The document describes current pharmaceutical practices and their limitations in Ethiopian healthcare facilities. It notes that receiving, storage, inventory, dispensing and other processes are poorly documented. Medicines are not properly tracked, monitored or secured. Physical inventories are irregular. There is a lack of standardized forms, procedures and tools. This makes auditing, accountability and quality assurance difficult. As a result, there can be wastage, expiry, stockouts and compromised patient care due to issues like poor adherence. Potential causes include deficiencies in organization, management, staffing and training. Improved practices are needed.

1. Existing Practices and Limitations

2. Objectives:
At the end of this session participants will be able:
• To describe the current pharmaceutical transactions
and services
• To discuss limitations of the current practices and
their consequences
• To list causes of the problems in current practices
• To identify potential interventions to rectify the
existing problems

3. Outline:
• Current practices on pharmaceutical service and
transactions
• Limitations of existing practice
• Causes and consequences of the problems in
current practices
• Potential interventions

4. 1. Current Practices
• Process
• Pharmaceutical Transactions
• Pharmaceutical Services
• Limitations
• Pharmaceutical Transactions
• Pharmaceutical Services

5. Receiving Pharmaceutical Products
• Pharmaceuticals are received at the store of the
hospital
• Receiving takes place using Model 19 which has 3
copies
• The store manager crosschecks products with the
delivery invoice,
• Updates the bin card

6. Storage and Handling of Products
• The store manager with support of porters places
medicines on shelves or pallets or floor
• Checks stock status by looking at the bin cards,
physical count
• Arranges store in a systematized order
• Monitors expiry dates of products and report those
with expiry date of less than 6 months
• Segregate expired medicines from usable stock and
stock it in a separate place

7. Storage and Handling …
• Corrosive and flammable products are stored
pharmaceuticals together with other products
• Storage spaces are cleaned randomly once in a month
or two months or more

8. Physical Inventory
• Physical count is carried out irregularly only in few
facilities
• The purpose of the physical count is either :
• to meet reporting requirements (in rare cases) or
• to facilitate handing over of responsibilities during
staff exchange (all the time)

9. Physical Inventory …
• The occasional physical count is conducted without
taking into account the full description of the
product and cost of medicine
• In most cases, physical count is carried out in the
presence of store manager, pharmacy head and
experts from finance/audit
• No registration and arrangement of prior to the
physical count
• The physical count is neither reported nor reconciled
with beginning/ending balance and consumption

10. Issuing Pharmaceuticals:
• The store manager receives an approved request (using
both IFRR and Model 20) from dispensaries and other
units
• The store manager checks for availability of requested
products in the stated quantities

11. Issuing Pharmaceuticals…
• The store manager transcribe the requested items
into Model 22 (issuing voucher) in 3 copies
• Signatories of issuing voucher are only two
individuals i.e. store manager and the receiver
• Updates the bin card

12. Storage and Handling of Medicines at DUs
• Products are shelved systematically
• Products are not shelved immediately after they are
received from the store.
• Expiry dates are not monitored on a routine basis
• Retail prices not labeled on packages
• Physical count is not conducted at all
• Actual consumption is not determined all the time
• Request is not based on actual consumption
• No system to control loss and pilferage

13. Dispensing Medicines to Patients at Pharmacies
• Medicines are dispensed to clients based on
prescriptions
• Prescriptions are filed without registering what has
actually been dispensed to clients
• Cashiers are usually located far from pharmacies
• No adequate labeling of medicines

14. Dispensing Medicines to Patients at
Pharmacies…
• No adequate counseling or inappropriate counseling
environment
• No appropriate tools for medicine transactions as:
o cash register,
o standard sales ticket,
o dispensing register, etc
• Medicines dispensed to free or insured patients are
not recorded

15. Administering to Patients or Issuing to Health
care Providers at Wards, Laboratory Units and
Outpatient Clinics
• Authorized persons (heads) from different departments
receive and store products
• Authorized persons issue products to health care
providers for conducting various procedures without
any recording and documentation

16. Administering to Patients …
• A physician/specialist prescribes medicine and issues
the prescription to the patient
• The care giver or the nurse collects the prescribed
medications and stores them into the patient’s
bedside cabinet.
• A nurse administers medicine as per the order of an
authorized prescriber

17. Planning, Budgeting and Monitoring:
• The pharmacy unit prepares list of medicines with
budget estimate
• The pharmacy unit prepares supply plan based on
the approved budget
• Selection of medicines is carried out based on past
experience of the pharmacy unit
• Quantification of medicines is carried out based on
incomplete data and information

18. Planning, Budgeting and Monitoring…
• Prioritization of medicines is not based on standard
methodologies and services provided
• No reconciliation of need and budget
• The pharmaceutical services rendered by the health
facility is not properly monitored

19. Auditing of Pharmacy Transactions
• Physical count is carried out irregularly or during staff
handover
• Transactions are difficult to audit

20. Human Resource Development and
Deployment
• Pharmacy services are being managed by pharmacy
personnel
• The performance of practitioners is evaluated
regularly
• In-service training is provided
• Pharmacy staff employment is carried out by the
regional health bureau

21. 2. Limitations of Existing Practices
• Models 19 and 22 lacks essential product information
and extra copy to update stock control cards
• Bin cards and stock cards are not recorded and
updated on regular basis
• Absence of appropriate storage places and facilities for
storage of medicines and undertaking pharmaceutical
activities
• Difficult to carry out physical count effectively and
within short period of time
• Results of physical count are not analyzed
appropriately in such a way that appropriate action
can be taken

22. Limitations …
• No system to rotate stock according to the first-expire-
first out principle
• No means to identify overstock and under stocks
• No practice to monitor storage temperature, moisture,
sunlight, and protect them from unnecessary damage
• There is a possibility of damage and loss due to storing
corrosives and flammables with other products

23. Limitations …
• There is not system to identify wastage, theft,
pilferages, etc… timely
• It is difficult to identify or trace specific products
(with specific batch, brand, expiry date and cost)
• Irrational requests of medicines (type and quantity)
from different units may be approved and issued
• The facility may fail to respond to emergency
situations in cases of limited stock levels
• Medicines may unnecessarily expire at service
delivery units

24. Limitations …
• No system to ensure accountability at dispensaries
and other service delivery points (responsibility is not
shared among all dispensers)
• Retail prices are not clearly understood by all
dispensers
• Average monthly consumption of a specific product is
difficult to calculate
• The system is liable to overage and shortage of sales

25. Limitations …
• Dispensaries are not appropriately organized and
staffed to provide quality pharmaceutical services to
patients
• The information entered by the cashiers in the receipt
is not descriptive of what is actually dispensed
• The receipt/sales ticket given to patients is not
appropriate for medicine transactions
• The system is exposed to high level of pilferage,
especially of medicines given free of charge
• Patients do not have adequate knowledge of their
medications

26. Limitations…
• The health facility does not have propor system to
collect account receivables from sponsors of free and
insured patients.
• The system is not favorable to implement revenue
retention and income generation activities
• For inpatients, lack of price and consumption records
makes it difficult to summarize total expense at the time
of discharge
• The lack of appropriate recording and documentation
leads to pilferage, theft and loss of valuable medicines

27. Limitations …
• The system in place does not ensure accountability
• Wastage of resources due to expiry
• Shortages and stock out of essential medicines may
occur due to poor prioritization
• Shortage of budget to avail vital medicines leading to
compromised services and patient suffering or death
• Poor satisfaction of clients/patients

28. Limitations…
• Compromised treatment outcomes due to poor
patient knowledge and treatment adherence
• Development of AMR due to poor prescribing
/dispensing practice and patient use of antimicrobials
• Clients lack of trust and credibility on the health
institution and health care providers

29. Limitations …
• Pharmacy transactions cannot be audited due to lack
of appropriate records and documentation
• Lack of accountability due to absence of transparency
• Identification of products during ADE or product
defects is almost impossible due to absence of
standard documentations
• Innocent professionals are being accused due to lack
of transparency and documentation in the system

30. Limitations …
• Lack of commitment, responsibility and
professionalism
• High attrition rate of experienced staff due to
dissatisfaction
• Compromised efficiency and effectiveness of
pharmacy services due to absence of adequate
support staff
• Pharmacy workforce allocation doesn’t take into
account the actual work load and quality of work
needed

31. Limitations…
• Pharmacy personnel are assigned to a specific job
without having proper orientation and clearly defined
job description
• Performance evaluation of pharmacy staff is not based
on objective criteria and accomplishments of defined
tasks
• The pharmacy staff do not have appropriate schemes
of remuneration/incentives and professional
development plan

32. 3. Causes and Consequences Problems in
the existing practice
• Problems are the results of multifaceted factors
• Organization and Management
• Human Resource Development and Deployment
• Work Flow
• Absence of Systems and/or Tools
• Accountability and Transparency
• Efficient Utilization of Limited Budget
• Infrastructure and Equipment/Facilities
• Protection of Financial and Other Risk Liabilities
• Legal Instruments and Enforcement

33. Causes and Consequences …
• The aforementioned problems have resulted in:
• Shortage of essential medicines
• Wastage
• Inefficient budget utilization
• Irrational use of medicines leading to AMR, morbidity
and mortality

34. 4. Potential Interventions
• Various interventions tried to improve supply
management and use of medicines
• IPLS
• DTC
• DIS
• Clinical pharmacy
• APTS addresses gaps that were difficult to resolve
by other interventions
• Transaction at dispensing units
• Dispensing and counseling
• Liking pharmaceuticals transactions with finance

35. 4. Potential Interventions
• APTS addresses gaps that were difficult to resolve
by other interventions
• Transaction at dispensing units
• Dispensing and counseling
• Liking pharmaceuticals transactions with finance
unit

36. Summary
• The current pharmaceutical service practices have
many limitations and resulted in problems:
• No relevant vouchers for pharmaceuticals products
and transactions
• There is no extra copy of receiving and issuing
vouchers to be given to the stock card clerk to
update the stock status in the stock
• No regular updating of stock
• Inadequate storage facilities

37. Summary…
• High rate of wastage and pilferage
• Inadequate pharmacy staff to deliver quality service
• No accountable and transparent system to recover
values from insured and credit patients
• Pharmacy transactions are not auditable
 APTS is an interventions designed and proved to be
effective to resolve these problems

38. Thank you