Availability and Stock Levels of Essential Medicines in Government Healthcare Institutions of Different Settings in a Rural District in Sri Lanka: a multicentre cross-sectional study

doi:10.21203/rs.3.rs-5051616/v1

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Research Article

Availability and Stock Levels of Essential Medicines in Government Healthcare Institutions of Different Settings in a Rural District in Sri Lanka: a multicentre cross-sectional study

https://doi.org/10.21203/rs.3.rs-5051616/v1

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Background: The availability of essential medicines (EMs) is an important aspect of quality healthcare services. This study aimed to assess the availability, stock-out periods, record-keeping, presence of expired medicines, and conservation and handling of selected EMs across different levels of Government Healthcare Institutions (GHCIs) in Monaragala, one of the rural districts in Sri Lanka.

Methods: A descriptive, cross-sectional study was conducted, with retrospective data collection methods where necessary. Six GHCIs representing four different levels of care were selected in Monaragala District, Sri Lanka. EMs for 23 diseases were selected from the National Essential Medicine List (EML) of Sri Lanka. Data was collected using survey forms adapted from the WHO operational package for assessing, monitoring, and evaluating country pharmaceutical situations (WHO-OP). Ethics review approval was obtained from the Ethics Review Committee, the Open University of Sri Lanka, and institutional permissions were obtained from the relevant authorities.

Results: The average availability of selected EMs was fairly high (77.1%) in the Monaragala district, while the “highest” availability (80.49%) was recorded by divisional hospitals type B. The highest average stock-out days (66 days) were reported from the Divisional Hospital- Type C. Only Divisional Hospital- Type A reported having expired medicines on shelves (2.43%). All six GHCIs reported more than 80.49% for record-keeping on medicines. Divisional Hospital Type-A reported having the lowest score for warehouse management.

Conclusions: The availability of EMs at the GHCIs of the Monaragala district was fairly high. Record keeping of EMs was high while the average number of stock-out days varied per institution. Conservation and handling practices of the store rooms and dispensing areas of the GHCIs in the Monaragala district should be further improved.

Essential medicines

availability

stock-out

storage facilities

record keeping

Access to essential medicines (EMs) is a vital component of ensuring the right to health for all individuals, regardless of their socioeconomic status or geographical location. According to the World Health Organization (WHO), EMs are medicines designed to meet the top health requirements of the population. They should always be accessible in functional health systems, in appropriate dosage forms and quantities, with assured quality, and at a cost that people in the community and individuals can afford. The WHO updates and publishes Model Lists of EMs and EMs for Children biannually. These lists act as resources for countries or regional organizations to adopt or modify their EM lists to comply with regional treatment recommendations and priorities for health [1]. There are 137 national lists of EMs available worldwide, each containing between 44 and 983 medicines, which is partly explained by differences in the characteristics of the country [2].

The National Essential Medicines List (EML) of Sri Lanka, 5^th edition [3], classifies government healthcare institutions (GHCIs) of Sri Lanka into 4 categories: level 1 (primary medical care units), level 2 (divisional hospitals), level 3 (district base hospitals and district general hospitals) and level 4 (provincial general hospitals and teaching hospitals). The national EML of Sri Lanka has listed 318 medicines for 29 major disease categories. The medicine information includes the medication name, strength, dosage forms, and the international non-proprietary name of the active ingredient, together with the recommended level of care [3].

One of the most essential elements of quality healthcare services is the availability of EMs, since their continuous availability guarantees that patients have access to health services without interruption [4]. Even a slight shortage of EMs can significantly affect the delivery of high-quality health care. Stockouts are an important indicator of the preparedness of healthcare services since clinics cannot operate continually without dependable and adequate access to critical medications [5]. Effective record-keeping of pharmaceuticals ensures efficient management of stock status and consumption data. The logistics management information system (LMIS) is crucial in effective record keeping. Hospitals maintain either manual or electronic records of pharmaceuticals [6].

Most medicines lose efficacy after their expiry date, and some may develop different adverse reactions. All expired pharmaceuticals should always be considered pharmaceutical waste and should never be used as expired medicines become unsafe for use [7]. The presence of expired medicines on pharmacy shelves, the appropriateness of handling, and conservation conditions are used as indicators of the quality usage of medicines [8].

The Sri Lankan government provides free health care to all citizens at the point of delivery. However, certain expensive medical supplies might be purchased by patients when they are unavailable in government hospitals, which creates a financial burden for low–income patients [9]. Monitoring and evaluating the pharmaceutical sector is vital for determining whether the main pharmaceutical aims are met. The WHO operational package for assessing, monitoring, and evaluating country pharmaceutical situations (WHO-OP) [8] provides a standard method to analyse and track progress over time and compare pharmaceutical situations in different facilities, districts, and nations.

A few studies have been carried out on the accessibility and cost of medicines in Sri Lanka, focusing on specific demographic areas or particular categories of medicines[10–12]. To our knowledge, this is one of the first studies to evaluate different pharmaceutical parameters at different levels of GHCIs in Sri Lanka. This study was conducted to assess the availability, stock-out periods, record-keeping, presence of expired medicines, and conservation and handling of selected EMs across different levels of GHCIs in Monaragala, a rural district in Sri Lanka.

Study design and study setting

A descriptive, cross-sectional study was conducted from May to June 2023 in Monaragala District, Sri Lanka. Retrospective data were used whenever necessary. Monaragala district is situated in the east and southeast directions of Uva province, Sri Lanka. The total area is 5959 km²^, and it is the second-largest district in Sri Lanka [13]. Agriculture is the main type of employment for 51.4% of the population [14].

All GHCIs in Monaragala district in Sri Lanka were considered as the population. The Monaragala district has 6 different types of GHCIs belonging to 4 levels of care as defined by the National EML. One government healthcare institution of each type was selected conveniently. The selected GHCIs are shown in Table 01. The identities of all the selected GHCIs were kept confidential. The outpatient department (OPD) dispensaries and the clinic pharmacies of the selected GHCIs were visited once for data collection. The presence of expired medicines at GHCIs was determined by randomly examining the expiration dates of each of the 44 medicines investigated in this study. To determine the one-year stock-out period, stock registers were checked for the last 12 months (from the 01^st of May 2022 to the 30^th of April 2023). Indoor pharmacies supplying medicines to wards and the Emergency Treatment Units (ETUs) of selected GHCIs, private sector healthcare facilities, retail pharmacies, and polyclinics were excluded from the study.

Table 1 Classification of selected GHCIs according to the National EML-Sri Lanka

Levels of care as per National EML	Total No. of GHCIs available in the district	Type selected of GHCI for the study	No. of Beds at the selected GHCI
Level 1	10	Primary Medical Care Unit (PMCU)	0
Level 2	1	Divisional Hospital -Type A (DH -A)	56
	5	Divisional Hospital -Type B (DH -B)	38
	8	Divisional Hospital -Type C (DH -C)	110
Level 3	3	Base Hospital -Type B (BH -B)	80
Level 4	1	District General Hospital (DGH)	579

Study instrument

Data were collected via survey forms adapted from the WHO Operational Package for assessing, monitoring, and evaluating country pharmaceutical situations (WHO-OP) on the basis of availability, average stock-out duration, adequacy of conservation conditions (level of storage facilities), and adequacy of record-keeping of the selected EMs. The WHO-OP recommends the selection of 15 key medicines for the assessment. The National EML Sri Lanka has been prescribed to make more than one dosage form or different strengths of the same medicine for EMs available. In this study, 44 EMs used to treat 23 diseases, including both communicable diseases (CDs) and noncommunicable diseases (NCDs), were selected from the National EML 5^th edition published in 2014. Each dosage form of medicine was considered as a separate entity.

Data analysis

The data were analysed according to the WHO-OP [8]. The data were presented as percentages and averages. The number of medicines entitled to be available at particular GHCIs was taken as the denominator when analysing the data. The availability of the selected EMs was reported based on previous national and international surveys; <30%: very low; 30-49%: low; 50-80%: fairly high; and >80%: high [10, 15].

Availability of EMs

The overall availability of selected EMs in the GHCIs in Monaragala district was “fairly high” (77.1%), which varied from “fairly high” (75%) at DH-B to “high” (80.49%) (Table 2). Only DH-A was reported to have expired medicines on the shelves during the survey period, and the product was “iron drops 100 mg/5 mL, in 15 mL droppers”.

All the selected EMs were available at all GHCIs for the disease categories of gastritis/gastric ulcers, nausea/vomiting, skin infection, eye infection, vertigo, diabetes, and angina. Beclomethasone, which is prescribed for the management of asthma, is prioritized to be available at all levels of care (levels 1, 2, 3, and 4) in the dosage forms of dry powder capsules (DPCs) (200 mcg) and metered dose inhalers (MDIs) (50 mcg, 100 mcg, and 250 mcg). However, the mentioned dosage forms or strength were not available at DGH on the day of the visit. This may be due to the high number of patients attending the DGH.

Table 2 Summary of the availability of EMs on the day of the visit, record keeping, and percentage of expired medicines at GHCIs in the Monaragala district

	DGH	BH -B	DH -A	DH -B	DH -C	PMCU
Number of entitled medicines in selected list	44	44	41	41	41	38
Number of entitled medicines at the time of visit	34	34	33	33	30	29
Number of entitled medicines with adequate records	43	44	41	41	41	38
Percentage (%) of availability for entitled medicines	77.27%	77.27%	78.05%	80.49%	73.17%	76.32%
Percentage (%) of medicines expired on shelves (entitled mediciness)	0.00%	0.00%	2.43%	0.00%	0.00%	0.00%
Percentage (%) of record keeping for entitled medicines	97.73%	100.0%	80.49%	100.0%	100.0%	100.0%
Average number of stock-out days for entitled medicines	56.82	23.52	46.93	27.88	65.51	54.89

DGH District General Hospital; BH-B Base Hospital-Type B; DH-A Divisional Hospital-Type A; DH-B Divisional Hospital-Type B; DH-C Divisional Hospital-Type C; PMCU: Primary Medical Care Units

Record-keeping

All the GHCIs maintained record-keeping practices of more than 80%. Except for DGH and DH-A, all the other four GHCIs in this study reported 100% record keeping. DGH was reported for not keeping records for beclomethasone DPC 200 mg. DH-A was reported as not keeping records for 8 medicines; beclomethasone MDI 50 mcg 200 doses, beclomethasone MDI 250 mg 200 doses, domperidone tab. 10 mg, folic acid tab. 1 mg, ciprofloxacin eardrops 0.3%, fluoxetine tab. 5mg, olanzapine tab. 5 mg, and carbamazepine tab. 200 mg.

Table 3 Availability of selected EMs during the day of visit at selected GHCIs in Monaragala district -2023

Key medicine to treat common conditions	EMs entitled levels of GHCIs	DGH	BH -B	DH -A	DH -B	DH -C	PMCU
Anti-thrombotic (NCD)
Aspirin tab. 75 mg, 100 mg, 150 mg	1, 2, 3, 4	Yes	No	Yes	Yes	Yes	Yes
Rheumatoid diseases (NCD)
Diclofenac sodium tab. 50 mg	1, 2, 3, 4	No	Yes	Yes	Yes	Yes	Yes
Paracetamol tab. 500 mg	1, 2, 3, 4	Yes	Yes	Yes	Yes	Yes	Yes
Paracetamol oral liquid 120 mg/5 mL	1, 2, 3, 4	Yes	Yes	Yes	Yes	Yes	Yes
Worm infestation (CD)
Mebendazole tab. 100 mg	1, 2, 3, 4	Yes	No	No	Yes	Yes	No
Respiratory tract infections (CD)
Amoxicillin cap. 250 mg, 500 mg	1, 2, 3, 4	Yes	Yes	Yes	No	Yes	No
Amoxicillin oral susp. 125 mg/5 mL,100 mL bot.	1, 2, 3, 4	Yes	Yes	Yes	Yes	Yes	Yes
Common colds, rhinitis (CD)
Chlorpheniramine maleate tab. 4 mg	1, 2, 3, 4	Yes	Yes	No	Yes	Yes	Yes
Chlorpheniramine oral solu. 2 mg/5 mL, 60 mL bot.	1, 2, 3, 4	Yes	Yes	Yes	Yes	Yes	Yes
Asthma (NCD)
Salbutamol tab. 2 mg	1, 2, 3, 4	Yes	Yes	Yes	Yes	Yes	Yes
Salbutamol MDI 100 mcg, 50 mcg per dose	1, 2, 3, 4	No	Yes	Yes	Yes	Yes	Yes
Ipratropium bromide MDI 20 mcg	3, 4	Yes	Yes	-	-	-	-
Ipratropium bromide DPC 20 mcg	3, 4	Yes	Yes	Yes*	Yes*	-	Yes*
Beclomethasone DPC 200 mcg	1, 2, 3, 4	No	Yes	Yes	Yes	No	Yes
Beclomethasone MDI 50 mcg, 200 doses	1, 2, 3, 4	No	No	No	No	No	No
Beclomethasone MDI 100 mcg, 200 doses	1, 2, 3, 4	No	No	No	Yes	No	Yes
Beclomethasone MDI 250 mcg, 200 doses	1, 2, 3, 4	No	No	No	Yes	No	Yes
Prednisolone tab. 5 mg	1, 2, 3, 4	Yes	Yes	Yes	Yes	Yes	Yes
Diarrhoea (CD)
Oral Rehydration Salt (ORS)	1, 2, 3, 4	Yes	Yes	Yes	No	Yes	Yes
Gastritis/GI ulcers (NCD)
Omeprazole cap. 20 mg	2, 3, 4	Yes	Yes	Yes	Yes	Yes	Yes
Nausea, Vomiting (NCD)
Domperidone tab. 10 mg	1, 2, 3, 4	Yes	Yes	Yes	Yes	Yes	Yes
Domperidone syrup 5 mg/5 mL	1, 2, 3, 4	Yes	Yes	Yes	Yes	Yes	Yes
Urinary Tract Infection (CD)
Nitrofurantoin tab. 50 mg	1, 2, 3, 4	Yes	Yes	Yes	Yes	Yes	No
Skin infection (CD)
Miconazole cream 2%	1, 2, 3, 4	Yes	Yes	Yes	Yes	Yes	Yes
Inflamation and pruritus (CD)
Hydrocortisone cream or ointment 1%	1, 2, 3, 4	No	Yes	No	No	No	No
Anemia (NCD)
Ferrous sulfate tab. 200 mg	1, 2, 3, 4	Yes	No	Yes	Yes	No	Yes
Folic acid tab. 1 mg	1, 2, 3, 4	Yes	Yes	Yes	Yes	Yes	Yes
Iron drops 100 mg/5 mL, in 15 mL dropper	1, 2, 3, 4	Yes	Yes	Yes	No	No	Yes
Iron syr. 25 mg/mL bot.	1, 2, 3, 4	Yes	No	No	No	No	No
Eye infections (CD)
Ciprofloxacin eye drops 0.3%	1, 2, 3, 4	Yes	Yes	Yes	Yes	Yes	Yes
Ear infections (CD)
Ciprofloxacin ear drops 0.3%	1, 2, 3, 4	No	No	Yes	Yes	No	Yes
Vertigo (NCD)
Prochlorperazine tab. 5 mg	1, 2, 3, 4	Yes	Yes	Yes	Yes	Yes	Yes
Diabetics (NCD)
Metformin tab. 500 mg	1, 2, 3, 4	Yes	Yes	Yes	Yes	Yes	Yes
Hypertension (NCD)
Nifedipine tab. 20 mg	1, 2, 3, 4	No	Yes	No	No	No	No
Enalapril tab. 5 mg	1, 2, 3, 4	Yes	Yes	Yes	Yes	Yes	Yes
Hydrocholorothiazide tab. 25 mg	1, 2, 3, 4	Yes	Yes	Yes	Yes	Yes	Yes
Angina (NCD)
Glyceryl trinitrate tab. (sublingual) 500 mcg	1, 2, 3, 4	Yes	Yes	Yes	Yes	Yes	Yes
Heart Failure (NCD)
Spironolactone tab. 25 mg	1, 2, 3, 4	Yes	No	Yes	Yes	Yes	No
Anti-coagulant (NCD)
Warfarin tab. 0.5 mg, 1 mg, 3 mg, 5 mg	3, 4	Yes	Yes	Yes*	-	-	-
Psychosis (NCD)
Fluoxetine cap. 20 mg	1, 2, 3, 4	No	Yes	Yes	Yes	Yes	No
Olanzapine tab. 5 mg	2, 3, 4	Yes	No	Yes	Yes	Yes	-
Epilepsy (NCD)
Sodium valproate tab. 100 mg, 200 mg	1, 2, 3, 4	Yes	Yes	Yes	Yes	Yes	Yes
Sodium valproate syrup 200 mg/5 mL	2, 3, 4	Yes	Yes	No	No	No	-
Carbamazepine tab. 200 mg	1, 2, 3, 4	Yes	Yes	Yes	Yes	Yes	Yes

The duplication of medicines in multiple disease categories of the national EML, Sri Lanka, was excluded from the calculation of availability (%). DGH District General Hospital, BH-B Base Hospital-Type B, DH-A Divisional Hospital-Type A, DH-B Divisional Hospital-Type B, DH-C Divisional Hospital-Type C, PMCU Primary Medical Care Units, CD Communicable Diseases, NCD Noncommunicable Diseases, MDI Metered Dose Inhaler, DPC Dry Powder Capsules

Yes - Medicine was present on the day of the visit, No - Medicine was not present on the day of the visit

* Available on the day of visit even though not entitled to present at the GHCIs as per the national EML.

Table 4 Summary of scores for conservation conditions and the handling of medicines at GHCIs from Monaragala district-2023

	DGH	BH-B	DH-A	DH-B	DH-C	PMCU	Average
Adequacy of conservation conditions and good handling of medicines at storerooms (%)	60	90	50	100	90	60	75
Adequacy of conservation conditions and handling of medicines at dispensing facilities (%)	80	80	50	80	80	80	75

DGH District General Hospital, BH-B Base Hospital-Type B, DH-A Divisional Hospital-Type A, DH-B Divisional Hospital-Type B, DH-C Divisional Hospital-Type C, PMCU Primary Medical Care Units

Stock-out duration

Over the last 12 months, the highest average stock-out duration was reported as 66 days at DH-C, whereas DGH, PMCU, DH-A, DH-B, and BH-B were reported as 57, 55, 47, 28, and 24 days, respectively. Among the stock-out medicines at DH-C, beclomethasone MDI 50 mcg, iron drops 100 mg/5 mL, in a 15 mL dropper, iron syr. 25 mg/mL in bot., ciprofloxacin ear drops 0.3%, and sodium valproate syr. of 200 mg/5 mL were reported for the longest stockout period, with 365 days. At DH-A, sodium valproate syr. 200 mg/5 mL, iron syr. 25 mg/mL bot. and spironolactone (tab. 25 mg) were reported to have a stock-out duration of more than 320 days. At DGH, only the beclomethasone MDI 50 mcg, 200 dose was reported for a stock-out duration of more than 300 days, whereas the PMCU reported stock-out per year for the beclomethasone MDI 50 mcg, 200 dose, and iron syr. 25 mg/mL bot., spironolactone (tab. 25 mg), and a fluoxetine cap. 20 mg for 365 days. DH-B reported for nifedipine tab. 20 mg and beclomethasone MDI 50 mcg, 200 doses stocking out for more than 150 days. (Additional file 1: Table A1: Stock-out duration of the selected EMs in days within the last 12 months)

Inventory management practices at GHCIs

Except for DH-A, all the other GHCIs scored 80 marks for the conservation conditions at dispensing areas, whereas DH-A scored 50 marks. DH-B, BH-B, and DH-C scored 90, 90, and 100 marks, respectively, for conservation conditions at storage rooms in the GHCIs, whereas the other three GHCIs scored 60 or 50 scores.

All the storerooms and dispensing areas were free from moisture, and no evidence of pests in the areas was found. Except for DH-A, in all the storage rooms and dispensing areas of the investigated GHCIs, medicines were stored first-expiry-first out (FEFO) principle, and windows or air vents were present. However, tablets/capsules were reported to be manipulated by the naked hand at the dispensing areas of all the GHCIs. Only the storerooms in DGH were reported to have direct sunlight in the room. Overall, the storage rooms and dispensing areas of the GHCIs scored 50 or more than 50 out of 100 for the conservation of medicines.

Availability of medicines

According to the WHO definition, EMs should exist within operating healthcare institutions at all times [1]. The availability of EMs mostly influences the quality of healthcare and patient satisfaction. The average availability of the selected EMs in Monaragala district was “fairly high” (77.1%), even though the country was facing an economic crisis. The availability was “high” at DH-B and “fairly high” at other GHCIs. A study conducted in another rural district in Sri Lanka revealed that “high” availability for EMs was reported only at the district hospital, whereas the base hospital and the PMCUs reported “fairly high” availability [16]. Another study conducted in Sri Lanka reported that the availability of selected EMs used for noncommunicable diseases were 36.4% and >50% for primary and secondary levels of care, respectively, with a mean availability of 58% (±0.32) in the public sector [10]. In this study, the availability of selected EMs for the secondary and tertiary care levels was reported as 77%. The secondary care level includes a few basic specialties, and the tertiary care level includes some subspecialties. The greater number of patients served by secondary- and tertiary-level healthcare facilities might be the reason for the unavailability of some of the EMs. However, 73% or greater availability of EMs in Monaragala district was reported for all the primary, secondary, and tertiary GHCIs considered in this study. Monaragala, a rural district with a high availability of EMs, is notable.

Studies conducted in other lower-middle-income countries (LMICs), such as Nepal [17], Pakistan [18], Malawi, and Bangladesh [19], have reported poor availability of EMs of less than 50%. A study conducted at 6 healthcare centers in Adama Town, Ethiopia, on 11 EMs reported an overall average availability of 76.3% [20]. Another study conducted in Iran [4], an LMIC, reported that 97.5% of 15 key medications were available in various cities, as well as in state and commercial pharmacies, with no significant variation [21]. The WHO affirms that the appropriate level of availability for essential medications is at least 80% [22]. Monaragla district accounted for 77.1% of all districts, which is closer to the WHO recommended level.

Record-keeping

This study revealed higher percentages (> 80%) of record-keeping of EMs, possibly because almost all the GHCIs were supported by the computerized Medical Supplies Management Information System (MSMIS) provided by the Medical Supplies Division (MSD) of the Ministry of Health. A study conducted in six healthcare centers in Adama town in Ethiopia assessed the accuracy of record keeping via inventory management assessment tool (IMAT) indicators and reported low accuracy of records [20].

Stock-out duration

Stock-outs arise from an inability to manage medical supplies, report shortages, and act swiftly and effectively to prevent their recurrence. The stock-out duration of essential medicines is an important measure for ensuring the availability of EMs [23]. The average stock-out durations assessed during the last 12 months in this study were reported as 65, 57, 55, 47, 28, and 24 days for DH-C, DGH, PMCU, DH-A, DH-B, and BH-B, respectively. A study conducted at two government healthcare centers in Northwest Ethiopia reported that the average stock-out durations in the last 6-month period were 38.8 days and 11.2 days [4]. Another study conducted in Adama Town, Ethiopia, reported that the average length of stock-out days for 11 EMs from 5 healthcare centers throughout the past 12 months was 40.6 days [20].

Paracetamol oral liquid 120 mg/5 mL), amoxicillin capsules (250 mg, 500 mg), amoxicillin oral suspension 125 mg/5 mL, 100 mL), beclomethasone MDI (100 mcg, 200 doses), hydrocortisone cream 1%; and ciprofloxacin eye drops 0.3% were stock out at the day of visit and in the last 12 months at all GHCIs. This may be due to the high consumption of these medicines at the GHCIs. Studies conducted in Ethiopia reported that ferrous salt + folic acid (150 mg + 0.5 mg), ORS, and amoxicillin syrup 125 mg/5 mL are the medicines most frequently stocked out [4, 20].

A shortage of EMs may increase the burden on healthcare staff, as patients may need to make additional visits and referrals. Patients might choose not to take medications that are out of stock owing to unavailability or financial constraints. These stockouts may result from long-distance transportation from suppliers during the procurement process, unavailability of medications from suppliers, or high consumption in the absence of an efficient supply system [4, 20]. A study conducted in 9831 primary healthcare centers in Indonesia reported

a lack of necessity was the primary reason for stockouts accounting for 46% of the stock-outs, whereas 38% of the stock-outs were due to medicines not being supplied to healthcare facilities [24].

Presence of expired medicines

Only iron drops of 100 mg/5 mL in 15 mL were reported to present as expired medicines on the shelves during the survey period, as reported by DH-A. A study conducted in Nepal assessing the availability, stockouts, and expiry of 17 EMs in 28 peripheral healthcare facilities (below the district level) reported an average of 3% for the presence of expired medicines at the levels of health posts and subhealth posts. At least 9 out of 17 medicines (52.9% of total medicines) included in that study were found to have expired in at least one health facility at the time of visit [17]. Iran reported only 1% for the presence of expired medicines among public health care facilities, which was reported only at one public pharmacy out of the 6 public pharmacies considered in the study [21]. A study conducted at 4 health facilities in the Awi zone, Amhara regional state, Ethiopia, reported that 8.1% of the medications out of 173 medications were reported as expired medicines [25].

The absence of expired medicines, adherence to the standard storage conditions at the dispensing facilities, proper conditions, and standard handling of medicines in storerooms are used as indicators to assess the quality use of the medicines as defined by the WHO [8].

Inventory management practices at GHCIs

The average value for conservation conditions and good handling of medicines at both storerooms and dispensing facilities was reported as 75%. This percentage varied from 100% to 50% for storeroom conditions and 80% to 50% for the dispensing area, whereas DH-B reported the highest scores for both the storeroom area and the dispensing area. A study conducted in 5 cities in Iran reported scores of more than 75% by all 5 public health care centers for the adequacy of conservation conditions and the handling of medicines in the storeroom area and the dispensing area [21]. A study conducted in 62 government health facilities across 21 districts of Nepal reported that only 13% of health facilities followed medicine storage guidelines and reported that temperature and humidity levels exceeded recommended limits [26]. A study conducted in Nepal identified delays in the procurement process as the major barrier to the effective management of essential medicines [27].

Limitations of the study

This study investigated only selected EMs, but examining all the EMs in the GHCIs would be of greater value. This study investigated only the availability, stock-out duration, and storage conditions at six GHCIs in the Monaragala district. Assessing the situation at other healthcare facilities in the district would be more representative. This research included only oral and topical medicines, and parenteral medications were excluded. Moreover, the study did not examine any of the factors that affect the availability of EMs in healthcare institutions.

Despite the economic crisis faced by Sri Lanka during 2023, the selected GHCIs in Monaragala district presented fairly high availability of selected EMs, indicating that free state health services were given priority when funds were allocated. However, certain areas, such as storage conditions, should be improved at all GHCIs. Even though this study revealed a minimal occurrence of expired medicines, consistent monitoring of healthcare facilities and enhancing the medicine supply system would ensure the availability of EMs and an uninterrupted supply of medicines to patients.

EMs: Essential Medicine; WHO: World Health Organization; EML: Essential Medicine List; GHCIs: Government Healthcare Institutions; LMIS: Logistics Management Information System; OPD: Outpatient Department; ETUs: Emergency Treatment Units; WHO-OP: WHO Operational Package for assessing, monitoring, and evaluating country pharmaceutical situations; CD: Communicable Diseases; NCD: Non-Communicable Diseases; MDI: Metered Dose Inhaler; DPC: Dry Powder Capsules; DGH: District General Hospital; BH-B: Base Hospital-Type B; DH-A: Divisional Hospital-Type A; DH-B: Divisional Hospital-Type B; DH-C: Divisional Hospital-Type C; PMCU: Primary Medical Care Units; FEFO: First-Expiry-First Out; LMICs: Lower-Middle-Income Countries; ORS: Oral Rehydration Salt

Informed consent: Since patient-related information was not collected in this study, informed consent was not applicable.

Ethics approval and consent to participate

The Ethics Review Committee of the Open University of Sri Lanka approved the study (FH/ERC/033). Administrative approval was obtained from the Provincial Director of Health Services, Uva Province; the Regional Director of Health Services, Monaragala District; and the heads of the relevant institutions. All methods were performed following relevant guidelines and regulations. The data were kept confidential and were only used for the intended purpose.

Consent for publication:

The consent to publish the information gathered from the GHCIs was obtained from the Provincial Director of Health Sciences. The data are reported in a way that it will not be possible to identify the individual institutions.

Availability of data and materials

The online version contains supplementary material available on the publishing website.

Competing interests: The authors declare that they have no competing interests.

Funding

The study was self-funded.

Authors’ contributions

RBJB conceived the idea of the study, and all the authors participated in designing the study. AAJY was involved in the data collection. AAJY, RBJB, NDDW, CA, JCMT, and RF were involved in the analysis and interpretation of the data. RBJB, AAJY, and NDDW drafted the manuscript, and AAJY, RBJB, NDDW, CA, JCMT, and RF critically revised it. All the authors read and approved the final manuscript.

Acknowledgments

We would like to express our gratitude to health professionals working in GCHIs in Monaragala district for their cooperation during data collection.

Authors' information

¹Department of Pharmacy, Faculty of Health Sciences, The Open University of Sri Lanka, Nugegoda, Sri Lanka, ²District General Hospital, Monaragala, Sri Lanka, ³The Pharmaceutical Society of Sri Lanka, Colombo, Sri Lanka, ⁴Provincial Director of Health Services, Badulla, Uva Province, Sri Lanka, ⁵Faculty of Medicine, General Sir John Kotelawala Defence University, Rathmalana, Sri Lanka

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No competing interests reported.

Supplementarydata1.docx
Additional file 1. Table A1: Stock-out duration of the selected EMs in days within the last 12 months.

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Availability and Stock Levels of Essential Medicines in Government Healthcare Institutions of Different Settings in a Rural District in Sri Lanka: a multicentre cross-sectional study

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