Analysis of patient care and facility indicators

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_________________________________
* Corresponding author:
Bayew Tsega,
College of Medicine and Health Sciences,
University of Gondar, PO Box – 196, Gondar, Ethiopia.
E-mail address: bayewtsega14@gmail.com
Available Online at: www.ijrpp.com Print ISSN: 2278 - 2648
Online ISSN: 2278 - 2656
(Research article)
Analysis of patient care and facility indicators in public and private health
institutions of wolkite town, south west Ethiopia
*1
Bayew Tsega, 2
Zeryawkal Ergetie, 1
Alemayehu Berhane
1
Clinical Pharmacy Unit, School of Pharmacy, University of Gondar, PO Box – 196, Gondar,
Ethiopia.
2
Pharmaceutical Chemistry Unit, School of Pharmacy, University of Gondar, Gondar,
Ethiopia.
_________________________________________________________________________
ABSTRACT
The main aim of this study was to evaluate the drug use pattern in private and public health sectors in Wolkite
town, South West Ethiopia. Drug use pattern study is a means of assessing the drug use situation in a health
facility or groups of facilities; it is a way to identify irrational drug use in health facilities. Six hundred patients
were interviewed prospectively in the private and public drug retail outlets in February and March, 2012. World
health organization patient care and facility indicators were used to evaluate the drug use status. The average
consultation and dispensing times were 7.8+2.1 minutes and 14.3+12.3 seconds, respectively. One thousand
ninety five (92.7%) drugs were dispensed, out of which 731 (61.9%) were adequately labeled. Five hundred
seventy (95.0%) patients had adequate knowledge of the drug instructions they were given. Two (11.1%) health
facilities had at least one copy of essential drug list or formulary, whereas three (15.8 %) health facilities had
clinical guideline. An average of 9.5 (86.4%) key drugs was available in the health facilities. Shortage of
essential drugs, copy of essential drug list/formulary and standard treatment guideline still occurred in the health
facilities studied. Short dispensing time and labeling of drugs in dispensaries were shown.
Key words: Patient care indicators, Facility indicators, Health institutions, South West Ethiopia
INTRODUCTION
According to World Health Organization (WHO),
rational drug use requires that patients receive
medications appropriate to their clinical needs, in
doses that meet their individual requirements for an
adequate period of time, at an affordable cost 1, 2, 3
.
Unfortunately,inappropriate use of medicines conti
nues to be a widespread problem in developing and
transitional countries; nearly half of the world’s
patients receive their drug inappropriately.
Such inappropriate use endangers lives and wastes
money. Ethiopia cannot be an exception as
availability of essential medicines, trained health
care providers and literacy level of patients is low
which is in coherent with the countries low
economic status 4, 5, 6, 7
.
The share of out-of-pocket expenditure on drugs is
very high in Ethiopia (47%). Unavailability of
drugs is the number one reason for the patients not
to take drugs from the public retail outlets. This
implies that a large segment of the population
purchase their drugs from private drug retail outlets
where prices of drugs are quite high. This results in
low economic access to drugs, particularly by the
poor, and creates equity problem 5, 8, 9
.
To ensure consistent, valid and reliable
identification of drug use problems, WHO
developed and tested a set of standardized
International Journal of
Research in Pharmacology and
Pharmacotherapeutics

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indicators of general out patients care 3, 10, 11
.
Among the uses of these indicators are to describe
current treatment practices, compare health
facilities and prescribers and allow for
identification of potential drug use problems that
may affect patient care 10, 11
.
The Patient care indicators include Average
consultation time, Average dispensing time,
Percentage of medicines actually dispensed,
Percentage of medicines adequately labeled and
Percentage of patients with knowledge of correct
dose; while facility indicators include availability
of essential drug list or formulary to practitioners,
availability of clinical guidelines and Percentage of
key medicines available in a facility 10
.
There is no drug use study done in the private
health sector despite the fact that following the
privatization policy in Ethiopia a lot of private
health facilities have been established and
significant section of the population is getting
health service in these facilities. Even the drug use
study in the primary public health sector in
Ethiopia, which covers 43% of the Ethiopian
population 12
, is very rare and outdated. Wolkite
town, the second largest town in South West
Ethiopia in terms of population, health facilities
were attended by more than 60, 000 patients in one
year, from September 2010 to August 2011 13, 14
.
No drug use study had been done in that town. So
there was no evidence that shows the drug use
situation in the town.
Therefore, the findings of the study may be used as
a baseline data. It in general help the health
management, in particular those looking after the
health institutions in the town understand the extent
of the problem in the private and public health
facilities and drug retail outlets and it trigor further
studies.
METHODS
The study was conducted in public and private
primary health care facilities and drug retail outlets
of Wolkite town, South West Ethiopia from
February 21 to March 12, 2012. Wolkite town was
founded in the 1940s and now it is the second
largest town, next to Jimma, in Southwest Ethiopia
13, 14
.
In the town there were one health center, two
clinics, one health post and two pharmacies.
Whereas the private health sector had six medium
clinics, two lower clinics, and six drug shops 14
. All
health sectors in the town, prescriptions, and
patients who attended them in the study period
were the source population for the study. The study
was a cross-sectional prospective in both public
and private primary health care facilities and drug
retail outlets of Wolkite town, South West
Ethiopia. In order to produce representative and
comparable statistics of appropriate dispensing,
indicators defined by WHO (patient care and
facility indicators) was employed in health
facilities10
. Prospective data consisting of
prescriptions, consulting and dispensing times were
collected from health facilities and drug retail
outlets in order to assess the patient care and
facility indicators as indicated.
Based on WHO recommendation to collect
prospective data 4, 10
, 50 patients per retail outlet in
the private sector were interviewed and observed
for adequate knowledge, dispensing time, adequacy
of labeling and prescribed drugs actually dispensed.
Stop watch was used to record the dispensing and
counseling times. The total patients that were
included in the 6 private drug retail outlets were
300. In the public pharmacy, 300 patients were
interviewed, observed and checked for their drugs.
Data were checked for its completeness every day.
The data outcome from those evaluations by the
aforementioned professionals was entered into
Statistical Package for Social Sciences (SPSS)
version-16.0 software to be edited, cleaned and
analyzed. The data were summarized and described
using cross tabulation and bivariate analysis with
95% confidence interval to infer associations and
predictions. The patient care and facility indicators
were calculated using the WHO formula to
calculate core drug use indicators.
Simple bivariate logistic regression analysis was
employed to see the association between patients
(age, sex, drug, and education.) and health sectors
characteristics versus WHO patient care and
facility indicators (crude odds ratio was obtained).
Then, to control the effect of confounding factors,
each variable was entered in to multiple logistic
regression models as the independent variable with
each medication use indicators being a dependent
variable in order to identify independent predictors
of process criteria and medication use indicators.
RESULTS
Patient care indicators
The socio-demographic characteristics of
respondents, who visited the drug retail outlets,
Wolkite town, South West Ethiopia, are shown in

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table 1. Male to female ratio was 0.9 which shows
comparable number of the two genders. The
average age of respondents attended the drug retail
outlets was 33.6+3.8. Responders in the age range
of 31-44 years comprised of 242 (40.3%). One
hundred seventy (28.3%) and 155 (25.8%)
responders were in the age range of 15-30 and 45-
64 years, respectively. Elderly comprised of 33
(5.5%).
Two hundred twenty five (37.5%) responders were
unable to write or read (illiterate), 152 (25.3%)
attended primary school, 147(24.5%) of responders
were in high school or above educational levels,
and 76 (12.7%) responders were able to read and
write.
Table 1: Socio-demographic characteristics of respondents (N=600) who attended the drug retail outlets,
Wolkite town, South West Ethiopia, February to March, 2012.
Characteristics Frequency (%)
Sex Male 282 (47.0)
Female 318 (53.0)
Age Ranges 15-30 170 (28.3)
31-44 242 (40.3)
45-64 155 (25.8)
>64 33 (5.5)
Education Illiterate 225 (37.5)
Read and write only 76 (12.7)
Primary school 152 (25.3)
Secondary school or above 147 (24.5)
The WHO patient care indicators are presented in
table 2. The average consultation times were 9.0
and 5.5 minutes in private and public health
facilities, respectively. The average dispensing
times were 17.5 seconds in the private and 11.1
seconds in public drug retail outlets. The likelihood
of getting consultations in private was 1.5 (95% CI
2.9- 8.1 and P value 0.001) times that in public
health facilities.
Table 2: Patient care indicators for patient encounters attending to private (N=300) and public (N=300)
drug retail outlets, Wolkite town, South West Ethiopia, February, 2012.
Patient care indicators Frequency (%) OR (95%CI) P value
Mean (+SD) Consultation time (Min)
Private health facilities
Public health facilities 9.0
5. 5
1.5 (2.9- 8.1)
1.0
0.001
Mean (+SD) dispensing time (Sec)
Private health facilities
public health facilities
17.5
11.1
1.34 (0.4- 3.2)
1.0
0.09
Medicines actually dispensed
Private health facilities
Public health facilities
450 (87.2)
645 (97.3)
1.0
1.8 (2.5-11.6)
0.04
Medicines adequately labeled
Private health facilities
Public health facilities
274 (53.1)
457 (69.0)
1.0
2.3 (3.6-18.7)
0.00
Patients adequate knowledge of
drug dosage regimen
Private health facilities
Public health facilities
278 (92.7)
292 (97.3)
1.0
1.6 (.14-9.5)
0.07

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Four hundred fifty (87.2%) and 645 (97.3 %) drugs
were dispensed in the private and public drug retail
outlets, respectively. Two hundred seventy four
(53.1%) dispensed drugs were adequately labeled
in private drug retail outlets where as 457 (69%)
drugs were adequately labeled in the public
pharmacy. Two hundred seventy eight (54%)
patients in the private and 292 (44%) patients in
public drug retail outlets had adequate knowledge
of drug instructions. The likelihood of getting
medicines adequately labeled and medicines
actually dispensed in public were 2.3 (95%CI 3.6-
18.7 and P value 0.00) and 1.8(95%CI 2.5- 11.6
and P value 0.04) times that in private health
facilities.
Facility indicators
World health organization health facility indicators
for the health facilities and drug retail outlets are
shown in table 3. One (7.1%) private and one (25.0
%) public facilities had at least one copy of
essential medicine list or formulary whereas one
(7.1 %) private and two (50.0%) public health
sectors had clinical guideline. An average of 9
(85.7%) and 10 (88%) key drugs were available in
private and public health facilities, respectively.
Table 3: Facility indicators for private (n=14) and public (n=4) health institutions, Wolkite town, South
West Ethiopia, February, 2012.
Health
facilities
Facility indicators
Availability of essential drug list or
formulary to practitioners
Availability of
clinical guidelines
Percentage of key medicines
available in a facility
Private N
(%)
1 (7.1) 1 (7.1) 9 (85.7)
Public N
(%)
1 (25.0) 2 (50.0) 10 (88.0)
DISCUSSION
The need and potential for counseling the patients
regarding their drug therapy has been an important
part of the pharmacy practice and pharmaceutical
care. It has been the responsibility of the
pharmacist to counsel the patients before
dispensing the medication although the prescriber
gives some information about drugs prescribed in
primary care. Counseling not only enhances
compliance (by enhancing knowledge), but also
reduces complications due to non-compliance to
treatments 15
. The quality of labeling applied by
dispensers, the time spent informing the patients,
and the communication skills of the dispenser can
therefore affect compliance rates 10
.
This study showed that average consultation time
was better than the previous studies done in
developing countries, including Ethiopia. But the
average dispensing time was short 16-18
. Adequacy
of patient knowledge on drug instructions was
found to be far better than those of previous studies
done in developing countries 7, 19, 14
. Percentage of
labeling was shown to be high when compared to
previous studies from Ethiopia and Sudan but
lower than finding from Tanzania 16, 17, 19
.
Prescriptions containing 1181 drugs were brought
to the private and public drug retail outlets by 600
patient encounters. Percent of drugs actually
dispensed was comparable to global study done by
WHO but higher than previous Ethiopian studies 18,
19, 20
.
To be able to prescribe rationally and cost-
effectively, prescribers require up-to-date,
contextual and readily accessible information on
medicines. It is, however, reported that, especially
in resource-poor settings, prescribers have
difficulties in accessing relevant information 21, 22
,
which may have severe consequences as the quality
of prescribing has been found to be associated with
accessible information on medicines 23
. In this
study only one private out of fourteen and one
public health out of four health sectors had at least
one copy of essential drug list or formulary. The
availability of essential drug list/ formulary was
lower compared to study finding from Tanzania 24
.
In modern medicine, there may be more than one
treatment modality available for many medical
conditions. This leads to confusion and in many
cases incorrect treatment. In this regard, standard
treatment guidelines provide a health professional a
system for controlling cost by using funds more
efficiently the most effective therapy in terms of

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quality and provide a basis for evaluating quality of
care provided by the health care professionals, and
can be a vehicle for integrating special programs
(diarrhea disease control, acute respiratory
infection, tuberculosis control, malaria) at the
primary health care facilities 25
. In this study only
one of the private and two public health sectors had
at least one copy of clinical guideline. Standard
treatment guidelines availability in those health
facilities was shown to be comparable to study
findings done nation-wide in Ethiopia but very low
as compared to that of the Tanzanian finding 16, 19
.
While most of the prescribers (12 out of 19) were
untrained nurses in the health facilities,
unavailability of essential drug list and standard
treatment guidelines would lead to irrational
prescribing in terms of economic cost and quality
of health care.
Eleven key medicines that should be available at all
time in the health facilities were selected based on
disease prevalence and drug utilization profile
assessment just during one month before data
collection. In this regard 84.5% key medicines
were available in the health sectors. Artemether +
Lumefanthrine tablet was available in 20% of
health sectors where as procaine penicillin powder
for injection in 70% of the sectors. Study from
Ethiopia (nation-wide) showed comparable result
but lower than what was seen in Tanzania 16, 19
.
While malaria and upper respiratory tract infections
were the most frequent diagnosis, Artemether +
Lumefanthrine and procaine penicillin shortage
would pose a great problem in the provision of care
in health facilities.
The average number of causes of morbidity per
encounter in Wolkite private and public health
facilities was 1.23 + 1.4. Malaria, upper respiratory
tract infections and intestinal parasite caused 36.2%
of total morbidity. Seventy eight percent of
prescribed drugs in Wolkite private and public
health facilities were antibiotics, analgesics or
antiprotozoals. This was incoherent with the
morbidity profiles found in the health facilities.
Diclofenac, paracetamol, amoxicillin, chloroquine
and ciprofloxacin alone comprised 47.1% of the
total drugs prescribed. Studies done in North West
Ethiopia and Mexico showed comparable profile of
antibiotics and analgesics use 18, 26
.
LIMITATION OF THE STUDY
Any drug utilization study based on the WHO core
drug use indicators has limitations. The patient care
indicators do not capture many fundamental issues
related to the quality of examination and treatment
10
. However, the present study provides important
useful baseline data which will be useful for
comparison when in future any patient care and
facility indicator study is carried out.
CONCLUSION
The present study showed that there was shortage
of drug information sources like essential drug
list/formulary and standard treatment guidelines.
Availability of drugs in dispensaries was high but
labeling of them was seen in low number of drugs
relative to other studies and dispensed at shorter
duration. Some health sectors were short of supply
of the key drugs like Artemether + Lumefanthrine
and procaine penicillin.
ACKNOWLEDGMENT
The researchers would like to thank the Gurage
Zonal health bureau, Wolkite Town health
administration office, the Wolkite town health
institutions administrations and professionals for
their keen cooperation during the study.
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