UNFAIR “BLACK EYES”

by Tyrone Jack 12.MAR.10

During the course of 2009, particularly during the referendum campaign the Pharmaceutical Services received a number of “black eyes” and “bruise nose” from some talk show media commentators, the written press and politicians in general. No Drugs at the Hospital was a famous refrain.{{more}} The general public could not help but join in the stone throwing. These knocks came from persons who at most are merely “Journeymen” to the issues involved or had been misled by others who were conscientiously stupid. They were grossly unfair. In fact, they came at a time when the service had remarkably turned around the performance of the sector, and nothing but praise was more deserving to these hard working Public Servants.

The realities are that no government in the world can or even tries to supply all the drugs that the population wants. Instead, countries will normally develop individual national formularies. e.g. the BNF (“British National Formulary”). For this process drugs are divided into four main categories: very essential, essential, non-essential and specially authorized drugs “SAD”

Essential Drugs — The World Health Organization (WHO) has developed a model list of essential drugs which it has assessed as those drugs which satisfy the health care needs of the majority of the population. These drugs should be available at all times in adequate amounts, appropriate dosage, at a price the community can afford. The list contains 306 active ingredients and is further divided into a main list and a complimentary list.

The Organization of Eastern Caribbean states (OECS) has developed a single formulary through their joint Pharmaceutical Procurement Services (PPS). This Formulary is based on the model of the WHO guidelines. It, however, goes way beyond the WHO skeleton list and it contains in excess of 600 drugs. Additionally, Physicians can also request “SAD” on demand, and special arrangements are in place for handling such requests.” SAD” are drugs which are not on the National Formulary but which may be required for rare or emerging disease conditions

SIGNIFICANT IMPROVEMENT IN PERFORMANCE

The Government Pharmaceutical Service SVG has shown significant improvement on three of four measurable outcome indicators over the past ten years. The primary performance indicator of the Pharmaceutical Services is the “Service Level” indicator. (i.e.) The number of drugs dispensed ÷ drugs prescribed * 100. In the late 90’s early 2000’s, the service levels had fallen for a number of reasons; ongoing local review would have shown constant stock out, repeated OECS PPS reports showed the performance to be less than acceptable, languishing at the bottom of the OECS ladder, and an audit commissioned in 2004 and conducted by the OECS-PPS pointed to several of the causes and make several recommendations.

Our performance indicators have since improved significantly. In its summary of the 2002 OECS- PPS Annual Report, which would be reflective of data and budget for the years 2000-2001, the writer stated the following “All countries except SVG and to a lesser extent Antigua preformed satisfactorily”. (St. Vincent and the Grenadines service level indicator was then 66%; and the average available drugs selected from a tracer list of 30 was 47%, the next closest to us in this category was Grenada with 90% . This meant that we could dispense less than 7 of every 10 drugs prescribed from the general list and less than 5 of ever 10 from a tracer list of 30 important drugs.

The Audit commissioned in 2004, looking back on data for the calendar year Feb. 2003 – Feb. 2004 showed SVG remaining at the bottom of the OECS ladder with a 72 % service level, this, despite significant addition to the budget.

The latest reports from the OECS- PPS shows that in the 2009 Annual Report, reflective of 2008 data has SVG at 93 % service level, (i.e.) of Nine (9 ) of every 10 prescribed drug within the Government Pharmaceutical Service are filled at the point where it is prescribed.* ( the acceptable international benchmark is Ž 85%. As a matter of fact, the ongoing service level reports from the Chief Pharmacist shows that every single month of the year for 2009, the service levels was above the bench mark in all Medical Districts and that the annual averages for the last three (3) years have exceeded 90 % both at the hospital and community levels.

N.B: These data are collected and tabulated by the individual pharmacists across the country compiled by the Chief Pharmacist. It is also worth noting that SVG has the lowest cost recoupment rate of all countries which participate in the OECS Pharmaceutical Procurement Services.

These data are indicative of;

1. Adequate inventory & stock management particularly at the Central Medical Stores (CMS); also at the district pharmacy levels. This would involve the effective selection and maintenance of sufficient and adequate range of buffer stocks.* (-the target is a total of 4 month buffer, 3 months at CMS and one month at the periphery / district pharmacy)

2. A substantial increase in the budgetary allocations.

(- between the years 1996 and 2001 there was an 18.4 % increase, whereas, for the last six budgeted years 2005-2010 the increase was 69.6% )

3. Enhance co-ordination between the prescriber and the Pharmaceutical Service which has been buttressed by the establishment of a Formulary and Therapeutic Committee.

4. Generally better management of the Pharmaceutical Service.

All of the pharmacists involved should be highly commended, particularly the CMS managers over the pass 4 years.

The Pharmaceutical Services Budget

The General public and some politicians seem to have the mistaken impression that all of the funds allocated under CMS for materials and supplies are available for drug purchases. This is certainly not so. These allocations support the purchase of (1) Pharmaceuticals which include Drugs, Vaccines, Contraceptives including condoms (2) Medical Supplies/ accessories which includes; Needles, Dressing, Cleaning agents, toiletries etc. (3) Laboratory Supplies which include testing reagents and kits, petri-dishes, test tubes etc. Contraceptives including condoms were originally supported by the UNFPA this is no longer so.

Also the Government allocated funds supported are supplemented by contributions from Global funds (Drugs for HIV/ HIV related conditions), donations from Brazil (HIV related drugs) and other small drug donations from visiting voluntary medical groups out of the US.

The average weighted percentage of inventory variation

This indicator measures the degree to which the stock record keeping system at CMS reflects the true quantity of stock seen. Variations between stock and records at CMS, though distressing, are not abnormal for storerooms which handle in excess of 1000 items. For the most part CMS hovers around the international benchmark of 4 and the 2009 OECS average of. It is my considered opinion that it was unfair for political commentators to publicly comment on the number of items which appeared missing (stock less that record) without mentioning that there was an even greater amount (both in cost and numbers) of items that were in excess of records, these types of variation point more towards human errors on the part of inventory clerks, the constraints imposed by a poorly constructed store room (which was constructed with insufficient space from its inception) than to pilfering. Nevertheless, there is evidence of some of the latter.

Tyrone Jack is a Senior Pharmacist who works at the Ministry Of Health as the Drug Inspector.