INDICATORS FOR MEDICINES INFORMATION SERVICES IN DEVELOPING COUNTRIES

1. INDICATORS FOR MEDICINES INFORMATION SERVICES IN DEVELOPING COUNTRIES Ball DE1, Tagwireyi D2 1Dept of Pharmacy Practice, Kuwait University, Kuwait 2Drug & Toxicology Information Service, Dept of Pharmacy, University of Zimbabwe, Zimbabwe

2. Indicators For Medicines Information Services In Developing Countries Ball DE1, Tagwireyi D2; 1Dept of Pharmacy Practice, Kuwait University, Kuwait 2Drug & Toxicology Information Service, Dept of Pharmacy, University of Zimbabwe, Zimbabwe Problem Statement: Medicines information centres (MICs) in developing countries need to be able to assess and plan their development and function. Objective: To develop & field-test indicators for monitoring MICs. Method: Structure, process and outcome indicators were developed with input from INDICES electronic forum. Tested on six MICs in Africa (Botswana, Eritrea, Ghana, Kenya, South Africa, and Zimbabwe). Results: • Structure indicators generally deficient except S. Africa, Ghana, Eritrea. • Constitution, budget, dedicated telephone line, full-time staff only all at SA, Gh • Funding varied from 0% to 100% public funding • Process indicators generally well met • SOPs, reference sources in place, access to library • Two centers did not have good MI filing systems • Outcome indicators results variable • Only one offered a 24-hour service; one able to accurately state the level of use • QA measures not commonly implemented • Participation in DTCs and health care training activities was high One MIC had operated >20yrs despite deficiencies in indicators suggesting other factors are important in sustaining a MIC. Conclusions: The indicators differentiated between MICs and provide a resource for rapid assessment of the growth and effectiveness of MICs. However, other less easily quantifiable factors e.g. staff enthusiasm, are also important in sustainability in resource-poor settings.

3. Background • WHO recognises medicines information (MI) to health care workers (HCWs) & public as component of rational drug use (RDU) • MI in WHO Medicines Strategy but emphasis is on consumers • Promote RDU; integrate into training for HCWs [WHA 52.19/99] • WHO Medicines Formulary, Bookshelf, EM Library, publications • But need the MI to reach the consumer/HCW in situ • Medicines Information Centres or services (MICs) are one avenue • Development of national MICs in anglophone Africa slow: • 3 in 1980  6 in 2003; Two of initial 3 still operating • Two more planned in 2004; also local/regional centres • Some constraints have been described (Kasilo et al. 1989; 1991) • Funding, staffing, training, resources • For existing services • Monitor efficiency and efficacy – improve & support • Learn about sustainability - what works, what doesn’t • Adapt functions to priority needs – planning and self-audit

4. Objectives & Methods • AIM: Develop indicators to monitor the development and effectiveness of MI services in developing countries • Field-test & refine the indicators and make available for wider use • Indicator development • previous work e.g. UK MI Group; DSE/WHO workshop report • input from INDICES (International Network of Drug Information Centres) electronic discussion forum • Draft indicators surveyed through e-mailed self-administered questionnaires to MI services in Africa: • Local/regional: Botswana (est. 2003), Kenya (2000) • National: Eritrea (1994), Ghana (2003), South Africa (1980), Zimbabwe (1979) • No response from Tanzania and Amayeza (S. Africa) • Indicators refined and development ongoing • To be used alongside DSE/WHO workshop report

5. Results • Structure, process and outcome indicators developed with assistance of INDICES - see following slides • Indicator field test results: Structure indicators (Table 1) • Generally deficient except Eritrea, Ghana, South Africa • Funding varied from total reliance on public sources to mixed income from consultancy and training services Process indicators (Table 2) • Generally well met with “deficiencies” due to MIC being proactive with limited reactive role Outcome indicators (Table 3) • Variable results from MICs • Only one centre offered 24 hour service; only one able to accurately state the level of use • Quality assurance measures almost non-existent • Most produced bulletins; participation in DTCs and healthcare training was high

6. Structure indicators • 1. Presence of a constitution (operating document): • 2. At least one full-time professional staff e.g. doctor, pharmacist, nurse: • 3. Total number of professional staff (full-time equivalents): • 4. At least one secretarial support person: • 5. Separate institutional budget for MI activities: • 6. The MI service is based in: (i) academic institution, (ii) health institution, (iii) government department • 7. Percentage of the budget (incl. salaries) from: (i) Gvt., (ii) NGOs, (iii) pharmaceutical companies, (iv) other • 8. Dedicated office space (MI room), including basic furniture needs: • 9. Present for MI activities: (i) dedicated telephone line, (ii) fax machine, (iii) working photocopier, (iv) working computer, (v) MIC e-mail address • (a) The latest edition of 10 specified key reference sources present • (b) Percent of key references above which are present Answer: Yes/No/Don’t know [DK]/number as appropriate

7. Process indicators 1. Presence of standard operating procedures (SOPs) for handling requests: 2. Standard enquiry record forms are immediately available for use: 3. Systematic method of filing records which facilitates future access: 4. Easy access to consultant physicians if required for information: 5. SOPs for induction of new staff are present and reviewed in past 5 years: 6. At least 1 staff member received MI-related training in the past year: 7. Access to a medical library or other source of biomedical journals: 8. Staff participate in hospital ward rounds: 9. Staff are involved in teaching undergraduate/postgraduate HCWs: 10. MI service has hosted international MI colleagues for training/ exchange in the past year: Answer: Yes/No/Don’t know [DK]/number as appropriate

8. Outcome indicators 1. Total number of MI requests in the previous calendar year: 2. No. of MI requests for past year was 90% or greater than previous year: 3. At least 1 issue of a MI bulletin or newsletter published in the past year: 4. Participation in local/national therapeutic committee in the past year: 5. At least 1 presentation given to a professional or public body in the past year: 6. Annual report from previous calendar year available: 7. A 24 hour service is offered: 8. Self-audit exercise has been conducted & documented in the past year: 9. Percentage of callers satisfied with their contact/response from the MIC: 10. Percentage of enquiries related to poisonings/ toxicology information: Answer: Yes/No/Don’t know [DK]/number as appropriate

9. Table 1: Structure indicator results Countries: Botswana, Eritrea, Ghana, Kenya, South Africa, Zimbabwe

10. Table 2: Process indicator results Countries: Botswana, Eritrea, Ghana, Kenya, South Africa, Zimbabwe

11. Table 3: Outcome indicator results Countries: Botswana, Eritrea, Ghana, Kenya, South Africa, Zimbabwe

12. Discussion • Indicators adequately sensitive • Differentiated between MICs • Able to identify areas needing strengthening • SOPs, record forms, lack of staff/equipment, no QA • All MICs concentrated on MI to HCWs, public lesser extent Limitations • Certain indicators not relevant to some MICs • Eritrea mostly a proactive service; not enquiry answering • Clinical activities of Botswana & Kenya not captured • Some MICs don’t need toxicology reference texts • Real outcomes are difficult to measure/show • User satisfaction; Improved patient health • Surrogate process measures used which may take the focus from the true desired outcomes • Sustainability in poorly resourced situations often depends on not easily quantified factors e.g. staff enthusiasm

13. Implications • The indicators provide a resource for rapid assessment of the growth and effectiveness of MICs • Regular use can assist in development of MICs if they are understood and used in planning • Further refinement and development of manual in process • To make available through INDICES and WHO-EDM website • Acknowledgements • INDICES e-mail discussion forum • The following in particular made valuable contributions: • Leesette Turner, Drug Information consultant, South Africa • Lee Baker, Amayeza Drug Info Service, Johannesburg, S. Africa • Jude Ike Nwokike, Maun Hospital, Maun, Botswana • Atieno Ojoo, Gertrude’s Garden Children’s Hospital, Nairobi, Kenya • Annoeskja Swart, Medicines Information Centre, Cape Town, S. Africa • Philip WO Anum, National DI Resource Centre, Accra, Ghana • Embaye Andom, Drug Information Unit, Ministry of Health, Eritrea

14. References • Menkes,DB. Hazardous drugs in developing countries. BMJ 1997; 315: 1557-1558 • Kasilo OJ & Nhachi FB. Recommendations for establishing a drug and toxicology information center in a developing country. Drug Intell Clin Pharm 1991; 25: 1379-1383 • Kasilo OJ, Nhachi FB. How to establish a drug and toxicology information centre in a developing country. Essential Drugs Monitor, No. 16, 1993: 8-9 • Kasilo OJ & Froese EH. A 10-year review of the Teaching Hospital-Based National Drug and Toxicology Information Service in Zimbabwe. J Clin Pharm Ther 1989;14(5): 355-371 • Barlett G, et al. Evaluating the quality and effectiveness of a drug information centre. DSE/WHO Seminar on Drug Information Centres, Berlin, 1997 • Funding: Self-funded