Pharmaceutical Management for Maternal Health: Assuring access to quality medicines and supplies

Beth Yeager May 4, 2012 Dhaka, Bangladesh

Dimensions of Access to Medicines

Accessibility and Availability
Country % births attended by skilled attendant1 14.3% Stock-outs of oxytocin in public facilities?2 Yes, rarely

Afghanistan

Bangladesh
India Indonesia Nepal
1

18%
47% 73% 19%

Yes, regularly
Yes, frequently No Yes, occasionally

WHO Global Health Observatory; Births Attended by Skilled Health Personnel Interactive Map; http://gamapserver.who.int/gho/interactive_charts/mdg5/atlas.html, accessed 4/11/2012 2 USAID/MCHIP Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia Status Report 2011

Affordability
Example from Bangladesh:
Location of delivery Total cost of health care during pregnancy, delivery, and postpartum period as percent of average annual income 15%

Home

Basic obstetric facility
Comprehensive obstetric facility

35%
452%

Borghi, J. et al. 2006. Household Costs of Healthcare during Pregnancy, Delivery, and the Postpartum Period: A Case Study from Matlab, Bangladesh. Journal of Health, Population, and Nutrition 24 (4) 446–455.

Acceptability
Policy Makers

Providers

Women

Elements of Pharmaceutical Management to Assure Quality of Products

Selection
• Protocol for case management based on consensus of experts and internationally recognized best practices • Criteria should include:
• Consideration of types of health providers at different levels of the system • Cost • Safety and efficacy • Are appropriate storage • Quality and stability conditions for oxytocin present? • Registration status • Is misoprostol included in • Availability for procurement EML for ob/gyn indications?
• Who is allowed to prescribe misoprostol?

• Agreement between STGs and EML

Procurement
• Quantity needed
• Management information system to monitor consumption; supply data

• • • • • •

Quality standards Packaging Storage conditions/capacity Shelf life of products Supplier performance Centralized vs. decentralized

Procurement (2)
• Do tender documents provide sufficient specificity on characteristics that may affect quality? (e.g. packaging for misoprostol) • Will re-packaging be necessary? • What data are used for quantification? • Is data on morbidity available? • Have needs of lower levels of the health system been considered? • Have multiple uses of medicines (e.g. oxytocin) been considered?

Distribution
• Distribution network and transportation
• Vertical vs. integrated • Frequency

• Conditions during transport
• Cold chain; light; protection from weather

• Quality assessment at distribution points
• Are appropriate conditions maintained during distribution (e.g. oxytocin)? • How are medicines distributed to lower levels of system (e.g. community-based distribution of misoprostol)? • Is this system really working?

Inventory Management
• • • • • Stock cards and registers FEFO; stock rotation Reporting Physical inspection Disposal of expired products

• Is consumption recorded at all levels? • Are records reconciled (e.g. pharmacy vs. delivery room)?

Storage
• • • • • • • Temperature monitoring Cold chain (oxytocin) Humidity (misoprostol) Light Ventilation Clean environment/absence of insects/rodents Security

Use
• Service delivery protocols
• Who is allowed to prescribe? • Indications, dose, contraindications • Management of side effects

• Job aids • Product availability • Dispensing
• Labeling • Packaging • Counseling

Management Support
• • • • • Standard operating procedures Management information system Human resources Financing Monitoring and supervision

Policy, law and regulation
• • • • • EML; STGs Registration Importation Financing mechanisms Human resources

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