Process Evaluation of Auditable Pharmaceutical Transaction Service in Seka primary Hospital, Jimma Zone, South West Ethiopia

In recent years, Ethiopia‘s FMOH has made tremendous efforts to improve the quality of health services at the hospital level, as laid out in the Ethiopian Hospital service transformation Guideline¹⁸.However, frequent stock-outs of essential medicines and poor quality of pharmacy services pose challenges to achieving the desired level of success in hospital improvement. A 2003 assessment of Ethiopia‘s pharmaceutical sector showed that the average duration of stock-outs of essential medicines was 99.2 days in the 2002 in public health facilities and regional drug stores. Various findings showed that essential medicines are poorly available 65% with high expiry rate 8.24% nationally There are poor information on product and financial values of medicines, inefficient utilization of medicines budget, poor pharmacy infrastructure and chaotic work flow, all together resulting in poor quality of medicines management and erratic dispensing activities including counseling services and low overall patient satisfaction on pharmacy services 74.5%¹⁹. Many of these problems were attributable to poor governance in the pharmaceutical sector. Specifically, a lack of transparency and accountability left pharmaceutical transactions and services vulnerable to mismanagement, including poor planning, decision making, prescribing and dispensing, and reporting, which compromised both the availability and use of medicines ²⁰.

And Since Seka primary hospital is the only hospital in Seka Chekorsa woreda Jimma zone south west of Ethiopia which serves a total of 242,302 populations. Hence, evaluating the implementation status of the system in order to make further improvements in the areas where gaps are seen.

Evaluating the program and identifying gaps and enabling factors of the program implementation is very important to provide information on some component parts the program implementation limitation. Therefore, this study identified the possible problems of APTS implementation, to identify implementation status of the program and forward recommendations for further improvement of the program

The World Bank identified corruption and lack of transparency in the pharmaceutical sector, as the greatest “cancer” and obstacle to social and economic development, keeping millions of people trapped in poverty. Execution of pharmaceutical transactions and services in hospitals of Ethiopia lacks transparency and accountability; thus vulnerable for corruption ²¹. Auditable pharmaceutical transaction service is the national wide focus area that the government put his effort to ensure transparency and accountability and efficient utilization of medicine budget ²³.

So, doing process evaluation is an input by identify the possible barriers of service implementation and provide systematic information guide on the bases of evaluation dimensions for improve the service in the future.

The evaluation was significant to find the gaps between actual practices with the desired practice during the implementation process of auditable pharmaceutical transaction service in Seka primary Hospital. So the result of the evaluation could provide some applicable recommendations to make further improvement in areas where gaps are seen and strengthen areas in which the system is good at in order to improve the pharmaceutical governance of the hospital. The result of this evaluation could also be used by the stakeholders both governmental and non-governmental organization that works in collaboration with the hospital in improving the health care system.

Thirdly, the evaluation will also be a contribution to the increase of the general knowledge of the subject matter and will act as a reference for future evaluators.

A facility based case study design with quantitative and qualitative data collection methods was employed and the qualitative data was complimenting the quantitative. Table 1, Table 2, Table 3, Table 4, Table 5, Table 6, Table 7, Table 8, Table 9, Table 10, Table 11, Table 12, Table 13, Table 14.

During Evaluability Assessment a lot of indicators were listed based on their relevance to the sub-dimensions /relevance matrix/criteria and prioritized. For this evaluation relevant indicators are used during this process evaluation of auditable pharmaceutical transaction service at Seka primary hospital through active participation of stakeholders. The indicators were adapted from the objective and strategies of national APTS guideline. The evaluation indicators are process indicators within the total of 38; availability, satisfaction (Accommodation) and compliance indictors 10, 15 and 13 respectively were identified and agreed for measuring the implementation of the program are used to judge the program of auditable pharmaceutical transaction service at Seka primary hospital.

The source populations to identify process of APTS was CEOs, clinical director, pharmacy head, health management information system focal person, finance head and APTS accountant .

The source populations for patient satisfaction was all patients who got pharmacy service on the data collection period in Seka primary hospital.

Documents related to finance, human resources, and stock records that are available at facility from January 8, 2020 to March 8, 2020 was reviewed to gather information on relevant indicators. Registers, vouchers, medicines sales reports, requisition/procurement forms, and bin/stock cards was reviewed.

Pharmacy staff was observed on counselling process for rational use of drugs and adequacy of labeling of medicine package.

CEOs , clinical director ,head pharmacist, APTS accountant, health management information system focal person, finance head and, patients got pharmacy service from hospital in Seka Chekorsa Woreda to receive pharmacy service during data collection, and

Documents related to finance, human resources, procurement, and stock records that are available at health facilities from January 8, 2020 to March 8, 2020 was reviewed to gather information on relevant indicators. Registers, vouchers, medicines sales reports, requisition/procurement forms, and bin/stock cards was reviewed.

Pharmacy staff was observed on counselling process for rational use of drugs and adequacy of labeling of medicine package.

Chief executive officer, clinical director ,APTS accountant ,health management information system focal person and pharmacy head , finance head, APTS user (clients), and registers (logbook, vouchers and dispensary tally sheet), documents was sampling unit.

Overall satisfaction

Patients socio demographic characteristics, (age ,sex ,religion, residency , Educational level

Waiting time,

Counselling time

All APTS monthly reports produced, all stock status analysis findings and ABC/VEN analysis conducted in the process of APTS from January 8, 2020 to March 8, 2020 was reviewed.

Chief executive officer, clinical director, APTS accountant, health management information system focal person and pharmacy head and finance head that fulfilled the inclusion criteria were the key informants. Sami-structured key informant interview guide was used to conduct interview.

Template for records and documents review and resource inventory observation was adapted from CDC 2000 program evaluation checklist ⁴⁵.

In-depth interview guide for key informants was developed after assessment of the program by using checklist.

Questionnaire for client exit interview were adapted from WHO 2000 satisfaction questionnaire with little modification ⁴⁶.

The data collection uses both quantitative and qualitative methods. Quantitative method used to describe service accommodation (client service satisfaction) and qualitative method (document review, expert interview and observation ) identifies the reasons for the observed level of achievement ^{8, 29}. Two diploma druggists data collectors and one BSc pharmacist supervisors was recruited for data collection and training was given to data collectors by Principal evaluator concerning the data collection tool, interviewing procedures, the sampling technique to follow, and to review document. The principal evaluators was overseeing the performance of each data collector’s daily, progress made and gave comments for each step. The collected data was sent to the principal evaluator from each of data collectors.

Data was collected from February 7 – March 5, 2020 from Seka primary Hospital.

During data collection the data collector reach the health facility before 2:30 A.M local time before the pharmacy is opened and data collection was proceed up to 10:30 P.M.

Data quality was controlled starting from the time of questionnaires preparations. The questionnaire was adapted by reviewing relevant literatures on the subject to ensure reliability. Before conducting the evaluation adapted tools with minimal modification, translated by an individual who have a very good ability of both English and Afan Oromo languages translate the English version to Afan Oromo.

Another individual of similar ability then translated the final or the agreed Afan Oromo version of the questionnaire back to English with the first to check for any inconsistencies or distortion in the meaning of words in the content of the tools. The collected data was sent to the principal evaluator from each of data collectors.

The data collectors were trained on the content of the data to be collected, ethical issues to be addressed during gathering the data, how to communicate with respondents, how to use the data collection guide and tools by principal evaluator 2 days prior to pre-testing the quality of the tool. Supervisors were also trained on the content to be covered during data collectors training, on how to manage data collection process and the way to monitor the quality of data by principal evaluator.

Pre-test was conducted to test quality of tool to advance the credibility of the tool on other than the study facility assisted by supervisors and principal evaluator 3 days prior to formal data collection.

Data editing, coding and verification of the filled in questionnaires was carried out during data collection. Right after data collection each data collector submits filled in questionnaires to the supervisor; and the supervisor and the evaluator edit and code the filled in questionnaires and check for consistency. To prevent loss of data, soft copy files was backed up regularly. Filled in questionnaires and formats will kept in secured place to ensure confidentiality and privacy until their proper disposal.

Quantitative data was entered onto Epi Data version 3.1 software templates for cleaning and checking of data for accuracy and completeness then exported to SPSS version 23, descriptive, bivariate and multivariate analysis was performed. A descriptive analysis was done by using frequency, mean and percentages.

Satisfaction of clients on pharmacy service was rated by 15 items each having five point Likert scale from strong disagree ¹ strong agree⁵ and that was re-coded in to new different variables. Satisfaction related variables which came up with a high internal consistency (Cronbach’s alpha= 0.756).

To see the total score of each respondent, the points obtained from the 15 items by each respondent was computed. A respondent have a minimum of 15 and a maximum of 75 points on APTS satisfaction score. Clients was categorized as not satisfied if they score below the mean and satisfied if they score ≥ to the mean satisfaction score.

The qualitative data was transcribed, translated, coded and categorized finally thermalized manually with respective dimensions and results was narrated.

Approval of ethical clearance was secured from Jimma University institute of health Sciences ethical committee before the beginning of data collection activity. Prior to the data collection, permission letter was obtained from Jimma Zone Health Department and Seka Chekorsa woreda health office and supportive letters was written to Seka primary hospital. In addition data collectors explained the purpose of the study, confidentiality and anonymity of the data; and verbal consent was obtained from all study participants.

After the first analysis of the data collected, the evaluator prepared a draft document and discussed with the major stakeholders for their comments. The final evaluation report with relevant documents will be submitted to Jimma University and the major stakeholders, after its final approval by the University. The report included abstract, background information, the problem statement, evaluation questions, general and specific objectives, study design and methodology that have been used, findings and interpretation of the results, conclusion and recommendations. Two hours presentation of major findings and discussion with program implementers will be held at the Seka primary Hospital. Publication will also be considered.

In the past three months, of the Birr 388,000.00, budget allocated for 2011\12 fiscal year for Seka primary hospital; they spent (on drug) the amount of Birr 328,913.95(85.2%).

“…..Drug and Therapeutics Committees (DTCs) have developed and approved hospital-specific medicines lists.” A 31 years old male pharmacist key informant, 2 years’ experience

The availability of key medicine in health facility is crucial in the overall treatment of diseases. Theoretically, APTS is believed to increase availability of medicine in the pharmacy store and dispensing unit of health facilities. To procure pharmaceuticals, direct procurement methods, followed by preforms based, and open tender methods. The average percentage availability of selected key medicine at the time of the survey data collection for Seka primary hospital was 10.7(81.0%), which was a medium achievement according the agreed upon judgment criteria(80-90%) and the 100 % target set in HSDP III ⁷ . The figure for the store supplying the dispensary was only two (15.4%), showing a very weak achievement. The reason given by the store’s manager was that the store only keeps free drugs and line items. The result of this survey 10.7(82.0%) was better than the 2003 Assessment of the Pharmaceutical Sector in Ethiopia ⁹ (76.8%) and almost similar to 83.3% figure of the 2006 DACA RDU study10. The improvement might be as a result of revolving drug fund and the BPR. This might also be due to the 2003 study was done seven years earlier than this study.

Availability of resources (human and physical) is considered paramount important in delivering quality APTS and has direct relation with implementation of activities planned. A well-functioning and well-performing health system requires the right number of skilled service providers in the right location at the right time. Availability of adequate and motivated human resources based on APTS system design assumptions is one of the critical APTS implementation enablers. Seka primary hospital has been implementing auditable pharmaceutical transaction service since 2017.The national APTS guideline recommend sixteen pharmacy professionals and four APTS accountants at primary hospital level. During data collection period, there were thirteen trained pharmacy professionals and four APTS accountant providing auditable pharmaceutical transaction services in Seka primary hospital had less than the required human power. The average percentage of professionals for Seka primary hospital was 17 of the required 20 human power (about 85%), which was high achievement according the APTS and the judgment criteria (>80%).

All pharmacy staff including APTS accountants were trained on auditable pharmaceutical transaction service except one APTS accountants, one druggist and BSc pharmacist. The percentage of APTS trained professionals for Seka primary hospital was 14 out of 17 (about 88.2%), which was high achievement according the judgment criteria (>80%).

Regarding Availability of APTS tools and pharmacy work flow arrangement in Seka primary hospital all recording and reporting formats related to APTS were available in the health facility including; monthly summary reporting format basic tools of APTS such as cash sales ticket and dispensing registers, tablet counting tray, refrigerator, facility specific list which is approved by drug therapeutic committee, computer in pharmacy accountant office, scientific calculator, swivel chair , recent edition of APTS guideline, standard treatment guideline, good dispensing manual and drug formulary, procurement police manual and room thermometer were available which is consistent with the national auditable pharmaceutical transaction service guideline .Pharmacy premises and rearranged patient flow as per the APTS standards; they are having rearranged workflow at OPD, having two doors, waiting area, counseling room, standard counters in place, and staff adjustment and being cashiers within the dispensary. So, the work flow arrangement restructured as ENTRY, Evaluator/Biller, cashier, drug use counselor and EXIT. The percentage of APTS tools and pharmacy work flow arrangement for Seka primary hospital was hundred percent available, which was high achievement according the judgment criteria (>80%).

During the data collection period, Seka primary hospital had both the Standard Treatment Guideline and facility specific list in the consultation and dispensing area. During discussion of preliminary report of the evaluation with the HCs the evaluator distributed the soft copies of the old and the 2010 editions of the Standard Treatment Guideline s and facility specific list, including some important SOPs. PFSA Jimma branch also distributed few hard copies of 2010 editions two weeks after data collection period of this study) The percentage availability of both Standard Treatment Guideline and facility specific list at Seka primary hospital was 100 % which was high achievement by the judgment criteria(>80% for both) and the expected 100% availability in health facilities6, 55-57, 60. The result was better than the study in Sudan (0.1%)14 and the 2006 RDU study of DACA (15.4%). This might be due to the DACA study was done four years earlier than this study.

Utilization of budget help to assess the efficiency and effectiveness of the health facility in using the budget allocated for purchasing drugs. In the past three months, of the total Birr 386,000.00 budget allocated to buy drugs for the 2011\12 fiscal year, the average percentage of budget utilization of the Seka primary Hospital was Birr 328,913.95(85.2%), which means the hospital utilized the budget allocated for the past three months on time. This was high achievement according to the judgment criteria set by the stakeholders (>80%).

The percentage of expired drugs on shelves at the time of the visit was 0% in Seka primary hospital storerooms\dispensaries, indicating the optimal (100%) achievement by the judgment criteria (<2%) and above the 1% achievement goal set in the HSDP III7. The result from the studies in Philippines ¹², the Sudan14 and Uganda15 shows the same result (0%). Whereas, the 2003 National assessment study for Ethiopia was much higher (9.7%). The improvement could be related to the decentralized procurement system set by the APTS.

The average time between requisition of drug and receipt (lead time), was used to assess the effectiveness of distribution system or procurement of drugs. Hospital drug therapeutic committee were responsible for determining the quantity of drugs they need to purchase and for delivery of their orders to their health facilities. It was found on average in Seka primary hospital the lead time from the time of ordering drugs from the next level or PFSA to the time obtaining drugs was less than 5 days, which was high achievement according the judgment criteria (>80%).

The calculated annual stock-out duration using the time covered by the study shows the stock-out duration of selected essential drugs of 20.3 days/year in Seka primary hospital. Even if they claim there was no stock-out during the past three months, there were no stock\bin cards to calculate the stock-out duration which indicate poor record keeping. The longer stock-out duration in Seka primary hospital store might not have strong effect on the availability of the selected key medicine at the facility level, because it keeps only free drugs. If the hospital store runs out of some free drugs, the health facility can buy it using their own budget\revolving drug fund.

“….. Even though we do not have stock cards to monitor the drug supply management, the other administrative reports and documents shows there was no drug stock-out”. A 27 years old male druggist store managers

The stock-out duration for the Hospital might not be more than the 20.3 days\year, which was high achievement according to the evaluation judgment criteria (>80%) but not reached the recommendation of zero stock-out6, 7, 60. The evaluation finding of average 20.3 days\year stock-out duration was almost similar to the findings of 18.4 days\year in Sudan( 2007)14 and 24.9 days\year in Philippine (2009)12; but much better than the 58.7 days\year of 2003 National assesement9.

As discussed above, the inventory management at Seka primary hospital was not computerized and there were no stock\bin cards to control the drugs supply management system. However, this facility uses requisitions and receipt vouchers (Models 19-22) to capture logistics data for selected key medicines. This pull down the average calculated record keeping adequacy of the 32 selected key medicine in Seka primary hospital was five of 32(20.8%); which was low achievement according to the judgment criteria (<60%) set by stakeholders.

“….lack of awareness and training were the major reasons for not using stock\bin cards in the hospital”. A 27 years old male druggist store managers

Overall record keeping system needs to be improved in the hospital store, but Similar finding of 28.5% was recorded in Sudan (2007)14.

During survey data collection, experts working in the Auditable pharmaceutical transaction service (store managers and dispensers) were interviewed on supervision of drug supply management (Survey Form 1). When asked when they received their most recent supervision visit within the last three months covered by the study, responded they had their last visit within the last month. The finding showed that among the expected at least one supervision within the three months covered by the survey, Seka primary hospital storerooms\dispensaries had been supervised by the higher level experts. The average percentages of storerooms\dispensaries received supervision in the past three months were therefore storerooms\dispensaries (100%), which was high achievement by the judgment criteria (>80%).

The exit interview of 362 outpatient‘s data revealed that significant percentage of patients 290(80.3%) had their prescribed drugs obtained the hospital dispensaries, which was (marginally) high achievement according the judgment criteria (>80%). This was in line with the 10.7(82.0%) average availability of the 32 selected essential drugs in Seka primary hospital. The survey result was closely similar with the 81.3 % and 81.4% reported in the 2003⁹ and 2006¹⁰ National studies in Ethiopia, respectively. This indicates that still a lot has to be done to attain the 100% availability of essential drugs objective goal set in the HSDP III ⁷.

The Hospital 1,179(99.7%) percentage of prescribed drugs on facility specific list was high achievement according to the judgment criteria and the expected optimal 100 %( 6, 7, 60). This indicates a good adherence of the prescribers to facility specific list. The percentage of drugs prescribed that were on the facility specific list was found to be high Seka primary hospital. The 99.7% Seka primary hospital percentage of drugs prescribed from the essential drug list was similar to 99.7 and 96.8% found in both Cambodia, 2002¹¹ and Uganda 2008¹⁵.

This evaluation reveals that, among the 611 patients‘ prescriptions reviewed, the average number of drugs per prescription received, at Seka primary hospital , was found to be 2.0, which can be considered marginally medium achievement by judgment criteria (1.8-2.1=60-80%) and acceptable prescribing practice when compared with the currently recommended not more than 2.0 drugs per prescription(6, 9, 55,59). The figures show that prescribing behavior is relatively best in Seka primary hospital (1.8) The 2.0 average number of drug per prescription at Seka primary hospital was similar to the two Ethiopia National studies of 2003⁹, 2006¹⁰ and the 2009 in Philippine¹², respectively.

Generic drugs are more economic than the branded drugs and prescribing drugs by generic name helps to reduce the confusion among the prescribers and dispensers while prescribing and dispensing. The percentage of drugs prescribed by generic name in Seka primary hospital was 1,154(97.9%), which was high achievement in relation to the judgment criteria (>85%) set by the stakeholders and the ideal 100%(6, 7, 60). The percentage of drugs prescribed by generic names (97.9%) in this evaluation was almost similar with the 99.8% recorded in Cambodia11.

An adequate label includes at least the name and strength of the drug and written instructions on the envelop how to take it. The written information on the drug containers\envelopes reflects the extent of the dispenser‘s careful attention during dispensing the drugs and it helps to remind the patient\caregiver when, for how long and how much quantity of drugs to take in case of forgetting the verbal instructions. The data concerning labeling of drugs shows extremely poor achievement in Seka primary hospital. The percentage of 189(57.9%) for the hospital was far below the agreed upon judgment criteria (<60%) and the expected 100% (58-60).

“…..patient load, especially on market days, week beginning and weekends forced to rush and give patients only verbal explanation how the individual drugs should be taken and it should not be the acceptable norm of conduct”. A 32 years old male dispensary head 3 years’ experience, KII

The 14.4% of drugs adequately labeled was not much far from the 20% reported in the DACA 2006¹⁰ study.

When we see location , cleanliness and hygienic condition of pharmacy shop , Convenience of the dispensing area and counter for service provision and counselling area of pharmacy shop 54.7 % , 39.0 % , 50.6%,and 54.9% respectively clients were satisfied at all,

During auditable pharmaceutical transaction service the satisfaction measured from the perspective of clients. When we saw comfortable and favorable of the service was found to be 50.6 % and 54.7%. This result is different from study conducted in Kenya which revealed that 82% and 84% respondents were reported that health the waiting area was comfortable and the location of pharmacy was convenient respectively ²⁸,

On the basis of the findings of our studies on satisfaction with the privacy of outpatient pharmacy is 122(37.8%) respondents were satisfied. But the baseline assessment did at Federal, Addis Ababa &teaching hospitals shows that 54.9% of respondents were satisfied with the privacy in dispensary area which is shows our finding is lower than Addis Ababa this may be due to not having proper and well organized premises or infrastructures.³²

Provider courtesy and respect, counseling time, necessary instruction and warning about medications and knowledge of counselling person were 62.3%, 71.5,56.1 ,50.6 and 40.2 respectively when we compare this result with other researches done, there is difference with research done in Kenya were the respondent happy about their interactions with the service provider, 97% of the respondent were reported the provider as friendly, 98% of them showed as the provider well prepared and the entire study participant (100%) reported the provider listened well ^{21, 28}.

This study revealed that 196(60.7%) of respondents in Seka primary hospitals are understands what the pharmacy service providers instructed them. this shows that it is not comparable with the studies done in Sudan that is 82% of respondents understand what the pharmacy service providers Instructed so the hospital has to be work greatly on instruction services which was given for the patients at the outpatient pharmacy services. ⁷

This our studies shows that 156(48.3%) of respondents in Seka primary hospitals were satisfied with the amount of time that the pharmacy professionals spend with them for providing the appropriate medications information. However, the study done in Gonder university referral hospitals shows that only 9.2% of the respondents were satisfied with amount of time spent with the pharmacy professionals.²² this may be due to there is a variation in pharmacy professionals approach to the respondents.

Nonexistence of expired drugs in storeroom\dispensaries at the time of the visit was judged to be optimal high achievement. So, the past three months, of the total budget allocated for the 2011\12 fiscal year, half of the entire budget allocated to buy drugs was spent on time. This was high achievement according to the judgment criteria. Availability of required human power for APTS was high achievement according the national APTS guideline and the judgment criteria, and the lead time (the time from ordering drugs from the next level or PFSA to the time obtaining drugs) was high achievement according the judgment criteria.

The average dispensing time was high achievement according the judgment criteria and the stock-out duration was high achievement according to the evaluation criteria but not reached the recommended zero stock-out.

However, prescribed drugs dispensed to patients were (marginally) high achievement according the judgment criteria and was in line with the average availability of the 32 selected key medicine in health facility.

Prescribed drugs on facility specific list were high achievement according to the judgment criteria and the 100% expected. This indicates a good adherence of the prescribers to facility specific list and Drugs prescribed by generic name were high achievement in relation to the judgment criteria set by the stakeholders and closer to the ideal 100%. Availability of both STG and facility specific list was high achievement by the judgment criteria which was 100 %

Judgment on the service accommodation where perceived/satisfied by clients were FAIR with respect to sated criteria. Mostly clients were reflected that the waiting area, availability of key medicine, waiting time, and counselling time maintenance of their privacy during counseling was not satisfied with.

The evaluation result of this study concluded that the overall process of auditable pharmaceutical transaction service in Seka primary hospital was FAIR as per-sated judgment criteria with key stakeholders during EA phase.

Counselling time was low achievement according to the evaluation parameter and the 10 minutes (and more) set by the national auditable pharmaceutical transaction service. Seka primary hospital was not used computerized data recording and bin cards, and were not considered as using scientific method for estimation of drug requirement, which was low achievement when compared to judgment and the facility were using requisitions and receipt vouchers (Models 19-22) to capture logistics data for selected essential drugs. This pull down the average calculated record keeping adequacy of the 32 selected essential drugs in Seka primary hospital; which was low achievement according to the Judgment criteria.

The findings of this evaluation recommends that the existing strategies on APTS documents, STGs, FSL and other SOPs needs to be implemented to make drugs more available and used in a more rational way. Although further investigation is required to obtain a more in-depth understanding of the causes and consequences of the findings, the results of this evaluation provide broad directions for future research and action. It is therefore recommended that the following steps be taken to improve APTS in Seka primary hospital:

The Standard Treatment Guideline (STG) and facility specific List should be made available to HCs and professionals.

Dispensers should improve the existing less than 10 minute counselling time they spent with their patients and make sure patients understand the information.

The established Drug Therapeutic Committees (DTCs) in the facility should be trained on how to quantify, estimate and procure drugs based on appropriate scientific method\s.

The facility should use the computers in the hospital for computerized record keeping and they should also use stock\bin cards to capture logistics data of drugs and supplies.

Pharmacy professionals should improve drug labeling and drug information provision to patients during drug dispensing.

Regional health bureau, zonal health department and partners (FMHACA\PFSA etc) should provide pre- and in-service trainings for all health workers involved in dispensing to improve on counselling time and to curb the tendency of over prescribing antibiotics in order to reduce the potential development of drug resistance.

2. To improve on poor drug labeling and poor record keeping, continuous training for pharmacy professionals and store managers is required to scale up dispensing practices and drug storage and distribution.