Background Information Of The Health Facilities
Presence of Basic Infrastructures
Four hospitals and nineteen health centers found in west Wollega zone were surveyed, to evaluate warehouse management and reproductive health medicines expiration. Regarding the availability of basic infrastructures, 11(47.83%) of the surveyed health facilities had tarmac, 19(82.61%) had operational electricity, 16(69.57%) had water and 22(95.65%) had operational telephone during the study period (Table 1).
Table 1
Presence of basic infrastructures at public health facilities of west Wollega zone, Oromia region, Ethiopia, July 2019
|
|
Hospital(N = 4)
|
Health centers(N = 19)
|
Total(N = 23)
|
S. No
|
Presence of Infrastructure
|
Yes
|
No
|
Yes
|
No
|
Yes
|
No
|
1
|
Tarmac to the facility
|
3(75%)
|
1(25%)
|
8(42.10%)
|
11(57.90%)
|
11(47.83%)
|
12(52.17%)
|
2
|
Operational Electricity
|
4(100%)
|
0(0%)
|
15(78.95%)
|
4(21.1%)
|
19(82.61%)
|
4(17.39%)
|
3
|
Water
|
4(100%)
|
0(0%)
|
12(63.16%)
|
7(36.84%)
|
16(69.57)
|
7(30.43%)
|
4
|
Operational telephone
|
4(100%)
|
0(0%)
|
18(94.74%)
|
1(5.26%)
|
22(95.65%)
|
1(4.35%)
|
In assessed health facilities, there were 77 health professionals with different professional backgrounds and educational levels under pharmacy units. From these professionals, 35(45.4%) were druggists. this research emphasized on store managers because they were principal personnel responsible for storage of pharmaceuticals. Majority (43.5%) of the store managers were nurses and 18(78.3%) had taken formal IPLS training. Majority (39.1%)) of them had 1 to 5 years of working experience (Table 2).
Table 2
Socio-demographic Characteristics of professionals working under pharmacy unit in Public health facilities of west Wollega Zone, Oromia region, Ethiopia, July 2019.
S. No
|
Variables
|
Hospital Frequency (%)
|
Health Center Frequency (%)
|
Total Frequency (%)
|
1
|
pharmacy unit staffing
|
Pharmacist
|
24(63.2%)
|
3(7.7%)
|
27(35.1%)
|
Druggist
|
14(36.8%)
|
21(53.8%)
|
35(45.4%)
|
Nurse
|
0(0%)
|
14(35.9%)
|
14(18.2%)
|
Health Officer
|
0(0%)
|
1(2.6%)
|
1(1.3%)
|
2
|
Service year (store manager)
|
< 1 year
|
1(25%)
|
4(21.1%)
|
5(21.7%)
|
1–5 year
|
1(25%)
|
8(42.1%)
|
9(39.1%)
|
> 5 year
|
2(50%)
|
7(36.3%)
|
9(39.1%)
|
3
|
Store managers trained
|
IPLS
|
4(100%)
|
14(73.7%)
|
18(78.3%)
|
SC Overview
|
2(50%)
|
4(21.1%)
|
6(26.1%)
|
Never trained
|
0(0%)
|
5(26.3%)
|
5((21.7%)
|
Availability equipment and furniture used in store
All hospitals had all basic equipment and furniture used in pharmaceutical store. However, majority of the health centers had no refrigerator, freezer, sufficient shelves, and office table with chairs (Table 3).
Table 3
availability of equipment and furniture in pharmaceutical store at public health facilities of west Wollega zone, Oromia region, Ethiopia, July 2019
S. No
|
Name of Equipment and furniture
|
Hospital(N = 4)
|
Health Center(N = 19)
|
Total(N = 23)
|
Available
|
Not available
|
Available
|
Not available
|
Available
|
Not available
|
1
|
Refrigerator
|
4(100%)
|
0(0%)
|
6(31.58%)
|
13(68.42%)
|
10(43.48%)
|
13(56.52%)
|
2
|
Freezer
|
4(100%)
|
0(0%)
|
6(31.58%)
|
13(68.42%)
|
10(43.48%)
|
13(56.52%)
|
3
|
Wooden pallet
|
4(100%)
|
0(0%)
|
9(47.37%)
|
10(52.63%)
|
13(56.52%)
|
10(43.48%)
|
4
|
Sufficient Shelves
|
4(100%)
|
0(0%)
|
7(36.84%)
|
12(63.16%)
|
11(47.83%)
|
12(52.17%)
|
5
|
Lockable cabinet
|
4(100%)
|
0(0%)
|
15(78.95%)
|
4(21.05%)
|
19(82.61%)
|
4(17.39%)
|
6
|
Ladder
|
4(100%)
|
0(0%)
|
7(36.84%)
|
12(63.16%)
|
11(47.83)
|
12(52.17%)
|
8
|
Computer
|
4(100%)
|
0(0%)
|
8(42.11%)
|
11(57.89%)
|
12(52.17%)
|
11(47.83%)
|
9
|
Office table with 2 chairs
|
4(100%)
|
0(0%)
|
13(68.42)
|
6(31.58)
|
17(73.91%)
|
6(26.09%)
|
Availability LMIS Tools (Forms)
Manual LMIS forms like Bin cards, stock cards, receiving and issuing vouchers (model 19 and 22), Report and Resupply Form (RRF), Internal Facility Report and Resupply Forms (IFRRs) were available and being used by all health facilities. All assessed hospitals were using electronic-LMIS during the study period, while only 6(31.58%) of HCs were using electronic-LMIS (Table 4)
Table 4
Availability and utilization of LMIS tools in public health facilities of west Wollega Zone, Oromia regional state, Ethiopia, July 2019
LMIS Form
|
Available
|
Utilized
|
Hospitals
|
HCs
|
Total
|
Hospitals
|
HCs
|
Total
|
Bin cards
|
4(100%)
|
19(100%)
|
23(100%)
|
4(100%)
|
19(100%)
|
23(100%)
|
Stock card
|
4(100%)
|
19(100%)
|
23(100%)
|
4(100%)
|
19(100%)
|
23(100%)
|
e-Recording system
|
4(100%)
|
8(42.1%)
|
12(52.17%)
|
4(100%)
|
6(31.58%)
|
10(43.48%)
|
Issuing voucher
|
4(100%)
|
19(100%)
|
23(100%)
|
4(100%)
|
19(100%)
|
23(100%)
|
Receiving voucher
|
4(100%)
|
19(100%)
|
23(100%)
|
4(100%)
|
19(100%)
|
23(100%)
|
RRF
|
4(100%)
|
19(100%)
|
23(100%)
|
4(100%)
|
19(100%)
|
23(100%)
|
IFRR
|
4(100%)
|
19(100%)
|
23(100%)
|
4(100%)
|
19(100%)
|
23(100%)
|
IPLS SOP Manual
|
4(100%)
|
19(100%)
|
23(100%)
|
4(100%)
|
11(57.89%)
|
15(65.22%)
|
Storage Condition
Among surveyed facilities, 17 (73.91%) fulfilled desirable storage condition. When classified according to type of facility; all hospitals (100%) and 13(68.42%) health centers fulfilled desirable (> 80%) storage condition criteria (Fig. 1).
The storage condition criteria fulfilled by all the facilities include; stacking products at proper height, store products separately from chemicals and insecticides, protecting products from direct sun light (100%), protecting cartoons from humidity (100%), and securing storage area with lock and key (100%). On the other hand, all the assessed facilities had no functional modern fire safety equipment. However, two (8.70%) of health centers made local fire extinguishers from sand. In majority (52.17%) of the facilities, the storage area is not sufficient (Table 5).
Table 5
Number and percentage of warehouses that fulfill desirable storage condition criteria at public health facilities of West Wollega zone, Oromia region, Ethiopia, July, 2019(N = 23)
No
|
Description
|
Yes
|
No
|
01
|
Products that are ready for distribution are arranged so that identification labels and expiry dates and/or manufacturing dates are visible.
|
18(78.26%)
|
5(21.74%)
|
02
|
Products are stored and organized in a manner accessible for first-to-expire, first-out (FEFO) counting and general management.
|
18(78.26%)
|
5(21.74%)
|
03
|
Cartons and products are in good condition, not crushed due to mishandling. If cartons are open, determine if products are wet or cracked due to heat/radiation (fluorescent lights in the case of condoms, cartons right-side up for Depo-Provera®)
|
23(100%)
|
0(0%)
|
04
|
The facility makes it a practice to separate damaged and/or expired products from usable products and removes them from inventory.
|
18(78.26%)
|
5(21.74%)
|
05
|
Products are protected from direct sunlight.
|
23(100%)
|
0(0%)
|
06
|
Cartons and products are protected from water and humidity.
|
23(100%)
|
0(0%)
|
07
|
Storage area is visually free from harmful insects and rodents. (Check the storage area for traces of bats and/or rodents [droppings or insects].)
|
18(78.26%)
|
5(21.74%)
|
08
|
Storage area is secured with a lock and key, but is accessible during normal working hours; access is limited to authorized personnel.
|
23(100%)
|
0(0%)
|
09
|
Products are stored at the appropriate temperature according to product temperature specifications.
|
20(86.96%)
|
3(13.04%)
|
10
|
Roof is maintained in good condition to avoid sunlight and water penetration.
|
21(91.30%)
|
2(8.70%)
|
11
|
Storeroom is maintained in good condition (clean, all trash removed, sturdy shelves, organized boxes).
|
18(78.26%)
|
5(21.74%)
|
12
|
The current space and organization are sufficient for existing products and reasonable expansion (i.e., receipt of expected product deliveries for foreseeable future).
|
11(47.83%)
|
12(52.17%)
|
13
|
Fire safety equipment is available and accessible (any item identified as being used to promote fire safety was considered).
|
2(8.70%)
|
21(91.30%)
|
14
|
Products are stored separately from insecticides and chemicals.
|
23(100%)
|
0(0%)
|
15
|
Products are stacked at least 10 cm off the floor.
|
17(73.91%)
|
6(26.09%)
|
16
|
Products are stacked at least 30 cm away from the walls and other stacks.
|
20(86.96%)
|
3(13.04%)
|
17
|
Products are stacked no more than 2.5 meters high.
|
23(100%)
|
0(0%)
|
Wastage Due To Expire And Proportion Of Expired Medicines
A total value of reproductive health medicines lost due to expiration in all assessed facilities was 357,920.52(12,323.8 USD), 78,398 (2,699.4USD) in Hospitals and 279,522.52(9,624.4 USD) in assessed HCs. whereas, the total value of usable medicines was 4,093,961.2(140,962 USD). The Percentage of Stock Wasted due to Expiration was 8.04%, and ranges from highest wastage rate for Levonorgestrel 0.75 mg tablet (33.08%) to the lowest wastage rate for combined oral contraceptive pills (3.51%) (Table 6).
Table 6
Value and percentage of reproductive health (RH) medicines wasted due to expiration from July 8, 2018 to July 7, 2019 at public health facilities of West Wollega Zone, Oromia region, Ethiopia, July 2019
S. No
|
product Name
|
Hospital
|
Health Center
|
Total
|
Usable
|
Expired
|
%age
|
Usable
|
Expired
|
%age
|
Usable
|
Expired
|
%age
|
1
|
Male Condom
|
41310
|
0
|
0
|
118357.2
|
7265.2
|
5.78
|
159667.2
|
7265.2
|
4.35
|
2
|
Etonorgestrel 68 mg
|
206829
|
5638
|
2.65
|
259516
|
66315.6
|
20.35
|
466345
|
71953.6
|
13.37
|
3
|
IUCD
|
70804.6
|
12192
|
14.69
|
495752
|
31526
|
5.98
|
566556.6
|
43718
|
7.16
|
4
|
Jedelle
|
55902.8
|
405
|
0.72
|
46383
|
3368
|
6.77
|
102285.8
|
3773
|
3.56
|
5
|
Norgestrel 0.03 mg
|
7300.6
|
2983
|
29.01
|
158837
|
3565.8
|
2.20
|
166137.6
|
6548.8
|
3.79
|
6
|
Levonorgestrel 0.75 mg
|
5315.6
|
3100.8
|
36.84
|
9207.2
|
4079.6
|
30.70
|
14522.8
|
7180.4
|
33.08
|
7
|
COC
|
737329.8
|
3192.4
|
0.43
|
103696.6
|
27441.2
|
20.93
|
841026.4
|
30633.6
|
3.51
|
8
|
Medroxyprogesterone
|
33988.2
|
0
|
0
|
128456.8
|
12799.52
|
9.06
|
162445
|
12799.52
|
7.30
|
9
|
Oxytocin 10 mg inj.
|
54108.8
|
1639.6
|
2.94
|
31168.4
|
3405.6
|
9.85
|
85277.2
|
5045.2
|
5.59
|
10
|
Ringer Lactate
|
71932.6
|
2530
|
3.40
|
25300
|
3520
|
12.21
|
97232.6
|
6050
|
5.86
|
11
|
MgSO4
|
291072
|
13833.2
|
4.54
|
91932.8
|
6341.4
|
6.45
|
383004.8
|
20174.6
|
5.00
|
12
|
Gentamycin
|
6510.8
|
240.8
|
3.57
|
10836.2
|
1568.2
|
12.64
|
17347
|
1809
|
9.44
|
13
|
Misoprostol
|
189552
|
17952
|
8.65
|
83424
|
15376
|
15.56
|
272976
|
33328
|
10.88
|
14
|
Ulcure kit
|
3314
|
596.6
|
15.25
|
6628
|
1314
|
16.54
|
9942
|
1910.6
|
16.12
|
15
|
Addis cure kit
|
11658.8
|
0
|
0
|
8716.8
|
1794.2
|
17.07
|
20375.6
|
1794.2
|
8.09
|
16
|
Addis cure plus kit
|
19440
|
2643.8
|
11.97
|
20995.2
|
1676.4
|
7.39
|
40435.2
|
4320.2
|
9.65
|
17
|
Benzanthine Penicillin
|
2898.6
|
0
|
0
|
15420
|
5078.2
|
24.77
|
18318.6
|
5078.2
|
21.70
|
18
|
Chlorhexidine
|
4075.8
|
0
|
0
|
267618
|
31208
|
10.44
|
271693.8
|
31208
|
10.30
|
19
|
Amoxicillin DT
|
10831.6
|
1792.8
|
14.20
|
39964.6
|
3133.8
|
7.27
|
50796.2
|
4926.6
|
8.84
|
20
|
Procaine penicillin
|
1068
|
0
|
0
|
5340
|
1204
|
18.40
|
6408
|
1204
|
15.82
|
21
|
ORS
|
57112
|
726
|
1.262
|
147136
|
30564.6
|
17.20
|
204248
|
31290.6
|
13.28
|
22
|
Zinc sulfate tab
|
10163.6
|
8780.4
|
46.35
|
47101.6
|
10693
|
18.50
|
57265.2
|
19473.4
|
25.38
|
23
|
TTC eye Ointment
|
1365.4
|
151.6
|
10
|
5879.2
|
577.2
|
8.94
|
7244.6
|
728.8
|
9.14
|
24
|
Ceftriaxone
|
19260
|
0
|
0
|
9630
|
1867
|
16.24
|
28890
|
1867
|
6.07
|
25
|
Vitamin A capsule
|
6400
|
0
|
0
|
37120
|
3840
|
9.38
|
43520
|
3840
|
8.11
|
|
TOTAL
|
1,999,544.6(68,847.7 USD)
|
78,398 (2699.4USD)
|
3.92
|
2,174,416.6(748688 USD)
|
279,522.52(9624.4 USD)
|
11.39
|
4,093,961.2(140962 USD)
|
357,920.52(12323.8 USD)
|
8.04
|
Regarding the contribution of each medicine to loss due to expiration, Etonorgestrel 68 mg subdermal (implanon) contributed highest value, holding 71,953.6 ETB/2,477.49 USD (20.10%) of expired medicines. Misoprostol with 17,952 ETB/618.12 USD (22.9%), and Etonorgestrel 68 mg subdermal (Implanon) with 66,315.6 ETB/2,283.36 USD (23.72%) contributed high value to loss due to expire in assessed hospitals and health centers respectively (Table 7).
Table 7
Proportion of expired Reproductive health medicines at public health facilities of West Wollega Zone, Oromia region, Ethiopia, July 2019
S. No
|
Name of product
|
Value and Proportion of each expired medicine
|
Hospital(N = 4)
|
HC(N = 19)
|
Total(N = 23)
|
Total Value (ETB)
|
Percentage (%)
|
Total Value (ETB)
|
Percentage
(%)
|
Total Value (ETB)
|
Percentage
(%)
|
1
|
Etonorgestrel 68 mg
|
5638
|
7.19
|
66315.6
|
23.72
|
71953.6
|
20.1
|
2
|
IUCD
|
12192
|
15.55
|
31526
|
11.28
|
43718
|
12.21
|
3
|
Misoprostol
|
17952
|
22.9
|
15376
|
5.5
|
33328
|
9.31
|
4
|
ORS
|
726
|
0.93
|
30564.6
|
10.93
|
31290.6
|
8.74
|
5
|
Chlorhexidine
|
0
|
0
|
31208
|
11.16
|
31208
|
8.72
|
6
|
Contraceptive pills
|
3192.4
|
4.07
|
27441.2
|
9.82
|
30633.6
|
8.56
|
7
|
MgSO4
|
13833.2
|
17.64
|
6341.4
|
2.27
|
20174.6
|
5.64
|
8
|
Zinc sulfate tab
|
8780.4
|
11.2
|
10693
|
3.83
|
19473.4
|
5.44
|
9
|
Medroxy-progesterone
|
0
|
0
|
12799.52
|
4.58
|
12799.52
|
3.58
|
10
|
Male Condom
|
0
|
0
|
7265.2
|
2.6
|
7265.2
|
2.03
|
11
|
Levonorgestrel 0.75 mg
|
3100.8
|
3.96
|
4079.6
|
1.46
|
7180.4
|
2.01
|
12
|
Norgestrel 0.03 mg
|
2983
|
3.8
|
3565.8
|
1.28
|
6548.8
|
1.83
|
13
|
Ringer Lactate
|
2530
|
3.22
|
3520
|
1.26
|
6050
|
1.69
|
14
|
Benzanthine Penicillin
|
0
|
0
|
5078.2
|
1.82
|
5078.2
|
1.42
|
15
|
Oxytocin 10 mg inj.
|
1639.6
|
2.09
|
3405.6
|
1.22
|
5045.2
|
1.41
|
16
|
Amoxicillin DT
|
1792.8
|
2.29
|
3133.8
|
1.12
|
4926.6
|
1.38
|
17
|
Addis cure plus kit
|
2643.8
|
3.37
|
1676.4
|
0.6
|
4320.2
|
1.20
|
18
|
Vitamin A capsule
|
0
|
0
|
3840
|
1.37
|
3840
|
1.07
|
19
|
Jedalle
|
405
|
0.51
|
3368
|
1.20
|
3773
|
1.05
|
20
|
Ulcure kit
|
596.6
|
0.76
|
1314
|
0.47
|
1910.6
|
0.53
|
21
|
Ceftriaxone
|
0
|
0
|
1867
|
0.67
|
1867
|
0.52
|
22
|
Gentamycin
|
240.8
|
0.31
|
1568.2
|
0.56
|
1809
|
0.51
|
23
|
Addis cure kit
|
0
|
0
|
1794.2
|
0.64
|
1794.2
|
0.5
|
24
|
Procaine penicillin
|
0
|
0
|
1204
|
0.43
|
1204
|
0.34
|
25
|
TTC eye Ointment
|
151.6
|
0.19
|
577.2
|
0.21
|
728.8
|
0.20
|
|
Total
|
78,398
|
100
|
279,522.52
|
100
|
357,920.52
|
100
|
Pharmaceutical store management challenges
The challenges of warehouse mismanagement and factors contributing to wastage of reproductive health medicines were identified through in-depth face-to-face interview with relevant key informants and the results were summarized under the following themes.
i. Infrastructure Related
Most of the KIs raised infrastructure related problem. Especially, most KIs from the HCs complained that the medical store was a simple room not built for the purpose of medical store. Especially, they explained these factors as a major reason for poor medicines storage. For example, one of the store managers explained the problem as follows:
As you see, the store is very congested. The roof is too short and it is difficult to clean daily. The roof needs maintenance. During rainy season, the water penetrates. I have reported to the management and they are discussing. It is long time since I told them. But they complain shortage of budget for maintenance.
In addition to the problem of the storeroom, KIs also complained lack of equipment and furniture used in store. Most of KIs from raised that lack of equipment like refrigerator, freezer, and insufficient shelves. This problem is stated by one of the KIs as follows:
We are putting cartoons on the ground due to lack of shelves. We have no refrigerator and freezer in our store. Therefore, we store cold chain products in another unit. Since I am not there, I do not know how much the temperature is and they do not record the temperature daily. Since there is frequent electric power interruption, the refrigerator there is not always functional.
ii. Human power Related
Another challenge identified by most KIs, especially in Health centers was, worker problem. They complained that due to insufficient pharmacy professional at their facility they assigned other professionals to manage pharmaceutical store. For example, one of the KIs expressed it as:
We have only one druggist in our facility. He does all pharmacy duties. We assigned him at dispensary. He also does procurement. So, we assigned midwife nurse at store and the druggist oversees it.
Another KI also stated:
I’m nurse. I have not taken any drug management related course during my college study, except pharmacology. However, due to lack of druggists in our facility, they assigned me as store manager. Most of the works are strange for me. I am just trying to manage all the works, but sometimes even, I encounter new terms. In addition, I have not taken any training.
Factors Contributing to Drug Expire
i. Supplier Related factors
Most of the KIs were complaining the problem of the supplier. They stated that the supplier pushes medicines in bulk without their request.
Most of the time PSA and partners dumps a huge amount of family planning medicines with short expire date. We do not need most of these medicines. So, they expire in bulk at our facility.
Another KI also explained the problem as:
PSA sends near expiry drugs with very essential drug we need, to a driver. If we want to return those near expiry medicines, the driver does not allow us. He obliges us either to receive all products or return all the products. Since some products are very important, we cannot return them; we are obliged to receive those near expiry drugs.
ii. Demand related
Most KIs raised less customer demand for some family planning methods as contributing factor for expiration. One of the KIs explains this as;
Most of our customers prefers medroxy-progestrone (Depo-polivera) over other long-term methods. I think that could be due to its convenience for them. Since the supply from the partners is not need based, the bring other medicines with low demand. Then, those medicines will expire at our facility.