DEBRE MARKOS, Ethiopia — A dozen people crowd a small outside window at Debre Markos Hospital, jostling each other, angling to get to the pharmacist who might have the medicine they need. They have already waited in two other lines, one to get their bills, another to pay. An elderly man coughs uncontrollably. One mother with malaria walked two miles to the clinic, three children in tow. The pharmacist shouts to be heard over the racket.
Ultimately, some of these patients receive their medication. Others are too late; the stock bin is empty. Still others may have departed with just one of the several medicines prescribed to them.
Fast forward six years, same hospital. Patients are indoors, waiting on benches. At a single counter, in private booths, each patient moves quickly through a process of handing over a prescription, paying for it, and receiving it. The pharmacist can easily locate and dispense the needed medicines, and he doesn’t run out of anything. The visit is capped off by a private counseling session. Patients can ask questions, and they can hear the instructions the pharmacist gives about dosages and side effects. The pharmacist has received on the job training, so he can answer most everyone’s questions. When the manager asks him about quantities for the next delivery, he can quickly run an inventory report.
A new way of getting medicines to people has transformed this hospital’s pharmacy and hundreds like it around the country, to better help the thousands of Ethiopians who rely on public hospitals for care.
The Auditable Pharmaceutical Transactions and Services (APTS) system, developed by MSH in partnership with Debre Markos Hospital in 2010, and with funding from USAID, is a package of interventions that transforms the environment, dynamics, services, and resources within pharmacies. With APTS, pharmacies are renovated with enhanced patient services in mind. They have systems to collect information about medicines and patients, which make decision-making, ordering, and inventory faster and more accurate. They have tools to build staff skills and improve budgeting practices.
APTS is the culmination of decades of work that MSH has done in Ethiopia to get the right medicine to the right patients when they need it.
In 2010, APTS was piloted at Debre Markos Hospital, a remote regional hospital that serves a population of about 4 million. It immediately showed signs of success. The hospital’s selection of medicines began to more accurately reflect the community’s health needs, and patients were much more likely to receive what they came for: 97.5 percent of the requested medicines were on hand, up from 65 percent. Far fewer had expired—a mere .27 percent, down from 8.24 percent.
With more service windows, the hospital could double the number of pharmacists and serve more patients. Waiting time dropped significantly—what used to take a half-day now took about 20 minutes. Patients noticed. In 2008, patient satisfaction was 25 percent; by 2012, it was 85 percent, with medicine availability the most significant contributor. Surveys showed that knowledge about how to take medicines markedly improved.
The hospital was delighted with the increased sales, which increased revenues by nearly 90 percent between 2011 and 2012. Theft and waste plummeted, also improving the bottom line. And audits became less of a headache, now that there was a robust system to provide accurate, up-to-date information on transactions.
Health officials also took notice. Regional governments, federal health facilities, and city administrations clamored for APTS, and USAID provided MSH the resources to respond. The Federal Ministry of Health mandated APTS as state-of-the-art practice for the nation’s public hospital pharmacies, featuring it in the new Health Sector Development Program for 2015-2020—the document that sets future priorities in the country’s health sector. Countrywide rollout is underway and will include university and federal hospitals, which have long suffered from acute shortages of medicines and supplies. To date, more than 50 health facilities country-wide rely on APTS.
As Ethiopia prepares to respond to the coming surge in chronic disease and greatly expanded access to medicines and services, this system will be essential.
Aster Desalegn’s Perspective
A few miles down the road from the hospital, Aster Amanuel Desalegn sits in her easy chair, softly smiling as her granddaughters Emaye, 6, and Blen, 8, shyly greet their visitors. Aster delicately fingers her gossamer white shawl as she starts to tell her story. She looks younger than her 70 years, and her clear eyes don’t betray everything she has been through. Diabetes. Tuberculosis. Arthritis. Breast cancer.
She has been getting her medicine at Debre Markos Hospital for almost 20 years. She recalls the early years, when she had recently been diagnosed with diabetes. Every visit to the pharmacy to replenish her insulin took at least a half-day and was filled with anxiety.
“We used to sit in the sun, in the rain, and get exhausted,” she says, her voice heavy with the memory. After all that waiting, there was always a chance the pharmacist would tell her that they didn’t have the medicine she needed. And if the public hospital didn’t have her medicine, her only option was to pay for it—with money she did not have—at a private pharmacy, where the workers may not have much medical knowledge and the medicine’s quality can’t be counted on. Once, she says, she had to instruct such a dispenser, who claimed to be a pharmacist, about the need to refrigerate insulin.
“These were the problems we faced before,” she says. “Now, we don't get told the hospital doesn’t have all the medicines we need.”
Earlier that day, she had zipped in and out of the hospital to get her monthly dose of insulin, which she could be confident had been refrigerated properly, and where she received counseling from the pharmacist. He reminded her of the importance of a low-sugar diet, and counseled her on when to use painkillers for her arthritis. He double-checked that she stores her insulin properly and knows what to do if the electricity cuts out.
“They don't skip the counseling service and send me home just because I go there all the time,” she says.
“To compare what it was like before and how it is now, there is such a big difference. There are seats where we can sit and wait. We get treated with respect,” she adds. She always gets what she came for, and she can count on being back home by midday.
“I am grateful I’ve lived long enough to see these changes,” she says with a sigh.
In Aster’s lifetime, Ethiopia’s population has quintupled, growing from about 18 million in 1950 to nearly 100 million as of 2015. She has seen the ravages of famine, war, and the AIDS epidemic.
But she has also seen her country rise to meet its health challenges. When she was born, almost 20 percent of children died before age five. By 2015, that statistic had dropped to 5 percent. Life expectancy for someone born in 1946 was 30; today it has risen to 65. And Aster has lived well beyond that.
But still, she is among the lucky ones, to have a high-functioning hospital so close by.
In any country, the pharmaceutical system—the movement of medicines from factory to warehouse, through distribution points to clinics and pharmacies, and finally to the patients in need—is largely invisible. It is also complex, even more so in countries with unrest, drought, or poor infrastructure. The transformation at Ethiopian hospitals shows what it takes to upgrade that system and keep it working well. It reveals what it takes to ensure a continuous, reliable flow of medicines to the people who need them, no matter the circumstances.
A Crying Need
The creation of APTS built on 13 years of an MSH partnership with the Ethiopian government and USAID to implement successive improvements to the country’s pharmaceutical system. Many of these improvements emerged from the need to respond to the seemingly unstoppable scourge of HIV and AIDS.
In 2003, African countries were under immense pressure to quickly and efficiently get AIDS medications to a huge number of patients. In Ethiopia, the continent’s second largest country, an estimated 1.5 million people were HIV-positive.
Even if enough medicine had been on hand, the pharmacies were not ready. Long neglected, they were in disarray. There were no systems or records — for patients or for medicines. Crowded and chaotic, pharmacies were riddled with logistical and structural problems, using systems developed 100 years earlier. James D. Wolfensohn, then the president of the World Bank, had publicly called corruption — rampant in pharmacies — a “cancer.” It was impeding social and economic development, he cautioned, keeping millions of people trapped in poor health and poverty.
Only those who could pay at private facilities or buy smuggled medicine were receiving treatment. That year, 120,000 Ethiopians died from AIDS. Due to the social stigma associated with AIDS, many in need avoided the health care system altogether. Without the ability to talk with a provider confidentially, many patients never started, or dropped out of, treatment. And suffering most from these system weaknesses were the poorest and most vulnerable, whose access to medicines had been limited to begin with.
“There were about nine thousand patients, all of whom were getting their medicines in a very dubious way,” recalls Negussu Mekonnen, MSH’s country representative in Ethiopia. “People were selling their property to buy counterfeit antiretroviral drugs. There was a general sense of desperation.”
The tide began to turn after President Bush launched the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003 to provide antiretroviral (ARV) medications. By 2005 they were available for free. The goal was to get ARVs to 15,000 people that year.
But how could the country reliably get a steady flow of medicine to so many people without delay or interruption? An innovator in ensuring medicine supply in the developing world since the early 1990s, MSH, in partnership with USAID, was called upon to get the job done. The campaign ultimately resulted in a 50 percent reduction in adult AIDS deaths in the Ethiopian capital over the next five years.
“It was a very big assignment, a very urgent, life-saving assignment. The US government and the local [USAID] mission entrusted us with this responsibility,” says Mekonnen.
MSH rapidly took stock of the situation, collected data, and prepared remedies. A preliminary assessment showed that more than one-third of Ethiopian health facilities routinely ran out of essential medicines. More than 8 percent of medicines were expired, and only half of patients knew what the correct dosage was. If a pharmacy ran out of a medication in 2003, it took an average of three months to get it back in stock again. Meanwhile, other medicines that didn’t match the needs of patients sat on shelves and expired before they were used. No one was keeping accurate records of what came in and what was dispensed. Pharmacists’ jobs were laborious, with disorganized rooms, storage, and workflow. Theft was common. Without secure storage or a way to keep track of inventory, the high-priced, high-demand HIV medicines were in jeopardy.
At the beginning, as MSH ramped up the project, “I used to use my own private car to distribute some of the commodities,” Mekonnen recalls. “The job had to be done because people were dying. On one occasion, the guard of the hospital refused me entrance because he was suspicious that medicines were being delivered using a private vehicle. “
MSH went on to ensure uninterrupted supply of ARVs by establishing data and inventory systems and embedding these systems in more than 280 health care facilities across the country. By 2008, more than 400 hospitals and health centers were using standard forms for patient registration, tracking, and inventory control. By 2011, MSH had trained more than 8,000 pharmacists in more sophisticated approaches and practices.
These efforts made possible the uninterrupted supply of ARVs, even in the most remote areas of the country.
In 2009, free ART was reaching about 100,000 Ethiopians. By 2011, that number had more than doubled.
Changing the Focus - From Products to Patients
After the first urgent push to supply ARVs, MSH turned its attention to the next essential step: making sure that people stayed on the medicines. The lens broadened to take on recordkeeping of both people and their medicines. Pharmacies began tracking patients who had dropped out of treatment, and eventually, adherence, with its many facets, became a national priority.
MSH continued to evolve one of its early tools, the Electronic Dispensing Tool, to track medication errors, harmful drug interactions, and adverse reactions, which by 2012 had expanded to 165 sites. For the first time in Ethiopia, patient pharmacy medication cards for ARVs were introduced at all ART facilities (by then there were more than 500 such pharmacies), making treatment and follow-up data available for 200,000 HIV and AIDS patients. Those improvements, MSH saw, could now be expanded to improve the entire medicine delivery system in Ethiopia.
“You cannot sustain a system to serve solely a single disease,” notes Mekonnen. “So we went on to strengthen the entire system, the base of the pharmacy services. This was crucial.”
A few years earlier, Ayalew Adinew had joined MSH as a senior technical advisor. He had grown up near Debre Markos Hospital and eventually became a pharmacist.
“I worked in hospitals for 12 years. I saw theft, pilferage, expiry,” he says.
He could see firsthand that these problems were costing millions and devastating lives.
His hunches were born out by the data. An MSH assessment in 2009 showed that a third of designated ARV sites had lost medicines to damage, expiration, and theft, and only one of these pharmacies had a reliable system to record such losses. Smuggling and re-sale were rife. In 2010, stock-outs of essential drugs nationwide were at 35 percent, patients’ knowledge on correct dosage was at only 68 percent, and the national average rate of medicines expiry was nearly 10 percent.
Shortly after he joined MSH, Debre Markos Hospital CEO Shegaw Alemu and Chief Pharmacist Edmealem Admassu contacted Adinew. They were having a lot of problems managing the hospital's pharmacy. They said they heard that MSH could solve “systems problems.”
Adinew was the right man to call. He had given this a lot of thought.
“Without pharmacy service there are no health outcomes,” says Adinew.
He knew that these problems were not just apparent when it came to ARVs. They were an issue for public pharmacies treating patients for all health problems.
He approached his MSH team, and APTS, the comprehensive improvement package for hospital pharmacies, was born through a strong partnership between Debre Markos Hospital and MSH. Adinew remembers the day: June 10, 2010.
APTS started as a spreadsheet on Adinew’s computer. He and a team analyzed and recorded each step in all of the processes of a working pharmacy. They mapped out the flow of medicines and supplies through a health facility system. They created new tools and forms such as vouchers, sales tickets, and dispensing registers to organize and record information. The next phase was testing the new system, and Adinew returned to his hometown to see it through.
The Gold Standard
At Debre Markos Hospital, CEO Tariku Belachew had been spearheading a number of improvements since he had started the job four years earlier. The appeal of APTS was its multi-faceted approach—it had the potential to rectify many major problems he was facing, including waste, stealing, and poor communication with patients. The other asset, Belachew says, was the opportunity to partner with MSH.
“We wouldn’t have gotten here on our own. We wouldn’t have even started.”
Every regional bureau official and regional chief pharmacist has visited Debre Markos Hospital's pharmacy to see first-hand the transformation that APTS has brought. As word of Debre Markos pharmacy’s successes spread, APTS was quickly scooped up by other hospitals in the district, then in additional districts. With each successive hospital’s tweaks, the Ethiopian standard was established for storage, financing, dispensing, counseling, and training. In the first five months of APTS at five hospitals, three of them had 100 percent availability of medicines.
Currently 50 public hospitals—of about 200—have implemented APTS, and it is now required by the government for all new facilities.
“APTS is now the property of Ethiopian professionals. Why? Because many professionals of Ethiopia commented on it and their cumulative knowledge was put into the system,” says Adinew.
MSH had turned the climate from a commodities-focused system to a patient-focused system.
“MSH has really introduced a new culture of pharmacy practice in Ethiopia, where the patient is at the center of all the services we provide and patients are protected from unnecessary harm related to the use of medicines,” says Hailu Tadeg, country project director at MSH. “They are given services in a respectful manner with their dignities respected.”
The operation of a pharmacy may be almost invisible. But it is on the front lines of patient care.
“The pharmacy is usually the last contact a patient has with the health care system,” says APTS creator Adinew. “The last encounter creates the first impression.”
Scroll down to meet Faith, HIV-positive at 36, who tells MSH about how she recovered from an adverse drug reaction in Nairobi, Kenya.
Related Technical Resources
- Enhancing Health Outcomes for Chronic Diseases in Resource-Limited Settings by Improving the Use of Medicines
- Building Local Capacity for Clinical Pharmacy Service in Ethiopia
- National Assessment on the Status of Implementation of Clinical Pharmacy Services at Public Hospitals in Ethiopia
- Appointment Systems are Essential for Improving Chronic Disease Care in Resource-Poor Settings