Beyond the Essential Medicines List: improving access to essential medicines at the primary healthcare level in Solomon Islands through the implementation of mobile electronic inventory
AuthorNunan, Michael James
Document TypePhD thesis
Access StatusOpen Access
© 2017 Dr. Michael James Nunan
Background: Access to essential medicines in low and middle-income countries remains limited, due in part to weaknesses in national and local supply chains. Emerging technologies present an opportunity to strengthen supply chains by improving stock management and providing real-time data to health planners but there has been a paucity of published data on the effectiveness of these approaches. Aim: To improve the availability, staff comprehension and usage of priority medicines for mothers and children in the Solomon Islands through the implementation of mobile electronic inventory systems at the provincial medical supply level. To explore the relationship between medicines availability, staff comprehension and medicines usage. Primary Hypothesis: That the implementation of mobile electronic inventory at provincial Second Level Medical Stores (SLMS) in Solomon Islands will improve the availability of priority medicines for mothers and children at the primary healthcare level. Method: A before-and-after intervention effectiveness field study, conducted over 12 months in Solomon Islands. Individual SLMS were purposely selected to be either in the intervention or control group – for operational reasons, these were not randomly allocated. Primary healthcare clinics across Solomon Islands were then part of the intervention or control arm, depending on which SLMS they were supplied from. Six SLMS, servicing 121 clinics, comprised the intervention group. Six SLMS, servicing 104 clinics, comprised the control group. Mobile electronic inventory systems were installed in the six SLMS supplying the intervention group. The six SLMS supplying the control group continued using the established paper-based ordering systems. A series of educational interventions was also implemented across all clinics. Baseline data collection commenced in April 2013 in 80 randomly selected clinics (control n = 40; intervention n = 40), assessing the: i) Availability; ii) Comprehension and; iii) Usage of 31 Priority Medicines for Mothers and Children. Follow-up data collection was conducted 12 months after the implementation of the intervention. The primary outcome measure was the mean percentage availability of 17 medicines, out of the 31 WHO priority medicines, that are mandated to be available at the clinic level. The mean was taken as the average percentage from all surveyed clinics in the intervention and control arms. Results: Availability: Overall - Medicines availability increased by 9.9% [6.4, 13.4] from baseline (n = 68, mean = 64.2%, s.d. = 14.5) to follow-up (mean = 74.0%, s.d. = 14.1); t=5.61, p<0.001 Control group - In the control group, medicines availability increased by 12.4% [6.8, 18.1] from baseline (n = 36, mean = 59.5%, s.d. = 16.0) to follow-up (mean = 71.9%, s.d. = 16.1); t=3.28, p=0.002 Intervention group - In the intervention group, medicines availability increased by 7.0% [3.0, 11.0] from baseline (n = 32, mean = 69.5%, s.d. = 10.5) to follow-up (mean = 76.5%, s.d. = 11.2); t=2.58, p=0.012 Primary outcome - The overall mean availability of medicines at baseline was 64.2% (SD = 14.5). Medicines availability increased by 9.9% overall from baseline to follow-up (p<0.001). The results for each group are shown in Table 2. There was strong evidence of a difference in medicines availability between the 2 groups at baseline, with the intervention group having 10.0% (95% CI: 3.4 - 16.7%) higher availability (p=0.004) at baseline than the control group. Follow-up availability was not different (95% CI: -6.6% to 6.3%, p=0.957) in the intervention group than the control group, adjusting for baseline availability. This analytical model did not show any evidence for a difference in the magnitude of change between the control and intervention groups. Comprehension: Overall, staff comprehension increased by 13.7% from baseline (mean = 58.5%) to follow-up (mean = 72.2%); t=6.83, p<0.001 In the control group, comprehension increased by 13.5% from baseline (mean = 58.6%, n = 50, s.d. = 13.0) to follow-up (mean = 72.1%, n = 43, s.d. = 13.2); t=4.94, p<0.001 In the intervention group, comprehension increased by 14.0% from baseline (mean = 58.4%, n = 51, s.d. = 14.6) to follow-up (mean = 72.4%, n = 40, s.d. = 13.5); t=4.68, p<0.001 Usage: The proportion of episodes of care where medicines usage was rational increased by 6.5% over the life of the study: from baseline (mean = 55.4%, 3404/6147 episodes of care) to follow-up, (mean = 61.9%, 3962/6400); χ2 = 55.1, p<0.005. In the control group, rational use of medicines (RUM) improved from 54.2% (1128/2083 episodes of care) to 63.4% (2184/3444); χ2 = 46.4, p<0.005. In the intervention group, RUM improved from 56.0% (2276/4064 episodes of care) to 60.1% (1778/2956); χ2 = 12.0, p<0.005 For every 1% improvement in comprehension, a corresponding 0.4% increase was observed in the rational use of medicines. There was insufficient evidence to show a strong correlation between medicines availability and usage. Discussion: The findings of this study did not support the primary hypothesis; there was no difference in the magnitude of change in medicines availability between the clinics serviced by medical stores which used electronic inventory compared with those that did not. There were significant improvements in both the control and intervention groups. In the first year of implementation however, there had been a possibility that availability would actually decline in the intervention group and this was not the case – medicines availability improved in the intervention group. Many factors influence the availability of medicines at the primary healthcare level in low and middle-income countries, including geography, funding, transport and storage infrastructure and staff training – more research is required to determine the extent to which each of these play a role. Staff comprehension and medicines usage increased in both groups. Availability of essential medicines remains a prerequisite for rational usage of medicines but this study suggests that improvements in availability do not lead to improvements in usage, unless comprehension also improves. There was no difference in staff comprehension between the control and intervention groups. This met expectations as all educational interventions were applied equally to both groups. Electronic inventory systems may have other benefits, including workload efficiencies, shorter lead times, reduced data entry duplication, real-time provision of data and less errors. Conclusions: Emerging technologies have the potential to improve supply chains in low and middle-income countries and to this end, this study has provided a model for the implementation of mobile electronic inventory systems that may be applicable across other Pacific island country settings. There is insufficient evidence from the current study however, to support the primary hypothesis that mobile electronic inventory systems improve the availability of essential medicines. Further research over longer time periods is required to determine the extent to which various factors influence availability. This would help to determine priority-setting and funding allocations.
Keywordspharmacy; Essential Medicines List; health services, maternal-child; Mobile apps; mHealth; availability of health services
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