Introducing management principles into the supply and distribution of medicines in Tunisia.

Introducing management principles into the supply and distribution of medicines in Tunisia A. Garraoui,1 P. Le Feuvre,2 & M. Ledoux3 A number of strategies have been proposed by various organizations and governments for rationalizing the use of drugs in developing countries. Such strategies include the use of essential drug lists, generic prescribing, and training in rational prescribing. None of these require doctors to become actively involved in the management of the drug supply to their health centres. In 1997, in the Kasserine region of Tunisia, the regional health authorities piloted a radically different strategy. This involved the theoretical allocation of a proportion of the regional drug budget to each district and subsequently to each health centre according to estimated demand. Medical staff were given responsibility for the management of these budgets, allowing them to control the nature and quantities of drugs supplied to the health centres in which they worked. This paper outlines the process by which this strategy was successfully implemented in the Foussana district of Kasserine region, and explores the problems encountered. It describes how the theoretical budgets were allocated to each district and how the costs of individual drugs and the consumption of drugs in the previous year were calculated. It then continues by giving an account of the training of the staff of the health centres, the preparation of a drug order form and the method of allocation of the theoretical budgets to each of the health centres. The results give an account of how the prescribing habits of doctors were changed as a result of the strategy, in order to take into account the costs of the drugs that they prescribed. They show how the health centres were able to manage their budgets, spending overall 99.8% of the budget allocated to the district. They outline some of the changes in the prescribing habits that took place, demonstrating a greater use of appropriate and essential drugs. The paper concludes that doctors and paramedical staff can successfully manage a theoretical drug budget, and that their involvement in this process leads to more rational prescribing within existing resource constraints. This has a consequence of benefiting patients, satisfying doctors and pleasing administrators. Voir page 528 le re´sume´ en franc¸ais. En la pa´gina 529 figura un resumen en espan˜ol. Introduction Various strategies have been proposed to deal with the rising cost of drugs and the need to decrease the use of non-essential drugs in developing countries. Only rarely, however, do they involve either the allocation of drug budgets to the peripheral level of health care or the participation of prescribing doctors in the management of drug supplies. These approaches are reported below from rural Tunisia, where the provision of prescribed drugs at health centre level is one of the fundamental features of primary care. In the Kasserine region, each of the 13 health districts serving between 10 000 and 70 000 people has up to 15 health centres. The supply and distribution of drugs is based on sector hospitals, each of which serves up to four districts. The central government allocates a budget to the hospitals which is managed by their directors. Excluding the cost of salaries, 40–50% of hospital budgets are spent on drugs. The health centres request drugs from their district headquarters, which in turn request them from the sector pharmacy. Prescribers are obliged to request drugs on an official list of those permitted at the health centre level. Until recently, the ordering of drugs and the management of drug supplies have not been regarded as a role for prescribing doctors. These tasks have generally fallen to health centre nurses, who have requested supplies each month in accordance with what health centre doctors normally prescribe and with what is likely to be available in the health sector pharmacy. Health centre nurses have not known the costs of the drugs ordered, while doctors have commonly adjusted their prescribing as closely as possible to the availability of drugs in the centres. Consequently, nurses have tended to order drugs that have previously been prescribed rather than ones that doctors would like to prescribe. Where prescribed drugs have been unavailable in a health centre, patients have had to purchase them from private pharmacies. Some drugs have not always been available in adequate quantities in the sector pharmacy. Nurses have been unaware of the criteria used by the sector pharmacy when distributing scarce drugs, and there- 1 Regional Director of Health, 1200 Kasserine, Tunisia. 2 General practitioner formerly with the Association for Cooperation in Tunisia; now at 7 Chelsea Court, South Road, Hythe CT21 6AH, England. Requests for reprints should be sent to this author. 3 Adviser in primary health care, Brussels, Belgium. Reprint No. 0018 525Bulletin of the World Health Organization, 1999, 77 (6) # World Health Organization 1999 fore may have tended to exaggerate requirements. This has occasionally resulted in the delivery of excessive quantities of certain drugs. As in most drug management systems there have been some unac- countable losses. These could be minimized if nurses felt directly responsible for the management of drugs in their health centres. Without a system of pricing and surveillance in the sector pharmacy there has been a tendency for spending by districts to be determined solely by demand and to be disproportionate to their size or needs. Doctors, unaware of the cost of drugs, have often not prescribed the less expensive of two equally effective drugs or have failed to take cost into consideration in some other way. Strategic vision In 1995, when drug costs were beginning to rise out of the control of hospital directors, it was decided that expenditure would have to be controlled in the Kasserine region and that health service staff would have to take personal responsibility for the activities undertaken. The equitable distribution and manage- ment of drug budgets was required. It was considered that costs could be reduced and greater availability of essential drugs achieved at district and health centre level if doctors became involved in ordering the drugs they needed and if they had a knowledge of costs. A study by doctors in the Sbiba district in 1996 indicated the value of this approach. It proved possible to calculate the average cost of a prescription for each of the district’s health centres, to demon- strate the proportion of inevitable losses, and to show how simple methods of stock control could be used to reduce such losses. As a result it was decided that health centres would be allocated their own theore- tical budgets, that new order forms would be produced for the costing of ordered drugs, and that doctors would become more closely involved in the management process. Towards the end of 1996, in anticipation of the launch of the system in Foussana district, theoretical budgets for 1997 were allocated to this and the three other districts in the same sector; the costs of individual medicines were calculated; the consump- tion of drugs in Foussana during 1996 was analysed; health centre staff were trained; an order form was devised; and theoretical budgets were allocated to the Foussana health centres. Allocation of district budgets At a meeting attended by the hospital director in the town of Thala, the sector pharmacist, and doctors representing the four districts, sums were allocated to the districts in accordance with the numbers of consultations that had occurred during the first ten months of 1996, after an allowance had been made for the funds estimated to be needed by the Thala hospital. Foussana district received a theoretical budget of 60 500 Tunisian dinars (1 dinar = US$ 0.95 approximately), considerably more than in previous years when spending had been based on demand and there had been no system for allocating budgets to districts. The actual amounts spent on medicines supplied to Foussana district in 1994, 1995 and 1996 had been 43 152, 35 067 and 41 324 dinars respectively. Calculation of costs of individual medicines A price was calculated for each drug on the basis of information obtained from the official list of the Central Pharmacy of Tunisia. Analysis of consumption of medicines The types, quantities and costs of drugs distributed in Foussana during the first ten months of 1996 were analysed. A district formulary was created that excluded various expensive or relatively unimportant medicines. The order for the first three months of 1997 was prepared such that a quarter of the annual budget would be spent. Training health centre staff Nurses from the central Foussana clinic and the nine peripheral health centres attended a half-day training course on: . estimating the drug requirements of their health centres, given the types and quantities of medicines prescribed in 1996 and the personal preferences of the doctors concerned; . preparing orders so as to ensure continuity in the provision of drugs for patients with chronic diseases, through drawing up lists of such patients and their drug needs; . managing their budgets so that each three- monthly order cost approximately a quarter of the sum available. Order form A form was devised listing all items that could be prescribed according to the district formulary. The unit costs and the health centre budget and its consumption to date were also indicated. Budget allocation to health centres Budgets were allocated to the health centres in line with the numbers of consultations during the first 11 months of 1996. The number of consultations in the district was calculated and the budget was distributed in proportion to the number of consulta- tions in each centre. The first order was placed in December 1996 and the drugs were received from the sector pharmacy about three weeks later. It was agreed that an order would be placed every three months. The first order, prepared by a group of doctors, did not reflect the true needs of the health centres. Policy and Practice 526 Bulletin of the World Health Organization, 1999, 77 (6) Subsequently, therefore, the nurses were informed of the cost of their previous order and of the percentage of their budget spent. These figures were taken into account when the next order was drawn up and the total cost was calculated, and were forwarded to the district. Centres that had overspent at the end of the first quarter reduced the cost of the next order; those that had underspent were able to increase the cost of requested drugs. The order sent by the district to the sector pharmacy was the sum of the orders submitted by the health centres. Problems encountered Between 20% and 30% of the drugs ordered from the sector pharmacy were not delivered to the district, because of a lack of drugs at the supraregional depot or the national level. The system was not sufficiently well established to permit subsequent provision of the drugs by the depot. Consequently, the health centres either had to re-order or go without. Stocks of essential drugs were exhausted in certain health centres before the quarterly periods covered by orders had elapsed for the following reasons: . lack of drugs at the supraregional depot or national level; . unexpected demand; . inaccurate calculation of previous order. Health centres were allowed to request small quantities of essential drugs between the three- monthly orders. However, as all drugs previously delivered to the district had been dispatched to the health centres that had ordered them, there was no district stock available for resupplying health centres. These drugs therefore had to be either subtracted from the stock and budget of the Foussana health centre or ordered from the sector pharmacy. Results Budget management The health centre staff were fully capable of managing their budgets (see Table 1). The district spent 99.8% of its allocated budget; health centre spending ranged from 76.1% to 106.1% of individual budgets. Doctors’ and nurses’ opinions Doctors and nurses confirmed that there had been an improvement in the quantity and range of drugs available in their health centres. For antibiotics, it was commonly reported that amoxicillin capsules and syrup, cotrimoxazole capsules and syrup, erythromy- cin syrup and cloxacillin capsules had been added to the stock of injectable penicillin, oxytetracycline, nitrofurantoin and metronidazole held by health centres. Doctors’ prescribing practices Between 1996 and 1997 there were marked changes in doctors’ prescribing practices, reflecting an under- standing of the need for appropriate prescribing and cost containment. Thus, whereas spending on oxytetracycline and injectable penicillin fell by 29% and 27% respectively, that on oxacillin capsules, amoxicillin syrup and co-trimoxazole tablets in- creased by 351%, 3002% and 139% respectively. A 39% drop in spending on kaolin powder was accompanied by rises of 89% and 158% in spending on antacid solution and famotidine tablets. Spending on aspirin tablets was down by 21%, while that on paracetamol tablets increased by 61%. A decline of 67% was reported for expenditure on vitamin C tablets, accompanied by increases of 52%, 474% and 170% on multivitamin drops, ferrous fumarate tablets and folic acid tablets respectively. Doctors prescribed the cheaper drug when two similar drugs were available. Discussion As a rule, strategies aimed at rationalizing drug use in developing countries focus on the supply of essential drugs and the development of guidelines on use, especially with regard to generics. Few interventions have concentrated on economic models directly involving prescribers in the management of their drug supplies. There is a need for better collaboration between clinicians and policy-makers and a strength- ening of the link between the theoretical and practical aspects of drug management (1). Although in the present intervention the budget available for spend- ing on drugs by the whole sector did not change, the way in which it was distributed and spent changed fundamentally: health centre budgets were allocated in accordance with the numbers of consultations during the previous year. No account was taken of morbidity, as had happened in a previous interven- tion (2). We were not convinced that morbidity reporting was accurate, and believed that the inclusion of morbidity analysis would greatly com- plicate budget allocation and present a potential source of dispute. However, there was a case for considering the number of patients with chronic disease, and the numbers of diabetic patients requiring insulin were taken into account when the 1998 budgets were calculated. Doctors changed their prescribing habits significantly once they became aware of the cost of the drugs in question. Many of the changes were similar to those reported in other interventions based on the education of prescribers and the limitation of non-essential drug use (1, 3). In the present programme, however, the prescribers themselves changed their practices in response to economic factors. Doctors and nurses readily engaged in the management of their drug budgets because they Management principles for the supply and distribution of medicines in Tunisia 527Bulletin of the World Health Organization, 1999, 77 (6) realized that this enabled them to influence which drugs and what quantities were delivered to the health centres where they worked. Professional satisfaction was heightened as a consequence of being able to prescribe more of the drugs they believed to be best for their patients. The idea that injections were cheap and syrups expensive was challenged, and this led to a significant change in the types of antibiotic pre- scribed. Many drugs had not previously been prescribed because it was thought that they were expensive or not available from the sector pharmacy in adequate quantities. Doctors rapidly changed their prescribing practices where it was shown that this was not so. Although the administrative load at district level increased, personnel at health centres found that, on balance, there was a reduction in the time needed to manage medicine stocks. The new system increased the likelihood that patients would receive the most appropriate medicines. Hospital directors found that the system allowed spending to be contained and that resources could be allocated equitably in proportion to clinical demand. The costs of managing the system were found to be low, and it was easily implemented without computerization at district level. The intervention involved collaboration be- tween clinicians and administrators to the benefit of both. The management of the system provided a forum for discussion and led to improvements in other areas of health care management. Conclusion By the end of 1997, various districts in the Kasserine region had adopted the approach outlined above. They reported that: . the management system benefited patients, satisfied doctors, and pleased administrators; . paramedical staff were capable of managing a theoretical budget and a quarterly stock of medicines; . the involvement of doctors and nurses in manage- ment was satisfying for them and increased their accountability and sense of responsibility; . the quality of health services could be improved without increasing financial resources. The experience gained in Foussana and other districts led to the introduction of a regional strategy for 1998 marked by the use of printed order forms and a limited list of drugs. n Acknowledgements We thank the many doctors, nurses and hospital directors in the Kasserine region who made it possible to carry out the intervention described. Gratitude is also expressed to Vincent De Brouwere of the Institute of Tropical Medicine, Antwerp, Belgium, for reviewing the present paper and providing helpful comments. Re´sume´ Gestion de l’approvisionnement en me´dicaments et de leur distribution Plusieurs strate´gies ont e´te´ propose´es par des orga- nisations et des gouvernements afin de rationaliser l’utilisation des me´dicaments dans les pays en de´ve- loppement. Elles pre´voient entre autres l’utilisation de listes de me´dicaments essentiels, la prescription de produits ge´ne´riques et des activite´s de formation a` la prescription rationnelle des me´dicaments. Aucune ne demande pourtant que les me´decins participent active- ment a` la gestion de l’approvisionnement des centres de sante´ en me´dicaments. En 1997, dans la re´gion de Kasserine en Tunisie, les autorite´s sanitaires re´gionales ont teste´ une strate´gie Table 1. Management of medicines, Foussana District, Tunisia, at the end of 1997 Health centre % consultations Annual Quantity spent % spent Number of Average theoretical (dinars) consultations prescription budget (dinars)a in 1997 cost (dinars) Foussana and casualty 54 32 670 34 664 106.1 29 220 1.2 Oued Errecheh 3 1815 1617 89.1 1680 1.0 Khemouda 8 4840 4797 99.1 4418 1.1 Ouled Bin Njah 5 3025 3072 101.6 2661 1.2 Ouled Mansour 3 1815 1526 84.1 1340 1.1 Sahraoui 6 3630 3517 96.9 2652 1.3 Ain Jnene 3 1815 1882 103.7 1397 1.3 Boudriesse 9 5445 4435 81.4 4314 1.0 D. Boughanem 4 2420 1842 76.1 1559 1.2 Ouled Mahfoudh 5 3025 2872 94.9 2291 1.3 El Hazza 0 143 242 District 100 60 500 60 367 99.8 51 774 1.2 a 1 dinar = US$ 0.95 approximately. Policy and Practice 528 Bulletin of the World Health Organization, 1999, 77 (6) comple`tement nouvelle : une part the´orique du budget re´gional pour les approvisionnements pharmaceutiques a e´te´ alloue´e a` chaque district puis a` chaque centre de sante´ en fonction d’une estimation de la demande. Les me´decins ont e´te´ charge´s de ge´rer ces budgets et notamment de controˆler la nature et les quantite´s des me´dicaments livre´s aux centres de sante´ dans lesquels ils travaillaient. Cet article de´crit comment cette strate´gie a e´te´ mise en œuvre avec succe`s dans le district de Foussana de la re´gion de Kasserine et explore les proble`mes rencontre´s. Il pre´cise comment des budgets the´oriques ont e´te´ alloue´s a` chaque district, et comment ont e´te´ calcule´s le couˆt de chaque me´dicament ainsi que la consommation de l’anne´e pre´ce´dente. Il rend compte de la formation qui a e´te´ donne´e au personnel des centres de sante´, de la pre´paration d’un formulaire pour les commandes de me´dicaments et des me´thodes selon lesquelles a e´te´ alloue´ un budget the´orique a` chacun des centres de sante´. Les re´sultats exposent comment cette strate´gie a amene´ les me´decins a` prescrire diffe´remment, en fonction du prix des me´dicaments. Ils montrent que les centres de sante´ ont pu ge´rer leurs budgets, de´pensant en tout 99,8% du budget alloue´ au district, et pre´cisent certains des changements qui se sont produits dans la fac¸on de prescrire, mettant en e´vidence un recours plus important a` des me´dicaments approprie´s et essentiels. La conclusion est que les me´decins et les personnels parame´dicaux sont tout a` fait capables de ge´rer un budget pharmaceutique the´orique et que leur participation a` ce processus les conduit a` prescrire de fac¸on plus rationnelle en fonction des ressources disponibles. Tout cela dans l’inte´reˆt des patients et pour une plus grande satisfaction des me´decins comme des administrateurs. Resumen Aplicacio´n de principios de gestio´n al suministro y distribucio´n de medicamentos Diversas organizaciones y gobiernos han propuesto varias estrategias para racionalizar el uso de los medicamentos en los paı´ses en desarrollo. Tales estrategias incluyen el uso de listas de medicamentos esenciales, la prescripcio´n de medicamentos gene´ricos y el adiestramiento en la prescripcio´n racional. Ninguna de esas opciones requiere una participacio´n activa de los me´dicos en la gestio´n del suministro de medicamentos a sus centros de salud. En 1997, en la regio´n tunecina de Kasserine, las autoridades sanitarias regionales introdujeron una estrategia radicalmente diferente, que entran˜aba la asignacio´n teo´rica de una proporcio´n del presupuesto regional para medicamentos a cada distrito, y poste- riormente a cada centro de salud, en funcio´n de la demanda estimada. Se asigno´ a los me´dicos la responsabilidad de gestionar esos presupuestos, auto- riza´ndoseles a controlar el tipo y cantidad de los medicamentos suministrados a los centros de salud en que trabajaban. En este documento se expone sucintamente el proceso que permitio´ aplicar con e´xito esa estrategia en el distrito de Foussana, en la regio´n de Kasserine, analiza´ndose los problemas que surgieron. Se explica co´mo se asignaron los presupuestos teo´ricos a cada distrito y co´mo se calcularon los costos de los medicamentos y el consumo de medicamentos del an˜o precedente. Seguidamente se da cuenta de la formacio´n del personal de los centros de salud, de la preparacio´n de un formulario de pedido de medicamentos y del me´todo de asignacio´n de los presupuestos teo´ricos a cada uno de los centros de salud. Los resultados muestran que los ha´bitos de prescripcio´n cambiaron de resultas de la estrategia, pues los me´dicos empezaron a tener en cuenta los costos de los medicamentos que prescribı´an, y que los centros de salud fueron capaces de gestionar sus presupuestos, utilizando globalmente el 99,8% del presupuesto asignado al distrito. Se hace referencia asimismo a algunos de los cambios experimentados por los ha´bitos de prescripcio´n, que reflejan un mayor uso de medicamentos apropiados y esenciales. La conclusio´n es que los facultativos y el personal parame´dico pueden gestionar satisfactoriamente un presupuesto teo´rico para medicamentos, y que su implicacio´n en ese proceso conduce a una prescripcio´n ma´s racional dentro de los lı´mites impuestos por los recursos disponibles. La medida beneficia a los pacientes y es del agrado tanto de los me´dicos como de los administradores. References 1. World Health Organization. Report on the International Conference on Improving Use of Medicines. Essential drugs monitor, 1997, 23: 6–12. 2. Pezzino G, Haile M. The right drugs in the right amounts. World health forum, 1991, 12: 175–180. 3. Sunartono et al. Impact evaluation of self-monitoring of drug use indicators in health facilities. International Conference on Improving Use of Medicines, Chiang Mai, 1997. Management principles for the supply and distribution of medicines in Tunisia 529Bulletin of the World Health Organization, 1999, 77 (6)