Availability of essential medicines and pharmaceutical inventory management practice at health centers of Adama town, Ethiopia

Medicines are vital components of patient care all over the world. World Health Organization (WHO) define essential medicines (EMs) as products that satisfy the priority healthcare needs of the population which should be available in the health facities at all times in adequate amounts with affordable price by the community [1].

Ethiopia has a national drug policy aimed to ensure adequate supply of medicines which are required for treatment of diseases affecting the majority of the country’s population [2], which gives the primary mandate to the government. To achieve this, the country developed national list of EMs which guides the decision of all health service providers with regard to selecting and availing the most needed medicines at every level of the healthcare system at all times with affordable cost [3].

Inventory management is vital for pharmaceutical supply system which involves the management of routine pharmaceutical ordering process. It helps to maintain a steady supply to patients, hence preventing product stock out, while minimizing the costs of holding inventory [4]. Accurate and updated stock records are crucial for proper inventory management since they are input to calculate future needs. Holding stocks is important to ensure availability of essential items almost all the time. The selection of items to stock should rely on their value to public health and volume of consumption [4, 5]. Nowadays, inventory management is assisted with computerized Logistics Management Information System (LMIS) that allows easy recording of all medicines transactions and connects all levels of supply chains [6, 7]. Despite the importance of LMIS in improving efficiency of the overall inventory management process [8, 9], it is underutilized in developing countries like Ethiopia [10].

Inventory management plays a major role in providing efficient healthcare in relation to three vital aspects of drug supplies used in the health facilities; availability, safety, and affordability. Those are the most important determinants of quality of care and patient satisfaction with services provided in public health facilities [11, 12]. Poor inventory management might lead to overstocking or under stocking of EMs which subsequently results wastage of resource and increased morbidity and mortality due to shortage of life saving drugs [13‐17].

Ministry of health of Ethiopia developed standardized inventory management tools expected to be utilized by public health facilities throughout the country whether operated manually or use LMIS. These are bin card, stock card, Internal Facility Request and Resupply form (IFRR), Report and Requisition Form (RRF). The bin card is kept with the product inside the store and up dated in every transactions while stock card is similar to the bin card but is used to track stock based on issuing and receiving orders. The IFRR voucher is used to report internal transfer of items between the facility’s pharmaceutical store and dispensing units. The RRF is used to order health commodities from PFSA whereas RRUC is used to track the transfer of supplies back to PFSA. The ministry recommends physical inventory and updating of bin cards and stock cards on regular basis [6].

As per the WHO recommendation, availability of EMs should be 100%, but it is estimated that about one-third of the world population does not have access to medicines, particularly in Africa and Asia [18, 19]. Availability of generic medicines at public sectors is less than 60% across WHO regions, especially in Africa region [20].

In Ethiopia, EMs stock out is still a common problem although the degree is variable from facility to facility, ranged from 26 to 91% [7, 21‐28]. In addition, poor inventory management challenges availability of EMs in the country [7, 22, 28]. Thus, it is crucial to assess the scope of problem in availability of EMs and inventory management practice of HCs in Adama town for interventions.

The study was aimed to evaluate availability of EMs and pharmaceutical inventory management practices among HCs in Adama town. Availability of drugs largely influence quality of healthcare and patient satisfaction. Stock out of EMs enforces patients to use more costier alternatives. Drug availability is affected by efficiency of inventory management.

The overall availability of EMs in this study was far from WHO recommended target point [12]. In 2009, the general availability of EMs in Ethiopia was reported to be 91% but, study conducted at different part of Ethiopia after 2009 showed big variation on the availability of EMs ranged from 26 to 91% [22, 27]. The availability of TDs documented in this study is better than Jimma and Amhara region but, lower compared to Gondar and Addis Ababa [16‐20]. The reason behind might be due to the stock status of regional PFSA and the budget put on primary public health facilities vary from one region to the other in Ethiopia. When the result of this study compared to Tanzania, it is lower but much higher compared with Ugandan study [15, 31]. Stock outing of EMs at the day of survery in this study (23.6%) is higher than previous studies in Tanzania (20%) [15] and Gondar, Ethiopia (9%) [22].

The severity of stock out duration of TDs in each HC was assessed by calculating the average stock out days of TDs within the past 12 months. The 1 year average stock out days of TDs in this study is lower when compared to the situation in Uganda, 72.9 days, and higher when compared to the result in Gondar, 30.5 days, [22, 31]. The reason for high stock out period in this study might be due to transportation during procurement process and unavailability of the TDs at PFSA as most professionals stated. Of the 11 TDs, ORS was stocked out for longer period when compared to the other TDs whereas, in Gondar from 26 TDs chloroquine syrup was stocked out for more days [22]. The long stock out period for ORS might be due its’ high consumption since it is important lifesaving medicine for diarrheal diseases, common in developing countries like Ethiopia. In addition procurement of drug for HCs is highly bureaucratic. The government allow purchase of drugs from private supplies only when unavailable in PFSA. It also limit quantity of drug to be purchased. High consumption, in the absence of fluidy supply system cause frequent stock out and cumulative longer day of stock out.

The physical count that is less than the balance on bin card is one of the indicators for poor record keeping practice. In this study, the percentage of discrepancy varies among all HCs, highest in Dembela HC. From the store keeper’s response, although there is guideline to use LMIS in this HC, the absence of computer software system and lack of training on logistic forms result poor record keeping practice in this HC. The discrepancy was high when compared to one of the public hospitals in Tanzania and lower than one of the HC in Gondar town [13, 22]. Ideally, a facility should not have discrepancies between the physical inventories and the balance on bin card for each item but, in practice there is acceptable level of errors. In general, discrepancies of more than 10% may require efforts to improve data quality [29]. Thus, except one HC all the other needs to improve their record keeping practice.

Utilization of different logistic forms is variable among HCs of this study. Bin cards were used in majority of HCs and updated on transaction which better than reported from Uganda primary health facilities [32]. Effective inventory management should be supported by LMIS. But in this study only two HCs in Adama town used LMIS in their facility which was low compared to the study done at HCs in Addis Ababa [7]. This might be due to lack of software system to manage their store and lack of training on LMIS in most HCs in Adama town.

Regarding lead time, this study revealed that the lead time was as long as 2 months when EMs procured from PFSA. It is longer when compared to the lead time reported from Addis Ababa, which was 1 week to 2 weeks [7]. This might be due to the stock status of regional PFSA varies from region to region.

This study is limited to one geographical area and single facility level (health centers) only due to financial constraints. Extrapolation should be taken with precaution with reviewing similar studies in other settings to get full picture of the country.

The availability of EMs and the accuracy of record keeping in the HCs were low. The major problem common for all HCs in the procurement process were PFSA stock status and transportation. The absence of computer software system and lack of enough pharmacy professionals are some of the challenges to perform inventory management practice in the HCs properly, which further decrease the availability of EMs in the facility. We recommend health proffessionals working at respective health centers to improve inventory management practice. The regional health bureau should provide capacity building to HCs with provision of computers and trainings.