1. Improving Access and Use of Medicines through Private Sector Initiatives: A case for an Essential Medicines Franchise in Ghana Eghan Kwesi, Mensah D, Idun J, Staley,R. Marsden,A. Arhinful,K. Ofori- Adjei,D. Dodoo A.

2. ABSTRACT

3. Background Demographics source: 2000 census data Population: 19 Million Sex Male: 49.5% Female: 50.5% LocalityRural: 56.2 % Urban: 43.8% Growth Rate: 2.7% Population Density: 79.3 pers/sq.km PHARMACIES 1028 CHEMICAL SELLER 7000 Maternal Mortality Rate: 214 Life Expectancy: 58 HIV Prevalence: 3.8% Ghana is a tropical country situated in the West Coast of Africa and located between latitudes 4 ˚ & 11 ˚ North of the equator Economic Indicators GNI per capita $340 Inflation Rate 2003 23.6% Per Capita Health Spending $8

4. Background The Strategies for Enhancing Access to Medicines (SEAM) Program was established in 2002 with a trinity of country-level public-private initiatives to improve access to essential medicines and commodities. The three (3) components are: Establishing a franchise of chemical seller shops that provide essential medicines and health supplies; Improving pharmaceutical supply and promoting more appropriate use of medicines in the Mission sector (Catholic) of Ghana; and Strengthening the Pharmacy Council’s capacity to regulate chemical seller shops in Ghana

5. Problem Statement Almost sixty –six (66%) 1 of Ghanaians visit the Licensed Chemical Seller ( LCS) as their first point of call when accessing health care services. Yet most have little or no healthcare background. Additionally LCS are small individually run operations with high overheads. This had lead to Poor quality service provision by LCS Resource- heavy and inefficient operations leading to high prices. Additionally there exist a low level of regulatory and supervisory visit from the authorities

6. Objective Questions The problems raises two questions Can we enhance the access to medicines and improve rational use of medicines by private sector initiatives? Specifically, can the above objectives be achieved through an essential medicines franchise in a sub-Saharan African country with limited resources?

7. Intervention An Essential Medicines Franchise network – branded as CAREshops was set up in the Volta Region as a pilot The Volta Region, with its 1.6 m people, is served by only 621(8.8%) and 17(1.5%) of the National 7000 LCS and 1028 Pharmacies 2 A Structured modular training programme was implemented for the accredited CAREshop Managers. This was over a 10 week period with 2 week breaks in between modules. A group purchasing program and a logistically sound distribution network was established by GSMFEL CAREshop Franchisor Regular monthly supervisory and mentoring visits were conducted with the CAREshop Periodic impact assessment of programwas is undertaken through - Review of Records, - Drug Availability and Affordability surveys, - Mystery shopping and Field observations. 1. MSH baseline Survey 2000 Ghana 2. Pharmacy Council 2002.

8. Methodology & Outcome Measures Based on the training needs assessment a Pre and post training knowledge assessment was conducted. Data was collected on the availability of tracer drugs in CAREshops Level of stocking and supply of insecticide treated nets– a key indicator in relation to contemporary initiatives in malaria control were and prevention in CAREshops were measured

9. Results 1- Improvement in knowledge of CAREshop operators The number of LCS obtaining a 60% basic score before and after training was measured This tool will be reapplied in Oct 2004and Jan 2005

10. RESULT 2 Tracer Drug Availability CAREshop Franchise Tracer Drugs Allowed to Stock VR N=66All Regions Franchise Jan 2004 N= 79 Acetylsalicylic acid tabs 300mg100.0%99.6% 100% Aluminium Hydroxide 500mg89.4%80.4% 98% Amodiaquine 200mg22.7%20.0% 34% Chloramphenicol Eye Ointment27.3%30.8% 45% Chloroquine Tab 150mg97.0%94.4% 100% Chlorpheniramine 4mg Tab78.8%68.8% 100% Condoms97.0%94.4% 100% Ferrous Sulphate/Fumarate 200mg Tab62.1%56.4% 98% Ibuprofen 200mg Tab86.4%76.4% 100% Oral Rehydration Salt89.4%92.4% 100% Paracetamol tab 500mg100.0%96.8% 100% Secure86.4%84.0% 90% Sulfadoxine/Pyrimethamine tab 500mg/25mg68.2%63.2% 100% Treated Bednets3.0%1.6% 7% Average % for Tracer Drugs 70.0 67.3 83.7% Availability of 15 tracer drugs (franchise to non franchise :70% to 83% Availability of ITN (franchise to non franchise : 3% to 7%

11. Discussion Measurable improvement noted in medicine supply and use by CAREshops especially through the established group purchasing and distribution system Increase in knowledge and practice level of Franchise Chemical Sellers observed Observations of the current interventions also show that working with the private sector requires an understanding of the motivations of private sector providers These motivations include, but in most cases are not limited to – financial benefits –image enhancement –increased skill and competence leading to increased commitment to proper sale and supply of medicines

12. Conclusion Private sector initiatives can improve access to medicines Franchising of essential medicine suppliers provides opportunity for training, improvement in service delivery and cost of reduction in supply chain Regular monitoring and an understanding of the motivation private sector providers is essential for success

13. Next Steps …..  Conclude and Implement Access dimensions for evaluation  Evaluation to measure the CAREshop Program impact on * Quality of Dispensing (communication and counseling) * Quality of Stocked products * Appropriateness of Recommendations * Affordabilty and availabilty of essential medicines * Acceptabilty /satisfaction with the CAREshop outlets  Assess the enablers and constraints of the franchise program implementation Post intervention regional assessment planned for October 2004 and March 2005