NATIONAL EVALUATION OF MEDICINES DISPENSING WITHIN BRAZILIAN AIDS PROGRAM

1. Third International Conference for Improving Use of Medicines Azeredo TB, Luiza VL, Esher A, Emmerick ICM, Matta SR, Avelar FG PAHO-WHO Collaborating Centre for Pharmaceutical Policies – Brazil Antalya, Turkey November 14-18th 2011 NATIONAL EVALUATION OF MEDICINES DISPENSING WITHIN BRAZILIAN AIDS PROGRAM

2. Background Pharmaceutical services concerning to People Living with HIV and Aids (PLWHA) are fundamental for the Brazilian response to the epidemic. Drug dispensation is a component of the pharmaceutical services that includes direct interaction with facility users. More than deliver quality drugs; the service should give orientation and inform users how to correctly use medicines. The environment should also be adequate. A service performance considered to be good should involve an adequate relation between professional and patient. This work was conducted in response to a requirement from the National Coordination of the Brazilian Aids Program, with its support.

3. Study Aims To evaluate the quality of pharmacies that dispense medicines for opportunistic infections and antiretrovirals in Brazil, focusing aspects of service performance and user satisfaction, within the public sector.

4. Methods Cross-sectional study. Data was collected by checklist oriented observation of services, document consultation and interviews with health workers and patients. Setting: PS (Pharmaceutical Service) within the public sector distributed in 19 municipal districts, in ten Brazilian states. • Municipalities and dispensing facilities were selected through systematic sampling, with proportional probability to the total patients in treatment, by using the database SICLOM (Medicines Logistic Control System). Patients sample size (n) was determined with a maximum absolute error (ε) of 7.5% and a significance level (α) of 5%. Study Population: 29 PS were visited, 101 health professionals and 1412 patients were interviewed. Outcome Measure(s): Performance and satisfaction indicators were organized in three ATM dimensions: accessibility (timing), availability and adequacy to technical standards.

5. Methods Satisfaction scores ranged from 0 to 100, based on a psychometric instrument. The applied questionnaire covered the following aspects: socio-demographic profile, previous experience with public health services, and opinion issues related with satisfaction. Items concerning to satisfaction were stated as opinion sentences to which users had to express their level of agreement. A database was constructed and analyzed using Excell and SPSS 9.0. The entire process involved interactions with main stakeholders, as civil society, national and local health managers and policy makers. The project followed the ethical guidelines presented in the National Health Council ruling (Resolução CNS 196/96 – Brasil, 1996) and was approved by the Research Ethic Committee of the National School of Public Health – Fiocruz/ MoH.

6. Framework

7. Results – Timing / convenience

8. Results – service performance Availability • 81.1% of the checked list of medicines was available, ARV (88%) more available then Medicines for opportunistic infections (63%) • None expired medicines were found. Adequacy to technical standards • 61.9% of stock register were confirmed by counting. • 60% of the items checked for environmental quality were adequate. • 20.5% of users were oriented by the pharmacy attendant and 50.8 of attended prescriptions were complete • 31% of DS with good procedures to stock control

9. Results – service performance Graph 1. Percentage of oriented patients and average available time to dispense medicines according to the possibility of privacy on the dispensary environment.

10. Results – user satisfaction Aspects declared as most important: availability of medicines and interpersonal relationship Aspects found to influence most satisfaction level: accommodation and interpersonal relationship Figure 1- User satisfaction average score, according to ATM dimensions.

11. Results – user satisfaction Within the accessibility (timing) dimension, choice of care provider and time spent received the lower scores, 39.7 (±2.2) and 58.4 (±1.6), respectively. Service organization was the best evaluated component, 90.0 (±0.7). The best estimated dimension was ARV availability, 77.4 (±1.5). Within the adequacy dimension, the component interpersonal aspects showed the worst result, 70.8 (±1.0).

12. Conclusions Strengths and weaknesses of the Dispensing of ARV in Brazilian Aids Program were identified • Strengths (e.g. High availability of ARV; No expired medicines were found – the problem exist, but it residual; Most users knew how to use their medicines; PS with better accommodation, specially privacy conditions are able to orient patients concerning to rational use) and • Weaknesses (There were municipalities with inadequate coverage of treatment offer; There were found problems on the availability of MOI; Problems with the stock control; Pharmacists are not totally contributing to patient care)

13. Conclusions The Program allowed feedback to stakeholders in many ways (meetings, publications and internet). As one of the results of this process a Working Group was established at national level, including representatives from state level programs, civil society and the evaluators group, aiming to set strategies related to problems identified.

14. Thank you!