Annual Pharmaceutical Sector Performance Report APSPR - 03 Jan 2018...Annual Pharmaceutical Sector...

Ministry of Health

Republic of Uganda

Annual Pharmaceutical Sector Performance Report

2015-2016

OCTOBER 2017


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FOREWORD

The Annual Pharmaceutical Sector Performance Report provides us with a valuable

picture of the progress made implementing the National Pharmaceutical Sector

Strategic Plan (2015-2020). The report is disseminated to all stakeholders within the

health sector and discussed in a number of meetings from the Medicines Procurement

Management Technical Working Group (MPMTWG) at central level, Regional and

District logistics meetings in order to guide decision making.

The pharmaceutical sector will use these findings as a starting point to assess the

implementation of the National Medicines Policy and National Pharmaceutical Sector

Strategic Plan 2015.

I therefore, urge all stakeholders to use this information to focus their efforts in

achieving sustainable improvements in the pharmaceutical sector.

I wish to thank all those who have contributed to the preparation of this report and

supported the pharmaceutical sector: the dedicated staff of the Pharmacy Department,

National Medical Stores, Joint Medical Stores, the schools of pharmacy, National Drug

Authority, registrars of health professional councils, district health officers, health

workers, and health development partners.


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TABLE OF CONTENTS

FOREWORD ............................................................................................................................................................. ii TABLE OF CONTENTS ........................................................................................................................................ iii LIST OF FIGURES .................................................................................................................................................. iv LIST OF TABLES..................................................................................................................................................... v LIST OF ANNEXES ................................................................................................................................................. v ACRONYMS and ABBREVIATIONS ................................................................................................................ vi EXECUTIVE SUMMARY ..................................................................................................................................... vii INTRODUCTION ..................................................................................................................................................... 1 METHODOLOGY ..................................................................................................................................................... 1 RESULTS AND DISCUSSION .............................................................................................................................. 2 ANNEXES ............................................................................................................................................................... 22

Annex 1: Summary of Key Performance Indicators for FY 2015/16 ................... ………….22

Annex 2: List of contents of EMHS baskets .................................................................................... 25


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LIST OF FIGURES

Figure 1: Average percent availability of commodity basket items in reporting facilities,

in the previous quarter, April–June, 2016 ............................................................................................ 4

Figure 2: Percentage of facilities that had over 95% availability of a basket of

commodities in the previous quarter, April- June 2016 ................................................................. 5

Figure 3: Percentage of items ordered by facilities not filled by NMS, 2014/15-2015/16

............................................................................................................................................................................... 6

Figure 4: Average percentage of facilities submitting their orders on time and NMS

deliveries on time, 2014/15-2015/16 ................................................................................................... 7

Figure 5: Percent facility performance on stock management Indicators, 2015/16 ........ 10

Figure 6: Percent facility performance on storage management Indicators, 2015/16 .... 10

Figure 7: Percent facility performance on ordering and reporting Indicators, 2015/16 11

Figure 8: Percent facility performance on prescribing quality Indicators, 2015/16 ........ 13

Figure 9: Percent facility performance on dispensing quality Indicators, 2015/16 ......... 14

Figure 10: Comparison of Horizontal Equity Ratio across Levels of Care ............................. 17

Figure 11: Percent of average international price paid for procured essential medicines

by NMS and JMS, 2014/15-2015/16 .................................................................................................... 18

Figure 12: Number of registered pharmacists and ratio to population, 2014/15-

2015/16 ........................................................................................................................................................... 21


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LIST OF TABLES

Table 1: Annual Pharmaceutical Sector Performance Report Data Sources ........................... 1

Table 2: Availability of EMHS indicators, 2015/16 .......................................................................... 3

Table 3: Percent availability of commodity basket items at central warehouse, 2015/16

Commodity basket ......................................................................................................................................... 3

Table 4: Procurement and Delivery indicators, 2015/16 .............................................................. 5

Table 5: Average facility performance on medicines management indicators. 2015/16 . 9

Table 6: Number of facilities visited and average total SPARS score by ownership and

level of care..................................................................................................................................................... 12

Table 7: Appropriate Medicines Use Indicators, 2015/16........................................................... 13

Table 8: Affordability and Financing indicators – FY 2015/16 Performance ...................... 15

Table 9: Per capita GoU expenditure on EMHS, in US$, 2010-2016 ......................................... 16

Table 10: Safety, Efficacy and Quality of EMHS indicators – FY 2015/16 Performance .. 18

Table 11: Number of adverse drug reaction reports submitted to NDA, 2014-2016 ....... 19

Table 12: Pharmacy Human Resources indicators - FY 2015/16 Performance .................. 20

Table 13: Pharmacist (P) and Pharmacy Technician (PT) positions filled in the public

sector ................................................................................................................................................................ 21

LIST OF ANNEXES

Annex 1: Summary of key performance indicators for FY 2015/16 ................................... 21

Annex 2: List of basket of EMHS.…………………………………………………………….…………….. 25


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ACRONYMS and ABBREVIATIONS

ACT artemisinin-based combination therapy ADR adverse drug reactions ARV antiretroviral DHIS District Health Information System EMHS essential medicines and health supplies EMHSLU Essential Medicines And Health Supplies List Uganda GF Global Fund GH general hospital GoU Government of Uganda HMIS HRH

health management information system human resources for health

HSSIP Health Sector Strategic Investment Plan ITN insecticide treated nets IRS indoor residual spraying JMS Joint Medical Store MAUL Medical Access Uganda Limited M&E monitoring and evaluation MoH Ministry of Health MOS months of stock NDA National Drug Authority NDP National Drug Policy NDQCL National Drug Quality Control Laboratory NGO Non-governmental organization NHP National Health Policy NMS National Medical Stores NMP National Medicines Policy NPSSP National Pharmaceutical Sector Strategic Plan NRH national referral hospital OI opportunistic infections PHP private health practitioners PNFP private-not-for–profit PSU Pharmaceutical Society Uganda QCIL Quality Chemical Industries Limited RRH regional referral hospital SPARS Supervision, Performance Assessment, and Recognition Strategy STGs standard treatment guidelines TB tuberculosis UGX Uganda shilling URTI upper respiratory tract infection USAID United States Agency for International Development USD U.S. dollar WHO World Health Organization


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EXECUTIVE SUMMARY

The MoH Pharmacy Division annually tracks performance of the pharmaceutical sector

using a wide range of information that includes published government reports, monthly

reports submitted through the national health information management system, as well

as data collected through routine supervision visits to health facilities. A total of 32

standardized indicators have been measured for the year 2015/16 to assess progress

made towards achieving the objectives and targets set out in the National

Pharmaceutical Sector Strategic Plan (NPSSP) III for 2015-2020.

This report presents results for the first year of the five-year period of the NPSPP III and

compares performance against the last year (2014/15) of the previous five-year period

to identify successes and the areas requiring further efforts to achieve set targets.

The following are highlights from the first year of implementing the NPSSP III.

Availability of essential medicines and health supplies (EMHS): The availability of a

basket of 41 tracer commodities improved this year, with 55% of health facilities having

95% availability of a basket of commodities, up from 49% in 2014/15. During the year,

80% of sampled hospitals and 70% of HCIV facilities submitted their EMHS orders on

time to National Medical Stores (NMS). The NMS lead time from order receipt to

delivery to public health facilities increased slightly, from 41 days in 2014/15 to 48

days in 2015/16, but is still well below the maximum of 60 days. Orders placed with

NMS that are fully filled decreased to 63% from 72% in 2014/15. Average facility

performance was 71% on the Supervision Performance Assessment and Recognition

Strategy (SPARS) indicators, the same as in 2014/15.

Affordability and financing of EMHS: Government financing for all EMHS including

ARV, TB and malaria medicines increased in nominal terms from UGX 219 billion in

2014/15 to 231 billion in 2015/16. The budget allocation to the health sector as a

proportion of the total GoU budget was 6.4% in FY 2015/16, the lowest for over a

decade. Government per capita expenditure on EMHS dropped this year to US$ 1.9, the

lowest since 2010. Both NMS and Joint Medical Store (JMS) continued to obtain generic

products at competitive prices, at 42% and 69% of median international reference

prices, respectively. Donor partners contributed 80% of the total estimated expenditure

on EMHS, posing a risk in the event of funding uncertainties.

Safety, efficacy and quality of EMHS: The percentage of medicines failing NDA quality

tests increased to 13%, up from 6% last year. NDA tested more items this year (175)

than in 2014/15 (118).

Appropriate use of EMHS: Facility compliance to the Uganda Clinical Guidelines (UCG)

in prescribing medicines improved slightly this year with adherence at 82% for

sampled malaria cases (compared to 79% in previous year) and 60% for diarrhea (59%


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last year), but dropped for upper tract respiratory infections from 42% in 2014/15 to

36% this year.

Human resources in the pharmaceutical sector: The number of registered

pharmacists increased by almost 60% compared to last year, increasing the ratio of

pharmacy staff to the population from 2.2 to 2.9 per 100,000 population. Only 40% of

pharmacist and pharmacy technician posts are filled in the public sector.

INTRODUCTION

The Annual Pharmaceutical Sector Performance Report 2015/16 reviews the progress

made towards achieving the targets set in the National Pharmaceutical Sector Strategic

Plan (NPSSP) III 2015/16 - 2019/20. Progress is assessed by examining the trends in

the selected 34 indicators over time and comparing them to targets set for 2015.

The report covers the seven result areas of the NPSSP II which are aligned with the

objectives in the National Medicines Policy 2015:

1. Increased Access and Availability of Essential Medicines and Health Supplies

(EMHS)

2. Increased Affordability and Financing of EMHS

3. Increased Safety, Efficacy and Quality of MHS

4. Improved Appropriate Use of EMHS

5. Strengthened Human Resources in the Pharmaceutical Sector

6. Strengthened Coordination and M&E

7. Strengthened Community Engagement and Private Sector Participation

METHODOLOGY

Data collection. The data collection process follows standardized methods, tools and

procedures outlined in the monitoring and evaluation plan for the NPSSP III. The data

sources include routine sources of data from the District Health Information System

version 2 (DHIS2) using the national data collection tools of the health management

information system (HMIS), the national Supervision, Performance Assessment and

Recognition Strategy (SPARS) reports, document review, Key informant interviews

reports and records from National Medical Stores (NMS), Joint Medical Store (JMS) and

National Drug Authority (NDA). The data are collected on an annual basis, analyzed and

reported by Pharmacy Division M&E specialists.

Table 1: Annual Pharmaceutical Sector Performance Report data sources Result Area Data sources

1. Availability of EMHS NMS and JMS issues and stock on hand reports,

HMIS 105 reports, SPARS reports

2. Affordability and Financing Ministerial Policy Statement and Budget framework

paper, NMS vote 116 health facility resource

allocations

3. Safety, Efficacy, Quality NDA annual performance and activity reports,

Pharmacovigilance quarterly bulletins

4. Appropriate Use SPARS report

5. Human Resources New registration and graduating students pharmacy

technician register, Human Resource register, PSU

and Allied Health licensed pharmacist and registers

6. Coordination and M&E SPARS report, Pharmaceutical Information Portal


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Result Area Data sources

data

7. Community Engagement and Private

Sector Partnership

HMIS 097b report

The selection of indicators was based on the priority strategies outlined in the NPSSP

2015/20. To ensure standardized measurements, operational definitions are clearly

defined for each indicator, with the data source, collection and calculation method, and

data limitations described in M&E plan. Where indicators can be measured through

more than one source of data these are presented together for the purpose of

comparison and validation.

Data Analysis. Data are entered into different Excel workbooks and cleaned to ensure

errors are corrected. Descriptive statistics for each indicator are generated. The focus of

analysis is current performance compared to the previous year’s performance and

against set targets.

Reporting. This report is disseminated through the MoH website1, the Pharmaceutical

Information Portal (PIP)2 and other public channels.

RESULTS AND DISCUSSION

Data on pharmaceutical sector performance in the seven result areas are presented

below. In each section, a summary of the targets and achievement for FY 2015/16 is

provided for all of the Result Area indicators, followed by a more detailed presentation

and discussion of the individual indicators. Data from the previous year (2014/15) is

shown to measure the annual progress made.

Increased availability of essential medicines and health supplies

The National Medicines Policy (NMP) 2015 emphasizes the importance of efficient and

appropriate procurement, storage, distribution and good management of EMHS at all

levels of the system as the foundation for ensuring consistent availability of EMHS for

the effective nationwide delivery of the Universal Health Care Package.3 Result Area I

has five components each of which has a set of indicators to measure progress.

1 http://health.go.ug/publications/reports 2 https://pip.nhdb.ug 3 The National Medicines Policy (NMP) 2015, aims to contribute to the attainment of the highest standard of health by the population

of Uganda, through ensuring the availability, accessibility affordability and appropriate use of essential pharmaceutical products of

appropriate quality, safety and efficacy at all times


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Component 1: Availability of EMHS

Three indicators in Component 1 measure the availability of 41 priority essential

medicines and health supplies at central and health facility level. A summary of the

2015/16 targets and achievements of the indicators is presented in Table 2. The list of

the 41 tracer EMHS is included in Annex 2.

Table 2: Availability of EMHS indicators, 2015/16 Indicator FY15/16

Target FY 15/16

Achieved

1. Percentage availability for a basket of 41 tracer medicines and supplies in last three 3 months (April – June 2016) at central warehouses

65% NMS: 60%, JMS: 67%

2. Average percentage availability of a basket of 41 commodities at all reporting facilities in the previous quarter (April –June 2016) 88% 89%

3. Percentage of facilities that had over 95% availability of a basket of commodities in the previous quarter (April – June 2016)

67% 55%

Note: Data source. NMS stock status data, and DHIS2 data

Indicator 1: Percentage availability for a basket of 41 tracer medicines and supplies in last 3 months at the central warehouses

This indicator measures how many months out of each quarter of the year the quantity

of the product at NMS and JMS is equal to or more than the set minimum of two months

of stock. The indicator is calculated as an average percentage of all the 41 tracer

commodities. If data for the month and commodity is not available from warehouse

records/reports, that month or commodity are dropped from the calculation. In

2015/16, the average percentage availability was 60% at NMS and 67% at JMS; the

target was 65%. At NMS, the ARV and TB baskets had the highest availability, 88% and

100%, respectively; the lowest was for lab items.

Table 3: Percent availability of commodity basket items at central warehouse, 2015/16 NMS JMS

ARV 88% 71%

TB 100% -

Lab 33% 67%

RMNCAH 63% -

EMHS 40% 56%


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Indicator 2: Average percentage availability of a basket of 41 commodities at all reporting facilities in the previous quarter

This indicator measures the number of days out of each quarter (90 days) the 41 tracer

commodities were in stock in government, PNFP and private reporting facilities. Data

for this indicator was obtained from the monthly facility reports (HMIS 105 form)

submitted through the national DHIS2 system. If the commodity is not managed by the

facility, the commodity is dropped from the calculation.

In the quarter April-June 2016, on average the 41 commodities were available on 80 of

the 90 days (89%) in 3,262 reporting facilities (Figure 1). This met the annual target of

88%. No item was available 100% of the time. The ARV and RMNCAH baskets had the

highest availability, 91% and 90%, respectively, while the TB basket had the lowest

availability at 85%4.

The same data are routinely collected on 15 tracer commodities during facility visits by

district Medicines Management Supervisors (MMS). Their reports for the same quarter

(April-June 2016) show that 84% average availability of a basket of 15 commodities on

the day of visit at the 1,266 health facilities supervised during the quarter.

Figure 1: Average percent availability of commodity basket items in reporting facilities, in the previous quarter, April–June, 2016

Indicator 3: Percentage of health facilities that had over 95% availability of a basket of commodities in the previous quarter

The indicator measures the proportion of health facilities that had each item in a

commodity basket on at least 86 of the 90 days (95%) in the previous quarter. The

indicator averages the percent availability of basket items across all reporting facilities.

If the data for the commodity, month or facility is not available, then they are dropped

4 April- June 2016 Facility Tracer Medicines Stock Status Report


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from the calculation. In 2015/16, 55% of reporting facilities had over 95% availability

of the basket of commodities, below the 67% target.

Figure 2: Percentage of facilities that had over 95% availability of a basket of

commodities in the previous quarter, April- June 2016

Component 2. Selection, Procurement and Delivery

NMS procures and distributes EMHS to more than 2,700 government health facilities on

a bimonthly schedule. Before the start of each financial year NMS coordinates annual

procurement planning exercises with higher level facilities (HCIV, general and referral

hospitals) and works with district health officials to revise the district’s essential

medicines kit that are sent to lower level facilities (HCII and HCIII). Facilities must

adhere to their allocated budgets, place orders by established deadlines and adhere to

national guidelines regarding the commodities that can be used at each level of care.

NMS is responsible for procuring adequate quantities of the commodities, correctly

processing facility orders and dispatching them to facilities in a timely manner. Central

warehouses and facilities are encouraged to prioritize the procurement and ordering of

vital, life-saving EMHS to optimize the use of limited resources.

Five indicators are used to measure Component 2. Table 4 provides a summary of

performance in FY 2015/16.

Table 4: Selection, Procurement and Delivery indicators, 2015/16

Indicator FY15/16 Target

FY 15/16 Achieved

4. Percent of health facility orders placed that are fully (100%) filled at NMS

75% Order fill: 63% Nil lines: 37%

5. Average lead-time (days) from ordering by the facility to delivery to the facility

Max. 60 days 48 days

(range 15-164 days)


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FY 15/16 Achieved

6. Percentage of health facility orders submitted on time as per NMS schedule

80%

74%

7. Percentage of deliveries made by NMS to the facilities within the scheduled delivery date

65% 77%

8. Percent of vital items (medicines, supplies and laboratory items) issued by NMS to facilities

60% Vital (90%),

Essential (4%), Necessary (6%). (n=1,384 items)

Indicator 4: Percent of health facility orders placed that are fully filled at NMS

The order fill indicator measures the percentage of the items ordered and received by

the facility in the correct quantities and products. The indicator here was calculated for

HCIV and hospitals only as they can send orders to NMS to receive supplies. The

opposite indicator is for the proportion of ‘nil lines’, a measure of how many items in an

order that were not supplied at all. Data for the two indicators was obtained from a

sample of 35 hospitals and HCIV facilities using facility orders submitted to NMS and

compared to NMS delivery notes for the sampled facilities.

In 2015/16, an average of 63% of the items ordered by higher level facilities were fully

supplied by NMS, while 37% of the items ordered by the sampled facilities were not

supplied in any quantity (Figure 3). Order fill rates can reflect issues in the adequacy of

financing, inventory management, picking, and shipping procedures; facilities might

also order items that are not appropriate for their level of care. The relatively low order

fill rate and high proportion of ‘nil lines’ is of concern given the negative effects this has

on provision of health services. The increase in proportion of ‘nil lines’ from 28% in

2014/15 to 37% this year is concerning but not unexpected given the stagnation in GoU

funding for EMHS and rapid population growth.

Figure 3: Percentage of items ordered by facilities not filled by NMS, 2014/15-2015/16

Note: The hospital category includes 12 general hospitals and 3 regional referral hospitals


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Indicator 5: Average lead time from ordering to delivery to the facility

The maximum lead time from receipt of facility order at NMS to delivery at the facility is

set as 60 days. The data on lead time was obtained from NMS order records and

delivery notes for a sample of 35 hospitals and HCIVs across the country. In 2015/16,

the average lead time was 48 days, well under the NMS maximum of 60 days. The range

of lead time days was a low of 15 days (this might have been an emergency order) and a

maximum of 164 days (3.6 months). The latter is much higher than the highest number

of days in the baseline year (2.4 months). Data on lead time submitted in routine SPARS

reports showed a lower average lead time of 35 days, with a range of 0 to 120 days.

Indicator 6: Percentage of health facility orders submitted on time as per NMS

delivery schedule and Indicator 7: Percentage of deliveries made by NMS to the

facilities within the scheduled delivery date

Indicator 6 is an average across the year of the percentage of hospitals and HCIVs that

submitted their bimonthly order on time as per the NMS order schedule. Indicator 7 is

the percentage of those orders that NMS delivered on time as per their delivery

schedule. It is helpful to review these two indicators together since NMS cannot deliver

to a facility on schedule unless the facility submits their order on schedule.

In 2015/16, 74% of facilities submitted their orders on time and 77% of NMS deliveries

were made on schedule (Figure 4). The percentage of facilities ordering on time is

below the desired target of 80% and performance dropped slightly (77%) compared to

2014/15. This year, NMS exceeded their on-time delivery target of 65% and their

delivery performance is up from 63% on time deliveries in 2014/15.

Figure 4: Average percentage of facilities submitting their orders on time and NMS

deliveries on time, 2014/15-2015/16

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Indicator 8. Percent of vital items (medicines, supplies and laboratory items) issued by NMS to facilities

The 2016 Essential Medicines and Health Supplies List of Uganda (EMHSLU) classifies all

of the items according to Vital, Essential, Necessary (VEN) classification5. The data for

this indicator was obtained from itemized NMS sales records issued to health facilities.

The indicator is a percent of VEN items issued from the total issued items (n=1,384

items) by value.

In 2015/16, 20% of the items issued to facilities were classified as ‘vital’, well below the

60% target however, the value of the ‘vital’ items was 90% of the total sales. The

majority of items (55%) ordered by facilities were ‘necessary’ items at a value of 6% of

the total sales. This result is of concern because it suggests that patients may have less

access to life-saving medicines because they are more expensive.

Component 3. Medicines Management

SPARS, the national medicines management systems strengthening and capacity

building program, has been implemented in all 116 districts. More than 2,478 public

facilities and 620 private-not-for-profit (PNFP) facilities have received at least one

SPARS supportive supervision visit by a trained medicines management supervisor

(MMS). Facility performance is assessed and monitored using 25 indicators in five

domains covering stock management, stores management, ordering and reporting,

prescribing and dispensing.

Each of the five domains has a maximum score of five points totaling up to 25 maximum

overall SPARS score. Within each domain, the number of performance indicators varies

but each domain has a maximum score of 5. If an indicator is not assessed for a facility

the indicator score is dropped from the calculation. Performance on the indicator is

calculated as the percentage of the average facility score out of the total possible score.

Data for the indicators was obtained from facility SPARS reports based on the last visit

in FY 2015/16 for 2,334 facilities that were supervised by MMS during the year.

Table 5 shows the average facility performance on medicines management indicators in

2015/16. All indicators include measurements of public and PNFP facilities.

It is important to note that there is wide variation in the length of time that facilities

have been implementing SPARS; some may have only started SPARS in/or shortly

before 2015/16, while others will have been implementing SPARS since the start in

2012.

5 Essential Medicines and Health Supplies List Uganda (EMHSLU) 2016

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Table 5: Average facility performance on medicines management indicators. 2015/16 Indicator FY15/16

Target FY 15/16

Achieved

9. Stock management 60% 56%

10. Stores management 80% 81%

11. Order and reporting quality score 80% 82%

12. Accuracy of the HMIS report on stock outs of tracer medicines

100% 79%

13. Average percent facility performance on 25 SPARS indicators

72% 71%

14. Cumulative percent of facilities with at least four SPARS visits

No target 62%

15. Prescribing quality 70% 66%

16. Dispensing quality 70% 71%

Indicator 9: Stock management, Indicator 10 store management and Indicator 11 ordering and reporting

Stock management is measured by four sub-indicators stock card availability,

correct filling of the stock card, correct use of the stock book and physical count agrees

with stock card balance. The proper filling and updating of stock cards and stock books

enable health workers to easily track the inventory levels and account for stock

transactions. At the end of each month, key data from the stock cards of all medicines

are supposed to be entered into the stock book. Correctly filling and using the stock

book helps health workers to calculate average monthly consumption rates, assess their

stock card balance and calculate the quantities they need to order each cycle. The

recorded stock card balance is validated whenever a physical count is conducted to

check if the figures agree. These steps are all fundamental to good medicines

management practices and ensuring availability.

In FY 2015/16, the average performance stock management score was 56% (2.8/5).

This performance is below the set target of 60% and the lowest of the five domains.

Availability of stock cards was 19.3% and 20.5% for accuracy of stock balance while the

average score for correct use of the stock book was only 5.8% (Figure 5). Stock books

were introduced in 2013 and although use continues to improve over time, health

facility staff in lower level facilities may not see the need to maintain an updated stock

book because their use is linked to ordering.


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Figure 5: Average facility performance on stock management indicators, 2015/16

Storage management is measured based on five sub-indicatorscleanliness of the

pharmacy, hygiene of the pharmacy, system for storage of medicines, storage conditions

and storage practices of medicines. Good storage conditions and practices ensure that

medicines are stored in a clean, safe, well maintained store protected from heat, light

humidity and pests to ensure the safety, quality and potency of the medicines. Better

resourced facilities, such as hospitals and donor partner-supported facilities, score

higher on the storage management indicators because they often have more space,

shelves, refrigerators, running water, and electricity.

In FY 2015/16, the average performance storage management score was 81% (4.1/5),

slightly higher the set target of 80%. Pharmacy cleanliness and storage system had the

highest average score at 17.6% and 17.8% with pharmacy hygiene scoring the lowest

13.8%. This indicator assesses if a facility has availability of clean and functioning

toilets with toilet paper and hand washing facilities with soap. Figure 6: Facility performance on storage management Indicators, 2015/16

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Ordering and reporting is measured by four sub-indicators reorder level

calculation, timeliness of the ordering, accuracy of stock out data reported in the HMIS

105, and filing of delivery notes and invoices. The accuracy and proper filing of records

is essential for accountability and good stock management and facilities must know how

to correctly calculate order quantities to ensure they maintain appropriate stock levels.

Accurate reporting on product stock outs is important for monitoring availability by

central level program managers.

In FY 2015/16, the average facility performance score for ordering and reporting was

82% (4.1/5), consistent with the set target of 82%. Facilities did well in general in this

area, particularly on the timeliness of ordering (22.8%) and filing (21%). The lowest

performance was on knowledge of reorder level calculation (18.3%), a critical sub-

indicator because facilities need to know how to calculate the right quantity to order

using average monthly consumption and stock on hand (this sub-indicator applies only

to higher level facilities that submit bimonthly orders).

Figure 7: Percent facility performance on ordering and reporting Indicators, 2015/16

Indicator 12: Accuracy of the HMIS 105 reports on stock outs of tracer medicines

Facilities are required to report the number of days of stock out of tracer EMHS in the

monthly HMIS 105 report. MMS compare the number of stock out days recorded on the

stock cards for the tracer medicines with the data submitted in the HMIS facility reports.

In 2015/16, the average facility performance on accuracy of HMIS reported stock out

data was 79%. The result is slight reduction from the previous year (82%).

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Indicator 13: Average facility performance on 25 SPARS indicators

This indicator measures the overall medicines management performance in

government and PNFP facilities in the five domains. The maximum possible facility

score is 25 (five points in each of the five domains). The indicator is calculated by

averaging the scores of all facilities assessed during the year and dividing it by 25. No

annual target was set for this indicator. The closer to 100%, the better the facility

performance is.

In 2015/16, the average overall facility performance was 71% (Table 6). HCIVs and

hospitals score higher than lower level facilities and regional referral hospitals scored

the worst. There is only a small difference in the average SPARS scores between public

(71%) and PNFP (69%) facilities.

Table 6: Average total SPARS score by ownership and level of care, 2015/16 Ownership Level of Care Facilities visited Average total score

Public

HC2 1063 17.8

HC3 637 17.7

HC4 106 18.9

Hospital 30 18.9

Referral Hospital 11 16.1

PNFP

HC2 252 16.0

HC3 192 17.6

HC4 9 18.8

Hospital 34 18.6

Grand Total 2,334 17.6

Indicator 13: Cumulative percentage of government and PNFP facilities with at least four SPARS visits

To date, over 19,000 SPARS visits have been conducted by 400 trained MMS. Regular

SPARS supportive supervision visits have improved medicines management

performance in facilities, with the most noticeable improvements occurring in the first

four SPARS visits.

In FY 2015/16, 61% (3062) of facilities had implemented at least four SPARS visits a

one percent point difference from 62 %( 2472) in 2014/15. No improvement is seen

because the implementation of SPARS though a national strategy has not been

implemented in a standardized way.

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Improved Appropriate Use of Medicines and Health Supplies

Improving medicines use through proper prescribing and dispensing practices ensures

the best use of limited resources and optimal patient care. Prescribing quality is

measured by three sub-indicatorsrational prescribing (number of medicines

prescribed per encounter, generic name, encounters with one or more antibiotics,

injections and diagnosis recorded), prescription recording system and adherence to

standard treatment guidelines. Dispensing quality is measured by seven sub

indicatorsdispensing time, packaging material, dispensing equipment, availability of

reference materials, services available at the dispensing area, patient care, labelling and

correct filling of the dispensing log.

Performance on both indicators is measured as the average facility score out of the total

possible score of 25. Table 7 shows the targets and results for 2015/16.

Table 7: Appropriate Medicines Use Indicators, 2015/16 Indicator FY15/16

Target FY 15/16

Achieved

14. Average facility performance score for prescribing quality

70% 66%

15. Average facility performance for dispensing quality

70% 71%

In FY 2015/16, the average facility performance for prescribing quality was 66%, with

an average score of 3.3 out of possible score of 5. This was the second lowest score of

the five domain areas.

Figure 8: Percent facility performance on prescribing quality indicators, 2015/16


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Average facility performance was highest for correct use of prescription recording

system (16.8%) and malaria management (15%). The lowest performance was for

management of non-pneumonia cough/cold (8%). The poor score for this sub-indicator

reflects a widespread inability to correctly diagnose this condition and overuse of

antibiotics and polypharmacy6. Despite years of regular MMS monitoring and

mentoring of facility staff on adhere to clinical guidelines on treatment of non-

pneumonia cough/cold and diarrhoea, provider prescribing habits have been proven to

be difficult to change because they require a combination of interventions to improve.

Public facilities had a better average prescribing quality performance score, 71%, than

PNFP facilities, 61% (data not shown).

For dispensing quality, the average facility performance was 71% which meets the

annual target of 70% in 2015/16. Within the dispensing domain, performance was

lowest on the sub-indicators of labelling and dispensing time. Although the medicines

name and dose were usually indicated on the dispensing envelope, other critical

labelling information is often left out, such as medicine strength, quantity, date, patient

name and facility name. PNFP facilities had a higher performance score on dispensing

quality (73%) compared to public facilities (66%).

Figure 9: Percent facility performance on dispensing quality indicators, 2015/16

6 International Bank for Reconstruction and Development/ the World Bank. Education and Health Services in Uganda. Data for results and accountability. 2013

15

Increased Affordability and Financing of EMHS

One of the key priorities of the National Medicines Policy 2015 is to ensure “adequate

financing of required quantities for the people of Uganda with equitable provisions of

the poor and vulnerable, as well as cost effective use of available resources”.7 The main

strategies for achieving this are the sustainable resource mobilization, with the aim of

reducing reliance on donors, and the establishment and maintenance of systems for

efficient utilization of EMHS resources and the equitable allocation of funds for

procurement of medicines and health supplies.

Six indicators are used to assess performance in this Result Area. The annual targets

and achievements for 2015/16 for each indicator is shown in Table 8.

Table 8: Affordability and Financing indicators – FY 2015/16 Performance


FY 15/16

Achieved

16. Per capita expenditure on EMHS* 1.9 1.9

17. Percentage of GoU funds released for EMHS out of the total health sector funds*

19% 18%

18. Horizontal equity ratio to measure difference in allocation per patient among government owned facilities at the same level of care

0.20

HC4 – 0.19 HC3 – 0.30 HC2 – 0.26

19. Percent of average international price by NMS and JMS for procured basket of EMHS

<100% NMS- 42% JMS- 69%

20. Percent of order-based facility with a PFM score of 80% and above

No target

PFM just started

21. Percent of PHC funds NGO non-wage recurrent funds spent on procurement of EMHS for PNFP sector

50%

50%

*Includes ARVs, TB, ACTs, essential medicines, vaccines, laboratory supplies and reproductive health

commodities.

Data Sources: NMS Vote 116 allocation report, Bank of Uganda exchange rate, Annual Health Sector

performance report 2015/16, UBOS 2016 statistical abstract

Indicator 16: Per capita expenditure on EMHS In the FY 2015/16, an estimated US$1.9 was expended per capita on EMHS, including

ARVs, TB, and ACTs, essential medicines, vaccines, laboratory supplies and reproductive

health commodities. This is lower than past five years where per capita expenditure for

all EMHS stagnated at US$2.3-2.4 (Table 9). The per capita expenditure of US$1.9 is only

7 Source: National Medicines Policy 2015


16

6.5% of the per capita need of US$29 calculated as required under the National

Pharmaceutical Sector Strategic Plan 2015-2020. Per capita expenditure reduces to just

US$0.8 with the exclusion of expenditure on ARVs, TB ACTS and vaccines.

Table 9: Per capita GoU expenditure on EMHS, in US$, 2010-2016

2010/11 2011/12 2012/13 2013/14 2014/15 2015/16

Including ARVs, ACTs, TB supplies, and

vaccines

2.4 2.3 2.4 2.4 2.3 1.9

Excluding ARVs, ACTs, TB supplies, and vaccines

0.5 0.96 0.94 0.99 0.97 0.8

Bank of Uganda average dollar rate 2015/16 was 3,402 UGX. The figures above do not include off budget support.

Indicator 17: Percentage of GoU funds released for EMHS out of the total health sector funds Of the total of GoU funds released for the health sector in 2015/16, 18% was allocated

to EMHS, just below the target of 19%. The UGX 231 billion released this year was

slightly higher than the UGX 218 billion released in 2014/15. The budget allocation to

the health sector as a proportion of the total GoU budget was 6.4% in FY 2015/16, the

lowest for over a decade. The health sector budget in 2015/16 was UGX 1,271 billion

(US$374 million), down from UGX 1,281 billion (US$488 million) in 2014/15.

Indicator 18: Horizontal equity ratio to measure difference in allocation per patient among government owned facilities at the same level of care

To achieve equitable access for the population the allocation of EMHS resources should

match the need at the different health facilities where services are being provided.

Horizontal equity means that health facilities at the same level of care receive equitable

allocations of EMHS resources per patient. The Gini coefficient is used to measure the

degree of spread of the resource allocation per patient across facilities at the same level

of care. It ranges between 0%, which represents perfect equality where every facility

has the same per patient allocation, and 100%, which represents extreme inequality

where the facility with highest per capita allocation has all the resources with the other

facilities having zero allocation. Data for this indicator was obtained from NMS Vote116

allocations to selected health facilities and DHIS2 monthly inpatient and outpatient

numbers.

In FY 2015/16, HCIVs had the highest level of equity (Gini=0.19) among the three levels

of care measured. HCIIIs had the lowest level of equity (Gini=0.30) and HCIIs fell

between the two. This pattern is not unexpected given that GoU EMHS resources are

allocated to health facilities based on the level of care not patient load. HCII and HCIII

facilities have widely varying patient loads yet their budget allocations are set by their

level of care. HCIVs have much higher budget allocations than the lower levels of care


17

and less variability in patient volumes than the lower level facilities. Inequity increased

in HCII and HCIIIs and decreased in HCIVs compared to 2014/15 (Figure 18).

Figure 10: Comparison of Horizontal Equity Ratio across Levels of Care

Indicator 19: Percent of median international price paid by NMS and JMS for

basket of EMHS

To ensure greater value for money, central warehouses should strive to achieve

competitive prices through a transparent tendering process. Data for this indicator are

obtained from NMS and JMS reported procurement prices for a basket of 51 EMHS. The

procurement prices are compared to the median international prices listed in the

Management Sciences for Health International Drug Price Guide. Performance is

considered good if the procurement agencies are below 100% of the international price.

In FY 2015/16, both NMS and JMS average procurement prices for the basket of

essential medicines were considerably below the average international prices, 42% and

69%, respectively. For NMS, this is a 15 percentage point decrease compared to

2014/15, while the average procurement price paid JMS increased by 6 percentage

points (Figure 11).


18

Figure 11: Percent of average international price paid for procured essential medicines by NMS and JMS, 2014/15-2015/16

Increased Safety, Efficacy, and Quality of Essential Medicines and

Health Supplies

Since 1993, NDA has been responsible for assessing the quality, safety, and efficacy of

medicines, inspecting and licensing all pharmaceutical outlets in Uganda and conducting

sensitization on pharmacovigilance. Table 10 shows the achievements in FY2015/16 for

the four indicators used to measure Result Area 3. There are no annual targets for

indicators 24 and 25.

Table 10: Safety, Efficacy and Quality of EMHS indicators – FY 2015/16 Performance Indicator 2015/16

Target 2015/16

Achieved

22. Number of ADR reports submitted per 100,000 people

2.35 1.88

23. Percentage of sampled medicines failing pharmaceutical, chemical or microbiological NDA quality tests

<1% 13%

24. Percentage of pharmacovigilance reports in the previous year due to therapeutic ineffectiveness

No target 7%

25. Percentage of pharmacovigilance reports in the previous year due to substandard products

No target 6%

Indicator 22. Number of ADR reports submitted per 100,000 people Pharmacovigilance is the detection, assessment, understanding and prevention of

adverse effects or any other medicine-related problems. To enhance patient care and

safety in the use of medicines the NDA collects information reported by providers on


19

cases of adverse drug reactions (ADR) and other medicines-related issues through their

11 regional pharmacovigilance centers. The reported ADRs include a large spectrum of

clinical manifestations, which are collated based on the WHO Adverse Reaction

Terminology, System-Organ Class. The number of reports submitted are a basic

indication of the functioning of the reporting and surveillance system.

In FY 2015/16, a total of 174 ADR reports were submitted, a 63% decrease in ADR

reports submitted compared to FY 2014/15 (Table 11). The decrease in the number of

reports is not explained.

Table 11: Number of adverse drug reaction reports submitted to NDA, 2014-2016

2014/15 2015/16

Number of ADR reports submitted during the year

471

174

Indicator 23. Percentage of sampled medicines failing pharmaceutical, chemical or microbiological NDA quality tests

NDA’s National Drug Quality Control Laboratory (NDQCL) tests medicines on a regular

basis to detect counterfeit and/or poor quality drugs, some upon entry into the country

and others through post-market surveillance. In 2015/16, the NDQCL tested 175

medicines, of which 23 (13%) failed to comply with pharmacopeia and chemical

standards. This failure rate is double that of the previous year (6%) and the highest

observed since 2010.

Strengthened Human Resources in the Pharmaceutical Sector

The MoH is committed to attaining and maintaining an adequate workforce in the

pharmaceutical sector that is equitably distributed, appropriately skilled, motivated and

productive. A comprehensive human resources for health policy and strategy is in place

and a review is underway of the whole health workforce structure and training of

pharmaceutical and other health workers.

Three indicators are used to track progress in building the pharmaceutical sector

workforce. Data for the indicators is obtained from the pharmaceutical society and

allied health records, pharmacy school registers, the Annual Health Sector Report

2015/16 and MoH Human Resource for Health Information System. The data, however,

are not readily available or updated. The annual targets and achievements for 2015/16

are shown in Table 12.

20

Table 12: Pharmacy Human Resources indicators - FY 2015/16 Performance Indicator FY15/16

Target FY 15/16

Achieved

26. Number of pharmacy students and pharmacy technicians enrolled and graduating per year

No target Enrolled: 106

Graduating: 92

27. Pharmacists/pharmacy technicians per 100,000 population ratio

No target

3.99 per 100,000

Pharmacists - 2.3 Pharmacy technicians - 1.7

28. Percentage of pharmacist and pharmacy technician positions filled in the public sector

No target Pharmacist - 40%

Pharmacy technician - 40%

Indicator 26. Number of pharmacy students and pharmacy technicians enrolled and graduating per year

Information on pharmacy school enrollment and graduation was obtained from the

country’s three pharmacy schools: Makerere University, Mbarara University of Science

and Technology and Kampala University International. In 2015/16, a total of 106

students enrolled in pharmacy school and 92 graduated. Many of the students end up

working in the private sector because of the greater opportunities offered compared to

the public sector.

Indicator 27. Pharmacists and Pharmacy Technicians per 100,000 population

ratio

According to the Pharmaceutical Society Uganda records there were 840 licensed

pharmacists practicing in the public and private sector in 2015/16, producing a ratio of

2.99 pharmacists to 100,000 people. This is higher than the 2.2 ratio in the previous

year with only 527 registered pharmacists. This year there were 621 registered

pharmacy technicians was 621, yielding a ratio of 1.69 pharmacy technicians to 100,000

people. There is no defined target ratio set as optimal for pharmacists8.

8 Global Pharmacy Workforce Intelligence: Trend Report.2015

21

Figure 12: Number of registered pharmacists and ratio to population, 2014/15-2015/16

Indicator 28. Percentage of pharmacist and pharmacy technician positions filled in the public sector The number of public sector posts for pharmacists and pharmacy technicians

(dispensers) has increased significantly since 2011, from a total of 148 to 535 posts in

2015/16. The fill rates for both pharmacist and pharmacy technician posts was 40%

based on data obtained from the Seventh Human Resources for Health audit performed

by the MOH in collaboration with USAID-funded projects implemented by Intra Health

International.

Table 13: Pharmacist (P) and Pharmacy Technician (PT) positions filled in the public sector

2014/15 2015/16

Cadre P/PT/Dispensers P PT

Total no. of posts 307

112

423

Number of posts filled 115

45

169

% of posts filled

37%

40%

40%

Data Source: Annual Health Sector Performance Report


22

ANNEXES

Annex 1: Summary of Key Performance Indicators for FY 2015/16

Key Pharmaceutical Indicators

Overall Progress

Baseline 2014/ 2015

Target 2015/16

Achievement 2015/16

Av

ail

ab

ilit

y

Percentage availability for a basket of 41 tracer medicines and supplies in last 3 months at the central warehouses

NMS: 63% Based on 34

tracer medicines

JMS: 85% Based on 16 tracer

medicines

65%

NMS: 60%

JMS: 67%

Average % availability of a basket of 41 commodities based on all reporting facilities in the previous quarter

ALL: 84% EMHS:87% ARV:91% TB:87%

LAB:88% RMNCH:89%

88%

89%

% of health facilities that had over 95% availability of a basket of commodities in the previous quarter

ALL: 49% EMHS:44% ARV:50% TB:62%

LAB:49% RMNCH:38%

67%

55%

Pro

cure

me

nt

an

d D

eli

ve

ry

% of facilities with the current EMHSLU and UCG available

TBD

No Data

% of vital (V) items issued at NMS (medicines, supplies and Laboratory items) to the facilities

TBD

60%

V: 90%

E: 4% N: 6% (n= 1384 items) Total Sales- 916 billion shillings

% of health facility orders placed that are fully filled at NMS

72%

75%

Order fill: NMS: 63%

Nil lines: NMS:

37% Average NMS lead-time (days) from ordering to delivery at the facility

41 days (Range: 8 – 74)

<60 days 48 days (Range: 15-164)

% of deliveries made by NMS to the facilities within the scheduled date

NMS: 63%

65%

77%

% of health facility orders submitted on time as per NMS delivery schedule

77%

80%

51%

Me

dic

ine

s M

an

ag

em

en

t

Stock management- % stock management score for public and PNFP facilities

60%

56%

Storage management- % storage management

80%

81%


23


Overall Progress

Baseline 2014/ 2015

Target 2015/16

Achievement 2015/16

score for public and PNFP facilities Ordering and reporting quality- % order and reporting quality score for public and PNFP facilities

80% 82%

Average % score of 25 SPARS indicators for public and PNFP facilities

OVERALL:72% PUBLIC:72%

PNFP:70%

72%

71%

Accuracy of the HMIS 105 report on stock outs of tracer medicines

82%

100%

79%

Cumulative % of government and PNFP with at least four SPARS visits

62%

Aff

ord

ab

ilit

y % of average

international price paid by the central warehouses for procured basket of essential medicines

NMS – 57% JMS – 63%

<100%

NMS – 42% JMS – 69%

Fin

an

cin

g

% of order based facility with a PFM score of 16 and above

Hospital – 63% HCIV – 51%

Hospital-63% HCIV-51%

Hospital – 63% HCIV – 51%

% of GoU funds released for EMHS out of the total health sector funds (Including ARVs, ACTs, TB medicines, Vaccines, Laboratory supplies and Reproductive Health Commodities)

18%

19%

18%

Per capita expenditure on EMHS (including ARVs, TB, ACTs, essential medicines, vaccines, laboratory supplies and reproductive health commodities)

1.7

1.9

1.9

Horizontal equity ratio to measure difference in allocation per patient among government owned facilities at the same level of care

HCIV – 0.26 HC3 – 0.18 HC2 – 0.20

0.20

HCIV – 0.19 HC3 – 0.30 HC2 – 0.26

% of PHC funds spent on procurement of EMHS for PNFP sector

50% of the PHC NGO non-wage

recurrent (NWR) for procurement

of medicines

No Data


24


Overall Progress

Baseline 2014/ 2015

Target 2015/16

Achievement 2015/16

Sa

fety

, Eff

ica

cy a

nd

Qu

ali

ty o

f M

ed

icin

es

& H

ea

lth

Su

pp

lie

s

% of sampled essential medicines from post market surveillance tested and failing pharmaceutical, chemical or microbiological NDA quality tests

<1%

<1%

13%

Number of ADR reports submitted per 100,000 people

1.35

2.35

1.88

% of reports in the previous year due to therapeutic ineffectiveness

TBD

7%

% of reports in the previous year due to substandard products

TBD

6%

Ap

pro

pri

ate

u

se o

f M

ed

icin

es

&

He

alt

h

sup

pli

es

Prescribing quality- % prescribing score for public and PNFP facilities

70% 66%

Dispensing quality- % dispensing score for public and PNFP facilities

70% 71%

Hu

ma

n R

eso

urc

e

Number of pharmacy students and pharmacy technicians enrolled and graduating per year

MUK Enrolled – 43

Graduating – 41 MUST

Enrolled – 38 Graduating – 66

KIU Enrolled – 39

Graduating – 08

TBD MUK Enrolled – 55

Graduating – 41 MUST

Enrolled – 51 Graduating – 51

KIU Enrolled –

Graduating – Pharmacist/pharmacy technician to population ratio

1.7 per 100,000 TBD 3.99 per 100,000 (Pharmacists: 2.3

per 100,000; Pharmacy

Technicians: 1.7 per 100,000)

% of pharmacist and pharmacy technician positions fully filled in the public sector

Pharmacists 55%

Number=370

Pharmacy Technician/

Dispenser 55%

Number=420

Pharmacists 40%

Number=112

Pharmacy Technician/

Dispenser 40%

Number=423


25

Annex 2: List of contents of EMHS baskets

ARV BASKET

Tenofovir/Lamivudine/Efavirenz (TDF/3TC/EFV)

Zidovudine /Lamivudine/Nevirapine (AZT/3TC/NVP)

Zidovudine/Lamivudine (AZT/3TC)

Tenofovir/Lamivudine (TDF/3TC)

Nevirapine (NVP) 200mg

Efavirenz (EFV) 600mg

Abacavir/Lamivudine (ABC/3TC) 60mg/30mg

Nevirapine (NVP) 50mg

LAB BASKET

Determine HIV Screening test

Stat -pack HIV Confirmatory rapid tests

Unigold HIV RDT Tie-breaker test

CD4 reagent Specify

Malaria Rapid Diagnostic tests

ZN reagent for AFB

Blood 450 ml

EMHS BASKET

Recommended first line ACT (Artemether/Lumefantrine 20/120mg)

Cotrimoxazole 480mg

Thearapeutic milk F75 (75Kcal/100ml)

Thearapeutic milk F100 (100Kcal/100ml)

Ready to use Therapeutic feeds (RUTF)

Cotrimoxazole 960mg tablet

Chlorhexidine 20%

Bendroflumethiazide (Aprinox) 5mg

Propranolol 40mg

Nifedipine tablets 20mg

Captopril 25mg

Metformin 500mg

Glibenclamide 5mg

Insulin short-acting

Cardiac Asprin 75mg

RMNCAH BASKET

Depo- Provera

Sulfadoxine/ Pyrimethamine tablet

ORS Sachets with zinc tablet

Measles Vaccine

Misoprostol 200mcg Tablet

Amoxicillin dispersible 250mg tablet (For children)

Ceftriaxone 1g Injection

Oxytocin Injection

Mama Kit

TB BASKET

RHZE blister strip

RH blister strip 150/75mg

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