Report tropical internship
Pharmaceutical healthcare in Ghana
Supervisor:
Charles Allotey
HAN – Health Access Network, Accra
Student:
Shirley Sparla
3008649
Period:
30th of May till 7th of July 2011
Signature student, I hereby agree with the facts of the report:
Place:
Date:
Signature:
Signature supervisor, I hereby agree with the facts of the report:
Place:
Date:
Signature:
Content
Content 2
1. Introduction 3
Goals 3
2. Health Access Network- National 3
General 3
Ministry of Health 3
Food and Drug Board 4
National Health Insurance Scheme 4
Medicine distribution Ghana 5
Hospitals 6
Health Access Network- organisation 6
Recommendations 8
3. ADHPL – Regional 9
General 9
Production eye drops 9
Production injections 10
Store management 11
Recommendations 11
Comparison KAMA and ADHPL 13
4. St Patricks mission hospital – Local 13
General 13
Output of the hospital 14
Hospital pharmacy 15
Rational use of drugs: HIV 17
Rational use of drugs: Diabetes 19
Challenges 19
Recommendations 20
5. Final conclusion 21
6. Analysis strengths and weaknesses 21
Literature 22
Appendix I – Terms of Reference 23
Appendix II – Table protection light and refrigerator 24
Appendix III – Literature on phenylephrine 25
Appendix IV – Protocol phenylephrine 25
Appendix V – Protocol chloramphenicol 26
Appendix VI – Logbook 27
Appendix VII – Evaluation form 28
1. Introduction
Health service in Ghana is not as self-evident as health service in the Netherlands. Disease like malaria, tuberculosis, HIV and malnutrition are still part of everyday live and they still cause daily deaths. Medicines for these diseases and some medicines in general are not always available and/or affordable. The affordability of medicines has improved by the introduction of the National Health Insurance. Unfortunately only 55% of the people in Ghana have insurances. The quality of the medicines can also be a problem. Counterfeit is at this moment still one of the challenges of Ghana.
In the six weeks of internship, the pharmaceutical health care in Ghana is observed at three levels, national, regional and local. At each level different environments have been seen to obtain a good overview of the Ghanaian health care c.q. pharmaceutical health care. In this report all the activities and recommendations are categorized according to the three levels discussed above.
Goals
Several goals were set for this internship. The first goal was to further develop my leadership qualities and professional behaviour. Extra attention should be given to production of medicines and in particularly the production of eye drops, store management and the distribution of medicines at larger scale. The final goal was to contribute to the education of pharmacy assistants.
Also I would like to acquaint myself with the standard treatment for the major tropical disease, like malaria and HIV.
In the Terms of References (appendix I) are the pre-set points of attention stated and also a proposed schedule for the six weeks of internship at the different locations.
2. Health Access Network- National
General
The first, fifth and sixth weeks of the internship were reserved for the introduction to the Ghanaian healthcare system at national level. Health Access Network (HAN) was the basis for this introduction. Using HAN, contacts were made with the ministry of Health, University of Ghana and the research institute of the University and pharmaceutical manufactures. I also attended a meeting of HAN and contributed on the topic administration. In the final week the modules for pharmacy assistants were revised.
In this chapter the different departments are discussed starting with the Ministry of Health (high level) and finishing with HAN (more local level).
Ministry of Health
The Ministry of Health is responsible for the general public health [1]. They are responsible for policy formulation, monitoring and evaluation, regulation of the health services and resource mobilization. Specific for pharmaceutical healthcare, the ministry of health develops the Standard Treatment Guidelines. The Standard Treatment Guidelines are designed to serve as a clinical guide as well as an educational tool. It will ensure the proper management of all patients throughout Ghana in a standardised, cost-effective and quality manner. Unfortunately the yearly update and the national wide distribution of the Standard Treatment Guidelines are lacking. At this moment doctors use old guidelines or guidelines from different sources. These are not as reliable as the ones from the Ministry of Health.
But most worrisome is the lack of distribution of the Standard Treatment Guidelines. At the Ministry of Health I saw piles of guidelines standing in the corner of the room. In the mission hospital I heard that they did not have any Standard Treatment Guidelines not even the doctors), I find a problem. The knowledge is there but due to logistical problems the doctors are not able to prescript according to the latest guidelines. The teaching part is also suffering under the lack of distribution. Medical students can really use the guidelines to get familiar with the standard treatment used in Ghana.
Another part of the Ministry of Health is responsible for the National Health Insurances Scheme (NHIS). This will be discussed below.
Food and Drug Board
The Food and Drug Board (FDB) is authorised to regulate the manufacture, importation, exportation, distribution, use and advertisement of food, drug, cosmetics, medical devices and household chemicals with respect to ensuring their safety, quality and efficacy [2]. The Ministry of Health is the coordination departments of the Food and Drug Board. All manufactures have to register their products at the FDB otherwise they can not be (legally) distributed in Ghana. Every new strength, active ingredient or change in the composition of the medicines should be register again. Also newly imported medicines and strengths have to be approved by the FDB. This applies for HAN as well, because the import their medicines by IDA (discussed below). HAN also has to apply for import permits for narcotics. The FDB is also responsible for the advertisement of drugs; this includes only the over-the-counter medicines and not the prescription only medicines.
In Ghana the medicines are exposed to more harsh conditions then medicines in European countries. The high humidity and temperature in Ghana can negatively influence the stability of the medicines. Therefore the FDB requests specific quality tests of all medicines that are register in Ghana. The FDB requests long term stability research at 30oC with 75% humidity.
The FDB does some post marketing surveillance, but not to the extent desired. A newly created department is created in March 2010, responsible for the monitoring of safety of the medicines. In the future this will have an important role in safety monitoring. Controlling the quality of medicines is done by the FDB during registration.
Unfortunately the pharmaceutical manufactures are only obligated to show the quality control of one batch during registration. When the medicine is register and approved no more quality checks are accomplished by any authorised organisation. Manufactures are not audited on a regular basis not even to check if the quality assurance has been done for every batch released.
In the Netherlands there is an authorised department the “Inspection van de gezondheidszorg” (the inspection of health care) that performs audits to see if the manufacturing of medicines is at the level desired. In Ghana such an authority can improve the overall quality of the medicines locally produced.
National Health Insurance Scheme
The NHIS (National Health Insurance Scheme) is introduced in 2006. It was developed to provide all Ghanaians with health insurance and to make health care more accessible. Citizens pay a certain amount of money (17 GhC corresponding with 7,80 euro) per year to the government. For this contribution they receive medical health care for most indications. A problem with the NHIS is that diseases like cancer (except for breast and cervix cancer) are not insured. Patients have to pay all health care, including consultation and chemotherapy by themselves, causing a division between rich and poor. Children less than 18 years of age are automatically insured if their parents are and patient older than 70 year do not to pay insurance anymore.
Even though the amount of money is low a lot of people are not able to pay the insurance. If they get ill they have to pay everything in cash or they do not go to the hospital to receive health care at all. The intention of the NHIS was that citizen’s pay in proportion to their salary. Unfortunately this has not (jet) been accomplished.
If citizen are insured only medicines and indication chosen by the NHIS are covered. All medicines of the essential medicine list of the World health Organisation (WHO) are covered. The WHO composed a list of medicines necessary to provide good health care to patients. The WHO made this list especially for developing countries as a tool to optimise health care.
The prices of the covered medicines are summarised on the NHIS medicine list. The NHIS medicine list states a fixed price for all the medicines. Taking the average price of the medicine composes these prices. Usually only the cheap brands are used to compose the NHIS medicine list. The fixed pricing of the medicines can cause problems for pharmacist, especially when a product is not available. The pharmacist has to pay attention to the procurement price. If the procurement price is above the NHIS price the pharmacy has to pay the remaining amount. If the cheap medicines are not available the pharmacy loses money and the entire budget gets compromised.
The NHIS medicines list use mostly prices of cheap medicine. These medicines are often from countries like India or China. Counterfeit medicines have to be taken into account when purchasing these medicines. Reliable medicines provide by for example HAN are more expensive and therefore they will not be procured unless the cheaper medicines are not available.
Medicine distribution Ghana
In Ghana different players contribute to the distribution of medicines. In figure 1 the distribution of medicine in Ghana is shown. The different players are briefly discussed. Central medical and regional medical stores are wholesales regulated by the government. They supply only government hospitals. More commercial wholesalers and/or pharmaceutical manufactures are KAMA health services (KAMA) and private manufactures like Ernst Chemist. These wholesalers distribute medicines to all willing hospitals and other organisations. Not all private manufactures produce and/or distribute affordable and reliable medicines. For example Ernst Chemist distributed three levels of medicines. The first level is the more expensive imported brands from western countries. The second level is the generic medicines from western countries. They also produce the medicines locally, this being the third and the cheapest level. Unfortunately the quality of the latest level can not be guaranteed like the first or the second level medicines.
Non-governmental organisations like HAN provide to mission hospitals and might expand to government hospitals and private hospitals.
Figure 1. This figure shows an overview of the medicine distribution in Ghana.
KAMA
KAMA health service is a large production pharmacy and wholesaler. The main goal is to produce and distribute medicines throughout Ghana. They produce mostly mixtures, eye drops, eardrops, ointments, mouthwashes and such. During the internship the production of large quantities of mixture has been seen and taken part of. Hundreds of litres of mixtures are prepared on a weekly basis. When examining the production numbers, I saw a large growth in the last three years.
As discussed above quality assurance of locally manufactured medicines can be hard. At KAMA quality assurance is executed in the laboratory using high performance liquid chromatography (HPLC). With the HPLC the concentration of the products are determined. KAMA also executes some quality control of the raw materials. Unfortunately I was not able to see the collected data. The challenges of KAMA are stock keeping. Some raw materials are used for several preparations and are therefore fast runners. At this moment KAMA has some difficulties to order the right amounts without having any shortages. Shortages of raw materials can delay the production, which ultimately cost KAMA money.
Hospitals
In Ghana there are different types of hospitals. The hospitals are either government hospitals (60%) or “faith based” mission hospitals (40%). Of the mission hospitals 27% are Catholic hospitals. A couple of differences are present between these types of hospitals. Governmental hospitals are in general low in efficacy, high in bureaucracy and payment has a high priority. In governmental hospitals patients are obligated to have an insurance or to pay cash otherwise they do not receive health care. In mission hospitals the necessary care is given even when no or little is paid.
All large teaching hospitals like Komfo Anokye Teaching Hospital are government hospitals.
Health Access Network- organisation
HAN is a non-profit non-governmental organisation (NGO), providing essential medicines to pharmacies in Ghana. Medicine accessibility and affordability are significant problems in Ghana. The focus of HAN is access to high quality drug for a reasonable price.
HAN has set three main goals:
1. Access to essential medicines; availability of medicine of high quality and low costs (affordability). Using International Dispensing Agent as a medicine supplier accomplishes this goal.
2. Drug therapeutic committee (DTC) in hospitals; HAN established the DTC in hospitals to discussed and improve the hospital’s medicine assortment and treatment guidelines.
3. Patient education by other organisation like MeTA. Co-operation with MeTA improves transparency of the pharmaceutical sector and information supply to patients.
Access to essential medicine
HAN receives their medicine from the International Dispensing Agent (IDA). This company imports medicines from countries like, India, which produce medicine at low costs. Every pharmaceutical manufacture is tested before the products are bought to assure high quality products. All imported medicines are tested for correct quantity and quality. Buying the medicines from IDA assures HAN high quality medicines at the level of the manufacture and at the level of medicine. Counterfeit is therefore not a problem with IDA.
Affordability is not a large problem for HAN because IDA states to deliver affordable medicines [3]. The availability can be a problem, sometime IDA does not have the medicine in stock and they have to be imported. HAN also procures medicines form private manufactures like KAMA. The quality can not be guaranteed like IDA.