Using indicators to measure country pharmaceutical situations Dr. Edelisa D. Carandang Medicines Policy & Supply Management Department of Technical Cooperation for Essential Drugs and Traditional Medicines (TCM) World Health Organization, Geneva Sept 2006
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Using indicators to measure country pharmaceutical situations Dr. Edelisa D. Carandang Medicines Policy & Supply Management Department of Technical Cooperation.
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Using indicators to measure country pharmaceutical
situations
Dr. Edelisa D. CarandangMedicines Policy & Supply Management
Department of Technical Cooperation for Essential Drugs and Traditional Medicines (TCM)
World Health Organization, Geneva
Sept 2006
Using indicators to measure country pharmaceutical situations
Concepts on pharmaceutical monitoring and assessment
The WHO process on assessing and monitoring pharmaceutical situation
Snapshots of current global pharmaceutical situations using Level I and Level II indicator survey- the fact book
New approaches in access indicators
Pharmaceutical monitoring and assessment
Monitoring Review of the progress toward completing program
activities and achieving objectives Allows for corrective action during program
implementation Focus on inputs and outputs -integral part of
management. Common methods in fully developed monitoring systems
• Supervisory visits
• Routine reporting of selected data
• Sentinel sites
• Special studies
Pharmaceutical monitoring and assessment
Assessment Discussed along with monitoring as part of overall
evaluation Analysis of progress and meeting objectives Types of evaluations
Field surveys using standard pharmaceutical assessment indicators & ongoing monitoring system, document review
Strategies for monitoring and assessment developed in parallel for comprehensive unified strategy
Principles in designing monitoring and evaluation system
Focus on key monitoring questions and indicators
Minimum data collection Develop practical procedures Consider comparisons between facilities
and performance over time. Plan how information will be available for
timely feedback and follow-up action Phase the design and implementation Design based on the current system
Who can use the results from assessment and monitoring?
Countries - focus action, prioritize, measure achievement
National policy-makers• synchronise policies • data and information to donors and other governmental agencies
International agencies• to assess the structure and capability of countries, assess the
progress, accomplishment and impact of aid Professional groups, NGOs and academia
• to focus advocacy activities and information campaigns
Health facilities to be aware of institutional problems & improve situations
Pharmaceutical indicators
Variables that measure situations and change (numerical, binomial)
Useful tools to track the performance of particular aspects or activities of the pharmaceutical system
Linked to an important input, process, or outcome Well-established indicators can be adapted/ modified
to reflect the realities Field test
Summarizing indicator measures Percentage: yes or no over total Measures of central tendency
• Mean: average value, sensitive to outliers, weighed toward skewed value, best summary of normally distributed values
• Median: middle value, resistant to outliers, good summary of any distribution
• Equivalent if data are normally distributed
Measure of variation• 25th and 75th percentiles:
boundaries of middle half of values, good summary of the overall spread of values, better summary of skewed data
Indicator measure: Ideal/logical values
Ideal value • 100%-adequate labelling, meds dispensed,
adherence to STG, availability of medicines, generic, adequacy of storage
• 0 days- of stock out Set by countries
• % affordability Logical value (% use of antibiotics,
%injection, ave drug)• complex
• can be calculated empirically
Antibiotics
51.7 50.0
36.746.3 43.3
60.0
0
20
40
60
80
Low Middle
Country Income Level
% of
patie
nts
25%ile Median 75%ile
Indicator measure: group norm
% patients receiving an antibiotic - distribution of results
0%
20%
40%
60%
80%
100%
facility
medianvalue
•Easy for region/facilities to relate to peers•Norms may be wrong
Why is it important to use indicators:(1)Setting target
% availability of key drugs in public sector
46%
78%73% 72%
25%
55%
75%
15%
0%
20%
40%
60%
80%
100%
Rural 1 Rural 2 Rural 3 Kampala
Health Facility
Warehouse
Ministry Target =
90%
Why is it important to use indicators:(2) For comparison
% Availability at public and private sector (2002)
0%
20%
40%
60%
80%
100%
Tanzania Mali Ghana
Public facility pharmacy
Private pharmacy
Why is it important to use indicators: (3) Seeing trends overtime
Comparing 1995-2002 key indicators shows progress in some areas but that enhanced efforts needed in others
0%
20%
40%
60%
80%
100%
Availability of keydrugs
% of presc. drug inEDL
% presc. withinjection
Availability of keydrugs
% of presc. drug inEDL
% presc. withantibiotics
% patient withadequate
knowledge
% presc. withinjection
1995 2002
Bulgaria Philippines
Background on WHO work on indicators and pharmaceutical assessment &monitoring
• Indicator and monitoring tools• Indicator for Monitoring National Drug Policy (94 & 99 Ed• WHO Operational package for Monitoring & Assessing
Country Pharmaceutical Situation
• Publications• 1988 World Drug Situation• 2003 World Medicines Situation• 2006 Using indicators to measure country pharmaceutical
situation: Fact book on WHO Level I and Level II monitoring indicators
• WHO medicines data base
Develop Develop implementation implementation plans and identify plans and identify strategies & strategies & interventions interventions based on based on data/information data/information on: on: availability, availability, affordability, affordability, pricing, drug use pricing, drug use and regulatory and regulatory profile, TRIPS, drug profile, TRIPS, drug management management
situation.situation.
Support implementation of activities and advise in the execution of work plans
Indicator-based tools to evaluate structures, Indicator-based tools to evaluate structures, processes, outcomes of in countriesprocesses, outcomes of in countries
WHO Evidence-Based Planning and InterventionsGuiding Country Works in Medicines
WHO Evidence-Based Planning and InterventionsGuiding Country Works in Medicines
Why WHO is monitoring and assess pharmaceutical situation using indicators?
Level II•Comprehensive monitoring of pharmaceutical strategy outcome and impact•Measures attainment of objectives
Level II •More detailed îndicators for monitoring and evaluating specifc areas/components
Level I indicators: structure and process indicators
Regular survey questionnaire
Advantages• Cheap way to get information across countries
• Can be done repeatedly/regular period
• Automated questionnaire and data encoding processing
Limitations• Validation of data
• Accuracy of responses
• Missing data
Level II indicators: WHO Operational Package for Monitoring and Assessing county Pharmaceutical Situations
Procedure and guidelines Administrative preparation:
• Coordinating with WHO, ministry/department of health, public health facilities, private drug outlets, warehouses
• Making logistic arrangements and budget allocations Technical requirements:
• Selecting geographic areas and facilities • Identifying country-specific items of the survey forms,
e.g. key basket of medicines, treatment guidelines, etc.• Training data collectors to carry out the survey and use
the survey and summary forms• Analyzing and computing the data• Preparing a report and using result
Indicators in the Level II survey
15 survey forms-public health facilities, public pharmacy/dispensary, private pharmacy, warehouses
indicators• on availability, stock out, record keeping and expiry of
key drugs
• conservation conditions and handling of medicines
• affordability (child and adult moderate pneumonia and option for other disease condition
• drug prescribing, dispensing,patient knowledge
Sampling for systematic survey
Follow specific procedures • to minimize selection bias
• study population is representative of the reference population
A balance between what is desirable and what is feasible- smallest one with a degree of precision
Training data collector for the survey
Important for consistency in data gathering process, validity & accuracy of data
Who can be trained?• Physicians, nurses, pharmacists or paramedical staff
• Health ministry/department staff and temporary employees (health related background and experience)
• data collectors from different parts of the country (language differences) • Fiji -used students from B.Pharm Y3/Y4,Improve FSm/MoH
relations
• Solomon Islands-pharmacy officers and pharmacists who are not from their own province
Level II Indicator (advantages & limitations)
Advantages Practical survey based on small samples Covers impact and outcome in one comprehensive survey Efficient in terms of resource requirement owing to
standardized process of training, data gathering and time allocation
Limitations Requires more resources for training and conducting
systematic survey Limitation in terms number of countries that can be
covered
Level III Indicators
Systematic survey and monitoring• Drug price survey and monitoring
Rapid assessment• Global survey on Paediatrics medicines
• Questionnaire on public sector medicines procurement and supply management systems in countries
• Assessment of regulatory capacity
Fact book on Level I & Level II indicator result
Product of years’ of work on developing and improving data-gathering tools, systematic collection of information
Overview of pharmaceutical sector components current status & impact
Countries grouped low, middle or high-income. Data and information in tables and graphs
• current situation – 2003 Level I survey
• progress - comparing Level I 1999 and 2003 surveys
• impact and outcome measures - Level I & Level II. Country data in CD ROM
Percentage of Countries with Official National Medicines
Policy (NMP) in 1999 and 2003
0
10
20
30
40
50
60
70
80
High Medium Low
1999
2003
Key pharmaceutical sector legislation
Country Income Level
Low Middle High
Policy area covered:Number
%of Countries
Number %
of Countries
Number %
of Countries
Establishment of regulatory authority 53 98.2 52 89.7 17 94.4
Manufacturing of medicines 48 90.6 50 86.2 16 88.9
Steps used in the current processOperational• Obtain complete data for candidate variables• Validate data accuracyStatistical• Formal statistical analysis to obtain appropriate
factor weights• Validate relationship between Level I structure and