Microsoft word - cbm_phase_iv__medicine_report3

Report on
Availability of essential medicines in PHCs of 5 districts of Maharashtra
During the 4th phase of Community based monitoring (CBM) in Maharashtra, availability of essential medicines in PHCs has been assessed quite extensively. Availability of 28 essential medicines was assessed in the 4th phase of CBM (data collected in the period Sept. 2010 to March 2011). All selected medicines belong to the list of essential medicines for PHC prepared by the Health Department. Data was collected from 71 PHCs belonging to 22 blocks across 5 districts of Maharashtra viz Pune, Amaravati, Osmanabad, Thane and Nandurbar. The list of selected medicines includes categories of medicines including analgesics, antibiotics, antiallergics, antiemetics, deworming medicines, steroids, sedatives, antimicrobial creams, antacids, anti snake venom, anti rabies vaccine etc. As per Maharashtra state Government guidelines, every PHC should have medicine supplies that would be adequate for estimated average requirement for a period of 3 months. For the purpose of this study, this 3-months requirement was used as the benchmark for evaluation. Further for the ease of analyzing collected data, following categories of stock availability were considered. A. Categorization of ‘medicine availability’ in terms of Stock level
Table No.1
Categorization of medicine
Parameter used in terms
availability situation
of Stock level
Stock for less than 1 month’s requirement Problematic excess of availability Stock of more than 6 month’s While analyzing the data, instances of medicine availability were taken as one of the basis. Stock of
each particular medicine in each PHC is counted as one instance of availability. Thus complete data
regarding 28 medicines in 71 PHCs would be expected to yield 28x71 = 1988 total instances of
medicine availability. Out of these instances, there would be some proportion of instances of no
stock, poor availability, good availability etc. Figures for ‘no stock’ and ‘poor availability’ when
combined were collectively considered as indicating ‘deficient availability’. The present report
summarizes important findings regarding availability of medicines in 71 PHCs from 5 districts of
Maharashtra.

B. Overall situation of medicine availability
Combining data from all the 5 districts, it has been seen that in half (50%) of the studied
instances, medicines were found to be deficient in stock. In 24% of total instances medicines
stock was found to be zero in the PHCs – these medicines were not at all present in the PHCs.
There were 26 % instances wherein medicines stock was poor in availability i.e. adequate for less
than 1 month period, and in only 26% of the instances situation of medicines was found to be good
∗ Report prepared by Shweta Marathe and Deepali Yakkundi, SATHI, based on information collected by coalition of civil society organizations implementing Community based monitoring in Maharashtra. across 5 districts of Maharashtra. Further in 11% of instances the medicines were found in excessive stock which would last for a period of more than 6 months requirement as per standard defined guidelines. Graph no 1.
Availability of medic ines  among  5 D is tric ts  of Maharas htra  : %  of 
Ins tanc es
C. Deficient availability of medicines in the PHCs

It has been observed that out of 28 selected medicines there were 18 essential medicines showing
deficient availability in above 40% of PHCs. These medicines include very commonly used and
high priority medicines such as Rabipur anti-rabies vaccine used against dog bite, syrup
Paracetamol, syrup Septran which is a major antimicrobial preparation for children, Inj. Oxytocin
used during delivery, and life saving medicines like Inj. Atropine. It should be noted that many of
these medicines are supplied from multiple sources of medicine supply i.e. Zilla Parishad,
various National health programs and medicine kits from Haffkine Institute. Despite supply from
multiple sources, these routinely required essential medicines were deficient in PHCs is a matter of
serious concern.
List of 18 medicines showing deficient availability across 5 districts
Table No. 2
% of PHCs where
medicine availability was
Name of medicine
deficient
Tab. Atenolol or Tab.Envas (Enalapril) 97 Tab. Glibenclamide
Following table describes the number of essential medicines showing deficient availability
in more than 40% of the PHCs in each district

Table No. 3
Name of district
medicines
showing deficient
availability
D. Zero stock situation of medicines in the PHCs

As mentioned above there were significant number of instances showing zero stock in the PHCs. 15
out of 28 selected medicines were showing absolutely zero stock in around 25% to 92% of PHCs
across 5 districts. The list of Zero stock medicines also includes routinely used and high priority
medicines such as Inj Oxytocin required during delivery, Syp. Paracetamol, Syp.Septran used as
antimicrobial especially for children, antibiotic Tab. Metronidazole, Tab. Diclofenac used in body
pain, Domperidone used against vomiting. Along with the issue of stock deficiency, zero stock of
the essential medicines in the PHCs is a worrisome situation which emphasises the immediate need
to take up the issue and improve medicine availability.
List of medicines showing zero stock in more than one-fourth of PHCs across 5 districts
Table No.4
Name of medicine
% of PHCs with zero
stock
Tab. Atenolol or Tab.Envas (enalapril) 56% Tab. Diazepam Following table describes number of medicines showing zero stock in over 40% of PHCs
in each district
Table No.5
Name of district
No. of medicines
showing zero stock
in > 40% PHCs
Pune 11 Amaravati 8 Osmanabad 10 Thane 8 Nandurbar 4 E. Maldistribution of medicines
Since shortage of medicine is a major problem, excessive stock of medicine is also a problem
which is suggestive of erratic supply, maldistribution of stock, and deficient management of
medicine distribution at district and block levels. As shown in graph no.1, in 11% of the instances
medicines were found to be excessive in stock among 5 districts. It includes medicines such as, Inj.
Adrenaline, Tab. Albendazole, Inj. ASV, Tab. Dicyclomine, Tab. Fluconazole, Tab. Metronidazole,
Inj. Oxytocin, and Inj. Tetanus Toxoid. It has also appeared that the same medicines which were
deficient or completely nil in some PHCs, were present in excessive quantity in other PHCs in the
same district. Having observed this paradox, it can be said that medicines are mal-distributed and
are managed inappropriately at district level. During district wise analysis of the data, this issue is
further discussed at length.
Graph no.2
Situation of problematic excess and deficiency of the
same medicines within the district
Snapshot of paradoxical situation showing deficiency and excess of the same medicines
within each district
Table No.6
Name of medicine %
PHCs % of PHCs
district
with deficiency with
problematic
excess
Amaravati
Osmanabad
Nandurbar
In case of these medicines, proper distribution across facilities and shifting of excess stock from certain PHCs to other PHCs with deficient stock could significantly solve the problem of shortages of these medicines.
The following part of the report specifically describes the specific situation of
medicine availability in each of the 5 districts.

1. Pune district
• The following graph (Graph No.3 ) depicts that in Pune district, in 14% of instances situation of medicine stock was partly satisfactory, in 24% of instances it was good i.e. stock was adequate for fulfilling requirement of around 6 months period. Graph no.3
Availability of medic ines  in 
P une dis tric t :  %  of ins tanc es
• However, in 48% of instances stock of medicines was found to be deficient out of which, in 30% of instances there was NIL stock in the PHCs. • On anaysing the data in depth, it reveals that out of 28 studied medicines 17 medicines were deficiently available in around more than 40% of the PHCs. 2 essential medicines namely Tab. Atenolol (used in high BP) and Tab.Glibenclamide ( used against diabetes) were found to deficient in all the studied PHCs. Also, there were 11 essential medicines which were showing zero availability of stock in between 40% to 93% of the PHCs.
List of 17 medicines showing deficient availability in more than 40% of the PHCs in Pune
Table no. 7
% of PHCs where medicine
Name of drug
was deficient
List of 11 medicines showing zero stock in over 40% PHCs in Pune
Table No. 8
Name of medicine
% of PHCs with zero stock
Tab. Atenolol or Tab.Envas (enalapril) 80 Inj. Carboprost or Inj. Prostidine 80 Tab. Diazepam • In Pune district we have found excessive stock of medicines in around 14% of instances. Following table enumerates contradictory situation of medicine availability i.e. same medicine showing deficiency and stock excess within the same district. Seeing the percentage instances of deficient and excessive stock it can be said that employing inter exchange or re distribution of medicines among PHCs within the district, would significantly help mitigating the problem of medicine shortage in PHCs within district. Perhaps for some medicines (Tab. Paracetamol, Tab. Fluconazole, Tab. Dicyclomine, Inj. ASV) inter exchange would have resolved the problem of shortage of medicine completely. Paradoxical situation showing deficiency and excess of the same medicines within Pune
district
Table no.9
Name of medicine % of PHCs with % of PHCs with
deficiency
problematic excess
2. Amaravati District
• In Amaravati district, in half of the instances (Graph no.4) medicines were deficient in stock. Out of this 50% of instances of deficiency, in 24 % instances there was NIL stock in the PHCs. • As shown in the graph no.4 there were 14% of instances, situation of medicine availability was partly satisfactory and in merely 28% of instances it was good. Graph no.4
Availability of medic ines  in 
Amaravati dis tric t : %  of  ins tanc es
• Detail scrutiny of the unavailability of medicines shows that, 14 medicines were
deficiently available in around more than half of the PHCs. 4 essential medicines
namely Tab. Diclofenac, Tab.Glibenclamide, Tab.Atenolol and Tab. Diazepam shows
deficient availability in almost 80% to 100% of the instances. Besides this, 8 essential
medicines (table no.10) were showing zero availability of stock in around 40% to
100% of the PHCs
List of 14 medicines showing deficient availability in more than 40% of the PHCs in
Amaravati district
Table No.10
% of PHCs where medicine
Name of drug
availability was deficient
Tab. Atenolol or Tab.Envas (enalapril) 94 List of 11 medicines showing zero stock in over 40% PHCs in Amaravati
Table No.11
Name of medicine
% of PHCs with zero
stock
• In 8% of instances problematic excess was reported in Amaravati district. There were 7 medicines showing deficiency and at the same time problematic excess in some PHCs within the Amaravati district. Hence it seems that instances of excess were quite sufficient to curb the shortage of the same medicines in some PHCs, if inter exchange of medicines from one PHC to other would have taken place.
Paradoxical situation showing deficiency and excess of the same medicines within Amaravati
district
Table No. 12
Name of medicine
% of PHCs with % of PHCs with
deficiency
problematic excess
3. Osmanabad District

• Situation of availability of medicines in Osmanabad district does not differ much from the deficient situation observed in other parts of the state under CBM. In 52% of instances deficiency was reported in Osmanabad district. On the contrary in 15% of instances problematic excess of medicines was found. There were only 21% instances observed wherein availability was good. While in 12% of instances availability was found to be partly satisfactory. Graph No.5
Availability of medic ines  in 
Os manabad dis tric t : %  of ins tanc es
• It was found that, there were 11 out of 28 selected essential medicines were deficiently available in more than half of the studied PHCs. List of medicines showing deficient availability in more than 40% of the PHCs in Osmanabad
district
Table No.13
% of PHCs where medicine
Name of drug
availability was deficient
Tab. Atenolol or Tab.Envas (enalapril) 50 Tab. Diclofenac • Out of 52 % of instances of deficiency, in 25 % of instances, stock of medicines was NIL. Detail analysis of the data illustrated that 10 out of 28 medicines were showing zero stock in 40% to 100% (i.e. in all the studied PHCs) of the PHCs List of medicines showing zero stock in over 40% PHCs in Osmanabad district
Table No.14
Name of medicine
% of PHCs with zero stock
Tab. Atenolol or Tab.Envas (Enalapril) 50 Tab. Diclofenac • Problematic excess of medicines stock were found to be quite significant. The following table presents contradictory situation of deficiency and excess stock of the same medicines within one district. There were 9 essential medicines showing such contradiction. If we see % of PHCs with deficiency and excess of these 9 medicines, inter exchange of stock would have solved the problem of shortage of these 9 medicines completely. Paradoxical situation showing deficiency and excess of the same medicines within
Osmanabad district
Table No. 15
Name of medicine
% of PHCs with % of PHCs with
deficiency
problematic excess
4. Thane district
• Thane district seemed to be a district facing highest level of deficiency among all 5 districts in Maharashtra under the CBM. It was reported that in 59% of instances medicines stock was deficient in position, in only 23% of instances situation was good and in 16% of instances its availability was partly satisfactory. Out of those 59% of instances of stock deficiency, in 24 % of instances there was zero stock in the PHCs. Graph No.6
Availability of medic ines  in 
T hane dis tric t :  %  of  ins tanc es
• Another striking observation was that out of 28 selected medicines 22 medicines were deficiently available in more than half of the PHCs. There were 11 medicines (Table No.16) with absolutely no stock in between 40% to 100% of the PHCs. List of 22 medicines showing deficient availability in more than 40% of the PHCs in
Thane district
Table No.16
% of PHCs where medicine
Name of drug
availability was deficient
Tab. Atenolol or Tab.Envas (enalapril) 92 Tab. Diazepam List of medicines showing zero stock in over 40% PHCs in Thane district
Table No.17
Name of medicine
% of PHCs with zero stock
• Since excessive stock was hardly observed in the studied PHCs from Thane district, there was no scope for cross-PHC exchange of medicines to resolve the deficiency of medicines.
5. Nandurbar District

• Though the situation of medicines availability in Nandurbar district was not found to be satisfactory, the situation is slightly better than the situation in other 4 districts. • It was observed that in 43% of instances medicines were deficient in stock, in 13% instances it appeared to be partly satisfactory, only 28% instances showed good availability and in almost 16% of instances stock of medicines was found to be excessive. • Out of 43% of instances of deficient stock, in 19% of the instances medicines were not at all Graph No.7
Availability of medic ines  in 
Nandurbar dis tric t : %  of ins tanc es
• Further, it was reported that 15 medicines were deficiently available in more than 40% of the PHCs. Few essential medicines were found to be deficiently available in almost all the PHCs. And there were 6 medicines showing zero absolutely no stock in the PHCs. List of 15 medicines showing deficient availability in more than 40% of the PHCs in
Nandurbar district
Table No.18
% of PHCs where medicine
Name of drug
availability was deficient
Tab. Atenolol or Tab.Envas (enalapril) 100 Tab. Glibenclamide List of medicines showing zero stock in over 40% of PHCs in Nandurbar district
Table No.19
Name of medicine
% of PHCs with zero stock
Tab. Atenolol or Tab.Envas (Enalapril) 71 Inj. Carboprost or Inj. Prostidine • It was observed that, 9 medicines were showing deficiency and at the same time excess situation in the same district. Seeing the number of instances of deficiency and excess of some of the medicines such as Inj. ASV, Tab. Fluconazole, Tab. Metronidazol, Inj. Oxytocin, and Syp. Septran, it can be said that, inter exchange of these medicines within the district would have completely solved the problem of their shortage within the district. Paradoxical situation showing deficiency and excess of the same medicines within
Nandurbar district
Table No.20
Name of medicine
with % of PHCs with
deficiency
problematic excess

Conclusions

• The findings from the above data show that combining data from all 5 districts, in half of
the instances availability of 28 selected essential medicines was deficient. Stock of these
medicines was not adequate even to suffice the requirement of one month period.
• Zero stock of these essential medicines is another area of concern. One-fourth of medicines
were found to be absolutely nil in stock. This problem has been observed across all 5
districts. The supplied quantities of medicines were overall too meager to fulfill the basic
requirements.
• The present data analysis makes it evident that, government has not been able to make available essential and high priority medicines which belong to the list of essential medicines for PHCs. • Many of the selected medicines such as Rabipur anti-rabies vaccine used in case of dog bite, Syp. Paracetamol, Syp. septran which are key medicines used for children, life saving medicines like Inj. Atropine, Inj. Oxytocin used during delivery and Inj. Tetanus toxoid are supplied from multiple sources, despite this routinely required essential medicines being deficient in the PHCs is an issue of serious concern. • Besides the problem of unavailability of medicines, problematic excess is also a matter of concern which needs serious attention. Problematic excess seemed to be related to missing links between distribution mechanism and actual requirement in the PHCs. In addition, mismanagement of stock from district to PHC level is also associated with this problem. As illustrated in the report above, several medicines were having shortage and at the same time stock excess in different PHCs within the same district. Inter exchange of their stock across PHCs and logical distribution would have solved much of the shortage at least for these particular medicines. • If we look at the comparison among districts, the present report shows that situation is somewhat better in a tribal district like Nandurbar, compared to Pune district which is considered to be a developed district. Thane is the district suffering from medicine deficiency to the maximum extent. • Widespread unavailability or deficient availability of important medicines including Inj. Tetanus Toxoid, Rabipur anti-rabies vaccine, commonly used analgesics such as Paracetamol, Diclofenac, syrups for children, Inj. Oxytocin which is important for care during delivery, antibiotics such as Soframycin and Metronidazole, calls for urgent measures to improve the medicine procurement and distribution system in the state. Annexure I
List of districts, blocks and PHCs from where data collection on availability of medicines was
carried out

District Block PHC
2. Amaravati
3. Osmanabad
5. Nandurbar
Annexure II
List of 28 selected medicines surveyed for availability in PHCs
No. Name of Medicine
4 Tab. Atenolol or Tab.Envas (Enalapril) 6 Inj. Carboprost or Inj. Prostodin 7 Tab. -------------------------------------------------

Source: http://www.sathicehat.org/uploads/ReportsOfCBMData/CBM%20Maharashtra%20phase%20IV%20PHCs%20availability%20of%20medicine%20report.pdf