PA00JT9S

MINISTRY OF HEALTH
THE REUBLIC OF UGANDA
UGANDA PHARMACEUTICAL SECTOR REPORT 2011
Produced by: The Division of Pharmacy Services

Ministry of Health, Government of Uganda
ACKNOWLEDGEMENTS
This report is made possible by the generous support of the American people through the
U.S. Agency for International Development (USAID) under the terms of cooperative
agreement number AID-617-A-00-09-00003-00. The contents are the responsibility of
Management Sciences for Health and do not necessarily reflect the views of USAID or the
United States Government.
The Ugandan Ministry of Health and SURE Program would like to thank everyone who has
contributed to the making of this Pharmaceutical Sector Report. We would specifically like to
thank Brenda Nalwadda (SURE Program) for analyzing data, Dorthe Konradsen (SURE
Program) for coordinating data collection and writing the report, and the data collectors
mentioned below for collecting the valuable data. Thanks, too, to Dr. Birna Trap (SURE
Program) for valuable inputs.
Most importantly, thanks to Mr. Martin Oteba, Assistant Commissioner for Health Services,
Pharmacy Division, Ministry of Health, for making this report possible.
Data collectors in the pharmaceutical sector data collection exercise:
Angonifua Jennifer Medicine Management Supervisor, Nebbi Hospital, Nebbi

Bingi Christopher Medicine Management Supervisor, Kibiito HC IV, Kabarole
Issa Stephen Medicine Management Supervisor, Obongi HC IV, Moyo
Karunga Jane Medicine Management Supervisor, Mucwa HC II, Kabarole
Moses Kakungulu Medicine Management Supervisor, Kalagala HCIV, Luwero
Peter Okot Medicine Management Supervisor, Kyanamukaka HCIV, Masaka
Rusoke Edward Medicine Management Supervisor, Busaba HC III, Butaleja
Timbyetaho Denis Medicine Management Supervisor, Kamukira HC IV, Kabale
Waniale Paul Medicine Management Supervisor, Namatala HC III, Mbale
RECOMMENDED CITATION
This report may be referenced if credit is given to the Ministry of Health. Please use the
following citation:
The Ministry of Health-Government of Uganda, Annual Pharmaceutical Sector Report 2011.

Kampala: Ministry of Health, 2013.
i
FOREWORD
The Pharmaceutical Sector Report 2011 was prepared by the Ministry of Health (MOH)
Pharmacy Division in collaboration with the United States Agency for International
Development (USAID)-funded Securing Ugandans’ Right to Essential Medicines (SURE)
Program that is implemented by Management Sciences for Health. This report presents the
findings from a performance assessment undertaken in 2011 assessing the current state of the
pharmaceutical sector in the public and private not for profit (PNFP) health facility
dispensaries, pharmacies, and stores in Uganda.
The report compares the state of the pharmaceutical sector in 2010 with 2011. The districts
included in this survey were not included in the SURE-supported districts and did not receive
any specific support in medicine management by any implementing partner, thus any changes
are solely a result of national strategies or policies.
The Pharmaceutical Sector Report does not offer any solutions to the challenges faced by the
health facilities but instead documents the current situation in Uganda related to ensuring
access to good quality essential medicines and health supplies (EMHS). The report is
intended for decision makers from the Ministry of Health, implementing partners, and others
who are interested in the Uganda pharmaceutical sector. Hopefully, the findings can be used
to guide new strategies to improve medicine management in the public and PNFP sectors in
Uganda and serve as a baseline when assessing the impact of interventions in the sector.
I sincerely hope that you will find the time to read this very comprehensive report that covers
general standards of the health facility, stock and storage management, availability of EMHS,
distribution of EMHS, and appropriate use of medicine.
I hope you will find this report helpful and interesting.
Martin Oteba
Assistant Commissioner for Health Services/Pharmacy
ii
TABLE OF CONTENTS
UGANDA PHARMACEUTICAL SECTOR REPORT 2011 .............................................. I

ACKNOWLEDGEMENTS .................................................................................................... I
FOREWORD........................................................................................................................... II
ACRONYMS AND ABBREVIATIONS ............................................................................. VI
SUMMARY .............................................................................................................................. 1
INTRODUCTION.................................................................................................................... 4
SURVEY OBJECTIVES ......................................................................................................... 4
METHODOLOGY .................................................................................................................. 4
SURVEY SAMPLING ................................................................................................................ 4
DATA COLLECTION TOOL, TEAMS AND PREPARATION........................................................... 5
DATA COLLECTION, ENTRY AND ANALYSIS........................................................................... 6
FINDINGS AND DISCUSSIONS........................................................................................... 6
1. GENERAL STANDARD OF THE FACILITY.............................................................................. 6
1.1 Health Facility Characteristics ................................................................................... 6
1.2 Patient Load ................................................................................................................ 7
1.2 Staff in Pharmacies/Dispensaries and Medicine Stores ............................................. 7
1.3 Services Offered ......................................................................................................... 8
1.4 Level of Hygiene in Staff Toilets and Hand Washing Facilities ................................ 9
2. SUPPLY CHAIN MANAGEMENT ........................................................................................... 9
2.1 Receipt of Medicines and Health Supplies............................................................... 10
2.2 Stock Management ................................................................................................... 11
2.3 Storage Management ................................................................................................ 14
2.4 Reporting and Ordering ............................................................................................ 17
2.5 Knowledge of VEN Classification ........................................................................... 18
2.6 Stock Management Supervision ............................................................................... 19
2.7 Quality of Medicines Inspection .............................................................................. 19
3. AVAILABILITY .................................................................................................................. 20
3.1 Availability of a Basket of EMHS ........................................................................... 20
3.2 Availability of Vital Items ........................................................................................ 21
3.3 Availability of Tracer Medicines ............................................................................. 22
3.4 Availability of MOH Technical Program-Specific Items ........................................ 25
3.5 Overstocking ............................................................................................................ 27
4. DISTRIBUTION .................................................................................................................. 28
4.1 Lead Time ................................................................................................................ 28
4.3 Nil Lines and Adjusted Items Ordered ..................................................................... 29
5. APPROPRIATE USE OF MEDICINE ...................................................................................... 30
5.1 Availability of Reference Material ........................................................................... 30
5.2 Prescribing ................................................................................................................ 31
5.3 Dispensing ................................................................................................................ 43
ANNEXES .............................................................................................................................. 48
ANNEX A. FACILITIES INCLUDED IN SURVEY ....................................................................... 48
ANNEX B. BASELINE DATA COLLECTION TOOL ................................................................... 49
iii
ANNEX C. BASKET OF ITEMS SURVEYED ............................................................................. 68
LIST OF TABLES
Table 1. Summary of findings for selected indicators ............................................................................ 1

Table 2. Characteristics of health facilities surveyed.............................................................................. 6
Table 3. Number of patients seen per day measured as prescriptions prescribed per day according to
prescription book ................................................................................................................... 7
Table 4. Staffing levels in pharmacies and dispensaries, level of effort, and years of experience ......... 8
Table 5. Services offered to patients in facilities .................................................................................... 9
Table 6. Conditions of toilet and hand washing facilities ....................................................................... 9
Table 7. Procedure for checking received supplies, before and after opening the boxes ..................... 10
Table 8: Actions taken in case of discrepancy between delivery note and actual received quantities.. 11
Table 9. Range of availability of stock cards ........................................................................................ 12
Table 10. Completed physical counting procedure in facilities that used stock cards .......................... 13
Table 11. Accuracy of stock card data by facility ................................................................................. 13
Table 12. Comparison of PNFP and public facilities in stock management and availability of medicine
............................................................................................................................................. 14
Table 13. Cleanliness of dispensary and main stores ............................................................................ 14
Table 14. Storage conditions assessed in main and dispensary stores .................................................. 15
Table 15. Storage systems and practices for EMHS ............................................................................. 16
Table 16. Dispensary storage practices for EMHS ............................................................................... 17
Table 17. NMS Order and Delivery Schedule knowledge and availability 2011 compared to 2010
average................................................................................................................................. 18
Table 18. Order timeliness and staff capability of calculating quantities to order ................................ 18
Table 19. VEN classification of EMHS ................................................................................................ 19
Table 20. Number of surveyed EMHS by level of care ........................................................................ 20
Table 21. Availability of a basket of 23 vital medicines and health supplies on the day of the survey 22
Table 22. Percent availability in previous six months period ............................................................... 24
Table 23. Average days medicine was out of stock over previous six months (180 days) ................... 25
Table 24. Availability of reproductive health commodities per healthcare level ................................. 26
Table 25: Availability of medicine for treatment of tuberculosis ......................................................... 26
Table 26. Percentage of facilities at each healthcare level where an item was overstocked ................. 27
Table 27: Number of items never overstocked at each healthcare level ............................................... 28
Table 28. Lead time from ordering to receiving EMHS ....................................................................... 29
Table 29. Nil lines and adjustment of items ordered ............................................................................ 30
Table 30. Reference materials available to pharmacy staff .................................................................. 31
Table 31: Information captured in prescription book, patient register and dispensing log ................... 31
Table 32. Availability of diagnostic equipment in consultation rooms ................................................ 32
Table 33. Number of medicines prescribed per prescription ................................................................ 40
Table 34. Prescribed antibiotics ............................................................................................................ 42
Table 35. Prescribed injections ............................................................................................................. 42
Table 36. Use of dispensing equipment in health facilities pharmacies ............................................... 44
Table 37. Dispensing time .................................................................................................................... 45
Table 38. % Medicine with labeling indicators (n=582)....................................................................... 46
Table 39. Patient knowledge of use of medicines dispensed ................................................................ 46
Table 40. Actual prescribed medicine dispensed .................................................................................. 47
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LIST OF FIGURES
Figure 1: Spidograph of the average health facility performance ........................................................... 3

Figure 2. Sampled Districts..................................................................................................................... 5
Figure 3. Availability of stock cards ..................................................................................................... 12
Figure 4. Availability of basket items by level of care on day of survey ............................................. 20
Figure 5. Availability in facilities on day of survey specific to level of care ....................................... 21
Figure 6. Percentage of tracer medicines available on the day of survey in each facility .................... 23
Figure 7. Availability of individual tracer medicines on the day of the survey .................................... 24
Figure 8. Medicine used for treatment of non-bloody diarrhoea (n=392) ............................................ 33
Figure 9: Medicines used in non-bloody diarrhea (n=392) ................................................................... 33
Figure 10. Medicine combinations used for treatment of mild diarrhoea (n=392) (AD=anti-diarrhoeal
medicine, OTH=other medicine, AB=antibiotics, ORS=oral rehydration salt, VIT=vitamin
A, ALB=albendazole).......................................................................................................... 35
Figure 11. Total percent medicines prescribed for treatment of mild ARI (n=598) ............................. 36
Figure 12. Medicine combination used in the treatment of mild ARI (n=598) (AB=antibiotic,
AP=antipyretic/analgesic, CC=cough/cold medicine, OTH=other medicine) .................... 37
Figure 13. Medicine used in treatment of malaria (n=629) (ACT=artemisinin-combination therapy
(here AL=artemether lumefantrine, SP=sulfadoxine/pyrimethamine)) ............................... 38
Figure 14. Medicine combination used for treatment of malaria (n=629) (QNN=Quinine,
AB=antibiotic, OM=other medicine, AL=Artemether and Lumefantrine,
PCM=paracetamol, SP=sulfadoxine and pyrimethamine) .................................................. 39
Figure 15. Use of packaging materials in health facility pharmacies/dispensaries ............................... 44
v
ACRONYMS AND ABBREVIATIONS
ACT Artemisinin-Combination Therapy

ARV Antiretroviral
BNF British National Formulary
DHO District Health Officer
EMHS Essential Medicine and Health Supplies
EMHSLU Essential Medicine and Health Supplies List for Uganda
FP Family Planning
FY Financial Year
GOU Government of Uganda
HC Health Centre
HIV Human Immunodeficiency Virus
HMIS Health Management Information System
HSD Health Sub-District
JMS Joint Medical Stores
MOH Ministry of Health
NA Not Applicable
NDA National Drug Authority
NMS National Medical Stores
OPD Out-Patient Department
ORS Oral Rehydration Salts
PNFP Private Not For Profit
SPARS Supervision, Performance Assessment, and Recognition
Strategy
SURE Securing Ugandans’ Right to Essential Medicines Program
UCG Uganda Clinical Guidelines
USAID United States Agency for International Development
VEN Vital, Essential, Necessary
WHO World Health Organization
vi
Summary
SUMMARY
Data for the Annual Pharmaceutical Sector Report 2011 was collected in December 2011
from the same 63 randomly selected facilities that were visited in 2010. The facilities are
located in nine randomly selected districts in Uganda and include both government and
private not for profit (PNFP) health facilities. Facilities represent all levels of the health care
system from health centre II (HC II) to hospitals.
The table below summarizes the findings of selected indicators from 2010 and 2011. Please
refer to “Findings and Discussion” section for more information.
Table 1. Summary of findings for selected indicators
2Value/Score Value/Score
No. Indicators Change
2010 2011
Stock Management
1. Facilities with stock cards available 68% 77% 

Facilities with correctly filled in stock cards (name,
2. strength, formulation, storage conditions, expiry 0% 1% 
date, AMC filled in)
Facilities that perform a monthly physical count (PC)
3. 4% 6% 
of essential medicines and health supplies (EMHS)
Facilities with accurate stock cards (the stock card
4. 53% 42% 
and PC balance are the same)
Store Management
Facilities with at least acceptable clean and tidy main
5. 63% 66% 
stores
Facilities with acceptable, hygienic, and functioning
6. 71% 57% 
toilet facilities
Facilities where medicines are stored in a systematic
7. 57% 27% 
manner
Facilities with adequate main storage facilities
8. (defined as enough space to move around between 63% 52% 
shelves and store medicine appropriately)
9. Facilities that monitor temperature in main store 3% 5% 
10. Facilities where no boxes are stored on floor 46% 23% 

Facilities where pharmacy staff covers open tins with
11. 48% 60% 
lids when not dispensing medicine from them
Ordering and Reporting Quality
Facilities that report they adhere to the National
12. Medical Store (NMS) schedule when ordering (in 33% 83% 
2011 only HC IV and hospitals order)
Availability of EMHS
Average availability of a basket of vital EMHS on day
of survey (2010: 22 in HC IV/hospital, 21 in HC III,
13. 53% 76% 
20 in HC II. 2011: 23 HC IV/hospital, 20 in HC III, 16
in HC II)
Average availability of tracer medicine on day of
14. 58% 89% 
survey
1
2Value/Score Value/Score
No. Indicators Change
2010 2011
Facilities with all six tracer medicines available on
15. 10% 39% 
day of survey
Distribution
Lead time (from time of order to time of delivery at
16. 57 days 38 days 
public health facilities)
Items ordered but not delivered (nil lines) according
17. 25% 29% 
to NMS orders and delivery notes
Prescribing Quality
Facilities that use prescription recording system
18. 98% 98% 
correctly
Rational prescribing (average for surveyed health
19.
facilities):
 Average number of medicines prescribed per
3.2 3.3 
prescription
 % of medicines prescribed by generic name 80% 43% 
 % of patients prescribed 1 or more antibiotics 68% 72% 
 % of patients prescribed 1 or more injections 23% 21% 
Adherence to Ugandan Clinical Guidelines

Patients who received correct treatment for
diarrhoea (2010: ORS or ORS + paracetamol. 2011:
20. 33% 14% 
ORS with vitamin A, albendazole/mebendazole
and/or zinc)
Patients who received correct treatment for acute
21. respiratory infection (antipyretic and/or cough/cold 1% 6% 
medicine)
Patients who received correct treatment for malaria
22. (artemisinin-based combination therapy (ACT) + 25% 59% 
paracetamol or quinine + paracetamol)
Dispensing Quality
23. Overall average dispensing time 42 seconds 21 seconds 

Facilities with dispensing envelopes available for
24. 62% 73% 
appropriate dispensing of tablets/capsules
Average availability of tablet counting tray, spatula,
25. 21% 20% 
graduated measuring flask, and blank labels
Facilities with chairs/benches available for waiting
26. 89% 86% 
patients
Facilities with privacy for patients when dispensing
27. 1 31% 56% 
takes place
Patients with knowledge on use of medicine
(average % patients with knowledge on dose,
28. 62% 50% 
frequency, duration, reason to take medicine, and
who got additional information)
Dispensed medicine is adequately labeled (average
% of labels that include medicine name, strength,
29. 28% 25% 
quantity, dose, date of dispensing, and patient and
facility name)
Average % of prescribed medicine that was
30. 61% 80% 
dispensed
1
Indicator changed
2
Summary
The reports from 2010 and 2011 document the great need for strengthening the public and
PNFP pharmaceutical sectors. There was little progress in most of the indicators, and some
even worsened. However, availability of medicines, adherence to the NMS ordering schedule
by the facilities, and a reduction in the lead time were the main areas of progress. These
improvements resulted from an increase in funding of essential medicines and health supplies
(EMHS) combined with roll out of the kit supply system for lower level health facilities.
Additionally, the implementation of a regular and well planned delivery schedule and door-
to-door delivery introduced by NMS following recommendations from the SURE 2009
policy option analysis led to indicator improvement.
The increased availability of EMHS positively resulted in more appropriate treatment of

malaria (more ACT was available) but also allowed more of the prescribed medicines to be
dispensed leading to a slight increase in number of antibiotics being prescribed. However, the
increased availability of EMHS could also be the reason for the reduction in the quality of
store management, which was quantified by the decreased percentage of facilities with
medicine arranged in a systematic manner and increased percentage of facilities with
inadequate space.
Though more medicine is being dispensed due to the increased availability, there is a
decrease in dispensing time, which could not be explained. Findings do show that the
decreased dispensing time is not a result of increased patient load.
The spidograph below illustrates the performance of the health facilities in stock and storage
management, rational prescribing and dispensing, and ordering and reporting.
Figure 1: Spidograph of the average health facility performance
3
INTRODUCTION
The annual Pharmaceutical Sector Report focuses only on the drug outlets in the public and
private not for profit (PNFP) sectors. Findings from each year are included in the report to
compare changes and improvements; this report includes data from 2010 and 2011, which
were collected in June 2010 and December 2011, respectively. The Ministry of Health
(MOH) collected all data with support from the United States Agency for International
Development (USAID)-funded Securing Ugandans’ Right to Essential Medicines (SURE)
Program. The areas covered in the report are general conditions of the health facility, supply
chain management, appropriate medicine use, and quality standards of the dispensaries and
pharmacies.
SURVEY OBJECTIVES
The overall objective of this study was to assess standards of essential medicines and health
supplies (EMHS) management within the Ugandan public and PNFP pharmaceutical sectors.
The areas of study were:
 General standards of the facility

 Supply chain management, including storage and stock management
 Availability of medicines and health supplies
 Distribution
 Appropriate use of medicine with regard to dispensing and prescribing
In this report, EMHS include all essential medicines, health supplies, and laboratory
commodities found on the Essential Medicine and Health Supplies List for Uganda
(EMHSLU). These are needed to provide basic health care services at all levels of the public
health care system (from primary health care level to specialist level in referral hospitals) and
implement public health care programs including HIV/AIDS, tuberculosis, malaria, leprosy,
and reproductive health programs.
METHODOLOGY
SURVEY SAMPLING
This survey re-visited the same health facilities found in the 2010 Annual Pharmaceutical
Sector Report to compare the 2010 and 2011 pharmaceutical standards. Nine out of fifteen
districts were randomly selected where the Supervision, Performance Assessment, and
Recognition Strategy (SPARS) has not yet been implemented by SURE or other
implementing partners. The districts are located in four geographical regions of Uganda,
illustrated in the figure below.
4
Methodology
Figure 2. Sampled Districts
Health facilities from each district were selected using the following criteria:
 District hospital (if exists)

 One Health Centre (HC) IV (randomly selected)
 Three HC III (randomly selected)
 Two HC II (randomly selected)
This gave a sample size of 63 health facilities at different healthcare levels. The selection
process included 16 PNFP health facilities (see Annex A for full list of facilities).
DATA COLLECTION TOOL, TEAMS AND PREPARATION

The data collection tool used for this survey is identical to the routine data collection tool
used by the Medicine Management Supervisors (MMS) for baseline assessments of health
facilities where SPARS is implemented. Data collection was undertaken by experienced
MMS, who are trained in medicine management and experienced in using the data collection
tool. Therefore, no additional training of the data collectors was necessary. To ensure the
highest degree of reproducibility, a review meeting was held for data collectors to ensure
streamlining in their scoring and reinforcing good understanding of indicators that have been
difficult to reproduce.
5
DATA COLLECTION, ENTRY AND ANALYSIS

Data collection and entry took place from 30th November to 14th December 2011 by three
data collection teams with three MMS each. Data were entered into Adobe PDF by the MMS
and later exported to STATA for data analysis.
FINDINGS AND DISCUSSIONS
This section presents the survey findings followed by a discussion of the findings. The
section is divided in the following subsections:
 General standard of the facility
 Supply chain management, including storage and stock management
 Availability of EMHS
 Distribution
 Appropriate use of medicine including dispensing practices
1. GENERAL STANDARD OF THE FACILITY

This section presents findings from the facilities regarding the following areas:
 Health facility characteristics

 Patient load
 Staffing in pharmacy/dispensary and medicine store
 Services offered
 Hygiene conditions of staff toilet and hand washing facilities
1.1 Health Facility Characteristics
As described in the methodology, the same facilities were surveyed in 2010 and 2011. The
characteristics of the health facilities are captured in the table below.
Table 2. Characteristics of health facilities surveyed
Type of Facility Private Not-for-Profit

Government Facilities Total
(n=63) Facilities
Hospital 7 2 9
HC IV 9 0 9
HC III 19 8 27
HC II 12 6 18
Total 47 (75%) 16 (25%) 63

The sampled 63 facilities represent 3% of the health facilities where SPARS has not yet been
implemented1.
1
According to the MOH, there was a total of 3,737 health facilities in Uganda as of July 2012 (1,750 of which
are supported by SURE and utilize the SPARS)
6
Findings and discussions
1.2 Patient Load
Outpatient prescriptions were used to estimate the patient load (number of patients seen per
day) in each facility. Patient load at PNFP facilities varied considerably from 2010 to 2011:
Hospitals saw a large decrease in load, while HC II increased significantly, and HC III
experienced no real change. Public facilities at all levels generally experienced a decrease in
patient load, except at the HC III level. Both in 2010 and 2011, there is a large range of
patient load at the same healthcare level.
Table 3. Number of patients seen per day measured as prescriptions prescribed per day according to
prescription book
Public Facility – Average # Patients PNFP Facility – Average # Patients

Type of Facility
Per Day (Range) Per Day (Range)
Report year 2010 2011 2010 2011
176 164 59 35
Hospital
(95-306) (74-268) (43-75) (14-56)
90 80
HC IV Not Available (NA) NA
(44-186) (43-121)
52 57 34 33
HC III
(12-124) (18-175) (10-118) (6-105)
38 25 5 19
HC II
(15-86) (11-46) (3-8) (2-59)
The large range of patient load across same levels of health care creates inequality in the
healthcare service provided. This is because each facility across same levels of health care
receives identical EMHS funding allocation regardless of patient load. This results in higher
funding allocation per patient in facilities with fewer outpatients and lower funding per
patient in facilities with high patient loads, and it directly affects EMHS availability.
An increase in EMHS availability is known to increase the number of patients. This effect
could not be documented in this survey. One reason could be that the health facilities still
experience stock outs of vital EMHS due to insufficient EMHS funding, wrong ordering, or
difficulties in redistribution of the kit supplied items.
1.2 Staff in Pharmacies/Dispensaries and Medicine Stores
Pharmacists and pharmacy technicians are educated in handling and dispensing medicines
and health supplies. However, in 2011, only 11% of health facilities had either a pharmacist
or pharmacy technician working in the pharmacy, which is a decrease from 22% in 2010.
Storekeepers and store assistants might also have medicine management skills, but this cadre
is only employed in less than one-third of the facilities.
On a positive note, fewer facilities had “other staff with client contact” working in the
pharmacy in 2011 compared to 2010, which indicates better service delivery as dispensing
staff are minimally educated in health.
7
Table 4. Staffing levels in pharmacies and dispensaries, level of effort, and years of experience
Facilities with ≥1
Staff Working Full Average Years of
Staff Level Staff Working in
Time (%) Experience
Pharmacy (%)
Report year 2010 2011 2010 2011 2010 2011
Pharmacists 7 5 100 100 3 3
Pharmacy Technicians 15 6 86 100 10 12
Nurses 87 100 89 71 6 5
Storekeepers/Assistants 41 29 100 85 8 5
Other Staff with Client
100 65 79 79 5 8
Contact
Pharmacists and pharmacy technicians are the only staff that work full time in the pharmacy.
The other cadres employ both full time and part time pharmacy workers, resulting in a large
number of staff carrying out dispensing work. When many staff work in the pharmacy, it is
important to establish clear guidelines and responsibilities for the varied tasks and to employ
a pharmacy in-charge with the overall responsibility for storing and dispensing medicines and
health supplies.
The policy to increase the amount of general pharmacists at district hospitals has not been
fully implemented and thus, its impact cannot be evaluated. Underlying this need is the small
decrease in health facilities with at least one pharmacist from 2010 to 2011. Pharmacists only
work in hospitals; government hospitals represent 11% of the facilities included in the survey
and should also represent 11% of facilities with at least one pharmacist. However, only 5% of
the facilities have a pharmacist employed in 2011. Additionally, pharmacy technicians are
only employed at 6% of facilities. The MOH prioritizes increasing pharmacist and pharmacy
technician hires.
1.3 Services Offered
The services offered at the health facility reflect staff effort to provide a good patient
experience. This includes providing the patient with the right medicine and correct
instructions to use the medicine.
One-fifth of health facilities did not have chairs available for patients who were waiting for
medicine, which is almost the same as in 2010. Waiting time is often long; therefore it is
unacceptable for ill patients to stand up while waiting to be served.
Privacy is also an important aspect of a good patient experience. It creates a comfortable and
secure environment where patients can ask questions and learn correct use of dispensed
medicine. In 2011, half the facilities dispensed medicine in privacy compared to only one-
third of the facilities in 2010. However, there is still need for improvement. Health facilities
can easily achieve privacy, for example, by making a line on the floor illustrating that other
patients must stay behind this “privacy line” until it is their turn.
8
Table 5. Services offered to patients in facilities
% Facilities % Facilities
Services Available
2010 2011
Chairs/bench to sit on (n=62) 89 86
Hand washing facilities (n=62) 35 29
Privacy when receiving dispensary services (n=62) 31 56
Drinking water available to patients (n=60) 30 24
Hand washing facilities are important to ensure good patient hygiene, but less than one-third
of the facilities had this service available to patients. Drinking water to take prescribed
medicine was only available in one-quarter of the facilities, making it impossible for patients
to take any prescribed medicine before leaving the facility.
1.4 Level of Hygiene in Staff Toilets and Hand Washing Facilities
Hygienic toilet and hand washing facilities are important to limit the spread of bacteria from
health workers to patients. Since 2010, there has been a decrease in the percentage of
facilities with acceptable, hygienic, and functioning toilet facilities: in 2011, only half the
facilities had acceptable conditions. Positively, there has been an increase in the percentage
of facilities with acceptable, hygienic, and functioning hand washing facilities.
Despite these changes, the percentage of health facilities with acceptable toilet facilities still
outnumbers the percentage of health facilities with acceptable hand washing facilities. This
clearly indicates that there are several facilities where staff uses toilets without being able to
wash their hands. Additionally, there are only few facilities with toilet paper (7%) and soap
(16%) available to the staff.
Table 6. Conditions of toilet and hand washing facilities
Hygiene
2010 2011
Toilet facilities acceptable, hygienic, and functioning 71 57
Toilet paper available 17 7

Hand washing facilities are acceptable, hygienic, and
30 42
functioning
Soap for hand washing available 14 16
2. SUPPLY CHAIN MANAGEMENT

Supply chain management is an essential component for ensuring availability of medicine
and health supplies, and includes stock and storage management and the ordering process. If
the health facility staff is unable to handle these processes correctly, the risk of EMHS stock
out increases. In this report, the following supply chain management sections were
investigated:
 Receipt of medicines and health supplies

 Stock management
9
 Storage management
 Reporting and ordering
 Knowledge about the vital, essential, and necessary (VEN) classification
 Stock management supervision
 Quality of medicines inspection
2.1 Receipt of Medicines and Health Supplies
In Uganda, public health facilities receive essential medicine and health supplies (EMHS)
from National Medical Stores (NMS), and private and private not for profit (PNFP) health
facilities receive EMHS from Joint Medical Stores (JMS). JMS generally provides EMHS
based on facility orders. NMS also provides EMHS to hospitals and HC IVs based on orders
but provides EMHS to HC II and HC III based on a push or kit system, where the content and
quantities are determined centrally.
Presently, JMS does not deliver EMHS. PNFPs or private for profit organizations pick up
their orders from JMS stores or arrange for transport and delivery. In 2010, NMS introduced
deliveries “to the door”. NMS’ own vehicle delivers to districts, where contracted private
logistic providers take responsibility for district distribution to the health facilities. Along
with “to the door” delivery and engagement with private logistic providers, more regular
order and delivery schedules have been introduced.
Whenever the health facility receives EMHS, it is important to check the delivery before
accepting the medicine and health supplies delivered. The table below shows the percentage
of facilities that perform specific checks when receiving supplies.
Table 7. Procedure for checking received supplies, before and after opening the boxes
Checks Completed upon Receiving Supplies

2010 2011
Before Opening
Check delivery note 87 79
Count the boxes 33 67
Check that all boxes are unopened 22 21
Check that all boxes are undamaged 18 30
After Opening
Check label information on all supplied items 25 22
Check for type of item, quantity, and physical damage 67 85
Check expiry date 40 64
Signing the delivery form 71 70
All these procedures are recommended when receiving EMHS, but only 3% of the facilities
had written standard operating procedures for goods receipts. The table shows that many
facilities do not follow the recommendations. For example, only one-fifth of the facilities
check that the boxes are unopened.
10
There has been a slight improvement for some of the processes: counting boxes; checking for
damage; and checking type, quantity, expiry date. The reason for the seen improvements is
not known. The only sizeable decrease from 2010 to 2011 was observed for checking the
delivery note. For the remaining processes, there has been a slight decrease in the percentage
of facilities performing the process.
It is important for the health facilities to check if they are receiving what is included in the
delivery note. The facility pays for the quantities noted on the delivery note. Thirty-eight
percent of the facilities have experienced discrepancy between the received quantity and the
quantity on the delivery note. The table below shows what health facility staff, who have
experienced discrepancy, do in cases of discrepancy between what should be and what is
actually delivered.
Table 8: Actions taken in case of discrepancy between delivery note and actual received quantities
% Facilities
Actions Taken in Case of Discrepancy
(n=22)
Communicate to supplier (NMS/JMS) 73
Follow up with supplier (NMS/JMS) 64
Communicate to DHO/HSD 45
Follow up with DHO/HSD 45
Fill in discrepancy report 32
File discrepancy report 27
Have written procedure for writing discrepancy report 5
Write in delivery note what the problem is – then sign delivery note 14
Of those who communicate and follow up with supplier and district, 57% receive a response:
64% from NMS and 33% from JMS.
2.2 Stock Management
Stock or inventory management includes monitoring of stock, quantification of needs, and

preparation of orders. It is important that monitoring of stock is punctually and accurately
reported on stock cards (part of the Ministry of Health’s (MOH) Health Information
Management System (HMIS). In this report, stock management was assessed for 31 items
(see list in Annex C: Basket of Items) for the following areas:
 Availability of stock cards

 Correctly filled stock card header
 Physical counts
 Accuracy of stock card data
 Comparison of public and PNFP facilities
11
2.2.1 Availability of Stock Cards
The first step to enable good stock management is availability of stock cards for each item.
There was an improvement in the availability of stock cards at all levels of health care from
2010 to 2011, raising the percentage of items with stock cards in a facility from 68% to 77%.
The best availability of medicine stock cards was at HC II in both 2010 and 2011.
Figure 3. Availability of stock cards
There is, however, still a considerable difference in stock card availability by facility level.
The table below shows that in 2011, the range is larger, but there are no longer any facilities
without any stock cards available. Further, there are stock cards available for all items
included in the basket at all level of care. The main reason for this improvement was the
inclusion of empty stock cards in NMS’ kits to HC II and HC III.
Table 9. Range of availability of stock cards
% Items per Facility

with Stock Card HC II HC III HC IV Hospital Average
Available
2010 % Range 0 – 85 50 - 77 50 - 77 43 – 93 4 – 75
2011 % Range 31 – 100 29 - 100 33 -100 45 - 100 29 – 100
There is still a need to improve stock card availability to allow staff to monitor stock
movements of all items.
2.2.2 Correctly Filled Stock Card Header
When the stock card is available for an item, it is also important that the health workers are
able to fill in the stock card correctly. In this report, a correctly filled stock card header means
that the header includes the generic medicine name, strength, dosage form, average monthly
consumption (AMC), and notes on special storage conditions. In all the surveyed facilities,
stock cards for the 31 basket items were assessed. It was found that only 1% of the stock
cards had a correctly filled stock card header.
12
2.2.3 Physical Count
Monthly physical counts are important to verify that the physical quantity of medicines and
supplies are correctly recorded on the stock card. In case of discrepancies between the
physical counted quantity on the shelves and the stock card balance, health workers must
investigate from where the discrepancy came.
Monthly physical count should be clearly recorded on each stock card, preferably using a
colored pen under the heading “physical count” or “PC”. Table 10 shows the percentage of
items per health facilities that were physically counted every month in the last three months.
Table 10. Completed physical counting procedure in facilities that used stock cards
Monthly Physical Count Hospital HC IV HC III HC II Average
2010 % Items per Facility 5 0 7 3 4
2011 % Items per Facility 0 2 10 5 6
2.2.4 Accuracy of Stock Card Data
Accuracy of stock cards was assessed by comparing the stock card balance with the physical
count on the day of the survey. There was a reduction in accurate stock cards from 53% of
the items in 2010 to 42% in 2011.
In 2010, there were many stock outs, thus many stock cards correctly showed a zero balance.
It is, however, not as challenging to ensure correct stock balance when the item is out of
stock. Therefore, an accurate record was not indicative of the actual difficulty or effort to
update the stock card and ensuring that the physical count corresponded with it. When
excluding items with zero stock card balance, the overall average of stock card accuracy was
37% in 2010. This is closer to the 2011 average and explains the initially measured decrease
in stock card accuracy.
Table 11. Accuracy of stock card data by facility
Accurate Stock Cards Hospital HC IV HC III HC II Average

2010 % Items per
54 44 52 58 53
Facility, Average
2011 % Items per
45 38 39 46 42
Facility, Average
2.2.5 Comparison of Public and PNFP Facilities
More items in the public health facilities had stock cards available, but a higher percentage of
the stock cards in the PNFP facilities were accurate with stock card balance equal to physical
count on the day of survey.
13
Table 12. Comparison of PNFP and public facilities in stock management and availability of medicine
PNFP Public
Indicator
(% Facilities) (% Facilities)
Stock card availability 70 79
Stock card accuracy 48 40
2.3 Storage Management
Store management is important to ensure that the EMHS are stored appropriately in the health
facility store and dispensary. Appropriate storage ensures that the medicine and supplies are
of good quality and that there is no risk of contamination. Storage management is measured
as:
 Cleanliness of store
 Storage conditions
 Storage systems and practices for EMHS
2.3.1 Cleanliness of the Store
The level of cleanliness in the main stores was checked and scored. The level of cleanliness
and tidiness in 2011 was acceptable or better in two-thirds of the main stores, and thus
unacceptable in one-third of all stores observed. There is no significant change compared to
2010.
Table 13. Cleanliness of dispensary and main stores
2010 2011
Acceptably Clean Not Clean and Acceptably Clean Not Clean and
and Tidy Untidy and Tidy Untidy
Main Store 70 30 66 34
Pests, such as rodents and insects, are destructive and can contaminate medicines, and they
should not be found in medicine stores. In 2011, 54% of the main and 63% of the dispensary
stores had traces of pests.
2.3.2 Storage Conditions
When EMHS are stored in the health clinic store before being issued out to the pharmacy or
wards, it is critical that EMHS are stored under correct conditions to preserve their quality.
The table below includes general storage conditions and indicators related to temperature of
the store. The table compares the 2010 and 2011 results for both the main store and the
dispensary.
14
Table 14. Storage conditions assessed in main and dispensary stores
Main Dispensary
Storage Conditions
(% Stores) (% Stores)
General Storage Conditions 2010 2011 2010 2011
Storage space sufficient and adequate 63 52 71 66

Storeroom lockable and access limited to authorized
90 92 76 86
personnel
Roof maintained in good condition to avoid water penetration 82 80 85 79
Fire safety equipment and items available and accessible 7 10 8 8
Storage Temperature
Medicines protected from direct sunlight by painted glass or
97 80 95 76
curtains
Temperature regulated by ventilation, heater, or air-
82 85 85 92
conditioner
Temperature monitored 3 5 2 2
Functioning cold storage system (refrigerator) to store
* 56 18 NA 39
medicines
Temperature of refrigerator recorded 100 67 80 94
Vaccines placed in centre of refrigerator (not in door) 87 86 83 97

*
The indicator monitoring availability of refrigeration capacity has changed from 2010 to 2011. The
new indicator measures availability of refrigerators in the store and pharmacy/dispensary separately.
There were not big differences in the findings for the general storage conditions between the
2010 and 2011 or between main stores and dispensaries. There were still only a few health
facilities with fire equipment available, which jeopardizes the safety of medicine and health
supplies. Further, the space is still not adequate and sufficient in 52% of main stores.
Some medicines and most vaccines must be stored below eight degrees Celsius to remain in
good condition, while other medicines can be stored at room temperature but must be
protected from direct sunlight to ensure good quality of the medicine. Findings show that
there was a decline in the percentage of stores and dispensaries where medicine is not
protected from sunlight. In only four out of five main stores, the medicine was protected from
direct sunlight in 2011 compared to almost 100% in 2010.
To maintain the quality of medicine and health supplies, the room temperature must be
regulated. Regulation can be achieved by opening windows or installing a ventilator or air-
conditioner. From 2010 to 2011, there was a slight increase in the percentage of stores and
dispensaries where temperature could be regulated. In 2011, 85% of main stores and 92% of
dispensaries could regulate the temperature; however only 5% and 2%, respectively,
monitored the temperature, thus making it impossible to know when regulation of
temperature is necessary.
Lastly, a functioning cold storage system is necessary to store certain medicine and vaccines.
According to the findings, it appears that there were more refrigerators available in 2010
compared to 2011. In actuality, this is not the case. In 2010, it was reported that 56% of the
main stores and dispensaries had refrigerators. However, this is an aggregated percentage of
15
refrigerators present in either main stores or dispensaries. In 2011, data collectors separately
reported the availability of refrigerators. Thus, the 2011 aggregate percentage of available
refrigerators is 57% (18% in main stores and 39% in dispensaries), which is a small increase
from 2010. In 2011, fewer health facilities recorded the refrigerator’s temperature, but more
correctly stored vaccines in the middle of the refrigerator instead of in the door.
2.3.3 Storage Systems and Practices for Medicines and Health Supplies
In addition to good storage conditions, the storage system and practices for EMHS are also
important to make sure that the patients receive the right EMHS. The findings are shown in
Table 15 below. There was a general decline in the percentage of health facilities that store
the medicine correctly.
In 2010, almost all medicines (92%) were stored on shelves or in cupboards. Unfortunately in
2011, facilities experienced a 27% decrease in shelf storage and the percentage of medicine
boxes stored directly on the floor increased. Medicine boxes have to be stored on pallets to
avoid humidity to enter into the boxes, potentially harming the medicine. The reason for this
fall in good storage practices could be higher availability of items resulting in inadequate
appropriate storage space.
Labeling and systematic storing helps store managers easily identify the right medicine and
decrease the risk of picking wrong medicine for the patient. Less than one-third of the
facilities stored medicines systematically in 2011 compared to more than half of the facilities
in 2011. There was no change in the percentage of facilities with labeled shelves.
Additionally, stock cards should be kept next to the shelved medicine to ease tracking. Only
8% of the facilities keep stock cards next to the medicine. A significant improvement should
be made for this indicator.
Expired medicine must be kept away from the usable stock to avoid dispensing expired
medicine to patients. In 2010, almost half the health facilities separately stored medicine from
the usable stock; in 2011, only one-third of facilities separately stored medicine. Records of
expired medicine, which are used for easy reporting to the district health office, was only
available in less than one of five facilities.
Table 15. Storage systems and practices for EMHS
2010 2011
Storage System and Practices Indicators
Medicines stored on shelves and/or in cupboards 92 65
Boxes not stored on the floor in the dispensary or store 46 23

Medicines stored on shelves and/or in cupboards in a systematic
57 27
manner
Shelves are labeled 18 21
Stock cards kept next to the medicines on the shelves NA 8
First expiry first out (FEFO) adhered to NA 29
Separate area used to keep expired drugs before disposal 48 31
Record for expired medicines exists 13 17
16
In the dispensary, bottles with liquids or mixtures must be labeled with their opening date, so
they are used while the quality is still good. Also, tins and bottles with medicine must have a
lid on when not being used. Using lids minimize the amount of humidity allowed into the
containers that could otherwise affect tablets. It was found that bottles were rarely labeled
with the opening date (2%) and though the use of lids increased (48% to 60%), there are still
too many facilities that do not adhere to the practice.
Table 16. Dispensary storage practices for EMHS
2010 2011
Storing Practice in Dispensary Indicators
Opened bottles of liquid/mixtures in dispensary labeled with the
5 2
opening date
Opened tins and bottles in the dispensary have a lid on them 48 60
2.4 Reporting and Ordering
Health facility staff are obligated to regularly report to the central level to comply with the
Health Managing Information System (HMIS) and to order and report on vertically or
technical program-supplied medicines. A great deal of effort has been made to ensure timely
and accurate reporting. Facilities use special forms for ordering TB and HIV/AIDS
medicines. Orders are made through the district and supplied by either the National Medical
Store (NMS) for public facilities or Joint Medical Stores (JMS) for PNFPs.
2.4.1 Reporting
In Uganda, health facility staff prepare several reports every month, including service
statistics and logistics data. The HMIS requires monthly, quarterly, and annual reports
providing general facility data, such as the total number of admissions, outpatients, and
patients receiving specific care. The report also includes the number of stock out days for the
six tracer medicines and health supplies. The MOH technical programs require more specific
patient and consumption data, which increases the workload in facilities with several specific
treatments available.
One of the most common reports is the monthly HMIS report (HMIS 105) that the central
level uses for quantification and decision-making. Accuracy of the report is therefore of high
importance. For example, the number of stock out days reported in the most recent report was
compared to the number of stock out days according to the stock card for the tracer medicines
during the reporting period. Seventy-eight percent of the most recent HMIS 105 reports
submitted by the surveyed health facilities were accurate. This moderate percentage of
accuracy should warn decision-makers to not only base decisions on HMIS data as it is not
always accurate. It is necessary to improve health facility report accuracy.
2.4.2 Ordering
All public HC IV and hospitals order medicine bimonthly according to the NMS Order and
Delivery Schedule. The schedule includes both order deadlines and delivery end dates. The
schedules have been more strictly implemented in 2011 and thus, a higher percentage of the
health facilities are familiar with and have the NMS Order and Delivery Schedule available in
17
2011 than in 2010. However, only half the HC III and a quarter of HC II have the schedule
available. Though HC II and III no longer place orders due to the introduction of the kit
system, it is still beneficial for them to know the delivery end dates.
Table 17. NMS Order and Delivery Schedule knowledge and availability 2011 compared to 2010 average
HC HC HC 2011 2010
Type of Facility Hospital
IV III II Average Average
% Facilities where staff are familiar with NMS
100 89 68 50 73 56
Ordering and Delivery Schedule
% Facilities where the NMS schedule for
100 89 55 25 62 49
ordering and delivery is available
All nine HC IV and three-quarters of the hospitals placed their orders before the deadline on
the NMS Order and Delivery Schedule, but when staff were asked to calculate quantity to
order based on stock card data, only one-third of the health facility staff were able to do so
correctly. This percentage is much lower for HC III (11%) and HC II (24%). This indicates
that either these skills were poor before introducing the kit, or these skills are reducing as the
kit system does not require orders to be prepared.
Table 18. Order timeliness and staff capability of calculating quantities to order
Average
Type of Facility Hospital HC IV HC III HC II
2011
% Facilities that place timely orders 75 100 NA NA 88
% Facilities with staff that can correctly
calculate quantities to order based on stock 33 33 11 24 21
card information
2.4.3 Filing Orders and Delivery Notes
Filing orders and delivery notes are part of good pharmacy practice. The pharmacy in-charge
should always be able to find information on items and quantities ordered and delivered.
However, only 44% of the health facilities had filed the orders, and 88% had filed delivery
notes.
Average
Type of Facility Hospital HC IV HC III HC II
2011
% Facilities where previous orders are
56 33 NA NA 44
filed
% Facilities where delivery notes are
100 89 93 75 88
filed
2.5 Knowledge of VEN Classification
Vital, Essential, and Necessary (VEN) classification is a method for prioritizing EMHS
according to their health impact. Vital items are life-saving medicines and must always be in
stock. As funding for EMHS is limited in Uganda, orders must be prepared using this concept
to ensure that the most efficacious life-saving medicine is available.
It is important that health workers know how to use VEN classification, so more vital items
than essential and necessary items are available in the health facilities. However, only 8% of
health workers had heard about VEN classification and of those, only 21% could mention
18
items that are Vital. It should be mentioned that at the time of the survey, there was no
document available to the health facility staff with VEN classification of items. In 2012, an
updated VEN-classified medicine and health supplies list will be published.
Table 19. VEN classification of EMHS
2010 2011
VEN Indicator
Facilities where health workers had heard of VEN classification 10 8
Facilities where health workers could correctly mention four Vital
NA 21
medicines or health supplies
2.6 Stock Management Supervision
Stock management in Ugandan health facilities remains poor, despite capacity building being
a high priority for the last decade. This might be because the main method used was
classroom-style training, though several studies have shown that on-the-job training and
supervision has a higher efficacy rate..
Eighty-seven percent of the health facilities reported receiving at least one supervisory visit
in the last six months prior to the survey to discuss medicine management, and 55% of the
health facilities have a supervision book that the supervisors use to communicate areas of
improvement. The quality of supervision is unknown from this survey. On average, each
health facility had two medicine management supervisions in the last six months. It should be
noted that the surveyed facilities do not yet receive supervisions as part of the national
Supervision, Performance Assessment, and Recognition Strategy (SPARS).
Compared to 2010, there is an increase in the percentage of facilities that were supervised.
Only 60% of the health facilities reported having a supervision visit including medicine
management in 2010, and only 40% had written supervisory reports available in the facilities.
2.7 Quality of Medicines Inspection
The National Drug Authority (NDA) is mandated to inspect pharmacies to make sure that the
pharmacies operate in accordance with specific quality standards. Currently, mandatory
inspections only take place in the private sector. However, NDA does make spot check
inspections in public health facilities to assess the suitability of the premises. Only 37% of the
surveyed health facility pharmacies or dispensaries reported having been visited by NDA
inspectors in the past year. Of these, 91% were satisfied with the way the inspection was
conducted.
There has not been a large increase in the number of facilities that were inspected from 2010
to 2011. It is not clear if the visits by NDA were licensing inspections or supportive
supervisions.
19
3. AVAILABILITY
3.1 Availability of a Basket of EMHS
3.1.1 Survey Basket of EMHS
The basket includes 31 items: 23 medicines and six health supplies. The table below shows
the number of medicines and health supplies recommended for the different levels of care
according to the Essential Medicine and Health Supplies List for Uganda 2012. A full list of
the basket items is available in Annex C Basket of Items.
Table 20. Number of surveyed EMHS by level of care
Level of Care # Medicines # Health Supplies
Hospital 25 6
HC IV 25 5
HC III 23 5
HC II 18 4
Average 23 5
3.1.2 Availability of EMHS
Availability of EMHS on the day of the survey increased from 2010 to 2011. Only half the
items were available in 2010, while three quarters were available in 2011. The lowest
availability was in HC II in both years, but the introduction of the kit system has improved
availability at that level.
Figure 4. Availability of basket items by level of care on day of survey
The availability of medicines did not differ significantly from that of health supplies. In 2010,
erythromycin and malaria rapid diagnostic test kits were among the EMHS commonly
20
unavailable on the survey day. In 2011, cotrimoxazole was, on average, available in less than
half of the facilities on survey day and thus had the lowest overall availability.
The graph below illustrates the items available at different healthcare levels on the day of the
survey. The items are divided into four groups that represent the percent availability of those
items in each facility level. Together, the graph illustrates the distribution of availability from
very low to an adequate percentage of EMHS in stock.
Figure 5. Availability in facilities on day of survey specific to level of care
Figure 4 shows that there is an overall increase in item availability at all health care levels
from 2010 to 2011. In Figure 5, this increase is illustrated by the higher percentage of health
facilities having more than half the items available in 2011. Overall, 93% of the health
facilities had more than half of the basket items available, and none of the facilities had less
than one-quarter of items available on the day of survey. In comparison, only 55% of health
facilities had more than half the items available and 13% had less than one-quarter of the
items available on the day of survey in 2010.
The main reason for the increased availability is due to more EMHS funding as decided by
Vote 116. For example, the funding for HC III kits increased by 58% to 2,992,250 Ugandan
Shillings from June 2010 to July 2011.
3.2 Availability of Vital Items
The basket of 31 EMHS includes vital, essential, and necessary items selected according to
the VEN classification. They are: 23 (74%) vital items, 7 (23%) essential items, and 1 (3%)
necessary item. Table 21 compares availability of the vital items on the day of the survey in
2010 and 2011. Range is included to show the variation of availability in different health
facilities.
At the time of both surveys, the 2007 Essential Medicine List for Uganda (EMLU) including
only recommendations for the level of care that medicines should be used at, but not VEN
classification, was in use in health facilities. The 2012 Essential Medicine and Health
Supplies List for Uganda (EMHSLU) which includes VEN classification of all items, was not
21
yet available in health facilities. However, early versions of the lists were shared with NMS
and used to revise the kit content and quantities. Though not available to health facilities, all
levels of care are included in the table below.
Table 21. Availability of a basket of 23 vital medicines and health supplies on the day of the survey
2010 % 2011 %
Availability of
vital medicines Facilities, Facilities, 2010 % Range 2011 % Range
Average Average
HC II 44 68 14 -88 27 – 100
HC III 57 78 24 – 81 47 – 86
HC IV 51 81 10 – 73 53 – 94
Hospital 59 82 36 – 86 64 – 100
Average 53 76 10 – 88 27 – 100
a
20 Vital items for HC III and 16 Vital items for HC II.
At all levels, availability of vital items has improved from 2010 to 2011; HC IV experienced
the largest improvement and HC III the smallest. Hospitals have the highest availability of
vital items, and four-fifths of HC IV have all vital items available. The largest range is at the
HC II level, indicating high inequality that is likely due to different patient loads. Some HC II
have 100% availability, while others have 27% availability.
There is still a need to improve the availability of vital items. Only 8% of health workers
knew about the VEN classification. In facilities receiving regular supervision and mentoring,
51% of the health workers know what VEN means. It is very important for health workers to
use VEN classification when ordering, especially at HC IV and hospitals that still place
orders with NMS. For HC II and HC III, central level is responsible for availability of vital
items.
3.3 Availability of Tracer Medicines
The MOH has identified six critical medicines that should be available at all times to provide
the Minimum Health Care Package. The availability of these six essential medicines is
monitored on a regular basis by MOH.
This survey measured two indicators: availability on the day of the visit, which provides a
cross-sectional perspective; and availability over the previous six months, which is a more
robust measure of supply chain performance. Both indicators reflect a combination of
influencing factors: facility priorities for procuring/ordering these specific items, staff skills
in calculating the correct amount to be supplied, availability of the item at central level in the
three months period, and the timeliness and predictability of NMS deliveries.
22
The tracer medicines are:
 Cotrimoxazole (CTX)
 First line antimalarial medicine (currently Artemether and Lumefantrine (AL))
 Sulfadoxine and pyrimethamine (SP)
 Oral rehydration salt (ORS)
 Measles vaccine
 Depo-Provera
There has been a big improvement in the day of visit availability for all six tracer medicines.
In 2011, almost 40% of the health facilities had all six medicines available; only 10% of
facilities had all six available in 2010. Another positive finding is that none of the facilities
had no tracer medicine available on the day of survey.
Figure 6. Percentage of tracer medicines available on the day of survey in each facility
For each individual tracer medicine, there is an improvement in the percentage of facilities
with the medicine availability on the day of survey from 2010 to 2011. The average
availability of tracer medicine assessed on the day of survey rose from 58% in 2010 to 89%
in 2011 (Figure 7). ORS and cotrimoxazole had the least availability, and ACT was the most
available and most improved in availability.
23
Figure 7. Availability of individual tracer medicines on the day of the survey
Table 22 shows the availability of items over the six months prior to the survey visit. There is
100% availability if the stock card showed no stock outs of an item over the previous 180
days. The average availability of the six tracer medicines over the six months period was 130
out of 180 days (72%).
Table 22. Percent availability in previous six months period
Measles
ACT SP ORS Depo-Provera Cotrimoxazole
vaccine
Hospital 100% 100% 97% 95% 91% 99%
HC IV 99% 97% 100% 98% 96% 91%
HC III 92% 100% 91% 97% 100% 86%
HC II 95% 100% 100% 92% 99% 87%
2011 Average 95% 99% 96% 95% 99% 89%
2010 Average 56% 93% 62% 79% 54% 86%
The average availability has largely increased from 2010 to 2011 for all items except measles
vaccine and cotrimoxazole; these two items already had high availability in 2010.
3.3.1 Stock Out Days for Tracer Medicine
The duration of tracer medicine stock outs was measured over a six-month period to assess
facilities’ service delivery. Stock outs were determined by calculating the number of days
each tracer medicine was recorded as out of stock on available stock cards. All items with
stock cards available were included in the calculations.
Depo-Provera and ACT had the highest average number of stock out days in 2010. Depo-
Provera was globally recalled by Pfizer, its manufacturer, over quality control issues, while
ACT’s manufacturer Quality Chemicals was unable to fulfill country requirements and
24
further faced administrative bottlenecks during Global Fund procurement. Findings from
2011 show that stock out days of both medicines have largely decreased. Depo-Provera was
now available for five months and ACT for four and a half months in a six months period.
Table 23. Average days medicine was out of stock over previous six months (180 days)
Measles
ACT SP ORS Depo-Provera CTX
Vaccine
Hospital 2 NA 32 59 32 13
HC IV 18 40 NA* 22 45 51
HC III 102 6 89 27 NA 55
HC II 23 NA NA 56 12 34
2011 Average 44 23 78 40 30 44
2010 Average 79 13 69 38 82 25
* Not enough data available
The average stock out days for measles vaccine, SP, and ORS increased from 2010 to 2011.
It is alarming that the measles vaccine and ORS are increasingly out of stock considering
their importance in reducing children under age five years morbidity and mortality.
3.4 Availability of MOH Technical Program-Specific Items
The survey included indicators on the availability of certain medicine groups provided by
technical programs under the Ministry of Health (MOH). This section considers the
availability of antiretrovirals (ARVs), maternal health, family planning commodities, and
medicine for tuberculosis treatment.
3.4.1. Availability of ARVs
HIV/AIDS treatment is only provided in hospitals, HC IV, and a few HC III. In this survey,
24% of the facilities provided ARV treatment including only HC IV and hospitals.
The first line treatment for HIV/AIDS in Uganda is the triple combination medicine
consisting of zidovudine, lamivudine, and nevirapine. Findings show that 79% of the health
facilities that provided ARV treatment had this medicine available on the day of survey. The
availability was lowest in HC III and highest in HC IV.
3.4.2 Availability of Maternal Health Commodities
The MOH has expanded maternity coverage to the HC II level. However, this expansion
takes time and in this study, none of the HC II had any of surveyed maternal health
commodities available.
Table 24 shows the availability of oxytocin and magnesium sulphate that are used for
maternal health before, during, and after child delivery. The table also includes the
percentage of health facilities with both products available on day of survey. 2010 data is
included for comparison.
25
Oxytocin was available in almost half of the facilities, and magnesium sulphate was available
in 83% of the health facilities. The highest availability of magnesium sulphate was in HC III,
though Oxytocin availability was lower than average at this care level.
Both products are infrequently used, which increases the risk of expiry and reduces their
prioritization when ordering. HC III do not order medicine and health supplies but instead
receive kits that are filled with products and quantities determined by the central level.
Table 24. Availability of reproductive health commodities per healthcare level
Hospital HC IV HC III Average

Maternal Health Commodities
(% Facility) (% Facility) (% Facility) (% Facility)
Oxytocin 33 57 38 43
Magnesium Sulphate 67 83 89 83
2011 Health facilities where both
50 69 83 74
commodities were available
2010 Health facilities where all three
commodities were available (including 38 13 10 12
2
ergometrine)
The percentage of facilities with both medicines increased from 2010 to 2011, though full
coverage has not yet been achieved. In 2010, calculations were based on availability of three
medicines (ergometrine included), which could influence the percentage of overall
availability. Improvements are needed to secure safer health for mothers when giving birth.
3.4.3 Availability of Family Planning Products
The annual population growth rate in Uganda is high at over 3%, and the country faces
constraining economic growth. Family planning is an important method to prevent unwanted
pregnancies and thus reduce the growth rate.
This study included an availability assessment of two common family planning products:
Microgynyn, an oral contraceptive, and Depo-Provera, an injectable contraceptive that works
for three months after injection. On the day of survey, 93% of facilities had Depo-Provera,
and 80% of facilities had Microgynon in stock. Over the last six months, 9% and 16% of
facilities experienced stock out of Depo-Provera and Microgynon, respectively.
3.4.4 Availability of Medicine for Treatment of Tuberculosis
Tuberculosis (TB) treatment is available at all health levels except HC II. Availability on the
day of survey is generally high for TB medicine. All HC IV had first line TB treatment
available, and hospitals had the lowest availability of 83%.
Table 25: Availability of medicine for treatment of tuberculosis
Hospital HC IV HC III Average

Treatment of Tuberculosis
(% Facility) (% Facility) (% Facility) (% Facility)
First line TB treatment 83 100 92 91
2
Ergometrine was not included in 2011 because it is classified as a necessary medicine and only available at HC
IV
26
Rifampicin, isoniazid, pyrazinamide, and ethambutol are required for first line TB treatment
and are available as combination tablets containing all four active ingredients, as well as
combination tablets of two or three active ingredients in different strengths.
3.5 Overstocking
At the time of the survey, essential medicines and health supplies (EMHS) were being
ordered by hospitals and HC IV on the basis of consumption and available funding from Vote
116. HC II and HC III facilities, however, receive a kit supply. The kit or push-based supply
system was introduced at all the HC II and HC III facilities in June 2010. It ensured that
overstocking at the primary healthcare level was not related to poor supply management or
funding but rather the composition of the kit and the quantities delivered.
Overstocking indicates poor quantification and stock management, tampering, a weak

redistribution system for over-supplied items at district level, changes in treatment guidelines,
or morbidity. The survey identified cases of overstocking by whether the facility had more
than five months of stock based on average monthly consumption (AMC) within the previous
six-month period. The data collectors calculated AMC for all items with available stock cards
(77% of the total items).
According to the national supply chain system, the maximum stock level is five months for
most medicine. Some items with a short expiry period have lower maximum stock levels,
including the measles vaccine (two months) and the laboratory supply Field Stain A (three
months).
On average, basket items were overstocked in 16% of the facilities. The table below shows
that the lowest percentage of overstocked items was found in HC II. The other three
healthcare levels had around the same percentage of overstocked items. The average
percentage of overstocked items is similar to the 2010 findings.
The items that were overstocked differed by healthcare level. At the lower levels, JIK and
measles vaccines were reported to be overstocked, indicating that their consumption was less
than expected.
Table 26. Percentage of facilities at each healthcare level where an item was overstocked
Hospital HC IV HC III HC II Average

2011
Overstocked Items 14 16 18 13 16
(% Facilities)
2010
Overstocked Items 16 14 23 15 17
(% Facilities)
Facilities that receive kit supply reported an increase in the number of items that were never
overstocked, though perhaps more items become out of stock instead.
27
Table 27: Number of items never overstocked at each healthcare level

2011
12 12 13 16 14
# Items Never Overstocked
2010
13 13 3 9 10
# Items Never Overstocked
Though poor stock management can cause overstocking, it might also be associated with the
amount of funding available. Facilities with low funding per patient would be expected to
have fewer overstocked items because the demand for products is higher.
4. DISTRIBUTION
A good distribution system maintains a constant supply of EMHS; keeps EMHS in good
condition throughout the distribution process; reduces waste from spoilage, expiry, theft, and
fraud; and delivers EMHS on time and in the right quantities. In Uganda, the National
Medical Stores (NMS) is responsible for storing and distributing EMHS to the public sector,
and Joint Medical Stores (JMS) is responsibility for the private not for profit (PNFP) sector.
JMS uses a collection system and is currently not responsible for distribution to the health
facilities.
This section includes findings on lead time and order fulfillment rate, which is the degree that
orders are fully or partially filled.
4.1 Lead Time
The lead time is the time it takes for EMHS orders to leave the health facility and EMHS
deliveries to arrive at the facility. This includes the time it takes for the order to be approved
by the district health officer, arrive at NMS, processed at NMS, delivered to the district, and
distributed by a third party logistics company to the health facility.
In this survey, data were collected from public facilities that receive supplies from NMS
based upon past order forms and delivery notes or invoices. However, there was a limited
amount of data available for this indicator because facilities seldom received or kept a copy
of their order forms. The facility copy of order forms is stored at the district. In addition, the
filing system for orders and delivery notes is weak, and it was difficult to match orders and
delivery notes as the present filing system is poorly managed.
The table below shows the average lead time for the different steps in the order-delivery
cycle. The 2011 average lead time of 38 days, reduced from 57 days in 2010, and this was
computed based on data with both the order forms and delivery note information available
(n=5).
In Uganda, the logistics system is based on stock levels of between two and five months with
bi-monthly forced ordering. Therefore, the maximum total lead time from order to delivery
should be less than two months (60 days) to avoid stock outs if facilities place their orders
when they have reached minimum stock level.
28
Table 28. Lead time from ordering to receiving EMHS
District to
Lead District to NMS to Total
District NMS Health
Time (n NMS Order District Lead
Approval Processing Facility
for 2010, Delivery Delivery Time
(n=17, 5) (n=8, 1) Delivery
2011) (n=8, 1) (n=24, 5) (n=19, 5)
(n=25, 5)
2011
2 6 25 4 1 38
Days
2010
3 18 26 3 5 57
Days
The overall lead time is reduced from almost two months in 2010 to only a bit over one
month in 2011.
In addition to bi-monthly deliveries, following the NMS delivery schedule is important to

prevent stock outs. This schedule also includes an end date for deliveries. Findings from this
study show that only 40% of deliveries are delivered before the scheduled end date, making it
difficult for the health facility staff to plan for the use of medicine and health supplies.
In 2011, more than half the days in the ordering and delivery cycle was spent processing
orders at NMS. A reason that this is the largest part of the lead time could be untimely order
submissions according to the NMS Order and Delivery Schedule. The survey found that only
78% of the facilities submitted orders on time. When the orders were submitted in between
order deadlines, the orders could only be delivered with the next scheduled delivery, which
could be several weeks later.
From 2010 to 2011, there was a large decrease in the number of days needed for districts to
submit orders to NMS. This could be a result of more districts being computerized, better
organized or due to orders being submitted through the regional NMS offices.
4.3 Nil Lines and Adjusted Items Ordered
Data collectors compared order forms with delivery notes to assess whether ordered items
were delivered in the right quantities. Since the introduction of the kit system, only HC IV
and hospitals make orders. Therefore, the 2011 data is based only on HC IV and hospitals,
whereas the 2010 average included all health care levels.
The table below summarizes these results and reveals that more than one-quarter of the items
ordered were not filled/delivered at all (nil lines), while 5% of the ordered items were
adjusted. Incorrect quantities delivered were typically less than (adjusted downwards) rather
than more than (upwards adjustment) what was ordered. In addition to the ordered medicine,
extra non-ordered items were also delivered. These equated to 7% of the total number of
delivered items (n=1686). In both 2010 and 2011, 66% of the ordered items were delivered
in the right quantities.
29
Table 29. Nil lines and adjustment of items ordered
Nil No Upward Downward

Facility Level
Lines Adjustment Adjustment Adjustment
Hospital (n=960) 35% 57% 2% 6%
HC IV (n=564) 23% 75% 1% 1%
2011 Average (n=1524) 29% 66% 1% 4%

2010 Average (n=1948,
25% 66% 1% 8%
includes HC II and HC III)
The low fulfillment rate is a problem caused by both facilities and NMS. If facility orders
exceed the allocated budget, then NMS is not able to deliver all items in the quantities
ordered. Another explanation raised by NMS is related to the procurement planning by the
health facilities. When a facility reaches their ceiling per their procurement plan, they cannot
be given the ordered items, which results in nil lines. Additionally, the availability of EMHS
at central level influences the fulfillment rate: low availability results in a low fulfillment
rate.
The study did not record which medicines were ordered but not delivered and thus is unable
to assess the cause for nil lines or adjustments in greater depth. A separate study that also
takes NMS availability and procurement plans into consideration is required.
5. APPROPRIATE USE OF MEDICINE

The World Health Organization (WHO) defines appropriate or rational use of medicine as
patients receiving the medication appropriate to their clinical needs, in doses that meet their
requirements, for an adequate period of time, and at the lowest cost to them and their
community.3 The inappropriate use of medicine is a global problem, which can be harmful to
the patient, increase the development of resistance, and result in the waste of limited financial
resources.
Appropriate medicine use includes both prescribing (5.2) and dispensing (5.3), and both are
included in the assessment described in this section. The survey also evaluated the
availability of reference materials (5.1)
5.1 Availability of Reference Material
The appropriate dispensing and prescribing of medicines depends on healthcare workers’

knowledge of correctly treating a certain condition. Prescribers need reference material to
find information on the appropriate treatment and to guide on medicine dosage and side
effects. The two main reference guidelines in Uganda are the Uganda Clinical Guidelines
(UCG) and Essential Medicine List for Uganda (EMLU). From 2010 to 2011, there was an
increase in the availability of the UCG and a slight increase in availability of the EMLU.
Both the 2003 and 2010 versions of the UCG were found: 77% of health facilities had the
2010 version, 17% had the 2003 version, and 6% had both versions.
3
The Rational Use of Drugs. Report of the Conference of Experts. Geneva, World Health Organization, 1985.
30
Table 30. Reference materials available to pharmacy staff
Reference Material
2010 2011
Uganda Clinical Guidelines (UCG) 2003/2010 48 82
Essential Medicine List for Uganda (EMLU) 2007 14 21
British National Formulary (BNF) 6 16
Martindale 5 14
Supply Chain Management Manual 3 11
Financial Manual 0 10
The survey did not include more information about the supply chain and financial manuals,
so it is not possible to clarify which organization or government entity disseminated the
manuals. These districts are not yet implementing SPARS, so manuals are not provided by
any of the SPARS implementing partners.
5.2 Prescribing
Appropriate prescribing is a combination of correct diagnosis and prescribing. It is difficult to

assess the appropriateness of a diagnosis but easier to assess the appropriateness of a
prescription. There are many problems related to prescribing, for example poly-pharmacy, the
overuse of injections, the inappropriate use of antibiotics, and the failure to prescribe in
accordance with clinical guidelines. This section assesses practices in the following areas:
 Prescription recording system
 Diagnostic equipment
 Adherence to standard treatment guidelines
 Appropriate duration of treatment
 Rational prescribing
5.2.1 Prescription Recording System
The Ministry of Health (MOH) provides health facilities with patient registers, which are
documents that record an individual patient’s prescriptions. In theory, this allows facilities to
track patients in case of medicine recall. The results of this survey showed that 62 of the 63
surveyed facilities (98%) had prescription data available in prescription books or patient
registers. This is the same as in 2010.
Table 31: Information captured in prescription book, patient register and dispensing log
Patient Medicine Prescriber Amount Amount

Information Date Diagnosis
Name Name Name Prescribed Dispensed
2010 %
100 100 NA 100 0 NA NA
Facilities
2011 %
81 91 92 29 0 96 77
Facilities
There is an overall decline in facilities with vital information about patients’ prescriptions.
None of the facilities had all the vital information, which is described in the table above. The
31
prescriber’s name was unavailable at all facilities. This data point is important to monitor the
prescriber’s habits and will be included in the prescribing and dispensing log, which is a new
Health Management Information System (HMIS) tool. There was a significant decline in the
percentage of facilities that provided the medicine name. The reason for this decline is likely
that the data collectors for the 2011 data collection mistakenly accepted only generic or brand
plus generic name rather than solely the brand name.
5.2.2 Diagnostic Equipment
There is an overall increase in availability of diagnostic equipment with the exception of the
vaginal speculum and torch. The largest increases in availability of equipment were blood
pressure machines, thermometers, and tongue depressors. In 2010, tongue depressors were
unavailable in all surveyed facilities and became available in 30% of the facilities in 2011.
Table 32. Availability of diagnostic equipment in consultation rooms
Diagnostic Equipment
2010 2011
Stethoscope 76 89
Blood Pressure Machine 11 83
Thermometer 25 78
Vaginal Speculum 78 46
Tongue Depressor 0 30
Otoscope 10 27
Torch 75 22
Patella Hammer 5 17
It is encouraging to see that there is increased use of thermometers. Thermometers are
necessary to diagnose several bacterial and viral diseases, so unavailability of this instrument
can lead to irrational use of medicine if a clear diagnosis cannot be established.
5.2.3 Adherence to Standard Treatment Guidelines
Adherence to standard treatment guidelines per the Uganda Clinical Guidelines (UCG) 2010
was assessed for three common diseases: acute diarrhoea without blood, mild upper
respiratory tract infection (URTI) / mild acute respiratory infection (ARI), and uncomplicated
malaria. Data were collected by reviewing ten prescription records per common disease in
each facility. A key constraint in assessing adherence to standard treatment is the widespread
use of symptomatic “diagnosis”; often, a specific diagnosis is not given.
Treatment of Acute Diarrhoea without Blood
Acute watery diarrhoea without blood indicates that it is not amoebiasis or dysentery and thus
antibiotics are not useful or recommended according to the UCG. Instead, the UCG 2010
recommends only oral rehydration salts (ORS) and zinc tablets to treat the associated
dehydration from excessive loss of body fluids. The figure below shows the percentage of
prescriptions containing ORS, antibiotics, anti-diarrhoeal (e.g. loperamide or charcoal), and
antispasmodic medicine (e.g. propantheline).
32
Figure 8. Medicine used for treatment of non-bloody diarrhoea (n=392)
Though not recommended by the UCG, antibiotics were prescribed to more than half of the
patients, while the recommended ORS was only prescribed to two-thirds of patients. No
significant improvement was observed from 2010 to 2011.
Anti-spasmodic medicines are symptomatic treatments, and their use should be avoided or
limited, especially in countries with a low medicine budget. Instead, priority should be given
for the procurement of life-saving medicines. It is therefore encouraging to see that anti-
spasmodics are hardly prescribed. The use of symptomatic treatment can be controlled by not
providing the medicine to the health facilities.
Figure 9: Medicines used in non-bloody diarrhea (n=392)
Zinc and vitamin A help reduce the morbidity and mortality of diarrhoea episodes by limiting
severity and duration. Therefore, it is important that all children with diarrhoea receive both
medicines. Findings show that 24% and 12% of diarrhoea patients received zinc and vitamin
A, respectively.
33
In line with national de-worming recommendations, all children should receive albendazole
or mebendazole whenever visiting health facilities. Though it is not known how many of the
patients were children, it is encouraging to see that 36% of patients received albendazole or
mebendazole for treatment of worms.
The most common inappropriate combination of medicines prescribed to diarrhoea patients is

ORS, an antibiotic, and other medicine or ORS with other medicine (see figure below). As in
2010, ORS only, which is one appropriate treatment, was prescribed to 2% of the patients. In
the table below, ORS with zinc, ORS with zinc and albendazole, and ORS with zinc and
vitamin A are also appropriate treatments. These treatments are labeled green and represent
only 11% of the patients.
Unfortunately, “other medicines” cannot be identified because the data collection tool did not
include this information. It is likely that they are paracetamol and other antipyretic medicines,
which were not category options. ORS and antipyretic are considered to be the correct
treatment, although antipyretic is for symptomatic treatment only and could be left out of the
regimen in resource-limited settings such as Uganda.
Only half of the treatments prescribed are included in the figure below. This indicates that
Uganda faces a challenge of non-adherence to diarrhoea treatment guidelines, as well as
inappropriate and overuse of medicine, especially antibiotics. In low-income and transitional
countries, the prescription of ORS for diarrhoea cases has increased from approximately 40%
in 2000 to 80% in 2006. In the same period, the use of antibiotics has decreased from 60% to
50%4. Compared to other developing countries, Uganda more frequently overprescribes
antibiotics and under prescribes ORS.
4
Halloway K., van Dijk L. The World Medicine Situation 2011. Rational Use of Medicine. Geneva, World
Health Organization, 2011:5-6.
34
Figure 10. Medicine combinations used for treatment of mild diarrhoea (n=392) (AD=anti-diarrhoeal
medicine, OTH=other medicine, AB=antibiotics, ORS=oral rehydration salt, VIT=vitamin A,
5
ALB=albendazole).
Treatment of Mild Acute Respiratory Infection
UCG 2010 does not include mild acute respiratory infection (ARI) or upper respiratory tract
infection (URTI) as a common medical condition, but it does include the common cold and
influenza, which are both mild ARI conditions. The recommended management of the
common cold is increased fluid intake and an analgesic/antipyretic. Influenza management
includes paracetamol, steam inhalation, or xylometazoline nose drops (for nasal obstruction)
and simple linctus (contains chloroform and citric acid monohydrate) for troublesome
coughs.
The figure below shows that 91% of all prescriptions for mild ARI patients inappropriately
included antibiotics, while 78% of all prescriptions included antipyretic/analgesic medicine.
This suggests that there is no difference in treating mild versus severe respiratory tract
infections (a simple cold is treated as a life threatening pneumonia). Generally, there was not
much difference in the use of medicine from 2010 to 2011. There was, however, an increase
in use of cough/cold medicine. Cough syrup, nasal drops and, mistakenly, antihistamines are
considered as cough and cold medicine. Antihistamines are widely available in the health
facilities and was the most commonly used cough and cold medicine. The classification and
5
The remaining treatment regimens (43%) are all inappropriate by providing wrong combinations
35
use of antihistamines in treatment of mild ARI indicates wrong diagnosis (antihistamines

should be used for allergies) or irrational use of medicine.
Figure 11. Total percent medicines prescribed for treatment of mild ARI (n=598)
The African continent prescribes the highest percentage of antibiotics. According to the
WHO database for medicines use for primary healthcare in developing and transitional
countries, just less than 80% of the prescriptions for acute respiratory infection (ARI) contain
antibiotics6. This is less than the average antibiotic use for this condition in Uganda.
In 2010, other medicines (the tool did not specify which medicines) were prescribed for 40%
(see figure above) of ARI cases. This is a significant contributing factor to the overall poly-
pharmacy in the country.
De-worming of children every three to six months is recommended in the UCG 2010 to
prevent infection with roundworm. To ensure that children receive the de-worming medicine,
all children should receive albendazole or mebendazole whenever visiting health facilities.
Only 7% of the ARI patients received any of these medicines (see figure above). The
findings, however, do not show what percent of the patients were children.
According to the Uganda Clinical Guidelines, appropriate management of mild ARI is

defined as including only antipyretics and cough/cold medicine, not antibiotics. The figure
below shows that only 6% of patients were treated appropriately with one or both of the
appropriate medicine types. The most common combination of medicine was by far
antibiotics and antipyretics/analgesics, which was prescribed to more than one-third of the
patients. These values remained the same from 2010. All other most common treatment
regimens include antibiotics.
As mentioned above, antihistamines are considered to be cough/cold medicines by some data

collectors. In the graph below, some of the appropriate treatments included cough/cold
medicine and should not be considered appropriate. The data collection was not detailed
enough to identify how many of the cough/cold medicines were antihistamines. Treatment
6
36
with cough/cold medicine remains rational in the graph below, since it is not possible to
identify appropriate from inappropriate treatments.
Figure 12. Medicine combination used in the treatment of mild ARI (n=598) (AB=antibiotic,
AP=antipyretic/analgesic, CC=cough/cold medicine, OTH=other medicine)
Treatment of Uncomplicated Malaria
Prescribing the appropriate treatment for uncomplicated malaria requires a parasitological test
using either microscopy or rapid diagnostic tests (RDTs). A positive test indicates that
treatment with an anti-malarial medicine is needed.
According to UCG 2010, first line treatment of uncomplicated malaria is artemisinin-

combination therapy (ACT) with the combination of artemether and lumefantrine (AL)
currently used, and second line treatment is oral quinine. The data collected for the survey did
not include information about testing. Laboratory information for this indicator is not
available in the Out-Patient Department (OPD) reference books. Therefore, appropriate
treatment was assessed only for patients with recorded diagnoses of malaria, which include
both clinical and test-based diagnosis.
37
Figure 13. Medicine used in treatment of malaria (n=629) (ACT=artemisinin-combination therapy (here
AL=artemether lumefantrine, SP=sulfadoxine/pyrimethamine))
Comparing 2010 to 2011, there is clear improvement in the rational use of anti-malarial
medicine. More patients were treated with first line (ACT), and fewer people were treated
with second line (quinine) and SP, which should only be used as a preventive treatment for
pregnant women and not for actual treatment of malaria. Inconsistent with UCG
recommendations, antibiotics are still prescribed to one-quarter of the patients. Paracetamol,
providing symptomatic treatment only, was the most common medicine prescribed for
malaria treatment in both 2010 and 2011.
Only 3% of the prescriptions provided AL exclusively, which is the most appropriate

treatment. Half of the patients received a combination of AL and paracetamol. Paracetamol is
not included in the clinical guidelines for treatment of uncomplicated malaria in Uganda, but
this combination is considered to be appropriate in countries with good medicine funding.
Though all sampled prescriptions had diagnosed patients with malaria, 2% of patients did not
receive any anti-malarial. This suggests that the anti-malarial was unavailable, patients were
misdiagnosed, or the correct diagnoses were miswritten in the OPD book.
38
Figure 14. Medicine combination used for treatment of malaria (n=629) (QNN=Quinine, AB=antibiotic,
OM=other medicine, AL=Artemether and Lumefantrine, PCM=paracetamol, SP=sulfadoxine and
pyrimethamine)
The table includes many different medicine combinations, indicating that the treatment of
malaria is not standardized, and prescribers do not adhere to standard treatment guidelines. A
wide range of combinations can also be due to prescribers failing to conclude a final
diagnosis. An example of failing to make a final diagnosis is the addition of antibiotic to AL
and paracetamol in cases where there is uncertainty if diagnosis is malaria or infection; this is
the case for 13% of the patients.
5.2.4 Rationing of Antibiotic Treatment
Appropriate prescribing includes prescribing medicine that is available for dispensing. This is
especially important for patients who likely cannot afford to buy medicine in the private
sector. Also, when prescribers prescribe an antibiotic that is not fully available in the health
facility, dispensers must either refrain from prescribing antibiotics or prescribe a full regimen
to avoid antibiotic resistance due to inappropriate treatment duration.
In this survey, five prescriptions with amoxicillin and five prescriptions with cotrimoxazole
per health facility were examined to evaluate rationing. Rationing was only found to take
place in two of the visited health facilities: one HC III and one hospital. Rationing in HC III
39
was due to low availability; cotrimoxazole was completely out of stock in the last three
months prior to the survey and amoxicillin was out of stock for 37 of the 90 days. No stock
card data was available for the hospital.
5.2.5 Rational Prescribing
Appropriate prescribing was assessed in a random sample of prescriptions made during the
previous two months prior to the survey at each facility. The assessment included several
WHO appropriate medicine use core indicators. The indicators were:
 Medicines prescribed per prescription

 Prescribing by generic name
 Prescription of antibiotics
 Prescription of injections
 Medicines prescribed from the Essential Medicine List for Uganda (EMLU) 2007
Medicines Per Prescription
The collected data revealed that an average of 3.3 medicines was prescribed per patient or
encounter in health facilities. Though it may be expected that higher referral levels, which
admit patients with complicated cases, would prescribe more medicines, this study only
evaluated out-patient prescriptions from which a similar pattern for the use of medicines
should be observed among all healthcare levels. It was found that lower health facilities
typically prescribed more medicine than higher health facilities. This was the case in both
2010 and 2011.
Poly-pharmacy is often linked to poor diagnostic skills, resulting in the treatment of all
possible conditions linked to the observed symptom. Prescribers at higher levels of care may
be better equipped to make diagnoses, thereby treating patients more appropriately and with
fewer medicines. This could explain why more medicines are prescribed per patient at lower
rather than at higher levels of care.
Though the increase in medicine prescribed per prescription is low, it could be associated
with the increase in medicine availability as reported in section 3.
Table 33. Number of medicines prescribed per prescription
2010 2011
Level of Care
Number of Drugs Prescribed Number of Drugs Prescribed
Hospital 3.0 3.0
HC IV 3.2 3.3
HC III 3.4 3.4
HC II 3.4 3.3
Average 3.2 3.3
Since 1982, developing countries prescribed two to three medicines per patient; with a 2006
average of 2.5 medicines. Across different regions of the world and both the private and
40
public sectors, East Asia and the Pacific has an above-average prescription of three medicines
per patient; however, this is still less than Uganda’s average of 3.2 medicines per patient 7.
Excessive medicines prescriptions increase patients’ risk of adverse effects and interactions
due to poly-pharmacy. Additionally, over prescribing is wasteful and costly, undermining an
already limited EMHS budget.
Prescribing by Generic Name
The generic name, also known as the international non-proprietary name (INN) is the official
WHO name given to a pharmaceutical substance. It differs from the brand name given by its
manufacturer. For example, the generic name of an analgesic is paracetamol, and one of its
brand names is Panadol. Often, there are numerous brand names for the same INN or generic
product.
To minimize costs, governments should procure medicines using the generic names, as these
are less expensive than brand names despite sharing the same active ingredients and having
the same effect. Further, the medicines should be prescribed and labeled with the fully spelled
out generic name as the use of the brand name can lead to confusion and possibly incorrect
prescribing and dispensing.
The 2011 findings show that on average, 43% of items were prescribed by their generic name
with a range of 38% in HC II to 46% in hospitals. In 2010, 80% of the items were prescribed
by generic name with no variation among health care levels. The WHO database on the
rational use of medicine shows that for public and PNFP facilities in Sub-Saharan Africa and
other developing countries, only 60% of medicines are prescribed by their generic name.
Private sector facilities tend to prescribe more brand names8. Prescribing by generic name in
Uganda has become less frequent than the Sub-Saharan Africa average from 2010 to 2011.
Prescription of Antibiotics
The irrational use of antibiotics creates a potential health problem of resistance to drugs,
thereby increasing medicine ineffectiveness in the treatment of infectious diseases. In Sub-
Saharan Africa, almost half of the patients receive at least one antibiotic when they visit a
health facility7. In Uganda, more than two-thirds of patients visiting public and PNFP health
facilities receive an antibiotic, and more than one-quarter of the medicines prescribed to
patients are antibiotics. There was a slight increase in patients receiving antibiotics and total
percentage of antibiotics prescribed from 2010 to 2011.
7
41
Table 34. Prescribed antibiotics
% Antibiotics of Total Medicine

% Patients Prescribed ≥ 1 Antibiotics
Prescribed
Level of Care
2010 2011 2010 2011
Hospital 69 74 27 31
HC IV 69 64 25 26
HC III 66 73 23 28
HC II 68 73 24 27
Average 68 72 25 28
The overprescribing of antibiotics is found at all healthcare levels without any significant
difference among the levels.
Prescription of Injections
The high rate of injections is a sign of inappropriate medicine use. Injection use is generally
high in Africa with one-quarter of all patients receiving injections. According to the WHO,
injection use in developing and transitional countries has remained steady with approximately
20% of patients receiving at least one injection.8
Similar to other African countries, one-quarter of all Ugandan patients received an injection
during every health facility visit in 2010, which fell to one-fifth of patients in 2011. Injections
were more commonly used in primary healthcare facilities than in hospitals and HC IV,
which raises concerns regarding costs, clinical capacity, and higher risk of infection if sterile
instruments are not used for each patient.
Table 35. Prescribed injections
% Injections of Total Medicine

% Patients Prescribed ≥ 1 Injection
Level of Prescribed
Care
2010 2011 2010 2011
Hospital 8 9 4 3
HC IV 22 18 8 7
HC III 29 26 10 9
HC II 35 19 14 7
Average 24 18 9 7
HC II and HC III have received kit supplies since June 2010, which allow the central level to
determine the availability of injection in the primary health care facilities. There has been a
8
42
reduction in the percentage of patients prescribed injections in HC II from 2010 to 2011,

which is likely due to revision of the kit content whereby availability of injections has been
reduced leading to reduction in use.
Medicines Prescribed from EMLU
Uganda developed an essential medicines list that includes all the medicines to be used in
public health facilities. The 2007 version of the EMLU was used for this assessment and
showed that all the medicines prescribed were included and that medicine not included in the
list were not prescribed.
5.3 Dispensing
Appropriate dispensing requires the right equipment, packaging materials, good dispensing
procedures, and specific instructions on how and when to take the medicines. This section
assesses the following:
 Packaging materials
 Dispensing equipment
 Dispensing time
 Labeling
 Patient knowledge
 The correlation between the medicines dispensed and medicines prescribed
5.3.1 Packing Materials
The type and quality of packaging materials for medicines dispensed to patients must be
appropriate to minimize damage due to handling, which may reduce medicines’
effectiveness.
Dispensing envelopes as opposed to paper cones are the appropriate option for tablets and
capsules. They are available from JMS and NMS and are bought as part of the facility credit
line. The use of dispensing envelopes had increased from 2010 to 2011.
Few types of syrup are available by NMS and are issued in small bottles containing one
treatment. Thus, the need for having empty bottles is limited. This reflects the low
availability of appropriate containers for dispensing liquids that are not pre-packed in their
original containers by the manufacturer. To ensure cleanliness and no possible contamination
of the medicine, liquids must be dispensed in a clean, unused container procured only for the
purpose of dispensing this formulation. NMS and JMS provide this type of bottle, but only
38% of the surveyed pharmacies and dispensaries had appropriate clean containers for
dispensing liquids available.
43
Figure 15. Use of packaging materials in health facility pharmacies/dispensaries
5.3.2 Dispensing Equipment
Appropriate dispensing is also defined by using dispensing equipment rather than counting
medicine with bare hands and the ability to measure liquids. Unavailability of dispensing
equipment may force the health worker to count the tablets with bare hands, which
potentially compromises their own health due to contact with potentially harmful active
ingredients in the medicines. Dispensing equipment must also be used to avoid cross
contamination and a potential reduction of the medicine’s shelf life from contact with human
skin.
Table 36. Use of dispensing equipment in health facilities pharmacies
2010 2011
Dispensing Equipment
Tablet counting tray available 25 22
Spatula/Spoon available 43 30
Graduated measuring cylinder available 11 0
Blank labels available 5 27
In only one-fifth of the pharmacies, healthcare workers used a spatula or spoon for counting,
while in one-quarter of the facilities, they used tablet counting trays. Either can be used by
itself to count, for example using a tin lid or pen when counting. Graduated measuring
cylinders were available in a few pharmacies in 2010; in 2011 none of the pharmacies used
this equipment for measuring liquids. Due to infrequent prescription of liquid medicine, this
finding is not critical. Blank labels to put on medicine bottles were rarely available in 2010,
but available in almost one-third of the pharmacies in 2011.
44
5.3.4 Dispensing Time
The dispensing time is the actual time the pharmacy staff takes to dispense the medicines to
the patient and provide information, counseling, and education about medicine to the patient.
The time spent with each patient reflects the quality standard of the information provided to
ensure appropriate medicines use.
When measuring dispensing time, data collectors excluded the time spent receiving the
prescription, identifying the medicine needed, and obtaining the medicine. The average
dispensing time in 2010 was 42 seconds and fell to 21 seconds in 2011. In 2010, the average
dispensing time in primary health care was longer than in both hospitals and HC IV. This
difference was not seen in 2011, where the dispensing time was similar across facility levels.
The shortest average dispensing time was at HC IV.
Table 37. Dispensing time
2011 Dispensing Time (seconds) 25 16 20 25 21
2010 Dispensing Time (seconds) 31 33 44 57 42
According to the WHO, the average dispensing time in low-income countries is over one
minute. This time, however, includes the preparation of a prescription and the dispenser’s
interaction with the patient, and it is not comparable to the dispensing time measured in this
survey. In fact, it is likely that the procedure used to prepare prescriptions requires more time
than interacting with a patient9.
5.3.5 Labeling
The appropriate labeling of medicines clarifies the information provided by the dispenser to
the patient, thereby minimizing medication errors. During the study, exiting patients were
asked to show the medicines they had received in the pharmacy to assess labeling. None of
the labels included all of the required information, though dosage and the medicine’s name
were most often written on the labels. The table on the next page summarizes the percentage
of medicine with the different labeling indicators included on the label.
9
Medicines Use in Primary Care in Developing and Transitional Countries. Fact Book Summarizing Results
from Studies Reported between 1990 and 2006. Geneva, World Health Organization, 2009.
45
Table 38. % Medicine with labeling indicators (n=582)
% Medicine
Medicine Medicine Medicine Date of Medicine Patient Facility
Labeled
Name Strength Quantity Dispensing Dose Name Name
With
Hospital 54 8 9 0 90 0 0
HC IV 38 15 5 0 78 0 0
HC III 59 4 19 11 86 5 10
HC II 48 6 10 8 90 5 8
2011 Overall
52 7 13 7 87 3 7
Average
2010 Overall
76 8 7 4 95 4 3
Average
In 2011, there were fewer medicines labeled with medicine name and dose compared to
findings from 2010 and additionally, there was only a small increase in medicine labeled with
quantity and facility name.
5.3.6 Patient Knowledge
Patient knowledge of medicines use is a WHO/INRUD10 indicator for rational dispensing that
focuses on patient adherence. It assesses patients’ understanding of how and why they should
take the medicine. On average, eight patients leaving each health facility were interviewed.
Table 39. Patient knowledge of use of medicines dispensed
Reason to
% Patients who Additional
Dose Frequency Duration Take
know Information
Medicine
Hospital 93 84 30 39 32
HC IV 86 82 28 41 16
HC III 90 74 11 44 18
HC II 93 81 25 38 17
2011 Overall
91 79 20 41 20
Average
2010 Overall
92 89 41 63 27
Average
Patients were found to be more knowledgeable about how much (dose) and how often
(frequency) to take the dispensed medicines than about how long (duration) they should take
the medicines. This corresponded with the labeling data on a dispensing envelope where the
dose and frequency were described in a pictogram. There were no significant differences
between facility levels for most of the indicators, except that knowledge about the duration of
medicines was lowest in HC III. In 2011, fewer patients knew the duration and frequency
than in 2010.
10
INRUD: International Network for Rational Use of Drug
46
Instructions on how to take the medicine were often available on the label (pictogram), but
information about the reason for taking the medicine, side effects, and whether medicine had
to be taken with or without food was to be communicated by the dispensing staff. Only 41%
of patients knew why they were to take the medicine, and only one-fifth of patients received
additional information, such as if medicine should be taken with food. Fewer patients
received this information in 2011 compared to 2010. Additional information is not easily
available to the dispenser, but referencing a national formulary book would make it easier for
the dispenser to access the information and pass it on to the patients.
5.3.7 Dispensing the Medicine Prescribed
This indicator measures the differences between the medicines prescribed and the medicines
dispensed. A higher percentage of the medicine prescribed was dispensed in 2011 compared
to 2010. Only at HC IV level was there a smaller difference in the percentage of medicine
prescribed and dispensed. Availability improved from 2010 to 2011, which likely caused the
improvement. The results show that on average, four out of five prescribed drugs were
dispensed per patient.
Table 40. Actual prescribed medicine dispensed
2010 2011
Level of Care % Prescribed Medicine Dispensed out % Prescribed Medicine Dispensed out
of Medicines Prescribed of Medicines Prescribed
Hospital 52 88
HC IV 79 60
HC III 59 82
HC II 34 82
Average 61 80
According to the WHO, the average percentage of medicine dispensed out of medicines
prescribed is approximately 85% in Sub-Saharan Africa; the Ugandan average is coming
closer to this overall average.11
11
47
ANNEXES
ANNEX A. FACILITIES INCLUDED IN SURVEY

Due to the establishment of new districts, some of the health facilities below are now part of
other districts. In the table, health facilities are still listed under the original district they were
sampled under. New districts are added.
AMURU/NWOYA DISTRICT YUMBE DISTRICT MASINDI DISTRICT

Anaka Hospital (GOU) – Nwoya
Yumbe Hospital (GOU) Masindi Hospital (GOU)
district
Atiak HC IV (GOU) Midigo HC IV (GOU) Bwijanga HC IV (GOU)
Alero HC III (GOU) – Nwoya
Kulikulinga HC III (GOU) Ikoba HC III (GOU)
district
Koch Goma HC III (GOU) –
Kochi HC III (GOU) Pakanyi HC III (GOU)
Nwoya district
Amuru HC III (PNFP) Ariwa HC III (GOU) Kinyara HC III (PNFP)
Otong HC II (GOU) Mongoyo HC II (GOU) Kijenga HC II (GOU)
Todora HC II (GOU) – Nwoya
Okuyu HC II (GOU) Kibyama HC II (GOU)
district
KALIRO KABERAMAIDO NAKASEKE
Bumanya HC IV (GOU) Lwala Hospital (PNFP) Nakaseke Hospital (GOU)

Gadumire HC III (GOU) Kaberamaido HC IV (GOU) Ngoma HC 4 (GOU)
Namugongo HC III (GOU) Alwa HC III (GOU) Wakyato HC III (GOU)
Kaberamaido Catholic HC III
Budini HC III (PNFP) Kinyogoga HC III (GOU)
(PNFP)
Nawaikoke HC III (GOU) Buluku HC III (GOU) Kirema HC III (PNFP)
Kasokwe HC II (GOU) Otoboi C/U HC II (PNFP) Lusanja HC II (PNFP)
Nawaikoke Flep HC II (PNFP) Apapai HC II (GOU) Kigegge HC II (GOU)
RAKAI MUBENDE KITAGATA

Kitagata Hospital (GOU) –
Kalisizo Hospital (GOU) Mubende Hospital (GOU)
Sheema district
Kakuto HC IV (GOU) Kasanda HC IV (GOU) Comboni Hospital (PNFP)
Rugazi HC IV (GOU) – Rubirizi
Mutukula HC III (GOU) Madudu HC III (GOU)
district
St. Joseph Maduudu HC III Katerera HC III (GOU) - Rubirizi
Kyebe HC III (GOU)
(PNFP) district
St. Gabriel Mirembe Maria HC Nyakatsiro HC III (PNFP) –
Buyamba HC III (GOU)
III (PNFP) Mitooma district
Rutoto HC II (PNFP) - Rubirizi
Kasensero HC II (GOU) Butoloogo HCII (PNFP)
district
Rwandaro HC II (GOU) -
Kyotera Muslim HC II (PNFP) Kaweeri HC II (GOU)
Rubirizi district
48
Annexes
ANNEX B. BASELINE DATA COLLECTION TOOL
BASELINE DATA COLLECTION TOOL

OCTOBER 2011 VERSION
Region:
District: Health Sub District:
Health Facility: Level:
Supervision Visit
Date Of Visit
No.:
Date of Next
Days To Next Visit:
Visit:
NAME OF PERSONS SUPERVISED
Gender Contact/Phone
# Name Profession
(F/M) No.
1.
2.
3.
4.
NAME OF SUPERVISORS
Contact/Phone
# Name Title
No.
1. □ District MMS □ HSD MMS
or
2. □ District MMS □ HSD MMS

or
Read and refer to “Guidelines on how to use the “Key points to

note when using the baseline data collection tool” before filling
the form or in case of clarification needs.
49
I. DISPENSING QUALITY
1. Dispensing Time
Observe and record the dispensing time for 6 patients.
Patient number 1 2 3 4 5 6 Average Comments
Dispensing time in
seconds
2. Packaging Material
Observe and verify the packaging material available and in use (Yes=1/No=0)
1/0 Comments
a) Are appropriate dispensing envelopes available?
b) Are appropriate clean containers i.e. bottles made
specifically for the purpose of dispensing liquids and
bottles that are not reused available?
Sum
3. Dispensing equipment
Verify that the dispensary has the following equipment in the dispensing area (Yes=1/No=0)
Equipment 1/0 Comments
a) A spatula or spoon
b) Tablet counting tray or similar
c) Tablets not counted by bare hands
d) Graduated measuring cylinder
Sum
4. Services available at the dispensing area

Verify that the dispensing area/health facility has the following services (Yes=1/No=0)
Services 1/0 Comments
a) Chairs or bench to sit on in dispensing area
b) Can privacy be achieved during dispensing?
c) Facility to wash hands by patient in facility?
d) Drinking water (to take tablets) by patient in dispensing
area?
Sum
50
Annexes
5. Patient care
Interview 10 patients and ask to see the medicines they have received and if possible their
prescription.
Select one of the medicines to check patient knowledge.
No. of medicines Patient knowledge (Yes=1/No=0)
Does pt.
Other
know
Dose/ Freq/ informat
Discrep Duratio why
Pt How How ion
ancy n/ how s/he is
no Prescribed Dispensed much often given:
(Y=1/ long to getting
. to to Adverse
N=0) take the
take take reaction
treatme
s, etc
nt
1
2
3
4
5
6
7
8
9
10
Comments:
6. Labelling
Interview 10 patients and ask to see the medicines they have received. Select one and check
for labelling (Y=1/ N=0)
Medicine Medicine Strength Quantity Date Dose Patient Facility
no. name* name name
1
2
3
4
5
6
7
8
9
10
*Note: The medicine name appears by generic name or by brand and generic name
Comments:
7. Non-Discrepancy between prescribed and dispensed medicines (antibiotics)

Select the last 5 entries including amoxicillin and the last 5 entries including cotrimoxazole
from the prescription and
dispensing log and record the amount of amoxicillin and cotrimoxazole prescribed and that
51
dispensed, respectively.
Drug Pt. no. 1 2 3 4 5 Sum Score: Percentage
[1 –
(sum/5)]
Amoxicillin Amount Comment:
prescribed
Amount dispensed
Discrepancy
(Y=1/N=0)
Cotrimoxazole Amount Comment:
prescribed
Amount dispensed
Discrepancy
(Y=1/N=0)
Average score and percentage
Comments:
II. PRESCRIBING QUALITY
8. Correct use of prescription recording system

Record from the last 10 entries from the prescription (or OPD) and dispensing log and note
whether the information below have been entered/recorded (Yes=1/No=0)
Prescription Date OPD Diagn Medi Prescrib Amount Amount Sum %
#
entries /IP osis+ cines er’s prescribe dispense (su
No. name name d d m/7)
* *10
0
1
2
3
4
5
6
7
8
9
10
Sum
% Average = % Sum of Last column/10
#
Date should be date of visit, date of previous day or last date the facility received patients if
the previous day was a weekend
+
Diagnosis refers to definite diagnosis e.g. Malaria, URTI, not symptoms e.g. fever
*Brand and generic name or generic name alone.
Comment:
52
Annexes
9. Rational prescribing
Randomly select 20 prescriptions from past 2 months and record information in table below
(Yes=1/No=0):
*When carrying out routine supervision randomly select the 20 prescriptions from the last
date of supervision
Pt No. No. of No. of No. of No. of No. & name of Diagnosis
medicines medicines antibiotics injections medicines not recorded
prescribe prescribed prescribed in the EMLU Diagnosis
d by =1/
generic symptoms
name =0
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Total # # #
………… ………… Patient/Dru Patient/Dru ……………… Diagnosis
…. gs gs ……. …….……
………/… ………/… ..
…… …….
Avera (total/20) % Patients % Patients (D/total
ge ………… receiving 1 receiving 1 i.e.
… or more or more 20)*100
antibiotics injections ………….
………… ………… .
….. ….
% % of % of drugs % of drugs % of drugs not
medicines being being in the EMLU
prescribed antibiotics injections ……………..
by generic ………… …………
name ….. …..
………..
Comments:
53
Adherence to standard treatment guidelines

Record from the prescriptions the adherence to treatment guidelines for diarrhoea, non-
pneumonia respiratory tract infection (cough/cold) and uncomplicated malaria. For each
condition, sample the last 10 prescriptions from the OPD book for each diagnosis. Only
consider prescriptions from the last 3 months. If there are not 10 prescriptions with that
diagnosis in the last month, leave the remaining fields blank and write comment.
Diarrhoea (No blood)

The appropriate diagnosis is diarrhoea. Only look at prescriptions for the last month from
today’s date.
Disease/Drug prescribed Cases (Yes=1, No=0) Total/No. of cases
* 100
Diarrhoea (No blood) 1 2 3 4 5 6 7 8 9 10
1 ORS
2 Antibiotics
3 Anti-diarrhoeal
4 Zinc
5 Vitamin A
6 Anti-spasmodic
7 Albendazole/Mebendazole
8 Other drugs given Sum of A=
Assessment (A=1,B=0) %A(1) =
(sum/total)*100:
Assessment: Mark 1 for A, appropriate (if ORS = 1, Zinc =1 or 0, Vitamin A = 1 or 0,
Albendazole/Mebendazole = 1 or 0 and all others = 0) ELSE mark 0 for B.
Comments:
10. Cough/Cold
The appropriate diagnosis for this are: Non-pneumonia, ART, ARTI, common cold, flu,
cough, cold, sore throat.
Disease/Drug prescribed Cases (Yes=1, No=0) Total/No. of cases
* 100
Cough/cold
1 Antibiotics
2 Antipyretic/ analgesic
3 Cough or cold drugs
4 Other drugs given Sum of A=
Assessment (A=1, B=0) %A (1) =
(sum/10)*100:
Assessment: Mark 1 for A, Appropriate (if antibiotics = 0 (No antibiotic given),
Antipyretic/analgesic = 0 or 1 and/or Cough/Cold drugs 0 or 1; Albendazole/Mebendazole =
1 or 0 and other drugs = 0] ELSE mark 0 for B (if Antibiotic = 1 and any other drugs given =
1).
Comments:
54
Annexes
11. Malaria treatment (uncomplicated malaria)

Consider both malaria and clinical malaria cases. In case no RDT for malaria or
functioning laboratory is available, score ‘Rapid test or smear conducted’ with NA.
Availability of testing facilities
Are Rapid Diagnostic Tests for malaria available?  Yes or  No
Is there a functional laboratory at the facility?  Yes or  No
Testing (1/0) 1 2 3 4 5 6 7 8 9 10 Sum %(sum/10)*100
1 Rapid test or smear
conducted
Treatment (1/0)
2 Artemether /Lumefantrine
(ACT)
3 Quinine Tab.
4 Pyrimethamine /Sulfadoxine
SP
5 Antibiotics
6 Paracetamol/Antipyretic
8 Other drugs given
*Appropriate treatment
(Y=1/N=0)
Assessment (A=1,B=0) %A (1) =
_____
*Appropriate treatment Y=1 if ACT given or Quinine tabs (but not both), Paracetamol=0 or
1, Antibiotics=0, SP=0, other drugs=0; else N=0
Assessment: 1 for A, Appropriate: [if Mal test =1 and ACT = 1 or Mal test =1 and Quinine
=1 AND Paracetamol=0 or 1, Albendazole/Mebendazole = 1 or 0, Antibiotic =0, SP=0, other
drugs given=0]
Assessment: 0 for B, Not Appropriate: [if Mal test =0 and (ACT=1, or Quinine=1) or
Antibiotic =1, or SP=1 or other drugs given=1]
Comments:
55
5
4
3
2
1
mg
56
24 tabs)
Calcium or
Name of medicine
III. STOCK MANAGEMENT
Amoxicillin caps 250 mg
sodium
Tin
100
Ciprofloxacin tabs 500mg tabs Pack
1000
bottle
Unit pack (e.g. tin of 1000)
/120mg tabs (Adult – dose of blisters
hypochlorite sol 0.5%V (JIK) ____ml
Chlorpromazine HCl tabs 100 Tin 1000
of
Artemether /Lumefantrine 20 Pack of 30
of
Item available? (check 1/0) Mark if expired (E)
Availability and correct use of stock cards, stock books etc.
Stock card/ledger book available (1/0)

needs to be taken. Don’t leave blank fields and explain all ‘NA’!
Is physical count done every month and PC

marked in stock card (check 3 months) (1/0)
Is the card filled correct with name, strength,
dosage form, AMC, special storage (1/0)
Balance according to stock card (record no. from
the card)
Count the no. of drugs in stock and record
Does balance & PC agree 100%? (1/0)
Record their monthly consumption (AMC)

NR/No.
Record the amount issued in the last 3 months
(From day of survey )
Record the number of days out of stock in the
last 3 months (day of survey)
Is stock book in use (with entry each month each
drug)
Is stock book correctly used (all fields filled &
AMC)
No. of days out of stock for the last 6 months;
record no. of days (from day of survey)
Record the highest balance on hand in the last 6
months (from day of survey). Circle if
Verify information recorded for the selected EMHS and complete the table (Y=1/N=0): If a product is never stocked, write ‘NA’ in all columns including
calculated write ‘NR’, not recorded. If item overstocked (column 16) for any of the 5 first items indicate by circling the highest balance. Action then
column 2; if stock card unavailable write ‘0’ in column 3 followed by ‘NA’ for other columns – only fill in column 2, 3, 13 and 14. If AMC not
overstocked for first 5 items (calculated

AMCx5)
9
8
7
6
15
14
13
12
11
10
500 ml
mg/5ml
60mg/400ug
Oxytocin inj 10IU/ml
Name of medicine
Erythromycin tabs 250mg
Measles vaccine inj IM/SC

Diazepam 5mg/ml Injection
Depo-provera inj 150 mg/ml
Cotrimoxazole tabs 400-80mg
Mebendazole tabs 100 mg Tin

Ferrosulphate+Folic acid tabs Tin
Tin
Tin
Magnesium Sulphate inj 2500 Vial

vials
vials
1000
1000
1000
amps
doses
Glucose (dextrose) inf 5% Bottles
Vial of
Pack of
Pack of
Pack of
__
10
25
10
of
of
of
of Item available? (check 1/0) Mark if expired (E)

the card)

NR/No.
drug)
AMC)
Annexes
57

AMCx5)
58
(HC I)
22 Sulfadoxine
preservative. 10ml
(AZT+3TC+NVP)
24 Water for injection

Name of medicine
19 Paracetamol tabs 500 mg
25 Surgical Glove latex – 7.5

20 Penicillin benzyl inj 1 MU
16 Metronidazole tabs 200mg
17 Oral rehydration salt sachet
/Fansidar tabs 500mg/25mg

18 Quinine sulphate 300mg tabs
23 Tetra cycline eye oint 1%V 5g

pyrimethamine
21 1st line ARV tabs (adult)
Tin
Tin
Tin
Tin
100
Pair
w. Pack
1000
1000
1000
1000
1000
Vials
3.5g tube
Pack of 60
Pack of 25
of
of
of
of
of
Item available? (check 1/0) Mark if expired (E)

the card)

NR/No.
drug)
AMC)
AMCx5)
kit
29 Field Stain A 25g
26 Syringe 5ML 21G
31 Microgynon (cycles)
Name of medicine
27 Blood collecting bag 250 ml

28 1st line anti-TB drug (RHZE)
100
Pack
30 Malaria diagnostic Rapid test Piece

Piece
Bottle
Cycles
Pack of 24
of Item available? (check 1/0) Mark if expired (E)

the card)

NR/No.
Comments (all ‘NA’ must to be explained! – if needed continue comments after scoring table on next page):

drug)
AMC)
Annexes
59

AMCx5)
IV. STORAGE MANAGEMENT
13. Cleanliness of the pharmacy (dispensary and main store)

(Tick only one Very clean Acceptable Not clean/ Comments
& tidy clean /tidy untidy
(score=1) (score=0.5) (Score=0)
The dispensary
is:
The Main store
is:
14. Hygiene of the pharmacy

Ask to be shown the toilet and hand washing facilities used by the pharmacy (dispensary &
store) staff. If there are no toilets, write ‘NA’ only for b) and c).
1/0/NA Comments
a) Are toilet facilities available?
b) Are the toilet facilities acceptable, hygienic and
functioning?
c) Is there toilet paper?
d) Are hand washing facilities acceptable, hygienic and
functioning?
e) Is there soap for hand washing?
19. System for storage of medicines and supplies

Ask to be shown around the pharmacy (main store) and observe the following conditions
1/0 Comments
a) Are medicines stored on shelves and /or in cupboards?
b) Are stock cards kept next to the medicines on the
shelves?
c) Are medicines stored on shelves or in cupboards stored
in a systematic manner (alphabetic, therapeutic etc)?
d) Are the shelves labelled?
20. Storage conditions

Ask to be shown around the main store and observe the following conditions
1/0/NA Comments
a) No signs of pests/harmful insects/rodents seen in the
area (Check traces, droppings etc from bats, rats, ants,
etc)
b) Are the medicines protected from direct sunlight
(Painted glass, curtains or blinds – or no windows)?
c) Is the temperature of the storage room monitored?
d) Can the temperature of the storeroom be regulated
(Ventilation, heater, air-condition, windows)?
e) Roof is maintained in good condition to avoid water
penetration?
f) Is storage space sufficient and adequate?
g) Is the store room lockable and access limited to
60
Annexes
authorised personnel?
h) Fire safety equipment is available and accessible (any
items for promotion of fire safety should be
considered)
i) Is there a functioning system for cold storage
(Refrigerator)?
j) If yes, are only medicines stored in the refrigerator –
no food or beverage?
k) Are vaccines placed in the center of refrigerator (not in
the door)?
l) Is the temperature of the refrigerator recorded?
Ask to be shown around the dispensary store and observe the following conditions
1/0 Comments
a) No signs of pests/harmful insects/rodents seen in the
area (Check traces, droppings etc from bats, rats, ants,
etc)
b) Are the medicines protected from direct sunlight
(Painted glass, curtains or blinds – or no windows)?
c) Is the temperature of the storage room monitored?
d) Can the temperature of the storeroom be regulated
(Ventilation, heater, air-condition, windows)?
e) Roof is maintained in good condition to avoid water
penetration?
f) Is storage space sufficient and adequate?
g) Is the store room lockable and access limited to
authorised personnel?
h) Fire safety equipment is available and accessible (any

items for promotion of fire safety should be
considered)
i) Is there a functioning system for cold storage
(Refrigerator)?
j) If yes, are only medicines stored in the refrigerator – no
food or beverage?
k) Are vaccines placed in the center of refrigerator (not in
the door)?
l) Is the temperature of the refrigerator recorded?
21. Storage practices of medicines in the pharmacy (stores & dispensary)

1/0 Comments
Store
a) Boxes are not on the floor in the store?
b) Is there a record for expired drugs (Check)?
c) Is there a place to store expired medicine separately?
d) Is FEFO adhered to? (Check 20 randomly selected
medicines)
Dispensary
e) Are opened bottles labelled with the opening date?
61
f) Do all tins/bottles that have been opened have a lid on

(dispensary)?
V. ORDERING AND REPORTING QUALITY
22. Reorder level calculation
Ask the supervisee how s/he decides the amount to order (including HC II & III, if they were to order)
No. Responses 1/0/NA

a) Select a stock card and stock book; select one drug (e.g. ACT) and check
whether the person knows how to determine the quantity to order. Let the
person show you how to calculate the quantity to order of the selected drug
Record: SOH= ………; Issued out (3 months)=.........; Stock out days (3

months)=.......; AMC=…….; Maximum quantity (AMCx5) =………
(Quantity to order = Maximum stock – Stock on hand)=……..
(Write 1 if quantity to order is correct)
b) What does VEN stand for? (score 1 if s/he knows all of VEN, otherwise 0)
c) Mention 4 vital items that you would always include in your order (applies
also to HC II & III).
Item 1:______________________ vital □ not vital □
Item 2: :______________________ vital □ not vital □
Score 1 if all items are vital, otherwise score 0.
Sum
Comments:
23. Timeliness of Orders and distribution
a) Do you know if NMS has a schedule for when to order and when to deliver:
 Yes  No NA
b) Do you have the schedule for ordering and delivery:  Yes  No NA
c) Do you adhere to the NMS schedule  Yes  No NA
d) Complete the dates of orders and delivery in the table below for the last order
*Fill all rows 1 to 5 for HC IV and hospitals; fill in only rows 3 to 5 for HC II & HC III as they receive kits.
No Cycle Cycle Cycle Cycle

1 2 3 4
1 Ordering schedule date
2 Actual date of ordering by facility (write date
stamped by DHO)
Was ordering timely (Y=1/N=0)
3 Delivery schedule date
4 Date of delivery from NMS
5 Date of delivery from district/HSD
62
Annexes
24. Accuracy of HMIS report: Check the accuracy of the last HMIS 105 report (Yes = 1/
No=0)
Date report was filled (use last report or last but one): ……. /…….
/…….
Medicine Is No. of Stock out Do the
information stock out days for report
on stock days for that month and
out days month as on the stock
available recorded Stock card card
from the on the (# days, data
last report report (# NA) agree?
(1/0) days, NA) (1/0/NA))
1. Artemether/Lumefantrine
2. Cotrimoxazole tabs
3. ORS sachets
4. Measles Vaccine (NA if no
refrigerator)
5. Sulphadoxine/Pyrimethamine(SP)
6. Depo-Provera (NA for catholic

PNFP)
Comments:
25.. Filing: Are the following filed? Check and see.

No. Item Yes=1/No=0/NA Comments
1 Discrepancy reports
2 Delivery notes
3 Previous orders made
4 Old prescription and dispensing
logs
Sum
26. Lead time

Time taken to submit a medicines order from the Health unit to NMS (Obtain and check copies of orders made)
1 2 3 5 6 8 10 11 Comments
Date Date Date Date Date Date Total
of order order order supplies supplies lead time
order approval received completed received received (Columns
Cycle
stamp at NMS at NMS at at 4 to 10

district facility OR Date
10 minus
date 2)
1
2
3
4
63
VI. ADDITIONAL BASELINE COLLECTION QUESTIONS
DISPENSING QUALITY
27. Number and training of staff

a) Record the staffing in the pharmacy/ store and dispensary responsible for managing and
handling medical supplies in the facility. Record number of staff and years of experience
Managing Medical
supplies Years of experience
Category of staff Number
Full Part-time record for each
time
1 Pharmacist
2 Pharmacy technicians
3 Nurse
4 Pharmacy orderlies,
5 Storekeepers / Store assistant
6 Other in contact with clients
7 Other not in contact with
clients
b) How many of the present pharmacy staff have been trained after graduation in supply chain
or logistics management?
c) On job training (number) ______________ Workshop (number) _____________
28. Reference material available to dispenser/pharmacy staff

a) What information sources are available – check their availability tick and record the year:
Reference materials Yes No Which
Year
1 Uganda Clinical Guidelines (UCG)
2 Essential Medicine List for Uganda (EMLU)
3 Essential Health Supplies and Laboratory Commodities
4 British National Formulary (BNF)
5 Financial Manual (add who it is prepared by)
6 Supply Chain Management Manual (add who it is prepared
by)
7 Other (Martindale etc. also incl. any patient leaflets
available)
29. Inspection by NDA

a) Ask the pharmacy staff if the pharmacy has been visited by NDA inspectors in the last one
year? Yes  No  Don’t know 
b) If Yes, were inspections helpful? Yes  No 
c) Are improvements needed? Yes  No 
d) If needed, please suggest which improvement:
64
Annexes
30. Supervision / coaching

a) Have you had supervisory visit in the last 6 month that included drug management?
Yes  No 
b) Do you have a supervision book or note: Yes  No  (Show it)

c) Do you use a visitor’s book for supervisory comments? Yes  No  (Show it)
d) Total number of supervisory visits received in last 6 month as recorded in book: ___
31. Dispensing procedure

Observe the dispensing process:
a) Is there a control carried out of the prescriptions and the medicines before dispensing, i.e. is
it counterchecked? Yes  No 
b) If Yes who undertakes the control: _______________________
PRESCRIBING QUALITY
32. Diagnostic equipment

Go to one OPD examination room and check for availability of the following
Tongue depressor Yes  No  Otoscope Yes  No 
Torch Yes  No  Stethoscope Yes  No 
Thermometer Yes  No  Vaginal speculum Yes  No 
BP machine Yes  No  Patella hammer Yes  No 
33. Patient load

Check in the prescription (OPD) book (if available) or from prescriptions stored by randomly
selecting three different days within the last month and record the number of prescriptions
filled:
Day 1 Day 2 Day 3 Average
No of prescriptions filled
STOCK MANAGEMENT
34. Stock management system

a) Does the main store have formal system for stock management that allows for the
following?
Stock management system Yes No Comments
1 Monitoring stock status of medicines
2 Calculation of reorder levels
3 Monitoring expiry of items
4 Calculation of average monthly
consumption
5 Reconciling physical and stock card
65
balance
6 Others; Specify:
b) Is the stock management system used in this store?

Manual stock card system 
Computerised inventory system 
Stock Ledger book based system 
Others; Specify__________________________ 
c) If you use stock cards; how long are stock cards kept? _______ Years
35. Nil lines and adjustments

Use delivery note or delivery invoices and order forms to fill the table below
Number of No of NIL No. of EXTRA Number of lines(items) that have
items in the lines items not been adjusted
orders (items ordered but (up+ ;down -)
Cycle ordered but supplied D
not supplied) Upward Downward Number
A C adjust. adjust. adjusted
B
1
Total
Total % of nil lines. Total (B) / Total [Total number adjusted / total
(A) X 100% items ordered] X 100%
36. Goods receipt procedures

a) What do you check when you receive medicines and commodities from the supplier?
Tick if mentioned, don’t tell the options!
Before opening
1 Check Delivery note
2 Check if all packages are unopened
3 Check that packages are all undamaged
4 Count the boxes
After opening
1 Check for type; quantity; physical damage
2 Check expiry date and number of month left
3 Check label information of all supplies type,
4 Signing the delivery note
5 Others (Which): _______
66
Annexes
b) Do you have written procedures (Standard Operating Procedures, SOP) for goods receipt?
Yes  No 
c) Have you ever received medicines where there was a discrepancy? Yes  No 
d) If Yes, how often has this happened?

Almost every delivery  Every 1-6  Annually 
e) What was the problem (Describe):
f) What do you do if a box or some medicines is missing or there is another discrepancy (Tick
off):
Tick
1 Note the officer name:
2 Write in delivery note the problem –then sign
3 Note vehicle registration number
4 Fill in a discrepancy report
5 Communicate to DHO/HSD
6 Communicate to supplier (NMS/JMS)
7 Others (Which)
g) Do you file discrepancy reports Yes  No  (check)

h) Do you follow up with the district Yes  No 
i) Do you follow up with the supplier NMS / DHO Yes  No 
j) If Yes, does it help / you get a response Yes  No 
k) Do you have written procedures for writing discrepancy report Yes  No 
67
ANNEX C. BASKET OF ITEMS SURVEYED

The basket items included in this survey are listed in the table below. The level of care and
VEN classification according to EMHSLU 2012 are included in the table.
Level of Care
Basket Item VEN
(EMLU)
Amoxicillin Tablets 250mg HC II V
Artemether/Lumefantrine Tablets 20/120mg HC II V
Calcium or Sodium Hypochlorite Solution
HC I E
5% (JIK)
Chlorpromazine HCL Tablets 100mg HC II V
Ciprofloxacin Tablets 500mg HC II V
Cotrimoxazole Tablets 480mg HC II V
Depo-Provera Injection 150mg/mL HC II V
Diazepam Injection 5mg/mL HC IV V
Erythromycin Tablets 250mg V HC IV N
Ferrosulphate/Folic Acid Tablets
HC I V
60mg/400ug
Glucose (Dextrose) Infusion 5%, 500 mL HC III V
Magnesium Sulphate Injection 2500
HC III V
mg/5mL
Measles Vaccine Injection IM/SC HC II V
Mebendazole Tablets 100mg HC II E
Metronidazole Tablets 200mg HC II V
Oral Rehydration Salt Sachet HC I V
Oxytocin Injection 5IU/mL HC III E
Paracetamol Tablets 500mg HC II E
Penicillin Benzyl Injection 1 MU/ 600mg HC III E
Quinine Tablets 300mg HC III E
Sulfadoxine/Pyrimethamine Tablets
HC II V
500mg/25mg
Tetracycline Eye Ointment 1%, 5g HC II V
Water for Injection with Preservative 10mL HC II V
st
1 Line ARV Tablets (Adult)
HC IV V
(AZT+3TC+NVP)
68
Annexes
1st Line Anti-TB drug (RHZE) HC III V

Ethinylestradiol/levonorgestrel Tablets
HC II E
30µg/150 µg (Microgynon)
Surgical Gloves Latex size 7.5 HC II V
Syringe 5cc Needle Disposable 21G HC II V
Field Stain A 25g HC III V
Malaria Diagnostic Rapid Test Kit HC II V
69

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MINISTRY OF HEALTH

THE REUBLIC OF UGANDA

UGANDA PHARMACEUTICAL SECTOR REPORT 2011

Produced by: The Division of Pharmacy Services

Data collectors in the pharmaceutical sector data collection exercise:

Angonifua Jennifer Medicine Management Supervisor, Nebbi Hospital, Nebbi

The Ministry of Health-Government of Uganda, Annual Pharmaceutical Sector Report 2011.

I hope you will find this report helpful and interesting.

UGANDA PHARMACEUTICAL SECTOR REPORT 2011 .............................................. I

Table 1. Summary of findings for selected indicators ............................................................................ 1

Figure 1: Spidograph of the average health facility performance ........................................................... 3

ACT Artemisinin-Combination Therapy

Table 1. Summary of findings for selected indicators

1. Facilities with stock cards available 68% 77% 

10. Facilities where no boxes are stored on floor 46% 23% 

 % of patients prescribed 1 or more antibiotics 68% 72% 

 % of patients prescribed 1 or more injections 23% 21% 

Adherence to Ugandan Clinical Guidelines

23. Overall average dispensing time 42 seconds 21 seconds 

The increased availability of EMHS positively resulted in more appropriate treatment of

Figure 1: Spidograph of the average health facility performance

 General standards of the facility

Figure 2. Sampled Districts

 District hospital (if exists)

DATA COLLECTION TOOL, TEAMS AND PREPARATION

DATA COLLECTION, ENTRY AND ANALYSIS

FINDINGS AND DISCUSSIONS

1. GENERAL STANDARD OF THE FACILITY

 Health facility characteristics

1.1 Health Facility Characteristics

Table 2. Characteristics of health facilities surveyed

Type of Facility Private Not-for-Profit

Total 47 (75%) 16 (25%) 63

1.2 Patient Load

Public Facility – Average # Patients PNFP Facility – Average # Patients

1.2 Staff in Pharmacies/Dispensaries and Medicine Stores

Pharmacists 7 5 100 100 3 3

Pharmacy Technicians 15 6 86 100 10 12

1.3 Services Offered

Table 5. Services offered to patients in facilities

Hand washing facilities (n=62) 35 29

Privacy when receiving dispensary services (n=62) 31 56

Drinking water available to patients (n=60) 30 24

1.4 Level of Hygiene in Staff Toilets and Hand Washing Facilities

Table 6. Conditions of toilet and hand washing facilities

Toilet paper available 17 7

2. SUPPLY CHAIN MANAGEMENT

 Receipt of medicines and health supplies

2.1 Receipt of Medicines and Health Supplies

Checks Completed upon Receiving Supplies

Count the boxes 33 67

Check that all boxes are unopened 22 21

Check that all boxes are undamaged 18 30

Check label information on all supplied items 25 22

Check for type of item, quantity, and physical damage 67 85

Check expiry date 40 64

Signing the delivery form 71 70

Follow up with supplier (NMS/JMS) 64

Follow up with DHO/HSD 45

Fill in discrepancy report 32