By Ayalew Adinew - WHOapps.who.int/medicinedocs/documents/s22267en/s22267en.pdf · Fekad Yeshaneh, Dr. Habtamu Adinew, Tenaw Andualem and Asrat Gebre, ... Graph7. 1 Rate of medicines

The findings of APTS evaluation by: A. Adinew. S. Ololo. F. Tessema Oct 2015

Evaluationoftheimplementationstatus,outcomesand

challengesof“AuditablePharmaceuticalsTransactions

andServices”inselectedhospitalsofEthiopia

By

Ayalew Adinew

A Research Project Submitted to College of Health Sciences, Jimma University;

Health Research and Graduate Coordinating Office, in Partial Fulfillment for the

Requirement of Masters of Public Health (MPH)

Oct 2015

Jimma University, Ethiopia


i

Evaluationoftheimplementationstatus,outcomesand

challengesof“AuditablePharmaceuticalsTransactions

andServices”intenselectedhospitalsofEthiopia

By

Ayalew Adinew

Advisors:

Shimeles Ololo (MPH, Assistant Professor, Jimma University)

Fasil Tessema (MSc, Associate Professor, Jimma University)

Oct 2015

Jimma University, Ethiopia


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Abstract

Background: Availability of essential medicines is necessary to maintain health of the

community. In Ethiopia, availability of medicines was low (65%), with high expiry rate (8.24%),

low patient knowledge on correct dosage (50.5%) and satisfaction on pharmacy services

(74.5%). To avert these problems, the government had enacted legislation on a system called

“Auditable Pharmaceutical Transactions and Services (APTS)”. The system is being

implemented in more than 45 hospitals. However, the outcomes and challenges in

implementation of this system were not evaluated.

Objective: To measure the status, outcomes, and challenges of APTS implementation in selected

hospitals in Ethiopia.

Methods: Cross sectional descriptive study and multiple case study designs were used

employing both quantitative and qualitative methods. This research was conducted in 10 APTS

implementing hospitals. In-depth interviews were made with 10 CEOs and pharmacy heads.

Self-administered questionnaire was distributed to 348 pharmacy staffs. APTS reports of 153

months (with different characteristics) were also reviewed. Using W.H.O questionnaire, 1000

patients were interviewed for their knowledge on correct dosage and satisfaction. Quantitative

data was entered and analyzed using SPSS version 20. Multivariate logistic regression was used

to determine crude and adjusted OR.

Result: The implementation statuses of APTS ranged from 68% to 95%. Slopes for trends of

cumulative rate of medicines expiry (-0.089) and gross profit from medicines sales ranged from

77 to 4079 respectively. Patients’, who were served in hospitals which had APTS standards,

knew correct dosage 4.6 times more than otherwise (AOR=4.6, C.I.95%). Patients’ satisfaction

on pharmacy services were associated with availability of medicines and seated service for

special counseling (AOR=2.3, AOR=4, C.I.95%) respectively. Patients served in a hospital

which identified medicines for top ten diseases and follow regularly, have got their prescribed

medicines 7.5 times more than otherwise (AOR=7.5. C.I. 3.887-14.473)

Conclusion and recommendation: APTS evaluation showed that it reduces rate of medicines

expiry and improve patient knowledge on correct dosage and satisfaction. Therefore, I

recommended that; APTS should be scaled up to all health facilities in Ethiopia by FMOH and

beyond to all African countries by FMOH of Ethiopia and Africa Union.


iii

Acknowledgements

I would like to express my profound gratitude for the supervisors of the research Ato Shimeles

Ololo and Ato Fasil Tessema for their meticulous follow-up and guidance throughout the

research.

I would like to thank data collectors for their commitment and scrupulous activities they were

doing during data collection.

I am pleased to acknowledge my wife, Seble Fentaw for her marvelous assistance during data

entry of this study in to SPSS.

In addition to my advisers, I want also to extend my appreciation to my brothers and friends; Dr

Fekad Yeshaneh, Dr. Habtamu Adinew, Tenaw Andualem and Asrat Gebre, Bruk Wogayehu for

their comments


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Table of Contents

Abstract ........................................................................................................................................... 2

Acknowledgements ......................................................................................................................... 3

Table of Contents ........................................................................................................................... 4

List of Tables and Figures ............................................................................................................. 7

Abbreviations ................................................................................................................................ 11

Chapter 1: Introduction .............................................................................................................. 12

1.1. Background ....................................................................................................................... 12

1.2. Statement of the problem .................................................................................................. 14

1.3. Significance of the study ................................................................................................... 16

Chapter 2: Literature Review .................................................................................................... 17

I. Objectives of the APTS program .......................................................................................... 20

II. Conceptual framework for APTS evaluation; Adapted from Logic Model .................... 22

Chapter 3: Objectives ................................................................................................................... 23

3.1. General Objective .............................................................................................................. 23

3.4. Specific Objectives ............................................................................................................. 23

Chapter 4: Methodology .............................................................................................................. 24

4.1. Study area and period ....................................................................................................... 24

4.2. Study Design ...................................................................................................................... 25

4.3. Population ......................................................................................................................... 25

4.3.1. Source populations ............................................................................................................................ 25

4.3.2. Study populations .............................................................................................................................. 25

4.3.3. Inclusion criteria ................................................................................................................................ 26

4.3.4. Exclusion criteria ............................................................................................................................... 26

4.4. Sample Size and Sampling Technique ............................................................................. 26

4.4.1. Sample size determination ................................................................................................................. 26

4.4.2. Sampling Techniques ........................................................................................................................ 27


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4.4.3. Sampling Frames: .............................................................................................................................. 28

4.5. Data Collection .................................................................................................................. 28

4.5.1. Development of data collection tools ................................................................................................ 28

4.5.2. Personnel recruitment and training .................................................................................................... 29

4.5.3. Data collection techniques ................................................................................................................. 29

4.6. Variables ............................................................................................................................ 30

4.6.1. Dependent variables .......................................................................................................................... 30

4.6.2. Independent variables ........................................................................................................................ 30

4.7. Operational Definition ...................................................................................................... 31

4.8. Data Processing and Analysis .......................................................................................... 33

4.9. Data Quality Management................................................................................................ 34

4.10. Ethical Considerations .................................................................................................. 34

4.11. Dissemination of Results ............................................................................................... 34

Chapter 5: Results ........................................................................................................................ 35

5.1. Socio Demographic Characteristics ................................................................................. 35

5.1. Documentary Survey ......................................................................................................... 36

5.2. Implementation status of APTS tools and systems .......................................................... 37

5.2.1. Efficient Budget Utilization (Result Area 1 of 4) .............................................................................. 37

5.2.2. Affordability ...................................................................................................................................... 46

5.2.3. Transparency; (outcomes of result area 2) ......................................................................................... 47

5.2.4. Effective workforce development, deployment and organization (Result A. 3) ................................ 48

5.2.5. Reliable information on product, finance and services; (result area 4) ............................................. 52

5.3. Availability of prescribed medicines ................................................................................. 52

5.4. Patient knowledge on correct dosage ............................................................................... 55

5.5. Patient satisfaction on pharmacy services ....................................................................... 58

Chapter 6: Discussion .................................................................................................................. 63

5.5. Socio demographic characteristics ................................................................................... 63

5.6. Rate of Expiry.................................................................................................................... 63

5.7. Income from sales of medicines and Affordability .......................................................... 65

5.8. Transparency ..................................................................................................................... 67

5.9. Effective workforce deployment, development and organization (R. Area 3) ................ 69

5.9.1. Pharmacy premises and workflow adjustment .................................................................................. 69

5.9.2. Human power adjustment .................................................................................................................. 69


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5.10. Availability of prescribed medicines and factors affecting .......................................... 69

5.11. Patient knowledge and factors affecting ...................................................................... 70

5.12. Patient satisfaction ........................................................................................................ 70

5.12.1. Patient satisfaction on overall pharmacy services ............................................................................. 71

5.12.2. Patient satisfaction on personnel services.......................................................................................... 71

5.12.3. Arrangement of workflow; a factor for patient satisfaction ............................................................... 72

5.13. Challenges of APTS implementation............................................................................ 73

5.14. Limitations of the Study ................................................................................................ 73

Chapter 7: Conclusion and Recommendation ............................................................................ 73

7.1. Conclusion ......................................................................................................................... 73

7.2. Recommendations ............................................................................................................. 75

Reference ...................................................................................................................................... 76

Annexes ........................................................................................................................................ 80

5.15. Annex 1. Check list for document review ..................................................................... 80

5.16. Annex 2: In-depth interview guide ......................................................................... 91

5.17. Annex 3: Self-Administered Questionnaire ................................................................. 94

5.18. Annex 4 Questionnaires to measure patient knowledge on correct dosage and

satisfaction on pharmacy services -adopted from W.H.O drug use indicators: ...................... 103

5.19. Annex 5: Consent Form for in depth interview .................................................. 108

5.20. Annex 7: Budget Breakdown .................................................................................. 109

5.21. Annex 8, APTS implementing sites, when data collection started, ........................... 110

as of March 2015........................................................................................................................ 110

5.22. Annex 9, Name list of data collectors ......................................................................... 111


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List of Tables and Figures

Table 1 Socio-demographic characteristics of pharmacy and finance staffs working in10 selected

hospitals; Jul 2015......................................................................................................................... 35

Table 2: Socio-demographic characteristics of patients served in a cumulative of 36 various

pharmacy outlets (OPD, Chronic care, Inpatient, ART, Maternity, Emergency and Especial

pharmacies) in 10 hospitals, Jul 2015 ........................................................................................... 36

Table 3: Implementation statuses of APTS tools and systems of the four result areas in ten

selected hospitals, Jul- 2015 ......................................................................................................... 37

Table 4: Rate of expiry, stock available for sale, sales, profits and number of patient served the

case of BMH hospital. The report collected from APTS launch up to Sept 30 2015, for the last

23 months; Oct- 2015 .................................................................................................................... 38

Table 5: Cumulative expiry of medicines from the start of APTS launch up to Sept 30/2015

compared with the cumulative expiry after 4 months from the APTS launch up Sept 30/2015, in

all the study hospitals; Report organized Oct 30/2015 ................................................................. 40

Table 6: Implementation status of one result areas of APTS (SSA), used to identify medicines at

risk of expiry in 10 selected hospitals, March 2015. .................................................................... 42

Table 7: Implementation statuses of few selected elements of result area 3 (organization, staffing,

dispensing counter and patient flow) in ten selected hospital pharmacies, March 2015 .............. 50

Table 8: Availability of prescribed medicines for patients served in a cumulative of 34 various

pharmacy outlets (OPD, Chronic care, ART, Maternity, Emergency, Especial pharmacies etc.) of

the 10 selected hospitals from 7 regions of Ethiopia, Organized June 2015. N=1000 ................ 52

Table 9: Logistic regression for availability of prescribed medicines for cohort of the same

patients who got service in a cumulative of 34 various pharmacy outlets (OPD, Chronic care,

ART, Maternity, Emergency, Especial pharmacies etc.) of the 10 selected hospitals; Organized

June 2015: N=1000 ....................................................................................................................... 54

Table 10: Frequency and mean of knowledge of patients on correct dosage during exit interview

after getting services in a cumulative of 34 various dispensaries (OPD, Chronic care, Inpatient,

ART, Maternity, Emergency) of the 10 selected hospitals, from 7 region of Ethiopia, Organized,

June 2015. N=1000 ...................................................................................................................... 55


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Table 11: Multivariate Logistic Regression analysis for knowledge of patients on correct dosage,

during exit interview among respondent patients who got pharmacy service in a cumulative of 34

various pharmacy outlets (OPD, Chronic care, ART, Maternity, Emergency, Especial

pharmacies) from pharmacies that have different implementation statuses of APTS; June, 2015;

N=1000 ......................................................................................................................................... 57

Table 12: Satisfaction of patients served in a cumulative of 34 various dispensing outlets (OPD,

Chronic care, Inpatient, ART, Maternity, Emergency, Especial pharmacies) of 10 selected

hospitals; using LIKERT scale questions and Nominal Scales questions, June 2015: N=1000 ... 59

Table 13: Multivariate logistic regression analysis for patient satisfaction with personnel service

in 10 selected hospitals; among respondents who got pharmacy services in a cumulative of 34

various pharmacy outlets (OPD, Chronic care, ART, Maternity, Emergency, Especial

pharmacies); of which hospital pharmacies with different level of implementation status of

APTS; June 2015 .......................................................................................................................... 60

Table 14: Multivariate logistic regression analysis for patients’ satisfaction with overall

pharmacy service in ten selected hospitals among respondents who got service in a cumulative

of 34 various pharmacy outlets (OPD, Chronic care, Inpatient, ART, Maternity, Emergency,

Especial pharmacies) of which hospital pharmacies with different level of implementation

statuses of APTS; June, 2015 N=1000 ......................................................................................... 61

Table 15: Crude and Adjusted Odds Ratio for patient satisfaction with dispensing process among

respondents for cohort of patients who got the service in a cumulative of 34 various pharmacies

(OPD, Chronic care, ART, Maternity, Emergency, Especial pharmacies etc.) of which hospital

pharmacies with different implementation statuses of APTS; June, 2015. N=1000 ................... 62

Graph7. 1 Rate of medicines expiry for the last 39 months in ten selected APTS implementing

hospitals from seven regions of Ethiopia; rate compared with the baseline (taken before APTS

implementation) up to September 30-2015. Report organized Oct 2015 ..................................... 40

Graph7. 2 The slope of the trend line of the cumulative rate of medicines expiry for the last 39

months of the ten selected APTS implementing hospitals from seven regions of Ethiopia; trend

compared with the baseline (taken before APTS implementation) up to September 30- 2015.

Report organized on Oct-2015 ...................................................................................................... 41


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Graph7. 3 The slope of the trend line of the rate of medicines expiry for the last 39 months in

DMH; trend compared with the baseline (taken before APTS implementation) up to September

2015; data organized Oct 2015. .................................................................................................... 42

Graph7. 4 Trends of cash sales of medicines in birr in ten selected APTS implementing hospitals

from 7 regions of Ethiopia: cash sales collected during 4500 days; starting from the first month

of APTS implementation in each hospital up to September 30, 2015 .......................................... 43

Graph7. 5 Trends of gross profit from cash sales of medicines in birr in ten selected hospitals

from 7 regions of Ethiopia: gross profit collected during 4500 days; starting from the first month

of APTS implementation in each hospital up to September 30, 2015 .......................................... 44

Graph7. 6 Trends of total sales of medicines (Cash + Credit + for Free) in birr in ten selected

hospitals from 7 regions of Ethiopia: total sales collected during 4500 patient-days (150 months

with different characteristics) ; starting from the first month of APTS implementation in each

hospital up to September 30, 2015; Data organized Oct 2015. .................................................... 44

Graph7. 7 Trends of gross profit from total sales (cash + credit + free) of medicines in birr in

ten selected hospitals; total gross profit collected during 4500 patient-days (151 months with

different characteristics) ; starting from the first month of APTS implementation in each hospital

up to September 30, 2015; Data organized Oct: 2015 .................................................................. 45

Graph7. 8 Trend of number of patient served on cash in ten selected hospitals from 7 regions of

Ethiopia, in the last 39 months, starting from the first month of APTS implementation onwards

up to September 30, 2015; Data organized Oct 2015 ................................................................... 45

Graph7. 9. The trend line of the number of patient served on (cash + Credit + for free) in ten

selected hospitals from 7 regions of Ethiopia, in the last 39 months, starting from the first month

of APTS implementation onwards up to September 30, 2015; Data organized Oct 2015. .......... 46

Graph7. 10: The median days’ wage for unskilled government worker that would have to pay to

buy medicines from 34 various pharmacy outlets (OPD, Emergency, Inpatients, Chronic care

etc.) of the ten selected hospitals from 7 regions of Ethiopia; of the last 39 months up to

September 30 2015. Data organized Oct. 2015. ........................................................................... 47

Graph7. 11: Trends of days’ wage that unskilled government worker would have to work to buy

medicines on cash in ten selected hospitals from 7 regions of Ethiopia, starting from APTS

initiation up to September 30 2015. Data organized Oct 2015. .................................................... 47


x

Graph7. 12: The time needed (in days) to conduct physical inventory of medicines, before and

after APTS, in 10 selected hospitals from 7 regions of Ethiopia, Oct 2015 ................................. 48

Graph7. 13 Implementation statuses of R 3 of APTS (Pharmacy staffs adjustment) based on

APTS workload analysis principles in ten selected hospitals from 7 regions of Ethiopia, before

and after APTS, June 2015. .......................................................................................................... 51

Graph7. 14 Implementation status of one result areas of APTS (finance staffs adjustment) based

on APTS workload analysis principles in ten selected hospitals, before and after APTS, June

2015............................................................................................................................................... 51

Graph7. 15 Availability of prescribed medicines and patient who got all prescribed medicines;

that patients served in a cumulative of 34 various dispensing outlets (OPD, Chronic care, ART,

Maternity, Emergency, Especial pharmacy outlets etc.) of the 10 selected hospitals from 7

regions of Ethiopia, June 2015. N=1000 ..................................................................................... 53

Graph7. 16 # of prescribed and dispensed medicines for patients served in in a cumulative of 34

various dispensing outlets (OPD, Chronic care, ART, Maternity, Emergency, Especial

pharmacies) 10 selected hospitals from 7 regions of Ethiopia, Organized June 2015 ................. 53

Figure 1: Multiple queue single server modeling for dispensary patient flow _ University of Jos,

Nigeria. 2011................................................................................................................................ 18

Figure 2: Single queue - multiple server- modeling for dispensary patient flow _ University of

Jos, Nigeria. 2011 ........................................................................................................................ 18

Figure 3: Result areas (dimensions) of Auditable Pharmaceuticals Transactions and Services

program, 2012, Amhara Region: Ethiopia [8] .............................................................................. 21

Figure 4: Regions of the Ethiopian; Nations, Nationalities and Peoples, where APTS is being

implemented and the study area that this thesis evaluated APTS: are regions those painted in

yellow; March, 2015 ..................................................................................................................... 24

Figure 5: Premises, work flow and patient queue modeling in APTS; (single queue - multiple

server modeling) Ethiopia, 2010; reported June 2015 ................................................................. 51


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Abbreviations

ABC A class, B class and C class

ABC/VEN A class, B class and C class medicines / Vital, essential and non-essential

AMR Anti-Microbial resistance

APTS Auditable Pharmaceuticals Transactions and Services

ARM Annual Review Meeting

CTA Consumption to stock analysis

FMOH Federal Ministry of Health

HSDP IV Health sector development IV (2010-2015) of Ethiopia

IFRR Internal facility report and requisition form

MAM/SAM Moderate Acute Malnutrition and Severe Acute Malnutrition

MDG Millennium Development Goal

MFRF Monthly Financial Reporting form of APTS

MOFED Ministry of Finance and Economic Development

MSRF Monthly Service Reporting form of APTS

RFEDB Regional Finance and Economic Development Bureau

RHB Regional Health Bureau

SIAPS Systems for Improved Access to Pharmaceuticals and Services

SPS Strengthening Pharmaceutical Systems

SPSS Statistical Package for Social Sciences

SSA Stock Status Analysis

SAS Stock available for sale

STI Sexually Transmitted infections

STR Stock Turnover Ratio

UN United Nations

UNICEF United Nations Children Fund

VEN Vital essential and nonessential

W.H.O World Health Organization


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Chapter 1: Introduction

1.1. Background

United Nations’-article 25 of the 1948 universal declaration of human rights states that-

“everyone has the right to a standard of living adequate for health and the right to security in the

event of sickness or disability” [1]. Governments that endorsed this declaration are responsible

and accountable to prevent and treat their citizens from manmade and natural disasters causing

morbidity, disability and deaths [2]. Ethiopia is one of the countries which endorsed the

universal declaration of human right [3]. In Ethiopia, communicable diseases such as pneumonia,

diarrhea, malaria, tuberculosis, meningitis, HIV/AIDS/STI, blindness, and non-communicable

diseases such as diabetes, hyper tension and cancer, mental illness are being the major causes of

morbidity and mortality [4]. To prevent and treat such diseases, huge capacities are needed

including; health facilities, trained human power and availability of medicines.

Availability of medicines at all times in adequate amounts, appropriate dosage, at affordable

price for the individual client and their proper use are indispensable since medicines complement

other types of health care services including; vaccination, prophylaxis, treatment and

rehabilitation [5, 6]. To avail these medicines and use in such a manner, selection of medicines

should be based on critical factors; disease prevalence, consumption pattern and adequate

personnel expertise to diagnose, prescribe, dispense and manage medicine. Financial resources to

buy these medicines and efficient use of resources are also necessary [7]. Further to this, factors

that leads to wastage of medicines in health facilities such as; expiry, pilferage, theft and

irrational use of medicines should be prevented. In turn, to perform the aforementioned duties,

pharmacy organizations and patient flow within pharmacies should be properly addressed [8].

Rational drug use is of the key factor; worldwide, more than 50% of all medicines are prescribed,

dispensed or sold inappropriately, and half of all patients fail to take medicines correctly and

hence the overuse, underuse or misuse of medicines harms people and wastes resources. More

than 50% of all countries do not implement basic policies to promote rational use of medicines.

This is high in developing countries; only less than 40% of patients in the public sector and 30%

in the private sector are treated according to clinical guidelines [9].


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Pharmacy organization of health facilities, workflow within pharmacy outlets, the number, mix

and ratio of pharmacist to client ratio are the basic elements to be fulfilled to deliver quality

pharmacy services and attain appropriate patient satisfaction [8]. The pharmacies of hospitals

should be organized as outpatient, inpatient and emergency pharmacies and a central medical

store of each directed by a registered pharmacist [10]. In addition, the hospital has to have

adequate personnel, equipment, premises and facilities required to store pharmaceutical supplies

and carry out compounding, dispensing and counseling activities. The work flow should be

designed in such a way that customers should enter in one gate of the pharmacy outlets and exit

in another, in a way inside the pharmacy; customers see prescription evaluator, biller, cashier,

and medicines use counselor in a queue [8].

Transparency and accountability is another big challenge in the pharmaceutical sector. The

World Bank has identified corruption as “the single greatest obstacle to social and economic

development keeping millions of people trapped in poverty” and labelled a ʺcancerʺ [11]. The

pharmaceutical sector is particularly vulnerable to corruption and unethical practices since the

commercial reality of the pharmaceutical market tempts many different actors [11]. Processes of

the pharmaceutical sectors that are vulnerable to corruption and need interventions are:

registration of medicines, licensing of pharmaceutical business, inspection of establishments,

medicine promotion, selection, quantification, procurement and issuing of medicines to various

health facilities and distribution to sections within health facilities [11, 8]. As per the W.H.O

strategy, improving good governance of pharmaceutical management in public health facilities is

very important especially for disadvantaged, poor and vulnerable populations [11, 12].

The Federal Ministry of Health (FMOH) of Ethiopia had developed the Ethiopian Hospital

Reform Implementation Guidelines (EHRIG) which includes the pharmacy service reforms [13].

Further to implementation of EHRIG in hospitals for the last five years, a system was designed

that assumed to curtail the aforementioned pharmacy service drawbacks, called Auditable

Pharmaceuticals Transactions and Services (APTS). The system, APTS is being put in to law

regionally in Amhara 2011 [14], Diredawa in 2012 [15], SNNP in 2014 [16], Tigray in 2015,

Oromiya in 2015, and by the Federal Government in 2014 [17, 18]. FMOH of Ethiopia decided

to scale up APTS nationwide.


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These were the main reasons why APTS implementation in health facilities of Ethiopia in

2014/2015 becomes one of the top priority agenda for the regional health bureaus, the Federal

Ministry of Health, the Federal Ministry of Finance and partners [2].

1.2. Statement of the problem

Globally, in developing and industrialized countries alike, efforts to provide health care are

facing new challenges. These include the rising costs of health care, limited financial resources,

shortage of human resources, inefficient health systems, the huge burden of disease, and

challenges to relate to treatment that one third of the world’s population does not yet have

regular access to essential medicines [19, 20]. Availability of medicines in low- and middle-

income countries is low, particularly in the public sector [20]. For many people, the affordability

of medicines is a major constraint due to high price especially in private sector reaching in some

cases 80 times the international reference price and requires over 15 days’ wages to purchase 30

days of treatment [19, 20, 21]. In low- and middle income countries, because of high prices,

medications account for 25% to 70% of total health care expenditures, compared to less than

15% in high-income countries. Inaccessibility and unaffordability to essential medicines are

aggravated by medicines diversion from government to private, theft, non-transparency, non-

systematic selection, poor procurement and wastage due to expiry, irrational use, and poor

pharmacy organization and workflow [8, 19, 20, and 21].

A recent report of the President’s Malaria Initiative to Congress of the US Government indicated

that until April 2014, the stealing is continuing and there was no solution solicited in Africa [22].

As per the study of World Bank in collaboration with anti-corruption authority of Ethiopia, even

though corruption is uncommon compared to other African countries, pharmaceutical sector is

found to be one of the two most corrupted sectors in Ethiopia that donated products are being

diverted for private resale within Ethiopia and abroad [23, 24].

Studies showed that the root causes of drug diversion in Ethiopia includes: non-transparent

transaction; while medicines entered in the store, issued to sections and dispensed to patients,

patients used to buy medicines with a receipt prepared by a cashier who is unable to write the


15

names and full descriptions of medicines. The type, quantity and price of medicines that are

transacted had not been traced. Therefore, a system that can transparently show step by step flow

of medicines until it reach the intended patient is becoming mandatory [8].

A recent baseline assessment for APTS implementation done by FMOH in collaboration

USAID/SIAPS project, revealed that: patient knowledge on how to take their medicines;

concerning dose, route of administration, frequency and duration showed that only 50.5% clients

properly know all parameters [25].

In Ethiopia, various findings showed that essential medicines are poorly available (65%) [26],

with high expiry rate (8.24% nationally) [27]. There are poor information on product and

financial values of medicines, inefficient utilization of medicines budget, poor pharmacy

infrastructure and chaotic work flow, all together resulting in poor quality of medicines

management and erratic dispensing activities including counseling services and low overall

patient satisfaction on pharmacy services (74.5%). [8, 13, 25]

It is to solve the aforementioned problems that the concept of APTS was innovated in Ethiopia,

piloted in Amhara Region, Debre Markos Referral Hospital, in 2011 [8, 28], commented by

various types of professionals of Ethiopians during consecutive workshops and is being scaled

up in health facilities throughout the country by RHBS and FMOH in collaboration with partners

(USAID/SIAPS and WHO).

Some outcomes of APTS intervention have been studied in Debre Markos Referral Hospital

during piloting. Additionally, few preliminary studies that assessed the outcomes of APTS have

been documented by Amhara RHB and individual hospitals. However, such big interventions

like APTS should be undertaken by the government and its stakeholders based on a thorough

knowledge on its outcomes and challenges faced during its implementation. Since prior research

on this topic is minimal, corresponding relevant information are scares. So, it is critical to

conduct this study and fill the gap by giving relevant information to the ministry of health,

regional health bureaus and relevant stakeholders.

The expected results of this study are to measure implementation status of APTS tools and

systems, to identify the type and amount of various outcomes of its implementation in terms of


16

reducing wastage of medicines, availability and affordability of medicines, improving work flow,

increasing revenue from medicines sales, improving patient satisfaction on pharmacy services.

1.3. Significance of the study

The baseline data for health sector development plan (HSDP IV 2010-2015) of Ethiopia [27]

showed that stock-out for essential drugs was found to be 35%, patients’ knowledge on correct

dosage (68%) and national average rate of medicines expiry (8.24%). The World Bank

identified corruption and lack of transparency in the pharmaceutical sector, as the greatest

“cancer” and obstacle to social and economic development, keeping millions of people trapped

in poverty [11]. Execution of pharmaceutical transactions and services in hospitals of Ethiopia

lacks transparency and accountability; thus vulnerable for corruption [8].

The aforementioned issues were the main reasons why APTS had been created since it is

intended to be a tool and system used to solve such problems. Preliminary assessment of APTS

implementation in one pilot site showed promising results [8]. It was the only reason that APTS

is being expanded throughout the health facilities in the country, with big investment and

commitment of the Government of Ethiopia and stakeholders. Additionally, various regional

governments like the Amhara, the SNNP, and the Diredawa Administration have enacted

regulation on APTS. However, there is no evidence based information formally studied that

showed APTS implementation status, challenges and outcomes. There is no full-fledged

scientific evidence based answer for questions arises on the system whether it is important or

futile exercise, whether the value added by the system and the expenses due to the system are

justifiable. Such big interventions like APTS should have been undertaken with a thorough

knowledge on above issues. Due to absence of such formal study, information for decision

makers is scares.

The expected results of this study are to measure the implementation status, outcomes and

challenges of APTS implementation in terms of reducing wastage of medicines, optimizing

medicines budget, improving work flow thereby improving patient knowledge on correct dosage

and satisfaction on pharmacy services by comparing with the national, regional and hospital

specific baseline data taken before APTS. Therefore, it is timely to conduct this study, to fill the


17

gaps and to provide information to FMOH, MOFED, RHBs, and donors so that respective bodies

could take appropriate measures. This study will also serve as a base line for the forthcoming

researchers.

Chapter 2: Literature Review

APTS is a service delivery scheme that assumed to enables establishment of transparent and

accountable medicines transaction and service provision. The ultimate objectives of APTS are to:

institute ethical, transparent and responsible pharmacy practice that enables health facilities

optimize utilization of medicines budget; improve access to medicines; continually improve the

number, skill, mix & efficiency of pharmacy workforce, improve documentation and pharmacy

premises and workflow, generate reliable and consistent information on products finance and

services for decision making, improve patient knowledge on prescribed medicines and

customers satisfaction. The system is intended to enables pharmaceutical transactions and

service to be audited at any time [8].

APTS has five main pillars: Efficient budget utilization, transparent and accountable

transactions, reliable information, effective workload analysis including; performance

measurement and workforce deployment and improving customer satisfactions [8]. The APTS

system [8] declares that there are many factors which affect the quality and volume of pharmacy

service provision; including, lack of training that intern reflected by lack of knowledge and

capacity, chaotic workflow, poor infrastructure, insufficient equipment and facilities needed to

give the service, lack of using the highest efficient mix of services units of pharmacy, medicines

budget and number of professionals.

A study in Kenyatta National Hospital, Kenya, indicated that “low employee’s capacity led to a

decrease in provision of service quality by factor of 0.981” while inadequate technology

adoption for health service led to a decrease in provision of service quality by a factor of 0.917.

The ineffective communication channels affected delivery service quality in public health sector

by a factor of 0.768 while insufficient financial resources resulted to decrease in provision of

health service quality by factor of 0.671. From this study, it was concluded that “low employees

capacity and insufficient fund affect delivery of service quality to patients in public health sector

affecting health service quality perceptions, patient satisfaction and loyalty” [29].


18

A study conducted by Dr Liz Sexton et al on factors influencing pharmacist performance, in the

“Centre for Pharmacy Workforce Studies”, in Great Britain, showed that; “ pharmacist

performance is affected by characteristics such as age, gender, ethnicity, place of primary

qualification, workplace factors, workload and mental and physical health problems, alcohol use

or drug addictions” [30].

Workflow in pharmacy services is a problem in many African countries. Its inefficiency also has

a negative impact in all over performance of the health facility. By the study made in Nigerian

faculty of pharmaceutical sciences, the impact of rearrangement of workflow pattern on queue

characteristics and discipline was measured. During the baseline of that study, the queue

characteristics in the pharmacy service _ patient flow modeling were “single server-multiple

queue model” as in the modeling figure below.

Figure 1: Multiple queue single server modeling for dispensary patient flow _ University of Jos, Nigeria. 2011

In this study what the researchers did was that they measured various models against the

baseline. The comparison queue model types were; single server with single queue model,

multiple servers with single queue model, and then multiple servers with multiple queue model.

Finally, after staff re-orientation the streamline process, the best model that reduces waiting time

from 167.0 to 55.1 minute which indicated a 67% reduction waiting time was adopted by

consensus and practiced. This patient flow model is multiple servers, single queue model as

indicated in the modeling figure below.

Figure 2: Single queue - multiple server- modeling for dispensary patient flow _ University of Jos, Nigeria. 2011

An article in Washington stated that:-“millions of dollars of donated antimalarial drugs have

been stolen, most often by staff of recipient government medical stores. For this reason, Sweden


19

and Germany have already suspended funding. The article recommended that the entire system

needs to change [31]. In the wall Street journal, a survey showed that antimalarial medicines are

diverted from east to West Africa due to lack of transparency of medicines supply management

system [32]. Therefore, a system that can transparently show step by step flow of medicines until

it reach the intended patient is becoming mandatory. APTS is expected to do solve such

problems and it will be proved or disproved when evaluated.

By the interviewing 500 patients, using descriptive workshop based epidemiological study made

in India showed that: “More than half (47.4%) reported that they did not ask and were not told

how to store their medicines properly at home”. Less than one 1/3rd (30.4%) of study

participants reported that they did not ask the doctor about any possible side effects of their

medicines. More than two thirds (72.4%) of the study population said that they discontinued their

treatment course when they felt that their symptoms disappeared [33].

One study done in Afghanistan by USIAD/SPS program, in 14 health facilities, in 2010 showed

that the patients who know all the seven WHO drug use indicators that enables on how to take

dispensed medicines (the name, dose, route of administration, the frequency, duration,

precaution, storage) ranged from less than 10% to 60% as shown in the graph below [34]. A

study done in Kenya health facilities by WHO Kenya office, indicated that the incidence of

expiry of medicines in dispensing shelves were found to 2.3% in government health facilities

where as 1.9% in private health facilities [35]. Study conducted in Uganda to assess expiry of

medicines in supply outlets at the public and private health facilities showed that high

contribution of the expiry medicines to be due to storing medicines that treat rare diseases

(81.8%) and drug donation (56 %) [36].

In the study conducted by Food Medicines Health Care Authority of Ethiopia in collaboration

with WHO in 2003 revealed that the national averages expiry rate of medicines was found to be

8%, 2% and 3% in health facilities, regional drug stores and private drug retail outlets,

respectively [25].

In the study conducted by Birma Abdosh on quality of hospital service in eastern Ethiopia, the

percentage of patient satisfaction for pharmacy service was 65% being less than laboratory

service (75%) [37]


20

From the study conducted by respective Ethiopian regional health bureaus and Federal Ministry

of Health in collaboration with USAID/SIAPS, during collection of APTS baseline data, in the

year 2013/2014, indicated that: in 2004 E.C (2012), there was an overall wastage of

3,281,562.20 ETB ($164,078.11) accounting to an average of 3.9% of the total value of

medicines received by 6 hospitals. In 2005 EC (2013), the value of wastage was estimated to be

birr 10,684,221.09 indicating an average wastage rate of 8.3% for 9 of the study hospitals [25].

This rate of expiry was found to be equivalent to the rate of expiry of medicines taken during

national HSDP-IV (2010-2015) baseline [27]. The six month data for 2006 EC (2014) of the

same hospitals shows total wastage of 1,542,491.6 ETB ($77,124.58) indicating an average of

5.1% wastage rate. When the outlier results of the two hospitals were excluded from the

analysis, the average wastage rate of the remaining 8 hospitals was found to be 4.8%, amounting

to 11,078,910.52 ETB ($553,945.53) [25].

In the second batch of hospitals that started APTS before two years showed that the medicines

expiry rate of Debre Markos were found to be 10%, Felege Hiwot Referral Hospital 9%, and

that of Debre Berhan was found to be 15% when compared with the stock availed for dispensing

[38].

In the APTS baseline assessments conducted at different times in these hospitals, overall patient

satisfactions on pharmacy services were found to be; 77% in Debre Markos Referral Hospital

[8] and 40% in Felege Hiwot Referral Hospital [39]

In the third batch of hospitals implementing APTS, the baseline data taken by respective regional

health bureaus in collaboration with USAID/SIAPS indicated that the average expiry rate of

these hospitals was found to be 5.4% [38, 40, and 41].

In the APTS baseline assessment conducted in 17 hospitals, the baseline data of the patient

knowledge on how to take dispensed medicines ranged that percentage of patients who knew all

parameters were 15.5% whereas who knew all five basic drug use indicators (dose, route,

frequency, duration, storage) were 46.6% [25]

I. Objectives of the APTS program

APTS was designed to address the following objectives:


21

To bring efficient medicines budget utilization in health facilities by reducing expiry and

improve revenue from sales of medicines

To establish transparent and accountable pharmaceutical transactions and services

To enable health facilities produce reliable information on product, finance and pharmacy

services regularly

To enable health facilities to measure workload, level of effort, develop human resource,

deploy and manage workforce effectively

To improve customer satisfaction on pharmacy services to the standard level

To improve rational medicines use and patient knowledge on correct dosage

Figure 3: Result areas (dimensions) of Auditable Pharmaceuticals Transactions and Services program, 2012, Amhara Region: Ethiopia [8]

APTS

Efficient Budget

Utilization

Improved Customer Satisfaction

Reliable Information

Effective Workforce

Deployment & Development

Transparent &

Accountable Transactions


22

II. Conceptual framework for APTS evaluation; Adapted from Logic Model

Conceptual framework for APTS evaluation; adapted from Logic Model Flowchart for Program

Evaluation, March 2015


23

Chapter 3: Objectives

3.1. General Objective

To measure the implementation status of APTS tools and systems with its outcomes and

challenges of its implementation in selected hospitals from Ethiopia

3.4. Specific Objectives

To measure the implementation status of APTS tools and systems

To evaluate outcomes of APTS implementation in reducing medicines expiry

To measure the outcomes of APTS implementation in increasing revenue from sales of

medicines

To evaluate the outcome of APTS implementation in improving patient knowledge on

correct dosage and satisfaction on pharmacy services

To identify the challenges of APTS implementation


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Chapter 4: Methodology

4.1. Study area and period

The study was conducted in hospitals from various regions of Ethiopia. The country Ethiopia

has nine Federal National States and two City Administrations with a recently estimated

population of 96,633,458 people, with growth rate 2.9% and life expectancy of the 60.75 years.

The country has a land mass of 1,127,127 square kilo meter bordered by Sudan in the west,

Djibouti in the east, Eretria in the north, south Sudan in the south west, Somalia in the south

east and Kenya in south. Ethiopia has huge capacity of health service delivery system, focusing

on prevention of diseases and attaining the MDG goals, with a capacity of 16,048 Health Posts,

3,245 Health Centers and 127 Hospitals [42]. This research was conducted in selected hospitals

from 5 APTS implementing regions of Ethiopia and 2 city administrations; namely, Amhara,

Harari, SNNP, Oromiya, Tigray, Addis Ababa and Diredawa (figure 6). From these regions,

APTS implementing sites were framed and ten hospitals were selected. Data was collected from

March 2015 onwards up September 30 2015 for 9 hospitals and from June 2015 for ALERT.

Figure 4: Regions of the Ethiopian; Nations, Nationalities and Peoples, where APTS is being implemented and the study area that this thesis evaluated APTS: are regions those painted in yellow; March, 2015


25

4.2. Study Design

Multiple case studies and cross-sectional descriptive study design were conducted employing

both qualitative and quantitative methods.

4.3. Population

Target Population: Health facilities to which the findings of this research will be targeted

(extrapolated) are APTS implementing sites in Ethiopia.

4.3.1. Source populations

1. The source populations for challenges and qualitative evaluations; the key informants were

CEOs and head pharmacist in ten selected APTS implementing hospitals of Ethiopia

2. The source populations to identify implementation status and challenges; all pharmacy and

finance staffs of all 10 selected hospitals in Ethiopia which are implementing APTS. They were

348 staffs.

3. The source populations for structured questions of patients for their knowledge and

satisfaction were all patients who got pharmacy service on the data collection period in the 10

selected hospitals of Ethiopia which implemented APTS.

4. The source populations for expiry rate, revenue from medicines sales, documents to be

reviewed were monthly reports of APTS starting from the first APTS monthly report generated

and submitted to RHB and or FMOH onwards, ABC/VEN analysis documents performed in the

APTS implementation year/s and stock status analysis made in the same year/s.

4.3.2. Study populations

1. The study populations for challenges and qualitative evaluations were sampled CEOs and head

pharmacist of hospitals which implement APTS in Ethiopia and which were selected for the

study.

2. The study populations for implementation status were all pharmacy and finance staffs in 10

selected hospitals in Ethiopia, to whom, self-administered question were distributed and who

fulfilled the inclusion criteria.


26

3. The study populations for structured questionnaire of patients for their knowledge to their

dispensed medicines and satisfaction on pharmacy services: are sampled patients by fulfilling the

inclusion criteria in ten selected hospitals of Ethiopia and who got pharmacy service in the data

collection period

4. The study populations for revenue, expiry rate and implementation status; documents to be

reviewed were all monthly reports of APTS starting from the first months of APTS monthly

report production onwards, sampled ABC/VEN analysis documents performed in the APTS

implementation year/s and sampled stock status analysis made in the same year/s.

4.3.3. Inclusion criteria

All pharmacy and finance staffs working in the pharmacy of the 10 selected hospitals of

Ethiopia that implemented APTS

For patient knowledge and satisfaction, patients who got pharmacy service in the ten

selected hospitals during the study period and willing to participate in the study with all

age groups were taken (for children care givers were targeted)

4.3.4. Exclusion criteria

Staffs who are in annual leave during the study period

Staffs who are sick during the study period

New staffs who were employed in less than six month period in the hospital

Patients who were very sick and unable to give information and also who are not willing

Documents which are disorganized

4.4. Sample Size and Sampling Technique

4.4.1. Sample size determination

1. The sample sizes for the in-depth interview were all CEOs and head pharmacists from 10

selected hospitals.

2. The sample size for self-administer questions to APTS implementing staffs from the selected

hospitals was 348 professionals. All who fulfilled the inclusion criteria were questioned.


27

3. For patient knowledge to dispensed medicines and patient satisfaction on pharmacy

services, the W.H.O. recommended sample size, at least 100 patients per facility and the

recommended number of health facilities (N=10) were selected to be sampled. So, the total

number of health facilities was 1000 as per W.H.O. recommendations [43].

4. The sample size for document review was all APTS monthly reports produced from each

hospital starting from the first month of APTS implementation onwards, all stock status

analysis findings and ABC/VEN analysis conducted in the APTS implementation period

5. Ten hospitals were selected from which CEOs, Head Pharmacists, documents were studied

4.4.2. Sampling Techniques

1. For qualitative evaluations, key informants were purposively the CEOs and head pharmacist

of all the 10 hospitals were interviewed using in-depth interview guide

2. For qualitative evaluations like challenges, the structured self-administer questions, data was

collected by self-administered questions to all pharmacy and finance staffs in the selected

hospitals. Questions were constructed according to the thematic areas of the APTS elements.

Staffs were asked to choose answers concerning their respective duties they had been

assigned.

3. For implementation status, expiry rate and revenue; data was collected from each selected

hospitals by reviewing various data sources- APTS monthly reports starting from APTS

implementation onwards. All ABC/VEN analysis documents and all stock status analysis

documents analyzed during the APTS implementation periods were also reviewed.

4. For patient knowledge and satisfaction, the W.H.O. recommended sampling technique that

enabled comparing health facilities amongst samples was employed. I.e.100 cases per health

facility were taken from 10 health facilities until arriving at 100 patients in each hospital and

a total of 1000 patients [43]. Since chronic care patients are usually scheduled either on both

Monday and Friday or on both Tuesday and Thursday in Ethiopian hospitals practice,

patients were interviewed starting from Monday onwards so that at least one of the days will

be chronic care day. For those hospitals which didn’t get enough samples of patients during

data collection in the first week, the next consecutive weeks were used. Samples were taken

on these days using convenient sampling technique until the number of patients reaches 100

from each health facility.


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4.4.3. Sampling Frames:

The proportion of hospitals that implemented APTS varies from region to region; i.e. Amhara

17, Addis Ababa 3, SNNPR 3, Tigray 2, Oromiya 1, Diredawa 1, and Hararie 1, a total of 28

Hospitals implemented APTS during start of data collection. To select study subjects for both

qualitative and quantitative methods from these hospitals that represents each region, number of

hospitals were assigned to respective regions by using a power allocation stratified sampling

technique; that enable to distribute sample size in skewed population, so that higher probability

for regions with a small number of APTS implementing hospitals was allocated [47].

So, all hospitals that implemented APTS from seven regions were framed. Then 10 were

selected based on stratified power allocation method to represent each region [46]. To select

hospitals from each region again, convenient sampling technique was used. Therefore, from

Oromiya=1 (Jimma University Hospital), Tigray 1 (Axum St Mary Hospital), Diredawa 1

(Dilchora Hospital), Harare 1 (Jegol Hospital), SNNP 1 (Arba Minch Hospital), Addis Ababa 1

(ALERT); a total of 6 hospitals were selected. The rest 4 hospitals were allocated to Amhara

region. The four hospitals from Amhara region were selected conveniently by dividing them in

to two zones (two hospitals were selected from west and two hospitals from east Amhara).

Accordingly, Debre Markos Referral Hospital and Felege Hiwot Referral Hospital were selected

from west Amhara while Borumeda Hospital and Dessie Referral Hospital were selected from

east Amhara.

A total of 348 self-administer questionnaire were distributed to all pharmacy and finance

professionals of the selected hospitals. All professionals who fulfil the inclusion criteria were

given a self- administer questions to measure implementation status and identify challenges.

Among the self-administer questions, 251(72%) were responded.

4.5. Data Collection

4.5.1. Development of data collection tools

Based on the objective of this study:

1. To collect information from key informants by in-depth interview, in-depth interview guide

was developed


29

2. To identify the implementation status of various result areas of APTS and challenges to

corresponding assigned professionals; self-administer structured questionnaire was

developed.

3. The portion of validated and standardized WHO drug use indicator assessment tool, that had

also been adapted by the Federal Ministry of Health and RHBs during baseline assessment of

APTS, was adapted for the APTS context and was used to collect the data by exit interview

from patients served in pharmacies of selected health facilities regarding patient satisfaction

and knowledge on correct dosage.

4. To collect secondary data from APTS monthly reports of each hospitals, and ABC/VEN and

SSA documents, a checklist was prepared

Each questionnaire had an introductory part which asks consent of the respondent and the

questions were formulated in a logical order according to result areas of APTS.

4.5.2. Personnel recruitment and training

Data collectors, which were already trained by each RHB during APTS baseline assessment and

who collected the baseline data of APTS, were purposively chosen from each region and were

given refresher training for one day by the principal researchers. The refresher training addressed

details about the data collection tool, interviewing procedures, the sampling technique to follow,

to review document and related ethical considerations. Twenty data collectors (two to each

health facility) were assigned.

4.5.3. Data collection techniques

The data collectors were assigned to nearby hospitals of their own region. Two data collectors

were assigned to one hospital. One of the two data collectors was assigned as a supervisor in

addition to data collection. The principal researcher was overseeing the performance of each

data collectors on telephone daily, progress made and gave comments for each step. Both, being

together saw the CEO and chief pharmacist of the hospital before starting their job. The principal

researcher communicated to the head of regional health bureau, pharmacy core process and CEO

and Chief pharmacist of the hospital prior to the start of data collection and obtained ethical

clearance accordingly. The patient interview was conducted starting from Monday until they

reached the sample size. The collected data were sent through EMS to the principal researcher

from each pair of data collectors.


30

4.6. Variables

4.6.1. Dependent variables

The outcome variables of this study are:

Category one:

1. The implementation status of APTS tools and systems

2. Availability of prescribed medicines

Category two

3. Expiry rate of medicines

4. Revenue from medicines sales

Category three

5. Patient satisfaction on pharmacy services

6. Patients’ knowledge on correct dosage

7. Challenges of APTS implementation

4.6.2. Independent variables

In this study the explanatory variables and the most proximate determinants for the dependent

variable are:

1. Category one:

a. implementation of APTS tools and systems

b. Adjustment of man power based on baseline and workload

c. Physical inventory an auditing

2. Category two:

d. Stock status analysis and ABC/VEN reconciliation analyses

e. Identifying of medicines used to treat top diseases

f. Bin management at dispensary

g. Implementation of effective medicines sales tools

h. Reduction of theft and pilferages

i. Patient knowledge on how to take medicines


31

3. Category three:

a. Pharmacy organization and workflow based on APTS standards

b. Dispensing /waiting area that fulfil APTS standards

c. Standard dispensing counter

d. Seated service for special counseling in OPD and chronic care pharmacies

4.7. Operational Definition

APTS standard vouchers and sales tickets: Models (19, 22, and sales tickets

standardized by Federal Ministry of Finance for APTS implementation.

APTS result areas: They are the pillars of APTS which includes; efficient budget

utilization, transparent pharmaceutical transaction, pharmacy organization and

workflow, reliable information used as in put of APTS and patient knowledge and

satisfaction as output of the system. Each of them has measurement indicators in APTS.

APTS standard dispensing area and counter: The dispensing areas of the outpatient

and emergency pharmacies of a hospital that has entrance door, billing/prescription

evaluation counter ( with height 0.75cm for sitting service, 1.10 meter for standing

service), for cashiers cubicle and medicines use counseling cubicle, and exit door in the

opposite side of entrance.

Availability of key medicines: it is the percentage availability of medicines used to treat

ten top diseases during the APTS reporting periods

Implementation status of APTS tools and systems: A hospital is said to be it has

implemented certain result areas of APTS; if documents are found that showed the result

area done as per the APTS guide for implementation or infrastructures are found being

built. Example: availability of drug list, prioritizations of drug list by VEN,

identifications drugs for ten top diseases, performing ABC analysis, conducting stock

status analysis and taking interventions. Receiving, issuing, selling of medicines using

vouchers/sales tickets approved by Federal ministry of finance, using drug codes,

auditing reports, producing daily summary and monthly reports, dispensary has two

doors, standard counters are built, man power adjusted, cashiers are inside the pharmacy,

process are rearranged as per APTS guide etc.


32

Knowledge of professionals: Level of understanding of the study participants

(pharmacists, cashiers, accountants) about their assigned duties concerning APTS

implementation is 100 % when they are asked to explain about their duties)

Key medicines: Medicines used to treat top ten disease are said to be key medicines

Management commitment: defined as the devotion of managers of the hospital to

allocate budget for renovation of dispensing area and employing human power.

Mean satisfaction: Mean satisfaction is the average of the results on LIKERT scale.

Patient knowledge: patients are considered that they know how to take their dispensed

medicines if they answer at least all 5 basic W.H.O drug use indicators (the dose, route

of administration, frequency, duration and storage) during exit interview.

Patient-days: The number of days in which patients were served in a hospital

Patient Satisfaction: patients are considered that they are satisfied if they answer either

agree or strongly agree for the LIKERT scale questions and that should be re-coded in

to new different variables

Patient dissatisfaction: patients are considered that they are dissatisfied if they answer

either disagree, keep quite or strongly disagree when they are asked. This also should be

recoded in to new variable.

Skill of professionals: the capacity of pharmacists, pharmacy accountants, cashiers and

store managers, to perform their respective duties of APTS implementation.

Revenue increment from sales of medicines: revenue is increased if there is a positive

slope of increment of revenue from sales of medicines starting from the baseline

Reduction of expiry rate of medicines: rate of expiry is said to be reduced if there is a

negative slope of rate of expiry of medicines for at least 3 months from the baseline.

Rate of expiry: It is the percentage calculated by dividing the expired value in monetary

forms to the stock available for sale.

Rate of sales of medicines: Rate of sales of medicines is the percentage of sales of

medicines divided by stock available for sale

Stock Available for sale: The sum of beginning stock and stock received during the

reporting period minus issued stocks to other party if any.


33

Trend of rate of expiry of medicines: is measured by calculating the slope of a serious

of values of expired medicines, which expired at different times since the start of APTS

report generation onwards

Trends of sales of medicines: it is measured by calculating the slope of sales of

medicines at each days and months since the start of APTS reporting dates onwards.

W.H.O drug use indicators: Variables that the World Health Organization (W.H.O)

uses as a standard for measuring patient knowledge on correct dosage

4.8. Data Processing and Analysis

The quantitative data was entered in to computer, explored, cleaned, standardized and

summarized by principal investigator using SPSS version 20. Data collected using LIKERT

scale questions to measure satisfaction and data collected to measure patients’ knowledge on

correct dosage using five W.H.O drug use indicators, were re-coded in to different variables,

counted and summarized to represent the dependent variables. Summarizations and recoding was

done based on the operational definitions. Logistic regression was used to determine crude and

adjusted OR. Bivariate analysis was carried out to assess association between the dependent and

all the independent variables and those variables which had statistically significant relationship

(p – value less than 0.25) were considered candidate for multivariate analysis. Then multivariate

analysis was performed to determine the independent predictors of the dependent variable

concerning implementation status of APTS and its results. The results were summarized by using

SPPS frequency tables. The challenges encountered by finance and pharmacy staffs, main points

obtained from CEOs and head pharmacists during in-depth interview, were summarized and

analyzed based on their thematic areas. Findings- data reviewed from documents, collected from

purposively selected CEOs and head pharmacists using in-depth interview guide, and data

collected from staffs by self-administer structured questionnaires and interviewed patients were

triangulated and association was analyzed. The results and associations were compared with the

regional, national and facility level baseline data of APTS descriptively. Odds ratios (OR) with

95% confidence intervals (CI) were calculated to determine the association and effect of

implementation status of APTS result areas with respective APTS outcomes. All p-values were

two-tailed and statistical significance was set at 0.05.


34

4.9. Data Quality Management

To improve the consistency of the tools prepared, tools was originally prepared in English. To

narrow language barriers during the interview, portion of tools that was used for patient exit

interview was translated into local languages of the respective regions including Amharic,

Tigregna, Oromiffaa and Gamugna.

The new portion of the tool was pretested in STH in Addis to check whether the tool was

sensitive enough to tempt interviewee in the intended manner and gather the necessary

information needed. The APTS baseline assessment tool, and the W.H.O. standardized tool of

patient knowledge and satisfaction were not modified. Data collector pharmacists were trained

for one day by a principal investigator. Final discussion was made with data collectors before

and after the start of the assessment to make sure each member of the data collector fully

understood the methods and tools. The guide was given for every data collector. Furthermore the

principal researcher was overseeing the whole data collection process. Once quantitative data is

entered in to SPSS, all questioners were reviewed to ensure accuracy of data entry.

4.10. Ethical Considerations

Ethical clearance with a formal covering letter, obtained from Jimma University (Reg. No:

RPGD 3079/2015) was submitted to the CEO of each hospital. Armauer Hansen Research

Institute (AHRI) ethical committee evaluated the proposal and gave another ethical clearance

(Reg. No: PO19/15). Oral informed consent was obtained from each respondent for patient

knowledge and satisfaction prior to the interview. For the purpose of confidentiality and ethical

issues, names of hospitals from which information obtained were recorded and analyzed using

uniquely identifying codes.

4.11. Dissemination of Results

The finding will be presented to the Jimma University and approval will be sought before

disseminating to other bodies. The principal investigator will report the approved findings and

give recommendations to the Federal Ministry of Health, Regional Health Bureaus, Hospitals,

Civil Service Bureau, Civil Service University and relevant NGOs concerning the

implementation status, challenges, outcomes, and recommendations. Finally, this thesis will be

published in international journals.


35

Chapter 5: Results

5.1. Socio Demographic Characteristics

Self-administer questionnaire distributed to 348 finance and pharmacy professionals from the

study hospitals and the response rate was 251 (72%). The majority of staffs were in the age

range of 19-29 (61%) with male predominance 149 (59.3%) and female 102 (40.7%). Majority

of them 171 (68%) were graduated from government universities/colleges. Staffs with degree

and above were dominant 150 (59.7%) with pharmacist by profession 125 (49.8%) and less than

2 years of experience 112 (44.6%), (Table 1). In addition, ten CEOs (all of them male) and ten

chief pharmacists 9 (male) and 1 female of these hospitals were also interviewed.

A total of 1000 patients from 10 selected hospitals were interviewed during exit after getting

pharmacy services; females 514 (51.4%), males 484 (48.5%) and majority were in the age range

of 19-29 (26.4%), (Table 2). The response rate for in depth interviews, patient knowledge and

satisfaction were 100%, but that of self-administered questionnaire was 72%.

Table 1 Socio-demographic characteristics of pharmacy and finance staffs working in10 selected hospitals; Jul 2015

Demographic characteristics

Frequency Percent

Sex Male 149 59.4 Female 102 40.6

Total 251 100.0 Age <18 1 0.4

20-29 153 61.0 30-39 59 23.5 40-49 11 4.4 50-59 4 1.6 Total 251 100

Type of sector (school, college, university) staff graduated from:

Government 171 67.6 Private: 79 31.2 Total 250 98.8

Educational status Certificate 7 2.8 Diploma 94 37.2 Degree and above 150 59.3 Total 251 99.2

Current position in the hospital Cashier 40 15.8 Auditor 12 4.7 Accountant 15 5.9 Druggist 53 20.9 Pharmacist 125 49.4


36

Human resource 6 2.4 Total 251 99.2

Work experience <2 years/Junior 112 44.3 2-5 full 71 28.1 5-7 senior 34 13.4 7-10 expert 16 6.3 > 10 senior expert 14 5.5 Total 247 97.6

Table 2: Socio-demographic characteristics of patients served in a cumulative of 36 various pharmacy outlets (OPD, Chronic care, Inpatient, ART, Maternity, Emergency and Especial pharmacies) in 10 hospitals, Jul 2015 Demographic characteristics

Frequency Percent

Sex Male 484 48.4 Female 514 51.4 Total 1000 100.0

Age <12 yrs. Being with care givers 101 10.1 >12<18 76 7.6 19-29 264 26.4 30-39 195 19.5 40-49 137 13.7 50-59 92 9.2 >60 118 11.8 Total 983 98.3 44 15 1.5 Total 1000 100.0

5.1. Documentary Survey

Each hospital included in the study started APTS at different seasons. Therefore, the numbers of

monthly reports they produced were also different. All reports they produced in excel sheet were

reviewed. The maximum number of monthly reports reviewed from a hospital was 39 (DMH)

and the minimum was ALH and JGH (3 months from each). A total of 153 months of APTS

reports (with different volumes and characteristics) from 10 APTS implementing hospitals

(DMH 39 months, BMH 23months, FHH 25months, AXH 16, DRH 19, AMH 14, DCH 7, JUH

4, ALH 3 and JGH 3 months) from APTS launch in each hospital up to Sept 30 2015 were

reviewed. Further to this, various analyses documents (including VEN, ABC and SSA) were

also studied.


37

5.2. Implementation status of APTS tools and systems

The lists of the four detailed result areas activities that should have been accomplished

whenever APTS is implemented as it is dictated by the guideline [8] were evaluated for their

implementation statuses. The implementation status of the four result areas altogether were

found ranged from 68% (JGH) to 95% (DMH). The mean implementation status of this result

area was found to be 83.6%. Six hospitals (AXH, BMH, DMH, FHH and JUH) were found

implementing overall result areas above the mean (Table 3). One of the ten hospitals was found

extending the system to x-ray (radiology units) beyond pharmacy services. There was a

cumulative of thirty six dispensing outlets in all ten hospitals.

Table 3: Implementation statuses of APTS tools and systems of the four result areas in ten selected hospitals, Jul- 2015

R1: Efficient Budget

Utilization R2:

Transparency

R3: Pharmacy

organization, workflow

R4: Reliable

Information on product, finance and services

Sum Total

Code yes No Total % yes No Total

% yes No Total

% yes No Total

% %

ALH 14 13 27 52 23 6 29 79 38 4 42 90 35 3 38 92 79

AMH 17 10 27 63 26 3 29 90 36 6 42 86 36 2 38 95 83

AXH 21 6 27 78 27 2 29 93 35 7 42 83 33 5 38 87 85

BMH 21 6 27 78 28 1 29 97 40 2 42 95 38 0 38 100 92

DMH 25 2 27 93 28 1 29 97 40 2 42 95 37 1 38 97 95

DRH 15 12 27 56 24 5 29 83 35 7 42 83 34 4 38 89 78

DCH 20 7 27 74 19 10 29 66 28 14 42 67 30 8 38 79 72

FHH 21 6 27 78 27 2 29 93 39 3 42 93 37 1 38 97 90

JGH 19 8 27 70 22 7 29 76 20 22 42 48 30 8 38 79 68

JUH 23 4 27 85 23 6 29 79 34 8 42 81 36 2 38 95 85

Mean 19 7.4 27 72 25 4.3 29 85 34 7.5 42 82 34 3.4 38 91 82.7

5.2.1. Efficient Budget Utilization (Result Area 1 of 4)

The implementation status of this result area ranged from 52% (ALH) to 93% (DMH). The

mean implementation status of this result area is 72.7%. Six hospitals (AXH, BMH, DMH,

DCH, FHH and JUH) were found implementing this result area above the mean (Table 3).

The Trend of Rate of Expiry of Medicines (outcome of result area 1)

Stock available for sale (SAS) and monetary values of expired medicines in birr of the ten

hospitals in a total of 153 months (with different characteristics) collected every day and


38

summarized in to monthly values were taken from the monthly report data. Rate was calculated

in percent. The cumulative monetary values of the expired along APTS implementing periods

were evaluated [Table 5]. Such analysis was also made by taking a single hospital as a case

study [Table 4].

Thirdly, the monthly rate of expiry of medicines was trended to see the slope whether it is

increasing or decreasing from the start of implementation of APTS by combining all hospitals

altogether [graph 7.1] and by taking one case [graph 7.2]. Both of the graphs showed that rate of

expiry were -0.889 [graph 7.1] and -0.94 [graph 7.2]

After implementation of APTS, the slope of the trends lines of the rate of expiry of medicines in

all hospitals included in the study were found to be negative, graph (7.1, and 7.2).

Table 4: Rate of expiry, stock available for sale, sales, profits and number of patient served the case of BMH hospital. The report collected from APTS launch up to Sept 30 2015, for the last 23 months; Oct- 2015

Characters Month1 Month2 Month3 Month4 Month5 SAS 1,726,271.12 1,783,127.82 1730598.56 1856028.66 1718125.98

Cash sales 78,088.70 121,682.15 92,022.89 184,774.28 168,184.88

Gross profit (cash) 15,617.74 24,336.43 18,404.58 36,954.85 33,636.98

Total sales 151,351.00 171,291.72 156,590.04 313,056.49 297,464.83

G. profit (total sales) 30,270.20 34,258.34 31,318.01 62,611.30 59,492.97

# of Patient on cash 1752 2172 1,572.00 3198 2562

# of patient (total) 2783 3204 2265 4580 4113

Price/ patient (cash) 61 46 47.00 54 65.00

Mean price / drug 34 20 19.00 22 24.00

Rate of expiry 0.77% 0.79% 2.38% 0.21% 2.26%

Expired value 13,292.00 14,086.70 41,188.20 3,897.60 38,829.64

Characters Month6 Month7 Month8 Month9 Month10

SAS 1895568.11 2109340.17 2315377.64 2823643.7 2561342.51

Cash sales 169,558.80 137,979.00 144,284.70 167,325.00 107,557.75


Total sales 294,783.90 282,008.40 282,127.40 289,493.65 240,390.70


# of Patient on cash 2598 2330 2240 2425 2,374.00

# of patient (total) 4052 4169 3737 4233 4,149.00

Price/ patient (cash) 65.00 59.22 64.00 69.00 45.00

Mean price / drug 23.00 18.00 27.00 32.00 24.00

Rate of expiry 0.29% 1.92% 0.39% 0.42% 0.00

Expired value 5,497.15 40,499.30 9,029.97 11,859.30 3,585.80

Characters Month11 Month12 Month13 Month14 Month15

SAS 2,416,659.65 2,505,179.71 2,457,702.18 2739726.73 2803112.76

Cash sales 167546.7 148516.8 138729.7 130563.28 149,352


39


Total sales 271372.85 264883.74 239034.91 240526.93 306,319


# of Patient on cash 2,280 2,817 2,496 2,188 2,737

# of patient (total) 3,881 4,460 4,165 4,044 5,180

Price/ patient (cash) 73 52 55 59 54

Mean price / drug 33 28 27 28 28

Rate of expiry 0.58% 0.13% 1.10% 1.09% 0.72%

Expired value 14016.6 3256.8 27034.7 29863 20182

Month16 Month17 Month18 Month19 Month20 SAS 2818187.95 2572761.27 2945361.23 2547163.48 2366619.53

Cash sales 206108.75 168712.65 152369.55 145888.35 99768.8

Gross profit (cash) 41221.75 33742.53 30473.91 29177.67 19953.76

Total sales 343752.03 318556.91 294084.67 300495.77 206361.77

G. profit (total sales) 68750.41 63711.38 58816.93 60099.15 41272.35

# of Patient on cash 2477 2707 2622 2631 2172

# of patient (total) 4429 4976 4656 4788 4038

Price/ patient (cash) 83 62 58 55 45.93

Mean price / drug 39 31

Rate of expiry 0.05% 0.58% 1.48% 0.03% 0.1%

Expired value 1409.1 14922 43591.35 764.15 2366.62

Month21 Month22 Month23 Rate of expiry: The cumulative rate of expiry for 23 months of this hospital was 3.5%, when the first four months of APTS implementation were reduced, rate were found to be 2.4% and when the last 6 months were taken, the rate reduced to 2% and the last quarter comes down below 2%.

SAS 3245477.01 2832953.04 2967683.32

Cash sales 100000 146707.15 136606.25

Gross profit (cash) 20000 29341.43 27321.25

Total sales 259655 297524 259599.38

G. profit (total sales) 51931 59504.8 51919.88

# of Patient on cash 2478 2991 2592

# of patient (total) 4751 5215 4414

Price/ patient (cash) 40.36 49.05 52.7

Mean price / drug

Rate of expiry 0% 1.8% 0.86%

Expired value 0 52976.22 25522.08


40

Table 5: Cumulative expiry of medicines from the start of APTS launch up to Sept 30/2015 compared with the cumulative expiry after 4 months from the APTS launch up Sept 30/2015, in all the study hospitals; Report organized Oct 30/2015

Code Name of Hospital

# of Month (start from APTS launch) SAS ( Birr)

% expired

Expired value (Birr)

# of Months (4 months after APTS launch)

SAS ( Birr)

% expired

Expired value Birr

DMH 39 29210312 3.4% 1008147 35 29486625 2.4% 707679

BMH 23 9385213 3.5% 336805 19 9396291.7 2.4% 225511

FHH 25 80125143 4.0% 3267230 21 81223571 2.8% 2274260

Axm 16 9477404.76 4.2% 398051 12 7323968.8 3.1% 234367

DRH 19 48136865.4 3.4% 1665264 15 28891483 2.8% 837853

AMH 14 14358358.2 0.7% 96201 10 13050263 3.8% 49591

DCH 7 6456020.56 1.8% 116208 3 5521687.5 1.6% 88347

JUH 4 34656900 2.9% 1005050 1 4077333.3 0.2% 6116

ALH 3 13110697.7 0.4% 56376 1 11958728 0.2% 19133

JRH 3 4066730.77 1.0% 42294 1 612965 2.2% 14098

Total 153 248983645 3.2% 7,991,626 118 191542916 2.3% 4456955

Graph7. 1 Rate of medicines expiry for the last 39 months in ten selected APTS implementing hospitals from seven regions of Ethiopia; rate compared with the baseline (taken before APTS implementation) up to September 30-2015. Report organized Oct 2015

0

2

4

6

8

10

12

14

16

R.B.Line

M1

M3

M5

M7

M9

M11

M13

M15

M17

M19

M21

M23

M25

M27

M29

M31

M33

M35

M37

M39

Rate of medicines expiryin %

Medicines rate of expiry from baseline and Month one (M1) up Month 39 (M39)

DMH

BMH

FHH

DRH

AXH

AMH

DCH

ALH

JUH

JGH

HSDP IV


41

Graph7. 2 The slope of the trend line of the cumulative rate of medicines expiry for the last 39 months of the ten selected APTS implementing hospitals from seven regions of Ethiopia; trend compared with the baseline (taken before APTS implementation) up to September 30- 2015. Report organized on Oct-2015

The slope of the trend line of the cumulative rate of expiry of medicines for the ten selected

hospitals altogether in each APTS implementing months was found to be negative -0.089.

The volume of expired medicines in all hospitals included in the study in a total of 153 months

(with different characteristics) was found to be birr 7,991626 with 1.4% an average rate of expiry

recorded during each APTS implementation months. The minimum and maximum cumulative

rate of expiry recorded after the baseline in these hospitals was 0.04% and 4.128% respectively.

The median of rate of expiry of medicines of all 153 months (with different characteristics) was

found to be 0.503%. [Graph 7.1)]

However, when stock available for sale (SAS) was calculated cumulatively for 153 months from

all hospitals considering them as one institution, and all expired values were rated against this

cumulative SAS from the study hospitals altogether, the mean rate of expiry became 3.2%, while

avoiding the first four months, mean rate expiry became 2.3% [Table 5].

y = ‐0.0889x + 2.9681

‐2.00

0.00

2.00

4.00

6.00

8.00

10.00

12.00

R.B.Line M1

M3

M5

M7

M9

M11

M13

M15

M17

M19

M21

M23

M25

M27

M29

M31

M33

M35

M37

M39

Rate of medicines expiryin %

Cumulative medicines rate of expiry from baseline and Month one (M1) up Month 39 (M39) for ten hospitals

CumulativeAverageexpiry

HSDP IVtarget

Linear(CumulativeAverageexpiry )


42

Graph7. 3 The slope of the trend line of the rate of medicines expiry for the last 39 months in DMH; trend compared with the baseline (taken before APTS implementation) up to September 2015; data organized Oct 2015.

The slope of the trend line of the rate of expiry of medicines for the case of DMH hospital was

also found to be negative -0.094.

Stock Status Analysis

Among ten hospitals included in the study, five hospitals conducted stock status analysis and

identified medicines at risk of expiry and took interventions [table 6]. If measure were not taken,

all medicines costing birr 3,509,097 would have been expired.

Table 6: Implementation status of one result areas of APTS (SSA), used to identify medicines at risk of expiry in 10 selected hospitals, March 2015.

Code Drugs that would have been

expired are identified using APTS

tool (SSA)

Cost of medicines identified and

saved that would have been

expired

# of saved

medicines

by type

Yes /No

ALH No - -

AMH No - -

AXH No - -

BMH yes 11,000.00 18

DMH yes 713,774.00 45

DRH yes 208,052.05 24

DCH yes 349,561.00 21

y = ‐0.094x + 3.1698

‐2

0

2

4

6

8

10

12

R.B.line

M1

M3

M5

M7

M9

M11

M13

M15

M17

M19

M21

M23

M25

M27

M29

M31

M33

M35

M37

M39

Rate of expiry in %

Medicines rate of expiry in DMH from baseline and Month one (M1) up Month 39 (M39) for a total of 39 months

Rate of medicinesexpiry in DMH

HSDP IV target

Linear (Rate ofmedicines expiry inDMH)


43

FHH yes 2,226,710.00 79

JUH No

JGH No

Total 3,509,097.05 187

Trend of cash sales of medicines and gross profit over the years

Starting from the baseline data onwards, during implementation of APTS in the last 39 months,

the slope of the trend line of cash sales of medicines in all hospitals included in the study was

found to be positive ranging from 386 in (BMH) to slope of 20,399 in (FHH) (Graph 7.4)

Graph7. 4 Trends of cash sales of medicines in birr in ten selected APTS implementing hospitals from 7 regions of Ethiopia: cash sales collected during 4500 days; starting from the first month of APTS implementation in each hospital up to September 30, 2015

The slope of the trend lines of gross profit from cash sales of medicines [graph 7.5], total sales

of medicines (cash + credit + for free) [graph 7.6] and gross profit from total sales of medicines

[graph 7.7], from the start of APTS implementation onwards, in all hospitals included in the

study was found to be positive.

y = 4559.2x + 290596

y = 386.09x + 137207

y = 20399x + 527781

y = 11201x + 347101

‐

200,000.00

400,000.00

600,000.00

800,000.00

1,000,000.00

1,200,000.00

1,400,000.00

M1

M3

M5

M7

M9

M11

M13

M15

M17

M19

M21

M23

M25

M27

M29

M31

M33

M35

M37

M39Revenue from cash sales of medicines

Trend of cash sales of mediicnes from from month 1 (M1) up to Month 39 (M39)

DMH

BMH

FHH

AXH

DRH

AMH

DCH

JUH

ALH

JGH


44

Graph7. 5 Trends of gross profit from cash sales of medicines in birr in ten selected hospitals from 7 regions of Ethiopia: gross profit collected during 4500 days; starting from the first month of APTS implementation in each hospital up to September 30, 2015

Graph7. 6 Trends of total sales of medicines (Cash + Credit + for Free) in birr in ten selected hospitals from 7 regions of Ethiopia: total sales collected during 4500 patient-days (150 months with different characteristics) ; starting from the first month of APTS implementation in each hospital up to September 30, 2015; Data organized Oct 2015.

y = 911.84x + 58119

y = 77.218x + 27441y = 77.218x + 27441

y = 4079.8x + 105556

y = 279.54x + 44304

y = 2240.3x + 69420

y = 2054.5x + 56845

‐

50,000.00

100,000.00

150,000.00

200,000.00

250,000.00

300,000.00

M1

M3

M5

M7

M9

M11

M13

M15

M17

M19

M21

M23

M25

M27

M29

M31

M33

M35

M37

M39

Gross profit from cash sales of medicines

Trend of gross profit from cash sales of medicines from from month 1 (M1) up to Month 39 (M39

DMRH

BMH

FHH

AXH

DRH

AMH

DCH

JUH

ALH

JGH

y = 13957x + 349029

y = 2956.3x + 228904

y = 67197x + 903804

y = 33306x + 573655

‐

500,000.00

1,000,000.00

1,500,000.00

2,000,000.00

2,500,000.00

3,000,000.00

3,500,000.00

4,000,000.00

M1

M3

M5

M7

M9

M11

M13

M15

M17

M19

M21

M23

M25

M27

M29

M31

M33

M35

M37

M39

Total Sales of medicines in birr (cash + credit +

for free)

Trend of all medicines sales from month 1 (M1) up to month 39 (M39)

DMRH

BMH

FHRH

AXMH

DRH

AMH

DCRH

JUSH

ALTH

JGH


45

Graph7. 7 Trends of gross profit from total sales (cash + credit + free) of medicines in birr in ten selected hospitals; total gross profit collected during 4500 patient-days (151 months with different characteristics) ; starting from the first month of APTS implementation in each hospital up to September 30, 2015; Data organized Oct: 2015

In addition, the trend lines slopes of the number of patient served in all hospitals included in this

study was found to be positive ranging from 21 to 195 (graph, 7.8).

Graph7. 8 Trend of number of patient served on cash in ten selected hospitals from 7 regions of Ethiopia, in the last 39 months, starting from the first month of APTS implementation onwards up to September 30, 2015; Data organized Oct 2015

y = 2791.4x + 69806

y = 591.26x + 45781

y = 13439x + 180761

y = 6661.3x + 114731

‐

100,000.00

200,000.00

300,000.00

400,000.00

500,000.00

600,000.00

700,000.00

800,000.00

M1

M3

M5

M7

M9

M11

M13

M15

M17

M19

M21

M23

M25

M27

M29

M31

M33

M35

M37

M39

Gross profit from sales of

medicines (cash + Credit + free)

Trend of gross profit from all kinds of medicines sales (cash, credit and free) from month 1 (M1) up to month 39 (M39)

DMRH

BMH

FHRH

AXMH

DRH

AMH

DCRH

JUSH

ALTH

JGH

y = 23.982x + 8435.7

y = 21.36x + 2196.3

y = 195.68x + 12445

y = 2.0015x + 5268.8

y = 248.18x + 7983.7

0

5000

10000

15000

20000

25000

M1

M3

M5

M7

M9

M11

M13

M15

M17

M19

M21

M23

M25

M27

M29

M31

M33

M35

M37

M39

Number of patients swerved on cash

Months of APTS implementation in which patients are served (M to M 39)

DMRH

BMH

FHRH

AXMH

DRH

AMH

DCRH

JUSH

ALTH

JGH


46

Graph7. 9. The trend line of the number of patient served on (cash + Credit + for free) in ten selected hospitals from 7 regions of Ethiopia, in the last 39 months, starting from the first month of APTS implementation onwards up to September 30, 2015; Data organized Oct 2015.

5.2.2. Affordability

Affordability was calculated as the number of days the lowest paid unskilled government worker

would have to work to pay for one treatment course for an acute condition or one month’s

treatment for a chronic condition from each hospital over the years. At the time of the survey, the

lowest paid Ethiopian government worker earned 690 ETB (US$ 34.5) per month or 23 ETB

(US$ 1.15) per day. Overall, a low-paid unskilled government worker would generally need

more than one day’s wages to purchase standard treatments in the selected government hospitals

(graph 7).

The median days’ wage of these unskilled workers to buy medicines on cash from each hospital

was taken for the calculation and the maximum median days’ wage among hospitals was 3.8

(ALTH) while the minimum was 1.2(JGH). The mean of these median days’ wage was 2.05

while the median of medians were 1.8 days’ wage. In general, there was no hospital with days’

wage less than 1 day.

Days’ wage was trended over the years (during 39 months) to see whether it has a positive slope

(increasing) or negative slope (decreasing). The trends lines of days’ wage of cash sales

calculated for every hospital in all 39 month was found to have positive slopes ranging from

0.005 to 0.034.

y = 114.28x + 10277

y = 73.277x + 3306.9

y = 556.81x + 18633

y = 383.71x + 10927

0

5000

10000

15000

20000

25000

30000

35000

40000

45000

M1

M3

M5

M7

M9

M11

M13

M15

M17

M19

M21

M23

M25

M27

M29

M31

M33

M35

M37

M39

Total number of patients served (cash +

credit + free)

Months of APTS implementation from month 1 (M1) to Month 39 (M39) in which patients Served

DMRHBMHFHRHAXMHDRHAMHDCRHJUSHALTHJGHLinear (DMRH)Linear (BMH)Linear (FHRH)Linear (DRH)


47

Graph7. 10: The median days’ wage for unskilled government worker that would have to pay to buy medicines from 34 various pharmacy outlets (OPD, Emergency, Inpatients, Chronic care etc.) of the ten selected hospitals from 7 regions of Ethiopia; of the last 39 months up to September 30 2015. Data organized Oct. 2015.

Graph7. 11: Trends of days’ wage that unskilled government worker would have to work to buy medicines on cash in ten selected hospitals from 7 regions of Ethiopia, starting from APTS initiation up to September 30 2015. Data organized Oct 2015.

5.2.3. Transparency; (outcomes of result area 2)

In this section, implementation status of tools and systems that are designed to bring

transparency and accountability; receiving medicines in the stores, issuing to units and

dispensing to patients with coding, physical inventory, auditing activities were evaluated. The

implementation status of this result area ranged from 66% (DCH) to 97 % (BMH and DMH).

1.8

2.52.3

1.7

2.3

1.6 1.51.8

3.8

1.2

0

0.5

1

1.5

2

2.5

3

3.5

4

DMRH BMH FHRH AXMH DRH AMH DCRH JUSH ALTH JGH

Median Days' Wage

Median Days'Wage

y = 0.0166x + 1.5244

y = ‐0.0127x + 2.6641

y = 0.0342x + 1.8527

y = 0.0055x + 1.5475

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

Days' wage

Months in which days' wage are calculated to buy medicines on cash for unskilled government employ would have to pay from month 1 (M1) up to

month 39 (M39)

DMRH

BMH

FHRH

AXMH

DRH

AMH

DCRH

JUSH

ALTH

JGH


48

The mean implementation status of this result area was found to be 85.3%. Five hospitals (AMH

90%, AXH 93%, BMH 97%, DMH 97% and FHH 93%) were found implementing this result

area above the mean (Table: 3).

Conducting physical inventory (another outcomes of result area 2)

Using the key informants and documents reviewed, it was studied that all hospitals that have

been using APTS principles for conducting physical inventory responded that the days needed to

conduct physical inventory was found to be ranged from 2 to 7 days after APTS and 7 to 30 days

before APTS The mean number of days needed to take one round of physical inventory was 19.2

before APTS and found to be reduced to 3.3 days (Graph7.11).

Graph7. 12: The time needed (in days) to conduct physical inventory of medicines, before and after APTS, in 10 selected hospitals from 7 regions of Ethiopia, Oct 2015

5.2.4. Effective workforce development, deployment and organization (Result A. 3)

The implementation statuses of APTS principles in terms of structure of the pharmacy, man

power development, training, and workload analysis, adjustment of man power based on

workload analysis, performance evaluation, and workflow and premises arrangement for

pharmacy services were evaluated. The implementation status of this result area ranged from

48% (JGH) to 95% (BMH and DMH) (Table: 3).

The mean implementation status of this result area was found to be 82.1%. Seven hospitals

(ALH, AMH, AXH, BMH, DMH, DRH and FHH) were found implementing result area 3 above

the mean.

Seven hospitals included in the study (AXM, DMH, BMH, JUH, ALH, FHH, AMH) renovated

the outpatient pharmacy premises and rearranged patient flow as per the APTS standards;

0

10

20

30

ALH AMH AXH BMH DMH DRH DCH FHH JUH JGH

30 30

7 7

20

10

30

21

30

72 2 2 2 3 2

8 73 2

Days needed to conduct

physical inventory

Hospitals included in the study

Days needed to conduct physical inventory of medicines

Days needed forphysical countbefore APTS

Days needed forphysical countusing APTS


49

whereas only five of them (DMH, BMH, ALH, FHH and AMH) did the same for all pharmacy

outlets in their hospitals.

Additionally, among 42 indicators of this result area, seven most important indicators were

selected. They are having rearranged workflow at OPD, having two doors, special counseling for

chronic care, standard counters in place, and staff adjustment and being cashiers within the

dispensary. These indicators were evaluated. The mean implementation status of these seven

selected indicators was found to be 72%. Five hospitals scored above the mean and five scored

below the mean with the range of 0 to 100% [Table 7]


50

Table 7: Implementation statuses of few selected elements of result area 3 (organization, staffing, dispensing counter and patient flow) in ten selected hospital pharmacies, March 2015

Code

Evaluator/

Biller /

Cashier/

Counselor

Two

doors

OPD

Special

counseling

Chronic

care

Special

counseling

Standard

counter

Staff

adjusted

Cashier

within

dispensary Total

Mean

%

AXH yes No yes yes No yes yes 5 71

BMH yes yes yes yes yes yes yes 7 100

DMH yes yes yes yes yes yes yes 7 100

DRH No yes yes yes No No yes 4 57

FHH yes yes yes yes yes yes yes 7 100

DCH No No yes No No No No 1 14

AMH yes yes yes yes yes yes yes 7 100

JGH No No No No No No No 0 0

ALH yes yes yes yes yes yes yes 7 100

JUH yes yes No yes No yes yes 5 71

Mean 7 7 8 8 5 7 8 50 72

Dispensary organization and patient Flow (one outcome of result area 3)

The case of FHH- OPD pharmacy renovated as per the APTS standard and patient flow inside

was taken as example. (Picture 1)

Picture 1: Patient flow at OPD pharmacy, the case of FHH; before (left) and after (right) APTS, renovated for APTS standard dispensing flow, picture collected from the hospital documentary unit and organized; June 2015


51

Figure 5: Premises, work flow and patient queue modeling in APTS; (single queue - multiple server modeling) Ethiopia, 2010; reported June 2015

Graph7. 13 Implementation statuses of R 3 of APTS (Pharmacy staffs adjustment) based on APTS workload analysis principles in ten selected hospitals from 7 regions of Ethiopia, before and after APTS, June 2015.

Graph7. 14 Implementation status of one result areas of APTS (finance staffs adjustment) based on APTS workload analysis principles in ten selected hospitals, before and after APTS, June 2015.

The number of pharmacy and finance professionals was found to be adjusted as per the baseline

data in 5 among ten hospitals included in the study. In these five hospitals, the number of

0

10

20

30

40

50

60


Pharmacist Before

Pharmacist After

Pharmacy Technician BeforeAPTS

Pharmacy Technician After APTS

0

2

4

6

8


Pharmacy Acountant BeforeAPTS

Pharmacy Acountant AfterAPTS

Cashier Before APTS


52

pharmacy and finance professionals, were found to be higher than before APTS [graph 7.13,

7.14]].

5.2.5. Reliable information on product, finance and services; (result area 4)

The implementation status of result area 4 ranged from 79% (JGH and DCH) to 100% (BMH).

The mean implementation status of this result area was found to be 91.5%. Six hospitals (ALH,

AMH, BMH, DMH, FHH and JUH) were found implementing result area 4 above the mean

[Table 3]

5.3. Availability of prescribed medicines

Patients interviewed for their knowledge and satisfaction were also observed for the medicines

they got from the hospital pharmacy and prescription they receive to buy medicines from outside

the hospital. A total of 1000 patients were observed prescribed with 2254 medicines and out of

these, 1967 medicines were dispensed from these hospitals. The mean availability of prescribed

medicines was found to be 87.2%. Seven hospital availed medicines above the mean. The range

of availability was from ALH 72% to DMH (96%). However, patients who got all prescribed

medicines were ranging from 151 (53%) to 172 (95%) [Table 8]

Table 8: Availability of prescribed medicines for patients served in a cumulative of 34 various pharmacy outlets (OPD, Chronic care, ART, Maternity, Emergency, Especial pharmacies etc.) of the 10 selected hospitals from 7 regions of Ethiopia, Organized June 2015. N=1000

Code Prescribed Dispensed Available %

% Patient who got all

prescribed medicines

ALH 210 151 72 53

AMH 191 172 90 95

AXH 240 217 90.4 78

BMH 230 208 90.4 92

DCH 268 208 77.6 57

DMH 255 247 96.8 91

DRH 200 185 92.5 86

FHH 217 203 93.5 91

JGL 215 182 84.6 70

JUH 228 194 85 76

Mean 2254 1967 87.2 79


53

Graph7. 15 Availability of prescribed medicines and patient who got all prescribed medicines; that patients served in a cumulative of 34 various dispensing outlets (OPD, Chronic care, ART, Maternity, Emergency, Especial pharmacy outlets etc.) of the 10 selected hospitals from 7 regions of Ethiopia, June 2015. N=1000

Graph7. 16 # of prescribed and dispensed medicines for patients served in in a cumulative of 34 various dispensing outlets (OPD, Chronic care, ART, Maternity, Emergency, Especial pharmacies) 10 selected hospitals from 7 regions of Ethiopia, Organized June 2015

Identification of medicines used to treat ten top diseases and following their availability on

monthly basis had association with availability of prescribed medicines (Adjusted OR=7.5, P.

value. 0.000, C.I. 3.887-14.473), (Table 8).

0

20

40

60

80

100

ALH AMH AXH BMH DCH DMH DRH FHH JGL JUH

53

95

78

92

57

91 86 91

7076

% Availability and % of Patients

Name of hospitals ‐coded

% of availability of prescribed medicines and % of patient who got all prescribed medicines in 10 selected hospitals, March

2015

MedicinesAvailable %

% Patient whogot allprescribedmedicines

0

100

200

300

# of prescribed and

dispensed drugs

Name of hospitals ‐coded

# of Availability of prescribed and dispensed Medicines

# ofPrescribeddrugs

# ofDispenseddrugs


54

Factors affecting availability of medicines

Table 9: Logistic regression for availability of prescribed medicines for cohort of the same patients who got service in a cumulative of 34 various pharmacy outlets (OPD, Chronic care, ART, Maternity, Emergency, Especial pharmacies etc.) of the 10 selected hospitals; Organized June 2015: N=1000

Variables

Patient who got all prescribed medicines from the pharmacy

Crude OR (95%.C.I)

P. Value

Adjusted OR (95%.C.I) Yes % No %

Patients served in a hospital which identified medicines used to treat 10 top diseases and follow availability monthly

Yes

356 (45)

433 (55)

3.1(2.176-4.475)

0.000

7.5(3.887-14.473)

No

44(21)

167(79)

0.69(0.631-0.762)

1

1

Patients served in hospitals that uses the ABC/VEN analysis for procurement

Yes

640(81)

148(19)

1.4(0.98-2.028)

0.000

0.324(0.184-0.57)

No

159(75)

52(25)

0.76(0.578-1.005)

1

1

Patients served in a hospital which adjusted staffs as per workload analysis:-

Yes

654 (83)

135(17)

2.15(1.526-3.048)

0.000

3.6(2.018-6.43)

No 146(69) 65(31) 0.5(0.431-0.716) 1 1

Patients served in

pharmacy with two

doors

Yes

422 (53)

367(47)

1.96(1.43-2.68)

0.054

0.621(0.382-1.009)

No 78(37) 133(63) 0.73(0.650-0.8) 1 1


55

5.4. Patient knowledge on correct dosage

Measuring patient knowledge (one of the combined outcomes of result area 1, 2 and 3)

Among 1000 patients interviewed during exit after getting services; 21.1%, 92.9%, 98.6%,

96.4%, 76.6%, 55.5% and 57.3% respectively were able to tell the name, dose, route of

administration, frequency, duration of treatment, where to store and precaution of their dispensed

medicines with mean 71.2%). Patients who knew the six basic W.H.O drug use indicators (dose,

route, frequency, duration, storage and precaution) were found to be 795 (79.5%) whereas those

who knew the five basic W.H.O drug use indicators were 84%. These patients, who knew 5

variables, are considered that they knew on how to take and manage medicines dispensed to

them (Table 9). Among 10 hospitals included in the study, five (AXH, BMH, DMH, ALH and

AMH) scored above the mean.

Table 10: Frequency and mean of knowledge of patients on correct dosage during exit interview after getting services in a cumulative of 34 various dispensaries (OPD, Chronic care, Inpatient, ART, Maternity, Emergency) of the 10 selected hospitals, from 7 region of Ethiopia, Organized, June 2015. N=1000

Name N=100

Dose N=100

Route N=100

Frequency N=100

Duration N=100

Storage N=100

Precaution N=100

Total N=1000

Mean N=100

AXH 11 100 100 100 96 89 94 590 84.3DRH 14 97 99 98 74 43 41 466 66.6FHH 18 100 100 100 35 10 18 381 54.4BMH 21 97 99 99 99 79 85 579 82.7DMH 34 100 100 97 82 42 78 533 76.1DCH 15 71 94 96 62 65 57 460 65.7JUH 29 86 97 91 88 54 38 483 69.0JGH 17 98 100 99 73 20 39 446 63.7ALH 16 88 99 96 86 81 52 518 74.0AMH 36 92 98 88 71 72 71 528 75.4Total 211 929 986 964 766 555 573 4984 712.0Mean 21.1 92.9 98.6 96.4 76.6 55.5 57.3 Mean 71.2The mean percentage of patients’ knowledge on correct dosage using 7 W.H.O indicators = (71.2%)

Dose Route Frequency Duration Storage Precaution Total Mean AXH 100 100 100 96 89 94 579 96.5DRH 97 99 98 74 43 41 452 75.3FHH 100 100 100 35 10 18 363 60.5BMH 97 99 99 99 79 85 558 93.0DMH 100 100 97 82 42 78 499 83.2DCH 71 94 96 62 65 57 445 74.2JUH 86 97 91 88 54 38 454 75.7JGH 98 100 99 73 20 39 429 71.5ALH 88 99 96 86 81 52 502 83.7


56

AMH 92 98 88 71 72 71 492 82.0Total 929 986 964 766 555 573 4773 795.5Mean 92.9 98.6 96.4 76.6 55.5 57.3 Mean 79.6 The mean of patients’ knowledge on correct dosage using 6 W.H.O indicators = (79.6%) Dose Route Frequency Duration Storage Total Mean AXH 100 100 100 96 89 485 97.0DRH 97 99 98 74 43 411 82.2FHH 100 100 100 35 10 345 69.0BMH 97 99 99 99 79 473 94.6DMH 100 100 97 82 42 421 84.2DCH 71 94 96 62 65 388 77.6JUH 86 97 91 88 54 416 83.2JGH 98 100 99 73 20 390 78.0ALH 88 99 96 86 81 450 90.0AMH 92 98 88 71 72 421 84.2Total 929 986 964 766 555 4200 840.0Mean 92.9 98.6 96.4 76.6 55.5 Total Mean 84.0

The mean of patients’ knowledge on correct dosage using 5 W.H.O indicators = (84%)


57

Table 11: Multivariate Logistic Regression analysis for knowledge of patients on correct dosage, during exit interview among respondent patients who got pharmacy service in a cumulative of 34 various pharmacy outlets (OPD, Chronic care, ART, Maternity, Emergency, Especial pharmacies) from pharmacies that have different implementation statuses of APTS; June, 2015; N=1000

Variables

Yes

Patient who knew Correct dosage on exit interview

No Yes No COR (95%. C.I)

P. Value

AOR(95%.C.I)

Sex:

M 290 194 0.8(0.67-1.13)* 0.137 0.8(0.61-1.06)

F 324 190 0.9(0.86-1.04)* 0.312 1.1(0.88-1.47) Age: <12 yrs/Care givers

50 (49) 51 (51) 0.1 (0.92-1.50)* 0.097 0.5(0.30-1.10)

<18>12 46 (61) 30 (39) 0.6 (.35-1.16) 0.081 0.7(0.34-1.04) 19-29 159(60) 105 (40) 0.6(0.408-0.02) 0.079 0.6(0.38-1.05) 30-39 124 (63) 71 (37) 0.5(0.345-0.91) 0.036 0.5(0.33-0.96) 40-49 89(65) 48 (35) 0.5(0.313-0.89) 0.011 0.4(0.27-0.84)

50-59 62(67) 30 (32) 0.4(0.264-0.85) 0.001 0.4(0.23-0.82) >60 74 (63) 44 (37) 0.4(0.264- 0.85) 0.005 0.4(0.23-0.77) Patients served in a pharmacy which had Rx evaluator- cashier - counsellor; all in queue:

Yes No

523(85) 92 (15)

277(15) 108(28)

2.2(1.61-3.034)* 1

0.000 1

4.6(2.37- 9.19) 1

Patients served in OPD dispensary with entry and exit doors

Yes

322(64)

178(36)

1.2(0.99-1.65)

0.003

0.5(0.36-0.81)

No 293(59) 207(41) 1 1 1 Patients served OPD pharmacy which has seated service for special

Yes

459(66)

241(33)

1.7(1.35-2.31)*

0.956

0.9(0.61-1.57)

No 156(52) 144(48) 1 1 1 Patients served in a hospital which had seated service in chronic care pharmacy:

Yes No

406 (68) 209(52)

194(32) 191(48)

1.9(1.47-2.48)* 0.6(0.58-0.78)

0.316 1

1.3(0.76-2.26) 1

Patients served with standard counter

Yes 474(68) 226(32) 2.3(1.79-3.19)* 0.000 3.4(2.01-5.63) No 141(47) 159(53) 0.60(0.52-7.09) 1 1

Note: * P. Value <0.25; significance is declared when P. Value is <0.05.


58

5.5. Patient satisfaction on pharmacy services

Measuring patient satisfaction (another combined outcome of result area 1, 2 and 3)

The same 1000 patients, (who were interviewed during exit about their knowledge on dispensed

medicines); were also interviewed about their satisfaction. They reported their satisfaction with

waiting /dispensing area and counter with mean (79.9%), privacy (72.8%), dispensing process

(83%), personnel service (87.2%), and with overall pharmacy services (86.8%). (Table 11)

The LIKERT result showed that patients who are strongly satisfied 2036 (40.7%), satisfied 2070

(41.4%), neutral 552(11.04%), dissatisfied 204 (4.08%) and strongly dissatisfied were

136(2.86%) (Table 11)


59

Table 12: Satisfaction of patients served in a cumulative of 34 various dispensing outlets (OPD, Chronic care, Inpatient, ART, Maternity, Emergency, Especial pharmacies) of 10 selected hospitals; using LIKERT scale questions and Nominal Scales questions, June 2015: N=1000

LIKERT SCALE

Satisfaction with waiting / dispensing area & counter

Satisfaction with privacy of dispensary

Satisfaction with dispensing process

Satisfaction with personnel service

Satisfaction With overall pharmacy services

Mean Satisfaction

5.Strongly agree 401 (40.1%) 324(32.4%) 427 (42.7%) 451 (45.1%) 433 (43.3%)

2036 (40.7%)

4. Agree 398(39.8%) 404 (40.4) 412 (41.2%) 421(42.1%) 435(43.5%) 2070 (41.4%) 3. Neutral 105 (10.5%) 151(15.1%) 102 (10.2%) 93 (9.3%) 101(10.1%) 552(11.04%) 2. Disagree 62(6.2%) 49 (4.9%) 44(4.4%) 25 (2.5%) 24 (2.4%) 204 (4.08%) 1.Strongly disagree 34 (3.4%) 72(7.2%) 15 (1.5%) 10(1.0%) 5 (0.70%)

136(2.86%)

Total 1000 1000 1000 1000 1000 5000 NOMINAL SCALE: Summarized Satisfaction

Satisfied 799 728 839 872 868 4106

Not Satisfied 201 272 161 128 132 894

% Patients satisfied 79.90% 72.80% 83.00% 87.20% 86.80% 82% Total 1000 1000 1000 1000 1000 5000

Patient satisfaction in each 10 hospitals on 5 different variables: Nominal Scale

Code

Patient satisfied with /dispensing area/ counter (%)

Patient satisfied with privacy (%)

Patient satisfied with dispensing process (%)

Patient satisfied with personnel service (%)

Patient satisfied with overall services (%) Mean %

AXH 100 99 95 93 86 94

DRH 31 59 67 84 70 62

FHH 93 71 98 94 94 90

BMH 98 78 98 97 99 94

DMH 100 100 100 99 100 99

DCH 56 61 61 72 80 66

JUH 83 75 79 89 89 83

JGH 73 55 78 75 86 73

ALH 96 65 97 100 99 91

AMH 69 65 66 69 65 67

Total 799 728 839 872 868 821

Mean 79.9 72.8 83.9 87.2 86.8 82


60

Table 13: Multivariate logistic regression analysis for patient satisfaction with personnel service in 10 selected hospitals; among respondents who got pharmacy services in a cumulative of 34 various pharmacy outlets (OPD, Chronic care, ART, Maternity, Emergency, Especial pharmacies); of which hospital pharmacies with different level of implementation status of APTS; June 2015

Variables

Patient satisfied with personnel services

Crude OR (95%.C.I)

P. Value

Adjusted OR (95%.C.I)

Yes No

Patient who got all Rx medicines.

Yes

696(88)

93(12)

1.4(0.976-2.27)*

0.227

1.3 (0.832-2.174)

No 176(83) 35(16) 0.71(0.49-1.016) 1 1 Patients served in a hospital which adjusted human power as per baseline :-

Yes

707(88)

93(11)

1.61(1.05-2.46)*

0.009

0.08(0.014-0.548)

No 165(82) 35(17) 0.66(0.46-.94) 1 1

Patients served in a hospital which adjusted staffs as per workload analysis:-

Yes

638(91)

62(9)

2.90(1.990-4.23)*

0.000

14(3.534-63.24)

No 234(78) 66(22) 0.403(0.293-0.55) 1 1

Patients served in a hospital which has cashier next to evaluator :-

Yes

725(90)

75(10)

3.4(2.35-5.168)*

0.000

4(3.1-23.255)

No 147(73) 53(26) 0.35(0.25-.48) 1 1

Patient served in pharmacy with two doors :-

Yes

459(92)

41(8)

2.3(1.590-3.49)*

0.051

3.2(0.99-10.84)

No 413(82) 87(17) 0.47(0.332-0.669) 1 1 Patient served in a chronic care pharmacy that has seated service for special counseling :-

Yes

567(94)

33(6)

5.3(3.517-8.143)*

0.000

1.2(0.389-4.325)

No 305(76) 95(24) 0.23(0.15-.337) 1 1 Patient served in standard counter :-

Yes

641(91)

59(8)

3.2(2.2-4.73)*

0.000

0.096(0.038-0 .242)

No 231(77) 69 0.36(0.266-.505) 1 1 Patient who knew correct dosage:-

Yes 564(91) 5(8) 0.4(0.29-0.66)* 0.000 2.5 (1.63-3.86) No 872(87) 2.7 129(12) 1 1

Note: Significance:*= P. value less than 0.25 in crude Odds Ratio


61

Table 14: Multivariate logistic regression analysis for patients’ satisfaction with overall pharmacy service in ten selected hospitals among respondents who got service in a cumulative of 34 various pharmacy outlets (OPD, Chronic care, Inpatient, ART, Maternity, Emergency, Especial pharmacies) of which hospital pharmacies with different level of implementation statuses of APTS; June, 2015 N=1000

Variables

Patient satisfied with overall services

Crude OR (95%.C.I)

P. Value


Yes (%) No (%)

Patient who got all Rx medicines.

Yes

669(88) 90 (12)

1.9(1.290-2.888)*

0.000

2.3(1.45-3.71)

No 169(80) 42(20) 0.5(0.411-.800) 1 1 Patients served in a hospital which adjusted staffs as per workload analysis:-

Yes

637(91) 63(9)

3.02(2.07-4.387)*

0.000

4.8(2.92-7.914)

No 231(77) 69(23) 0.3(0.286-0.535) 1 1


Yes 702(88) 98(12) 1.4(0.959-2.245)* 0.000 0.03(0.014-.082)

No 166(83) 34(17) 0.7(0.504-1.031) 1 1


Yes

457(91)

43(9)

2.3(1.562-3.391)*

0.53

1.19(0.677-2.125)

No 411(82) 89(18) 0.483(0.34-0.680) 1 1 Patient served in a chronic care pharmacy that has seated service for special counseling :-

Yes

548(91)

52(9)

2.6(1.81-3.835)*

0.000

4.0(2.3-7.293)

No 320(80) 80(39) 0.4(0.313-0.600) 1 1 Patient served in standard counter :-

Yes

632(90)

68(10)

2.5(1.736-3.659)*

0.000

12.1(5.856-25.1)

No 236(78) 64(22) 0.56(0.456-0.690) 1 1 Patients who knew correct dosage:-

Yes 474(77) 141(23) 2.3(1.794-3.119)* 0.000 2.2(1.484-3.487) No 226(59) 159(41) 0.55(0.46-.670) 1 1



62

Table 15: Crude and Adjusted Odds Ratio for patient satisfaction with dispensing process among respondents for cohort of patients who got the service in a cumulative of 34 various pharmacies (OPD, Chronic care, ART, Maternity, Emergency, Especial pharmacies etc.) of which hospital pharmacies with different implementation statuses of APTS; June, 2015. N=1000

Variables

Patient satisfied with dispensing process

Crude OR (95%.C.I)

P. Value


Yes (%) No (%)


Yes

700(83)

139(17)

3.0(2.12-4.433)*

0.000

0.031(0.011-0.083)

No

100 (62)

61(38)

1

1

1


Yes

459(55)

380(45)

3.5(2.4-5.168)*

0.069

2.9(0.918-9.514)

No

41(26)

120(74)

0.60(0.541-0.683)

1

1

Patient served in a chronic care pharmacy that has seated service for special counseling :-

Yes 555(66) 284(34) 5.0(3.470-7.313)* 0.002 5.0(1.821-14.00)

No 45(28) 116(72) 0.25(0.188-0.356) 1 1 Patient served in standard counter :-

Yes

633(90)

67(10)

4.3(3.03-6.1)*

0.000

9.3(3.473-25.215)

No

206(68)

94(32)

0.30(0.230-0.405)

1

1

Patients served OPD pharmacy which has seated service for special counselling:-

Yes 634(91) 66(9) 4.4(3.133-6.326)* 0.010 5.7(1..514-21.661)

No 205(68)

95(32)

0.29(0.224-0.395)

1

1



63

Chapter 6: Discussion

5.5. Socio demographic characteristics

In the study conducted on factors influencing pharmacist performance, in Great Britain and

in Kenya, showed that; “ pharmacist’s performance was found to be affected by

characteristics such as age, gender, ethnicity, low employee’s capacity and place of

primary qualification [29, 30]. Expecting similar findings, socio demographic characteristics

were seen for association. However, there was no significant association found between

implementation status of APTS result areas with assigned personnel’s demographic

characteristics (educational status, type of university graduated from (private/government),

work experience, sex and age. Staffs were found working their own assigned result areas of

APTS equivalent to each other. The main factor that hidden the difference might be due to

the fact that staffs were found being assigned based on graduation profiles. In majority of the

hospitals, stores were found being managed by pharmacy technician of diploma graduate,

cash collection were managed by cashiers of certificates graduates, accounting parts were

found being managed by finance professionals of degree graduates whereas almost all

pharmacists were working in the front line with patients . This type of job assignment might

make staffs to work their own duty effectively.

5.6. Rate of Expiry

The cumulative rate of medicines expiry in a total of 153 months were found reducing that it was

decreasing from 3.2% to 2.3% during APTS implementation periods [Table 5]. The cumulative

rate of expiry from the start of APTS launch up to Sept 30/2015 of all study hospitals (3.2%)

were compared with the cumulate rate of expiry after 4 months from the APTS launch up to Sept

30/2015 (2.3%)[Table 5]. Such analysis was also made by taking a single hospital as a case

study [Table 4]. The cumulative rate of expiry for the total of 23 months of this hospital was

3.5%; whereas, when the first four months of APTS implementation were reduced from the data,

the rate was found to be 2.4% and when only the last 6 months were taken, the rate was found to

be reduced to 2% and then the last quarter came down below 2%. This shows that APTS

implementing hospitals were found to reduce rate of expiry of medicines from the start of APTS

implementation onwards.


64

Another method of evaluation was made by using slope of trend lines. The slope of the trend

lines of rate of medicines expiry was found sharply reducing in all hospitals included in this

study with a negative slope hitting HSDP IV target of Ethiopia (graph 7.1). Since the slopes are

negative, it shows that expiry in these hospitals are reducing from the baseline (start of APTS

implementation) onwards.

The monetary values of expired medicines were also evaluated. The monetary value of

cumulative expired medicines during 153 months (with different characteristics) was found to be

birr 7,991,626 in an average rate of expiry 1.4% (below HSDP IV target which is 2%), [24]. The

three years (2012, 2013, and 2014) mean baseline data for rate of expiry of medicines for 8

hospitals in the baseline conducted by FMOH before APTS implementation was 4.8%; which is

equivalent to the baseline rate of expiry of the majority of hospitals (i.e. 4.6%). In 2013), the

value of wastage was estimated to be 6,254,856.31 ETB ($312,742.82) indicating an average

wastage rate of 8.3% for 9 of the study hospitals [24] which is equivalent the HSDP IV baseline

(8.24%). Using these values as a comparison for the same calculation, if interventions were not

taken by APTS principles, the value of medicines that would have been expired for 153 months

would range from 4.6% (about birr 11,453,247.67) to 8.3% (birr 20,665,642.54). If expired

values recorded after 4 months of APTS implementation for 118 months were taken as a

comparison, the expired value would have been ranged from birr 8,810,974.136 for 4.6% to birr

15,898,062.03 for 8.3%.

Taking the minimum 4.6%, expired value in 118 months as a reference, the difference (the

amount saved medicines’ costs) is calculated to be birr 4,354,019, i.e. (8,810,974.13-4,456,955=

4,354,019). Hospitals expenditure to implement APTS (example; renovation of the pharmacy

outlet, equipping the pharmacy and so on) is by far less than the value of saved medicines. In

addition, saving medicines from expiry has implication of availing essential medicines that can

save lives. Therefore, it is needless to explain that implementing APTS is important for hospitals.

Ethiopia has been taking various reforms in the health sector that might contribute in reducing

medicines expiry [10]. Minimum of two other programs are being implemented since 2010 in all

hospitals included in the study that may affect such reduction of rate of expiry. However, since

hospitals started APTS at different periods ( one hospital started APTS after years or months of

another hospital); whereas, the baseline taken at those various periods from different hospitals

showed that hospitals had almost equivalent rate of expiry of medicines at any time before APTS

implementation in those hospitals [8, 24, 25, 26, 38, 39, 40, 41]. During these periods,


65

interventions other than APTS had been implemented in those hospitals, but with no difference

of expiry rate of medicines in the baselines. Whenever hospitals started APTS, rate of expiry of

medicines were found to go down with a negative slope. Further to this, hospitals are shown to

conduct SSA and identify medicines at risk of expiry and took subsequent measures.

The main tricks and reasons given that APTS enabled reducing expires of medicines were

identified by the triangulated data from in-depth interview. Major reasons include that APTS:-

Is used to identify rate of expiry on monthly basis

Share responsibility among staffs by dividing medicines to each of them through bin

management system,

Bring expired amount for discussion every month with the management and responsible

staffs

Enable hospitals to identify top ten diseases and traces availability of medicines used to

treat them

Has effective tool to conduct stock status analysis on stock at hand and open the path to

take subsequent measures such as exchange products, return to suppliers, take care

during quantification for the second time, promote to prescribers, selling to other health

facilities, whenever there is over stocks.

It also enabled health facilities to list their hospital specific medicines prioritized by

ABC/VEN analyses, quantify and use the data for procurement.

Majority of hospitals included in the study did accomplished many of these actions and took

subsequent measures. The in-depth interview and baseline data also revealed that such activities

were not done before APTS in these hospitals. Such analysis showed that contribution of

confounding factors that might reduce medicines expiry is minimal whereas APTS contribution

in this regard was found so significant. Therefore, reduction of rate of medicines expiry can be

taken as a success for implementation of APTS in all hospitals included in this study.

5.7. Income from sales of medicines and Affordability

Cash sales of medicines over 39 months were found to be sharply increasing in almost all

hospitals included in the study with positive slopes ranging from 386 (BMH) to 20,399 (FHH)

(graph 7.4). To determine whether the increment of cash sales of medicines and thereby gross

profit from it is due to APTS or not, factors that might be confounder of sales increment were

assessed. These include growth of average price of a single medicines, price per patient,


66

increment of wage days to pay for medicines, shifting from free to cash sales, devaluation of

ETB (Birr) versus US dollar, salary increment and so on. Wage days’ to buy medicines

increases slightly with a positive slope graph (7.10) indicating that price per patient increases

over the years since the start of APTS implementation. This may confound increment from sales

of medicines.

The difference between increment of sales of medicines amongst hospitals included in the study

may also be due to the difference in volume of the budget of the hospitals, the difference of

customer numbers, and the time they started APTS; otherwise, days’ wage across hospitals

included in the study were found to be almost comparable in similar periods; less than 2 days

except two dermatology hospitals which became 2.5 and 3.8 days respectively [Graph 7.9]. This

also shows that profit margins of hospitals from sales of medicines are not significantly different

to each other.

Days’ wage is comparable with the study in Philippines by W.H.O. In the same study, the days’

wage for standard treatments with surveyed medicines generally cost more than 2 days and,

some medicines for chronic conditions were very expensive and clearly unaffordable for a low-

paid unskilled government worker [52]. Since the mean of median days’ wage was found to be

2.05 in these hospitals, to get medicines in one days’ wage or less, the lowest paid unskilled

Ethiopian government worker should earn ETB 1414.5. This is almost double of what is being

paid now (690 ETB, (US$ 34.5) per month or 23 ETB (US$ 1.15) per day.

The slope of the trendlines of days’ wage increases slightely (slopes = 0.034 and 0.017). This

indicated that affordability becomes questionable from time to time for smallest unskilled

gvernment worker even though there is new increase of salary. Thus sales increment and profit

from sales is confounded by days’wage increment that it is very dificult to conclude the new

system (APTS) is the sole factor. As expected, the number of patient served on cash in each

hospital also showed increment over the years with a positive slope ranging from 21.3 to

195[Graph7.7]. Additionally, during the last three years of APTS implementation, ETB was

devaluated almost from 17ETB for 1 $USD to 21 ETB for 1 $USD.

These all findings indicated that the increment of sales of medicines are also confounded by

increment of number of patient served, increment of price per patient, devaluation of birr, salary

increment and increment of wage days to buy medicines. Therefore, it is very difficult to

conclude that APTS is the sole factors to increase revenue from sales of medicines unlike the

report of FMOH in ARM 2014 [2]. However, since there are saved medicines that cost more than


67

3.5 million of birr (Table: 5) by using APTS principles, the reduction in expiry of medicines by

APTS implementation was found to be high hitting HSDP IV target, favorable environment was

created for customer service due to APTS, and availability of medicines improved, it is possible

to definitely say APTS has great contribution for the observed increment of sales of medicines

after APTS implementation.

5.8. Transparency

To establish transparency and conduct auditing on medicines transacted, physical inventory is a

key factor. One of the difficult issues for hospitals to take physical inventory of medicines was

the time needed to accomplish it. All hospitals included in the study were able to reduce the days

needed to conduct physical inventory by a range of 28 days to 5 days; Graph (7.11). This

indicates that the most time taking exercise before APTS becomes one of the easiest activities to

be accomplished in few days. The qualitative report showed that while a hospital was conducting

physical inventory of medicines before APTS, staffs used to count each product only once to

report one physical inventory and this process used to take up to 30 days. While using APTS

systems; staffs used to count each product once and recount all of them again for confirmation at

a time to report one physical inventory and this process is taking only 2 to 5 days.

The tricks of APTS that reduced the mean number of days needed to take physical inventory of

medicines from 19.2 days to 3.3 days are:-

Arrangement of medicines

Medicines should be arranged before registration and actual physical count by the bin owners

Standardizations of inventory forms

The old traditional inventory form is found to be qualified and divided in to three; the before,

during and after parts. The form has been qualified according to the information available in

dispensaries and in stores that medicines have to be registered in packs in the store with costs

while in retail units in dispensaries with selling prices

Division of labor and human resource deployment

Human resource allocation and division of labor brought significant changes. During

preparation, actual physical count and financial calculations after physical count are allocated for

different team of experts. The human resource deployment style makes the great difference. The

bin owners did the preparation, all staffs of the pharmacy count products being in pair and

dividing by bins and shelves. When pairs of counting team finish one shelf, they exchange with


68

another team for recounting and checkup. The workflow activity during physical counts also has

rules that they count sequentially from top to down shelves and fill only the quantity of products

in one column of the counting sheet. During actual count, the before part of the sheet is already

been completed by bin owners and the after part will remain for pharmacy accountants. Since

every staff member participate in the inventory, responsibility and accountability is shared.

Before APTS; hospitals used to establish a committee comprised of few professionals that should

rearrange medicines in the stores, record in the inventory sheet, take physical inventory, label

price for each medicines, reconcile with bin cards and report to the management. The committee,

being together, used to count the whole medicines starting from one side of the store towards the

other sequentially. During the physical count, dispensaries and stores had to be closed and

services were being compromised. Since the processes were so lengthy, pharmacies should have

to be closed for 30 days. For managers, allowing this situation to happen while thousands of

patients are waiting for the service is very difficult. That was one of the main reasons that

physical count and auditing was almost impossible.

However, to take physical inventory after APTS; all staffs working in the pharmacy are

responsible to register medicines from their assigned bins, on the before part of the physical

inventory sheet and make ready for physical count. This becomes the routine activity of staffs.

Accountants had been assigned to do the financial calculations of the output of the physical

inventory after the physical count. Therefore, stores and dispensaries should not have been

closed during activities performed in the before and after art of the physical count. The only

activity that the pharmacy should be closed is during actual count and the activity in which

physical count is filled in one column. Secondly, this process becomes so fast since pharmacy

professionals are taking physical count being paired and assigned to each bin or shelves. This

makes counting simple and reduced the mean days to be closed for physical count from 19.2 to

3.3 days. It is not only the days are shortened, but also perfection is improved since counting is

twice after APTS. This change showed that APTS contributed for transparency, auditability,

efficiency and improved performance of staffs. These all enabled all hospitals included in the

study to do their daily summary, take inventory and audit products, finance and services. In this

qualitative evaluation, the contribution of APTS for transparency and accountability was found

to be immense.


69

5.9. Effective workforce deployment, development and organization (R. Area 3)

5.9.1. Pharmacy premises and workflow adjustment

As boldly seen in the hospital (picture 1 and 2) selected to be the case, the pharmacy premises

and patient flow before APTS was not suitable for patients. The two mothers carrying children

observed standing behind the queue. For these mothers, it will be very difficult to inter inside the

mass and get their medicines through the grilled windows with proper counseling on correct

dosage. However, in the same pictures, the patient flow after APTS is observed to be suitable for

patients and for staffs to give services. It reduces waiting time and the long queue by distributing

patients in to many counters and staffs.

5.9.2. Human power adjustment

After implementation of APTS, majority of hospitals hired more pharmacy and finance

professionals than before installation of the system. This indicated that the system requires more

staffs. When compared with patient satisfaction improved after APTS, saved medicines and

reduction of expiry of medicines (graph 7.1, Table 4, and 5), hiring more staffs due to APTS was

found to be by far better choice for health facilities . The qualitative report indicated that hospital

were able to calculate human power based on patient load. Hospitals that fulfilled human power

based on workload were found to be more effective than others in terms of patient satisfaction

and availability of medicines [table 11].

5.10. Availability of prescribed medicines and factors affecting

The percentage of availability of medicines in seven hospitals was found to be higher than the

HSDP IV baseline (Table 7), study done in Jima University Hospital [44], and from a research

done in Malawi [45]. However, the mean availability amongst all hospitals is comparable with

the study done in Jimma and higher than the baseline and HSDP IV.

Patients, who were served in hospitals which have identified medicines that are used to treat top

ten diseases of the hospital’s catchment area, and follow their availability on monthly basis, have

got all prescribed medicines from the hospital pharmacy 7.5 times more likely than patients

served in hospitals which did not do such activities (AOR=7.5, P. Value 0.000, C.I 3.887-14.47).

This finding showed that implementation of APTS systems contributed to availability of

medicines.


70

5.11. Patient knowledge and factors affecting

The overall patient knowledge on correct dosage was measured by seven W.H.O. drug use

indicators (name, dose, route, frequency, duration, storage and precaution) was found to be 712

(71.2%); Table (9). When five basic, selected indicators were considered, the mean of patient

knowledge on correct dosage became 84%. This was found to be higher than the HSDP IV

Ethiopia baseline which was 68% [26], and very high compared with the FMOH findings during

APTS baseline assessment which was 50.5 % [24], from the study conducted in Jima University

Hospital which was 69% [44], and Afghanistan, 10-60 % [34,] but comparable with the study

conducted in Malawi [45].

The reason for increment of patient knowledge was evaluated considering various factors

including the radical shift in pharmacy dispensing flow and the infrastructure, manpower

adjustment, educational status of staffs, sex, age range, working experience of staffs, the

university from which they have been graduated, dispensary having two doors, manpower

adjustment. Patients’ knowledge about correct dosage was found to be significantly associated

with presence of standard dispensing counters and workflow organized as prescription evaluator,

cashier and counselor, all in a queue. Patients who were served through a dispensing out lets

with a standard counter (of height ranging from 0.75m to 1.10 meter) knew dosage of their

dispensed medicines 3.4 times more likely than those patients served through a pharmacy with

grilled windows (P. value 0.000, AOR=3.4 C.I.95%). Patients who were served in a hospital

having workflow organized as prescription evaluator, cashier and medicines use counselor knew

correct dosage 4.6 times more likely than patients served in hospitals which don’t have such

services (P. value 0.000, AOR=4.6, C.I.95%), [Table 10]. The improved patients’ knowledge of

those served in hospitals that have standard counter seems due to the new pharmacy setup and

patient flow built according to APTS standards. However, it doesn’t mean that other factors

observed in the crude odds ratio and which were factors in other studies are not affecting patient

knowledge, but found with less significance in this study [37, 44, 45], (Table 10).

5.12. Patient satisfaction

The mean patient satisfaction on overall pharmacy services in hospitals included in the study

(86.8%) was found to be higher than the study conducted in eastern Ethiopia (65%) [37], in

Felege Hiwot Hospital (40%), Debre Markos Hospital (77%), the national average (74.5%) [24


71

and 38]- Table 11. However, mean satisfaction in 4 hospitals is found to be less than the national

average-baselines (62%, 66%, 73%, and 67%), (Table 11).

5.12.1. Patient satisfaction on overall pharmacy services

Patients who got all prescribed medicines are 2.3 times more likely satisfied on overall

pharmacy services than those patients who didn’t get all prescribed medicines from the

pharmacy [Table 13]. Patient served in a hospital that had standard dispensing counter are 12

times more likely satisfied on overall pharmacy services than those patients served in a hospital

pharmacy that do not have standard counter (Table 13). Patient who knew dosage of prescribed

medicines are 2.2 times more likely satisfied on overall pharmacy services than those patients

who didn’t know the correct dosage of their dispensed medicines ( Table 13). Patients served in a

hospital that had seating service for counseling of chronic care patients are satisfied 4 times than

patients served in a hospital that did not have such facility. These results showed that

improvement in overall patients’ satisfaction on pharmacy service, (Table 11, 12, 13), recorded

are more likely due to implementation statuses of APTS systems and tools.

5.12.2. Patient satisfaction on personnel services

Patients served in a hospital that had cashiers next to prescription evaluator / biller satisfied 4

times more likely than patients served in a hospital that did not have cashiers in such a manner.

If cashiers were not between prescription evaluator and counselor, the patient would have been

in a queue for payment in a cashier counter. This may be the reason for satisfaction of patients in

this regard. Patient who knew dosage of prescribed medicines are 2.5 times more likely

satisfied on personnel services than those patients who didn’t know the correct dosage of their

dispensed medicines (Table 11). This indicated that patient are satisfied on personnel service

when counseled properly and understand their dosage. Patient served in a hospital that adjusted

pharmacy staffs based on APTS workload analysis are 14 times more likely satisfied on

personnel services than those patients served in a hospital pharmacy that did not conduct such

adjustment (Table 11). It is needless to explain the relationship between staff adjustment based

on workload analysis and patient satisfaction on personnel services that whenever manpower is

adjusted based on workload, service will be faster than before. This is already known variable.

Patients served in a hospital which had two doors for patient entry and exit with cashiers inside

the dispensary were found to be satisfied 3.1 and 4 times more likely than patients served


72

otherwise respectively (C.I. 0.000). This indicated that giving all process and service altogether

is suitable for patients.

5.12.3. Arrangement of workflow; a factor for patient satisfaction

The patient flow designed by APTS (evaluator, biller, cashier and counselor, all in a single

queue that are distributed to a multiple server is a system similar with the queue modeling system

studied by the Nigeria-faculty of pharmaceutical sciences. The Nigerian pharmacy service

patient flow was “single server-multiple queue model”. This is a type service where pharmacy

professionals being in a single window to serve customers that come from different directions.

This system is similar to many of the Ethiopian civil service giving offices. In Nigeria, various

pharmacy dispensary workflow modeling types were compared including single server with

single queue model, multiple servers with single queue model, and then multiple servers with

multiple queue models. At last, the patient flow queue model which was chosen by the study was

multiple servers, single queue model; which is similar with APTS patient flow model. The main

difference between patient flows modeling in APTS standards from the patient flow modeling

selected by the Nigerian University of Jos is that, the APTS patient flow modeling included

cashiers within pharmacy dispensaries and the pharmacy should have to have two doors (Figure

7) which resulted in patient satisfaction on personnel services 4 and 3.2 times more likely than

otherwise (C.I. 0.000) Table (12). The second diffidence is that there is standard for height of

counter in APTS (0.75 for seated service and 1.10 meter for standing services) which contributed

for patient satisfaction (OR=3.4, C.I, 0.000); whereas the selected Nigerian patient flow

modeling doesn’t include cashier within pharmacies and doesn’t compel to have neither two

doors nor standard height of counters [8 and 46]. Further to this, the APTS principles compels to

have seated service for special counseling in OPD and chronic care pharmacies which resulted

in significant patient satisfaction that patients served in a hospital which fulfilled these standards

were found to be 4 time satisfied than otherwise (C.I.0.000) Table13.

The APTS patient flow and queue modeling showed significant improvement for both patient

knowledge on correct dosage (OR=3.4 times), (Table 10) and satisfaction on overall pharmacy

service (OR=12 times), (Table 12); whereas, the Nigerian queue modeling showed that it reduces

waiting time by 67% (from 167 to 55 minutes). The APTS patient flow, which has similarity

with the Nigerian modeling, also definitely reduces waiting time since it distributes patients in

to various counters, by changing service that would have been given in a single grilled window


73

(picture 1). Majority of hospitals changed the single window in to more 5 windows that waiting

time reduces accordingly.

5.13. Challenges of APTS implementation

The qualitative report collected by in-depth interview of CEOs and chief pharmacists,

questionnaires from staffs indicated that they considered the system to be very important tool for

performance evaluation, improvement of patient satisfaction, generating information for decision

making, to bring transparency and efficiency. The system is proved being one of the key priority

of the management and board of all hospitals included in the study.

However, the delay of indemnity for compensation of shortages that might come due to human

error and at the same time, due to measures being taken based on the auditor reports about

discrepancies occurred on pharmacy and finance professionals who committed human error

caused grievance. This caused some staffs to be resistant to the implementation of the system.

Respondents described that doing the system in hard copy is so tiresome. Among 10 hospitals

included in the study, 9 of them were found implementing the systems using excel sheet for daily

summary and monthly report while recording of medicines in a hard copy. Only one of the ten

hospitals had developed software program for APTS implementation. All the 9 hospitals

demands to get software for the same reason.

5.14. Limitations of the Study

Hospitals included in the study started APTS at different times; therefore, some results like

revenue increment from medicines sales might not be comparable to each other.

To this date, there are many reforms and health system strengthening interventions being

implemented in hospitals, therefore, few improvements in the APTS result areas may be

confounded by these interventions. Since APTS is a new system implemented in Ethiopia only,

literatures on the issue to be reviewed that could be used for comparison were scarce.

Chapter 7: Conclusion and Recommendation

7.1. Conclusion

Hospitals included in this study implemented APTS tools and systems with big

difference of implementation statuses ranging from 68% to 95%. The more hospitals


74

implemented the system, the more they have got better outcomes in terms of

improvement in availability of prescribed medicines, patient knowledge on correct

dosage and patient satisfaction on pharmacy services.

Rate of medicines expiry was found to be sharply reducing in all hospitals included in

the study with a negative slope hitting HSDP IV target of Ethiopia planned in this

regard. Contribution of other programs to reduce expiry were found to be minimal.

Therefore, reduction of expiry of medicines was found to be significantly contributed by

APTS implementation.

Implementation of APTS tools and systems was found to contribute for increment of

revenue from sales of medicines. Other interventions and factors were also found to

contribute for increment of revenue from sales of medicines.

Implementing APTS tools and systems contribute significantly to increment of patient

knowledge on correct dosage and patient satisfaction on pharmacy services.

The two most challenging factors faced during implementation status of APTS were

found to be:

o Absence of software better than spreadsheet makes the system so tiresome

o Delay of indemnity for discrepancies that might occur due to human error causes

grievance among staffs.

In conclusion: APTS was found to improve availability of medicines, reduce wastage

and expiry, increase performance of staffs, reduce time to take physical inventory and

make conditions suitable for auditing, contribute for increment of revenue from

medicines sales, generate information on; product, finance and services. Above all, due

to APTS, waiting time is reduced, patient privacy is ensured, patient knowledge on

correct dosage is also increased thereby adherence to dosages is improved, and

satisfaction on pharmacy services are increased. Cumulative of these milestone

achievements contributed to a great share for saving lives.

Since the system was found to be the best means for implementation of the

USAID/SIAPS program and best aligned with the countries priority objective of the

pharmaceutical sector, this system is being orchestrated by the technical and financial

supports of the program and the government of Ethiopia. That helped it to be effectively

implemented.


75

7.2. Recommendations

It is highly recommended that the system called Auditable Pharmaceuticals Transactions

and Services (APTS) should be implemented in all hospitals, health centers and health

posts in all over Ethiopia by RHBs, FMOH and partners.

The FMOH, RHBs and partners should focus on quality of the services and transactions

since results showed significant variations amongst hospitals implementing the system.

o Major interventions that brought difference in quality of service and transactions

amongst hospitals; i.e. identifying top ten diseases and medicines for them,

improving dispensaries (dispensing area, standard counters and dispensing flow),

human power adjustment, bin management, SSA, drug list by VEN, ABC/VEN

reconciliations, availability and affordability, special counseling , uniquely

identifying codes, taking inventory using the smart methods of APTS, auditing,

using reliable data and reporting should be taken as a priority

The RHBs, FMOH, USAID/SIAPS should find better software for the system.

Staffs working in health facilities handling drugs and medical supplies that cost millions

of birr should better to be guaranteed by equivalent indemnity for discrepancies that

might occur due to human error through RHBs and FMOH.

To use the system for customer service delivery systems for any organization, and for all

types of stock management of any commodity other than medicines, concerned bodies

like the civil service bureau, the civil service university and Jima university shall better

take actions

o However, other studies are recommended to prove and indicate the means

whether this system is working for all types of customer service delivery schemes

and any type of stock managements

The Ethiopian FMOH has moral responsibility to assist African union so that it could

take experience of APTS and scale-up the system to all African countries through Africa

Union


76

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Annexes

5.15. Annex 1. Check list for document review

(Ask chief pharmacist and review documents)

Instruction: Communicate the CEO of the hospital. Then being guided by head pharmacist,

review secondary data from the hospital pharmacy documents; such as registers, sales tickets,

and ABC/VEN data, APTS monthly reports, SSA, documents, finance documents and human

resource documents

Sn Cat

No

Questions Yes

(1)

No

(2)

100 Efficient budget utilization:

Drug List, ABC Value Analysis, VEN Analysis and ABC/VEN, Reconciliation

Analysis, Bin Management, Stock Analyses (stock turnover analysis, consumption

to stock analysis, stock status analysis), Rational use of medicines,

1 101 Does the hospital have a medicines formulary or drug list that lists all drugs,

medical supplies and consumable equipment that can be used in the facility?

2

If the answer to question no 101 is no, skip to question number 105

102 Does the formulary or drug list have been reviewed and updated in the last

two years

3 103 Does the formulary or drug list shared to hospital staffs

4 104 Does the formulary or drug list prioritized by VEN

5 105 Does the hospital performed ABC value analysis on received stocks in the last

1-3 years

If the answer for either question number 104 or 105 is no, skip to

question number 114

6 106 Does the hospital identified drugs used to treat 10 top diseases of the

catchment area

7 107 Does the hospital performed ABC/VEN reconciliation analysis

8 108 If the answer to Q. No 107 is yes, are there drugs that fall in A in ABC and N

in VEN?

If the answer for question number 107 is no, skip to question no 114

9 109 Does the hospital uses the ABC/VEN reconciliation analysis for procurement


81

Sn Cat

No

Questions Yes

(1)

No

(2)

10 110 How many percent of drugs in monetary value fall in A category of ABC

value analysis while they are V in VEN analysis __________

11 111 How many percent of drugs in monetary value fall in A category of ABC

value analysis while they are N in VEN analysis________

12 112 How many percent (in monetary value) of drugs fall in A category of ABC

analysis while they are not available in the drug list-prioritized by VEN____

13 113 How many percent (in monetary value) of drugs fall in B and C category of

ABC analysis while they are not available in the drug list _______

14 114 Stock Status Analysis: Does the hospital perform stock status analysis in the

last six months to 1 year

If the answer for question number 114 is no, skip to question No124

15 115 Does the hospital uses average monthly consumption data for stock status

analysis

16 116 Does the hospital identified candidate for stock status analysis from

ABC/VEN reconciliation data

17 117 Does the hospital uses data of expiry dates of drugs for stock status analysis

18 118 Does the hospital uses month of stock data for status analysis

19 119 Does the hospital uses morbidity data for stock status analysis

20 120 Does the hospital calculates consumption to stock analysis in monthly basis

and use as indicator for SSA

21 121 Did the hospital take any measure based on the result of stock status analysis,

stock turnover analysis, and consumption to stock analysis?

22 122 If yes to Q no 114, what measure did the hospital took? You can choose more

than one

A. Transfer to other health facilities

B. Selling to other organizations

C. Exchange with other medicines

D. Taking account in to quantification and limiting procurement of the

same item in the consecutive procurements


82

Sn Cat

No

Questions Yes

(1)

No

(2)

E. Introducing and promoting medicines for prescribers

F. Other, please specify

23 123 How many number of medicines by type saved from the analysis? _______

24 124 How much does the above saved medicines (in Q. 123) cost in monetary

values_____

25 125 Bin management: are the dispensary bins labelled and shared to dispensers

for management

26 126 Are the IFRR filled by bin owners in the dispensary?

27 127 Is there any key drug (among selected 30 key drugs) available in the store but

not in the dispensary?

28 128 If yes to Q. No 127, how many key drugs are available in the store but not in

the dispensary? ______

29 129 Is there any drug expired in the dispensary which is not informed to head

pharmacist?

30 130 Does expiry rate of medicines decrease sharply from start of APTS to date

31 131 Is expiry rate of medicines constant from start of APTS to date

32 132 Does expiry rate of medicines increases sharply from start of APTS to date

33 133 Is there theft/pilferage recorded after the start of APTS

34 134 Was there theft/pilferage recorded before the start of APTS

200 Transparent and Accountable Transactions (Tools, Systems, Coding, Auditing)

35 201 Transaction Tools and Coding: Did the health facility print or received the

standard APTS vouchers, sales tickets and registers?

36 202 Are all medicines received in the store uses standard APTS receiving

vouchers

37 203 Are all medicines issued to all wards, laboratory sections and dispensing

outlets uses standard APTS issuing vouchers

38 204 Are all medicines received by receiving vouchers coded

39 205 Are all medicines issued by issuing voucher coded

If the answer for Q. No 205 is no, skip to Q. No 207


83

Sn Cat

No

Questions Yes

(1)

No

(2)

40 206 Which coding system the hospital applies

a. Numeric

b. Alphanumeric

41 207 Are all medicines received in the last and recent transaction of the receiving

model labelled with costs or estimated monetary values

42 208 Are all medicines issued in the last and recent transaction of the issuing

model labelled with prices or estimated monetary values

43 209 Are the expiry dates of all medicines received by the recent transaction

recorded in the receiving voucher

44 210 Are the batch numbers of all medicines received by the recent transaction

recorded in the receiving voucher

45 211 Does the hospital uses standard APTS cash sales tickets for cash transactions

46 212 Are all medicines dispensed in the recent cash sales ticket pad on cash coded

47 213 Are all dispensed products on cash, credit and for free summarized daily

48 214 Did the facility prepare APTS monthly financial report in the last month

49 215 Did the facility prepare APTS monthly service report in the last month

50 216 Did the facility do monthly APTS financial and service report using computer

51 217 Physical inventory: did the facility take physical of medicines inventory in

the last month in the dispensary

52 218 Did the facility take physical inventory of medicines in the last quarter in the

store

53 219 How many days do physical inventory of pharmacy store used take before

APTS? _______

54 220 How many days do physical inventory of pharmacy store used take after

APTS has been implemented? ___.

55 221 Medicines sales Management: are all medicines sold on credit or for free

uses standard APTS credit /free sales tickets or equivalent registers

56 222 Are medicines sold on credit or for free in the last day coded

57 223 Did all customers, served for free/or on credit in a register being used in the


84

Sn Cat

No

Questions Yes

(1)

No

(2)

recent day, have signed on the space provided confirming they received

medicines

58 224 Are medicines dispensed on cash, on credit and for free, in the recent days ,

coded

59 225 Are all medicines dispensed credit and for free, in the recent day labelled with

prices in the register

60 226 Random Sample Product Auditing: did the health facility conducted

random sample product auditing in the last quarter

61 227 If yes, how many times did the facility conducted random product auditing

per quarter , please specify_____

If the answer for Q. No 226 and 227 is no, skip to Q. No 230

62 228 Does the audit report show discrepancy between calculated ending balance

and physical inventory balance taken during random sampling audit

63 229 If yes to Q. No 228, how much does the discrepancy found in the random

sample audit per quarter in monetary value in birr __________

64 230 Financial Auditing of Medicines: Did the health facility conduct auditing on

financial values of medicines in the last quarter

If the answer to Q. No 230 is no, skip to Q. No 233

65 231 Does the audit report show discrepancy between calculated ending balance of

the quarter financial report of medicines transactions and physical inventory

balance taken for the Quarter

66 232 If yes to Q. No 231; how much does the discrepancy found in the quarter

financial report of APTS in monetary value (at cost) in birr __________

67 233 Service auditing: Did the health facility conduct service auditing in the last

quarter

If the answer to Q. No 233 is No, skip to Q. No 300

68 234 Are there comments given to professionals orally

69 235 Are there comments given to professionals in written document

70 236 Do the service auditing bring change in the quality of pharmacy services


85

Sn Cat

No

Questions Yes

(1)

No

(2)

300 Effective workforce development and deployment (pharmacy

organization, workflow, training, workload analysis, performance

evaluation)

71 301 Workforce deployment- pharmacy accountant: Is there job position for

pharmacy accountant in the health facility

72 302 Does the hospital pharmacy had Pharmacy accountant

73 303 If the answer for Q No 302 is No skip to 305

74 304 Is the number of pharmacy accountant fulfilled based on the APTS baseline

gap identified

75 305 Workforce deployment -pharmacy professionals: did the hospital had

adequate number of pharmacy staffs for pharmacy services before APTS

If the answer for Q. No 305 is yes, skip to Q. No 310

76 306 Do you think that the insufficiency of pharmacy staffs before APTS hindered

proper pharmacy services

77 307 Does the hospital adjust the number of pharmacy professionals as per the

baseline gap identified during APTS baseline assessment

78 308 Did the hospital employed additional number of pharmacy staffs using the

information obtained from APTS workload analysis and man power

calculation

79 309 How many pharmacy professionals have been employed using APTS baseline

gaps identified ____

80 310 Workforce deployment- cashier: Does the health facility pharmacy have a

cashier within pharmacies

81 311 Is the number of cashiers adjusted as per the baseline gap identified

82 312 Workforce deployment-Auditor: Is there a job position for auditor in the

health facility

83 313 Does the job description of auditors include to audit pharmacy transactions

and services

84 314 Pharmacy organization: Are any of the following services available?


86

Sn Cat

No

Questions Yes

(1)

No

(2)

a) OPD (dispensing) pharmacy

b) Emergency pharmacy services

c) Inpatient pharmacy services

d) ART pharmacy

e) Clinical pharmacy services

f) Chronic care pharmacy (other than ART)

g) Drug information services

h) Extemporaneous compounding

i) Medicines selection quantification and procurement (Drug supply

management section)

j) Warehousing and Inventory management for medicines

k) Warehousing and Inventory management for medical supplies and

equipment

l) Overall management and coordination of pharmacy services

m) Others, please specify_________

85 315 Workflow: Does the outpatient pharmacy workflow organized and counters

are labelled in APTS criteria (prescription evaluator/ biller, cashier and

counsellor all in queue

86 316 Does the health facility outpatient dispensary has two doors (entry and exit for

customers)

87 317 Doe the health facility outpatient pharmacy have sited service for special

counselling

88 318 Doe the health facility chronic care pharmacy have sited service for special

counselling

89 319 Doe the health facility outpatient pharmacy have convenient counters for both

customers and professionals with height ranging from (75 cm for sited

service to 1 meter and 10 centimetres for standing services)

90 320 Does the health facility have at least one computer in the pharmacy outlets

used for reference for at least patient counselling on medicines use


87

Sn Cat

No

Questions Yes

(1)

No

(2)

91 321 Does the health facility have computer for pharmacy accountant used to

summarize daily summaries and monthly reports

92 322 Does the pharmacy has formulary or a soft copy used for reference in the

dispensary

93 323 Does the pharmacy has STG or a soft copy used for reference in the

dispensary

94 324 Do dispensaries have calculators for dispensing use

95 325 Do dispensaries have tablet counting tray for dispensing

96 326 Do dispensaries have envelope for packing of medicines

97 327 Do dispensaries have labelling for medicines dispensed

98 328 Does dispensaries have refrigerators

99 329 Does the pharmacy have room/wall and refrigerator thermometers

100 330 Does the pharmacy have swivel chair for pharmacy staffs in the dispensaries

101 331 Training: had training on APTS been given for pharmacy and finance staffs

102 332 Did RHB, FMOH, USAID/SIAPS give on job mentoring on APTS for

pharmacy and finance staffs

103

333

Performance evaluations: Does the human resource section uses the

information produced from APTS monthly service report for performance

evaluation concerning:

a. Volumes of job done by each staff working in the pharmacy

b. Quality of job done by each staffs working in the pharmacy

400 Reliable Information (Service/Performance, Product and Financial

Values of Medicines Transacted)

104 401 Does the pharmacy produce monthly service report

105 402 If yes to Q. No 401 is yes; does the pharmacy produce monthly service report

both in soft and hard copy

106 403 Does the pharmacy produce monthly service report only in hard copy

107 404 Does the pharmacy produce monthly financial report

108 405 If the answer to Q. No 404 is yes, does the pharmacy produce monthly


88

Sn Cat

No

Questions Yes

(1)

No

(2)

financial report both in soft & had copy

109 406 does the pharmacy produce monthly financial report only in hard copy

110 407 Does the pharmacy produces daily summary

111 408 If Q. No 407, is yes, does the pharmacy produces daily summary in soft copy

112 409 Does the pharmacy produces daily summary only in hard copy

113 410 Dispensing and counselling: Does the pharmacy applied 6 dispensing steps

If the answer to Q. No 410 is no, skip to Q No 413

114 411 Were prescription evaluators evaluating prescriptions at the time of visit

115 412 Were medicine use counsellors counselling patients at the time of visit

Review the APTS monthly service report to answer Q. No 112 up to 442

116 413 Could the total number of patients served per month by cash be identified

117 414 Could the total number of patients served per month by credit be identified

118 415 Could the total number of patients served per month for free be identified

119 416 Could the total number of patients served per month by staff service be

identified

120 417 Could the total number of patients served per month by maternity service

(ANC + Delivery + PNC) be identified

121 418 Could the total number of patients served per month by OI/ART services be

identified

122 419 Could the total number of patients served by food by prescription service be

identified

123 420 Could the total number of patients served per month by hospital pharmacies

be identified

124 421 Could the average number of patients served per month in the hospital be

identified

125 422 Could the average number of patients served per month per dispenser in the

hospital be identified

126 423 Could the average number of medicines use counseling delivered per month

per dispenser in the hospital be identified


89

Sn Cat

No

Questions Yes

(1)

No

(2)

127 424 Could the average number of medicines dispensed per encounter in the month

in the health facility be identified

128 425 Could the average number of medicines dispensed per encounter in the month

in the outpatient pharmacy be identified

129 426 Could the average price of medicines dispensed per patient on cash in the

month be identified

130 427 Could the affordability of medicines dispensed per patient in the month be

identified

131 428 Could the percentage availability of 30 indicator medicines that used to treat

10 top diseases in the health facility in the month be identified

132 429 Could Wastage rate of medicines (expired + damaged) during the month be

identified

133 430 Could the stock turnover rate of medicines in the health facility during the

month be identified

134 431 Could consumption to stock ratio of medicines in the health facility during

the month be identified

If the answer for question No 430 is no, skip to question number 433

135 432 Is there any measure taken from the result of consumption to stock ratio,

stock turnover ratio, stock status analysis of medicines in the health facility

identified during the month

136 433 What is the monetary value of medicines that the health facility took measure

137 434 Could stock available during the month be identified in monetary values

138 435 Could sold stock on cash during the month be identified in monetary values

139 436 Could stock sold on credit during the month be identified in monetary values

140 437 Could stock dispensed for free during the month be identified in monetary

values

141 438 Could sales of medicines by each dispenser during the month be identified in

monetary values

142 439 Could overages and under sales* of medicines during the month be identified


90

Sn Cat

No

Questions Yes

(1)

No

(2)

in monetary values

143 440 Could ending stock available during the month be identified in monetary

values

144 441 Could stock discrepancy during the month be identified in monetary values

145 442 Could gross profits of medicines sales during the month be identified

Would you please give me all monthly reports you have so that I can

summarize them to see the trends of services and finance reports?

500 Customer Satisfaction

146 501 Does the facility conducted patient satisfaction survey or perceived or

received comments before and after APTS

If the answer to Q. No 501 is No, , skip question 505

147 502 Does customer satisfaction in the health facility improved after APTS

148 503 Is customer satisfaction in the pharmacy service constant before and after

APTS

149 504 Does customer satisfaction in the pharmacy service improved after APTS

150 505 If the answer to question no 504 is yes, the improvement of customer

satisfaction in the pharmacy is due to: (you can choose more than one)

a) Patient flow improvement

b) Medicines use counseling improvement

c) Privacy improvement

d) Medicines availability improvement

e) Other please specify


91

5.16. Annex 2: In-depth interview guide

The information provided by all respondents will be treated confidentially. The information

herein is for the sole use of research on APTS status of implementation, and secondly,

implementation and challenges, outcomes of will be presented to Jimma University Public

Health Graduate Studies, and will not be given to any third parties without the expressed consent

of the respondent

Semi structured interview guide for CEO and head pharmacist

700 Questions prepared for in-depth interview

Ice breaking: How do you assess the overall health service in this facility?

How is the general level of implementation of EHRIG in this facility

Probe, how is the pharmacy service EHRIG implementation?

151 701 How did you get APTS?

152 702 Can you please tell me the implementation status of APTS?

a. Probe; did all units of the pharmacy implement APTS?

b. What challenges do you encounter?

153 703 Have you seen the effect of APTS in one way or another, from the monthly report

or so, in terms of?

a. Efficient Budget Utilization

b. Performance evaluation and human resource deployment

c. Efficient workflow

d. Patient satisfaction and patient knowledge on prescribed medicines

e. Transparency and auditability of transactions and services

f. Challenges in implementations

154 704 How the hospital management and board do got the implementation of APTS?

a. Probe, are they happy? Did they support you in

b. Renovation, in human resource? Others mention ________

155 705 a. Do you have anything to add?

Thank you for your time and cooperation!!!


92

1. Self-administered questionnaire

Fill this part of the questionnaire for all staffs who will be asked in various result areas of APTS

from question number 803 up to 231)

156

800

Socio

Demographic

Characteristics

1. A. What is your Age? Age in years________ prefer not to tell

B. Sex: a. Male ___b. Female______

157

801

Educational

background

2. What is your educational level

a. Certificate ________

b. Diploma _________

c. Degree and above________

3. In your answer to q number 2: in which type of sector

(school/college/university) you graduate

a. Government

b. Private

158

802

Profession

5. What is the current position in the hospital? Please encircle one

A. Cashier , B. Auditor , C. Accountant , D. Druggist

E. Pharmacist , F. Human resource

159 803 Experience Work experience in your current position of the hospital ________years


93

804. (Code 160) : Availability of Services and Adequacy of Staffing (ask human resource

head)

1.1.Number of technical and support pharmacy staff in full time for pharmacy service:

a. #Pharmacist (before APTS implementation) = ____ After APTS implementation

b. #Druggists (before APTS)= ____ After APTS implementation =___________

c. # Pharmacy technicians Before APTS = ____ After APTS =_______________

d. # Cashier dedicated to pharmacy services (before APTS= ___________ After APTS

=_______

e. #Accountant (before APTS) = _______________________ (After

APTS)=__________________

f. #others (please specify) before APTS ______________After APTS _________________

804. (Code 161): Finance, Budgeting and Audit (ask finance head and pharmacy head)

2.1. What was the total annual medicines budget of the hospital? In the year 2007= ____ 2006=

_____ 2005= ______2.2. Was the pharmaceuticals budget adequate to cover annual needs

(2006)? 1. Yes 2. No

2.3. Is there any increment of budget comparing before and After APTS (before APTS ______1

year after APTS,_______); 2 years after APTS_____, 3 years after APTS______


94

5.17. Annex 3: Self-Administered Questionnaire

900

Questions

Yes

(1)

No

(2)

If your answer is no, please select encircle any

challenges/problems/ you faced among the

choices below, or specify if the challenge is

not in the choice , you may choose more than

one

Ask chief

pharmacist

215 Does the hospital

have a medicines

formulary or drug

list listing all drugs,

medical supplies and

consumable

equipment that can

be used in the

facility?

a. Lack of knowledge to implement the

result area

b. Lack of skilled man power to implement

the result area

c. Shortage of skilled man power and time

constraint to do the job

d. Lack of willingness/low devotion/ of

professionals to do the job

e. Lack of reference materials to do the job

f. Lack of budget to do the job (in case

budget is needed)

g. Lack of concern of officials (supervisor,

CEO, CCO, Board, Management)

h. Other, please specify

____________________ ___________

If the answer to question no 215 is no, skip to question number 219

216 Does the formulary or drug

list have been reviewed

and updated in the last two

years


result area


the result area





95




budget is needed)




____________________ ___________

217 Is the formulary or drug

list prioritized by VEN


result area


the result area







budget is needed)



h. Other, please specify __________

If the answer for question no 217 is no, skip to question number 222


performed ABC analysis

on received stocks of last

three years


result area


the result area







96

f. Lack of budget to do the job, in case

budget is needed




____________________ ___________


performed ABC/VEN

reconciliation analysis


result area


the result area






f. Lack of budget to do the job in case budget

is needed




____________________ ___________

220 Does the hospital uses the

ABC/VEN reconciliation

analysis for procurement


result area


the result area







is needed


97



h. Other, please specify __________

Ask drug supply manager or head pharmacist if not applicable

221 Does the hospital perform

stock status analysis in the

last one year


result area


the result area







is needed




____________________ ___________

Ask Pharmacy Accountant

222 Do you prepare daily

summary, and monthly

report


result area


the result area








98

is needed




____________________ ___________

2

2

Q223 and 224 _ Ask auditor

Did you conduct random

sample product auditing

and financial value

auditing of medicines


result area


the result area



d. Lack of willingness/devotion/ of



f. Lack of budget to do the job

g. Lack concern of officials (supervisor,



____________________ ___________

224 Ask auditor

Did you conduct service

auditing


result area


the result area






99






____________________ ___________

225 Ask human resource

Did you fulfil the

pharmacy staffs based on

either the APTS baseline

assessment gap/ or the

volume of work calculated

by APTS reports


result area


the result area










____________________ ___________

Ask Cashiers for Q No 226 and 227

226 Do you used to arrange

cash sales tickets based on

serial number of tickets

assigned to each dispenser

before you deliver to the

accountant


result area


the result area








100




____________________ ___________

227 Did you add the price of

medicines horizontally and

vertically in the sales ticket


result area


the result area







is needed



h. Other, please specify ________

2

2

Ask dispenser ( pharmacy professionals) for Q No 227 to 230

Do you evaluate

prescriptions before you

bill as per the six

dispensing steps principles

a. Shortage of skilled man power and time


b. Lack of willingness/devotion/ of


c. Lack of reference materials to do the job

d. Lack of budget to do the job

e. Lack concern of officials (supervisor,


f. Other, please specify ___________




101

i. Other, please specify ________

229 Ask dispenser ( pharmacy professionals)

Do you counsel patients

on how to take their

prescribed medicines by

labelling on each drug and

ask the patient to confirm

he/she understood


result area


the result area










____________________ ___________

230 Do you give cost for all medicines that may not carry label of cost when

entered in the facility


result area


the result area











102

____________________ ___________

231. Ask store manager

Did you give codes for all

medicines when entered

and issued to service

delivery units

Lack of knowledge to implement the

result area

Lack of skilled man power to

implement the result area

Shortage of skilled man power and

time constraint to do the job

Lack of willingness/devotion/ of


Lack of reference materials to do the

job

Lack of budget to do the job

Lack concern of officials (supervisor,


Other, please specify

____________________


103

5.18. Annex 4 Questionnaires to measure patient knowledge on correct dosage and satisfaction on pharmacy services -adopted from W.H.O drug use indicators:

S

N

English፣ Amharic, Oromifa, Gamugna and Tigregna

versions 1 2 3 4 5

Fill one number for each question that comes closest in reflecting the scale of satisfaction of patients

Str

ongl

y

Dis

agre

e

Dis

agre

e

Neu

tral

Agr

ee

Str

ongl

y

Agr

ee

A. Dispensing area and counters

The dispensing area and counters are very suitable

for the service

የመድኃኒት ማደያ ክፍሉ እና የማስተናገጃ መስኮቶቹ በጣም ምቹ

ናቸው ብለው ያምናሉ

Manni rabsaa qorichaafii meeshaleen keessa jiran

mijatoodha jettanii yaadduu?

B. Patient privacy

The dispensing area keeps my privacy

የመድሃኒት ማደያ ክፍሎ በነጻነት የፈለግሁትን እንድጠይና ምክር

እንድቀበል አስችሎኛል ብለው ያምናሉ

Haalli manna rabsaa qorichaa kuni iccittiin

keessan eegamee gorsa akka argatan isin goosisuu

ni danda’a ?

C. Dispensing process

I enjoyed the dispensing process and it reduces

waiting time

የመድኃኒት አገልግሎቱ ፍሰት መጀመሪያ ባለሙያ ማግኜትዎ ከዚያ

ካሸር ማግኘትዎ ከዚያ መድሀኒቱን የሚያድልና አወሳሰዱን

የሚመክርዎት ማግኘትዎ ገዜ ቆጣቢ እና ምቹ ነው ብለው ያምናሉ

Haalli mana qorichaa kun it ijaarame tajaajila sadrkaa

isaa eeggate saffisan akka argattan isin godheeraa?

D. Personnel service

I enjoyed staffs service and I understand all what they

advised me


104

የተሰጠኝን የመድሀኒት አወሳሰድ ምክር በደንብ ገብቶኛል

ባለሙያዎችም ጥሩ ናቸው ብለው ያምናሉ

Gorsi akkaataa itti fayyadama qorichaa oogeessaan

issinii kenname akka sirriitti fudhatan isin

gargaareeraa?

E. Overall satisfaction

Considering everything, I am satisfied with the

pharmacy service

በጥቅሉ በአገልግሎቱ እረክቻለሁ ብለው ያምናሉ

Walumaa galatti kenniinsi tajajilaa qorichaa ilaalchisee

gammachiisadha jettanii yaadduu?

English and Gamugna Version

SN Please fill one number for each question that comes

closest in reflecting the scale of satisfaction of

patients

1 2 3 4 5

Darisad

a

Gigetikes

Gigetikes

Aykoka

gike

Gigayis

Darisad

a

Gigayis

A. Dispensing area and counters

The dispensing area and counters are very suitable for

the service

(Dahaliya neeni ekkiza sohoy ekos giige)

B. Patient privacy

The dispensing area keeps my privacy

(Dahle neeni ekkiza sohoy harganchati bantta meto

akkimes qotan yootanes giiga soho)

C. Dispensing process

I enjoyed the dispensing process and it reduces waiting

time

(Dhale imte imishe daro wode gamize)

D. Personnel service

I enjoyed staffs service and I understand all what they

advised me

(Aakimey imiza zoke siyadi)

E. Overall satisfaction

Considering everything, I am satisfied with the

pharmacy service: (Dhale immiza imotan ufayadi)


105

Part I. Exit interview questionnaire to assess patient Knowledge on how to take and manage their dispensed medicines

Part II. Exit interview to assess availability

Part III. Exit Interview Questionnaire to assess patient atisfaction using Likert Scale

Like gidiko(1) like giddena exxiko(0) Paydo wothite

1=Darisada gigeikes 2=Gigetikes 3=Aykoka gike 4=Gigayis 5=Darisada gigayis

Ser

ial N

o

Ay

keen

a dh

ale

ekay

N

eeni

ekk

iya

dhal

iya

ay a

gera

ek

kay

Isi g

alla

si a

ppun

to

ho d

haliy

a ek

kay

App

un g

alla

sas

ekka

y D

haliy

a ne

eni

bess

iza

woy

kko

naag

iza

Nee

s m

ittan

a m

ala

imet

tiza

dh

aliy

a da

rote

tha

Ay

keen

e N

eeni

ekk

ida

dahl

e aa

pune

dahl

e aa

pune

ekkiza sohoy

ekos giige

harganchati bantta

meto akkimes qotan

yootanes giiga soho

Dhale im

te im

ishe

daro wode

gamize

Aakimey im

iza

zoke siyadi

Dhale im

miza

imotan ufayadi

1

English, Amharic, Oromifa፣ Gamugna and Tigregna Version

Name of

drug Dose Route Frequency Duration Storage Precaution

የመድኃኒቱን

ስም

ያውቁታል

ስንት

እንደሚወሰድ

ያውቁታል

በምን

እንደሚወስ

ድ

ያውቁታል

በየ ስንት ጊዜ


ያውቁታል

እስከመቼ


ያውቁታል

የት

እደሚያስቀምጡት

ያውቁታል

ምን ጥንቃቄ

ማድረግ

እነዳለብዎት

ያውቁታል

Maaqaaነ

qorichaa

maali?

Meeqa

akka

fudhatamu

ni

beektuu?

Karaa

kam/akka

mittiin

akka

fudhatam

u ni

beektuu?

Sa’aatii meeqa

meeqaan addaan

fagaatee akka

fudhatamu ni

beeektuu?

Guyyaa

meeqaaf

akka

fudhatamu

ni beektuu?

Eessaa akka

ka’amu ni

beektuu?

Offeeggannaa

akkamii akka

gochuu

qabdan ni

beektuu?

ናይ ሽም

ትፈልጦዶ

ክንደይ

ትወስድ

ከመይ

ከምዝወስድ

አብ ክንደይ ሰዓት

ከምዝወስድ ትፈልጦዶ

ስጋብ መአዝ

ከምዝወሰድ

ትፈልጦዶ

አበይ ከምዝቀመጥ

ትፈልጦዶ

መድሓኒት

ክትወስድ እንተይ

አይነት ምጥንቃቅ

ትገብር


106

English Version

Part I.

Exit interview questionnaire to Assess Patient

Knowledge on how to take and manage their

dispensed medicines

Part II.

Exit interview

to assess

availability of

drugs

Part III.

Exit Interview Questionnaire to Assess

Patient Satisfaction using Likert Scale

Fill (1) if the answer is Yes and fill (0) if the

answer is No in the space provided

Put numbers

for :

Fil 1, 2, 3,4 or 5 as per the

corresponding Likert scale choices for

each satisfaction questions from A up

to E above

Ser

ial N

o

Nam

e of

dru

g

Dos

e

Rou

te

Fre

quen

cy

Dur

atio

n

Sto

rage

Pre

caut

ion

# o

f dr

ugs

pr

escr

ibed

# dr

ugs

actu

ally

di

spen

sed

Dis

pens

ing

coun

ters

Pat

ient

privacy

Dis

pens

ing

proc

ess

Per

sonn

el

serv

ice

Ove

rall

sa

tisf

acti

on

1

2

3

4

5

6

7

8

9

10

.

.

.

100


107

Dummy Table for Likert Scale

Likert

Scale

Strongly disagree (1), Disagree (2), Neutral (3), Agree (4) and

Strongly Agree (5): N=1000

Thematic

areas of

satisfaction (A)

Dis

pens

ing

area

and

coun

ters

(B)

Pat

ient

pri

vacy

(C)

Dis

pens

ing

proc

ess

(D)

Per

sonn

el

serv

ice

(E)

Ove

rall

sati

sfac

tion

Lik

ert

Yes

/No

1 Yes

No

2 Yes

No

3 Yes

No

4 Yes

No

5 Yes

No

Declaration Sheet

The investigators declare that the objective of this study is to measure the status, outcomes and

challenges of implementation of the new system initiated in hospitals pharmacies (including

ALERT) called Auditable Pharmaceuticals Transactions and Services (APTS).

I the principal investigator declare that the proposal is prepared by my-self. The two co-

investigators (data collectors) are trained and will do as per the standards of ethical principles.

Consent forms will be filled after oral consent of patients to be interviewed.

Name of the principal investigators___________________ Signature _______________

Name of

1. Co-investigators: _____________________, Signature _____________

2. Co-investigators: _____________________, Signature _____________


108

5.19. Annex 5: Consent Form for in depth interview

I have been informed of and understand the purpose and procedures of this study and the purpose

and procedures of these interviews

I understand that I am free to withdraw my consent and discontinue my participation in this

interview at any time. I understand that I can choose to answer only the questions that I wish to

answer

I understand that the interview will be audio taped or digitally recorded and then transcribed only

for the purpose of transcription. I understand that the information I provide is anonymous.

I agree to be audio taped () or I disagree agree to be audio taped () (tick √ this symbol in one

of the blank spaces to confirm agreement or disagreement)

By signing this consent form, I am indicating that I fully understand the above information and

agree to participate in this study.

Participant's signature ________________________________

Date: _____________________________________________

Data Collector's signature: _______________________________

Date: _____________________________________________

If you have any questions about this study, please contact principal investigator, Ayalew Adinew

([email protected]) or + 251 911 68 77 58)

ASSURANCE OF PRINCIPAL INVESTIGATOR

The undersigned agrees to accept responsibility for the scientific ethical and technical

conduct of the research project and for provision of required progress reports as per terms

and conditions of the Faculty of Public Health in effect at the time of grant is forwarded as

the result of this application.

Name of the student: _______________________________________

Date.____________________ Signature _________________

APPROVAL OF THE FIRST ADVISOR

Name of the first advisor:_________________________________

Date.____________________ Signature _________________


109

5.20. Annex 7: Budget Breakdown

Category Activity Unit Quantity Unit

Cost Total Cost

100 Training and Data Collection Process

101 Refresher trainings for 20 data

collectors in 10 training sites

Trainer

fee 10 300 3000

102 Refreshment for data collectors during

refreshment training Lunch 28 50 1400

103 Questionnaire testing of sensitivity and

specificity Perdiem 2 200 400

104 Data Collection by data collectors Perdiem 20 900 18000

200 Stationaries and translation 0

201 Duplication and binding Pages 150 1.5 225

203 Translation fee in to five languages Each 5 150 750

300 Logistics 0

302 Telephone card days 28 30 840

304 Bed rent (average) days 30 300 9000

305 Bus and Taxi days 30 300 9000

306 Researcher Perdiem days 30 300 9000

307 Average cost of fuel to drive for one

day days 30 500 15000

Contingency 0

Total 66, 615


110

5.21. Annex 8, APTS implementing sites, when data collection started,

as of March 2015

S.N Hospital Region

1. Debre Markos Referral Hospital Amhara

2. Felege Hiwot Referral Hospital Amhara

3. Debre Tabor Referral Hospital Amhara

4. Mota Hospital Amhara

5. Debark Hospital Amhara

6. Finoteselam Hospital Amhara

7. Debre Birhan Referral Hospital Amhara

8. Woldya General Hospital Amhara

9. Enat General Hospital Amhara

10. Borumeda General Hospital Amhara

11. Desse Referral Hospital Amhara

12. Akasta (Hidar 11 Hospital) Amhara

13. Ataye Hospital Amhara

14. Mekaneselam Hospital Amhara

15. Lalibel (Yemekela Jegnoch M.) Hospital Amhara

16. Mehal Meda Hospital Amhara

17. Sekota (Tefera Hailu Memorial) Hospital Amhara

18. Jugel General Hospital Harar

19. Dilchora Referral Hospital Dire Dawa

20. Tirunesh Bejing General Hospital Addis Ababa

21. St Peter specialized Hospital Federal, Addis Ababa

22. ALERT specialized Hospital Federal, Addis Ababa


111

23. Nigist Eleni (Hosaena) General Hospital SNNPR

24. Butajira General Hospital SNNPR

25. Arba Minch Hospital SNNPR

26. JImma University Hospital Federal, Oromia

27. Axum General Hospital Tigray

28. Mekele General Hospital Tigray

Total 28

5.22. Annex 9, Name list of data collectors

1. Abebe Dagne: Felege Hiwot Referral Hospital

2. Andinet Assefa: Arbaminch General Hospital

3. Andulaem Ababu: Dilchora Referral Hospital

4. Arafat Osman: Jugal General Hospital

5. Buruk Wogayehu: Arbaminch Health Science College

6. Chala Damena: Jimma University Hospital

7. Chaslachew Bayu: Debre Markos Referral Hospital

8. Dereje Mirkano: ALERT Referral Hospital

9. Gashaw Belete: Debre Markos Referral Hospital

10. Getachew Agegn: Dessie Referral Hospital.

11. Hussien Jemal: Borumeda Referral Hospital

12. Kibi Balcha: Jimma University Hospital

13. Mahadi Abdella: Diredawa City Administration Health Bureau

14. Mehari kasay : Axum St Mary General Hospital

15. Mekonnen Legesse: ALERT Referral Hospital

16. Nigus Hiluf: Axum St Mary General Hospital

17. Remezi Baharudin: Jugal General Hospital

18. Sisay Keshto: Arbaminch General Hospital

19. Tilahun Gete: Felegehiwot Referral Hospital

20. Wondosen Abate: Borumeda Referral Hospital