The National Drug Policy in Practice
(A Case Study of the Dangme West District)
A Dissertation Submitted In Partial Fulfillment 
Of The Masters In Public Health Degree.
Presented To School Of Public Health, 
University Of Ghana, Legon
Submitted
by
Nana Akua Mensima Essah
AUGUST, 2000-08-28
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- £ 3 6 5 6 8 2
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DECLARATION
I DECLARE THAT ALL THE WORK IN THIS STUDY HAS BEEN A RESULT OF 
MY OWN RESEARCH, EXCEPT WHERE SPECIFIC REFERENCES HAVE BEEN 
MADE; THAT THIS WORK HAS NOT BEEN SUBMITTED TOWARDS ANY 
OTHER DEGREE, NOR IS IT BEING SUBMITTED CONCURRENTLY IN 
CANDIDATURE FOR ANY OTHER DEGREE.
SIGNED N a o < ^  A  {Y\ • -9^ lo
DESIGNATION .........................................................
DATE. S e p -  Q-OOO
DESIGNATIC
SIGNED
DATE.
DATE.
DESIGNAT1
SIGNED
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ii ACKNOWLEDGEMENT
My sincere gratitude goes to Professor Samuel Ofosu Armah, 
Mr A. A. D Oboubi, Dr Eric Amuah and all the staff of the 
Dangme West District Health Administration.
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Dedication
To Paul, Fred, Akyea, Morkor, Fenella and David
Whose support, vision and energy brought my aspirations 
for an MPH to life to life
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iv LIST OF ACRONYMS
ADR Adverse Drug Reactions
DA District Assembly
DTC Drag Therapeutic Committee
EDC Essential Drug Concept
EDL Essential Drags List
EDL Essential Drug List
EOQ Economic Order Quantities
INRUD International Network for Rational Drag Use
MCH/FP Maternal and Child Health/ Family Planning
MOH Ministry of Health
MOH Ministry Of Health
NDP National Drugs Policy
NDP National Drugs Policy
PHC Primary Health Care
WHA World Health Assembly
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V. ABSTRACT
Objective
The main objective of the study was to determine which component of the National Drug 
Policy was working and which was not. Thus this study aimed to compare the current 
practices in the implementation of the Drug Policy with findings obtained in 1996 and 
1998 and to determine strengths and weaknesses of some of those strategies adopted in 
the implementation process.
The study took place in the Dangme West District. Subdistrict health staff working in the 
ten Health Centres and Community Clinics and who were responsible for dispensing 
were interviewed to assess knowledge o f Rational Drag Use / Drug Storage /Drug 
Distribution components of the essential drag concept and to determine implementation 
arrangements and status of implementation. Key personnel of private sector health 
facilities and drag shops were also interviewed using the same criteria and questionnaire.
At the community level, heads of households were interviewed to determine level of and 
impact of the drag distribution component of the policy implementation by measuring 
accessibility, availability and perception of cost to the individual as an indicator of how 
far the goal of the NDP had been achieved.
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Summary of Key Findings and Recommendations
1. Knowledge of MOH policies
1.1 Finding: Knowledge of MOH policies is very scanty
1.1.1 Recommendation: Distribution of policy documents must be improved. The re 
was a need to disseminate information about the whole policies and not just 
components of a policy in order to improve intersectoral collaboration.
2. Implementation of components of the NDP
2.1 Findings: The training component of the NDP was very well implemented. 
Training had been given to 78.6 % of public sector respondents in the last two 
years and to 61.5% of the private sector respondents.
2.1.1 Recommendation: In addition, training programmes must tackle the beliefs and 
attitudes of trainees if behavioural change is aimed at. Secondly the target group 
of trainees must be expanded to include staff especially those in the community 
clinics who act in the absence of the in-charge.
2.2 Finding: Facilities in the private sector are inspected more regularly than the 
public sector facilities. Facilities are inspected 85.7% of the time in public 
facilities and 92,3% in Private Sector facilities.
2.3 Finding: Storage facilities and practices are generally good in 50% of public 
sector facilities and in 84.6 % of the private sector facilities. Stockouts were 
experienced more often in the public facilities and 60% of the public facilities
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reported no experience with expiration of drugs in storage in contrast with the 
100% ‘no expiry" rate in the private sector. The Stock control component of the 
policy is not working very well in the public sector.
2.3.1 Recommendation: Improved storage facilities and practices
Budgets must be made for the construction of or improvement of storage facilities 
of in all health facilities especially those in the public sectors. Better storage 
facilities will reduce the occurrence of deterioration of goods in storage and 
prevent he use of scarce resources on replacement drugs.
2.3.2 Recommendation: Third Party contacting of dispensary services 
Alternatively other mechanisms such as third party contracting could be 
established for employing independent private sector pharmacists to man 
dispensaries in health facilities to provide services to clients.
2.4 Finding: Out of 119 respondents (heads of households) interviewed on ability to 
purchase drugs, 84.3% reported that they found drugs affordable
2.5 Finding: 73% of the 119 respondents reported that drugs were easily accessible
2.6 Finding: Counselling on drug use is performed excellently by the Medical 
Assistants and persons in charge of the community clinics and not by the 
Dispensing Assistants. The best interaction between clients and service providers 
were found at the community clinics.
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2.6.1 Recommendation: To improve communication between the Dispensary Assistant 
and the patient dispensary windows should be widened.
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TABLE OF CONTENTS
1.1 D rug  M a n a g em en t  a nd  D rug  Po l ic ie s .................................................................................................................... 12
1.2 PR O B LEM  S T A T EM E N T ...................................................................................................................................................15
1.3 D E SC R IP T IO N  O F  T H E  STU DY  A R E A .................................................................................................................. 18
1.3.1 Geography Dangme West D istrict ..................................................................................................................................................................................................18
1.3.3 Health Service Infrastructure ..................................................................................................................................................................................................................19
1.4 JU S T IF IC A T IO N  FO R  T H E  S T U D Y ........................................................................................................................... 21
1.4.1 Rationale and Justification ..........................................................................................................................................................................................................................21
1.4.3 Hypothesis ................................................................................................................................................................................................................................................................................21
1.4.4 Research Objectives ...............................................................................................................................................................................................................................................22
2.1 L it e ra tu r e  Re v ie w ................................................................................................................................................................24
3.1 Th e  St u d y  P e r io d ................................................................................................................................................................... 2 9
3 .2  St u d y  D e s ig n ............................................................................................................................................................................. 29
3 .3  C om po n en t s  o f  t h e  s t u d y .................................................................................................................................................2 9
3 .4  T h e  F ield  W o r k ........................................................................................................................................................................30
3 .4  D a ta  C o l le c t io n  M e t h o d s ............................................................................................................................................. 31
3 .5  Sam pl in g  M e t h o d s ................................................................................................................................................................33
3.5.1 Study Units ..............................................................................................................................................................................................................................................................................34
3.5.2 Sample Size ..............................................................................................................................................................................................................................................................................35
3 .6  D a ta  Q u a l it y  C h e c k s .........................................................................................................................................................35
3 .7  So rt in g  Q u e st io n n a ir e s ....................................................................................................................................................36
3 .7  St a t is t ic a l  M e t h o d s ...........................................................................................................................................................36
3 .8  C l ea ran c e  from  lo ca l  a u t h o r it ie s .........................................................................................................................37
3 .9  M a jo r  C o n s t r a in t s ...............................................................................................................................................................37
4.1.0 Knowledge o f  MOH po lic ies ....................................................................................................................................................................................................................37
4.1.1 The National Drug Po licy .............................................................................................................................................................................................................................38
4.1.2 The Essential Drug L ist ......................................................................................................................................................................................................................................38
4.1.3 Ministry o f  Health Treatment Guidelines fo r  middle level providers ................................................................................39
4 .1.4 Procurement Guidelines ...................................................................................................................................................................................................................................39
4 .2  P e r fo rm a n c e  on  d if fer en t  C om po n en t s ................................................................................................................39
4.2.1 Training .........................................................................................................................................................................................................................................................................................39
4.2.2 Drug Information ........................................................................................................................................................................................................................................................40
4.2.3 Reported Prescribing Practices: Labelling ....................................................................................................................................................................40
4.2.4 Patient Information and Counselling ........................................................................................................................................................................................41
4.2.5 Inspection ..................................................................................................................................................................................................................................................................................41
4.2.6 Reporting .....................................................................................................................................................................................................................................................................................42
4.2.6.2 Compiling Information on A D R .........................................................................................................................................................................................................42
4.2.6.3 Drug Therapeutic Committee ..................................................................................................................................................................................................................42
4.4.1 Stockouts ......................................................................................................................................................................................................................................................................................43
4.4.2 E xp iry ...............................................................................................................................................................................................................................................................................................43
4.4.3 L icensing ....................................................................................................................................................................................................................................................................................44
4 .5  Im pa c t  o n  P ro v id e r  b eh av io u r  /  Im pa c t  o n  c l ie n t .........................................................................................44
4.5.1 Observing Patient Provider Communication ......................................................................................................................................................44
4.5.2 Labelling. ....................................................................................................................................................................................................................................................................................45
4.5.3 Legibility o f  labels ......................................................................................................................................................................................................................................................45
4.5.4 Assessing Patient Understanding and Compliance ...........................................................................................................................................46
4.5.4 Patient understanding o f  labelling .................................................................................................................................................................................................47
4 .6  T o  m ea su r e  th e  im pa ct  o f  D rug  d istr ibu t io n  com po n en t  on  u s e r s ..................................................... 47
4.6.2 Alternative action when drugs are unaffordable ....................................................................................................................................................47
Perception o f  cost o f  Drugs .......................................................................................................................................................................................
The follow ing diagram show the respondents perception o f  the cost o f  drugs ...................................................................................48
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4.7.1 Knowledge o f  tracer drugs .........................................................................................................................................................................................................................48
4.7.2 Frequency o f  purchase ......................................................................................................................................................................................................................................48
4.7.3 Place o f  purchase .......................................................................................................................................................................................................................................................49
4.8.1 Nearest place to get tracer drugs ....................................................................................................................................................................................................49
4.8.2 Where to go fo r  tracer drugs ......................................................................................................................................................................................................................49
4.8.3 Difficulty in accessing drugs .....................................................................................................................................................................................................................49
4.8.4 Availability o f  drugs at preferred place o fpurchase .......................................................................................................................................49
4.8.5 Difficulty in accessing tracer drugs ...............................................................................................................................................................................................50
4.8.6 N eed for improvement ..........................................................................................................................................................................................................................................50
To assess the level o f  Implementation o f  the Rational Drug Use Component  - .................................................................................52
5.1.3.1 Training .....................................................   52
5.1.3.2 Dispensing Practices ............................................................................................................................................................................................................................................52
5.1.3.3 Labelling. ..................................................................................................................................................................................................................................................................................53
5.1.3.4 Appropriate monitoring ....................................................................................................................................................................................................................................54
6.1 Improving access to documents .......................................................................................................................................................................................................................56
6.2 Training ...................................................................................................................................................................................................................................   56
6.3 S torage ....................................................................................................................................................................................................................................................................................................57
6.4 Dispensary Services .........................................................................................................................................................................................................................................................57
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1.0 INTRODUCTION
Drug Management and Drug Policies
Public policy is defined variously as “ ‘whatever governments choose to do or not to do’, 
‘as the authoritative allocation of values for the whole society, ’ as ‘an indication of 
intention: or a guide to action encompassing values which set priorities and relations 
between government and society’ and as ‘a very complex and dynamic process whose 
components make different contributions to it’”1
A National Drug Policy (NDP) is a guide for action; it is a document containing goals set 
by the government for the pharmaceutical sector and it provides a frame work to co­
ordinate activities by the various actors in the pharmaceutical sector, the private sector, 
NGO’s and other interested parties. The central aim of a drug policy is to ensure 
availability, equal access and rational use of drugs that are safe, efficacious, o f good 
quality and affordable to the entire population.11 At the core of the NDP is a commitment 
to the public health benefits of the Essential Drugs Concept (EDC).
Elements of the National Drug Policy have been in existence in Ghana as far back as in 
1961. Ghana has had a drug legislation and regulation for decades, has adopted, 
published and revised an essential drug list, has developed treatment guidelines and 
instituted quality control laboratories and public sector drug financing schemes.
Over the years many statutes and peicemeal approaches have been instituted in the 
country in an attempt to improve availability, accessibility, the affordability and rational 
drug use.
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Amongst the statutes and approaches were:
Year Title Number
1961 Disease and Animal Act Act 83
1973 Standards Decree N.R.C.D 173
1975 Centre for Scintific Research into Plant Medicine N.L.C.D 344
1985 Hospital Fee Regulations LI 1313
1990 Narcotic Drugs (Control, Enforcement and Sanctions Law) P.N.D.C.L. 236
1992 Food and Drugs Law P.N.D.C.L. 305B
1992 Veterinary Surgeons Law P.N.D.C.L. 305C
1994 The Pharmacy Act Act 489
1994 The Environmental Protection Act Act 490
The need to co-ordinate activities enshrined in these statutes and schemes became 
increasingly evident and in 1994 efforts were put underway to develop a National Drugs 
Policy to serve as a guide for action for the pharmaceutical sector and to provide a 
framework to co-ordinate activities of the various actors in the pharmaceutical sector.
The development of NDP has it’s origins in concerns expressed by ministers of health 
from developing countries during the 1975 World Health Assembly (WHA). The 
concerns expressed with regard to access to pharmacueticals resulted in the WHO model 
list of essential drugs published in 1977 and reviewed every two years since.
The main components of the drug policy are:
a) Drug selection and Registration
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b) Drug Procurement
c) Local Manufacture -  including herbal medicines and raw materials
d) Drug storage
e) Drug distribution
f) Rational Drug Use -  Training , information, prescribing, patient information
counselling and drugs Therapeutic Committees
g) Drug Advertisement and promotion
h) Drug Financing
i) Quality Assurance
j) Research and Development
k) Traditional Herbal Medicines
1) Intersectoral Cooperation
In 1999, the National Drug Policy document obtained cabinet approval but has not been 
launched yet, meanwhile the various components covered by the policy such as the 
Rational Drug Use, Drug Storage and Drug Distribution continues to be implemented all 
over the country. This study will attempt to evaluate the implementation of the three 
components mentioned above.
The criteria for Rational use of drugs should include:
Appropriate indication - Drugs are based on medical rationale, therapy is safe, and
effective
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Appropriate Drug - Selection of drugs is based on efficacy, safety, suitability
and cost effectiveness
Appropriate Patient - Drug is acceptable to patients, no contraindications are
experienced and minimal adverse reactions are suffered 
Appropriate Information- Patients should be educated about their ailments and the
medications prescribed for them 
Appropriate Monitoring- Unexpected effects of the drugs should be suitably
monitored1"
Drug Storage - Suitably constructed and equipped storage facilities, regular
monitoring and inspection of storage facilities, adequate 
information on inventories maintained.IV
Drug Distribution - Equitable distribution of drugs throughout the country
1.2 PROBLEM STATEMENT
The Ghanaian Situation
Over the last decade there have been many improvements in the selection, financing and 
distribution of drug supply as the result of the Essential drugs programmes in many 
countries including Ghana. In 1988 the first international course on rational drug use was 
held in Yogyakarta, Indonesia using materials developed by the ‘Management Sciences 
for Health and the Harvard Policy Group, in 1989 an International Network for Rational 
Drug Use (INRUD) was formed and members became involved in developing indicators
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for drug use and to test interventions. The Ghana INRUD group was formed in 1990 and 
in November 1998, an international course was organised in Accra, sponsored by 
INRUD, Ministry of Health Ghana, University of Ghana Medical School and the World 
Health Organisation. Participants included prescribers, dispensers and consumers from 12 
African countries and 2 participants each from all the ten regions of Ghana. In January 
1999 the Human Resource division of the Ministry of Health organised a two week 
training of trainers’ course to further develop presentation and teaching skills of those 
responsible for promoting rational drug use.v
There is an erroneous perception that Drug policies, the Essential Drug and Rational 
Drug Use concepts are all innovations directed at the public sector only. The private 
sector often say these strategies are not applicable to them but in reality they are, 60% 
consumption of drugs occurs in private facilitiesvl. The issue of access, equity, 
efficiency, finance, rational use and enforcement are relevant to both sectors.
Rational Drug Use requires that “patients receive medications appropriate to their clinical 
needs, in doses that meet their own individual requirements for an adequate period of 
time and at the lowest cost to their community” Unfortunately prescribing patterns do not 
follow the set criteria, antibiotics are often prescribed for (colds) viral upper respiratory 
infection, there is a failure to prescribe ORS for diarrhoea, brand names as opposed to 
generic are used during prescribing and dispensing, pharmacists in drug stores sell drugs 
without prescription, sell smaller quantities than required to those who make requests
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and lastly storage facilities for drugs are poor in most facilities leading to deterioration in 
storage and poor quality and ineffective drugs.
The problem in Dangme West District
Even though there is a lot of reform going on in the pharmaceutical sector, even though 
in 1996 intervention norms for specific disease conditions, injection use and patient 
counseling were distributed to 15 facilities in the Greater Accra Region as part on a 
study,™ a preliminary problem diagnosis carried out January, 2000 revealed that there 
were still gaps in the implementation of the Rational Drug Use, Drug Storage and Drug 
Distribution components of the NDP and these were:
From service providers:
Patients not counselled adequately 
High cost of drugs
Slow moving and frequently expired drugs,
Inadequate drug storage facilities, List of drugs need to be changed.
From Clients:
Poor communication from providers,
High cost of drugs
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An analysis of these statements1 reveal the factors contributing are; unpublicised or 
unclear policies and guidelines, infrequent and nonspecific training and lack of effective 
structures.
Researching into the factors which contribute to the current situation in the Dangme West 
District will give a better insight to the problem and help improve the effectiveness of 
and impact o f the drug policy.
1.3 DESCRIPTION OF THE STUDY AREA
1.3.1 Geography Dangme West District
The study took place in the Dangme West District situated in the south -  eastern part of 
Ghana, lying between latitude 5 45’ South and 6 05 ‘ North and longitude 0 05 and 0 02 
West. The Dangme West district is one of the two purely rural districts in the Greater 
Accra Region which have not yet been caught up by the rapid urbanization of the 
peripheral areas surrounding the city of Accra. It is also the district with the largest land 
surface area (about 1,700 square kilometers) in the region. The population is however 
not dense, with an estimated 1998 midyear population of 106,307. The bulk of the 
population is scattered in relatively small settlements with populations under a thousand.
The district is divided into 4 sub-districts, which are:
• Dodowa ( Shai) sub-district
• Prampram sub-district
1 See Analysis diagram in Annex 1
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• Great Ningo sub-district (Formerly Old Ningo)
•  Osudoku sub district
The population of the sub-districts from the 1984 census were: Dodowa = 15,743; 
Osudoku = 12,673; Prampram = 14,413; Old Ningo = 27,021. However currently 
osudoku is estimated to have the same population as Dodowa.
The actual population in the Osudoku sub-district may therefore be a little lower than the 
estimate of 26,086 calculated at the regional level. A census carried out in May/June 
1993 (as part of research into community based health insurance by Dr. Dyna Arhin from 
the London School of Hygiene) gave the 1993 mid year population of this sub-district as 
16,473 compared to a projected population of 22,104.
A recent census (1998) also as part of a proposed Health Insurance Scheme for the 
district also gave the population of this sub-district as 17,397. The population for the 
whole district was found to be approximately 75,900. This data is currently being 
updated.v'“
The results of the 2000 population and housing census gives the population figure for the 
Dangme West District as 96,017'x
1.3.3 Health Service Infrastructure
Dodowa
Sub-district:
Prampram
Subdistrict:
Great Ningo 
Subdistrict
Osudoku
Subdistrict
Health Centre 1 1 1 1
Community Clinic 2 1 1. 2
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In Dodowa Sub-district, all the institutions use part of the OPD as emergency wards. 
There are no operation theatres. There is a district Drug Store at Dodowa from which all 
institutions in the District procure drugs. There is a laboratory at Dodowa which caters 
for patients at Dodowa sub-district. Services Provided include: Maternity Services , 
Outreach Clinics, MCH/FP, Community Psychiatry, Nutrition Surveillance & education 
Organization of services. Services are provided from both Static & Outreach Clinics 
The Prampram Sub-district The health centre runs a 24-hour service according to a duty 
roster. It uses part of the OPD as emergency ward and has no theatre. There is a 
laboratory at Prampram providing laboratory services. Services Provided in Prampram 
Health Centre includes: Maternity services, laboratory services, Medicare, Nutrition 
rehabilitation and education & MCH/FP. Services in are organised from both static and 
outreach clinics, static, outreach.
The Dawhenya Community Clinic is a new clinic ran by only one staff and does not ran 
a 24-hour service at the moment.
Great Ningo Sub-district:
This institution runs a 24-hour services according to a duty roster. There is a recovery 
ward which forms part of the OPD. There is no theatre nor laboratory services. Services 
Provided include: Medicare, Maternity, MCH/FP, Community Psychiatry.
Services are also provided form both static and outreach clinics.
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The Osudoku Sub-district also renders 24-hour service with a duty roster. Part of the 
OPD is used as an emergency ward. There are no theatres and no laboratory services. 
Services available include: Medicare, Maternity, MCH/FP,
Organization of Service: Both static and outreach clinics are run in this sub district.
1.4 JUSTIFICATION FOR THE STUDY
1.4.1 Rationale and Justification
There are many divergent views on the appropriateness and impact of reforms on 
programme effectiveness. It is necessary to give credence to the views expressed and also 
important to determine whether i.e. the Essential Drug Concept and programme on 
Rational Drug Use is achieving the goals that it set out to accomplish and a scientific 
process is the most appropriate way to do this. It is four years since a baseline study on 
the impact of group development of treatment norms on prescribing at P.H.C. levels in 
the Greater Accra Region was carried out and two years since the baseline study on the 
pharmaceutical sector and it is not too soon to monitor implementation progress made so 
far. Thus the study will compare findings with those obtained in 1998. It will determine 
strengths and weaknesses of some of the strategies adopted in the implementation process 
and as plough back mechanism will feedback whatever information obtained to policy 
makers and implementers to guide future decisions and actions.
1.4.3 Hypothesis
The gap between expected performance and actual performance of components of the 
Rationale Drug Use concept in the Dangme West District can be blamed on inadequate
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distribution, dissemination and knowledge of the guidelines, lack of education and 
training.
1.4.4 Research Objectives
The objective o f this study is to describe the current situation as regards the promotion of 
Rational Drug Use and the implementation of the Drug Storage Drug / Distribution 
components o f the NDP in Dangme West District.
Main Objectives
The main objectives are (1) assess the documentation and dissemination process , (2) to 
measure level of knowledge and implementation of these components of the NDP in the 
Dangme West District and Subdistrict level, (3) to evaluate the impact of rational drug 
use concept at the household level.
Specific Objectives and Processes
1. To measure the diffusion of information through the distribution of documents to 
staff of the district and sub district
2. To determine whether basic structures such as Drug Therapeutic Committees, 
Drug information Committees, training plans etc. are in place and if they are, whether 
they are performing effectively.
3. To determine which components of the Essential Drug Concept; rational drug use, 
drug storage and drug information and advertisement are performing well in the district 
and which are not.
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4. To assess the drug distribution component of the essential drugs concept by 
measuring availability, accessibility and affordability of drugs at the household level 
in the district
5. To evaluate the correctness of specific practices (prescribing/labelling) covered by the 
promotion of rational drug use component on clients of the health centres and 
community clinics.
6. To compare findings with those of previous studies
7. To make recommendations for future action
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2.0 LITERATURE REVIEW
2.1 Literature Review
It is reported that as early asl959, Sri Lanka acted to rationalise prescribing in the public 
sector by restricting all health service prescriptions to 500 drugs on the government 
formulary. Many o f these lists were purely policy goals and were not enforced, moreover 
they were restricted to the public sector only and often controls on government purchases 
could be circumvented. Mozambique introduced similar but more restrictive legislation 
in 1997 and Doctors had to seek special permission to prescribe non formulary drugs. In 
Afghanistan, legislation in 1979 compelled wholesalers to import only generic drugs 
listed in the formulary and brand names could be imported only if equivalents were not 
available. An attempt at using generic names only failed in Pakistan in 1976 four years 
after being instituted when large amounts of substandard drugs flooded the country. An 
investigation by the Pakistan Monopoly Control later revealed that the quality control 
checks were totally inadequate making the implementation process rather than the policy 
itself wrong.
Sri Lanka was the first to prove that the bill for drug import could be reduced immensely 
through centralised procurements when in 1972/3 the state pharmaceutical Corporation 
(SPC) begun a phased take over of drug imports that had previously been carried our by 
134 private suppliers. At the end of the second half of 1972, the SPC compared the cost 
of drugs it had bought with the cost of the same drugs bought by the private suppliers in 
the first half of 1972 and realised a 40% savings in the cost of importing just 52 drugs. x
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A paper written by Pascale Brudon X1 reports that many countries in the 1970’s tried to 
solve problems of ineffective drug procurement and distribution without looking at drug 
use resulting waste of effort and resources spent on these specific issues with no positive 
impact on the use of drugs. She reports also that many essential drugs programmes 
covered only the public sector when consumption was influenced by and occurred largely 
in the private sector and says that it is imperative for countries to choose components of a 
drug policy which are most necessary and urgent to their current situation. Brandon 
continues by saying that monitoring and evaluation should be of key importance in the 
case of a national drag policy to determine if policy makers and implementers are on the 
right path and if  strategies and activities are meeting the needs for which they were 
drawn.
Jonathan Quickx" in his report states that from a public health perspective the main 
concerns with the private pharmaceutical market are affordability (economic access), 
availability (geographic access) and appropriate use of drugs. He asserts that where 
purchasing power is concentrated in urban areas and the number of pharmacists is 
limited, the availability and range of drugs decline significantly in the remote areas. The 
report also describes surveys conducted in the Philippines, Cambodia and Kenya which 
show that even though poor people buy drugs, the combination of high prices and lack of 
information makes them delay treatment and drives them to purchase sub therapeutic 
doses. The writer of this article then goes on to recommend the institution of policy 
options such as price control / competition, price awareness and health insurance to
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improve affordability and licensing schemes and financial incentives to improve 
availability.
The subject of this report describes a situation similar to that found in Ghana where 
surveys have shown that approximately 55% of the 300 Medical Practitioners in the 
Private Sector are found in the Greater Accra Region, 70% of the total number of 
pharmacists are found also in the Greater Accra Region, 90% of the medical practitioners 
and pharmacists are located within Accra and Temaxni thereby limiting availability of 
drugs in the rural area.
James Rankins’ paper on the private sector in the public pharmaceuticalxlv gives the 
various areas of collaboration as: private support to public logistics and direct pharmacy 
service to public patients. In this era where privatisation and private sector participation 
in public services is being promoted it might be beneficial to make use of the numerous 
small scale pharmacist /drug sellers situated across the country. Logistics functions are 
expensive. To move, store and distribute drugs (materials) require a lot of space, 
equipment and people and increasingly a lot of computer hardware and software. Since 
the Ministry of Health is severely constrained for resources it might be necessary to 
consider; how much they are paying for each logistics activity, whether they need direct 
control over their logistics assets and whether costs can be significantly reduced by 
contracting out to logistics activities to a third party and whether service provision can be 
improved by using private sector companies on performance bound contracts.
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A report on cost effectiveness by David Henryxv states that economic analysis relates the 
benefits of the drug to all the costs associated with it’s use, that the main costs to consider 
in any evaluation of cost effectiveness are the costs of purchasing the drug, storage, 
distribution, giving the drug and treating adverse effects. The report describes the 
Australian system where equity of access is one of the main arms of the Australian 
Medical Drug Policy of which economic analysis / cost effectiveness is an important part 
of this arm. In this case the economic analysis is used as a mechanism for price setting on 
individual drugs in a system where there is no restriction on the budget. The report then 
recommends that in developing countries the focus on economic analysis could be on 
programmes rather than on individual drugs as in the Australian system because it is 
reactive and industry-driven and not appropriate.
The second half of the 20th century has seen the ideas of national drug policy progress 
from just a series of reactions to current problems to a positive concept. It is now widely 
accepted that each country should make a positive effort to achieve optimal availability, 
and use of drugs for it’s people. In order for these efforts to be coordinated and to support 
one another, well designed overall drug policies need to be developed and implemented.
In 1996, a study of the impact of group development of treatment norms on proscribing at 
P.H.C. Levels in the Greater Accra Region. In 1998 another study was carried out on 
pharmaceutical sector” ' to identify the main deficiencies in the system of drug 
procurement, distribution and the revolving of funds prior to the establishment and 
institution of the National Drugs Policy. Both recommended amongst others that rational
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use of drugs needed to be improved in most of the criteria that were assessed, that drug 
procurement systems in the public sector needed strengthening. It would be interesting to 
find out if  some o f these recommendations have been worked on at least in the Dangme 
West District.
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3. SURVEY DESIGN AND EXECUTION
3.1 The Study Period
Data collection for the period was carried out over a four week period from July 13 to 
August 14, 2000
3.2 Study Design
The Study was both descriptive and analytic. The analytical aspect of the study attempted 
to determine at the organisational level, who knew the specific policy selected for the 
study, which components of the policy were known and practised properly, which what 
gaps existed in implementation.
3.3 Components of the study
The following components of the National Drug Policy will be studied.
(a) Component One: Distribution of Documents and Dissemination of Information 
Distribution of the National Drug Policy Document
Distribution of Essential Drug list
Distribution of Middle Level Treatment Guidelines
Distribution of Procurement Guidelines
(b) Component Two: Rational Drug Use -level of Implementation of the following 
components
Training
Drug information 
Dispensing Practices
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Dispensing information
Patient / Provider Communication
Labelling
Inspection
(c) Component Three: Drug Storage
Expiry of drugs
Stockouts 
Storage facilities
(d) Component Three: Drug Distribution
Measuring impact on accessibility, availability and affordability at the household 
Level
3.4 The Field Work
The District and Subdistrict Levels
Subdistrict staff in all ten health centres and community clinics responsible for dispensing 
were interviewed to assess knowledge of Rational Drug Use / Drug Storage /Drug 
Distribution component of the essential drug concept and determine implementation 
arrangements and status of implementation. Key personnel of private sector health 
facilities and drug shops were also interviewed using the same criteria and questionnaire.
The Community Level
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At the community level, heads of households were interviewed to determine level of and 
impact of the drug distribution component of the policy implementation by measuring 
access, availability and perception of cost to the individual as a indicator of how far the 
NDP has achieved it’s goal.
3.4 Data Collection Methods
Frame work o f  variables and data collection instruments 
Table 1: Frame work o f variables and data collection instilments
Variable
(Objectives)
Indicator Data Collection 
Techniques used
Source o f Information
To determine how wide and 
thorough is the distribution of 
Documents and Dissemination o f 
Information on components o f the 
National Drugs policy
Availability f  the NDP, 
EDL, Procurement 
manual, treatment 
guidelines
Key informant 
Interviews 
Interview by 
questionnaires
Dangme West District 
and Sub-district Level 
Health /Drug Facilities
In both Public and 
Private Facilities
To assess the level o f 
Implementation o f  the Rational 
Drug Use Component -
Training
Drug information 
Dispensing Practices 
Dispensing information 
Patient /  Provider 
Communication 
Labelling 
Monitoring (ADR)
Observation 
Key informant 
Interviews 
Interview by 
questionnaire
Health service 
providers 
Public and Private 
Facilities
To assess how implementing 
activities have impacted on 
provider behaviour
To measure the impact o f  provider 
practices on users
Dispensing Practices 
Dispensing information 
Patient / Provider 
Communication 
Labelling
Client understanding
Key informant 
Interviews 
Interviews by 
questionnaires 
Observation
Exit interviews
Health service 
providers
Public Facilities onlv 
Clients o f facilities
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To measure the impact o f  Drug Drug availability, Interviews by Heads o f households
distribution component on the affordability, questionnaire
households accessibility
The data collection process used a combination of open and closed ended questionnaires. 
Though most questions appearing on the questionnaires were pre-coded certain answers 
were probed to obtain a better insight into specific situations.
Questionnaires were tested on staff of the Dodowa Health Centre who were not included 
in the main study to avoid sensitisation of respondents to questions and avoid receiving 
premeditated answers.
Ample time was spent carrying out a document review to examine The Rational Drug 
Use Concept and Drug Storage component of the National Drug Policy. A Checklist of 
what was expected was developed as a standard for knowledge and performance at 
district, sub district levels.
Respondents consisted of Medical Assistants and Dispensing Assistants in the health 
centres/private clinics, Nursing Officers and Community Health Nurses at Community 
Clinics in charge of community clinics and Dispensers and shop assistants at chemical 
and drug stores. These people were interviewed to assess their knowledge of the policy 
and determine level of implementation of specific components of the policy at these 
levels. Interviews covered all orthodox public and private sector health providers i.e. 
clinics, maternity homes and drug/chemical sellers.
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Data was collected through direct observation of health service providers at work, 
specifically at prescribers, dispensers and others responsible for prescribing and 
dispensing drugs. Exit interviews of clients were conducted to assess patient provider 
communication, client understanding and compliance of instructions and provider 
practices. The study identified deviations from provisions of the policy.
3.5 Sampling Methods
A purposive sampling was used at the district and subdistrict levels and in using this 
process all four health centres and six community clinics were reviewed by interviewing 
medical assistants, dispensary assistants and nurses/midwives responsible for prescribing 
and dispensing. At least two respondents were interviewed in each health centre. All 
private sector health and drug facilities were also covered by this sampling method. One 
respondent was interviewed in each private facility. Since this sampling method covered 
100% of the study population it is expected that conclusions drawn are valid and 
representative of the population of health/drug facilities in Dangme West District.
A system of random sampling was used to select heads of households to be interviewed 
in the study. The total population of the district is 75,882 and to determine the study 
population it was estimated that each household had an average of ten people making the 
number of households in the district 7,588. A sample size of 120 was determined to be 
adequate for the purpose of the study. Since there are 4 very different subdistricts 
comprising Dangme West District and a representative sample was required each 
subdistrict was made to contribute 2.5 % to the sample population. Hence 30 households
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in each subdistrict were chosen at random using the house numbering system developed 
for the Dangme West National Health Insurance programme.
Patients seeking services at the four health centres and the six community clinics at the 
time of visit and data collection were interviewed after they had received care in order to 
assess patient provider communication, patient understanding and compliance and 
rational drug use.
3.5.1 Study Units 
Table 2: Study Units
Study Units Number of Units Number of Respondents
Health Centres 4 8
Community Clinics 6 6
Drug / Chemical Stores 11 11
Private Clinics / Maternity Homes 2 2
Heads of Households 120 120
Exit Interviews (Clients of Health / 
Drug Facilities)
11 11
Total Sample Population 151
The study units were defined as:
Health providers responsible for prescribing and diagnosing in both public and private 
sector facilities in the Dangme West District at time of study. This was limited to the
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head of the facility and his assistant (in community clinics) or the head of the facility and 
the dispensing assistant in health centres.
Heads of households in the Dangme West District who used conventional health /drug 
facilities and
Clients of health facilities met during data collection
The study unit did not include personnel who had been trained to prescribe/dispense but 
by their position were currently not authorised to do so at their work places.
3.5.2 Sample Size
Areas of location were chosen in order to obtain a geographical representative of the 
district. Although facilities in all four subdistricts in the Dangme West district were 
included in the study, the Ministry of Health facilities constituted the important units for 
the study. All the different types of health facilities were sampled in the process of data 
collection and the background of service providers were identified to identify variations 
or similarities in performance.
3.6 Data Quality Checks
Supervisory visits were made to selected sites to ensure proper data collection. All 
completed questionnaires were also checked for consistency and logic and to ensure no 
data got missing.
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3.7 Sorting Questionnaires
The questionnaires were sorted out into convenient piles consisting of:
District And Sub district Public Health Facilities 
District And Sub district Private Health /Drug Facilities 
Exit Interviews 
Households
Coding and Analysing Open Questions
Even though respondents expressed themselves differently, their answers, the concerns 
they raised and agreements were similar consequently the coding process made use of 
similarities in responses. A combination of qualitative and quantitative procedure was 
used for coding and analysing the questionnaires administered at the Subdistrict health 
and drug facilities. The procedure for sorting involved;1™1 reading through all the 
questionnaires and identifying the most common responses, constructing short summary 
responses that were typical of the answers given and placing them into categories called 
generic categories, tallying the number of respondents whose answers fit into each 
generic category and inputting data in to the computer using Microsoft Excel 97 software 
which calculated the number of responses as a percentage of the number of respondents.
3.7.1 Statistical Methods
The questionnaires administered to clients leaving health facilities after receiving care 
and at the household level were analysed by an analysis of variances using two by two 
tables created with the SPSS computer software.
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3.8 Clearance from local authorities
Permission was obtained from the District Health Administration and the District 
Assembly before the study was carried out. The chiefs and elders of the communities 
were informed about the research programme and assistance was sought from them and 
all those concerned with health. The team ensured maximum confidentiality of every 
respondent.
3.9 Major Constraints
The limited period of stay in the district and the amount of field practice work to be done 
impaired optimum background study and sampling procedures. Purposive and convenient 
sampling procedures had to be used to obtain the study population. The number of clients 
attending community clinics was very low and this made it impossible to get an adequate 
sample of clients at this level to assess patient encounters.
4. FINDINGS
4.1 Measuring the diffusion of information
4.1.0 Knowledge o f  MOHpolicies
Respondents in the MOH were asked to ‘name a few of MOH policies’ Polio eradication, 
Family planning, Health for all by the year 2000 (which was cited by almost 98% as a 
policy) quality care, cash and carry, health insurance, Ghana Health Service, and 
exemption were the most common examples given. Respondents in the private facilities
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cited; must have ‘O’ Level, sell class C drugs, First aid, referring of patients, be within 
limits of specification, Keep place clean and free care.
4.1.1 The National Drug Policy
Out o f the 14 respondents interviewed in the ten Ministry of Health facilities all 14 
(100%) had not heard of nor seen nor owned a copy of the National Drug Policy 
Document.
In the private sector facilities 2 respondents out of the 13 (15.4%) reported that they had 
not seen the Drug Policy. Upon further questioning it was discovered that the 84.6% of 
respondents in the private sector facilities who said they had knowledge of or owned the 
policy document were referring to documents on the limits set for different classes of 
drug facilities, first aid and licensing.
4.1.2 The Essential Drug List
64.3 % of respondents in the public facilities had access to the EDL, knew the contents 
very well and had the document on hand for inspection.
28.6% mentioned they had the document but that it was not within reach for easy for 
inspection or for reference and one (7.1%) respondent reported that the EDL was kept 
with his boss.
In the private sector facilities, 38.5% of respondents had the EDL available and 61.5% 
did not have the EDL at all of this most respondents said the EDL was not applicable to 
them in the private sector.
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4.1.3 Ministry o f  Health Treatment Guidelines fo r  middle level providers
The treatment guideline is available and within easy reach for reference for 71.4 % of 
respondents and not available to 14.3 % of respondents in the Ministry of Health 
facilities.
In the private sector facilities 61.5% of respondents used a variety of guidelines which 
included ‘Where there is no doctor, the BNL, workshop guidelines, notes given to 
licensed chemical sellers and the service provider manual’ Of the remaining, 38.5% did 
not use any guideline and only 7.7% (of the 61.5 ‘5 using guidelines) had the Ministry of 
Health Treatment Guidelines for Middle Level Service Providers.
4.1.4 Procurement Guidelines
Only 7.1 of the respondents in the MOH facilities had the procurement guideline as 
opposed to 23.1 % in the private sector facilities.
4.2 Performance on different Components
4.2.0 To assess the level o f  Implementation o f  the Rational Drug Use Component -
4.2.1 Training
Training had been given to 78.6 % of public sector respondents in the last two years and 
to 61.5% to of the private sector respondents. 14.3 % of public sector respondents had not 
received any training since their school days compared to 38.5% of the private sector 
respondents.
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4.2.2 Drug Information
The Chief pharmacist, inserts from manufacturers and suppliers was stated as the main 
source of drug information by 85.7% of the public sector respondents while 14.3% stated 
their source of information on drug as suppliers, suppliers, manufacturers and 
advertisements.
In the private sector facilities, 76.9% quoted their source of information on drugs as; 
suppliers, manufacturers and advertisements and 23.1% mentioned their source of 
information as their Association, suppliers, manufacturers and advertisements.
4.2.3 Reported Prescribing Practices: Labelling
Labelling o f drugs in the public sector facilities was more comprehensive than labelling 
in the private sector facilities, however 21% and 14% of labels had brand names or had 
no labels ate all and this contravenes the requirements of the NDP.
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Public Sector Realties
Private Sector Facilities
and name 
21%
No label 
23%
Generic name 
0%
Brand name 
0%
Combination of
___________________ all
0%
4.2.4 Patient Information and Counselling
100% of Respondents in both Public and Private Sector facilities reported they routinely 
counselled patients on drug usage.
4.2.5 Inspection
MOH Regional and District staff are reported to have regularly inspected 85.7% o f Public 
Sector premises and 7.7% of private sector premises. Personnel from the Pharmacy 
inspected by 92.3% of Private Sector premises.
All facilities in the private sector are inspected regularly and 14,3% of facilities in the 
public sector have not been inspected at all.
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4.2.6 Reporting
4.2.6.1 DIS Section of the MOH
7.1% of respondents in the public facilities had heard of the DIS section of the MOH as 
opposed to 30.8% of private sector respondents.
4.2.6.2 Compiling Information on ADR
92.9% and 92.3% of respondents did not seek nor compile information on Adverse Drug 
Reaction in the Public and Private Sector facilities respectively
4.2.6.3 Drug Therapeutic Committee
Table 3 : Responses on Drug Therapeutic Committee
Responses Public Sector 
% o f  Respondents
Private Sector 
% o f Respondents
Centre does not have a Drug 
Therapeutic Committee
71.4 30.8
Not Sure 14.3 38.4
Has other forum which meets regularly 
to discuss drugs
14.3 30.8
4.3 Drug Financing
100 % of the respondents in the public health facilities are issued regularly with price 
lists and 100% of the respondents in the private sector stated that they do not use any 
form of price lists because prices change very quickly.
On the question of affordability, 71.4 % of respondents of the MOH facilities declared 
that their prices were affordable to clients whereas only 15 % of private sector
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respondents thought prices of drugs were affordable. It is interesting to note that the 
28.6% who reported in the public sector that prices were not affordable to clients were all 
from the community clinics.
4.4. Drug Storage
Storage facilities and practices are generally good in 50% of public Sector facilities and 
in 84.6 % of the private sector facilities.
4.4.1 Stockouts
Stockouts have been experienced in the last couple of years in 60 % of the MOH facilities 
and in facilities and in 30% of the private facilities.
33.3 % of those who reported stockouts in the public sector facilities state that the 
stockouts were artificially caused by the frequent absences of the district pharmacist and 
were not due to unprofessional practices on their part.
4.4.2 Expiry
60% of the public facilities reported no experience with expiration of drugs in storage. 
This is in contrast with the 100% no expiry rate in the private sector.
The 40% of respondents who reported incidence of expired drugs said the event was due 
to bulk purchases (by the central procurement unit) of drugs close to their expiry date.
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4.4.3 Licensing
Licenses of all thirteen respondents in the private sector were checked and 100% of them 
were found to be available and up to date.
4.5 Impact on Provider behaviour / Impact on client
4.5.1 Observing Patient Provider Communication
This section describes the lack of proper communication between dispensers and clients 
of the health facilities. It provides evidence that training given to Dispensers and 
Dispensary Assistants have had no impact on actual performance in the Dangme West 
District. This aspect of the NDP is not working well.
Table 1: Provider Communication
Time in Time Out Type of Communication
Patient 1 11:23 dropped 
card
11:31 picked drugs Spent 30 seconds at counter, instructions 
given, no questions asked
Patient 2 11:27 11:29 Spent 30 seconds at the counter, 
instructions given , no questions asked
Patient 3 11:33 11:38 11:33 -  11:40 Provider asked some 
questions
Patient 4 11:00 11:03 dropped bottles 
11:06 picked drugs
No communication
Patient 5 11:03 11:07 picked drugs A few words , no questions
Patient 6 10:16 10:18 Time spent counting and labelling drugs
Patient 7 10:30 10:40 dropped bottles 
10:46 -  10:48 at 
counter
Some words, Time spent by service 
provider wiping and covering bottles
Patient 8 10:43 10:50 collect drugs No communication
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An actual count of the number of drugs received by patients were made and below 
are the figures obtained.
Table 2: Number o f Drugs
Value Label Frequency Percentage
1 Drug 1 9.1%
2 Drugs 2 22.2%
3 Drugs 3 33.3%
4 Drugs 3 33.3%
More than 4 drugs 2 22.2%
Table 3: Injections
Value Label Frequency Percentage
Received an injection 1 9.1%
No injection 10 90.9%
4.5.2 Labelling 
Table 4: Labelling practices
Value Label Fes No
Name of Patient 18.2% 81.8%
Name of drug 72.7% 27.3%
Dose on Package 100.0% 0.0%
Frequency 90.9% 9.1%
4.5.3 Legibility o f labels 
Table 5: Legibility o f  labels
Value Label Frequency Percentage
Patient likely to understand 10 90.9%
Patient not likelv to understand 1 9.1%
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4.5.4 Assessing Patient Understanding and Compliance
4.5.4.1 Information on drugs
When asked whether patients had been told about drugs, 81,2% answered in the 
affirmative and 18.2% answered no.
Table 6: Knowledge o f  drug quantity
Can patient tell number o f  
drugs
Frequency Percentage
Yes all 8 72.7%
Yes some 2 18.2%
No 1 9.1%
Table 7: Knowledge o f Correct Dose
Value Label Frequency Percentage
Knows correct dose 10 90.9%
Does not know correct dose 1 9.1%
Table 8: Knowledge o f  frequency o f  dose
Value Label Frequency Percentage
Knowledge 11 100%
No Knowledge 0 0%
Table 9: Knowledge o f  effect o f Drugs
Value Label Frequency Percentage
Knowledge 6 54.5%
No Knowledge 5 45.5%
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Table 10: Intention to comply with instructions
Value Label Frequency Percentage
Intention 11 100%
No Intention 0 0%
Table 11: Reasons for compliance
Value Label Frequency Percentage
To be healed 11 100%
Others 0 0%
4.5.4 Patient understanding o f  labelling
All patients interviewed had a good understanding of and gave the correct 
interpretation of the labels made on their drug packages.
4.6 To measure the impact of Drug distribution component on users
4.6.1 Drug Affordability
Out of 119 respondents (heads of households) interviewed on ability to purchase drugs, 
9.6% responded in the negative, 84.9% responded in the affirmative and 6.1% said they 
were not always able to afford drugs.
4.6.2 Alternative action when drugs are unaffordable
When asked what action they took when drugs were unaffordable, 7.7% stated that they 
bought smaller quantities of drugs, 0.9% of respondents bought only one drug prescribed 
and 91.5% responded that the options were not applicable to them.
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4.6.3 Perception o f cost o f  Drugs
The following diagram shows the respondents perception o f the cost o f  drugs.
4.7 Drug Availability
4.7.1 Knowledge o f  tracer drugs2
Most respondents, 97.3% were familiar with the tracer drugs and 2.7% did not know the 
drugs as mentioned to them
4.7.2 Frequency o f  purchase
95.6% of respondents purchased the tracer drugs very often and 4.4% did not purchase 
the listed drugs.
2 Tracer drugs are the four most commonly used/prescribed drugs in the District. These ere used to assess cost, 
availability and accessibility.
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4.7.3 Place o f  purchase
The place of purchase of drugs were; 0,9 % for market, 2.6% for chemical seller, 89.7% 
for drug store and 6.8% said the options were not applicable to them.
4.8 Accessibility to Drugs
4.8.1 Nearest place to get tracer drugs
Responses given for the above question were; less than 30 minutes walk, 92.1%, more 
than 30 minutes walk 7.9%. There were no answers for ‘have to travel by car’
4.8.2 Where to go fo r  tracer drugs
5% of the respondents reported they went to a chemical seller, 94% reported they went to 
a drug store and 1.7% visited other places.
4.8.3 Difficulty in accessing drugs
The responses for this question are as follows; 73% answered 'no’ to the question, 16.5% 
answered 'yes’ and 10.4% said they didn’t know.
4.8.4 Availability o f  drugs at preferred place ofpurchase
14 % of respondents do not obtain drugs first time at their preferred place, 96% obtained 
their drugs from their preferred place of purchase and 3% did not know their answer to 
the question.
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4.8.5 Difficulty in accessing tracer drugs
A total o f 95.7% respondents reported no difficulty in accessing tracer drugs, 2.6% had 
difficulty and 1.7% o f the respondents did not know their thoughts on the subject.
For this question, the majority of the respondents who stated ‘Other’ were referring to the 
personnel o f the MOH.
4.8.6 Need for improvement
When respondents were asked if they thought the drug situation needed an improvement, 
20.5% responded ‘no’ to the question, 51.3% responded ‘yes’ and 28.2% said they were 
not sure.
4.9 Source o f  information on drugs
Below is a bar chart showing responses obtained
80.0% 
i  70.0%<9
|  60.0%
|  50.0%
|  40.0%
§ 30.0%
|  20 .0%
10 .0%
0 .0%
Dodowa Prampram Ningo Asutuare
S u b  -d is tr ic ts  in D an gm e  W e s t  D istr ic t
Source Of Information On D rugs
□  Se lf Know  ledge
□  Seller
n  Relative/Friend
□  Other
For this question the majority of the respondents who stated other were refering to the 
personnel o f the Ministry of Health.
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5. DISCUSSION AND CONCLUSIONS
5.1.1 Knowledge o f Ministry o f Health policies and documents
Responses to the first question, “ Do you know of any Ministry of Health policy, name a 
few” and ‘Do you have the National Drug Policy document’ were very disappointing. 
However it is not surprising that no one had a copy of the National Drug Policy document 
since it is yet to be launched.
The impression gained was that the private sector had better access to relevant 
information on their tasks, than did the public sector. They also had a wider view of 
things and of the different responsibilities of other partners in the pharmaceutical sector.
It is obvious here that personnel in both public and private sectors are conversant with 
specific components of policies such as the EDL but lack a comprehensive view of the 
wider framework within which these familiar components were found. So personnel did 
not know their connection with the goals of other department and other sectors. Such a 
situation presents a narrow minded view of issues and limits the potential for 
collaboration.
5.1.2 Distribution o f documents
The Study revealed that distribution of certain documents which formed components of 
the National Drug policy had not changed since the 1998 baseline survey o f the 
pharmaceutical sector. The percentage who had verifiable access to the EDL in this study
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was 64.3% for public facilities, 38.5 in private facilities making a total 51.8% of 
respondents which is the same percentage (51%) found by the baseline survey.
5.1.3 To determine which components o f the policy are performing well and which 
are not
To assess the level o f  Implementation o f  the Rational Drug Use Component -
5.1.3.1 Training
The output of the component is quite impressive in the district and this confirms the 
claims made in the Dangme West 1999 Annual Report. Nevertheless the impact of the 
training programme especially in dispensing practices seems to be negligible. Patients are 
not being counselled properly by dispensing assistants, labelling and the use of generic 
names do not conform to the standards that have been set by the rational drug use 
component of the policy.
5.1.3.2 Dispensing Practices 
Patient Counselling on Drugs
Counselling on drug use is performed excellently by the Medical Assistants and staff in 
charge of the community clinics and not by the Dispensing Assistants. This is similar to 
results obtained in 1996 by the survey ‘on the impact of group development of treatment 
norms at P. H. C. Levels in Greater Accra Region.’ The best interaction between clients 
and service providers were found at the community clinics. The low turn out rate could 
be a contributory factor but attitudes of providers were also impressive.
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The structure and layout of all dispensaries made communication very poor. Most 
interaction times ranged between 4 and 15 minutes but 90 percent of this ( 2 - 1 0  minutes) 
was used by the Dispensing Assistant to select, count and label drugs.
The small windows through which clients collect their drugs prohibited any form of 
communication especially one initiated by the patient. Terse instructions given consisted 
of; “take this, take that, take that”
5.1.3.3 Labelling
The correct procedure for labelling (according to guidelines) was also not practised in 
any place. Some service providers thought the exigencies made on them, in respect of 
labelling o f drugs were inappropriate. They said that most of the clientele were illiterate 
and would be unable to decipher the names of drugs, some also were of the view that 
using generic names which were long, sometimes very similar and complicated would 
confuse the dispensing staff thereby increasing the occurrence of mistakes.
I tend to agree with these views.
However the method of using symbols and signs to show dosage and frequency was very 
ingenious and served the right purpose for most of the patients.
Again there is a big difference in labelling practices between the Ministry of Health 
facilities and the private sector facilities.
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5.1.3.4 Appropriate monitoring
This aspect of the rational drug use component is not performing well at all. No 
information on ADR is sought nor compiled. Such a gap in information was experienced 
during the formulation of the National Drug Policy when it became obvious during 
research that ‘data was not collected on a day to day basis and in a manner as to provide 
information for future decision making.’3 In this situation, the chance to provide 
feedback through planned information that is collected periodically is lost. The 
opportunity to detect the emergence of drug resistance and resistant strains of specific 
diseases could be either delayed or missed altogether.
5.1.3.5 Number o f  Drugs
Only 22 .9% of clients received two drugs, meeting the recommendations made by the 
policy makers. This implies that most prescribers are treating suspected multiple 
conditions and are uncertain of the specific ailments affecting clients.
5.1.3.5 Number o f  Injections
There seems to be an improvement in the use of injections from the 1996 and 1998 
survey figures but this could also be because no hospital was included in this survey in 
the Dangme West District and results must be taken with caution the implication is that at 
least in this district this component of rational drug use is working well.
3 Information obtained during interview with staff o f the National Drug Programme
54
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5.1.4 Drug Storage
Facilities for storage were either average or very poor in the public facilities and this 
impacted negatively on storage practices. It is difficult to keep a windowless or rat 
infested store clean. For these reasons, stock recording was postponed to a more 
convenient time or place, meaning that some records were kept away from the stock 
increasing the tendency to have outdated records. Storage facilities were better in the 
private sector, this could probably be because most of the drug store /chemical sellers did 
not keep separate storerooms, their drug expiry and stockout rates were far more 
impressive than those of the public sector implying accurate forecasting and needs 
assessments.
The occurrence of stockouts in the MOH facilities seemed to be a managerial issue and 
not due to a lack of skills in forecasting quantities of drugs required. In the absence of the 
chief pharmacist, drugs were bought from the open markets and this could exacerbate the 
presence of slow moving stock in the central warehouse.
The incidence of expired drugs in the district also seemed to point to the larger problems 
within central drug procurement unit.
The Stock control component of the policy is not working very well in the public sector.
5.1.5 Drug Distribution
Results obtained form interviewing the 120 heads of households reveal that basically 
essential drugs ( represented by the 4 tracer drugs used in this study ) are accessible 
mostly less than 30 minutes walk away from homes and are available in 96% of 
respondents preferred place of purchase.
55
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8. RECOMMENDATIONS
6.1 Improving access to documents
If public policy is said to outline “ ‘whatever governments choose to do or not to do’, 
‘they present an authoritative allocation of values for the whole society, ’and give ‘an 
indication o f intention: a guide to action encompassing values which set priorities and 
relations between government and it decides major guidelines for actions directed at the 
future.”4 Then there is the need to distribute policy documents disseminate information 
about specific policies and not just components of a policy in order to improve 
intersectoral collaboration.
To correct the perception that certain policies or strategies are meant for the public sector 
only, the National Drug Programme and the Dangme West District Administration must 
endeavour to improve access to guidelines in the private sector also.
Guidelines used in both the public and the private sectors must be standardised
6.2 Training
The training programmes must tackle the beliefs and attitudes of trainees if  behavioural 
change is aimed at. Training sessions should include participants from both the public 
and the private sectors.
4 P rofesso r K ayode Odusote: W est A frican  Post G raduate  M edical College (A gency  o f  W est A frican  H ealth  C ommunity ) H ealth  
Serv ice  M anagem en t C ou rse  V olum e 1
56
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Secondly the target group of trainees must be expanded to include staff especially those 
in the community clinics who act in the absence of the in-charge.
A system should be designed for collecting and compiling and data on ADR as part of 
the routine monitoring system, this should be done in both private and pubic facilities.
6.3 Storage
Improved storage facilities and practices
Budgets must be made for the construction of or improvement of storage facilities of in 
all health facilities especially those in the public sectors. Better storage facilities will 
reduce the occurrence of deterioration of goods in storage and prevent he use o f scarce 
resources on replacement drugs.
6.4 Dispensary Services
Third Party contracting of dispensary services
Alternatively other mechanisms such as third party contracting could be established for 
employing independent private sector pharmacists to man dispensaries in health facilities 
to provide services to clients. Such an arrangement will ensure better service provision 
and accountability because contracts will be renewable based on previous performance. 
Health personnel will be free to perform activities in which they have the expertise.
57
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7.0 BIBLIOGRAPHY
1. Antwi P. The Budget Management Center (BMC) Concept. Are the Sub districts 
ready? The Assin District Situation. July 1998
2. Bie Nio Ong: Rapid Appraisal and Health Policy. 1996, Gt. Britain, 140
3. Brudon P. Monitoring and Evaluating National Drug Policies: where are we today. 
Australian Prescriber. Vol. 20 Supplement 1 1997)
4. Cassels A. & Janovsky K: Ghana Health Sector. AID, Health Policy. Strategy and 
Systems Development Proposed Programme of Work 1993 -  1995
5. Dodoo, C. D: Staff appraisal in the Ashanti Akim North District. 1999, 8 pages
6. Fulop T. & Roemer M. Reviewing Manpower development. A method of approving 
National Health Systems. WHO Public Health Papers No 83, Pages 25, 44- 45
7. Ghana National Drugs Programme: Baseline Study of the Pharmaceutical Sector in 
Ghana. Rational Use. Procurement and Financing of Drugs. September 1999.
8. Ghana National Drugs Programme: Promoting Rational Drug Use in Ghana. Training 
Manual. August 1999
9. Ghosh B: Health Implications of Public Policy. 1991 Indian Institute of Management, 
385 pages
10. Henry D: Cost effectiveness and it’s potential application in the region to ensure the 
affordability of medicines: Australian Prescriber. Vol. 20 Supplement 1 1997)
11. Howe S; Essential Elements of Human Resource Management. 1995, Great Britain
12. Kubr M. (ed.) Management Consulting. A guide to the Profession. 3rd Edition. 
Geneva. International Labour Office, 1996: 850
13. Management Sciences for Health: Managing Drug Supply. The selection. 
Procurement. Distribution and Use of Pharmaceuticals. Second Edition, 1997, USA, 
309 pages
14. Melrose D: Bitter Pills. Medicines and the Third World Poor. Oxfam 1982, 275 
pages
15. Ministry of Health: Health Sector 5 Year Programme of Health. August 1996, 34 
Pages
16. Odusote K: West African Post Graduate Medical College (Agency of West African 
Health Community-) Health Service Management Course Volume 1
58
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17. Opoku Amankwa C: An Addendum to Dangme West District Profile. September 
1999, 71 pages
18. Pearson C. A. Medical Administration for Front-line Doctors. 2nd ed. Cambridge. 
FSG Communications, 1995, 290 pages.
19. Quick J: Affordability and Availability of Drugs in the Private Market: promising 
experiences and cautions: Australian Prescriber. Vol. 20 Supplement 1 1997
20. The Family Planning Manager. Planning for sustainability: Assessing the 
management capabilities of vour organisation. 1996/7 Volume V, No 4. 20 pages
21. The Manager. Human Resources: Managing and Developing Your Most Important 
Asset. Spring 1999, Volume VIII, No. 1
22. Varkevisser Corlien. M et alHealth Systems Research Training Series Volume 2 Part 
L_Canada. IDRC, 1991: 375
23. WHO, Challenges and Strategies for Health Systems Development Discussion Paper, 
Prepared for the Informal Consultation on Health Systems Development
24. WHO, Geneva, 2000: Health Technology and Pharmaceutical Cluster: Progress in 
Essential Drugs and Medicines Policy 1998-1999,
25. World Health Organisation: The World Health Report 1995. Geneva 1995
59
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8. ANNEXES
ANNEX 1
ID Number............................................................... Location..................................................................... Type o f  Facility ......................................................Designation o f  Respondent.
..................... Date o f  Interview .................................................. Interviewers N am e...............................................
Im p lem en ta tio n  A t D is tric t and  Sub  D is tric t Levels
Public And  Private Health Facilities
Data to Gather Variables Answers &  Codes
a) General 1. Do you know  any health policies 
Name a few
l.N o  2. Yes 3. Don’tK now  
List:
b) NDP
c) EDL
2. Has the centre got a copy o f  the N ational Drugs Policy
3. I f  yes is this available for your use
4. Have you got a copy o f  the N ational D rug Policy
5. What are the main points o f  the drug policy
6. Have you got the EDL
7. How  well do you know the contents o f  the EDL
8. W hich edition o f  the EDL do you have 
an we see it
l .N o  2. Yes 3 .Don’t  Know 
l .N o  2. Yes 3.Don’t Know 
1. N o 2. Yes 3 .Don’t Know 
Please State:
l .N o  2. Yes 3. Don’tK now  
1. N ot Well, 2. Very Well 3. Excellent 
1. Before 1996 2 .1 996  Version 
1. No 2. Yes 3. N ot Available
d) Finance 9. Do you have a standard price list
10. Do you use the prices on this list
11. W hat are the prices o f  the following drugs: 
(Paracetamol Chloroquine, Ampicillin ORS, M ebendazole)
12. In your view are the prices affordable to clients 
Do clients pay for drugs easily
1. N o 2. Yes 3. D on’t Know 
1. N o  2. Yes 3. D on’t Know
P ...................... C h ....................A m .................  ORS ...................  M ....................
l.N o  2. Yes 3. Don’tK now  
l.N o  2. Yes 3. Don’tK now
e) Training 15. Have you received any formal training or attended a workshop/ in-service training/ 
skills upgrading on:
(i) drugs policy
(ii) diagnosis
(iii) prescription
(iv) dispensing
l .N o  2. Yes
I f  yes when: 1. 2000 2 .998 /9  3 .1996 /7  4. In School 
N o Yes
If  yes when 2000 1998/9 1996/7 4. In School 
No Yes
I f  yes when 2000 1998/9 1996/7 4. In School 
N o Yes
I f  yes when 2000 1998/9 1996/7 4. In School
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f) Storage
g) Availability (Stock 
Control)
16. Describe your drug storage facilities (ventilation, security, racking, general 
housekeeping)
17. Do you have all the on the EDL in Stock
18. How many stockouts have occurred in the past year Have you experienced 
stokouts in any o f  the ff.
(Para, Chloroquine, Ampicillin ORS, M ebendazole)
15. M inimum Level (for the above drugs)
16. M aximum Level ( for the above drugs
17. W hat are your reorder levels ( for the above drugs)
Ventilation: 1.
Lightening: 
Racking: 
Records: 
C leanliness 
Packaging: 
Preservation: 1 
Security: 1
Good 
Good 
Good 
Good 
Good 
Good 
. Good 
Good
2. Moderate 
2. Moderate 
2. Moderate 
2. Moderate 
2. Moderate 
2. Moderate 
2. Moderate 
2. Moderate
3. Poor 
3. Poor 
3. Poor 
3. Poor 
3. Poor 
3. Poor 
3. Poor 
3. Poor
Stockouts in last 2 Years: l.O ne 2. Two 3. More than Two 
Standard Actual
Standard Actual
Stock levels: 1. Good 2. M oderate 3. Poor
h) Information 18. Do you have any treatment guidelines for reference l.N o 2. Yes 3. Name them
19. Can we see these guidelines l.N o 2.Yes
20. Do you have any procurement guidelines l.N o 2. Yes 3. Don’t  Know
21. Can we see these guidelines l.N o 2. Yes
22. Are you provided with inserts/drug data from  manufacturers l.N o 2. Yes 3. D on’t Know
23. What other sources o f  information on drugs and drug management do you have List:
i) Prescribing
j )  Inspection
24. What information do you provide when:
(i) Prescribing drugs
(ii) D ispensing drugs
25. Do you routinely counsel patients on drug use
26. I f  yes what information do you give
27. W hat information do you provide with reference to 
(Paracetamol, Chloroquine, Ampicillin ORS, M ebendazole)
28. Has this premises been inspected by officers appointed by the Pharmacy Board or 
any other body
29. When did the inspection take place_____________________________________________
Patient N ame/ Generic name/active ingredient/dose regime/name & address o f 
facility/ date o f  dispensing
Patient N ame/ Generic name/active ingredient/dose regime/name & address o f 
facility/ date o f  dispensing
1. No 
State :
l.N o
2. Yes 3. D on’t Know
2. Yes 3 .Don’t Know  Date:
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k) Reporting 
1) M arketing
30. Do you know  o f the DIS section o f  the MOH
31. Do you compile data on Adverse D rug Reactions
32. Where is this information sent to
33. Do you have a D rug Therapeutic Committee in this facility
34. I f  yes, are you a  member and how often do you meet
35. W hat are your sources o f  information on drugs:
l .N o  2. Yes 3. D on’tK now
l .N o  2. Yes 3. Don’tK now
1. D istrict D irector 2. Regional Office 3. Head Office
l .N o  2. Yes 3. D on’tK now
1. Monthly 2. Eveiy Six M onths 3. Annually
1. MOH 2. Suppliers 3.Advertisements
m) Qualification & 
Authority
36. Do you have a dispensing licence
37. Is this available for viewing
l .N o  2. Yes 3. D on’tK now  
l .N o  2. Yes
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ANNEX 2
ID Number....................................................  Place/ Community
Date o f Interview.......................................... Interviewers Name....................
Data to Gather Indicators Answers and  Codes
a) General 1. What are the common health  problems in your community
2. W hat do you first do when you are ill
3. I f  first treatment does not work what do you do next
4. Have you ever v isited the health centre
1. Fever, 2. D iarrhoea, 3. Bodily Pains, 4. O ther...
1. Se lf M edication, 2. Herbalist, 3. D rugstore 4 .0 th e r 
1. C linic 2. O ther (G ive Name) 
l .N o  2. Yes
b) Affordabil
ity
5. A re you able to purchase all drugs prescribed
6. I f  N o what so you do
7. How much do you normally pay for Paracetamol, Chloroquine, 
Ampicillin ORS. Mebendazole
8. What do you think o f  the cost o f  these D rugs
9. How  do you pay for your drugs
l .N o  2. Yes 3. N ot Always
1. Buy N one 2. Buy Smaller Quantity 3. Buy Only One Drug 
List Prices
1. Cheap 2. Reasonable 3. Expensive 
1. C redit 2. Cash 3. O ther
c) Availabilit
y
10. Do you know  these drugs: Paracetamol, Chloroquine, Ampicillin, 
ORS, Mebendazole
11. Do you buy them  often by yourself
12. W here do you buy them
13. W here do you get information on the drugs you buy
l .N o  2. Yes 3. D on’tK now
l .N o  2. Yes 3. D on’t Know
1. M arket 2. Chem ical Seller 3. Drug Store 4. Other
1. Se lf Knowledge 2. Seller 3. Realtive/Friend 4 .0 th e r
d) Access 14. How  far is the nearest place to get drugs
15. W here do you normally go for your drugs
16. Is it d ifficult to get any drug
17. Do you always get the drugs you want at your preferred place
18. Is it d ifficult to get Paracetamol, Chloroquine, Ampicillin, ORS, 
M ebendazole
19. Does the situation need improvement
1. <30m inutes walk 2.>30m inutes 3. Journey by car 
1. M arket 2. Chem ical Seller 3. D rug Store 4. O ther 
l .N o  2. Yes. D on’tK now
l . N o  2. Yes. D on’tK now  
l . N o  2. Yes. D on’tK now
l . N o  2. Yes. D on’tK now
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ANNEX 3 
ID Number........
Type of Facility.. 
Date of Interview.
1. Patient - 
Provider 
Communication
Time o f arrival at Counter 
Time o f departure from counter 
Did patient ask questions
Arrival .... 
Departure... 
l .No  2.Yes 
Comment interaction
2. Patient
Understanding 
and Compliance
Have you been told about the drugs you have 
received
How many drugs have you received
How many tablets are to be taken at a time 
How many time a day are you to take the drugs 
What will the drugs do
Do you intend to comply with instructions/ why
l .No  2. Yes
Can patient tell number of drugs: 1. No 2. Yes/ All 3. Yes/Some 
Count drugs received by patient 1 .One 2. Two 3. Three 4. >Four
Does the Patient know the correct dose 1. No 2. Yes 
Does the Patient know the correct frequency l .No  2. Yes 
Does the patient know what drugs are for 1. No 2. Yes 
l .No  2. Yes
Give reasons for compliance/noncompliance
3. Labelling Are the following present on drug package 
Is patient likely to understand the labelling
Name o f patient 1. No 2. Yes 
Name of drug l .No  2.Yes 
Copy names o f Drug
Dose (1  tablet /  2 tablet eg.) 1. No 2.Yes 
Frequency (3 times 2 times etc.) 1. No 2.Yes 
l .No  2. Yes
Explain. |
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End Notes
1 Odusote Kayode: West African Post Graduate Medical College (Agency of West 
African Health Community) Health Service Management Course Volume 1 
" Management Sciences for Health: Managing Drug Supply, The selection, Procurement, 
Distribution and Use of Pharmaceuticals, Second Edition, 1997, USA, 309 pages
III Ghana National Drugs Programme: Promoting Rational Drug Use in Ghana, Training 
Manual, August 1999
IV Ghana National Drug Policy, Ministry of Health, March 1998
v Ghana National Drugs Programme: Promoting Rational Drug Use in Ghana, Training 
Manual, August 1999
Vl Research conducted into the provision of health services by the private sector in 
Greater Accra Region and to differentiate between their contributions to health care 
delivery, promotive and preventive care.
V1‘ Irene Adjepong, Philip Anum, Daniel Arhinful, David Ofori-Adjei: The Impact of 
Group Development Treatment Norms on Prescribing at P.H.C. Levels in the Greater 
Accra Region. 1996.
Vl" Opoku Amankwa C: An Addendum to Dangme West District Profile. September 
1999, 71 pages
ix Statistical Service: provisional Figures for 2000 Population and Housing Census
x Dianna Melrose: Bitter Pills, Medicines and the Third World poor, Oxfam 1982, 275 
pages
X1 Monitoring and evaluating National Drug Policies: where are we today. Australian 
Prescriber. Vol. 20 Supplement 1 1997
65
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xii (Affordability and availability of drugs in the private market: promising experiences 
and cautions; Australian Prescriber. Vol. 20 Supplement 1 1997) 
xm Source: Seminar on Research conducted into the provision of health services by the 
private sector in Greater Accra Region and to differentiate between their contributions to 
health care delivery, promotive and preventive care. 22 September 1999, School of public 
Health.
X1V Engaging the private sector in the public pharmaceutical system: Australian Prescriber. 
Vol. 20 Supplement 1 1997
xv David Henry: Cost effectiveness and it’s potential application in the region to ensure 
the affordability of medicines; Australian Prescriber. Vol. 20 Supplement 1 1997 
XV1 Baseline Study of the Pharmaceutical Sector in Ghana: Rational Use, procurement and 
financing of Drugs, Accra 1999
xv" Joycelin Chalmers and W. Lutz: Presenting Survey Information. A guide for Health 
Workers, International Epidemiological Association, 1989
66
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