2. Improving Access and Use of Medicines through Private Sector Initiatives: A case for an Essential Medicines Franchise in Ghana

3. MSH – GSMFEL - INRUD  Presented By Kwesi E. Eghan  Co Authors  Marsden Andy  Staley Robert  Mensah Daniel  Idun John  Arhinful Kojo  Dodoo Alex  Ofori Adjei David MSH GSMFEL INRUD

4. 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

5. Background and setting  Access to medicines in the rural and peri-urban Ghana is characterized by - Comparatively high price -Inadequate availability of essential medicine - poor quality of services  Almost 66% of Ghanaians visit the Licensed Chemical Seller ( LCS)

6. CAREshop Franchise  A unique private- public sector initiative In Ghana to achieve public health objectives of improving access to medicines  First private drug outlet data source for improving public health surveillance in Ghana

7. Study Question  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?

8. Improving access to medicine through a franchise Health care Providers Product Suppliers Modify existing operations Establish new structures Modify existing function Add new function Option 4 Option 5 Option 6 Framework of Franchise Options* Establish new structures Modify existing function Modify existing operations Option 1 Option 2 Option 3 Add new function *number of options could potentially double as each franchisee could buy products exclusively or partially (fractionally) from the franshisor

9. Agree on development approach Geographic Areas Selection of franchisee Shop Remodeling & Branding Training Procurement & Distribution Supervision & Support Identify and Secure Sources of Funding Contractual Arrangement / Setting Up Franchisor Identification Of Partners 1 Advocacy

10. Phase 1 Phase 2 Phase 3 Pharmacies

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13. Achieving through: CUSTOMER LOYALTY & BRAND DEVELOPMENT DISTRIBUTION NETWORK SUPERVISORY VISIT TRAININGSUPPLIES HEAD OFFICE Improved Quality of Health Service Delivery SUSTAINING COMPETITIVE ADVANTAGE

14. Training Business & Entrepreneurship Development Introduction to Franchising Drug Management Managing Simple Aliments Action Planning

15. Training: Use of Structured Questionnaires  to obtain information from patients and clients to manage diarrhoea, malaria, anaemia, worm infestation etc  identify conditions require referral to appropriate health professionals  understand the concepts of rational drug use

16. Training : Use of structured Question  W-WHAM  What does it stand for?  W – who is the medicine for?  W – what are the symptoms?  H – how long have they had the symptoms?  A – action already taken including what medicines have been tried  M – medicines (including herbal remedies) being taken for other problems

17. PROCUREMENT AND LOGISTICS  List of 214 products 174 generic has been agreed upon with LCS.  Drugs are negotiated for, at very competitive prices, thus enhancing the access to affordable drugs.  A consistent and reliable delivery/supply system to CAREshops has been implemented

18. Procurement and Logistics  Sales per shop is 30-100USD per day  Franchisees pay for work gear, re- modelling of shop however they part pay for cost of modular training.  Franchisor obtains favorable trade terms with Manufacturers because of size of purchase

19. Supervision  A productivity enhancement tool that captures issues on - Drug Management - Customer relations/services - Record Keeping This tool is being used to ensure that care shops deliver services in line with set standards

20. Data collection  Data is collected on complaints and drug consumption.  Data collection in the shops have been kept to a minimum by designing and using a unique and easy to complete  Combined Patient - Cash Record Register.

21. Intervention  An Essential Medicines Franchise network – branded as CAREshops was set up in the Volta Region as a pilot.  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..

22. 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

23. Results 1- Improvement in knowledge of CAREshop operators  Most LCS had no formal training in Drug Supply Mgt, Business and Entrepreneurship and Managing Simple Ailments  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

24. 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%

25. RESULTS  Improvements( compared to 2002 SEAM Regional Baseline Assessment)  Availability of 15 tracer drugs (franchise to non franchise :70% to 83%)  Increase in knowledge level of franchised Chemical Sellers  Availability of ITN (franchise to non franchise : 3% to 7%

26. Discussion  Measurable improvement in medicine supply & use by CAREshops( group purchasing and distribution system  Increase in knowledge & practice level of Franchise Chemical Sellers observed  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

27. 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 * Affordability and availability of essential medicines * Acceptability /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

28. Challenges of the CAREshop Project  Communicating the concept of Franchising  Obtaining buy- in from all stakeholders  Supervision is seen sometimes as an intrusion by Franchisee  Ensuring financial sustainability through robust re-design and financial risk taking measures on the part of Franchisor.

29. 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

30. Research and Policy Implication  Can Models such as franchising be replicated in other setting  The arguments for expanded drug list for rural drug outlets can franchising be the solution  Franchise shops can be used for testing/piloting policy changes with drug outlets

31. C ustomer focused A ffordable R eliable E fficient shop BRANDING