REVIEW OF PUBLIC SECTOR INDICATOR STUDIES IN ZIMBABWE—WHO IS PAYING ATTENTION?

1. REVIEW OF PUBLIC SECTOR INDICATOR STUDIES IN ZIMBABWE—WHO IS PAYING ATTENTION? Tisocki K, Ndhlovu CE, Simoyi T, Wilson E, Goredema, National Drug and Therapeutic Advisory Committee, Zimbabwe Problem Statement: Zimbabwe has developed and implemented a national essential drug program since the country gained its independence. Regular pharmaceutical indicator studies have been used to assess the performance of this program for the last two decades. A previous study from Zimbabwe, presented at ICIUM 1997, evaluated the usefulness of such studies to managers of the Zimbabwe Essential Drugs Program. Recent health sector reforms and adverse political and economic conditions have dramatically altered the management and implementation of the program, however; follow-up study was needed. Objectives: To review the results of public sector surveys conducted in the last five years (in 1998, 2000, and 2001) and assess the extent to which recommendations made from the surveys have been followed by the relevant policy makers and decision makers. Design: Descriptive, cross-sectional studies based on World Health Organization (WHO) indicators methodology and conducted in randomly selected facilities. Setting: Public sector health facilities at all levels of care. Outcome Measures: Information collected was compared to previous years’ results to assess trends. The surveys aimed at assessing the availability of essential medicines, drug management processes, and the rational use of medicines. Nationally established targets were used for comparison, and evaluation of performance was measured by the various WHO indicators for prescribing, patient care, and facilities. Results: Overall drug availability has been declining, though some improvements were observed for specific items, such as TB drugs and vaccines, at certain levels of the public health care system. Overall adherence to standard treatment guidelines for indicator diseases has also been declining, with just 49% overall adherence measured in 2001. The Drug Management Supervisory Program, which was recommended to strengthen decentralized drug management activities, appears to be poorly implemented, as indicated by the low number of annual visits by supervisors. Conclusions: Regular pharmaceutical surveys can provide a clear picture of existing performance and certain problems of the pharmaceutical system. In the last three years, significant changes in the donor support structures and availability of funds, as well as changes in the economic climate of the country and the managerial capacities of the Ministry of Health, have occurred. As a result, in the current situation it is often difficult to implement recommendations arising from these routine pharmaceutical surveys. There is a need for introducing other sensitive, rapid evaluation tools that can assist decision makers in dealing with near-emergency situations as well as in conducting more in-depth studies to identify fundamental causes of problems and barriers, which can allow decision makers, in turn, to strengthen their capacity to effectively plan appropriate interventions.

2. BACKGROUND AND SETTINGS • Zimbabwe has started an essential drug program in the early 1980s • Since 1986 regular surveys were conducted to monitor and evaluate the impact of the Zimbabwe Essential Drug program. • The results of the survey in the past have provided important information to the managers of ZEDAP at Ministry of Health. • Major changes have occurred in the last 5 years; • Decentralisation has shifted decision making on drug management towards the district and local authority level. • The Central Medical Stores has been replaced by the parastatal National Pharmaceutical Company (Natpharm) • Long standing donor support of ZEDAP by Danida ended • Adverse economic conditions created chronic shortages of financial and human resources in the health sector both at central and local level • The chronic shortages of foreign currency has lead to serious shortages of essential drugs and other medical supplies • Rapidly rising inflation and unemployment has lead to increasing poverty and food insecurity • heavy burden of HIV/AIDS and communicable diseases places high demands on the health sector

3. OBJECTIVES • Objectives • To review current trends in implementation of the National Drug policy in relation to availability, management and rational use of drugs in Zimbabwe. • Specific aims of regular public sector surveys: • Monitor drug availability in relation to VEN, stock management systems and drug procurement • Monitor rational drug use by measuring adherence to standard treatment guidelines • Evaluate the implementation of essential drug programme by making comparisons to results of past surveys • Provide recommendations for future interventions and strategies

4. METHODS Survey methodology: • Design: descriptive, cross sectional study, utilizing time series analysis with no controls for comparison. • Settings: Randomly selected health facilities from all levels of public health sector facilities • What is surveyed? • Indicators developed to measure every point of the drug management cycle Management Quality assurance Monitoring & Evaluation

5. RESULTS 1998 2000 2001

6. RESULTS V=Vital Should be 100% E= Essential Should be >80% N=Necessary Should be >40%

7. DRUG MANAGEMENT Selected Indicators 1998 2000 2001 Total stock management score# 43.3 39.3 44.8 % of drugs expired 2.8% 5.5% 9% % of facilities managed by 52% 75% 70% Drug management Supervisor Average No. of annual visits by 0.5 0.7 0.8 Drug management Supervisor # Total Stock Management Score is calculated on the basis of average • correct use of stock cards • Correct se of stock book • Correct minimum stock

8. ADHERENCE TO STANDARD TREATMENT GUIDELINES BY MARKER DISEASES

9. Strengthen procedures for procurement from private sector using local Health Sector Funds Strengthen Drug Management Supervision and training. Improve drug availability and supply performance of NatPharm stores Improve patient care and review of STG and establish Hospital Drug and Therapeutic Committees that should assist with implementation of STGs High inflation rapidly eroded buying power of allocated resources resulting in recurrent essential drug shortages Pharmacists, nurses have left the public sector in large numbers. Critical shortage of manpower present country-wide Even though significant restructuring and re-organsiation has taken place at Natpharm, the chronic shortage of foreign currency and fuel severely limits capacity to deliver needed drugs Already mentioned shortage of manpower and shortage of essential drugs severely limits training and promotion of rational use of drugs RECOMMENDATIONS & BARRIERS

10. DISCUSSION & SUMMARY • Conduct of regular drug management surveys in the public sector continues to provide valuable information on the performance of the essential drug program • However, as the survey provides only a snapshot picture of the two weeks survey period current dramatic fluctuations in drug availability may not be captured. • Access to treatment with essential medicines have been dramatically declining in the past 4 years due to • high inflation eroded purchasing power of local funds allocated through decentralized health structures as well as patient’s ability to pay form essential medicines • critical manpower shortages in public sector health facilities • rapid changes in donor support and allocation of donor funds • There is a need for introducing other sensitive, rapid evaluation tools that can assist decision makers in dealing with near-emergency situations. • It is important to conduct more in-depth studies to identify fundamental causes of problems and barriers for example in cases of declining adherence to STGs. • Essential drug program implementation needs to be urgently strengthened at all levels to deliver basic health care to patients whose vulnerability rapidly increasing due to existing adverse economic conditions.