Routine monitoring of medicine use is costly. Medicine use monitoring in most low- and middle-income countries is heavily reliant on donor support, which is not sustainable. Innovative models to close gaps in monitoring of medicine use are critical towards strengthening pharmaceutical services.
To pilot an inter-institutional collaborative model for monitoring medicine use in Namibia over a three-year period, 2013–2015.
An interventional analytical design that piloted an inter-institutional collaborative model for monitoring medicine use in public health facilities in Namibia was followed. Three key stakeholders – the Ministry of Health and Social Services (MoHSS) division of pharmaceutical services, University of Namibia School of Pharmacy and United States Agency for International Development–funded Systems for Improved Access to Pharmaceutical Services (SIAPS) project – collaboratively designed and implemented a concept model, tools and guidelines for routine medicine use assessment. The model integrated medicine use monitoring as a component of the annual rural placements of Bachelor of Pharmacy students at public hospitals. The pharmacists at the hospitals and MoHSS provided support and supervised the students prior to, during and after the placement. Each student undertook a mini-project on medicine use at the facilities which included data collection, analysis as well as reporting using the World Health Organization or International Network of Rational Use of Drugs indicators. These were subsequently aggregated by the university with technical assistance from SIAPS and findings reported to the Ministry. Data collected by the students on hospital placements were entered in Microsoft Excel® template for descriptive analysis for patient care indicators. All students discussed their findings with health facility supervisors.
The collaborative efforts enhanced local institutional and students’ capacity on analysing, reporting and presentation of data on medicine use. A total of three medicine use surveys (MUS) involving over 1938 patients were conducted from 2013 to 2015. The local capacity to conduct medicine use evaluation (MUE) was increased among 74 pharmacy students. At least 15 public hospitals in 12–14 regions participated in the MUS. Findings reveal 83% of prescribed medicines were dispensed; 53%–57% patients were satisfied with medicine information; 50%–59% of patients felt they waited too long (consultation time of more than 3 h) before getting their medicines; over 80% patients did not know how to take their medicines correctly; 56%–80% of dispensed medicines were labelled correctly.
A multisectoral collaborative model is cost-effective in medicine surveys, if there are mutual benefits. Student placements provide an opportunity to build local capacity for routine MUE. Ministries of Health should utilise this innovative approach to assess service delivery.
Access to quality, safe and cost-effective medicines is a fundamental human right (Toebes
Inter-institutional collaborative model for best practices on medicine use evaluation.
Currently Namibia uses a passive report of PMIS for reporting indicators on medicine use. This is implemented by the MoHSS and all public health facilities self-report on medicine use. The validation of the PMIS data from health facilities through active surveys on medicine use was last done in 2001 (Lates & Shiyandja
‘Health Care Delivery models of the future clearly envision teams of health care providers working together to meet patient needs’. The inter-professional and inter-institutional collaborative efforts on monitoring of medicine in Namibia are limited by funding and models. The WHO has recommended collaborative efforts among institutions and professionals to optimise resources in monitoring medicine use and improve the quality of care (WHO Medicine Strategy
Expenditures on medicines rank highest on most health care budgets in LMICs (Stuart, Doshi & Terza
The main aim is to pilot an inter-institutional collaborative cost-effective model for active monitoring of medicine use in Namibia. The study also determined the medicine use patient care indicators and progress of the collaborative efforts among the institutions.
This paper highlights a cost-effective model for monitoring medicine use among LMICs. Such models are necessary to optimise medicine use and treatment outcomes. This model will minimise budget wastages and provide routine information for decision-making regarding medicine use. These models suggest a mechanism to optimise local capacity and minimise over-reliance on donor funds for monitoring of public health care. The model also highlights better approaches to synergise efforts among local institutions for collaborative monitoring of medicine use.
Wastage of medicines through inappropriate use particularly with antimicrobial antibiotics is a global public health problem (WHO
Inter-institutional and inter-professional best practice models for medicine use monitoring are ineffectively and inconsistently used in training institutions and practice settings (Kilo
Inter-institutional and inter-professional collaboration on medicine use is inconsistent. There is need for a best practice model for active medicine use monitoring in Namibia. There is limited capacity for routine MUE in Namibia. A high workload at health facilities is a major barrier to completion of electronic data entry and there is no system to ensure the quality and validate the accuracy of the data entered in the PMIS. The routine survey of medicine use in Namibia is infrequent and the need for a cost-effective approach is urgent.
Data on medicine use were collected from health facilities of MoHSS, Namibia. These public health facilities were hospitals in all the 14 regions of Namibia. These included district hospitals and regional referral hospitals that are used as placement training sites for the Bachelor of Pharmacy students of the UNAM for the rural placement training. All the health facilities had a PMIS system in place for monitoring medicine use and the responsible person was a hospital pharmacist or regional pharmacist. The students are placed at the site for four weeks to undertake rural placement training that includes conducting a MUE and rational use of medicines. Regional pharmacists aggregate and report on medicine use indicators on a monthly or biannual basis to the MoHSS division of pharmaceutical services.
The pilot project utilised an interventional design where an inter-institutional model for monitoring medicine use at public health facilities was implemented. In addition, MUEs were recommended by WHO (
A data collection tool was developed in collaboration with the UNAM-SoP, the MoHSS Pharmaceutical division and the MSH, Namibia. The tool was pretested on 10 patients at Katutura State Hospital, Windhoek, and standardised (
Quantitative data on 14 items entered from all the students were aggregated into one Excel data set. This aggregated data set was used as a research project for final-year B.Pharm. students under the supervision of representative researchers – that is, MoHSS, UNAM and MSH. Each student performed basic data analysis on the data that they collected and presented results mainly in the form of percentages. The data were analysed using descriptive statistics – using means and absolute and relative frequencies in Excel. The main outcome variables were the WHO medicine use indicators and the level of satisfaction with dispensing services. The factors associated with the level of satisfaction and medicine use indicators were evaluated using bivariate analysis using chi-squared test and student’s
The model was adapted from models for best practices for inter-professional collaboration (Charles, Bainbridge & Gilbert 2004). The goal of inter-institutional collaboration was adapted for routine MUE to improve patient care in LMIC. The model requires identification of settings in which the MUE is to be done. The standards of performing the MUE in this setting are determined collaboratively by the team. The team agreed on items to be assessed and the methodologies to be used in the assessment. In this model the data collectors are medical students undertaking placement or internship programmes in these settings. The data collectors are collaboratively trained by the stakeholders on three skills related to professional and ethical skills to be maintained, the personal skills of data collection such as communication and inter-professional skills to encourage teamwork during the data collection process. In addition, the inter-institutional collaboration among the institutions should follow a development process with three stages including awareness stage, application stage and the competence stage. The awareness is the introduction of the concept of inter-institutional collaborative practice. At this stage, the roles of each institution and designate are identified and clarified and also require building inter-professional and inter-institutional relationships. The application stage is when advances in the depth and breadth of inter-institutional collaborations on medicine use evaluations are developed. This requires active team participation as well as interaction to apply their knowledge, skills and experiences on medicine evaluations. At this stage, competences on medicine use evaluations are developed including trust, communication and data collection and analysis. The last stage is the application of competences in the delivery of inter-institutional implementation of medicine use skills and knowledge as part of a team. The skills of each institution and designates are integrated into the actual practice of MUE. This requires active participation and decisions in collaborative MUEs.
Collaborative efforts between the three key institutions enhanced collaborative training on and active monitoring of MUE in Namibia. The WHO recommends IPE/IPC best practice models for transformative training that encourages building capacity by learning together in order to work together with the aim of providing quality health care and outcomes. The collaborative efforts between the three institutions improved trust as well as well as inter-professional and inter-institutional communication. The roles of the three institutions were clarified in the collaboration with UNAM helping with the research component, the MoHSS assisting with integration of learners into the practice sites and MSH-Namibia providing technical assistance in the development of tools and implementation of the MUEs. The collaboration also gave an opportunity for collecting patient level data on satisfaction with pharmaceutical services at the public health facilities nationwide. The team functioning between the three institutions has improved and similar collaborative efforts have been achieved with other programmes such as the Diploma in Pharmacy placements. This also gave an opportunity for the three institutions to take collaborative leadership on the various aspects of the MUE.
The collaborative efforts for medicine use required the following best practices: Clarity on the responsibilities of each institution. This requires the development of the plan and one of the institutions to coordinate the activities. The tertiary institutions are strategically placed to coordinate activities for training and research on medicine use. There was a need to agree on standards for inter-institutional collaboration on MUE so as to eliminate ambiguity, duplication and wastage of resources. The assessment also highlighted aspects of a healthy team and dynamics, that is, to have the right representatives of the different institutions to form the coordinating committee; these personnel should be committed and qualified to perform the duties with the right mix of competence in medicine use as well as empowerment and accountability to the activities. In addition, there is need for alignment of strategies for training and implementation of MUEs to the current needs and existing capacity as well as the level of practice of the student data collectors and setting in which the data is to be collected. The surveys strategically chose facilities that had a pharmacist to provide support supervision to the students. The collaboration also ensured that the training and surveys are executed within the same time period. The outcomes of the survey were similar for every student. Another important lesson is to use methods that are routinely used by the health facility to collect data and to not interfere in routine work at the facilities.
A total of four MUEs involving over 1938 patients have been conducted from 2013 to 2015 (
Medicine use indicators at health facilities in Namibia.
Covariate | Cohort 1 (2013) Thandiwe Trish | Cohort 2 (2014) Pelekekae T | Cohort 3 (2015) Pucuta D | Total/mean |
---|---|---|---|---|
Region coverage | 6 | 9 | 11 | 12 |
Facility coverage | 7 | 15 | 12 | 15 |
Respondents | 289 | 990 | 659 | 1938 |
Namibian nationals | - | 83% | 82% | 82.5% |
Mean age (years) | 33 | 44 | 39.5 | 38.8 |
Students trained | 14 | 33 | 27 | 74 |
Dispensed by pharmacist | 17.8% | 44.1% | 20% | 27.3 |
Sex (female) | 56.7% | 59.1% | 59.8% | 58.5 |
Satisfaction | 73% | 85.8% | 83.9% | 80.9% |
Medicines received as prescribed | - | 83.4% | 72% | 77.7% |
Know how to take medicines correctly | - | - | 89.7% | - |
Medicines adequately labelled | 56.4 | 80.1% | 41.4% | 59.3 |
Satisfied with information on medicines | 58.2% | 56.6% | 85.6% | 66.8% |
Overall quality indicator | 62% | 78.6% | 84.2 | 74.9% |
Average waiting time (hours) | _ | _ | 3.06 | 3.06 |
The students Thandiwe Trish, Pelekekae T and Pucuta D were the university students who compiled the reports for each survey as part of their research projects.
The main objective of the assessment was to develop a cost-effective model for medicine use evaluation in Namibia. The study aimed at describing findings of an inter-institutional collaborative model and performed a strength weakness opportunities and threats analysis of the model.
The study aimed at providing a mechanism for consistent monitoring of medicine use in LMIC. To date, three consecutive MUE have been conducted in up to 12 regions of Namibia. This gives a national coverage of 86% for the medicine use evaluations in the past three years (2013–2015). Over the three years (2013–2015), the study found that patient care and dispensing indicators were suboptimal and vary by year and health facility. Various surveys among LMIC have reported suboptimal indicators of medicine use (Bergman et al.
A framework to enhance collaborative MUEs was developed. The collaborative model between a local university placement programme, the MoHSS public health facilities and development partners is cost-effective. The collaboration has yielded annual reports on the quality of dispensing services at health facilities in Namibia. The WHO recommends collaborative efforts between professionals to improve patient care (WHO
The study aimed to identify the benefits and challenges of the inter-institutional collaborative model to reduce costs for medicine use evaluations. The main strength of the programme was strengthening the collaboration between stakeholders with minimal costs and optimising the competences. The assessment also developed teamwork among the institutions, designates and the students. There were opportunities to use existing placement programmes of the university at the health facilities to conduct routine MUEs at no costs. This in turn provided a service to the MoHSS to provide routine data on patient care indicators at the health facilities. The main weakness of the survey was that coverage of the facilities was restricted to facilities where students were placed and this excluded primary health care facilities. The main threat to the model is lack of commitment by the stakeholders for continuous improvement of the medicine use evaluations.
The study depicts a model to enhance inter-institutional collaborative efforts to minimise costs and improve the quality and frequency for conducting regular MUEs. Secondly, the study highlights a model framework for institutional collaborations on medicine use evaluations. The survey highlights standards for conducting the MUEs that have been developed to provide guidance to LMIC (Kibuule et al.
The main limitations of this survey were seeking ethical approval to conduct routine surveys on behalf of the Ministry of Health. This caused delays in collecting data in some facilities. There is need of integration of the MUEs in the strategic and operational plans of the various institutions involved.
The study recommends that inter-institutional and inter-professional collaborative efforts should be promoted by the MoHSS to enhance service delivery outcomes. The medical and pharmacy schools have a great potential of supporting medicine use evaluation. Enhancement of pre-service capacity for medicine use evaluations will improve future health care and reporting practices as well as close the gaps of human resource capacity in specific technical gaps. The concept and guidelines developed by the collaborative efforts in Namibia may be adapted by other LMIC to improve medicine surveillance efforts. There is need for in-country policy framework to guide inter-institutional collaborative efforts particularly when many parties are involved such as students.
The inter-institutional collaborative model between the UNAM-SoP, the Pharmaceutical Division of the Ministry of Health and Management Sciences for Health greatly improved monitoring of medicine use in Namibia over the past four years. Although medicine use indicators remain suboptimal, collaborative efforts and teamwork remain the key components for improving medical and pharmaceutical service delivery.
The authors would like to acknowledge the permission from the Ministry of Health and Social Services to access the public health facilities for placements of students and to conduct the survey. The authors also appreciate the support given by the individual students to collect data during the placement as well as the pharmacists who worked as site supervisors during this placement. Special acknowledgement goes to Ms Toga Trish, Ms Pelekekae Tumo and Ms. Herondina Pucuta who compiled the three reports whose results have been included in this manuscript. Appreciation also goes to the US Agency for International Development, Systems for Improved Access to Pharmaceutical Services Program, for funding the Management Sciences for Health staff time for the technical assistance rendered in these studies. Technical support was provided by the Management Sciences of Health, Namibia.
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this paper.
D.K. played a major role in conceptualising and implementing the studies, supervised implementation of the studies, data analysis and report writing. He performed additional data analysis and co-authored this manuscript. J.L. contributed to documentation of the study concept, supervised data collection and reviewed the manuscript. H.R.K. contributed to the annual study concept, developed initial data collection tools, implementation of the study and wrote the manuscript. B.P. gave technical insights on medicine use assessments, data collection, and reviewed the manuscript. Q.N. contributed to conceptualisation of the study, coordinated data collection in public health facilities and reviewed the manuscript. T.R. contributed to the study design, implementation and writing of the manuscript.