New Performance-Based Reward Strategy to Improve Pharmacy

Practices, Financial Management, and Appropriate Medicines Use in the

Public Sector in Uganda Birna Trap (1), Martin Oteba (2), Kate Kikule

(3), and Belinda Blick (1)

(1) Management Sciences for Health, SURE, Uganda; (2) Ministry of Health, Pharmacy Division, Uganda; (3) National

Drug Authority, Uganda

BACKGROUNDTo strengthen Medicines Management SPARS was introduced SRARS combines all four intervention strategies:

Supervision or On the job training• District and HSD staff are trained as Medicines Management Supervisors

(MMS) in a 2 weeks examinable course followed by practical field training enabling them to do on-the-job (OTJ) training.

Performance assessment• Performance assessment based on 25 qualitative and quantitative

indicators assessing:Recognition• Recognition strategy is targeting both the MMS and the facilities that

performs well ( mugs to netbook and motor bikes) 3

Educational Managerial

Regulatory Financial

Theoretical

Performance Assessment

Recognition strategy

On the job training SPARS

Practical

STUDY AIMS

To assess impact of a) SPARS implemented by trained MMSs b) Financial Management c) Computerization of medical stores (Rx Solution) on:

stock and storage management prescribing and dispensing quality, and ordering and reporting quality

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METHODS

SettingThe study includes 45 intervention districts, 9 control districts, with all level of care facilitiesDesignPre-post with control and randomized longitudinal intervention study with randomization by facilities; Preliminary assessment72 facilities by level of care (hospital, HC 4, 3, 2) from 9 intervention districts – Pre/post assessment.Statistical analysisPre-post analysis: Preliminary assessment and intervention A and B vs. Control - paired observations, Wilcoxon-sign ranksum and paired student t-testLongitudinal analysis: Multivariate analysis of variance (MANOVA) for repeated measurements or generalized estimating equations analyses.

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InterventionIntervention A: SPARS . Performance assessment /OJT intervention to all facilities in 45 intervention districts. Sustainability measured after 6 months. Comparison to 63 control facilities randomly selected from 9 control districtsIntervention B: Financial management and computerization. After four OJT, 42 hospitals and 68 HC 4 are randomly allocated to one of three groups (1) OJT in FM targeted at certification in good FM, (2) OJT in stores computerization and (3) control group.

Time (month) 2 2 2 2 2 2 2 2

Intervention AH;4;3;2 (1482HF/45 D) V1 OJT V2 OJT V3 OJT V4 OJT V5

PA PA PA PA PAPre/post data PRE POST POSTlongitudial data B A A A A

Intervention BH(42) HC 4 (68)/45 D a V5 OJT V6 OJT V7 OJT V8 OJT V9

PA PA PA PA PAFM FM FM FM FM

b V5 OJT V6 OJT V7 OJT V8 OJT V9PA PA PA PA PARx Rx Rx Rx Rx

c V5 V6PA PA

Control V1 V2 V3H;4;3;2 (63HF/9 D) PA PA PA

Performance Assessment: PA in pharmacy practice PA + financial management PA + Rx indicators

Intervention SPARS Sustainability

Financial management

Intervention: Rx

ICIUM

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Performance indicatorsA. Dispensing quality1. Dispensing time2. Packaging material3. Dispensing equipment4. Services available5. Patient care6. Labeling7. Discrepancy prescribed/dispensed

C. Storage management13. Stock card availability14. Correct filling of stock card15. Does physical count agree with stock card balance16. Is stock book correctly used

B. Prescribing quality8. Correct recording of prescriptions9. Rational prescribing10. Adherence to STGs for Diarrhea11. Adherence to STGs Cough/cold

(ARI)12. Adherence to STGs Malaria

D. Storage management17. Cleanliness of the pharmacy18. Hygiene of the pharmacy19. System for storage of medicines20. Storage conditions21. Storage practices of medicines

E. Ordering and reporting quality22. Reorder level calculation23. Timeliness of order and distribution24. Accuracy of HMIS reports25. Filing

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RESULTS -1 Dispensing quality

Prescribing quality

Stock management Storage management

Ordering & reporting quality

0.00

5.00

visit 1visit 3

Improvement following only 2 OJT

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Results-2Average improvement was 58% Improvements:

stock management, dispensing and prescribing quality : 67-75% ordering and reporting improving : 44%storage management : 29%

Highest improvements included:

• Correct use of stock card and having correct balance• Use appropriate packaging material –dispensing envelope

instead of paper cone, and labeling• Ensuring that a full course of antibiotics was given. • Adherence to STG for diarrhoea and common cough and cold (no

use of antibiotics).

Key lessons learned

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1. SPARS - result in significant improvement in all but 2 of the 25 indicators.

2. SPARS was found to make a significant impact : • stock and storage management• prescribing and dispensing quality,• ordering and reporting quality. • Staff are proud about their achievement

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Implications • SPARS to be used for capacity building in other areas and to

strengthen MOH technical programs• Public sector HF for first time to meets NDA inspection

criteria's• MMS - new focus on pharmaceuticals at district level• SPARS ensures critical mass

Future research agenda• Assess impact of strengthened financial management

capacity and computerized logistic management (RxSolution) combined with SPARS on PP and AMU

• Explore sustainability • Assess costs and benefits in longer term