy and vision     Survey with sampling More expensive and time consuming Outcomes Based on EMP's strategy and vision

From Structures to outcomes

Level I- Is there a EML?

Level II- Is the EML available at facility level? What is the percentage of medicines prescribed that are in the EML?

 LEVEL II- Are policies achieving their effect?     Availability- of a list of tracer medicines, and number of stock out days.

Affordability- (number of days of pay to purchase treatment for selected illnesses).

Quality- % Adequately labelled medicines, % expired medicines.

Rational use- INRUD Prescribing indicators.

Facility Survey

 5 Areas selected- The Capital (or richest), the most rural one (or poorest) and another 3.

 In each Areas select 1 Warehouse, 6 Public Health Care Facilities, 6 private drugs outlets.

5 30 30 Warehouses Public Health Care Facilities Private Medicines Outlets

Some results

Household Survey

The household survey sampling scheme

   5 regions in the country From each region select 6 public health facilities (30 reference public health facilities)

Facilities

In each of reference facility, select 30 households (

900 households

)

Region Households <5km 5-10 km >10 km

Household Survey

    Household situations  How they access their medicines, where they get them  How much they pay Identify access and affordability in relation to socio economic indicators, barriers Examine use of medicines (acute and chronic diseases) Perceptions on access, use and quality; handling of medicines

Households with medicines at Home

Geographical issues

COUNTRY A Do you receive free medicines at public health care facilities?

95% 56% 96% 77% 97%

Medicines Expenditure

% of HH expenditure 18 16 14 12 10 8 6 4 2 0 A B C Medicines expenditure as a percentage of total HH expenditure Medicines expenditure as a percentage of total HH expenditure A Medicines expenditure as a percentage of total HH expenditure B Medicines expenditure as a percentage of total HH expenditure C

Source of medicines

Source of medicine for acute illness

70 60 50 40 30 20 10 0 A va ila bl e at h om e Fr ie P nd ub lic h os pi ta l P riv at e ho P sp ub ita lic l D is pe ns ar y P riv at e pr ov id er Tr ad h P ea riv le at r e P ha rm ac y D ru g se lle r O th er s A B C

Tools and Reports

 Level I Assessment 2003 http://apps.who.int/medicinedocs/documents/s14101e/s141 01e.pdf

 Manual Level II Assessment http://apps.who.int/medicinedocs/documents/s14877e/s148 77e.pdf

 Uganda Facility Survey 2008 http://apps.who.int/medicinedocs/documents/s16377e/s163 77e.pdf

 Uganda Household Survey 2008 http://apps.who.int/medicinedocs/documents/s16374e/s163 74e.pdf

 Thank you for your attention