ACCESS TO AND RATIONAL USE OF

MEDICINES AT THE

HOUSEHOLD LEVEL

Federal Ministry of Health

© 2010 Federal Ministry of Health, Nigeria

All rights reserved. No part of this publication may be reproduced, stored in

retrieval system or transmitted in any form or by any means, electronic, mechanical,

photocopying, recording and/or otherwise, without prior written permission of the

Federal Ministry of Health, Nigeria.

ISBN 978-978-49531-3-9

For all enquiries or comments, write to the publishers:

The Honourable Minister,

Federal Ministry of Health,

Federal Secretariat Complex,

Shehu Shagari Way,

P.M.B. 080 Garki,

Abuja,

Nigeria

Printed in Nigeria

i

TABLE OF CONTENTS

TABLE OF CONTENTS..................................................................................................................ii

ACKNOWLEDGEMENTS............................................................................................................iii

LIST OF ABBREVIATIONS..........................................................................................................iv

EXECUTIVE SUMMARY..............................................................................................................1

METHODOLOGY...........................................................................................................................3Study purpose and objectives ......................................................................................................3Study area.....................................................................................................................................4Study design.................................................................................................................................4Sampling procedures....................................................................................................................4Training of data collectors and pretesting of survey instruments................................................7Data collection.............................................................................................................................8Data analysis................................................................................................................................8Ethical considerations..................................................................................................................8

RESULTS.........................................................................................................................................8Characteristics of households/respondents..................................................................................9Access........................................................................................................................................16Rational use of medicines..........................................................................................................21

DISCUSSIONS..............................................................................................................................25Sociodemographic characteristics..............................................................................................25Access........................................................................................................................................25Rational use of medicines..........................................................................................................26Limitations.................................................................................................................................27

CONCLUSION AND RECOMMENDATIONS...........................................................................28

ii

ACKNOWLEDGEMENTS

The Federal Ministry of Health is grateful to Prof. Babatunde Osotimehin, the Honourable

Minister of Health and Mr. J. E. B. Adagadzu, the Acting Head, Food and Drug Services

Department for their contribution to the project.

The Ministry also appreciates the continued support of the World Health Organization in

Nigeria in the pharmaceutical sector. We are particularly grateful to Dr. Peter Eriki, the WHO

Representative in Nigeria, Dr. Edelisa Carandang, Technical Officer, WHO Geneva, Dr. Ogori

Taylor, the Essential Drugs and Medicine Policy (EDM) Advisor for Nigeria and Dr. Olaokun

Soyinka, Health Promotion Advisor for Nigeria for their commitment to the realisation of the

project. We wish to thank the European Commission for their financial contribution to the

project.

The contributions of Mrs. Catherine Vialle-Valentin from Harvard Medical School, Boston and

Mrs. Oluwatosin Ayo-Ajayi are also acknowledged. Mrs. Bridget Okala is appreciated for

coordinating activities at the Federal Ministry of Health level. The contributions of the

Pharmacists in Food and Drug Services Department who collected data are gratefully

acknowledged.

iii

LIST OF ABBREVIATIONS

iv

ACT Artemisinin Combination Therapy

CHEWS Community Health Extension Workers

GMP Good Manufacturing Practice

HMO Health Maintenance Organisation

MDCN Medical and Dental Council of Nigeria

NAFDAC National Agency for Food and Drug Regulation and Control

NGO Non-governmental Organisation

NHIS National Health Insurance Scheme

NMCN Nursing and Midwifery Council of Nigeria

NRA National Regulatory Authorities

OTC Over the Counter

PHC Primary Health Care

PCN Pharmacists’ Council of Nigeria

PMS Patent Medicine Shop

TBA Traditional Birth Attendant

USD United States of America Dollars

WHO World Health Organisation

EXECUTIVE SUMMARY

The main objective of the National Medicines Policy is to make available at all times and in all

sectors of the health care system, adequate supplies of medicines which are effective,

affordable, safe and of good quality; and also to promote rational use of medicines. The

objective of this study was to assess the extent to which the population has access to medicines

required to treat acute and chronic illnesses.

One state from the 6 geopolitical zones of the country was randomly sampled. Six

reference health facilities were chosen from both urban and rural areas. Households were

surveyed at less than 5km, between 5-10km and more than 10km from the reference facilities.

ne thousand and eighty (1080) households using the newly

revised WHO household survey tool.

� The results show there is good access to health care facilities as less than 2% of

households travel more than 1 hour to the nearest health facility in the public and

private sectors to obtain care. The most accessible health facilities were the public

hospital, the drug seller and the health centre in descending order of accessibility.

� Most households pay for medicines out of pocket as fewer than one out of every 5

households claimed to have obtained medicines free or supported by any form of

health insurance.

� Most households did not consider availability of medicines to be a hindrance to the

treatment of acute illness in members. However, they rated availability in both public

and private facilities low, with public facilities being the more affected.

each of

Interviews were conducted in o

Key Findings

Access

1

� Affordability of medicines constituted a barrier to access to medicines to about half of

households and the same proportion claimed to have borrowed or sold assets to be

able to pay for their medicines. About one out of every 3 chronically ill patient did not

take medicines because they could not afford them. The majority of chronically ill

patients (76%) did not have up to 30 days supply of medicine

� Most household members with acute illness sought care outside the home. In about

two thirds of cases, doctors prescribed for those with acute illnesses while drug sellers

prescribed for 13% and pharmacists for 7%. Almost all of them took medicines to treat

the acute illness.

� While most medicines found at the household were dispensed using adequate primary

packaging materials only half were adequately labelled with medicine name, dosage

instructions and expiry dates.

o The Nigerian health system needs to be re-engineered to ensure that different levels of

health care play the role for which they were established. The PHC needs to be

revitalised to ensure greater utilisation for care.

o Since drug sellers were shown to be important pharmaceutical care providers in the

community, they need to be adequately regulated and their capacity strengthened to

ensure that they provide adequate care. Of particular importance is the labelling of

medicines which needs to be standardised and enforced.

o Interventions to increase affordability of medicines especially for the chronically ill

should be devised by the government. Such interventions may include,

Increasing health insurance coverage for the populace especially for the poor

and the chronically ill

Ensuring greater access to medicines by exploring mechanisms such as

providing free medicines to the poor and chronically ill, monitoring the price

of medicines and developing and implementing a pricing policy

Rational Use of Medicines

Recommendations

2

METHODOLOGY

Study purpose and objectives

Figure 1: Map of Nigeria

Information on access and rational use of medicines are usually obtained from healthcare

facilities and retail outlets; however little information is available from end users of medicines.

This survey therefore aims to obtain accurate information from the end users on how they

obtain and use medicines. Results from the study are intended to serve as a basis for strategic

planning and implementation of programmes by policy makers; either in the short term or long

term, so that an enabling environment can be created and people empowered and motivated

to seek healthcare and use medicines for their acute or chronic illnesses

3

The following are the objectives of the study:

O To make recommendations for improvement in access to and rational use of medicines

Nigeria is located on the West Coast of Africa and has a landmass of 923,678 square

kilometres. It is divided into six geopolitical zones, which comprises 36 states and a Federal

Capital Territory. The states are further divided into 774 Local Government Areas (LGAs).

The 2006 census indicates that Nigeria has a population of about 140 million with a life

expectancy of about 48 years. There are over 250 ethnic group of which the predominant ones

are the Hausa-Fulani, Yoruba and Ibo in the north, southwest and southeast respectively. The

official language is English, but over 250 other languages are spoken.

It was a cross-sectional, descriptive time delimited study aimed to determine access and

rational use of medicines in households in Nigeria using the newly revised WHO Household

survey tool.

A multistage sampling technique was used to select the study population. Nigeria is divided

into six geopolitical zones each comprising between five to seven states and each state further

divided into LGAs.

O To determine the sociodemographic characteristics of the surveyed households

O To determine the various geographical and financial barriers to access to medicines in

the public and private sectors

O To determine the level of rational prescribing, dispensing and use of medicines at the

household level.

Study area

Study design

Sampling procedures

4

Selection of Reference Healthcare Facility

TABLE 1: SAMPLED HEALTH FACILITIES

One state was randomly selected from each of the six geopolitical zones. Six LGAs comprising

three rural and three urban LGAs were randomly selected from a list of LGAs in each of the six

selected states.

A reference central point, which is a secondary healthcare institution (general hospital) was

identified in each of the LGAs. Any selected LGA which does not have a secondary healthcare

facility was replaced with another randomly selected LGA..

The table below shows reference healthcare facilities selected from each of the six geopolitical

zones of the country.

5

Geopolitical

Zone

Sampled State Identified Reference Healthcare

Facility/LGAGeneral Hospital, Illela

General Hospital, Bodinga

UDUTH, Wamako

Maryam Abacha Hospital

Sokoto Specialist Hospital

Northwest Sokoto

General Hospital, Rabah

General Hospital, Share

General Hospital, Offa

General Hospital, Omuaran

General Hospital, Lafiagi

Ajikobi Cottage Hospital

Northcentral Kwara

Civil Service Hospital, Ilorin

Federal Medical Centre, Jalingo

Cottage Hospital

Cottage Hospital, Mutun Byiu

Cottage Hospital, Ardokola

General Hospital, Zing

Northeast Taraba

General Hospital, Wukari

Selection of Households

Thirty (30) households divided into six (6) clusters were selected at a given distance from the

reference healthcare facility in each LGA. This consists of two (2) clusters of five (5) households

each selected within 5km radius from the facility, ten (10) households (2 clusters) between 5km

and 10km and another ten (10) households (2 clusters) more than 10km from the reference

healthcare facility. Each cluster of household per given distance was selected from different

directions from the reference facility.

With the secondary healthcare facility as the central reference point, a household per cluster in

which an appropriate household informant was present was chosen for the interview.

Depending on the population density of an area, subsequent households were selected per

cluster skipping between appropriate numbers of households before the next interview was

conducted. If an appropriate household informant was not present at the time of conducting

the interview, a later time was re-scheduled. However, households that declined participation

were replaced with another household.

6

General Hospital, Epe

General Hospital, Badagry

General Hospital, Orile-Agege

General Hospital, Ajeromi

General Hospital, Somolu

Southwest Lagos

General Hospital, Isolo

General Hospital, Ebonyi

General Hospital, Amachi

General Hospital, Itim Afikpo

General Hospital, Owutu

General Hospital, Ishiagu

Southeast Ebonyi

Comprehensive Health Centre

Central Hospital, Ughelli North

Central Hospital, Warri

Govt. Hospital, Ibusa

General Hospital, Otujeremi

General Hospital, Bomadi

Southsouth Delta

General Hospital, Okwe

Selection of Household Informants

Data collectors

Training of data collectors and pretesting of survey instruments

The household informant or an appropriate substitute who met at least three of the following

criteria listed below were selected.

� Main health care decision maker

� Most knowledgeable about health of household members

� Most knowledgeable about health expenditures of the household

� Most knowledgeable about health utilization by household members

� Designated care giver for sick household members

Twelve (12) pharmacists drawn from the Federal Ministry of Health were trained and used as

supervisors for the collection of data in the six geopolitical zones of the country. They in turn

recruited and trained twelve pharmacists in each of the sampled states. Each of the teams was

supported by the Community Development Committee representative who helped them gain

easy access to households.

A two-day training for supervisors was conducted in Abuja, the Federal Capital Territory. The

training provided background information on the survey as well as data gathering (using the

questionnaire) and data entry (using the epidata software) techniques. Qualities required of

enumerators were also highlighted.

The trainees pretested the data collection instrument with their own families and neighbours.

Experiences, observations made and lessons learnt were discussed on the second day of the

training. The culture and predominant language spoken was taken into consideration when

drafting supervisors to each geopolitical zone.

7

The supervisors in turn trained the recruited enumerators in the selected states. Training lasted

one day using methods such as lectures, demonstration, discussion and role play. Emphasis

was laid on skills required for asking questions on sensitive issues such as amount spent on

household expenditure, types of illness, taking cultural factors into consideration. Pre-testing

of the instrument was done on the same day among the participants and clarifications on the

tools were made. Training also continued in the field as supervisors were present to provide

support throughout the period of data collection.

Data collection was done by a team of two enumerators per 30 households and spanned a

period of two days. Interviews were scheduled on Sundays and Saturdays in order to increase

the possibility of meeting household informants. Revisits were made where the household

informant was absent.

The data obtained were manually sorted, verified, coded and entered into the computer for

statistical analysis using the Epidata software. Data was presented using descriptive statistics

(means, percentages) charts and graph.

Consent was sought and approval obtained from the Ministry of Health of each of the selected

states and the community leader prior to the commencement of the study. Furthermore,

informed consent was obtained from the head of each household before conducting the

interview. Consent was verbal and not written. Written consent may have created a barrier to

the study due to cultural peculiarities. Verbal consent was therefore regarded as sufficient.

A total of one thousand and eighty (1080) respondents from households located at specified

distances from reference healthcare facilities were interviewed from the predetermined

locations

Data collection

Data analysis

Ethical considerations

RESULTS

.

8

Characteristics of Households/Respondents

Table 2: Household income bands

Demographic Information

Socioeconomic Information

The results of the survey showed the median number of persons in the households was 7 with

half of interviewed households having between 5 and 10 people living in them. Almost all the

households had children aged 12 years and below and 72% of households had at least one

child under 5. Most of the respondents were males (61%) and were between 25 and 50 years of

age (69%). One out of every 5 respondents had no formal education.

The majority of the households had a source of livelihood; the main income earners being

either traders/artisans (36%) or civil servants (32%). Only about (13%) of households did not

have anyone who earned income.

Sampled households had a median of 5 rooms; with half of these having between 3 and 7

rooms. Seventy four percent (74%) of the households had electricity, 55% had toilets not

shared with neighbours and 22% had tap water.

The main assets owned were radio (91%), mobile telephones (70%), house/land (68%).

Among those which had electricity, 82% had television and very few had computer (11%) or

air conditioner (10%).

9

Income bands Per capita expenditure % of respondents Number

A <1997 22.1 237

B 1997 – 3295 26.0 279

C 3296 – 4950 21.5 231

D 4951 – 9697 24.1 259

E > 9697 6.2 67

Table 3: Socioeconomic information of households

Figure 2: Age distribution of respondents

10

Percentage of Respondents by Age

<25 years

3%

26-50years

69%

>50

28%

Indicator Value

Median number of members per HH 7

Percentage of households with children 90.8

% female respondents 39.2

Median number of rooms per HH 5

% HH with the following:

Electricity

Running water

Own toilet

74.4

54.7

22.3

% HH with no one earning money 12.6

Figure 3: Educational attainment of respondents

Figure 4 : Occupation of respondents

11

Figure 5: Percentage of households with certain assets

Health Expenditure Indicators

Table 4: Health Expenditure indicator

The results show that 8.9% of households have monthly medicine expenditures that represent

more than 20% of their total expenditures. It also reveals that medicines account for 3.5% of

total household expenditure; with about 2,600 naira being spent on medicines per person on

an annual basis.

12

Indicator Percentage/

Median

% HH whose monthly medicine expenditures represent at least > 20% of

total expenditures

8.9

Median household medicine expenditures as % of total expenditures 3.5%

Median household medicine expenditures as % of non-food expenditures 12.7%

Median household medicine expenditures as % of total health

expenditures

100%

Median annualized health expenditures per person (Naira)

Medicine

Hospital

Other health expenditures

Health insurance expenditure

Total health expenditure

2600

2888

1381

2437

3250

Median HH medicine expenditures for a reported illness as a % of total

expenditures

Acute illness

Chronic illness

3%

1%

Morbidity Characteristics of Households

Table 5: Illness Characteristics of Household

Fifty seven percent (57%) of households interviewed reported at least one episode of acute

illness while 27% reported at least one chronic illness. Seventeen percent (17%) of households

had members who had both acute and chronic diseases in the period under investigation.

The main acute illnesses reported include fever and headaches (77%), acute respiratory tract

infections (ARI) (39%), and 68% of these were regarded as either very serious or somewhat

serious.

The main chronic illnesses reported include hypertension, (32%), arthritis or chronic body

pain (32%), ulcer or chronic stomach pain (20%), diabetes (12%) and asthma, wheezing or

chronic difficulty breathing (11%). The median age of household members with chronic illness

was 50 years, and half of those with chronic illness were between 36 and 60 years old

13

Indicator Percentage/Median

% HH reporting no illnesses 32.8

% HH reporting at least one acute and one chronic illness 29.9

% HH reporting at least one acute illness 56.9

% HH reporting at least one chronic illness 27.3

Median number of acute illnesses per HH 1

Median number of chronic illnesses per HH 1

Median age with acute illness

Years

Months

4

6

Median age with chronic illness 50

% females with acute illness 48.2

% females with chronic illness 43.5

Figure 6: Percentage of household members with acute illnesses by category of symptoms

Figure 7: Perceived severity of acute illness

14

Perceived Severity of Acute Illnesses

Not serious

32%

Somewhat

serious

47%

Very serious

21%

Figure 8 : Percentage of household members with chronic diseases

Medicine Financing

Table 6: Medicine financing indicators

Access

The survey shows that very few respondents (17%) claimed to obtain free medicines from

public healthcare facilities or had at least partial insurance coverage for the medicine used for

either acute (7%) or chronic (4%) illness. About one third would usually obtain credit from

pharmacies.

15

Indicator Percentage/Median

% respondents who can get free medicines at public health care

facility 16.6

% respondents who say they can get credit from the private

pharmacy

28.5

% HH with at least partial insurance coverage for at least one

medicine

Acute illness

Chronic illness

6.6

4.0

Geographical Accessibility

Table 7: Geographical accessibility indicators

Figure 9: Respondents who traveled more than one hour to reach the closest facility

Only 11% of respondents regarded distance of the facility from which medicines can be

obtained as a hindrance to adhering to prescribed medications and only 2% of respondents

have to travel more than one hour to reach any healthcare facility closest to them. Nearly a

quarter of those with chronic illnesses reported not taking prescribed medicines because the

place where medicines can be obtained was too far away. Most respondents considered the

location (70%) and opening hours (74%) of their public healthcare facility as convenient.

16

Indicator Percentage/Median

% respondents who say that prescribed medicines were not

taken “because the place where medicines can be obtained was

too far away”

Any illness

Acute illness

Chronic illness

10.6

3.4

23.3

% respondents who agree that the location of their public

healthcare facility is convenient.

69.6

% respondents who agree that opening hours of their public

healthcare facility are convenient

74.4

Figure 10: Respondents who traveled more than one hour to reach the facility used for

treatment of acute illness

Availability

Less than 10% of the respondents who had either an acute or chronic illness attributed non-

adherence to their prescribed medication to non availability at healthcare facility. More

respondents agreed that medicines are available at their pharmacy (52%) than their public

healthcare facility (37%).

The median number of medicines kept at home was three and one quarter of the medicines at

home were kept for future use. Forty two percent (42%) of households with children did not

have any medicines at home. About 30% of households with chronically ill members did not

have prescribed medications.

Of the medicines kept in households, analgesics (31%), multivitamins and supplements (22%)

antibiotics (12%) and anti-malarials (10%) were most frequently seen. Of the classes of

medicines seen in households paracetamol (analgesic), metronidazole, ampicillin/cloxacillin

and cotrimoxazole (antibiotics) and chloroquine (antimalarial) were most prevalent.

17

Table 8: Availability of Medicines in Healthcare Facilities in both Public and Private Sectors

Table 9: Availability of Medicines at the Household Level

Figure 11: Medicines kept at home

18

Indicator Percentage/

Median

Median number of medicines at home 3

% HH with no medicines at home 43.0

% HH who have children and have no medicines at home 41.9

% HH who have children <5 year and have no medicines at home 42.4

% HH who do not have at home the medicines prescribed to a chronically ill

HH member

29.2

% HH classes of medicines kept for future use 24.8

Indicator Percentage

% respondents who say that prescribed medicines were not taken “because

medicines were not available at the healthcare facility”

Any illness type

Acute illness

Chronic illness

7.3

4.6

11.6

% respondents who agree that medicines are available at their public

health care facility

36.7

% respondents who agree that medicines are available at their pharmacy 51.8

Figure 12 : Analgesics kept at home

Figure 13: Antibiotics kept at home

19

Figure 14: Antimalarial kept at home

Affordability

Table 10: Medicine affordability indicators

Fifty four percent (54%) of respondents claimed to be able to afford to buy the medicines they

need. About fifty percent agreed that medicines are more expensive at private pharmacies than

public healthcare facilities and 46% had to borrow money or sell things to pay for medicines.

Although very few (15%) mentioned non-affordability as reason for not adhering with

prescribed medication for their illnesses, it was more of a hindrance to those who were

chronically ill (28%) than those who had acute illness (7%). They however agreed that better

insurance coverage would increase their use of medicines.

20

Indicator Percentage

% respondents who agree medicines are more expensive at private pharmacies 48.9

% respondents who can usually afford to buy medicines they need 53.8

% respondents who have had to borrow money or sell things to pay for

medicines

46.3

% respondents who say that prescribed medicines were not taken “because HH

cannot afford medicines”

All illnesses

Acute illness

Chronic illness

14.6

6.9

27.9

% respondents who agree that better insurance coverage would increase their

use of medicines.

49.5

Rational Use of Medicines

The survey showed that majority of household members who had acute illness sought

healthcare from the public hospital (45%), drug seller (29%), private pharmacy (14%) and

public healthcare/dispensary (11%). Sixty percent (60%) of medicines used for acute illness

were prescribed by doctors, 13% by drug sellers, 7% by pharmacists and 5% by community

health officers. About one out of every ten respondents who had an acute illness was treated

with injections and up to 8% of respondents who had acute illnesses practiced self-

medication.

Medicines used for acute illness were mostly procured from public hospital (35%), drug seller

(24%), private pharmacy (17%), public health centre/dispensary (8%) and private/NGO

hospital (8%). Most of these were dispensed using adequate primary packaging (80%); but

only 52% were adequately labelled with the name of the medicine, dosage instruction and

expiration date.

Almost all household members who had a serious acute illness and sought care outside took

some medicine (98%); however 10% did not take all prescribed medicines because of

previous side effects.

Among household members who were chronically ill only 5% were never told to take

medicines. Majority (84%) claimed to take their medicines regularly. The main reasons cited

by those who did not take recommended medicines regularly were more related to

acceptability (78%) than previous experience of side effects (16%). Seventy six percent (76%)

of household members with chronic illness usually obtained less than 30 days supply of

medicines.

Sixty percent (60%) of households regarded the quality of services delivered either at their

public healthcare facility or by their private provider as being good.

21

Figure 11: Quality of Care Indicators

Figure 12: Rational Use of Medicines Indicators

22

Indicator Percentage/

Median

Number/

Interquartile range

(25%-75%)

% of acute illnesses treated with injections 11.5

% HH medicines with adequate label 51.9

% HH medicines with adequate primary packaging 80.1

% HH with a chronically ill person who was never

told to take medicines

5.4 (16) 16

% HH who usually obtain less than 30 days of

medicines for a member with chronic illness

100 (279) 279

% respondents who agree that quality of services at

their public healthcare facility is good

59.5 (643) 643

% respondents who agree that quality of services

delivered by their private provider is good

57.0 (616) 616

% respondents who agree that brand name medicines

are better than generics

47.3 (511) 511

% respondents who agree that imported medicines

are of better quality than locally manufactured

medicines

43.6 (471) 471

Indicator Percentage Number

% HH reporting a serious acute illness who

sought care outside but did not take any

medicine

2.3

% HH reporting a serious acute illness who

sought care outside but did not take all

prescribed medicines

10.9 14

% HH with a chronically ill person who does

not take recommended medicines regularly

15.7 43

%Respondents who said prescribed medicines

were not taken for a reason related to

acceptability

Chronic illness

76.7

33

%Respondents who said prescribed medicines

were not taken because of previous side effects

Acute illness

Chronic illness

10.3

16.3

9

7

Figure 15: Source of care for acute illness episode

Figure 16: Prescribed of medicines for acute illness episode

23

Figure 17: Source of medicines for acute illness

24

DISCUSSIONS

Household characteristics

Socioeconomic indices

Sociodemographic Characteristics

Access

The majority of respondents were men which is consistent with results obtained from the latest

Nigeria Demographic and Health Survey (2003 NDHS) in which decision making in

households was dominated by husbands.

The number of persons living in a household found in this survey is higher (7) than obtained in

the 2003 NDHS (5). This might be a reflection of the method of determining the number of

people living in a household. In this survey the main concern was estimating the financial

burden of households in relation to their ability to have access to medicines. Thus, members of

the household who were not present but who shared resources of the household were

included in the study. For example, children who were living in boarding schools who are

wholly taken on charge by the household were counted as members. On the other hand, the

2003 NDHS measured only members of the household who were present during the survey.

The study revealed that Nigeria has achieved geographical access to health facilities to the

populace as only about 2% of respondents had to travel more than 1 hour to the nearest health

facility. The fact that a majority of respondents sought help for acute illnesses in public

hospitals rather than primary health care centres or dispensaries shows a departure from the

norm in which primary health care centres are meant to serve as the first port of call before

being referred to hospitals. This gives an indication of a non functional primary health care

system. Some studies have shown that most of the PHC lacked medicines and were non

functional.

In the private sector, the drug seller was shown to be the most accessible medicine provider.

Indeed they are available in rural areas which may not be attractive to the pharmacist. The

1

25

challenge is to ensure adequate regulation and capacity building such that they are able to

provide good quality medicines as well as adequate health care counselling to the populace.

The study shows that most patients are still paying for medicines out of pocket as only 16%

reported receiving medicines free from facilities. About one out of every 5 patients reported to

having access to credit facilities in private pharmacy and half of the population had to borrow

money or sell their belongings to pay for medicines used for their illnesses. These are

indications that medicine affordability is a problem to the population, and the chronically ill

were more affected than those with acute illness as most of them (76%) were not able to obtain

30 days' supply of medicines. This can be expected considering the socioeconomic profile of

sampled households, which consists mainly of low and middle income group earners. Thus,

management of chronic illnesses would pose a challenge to most people. Other studies have

demonstrated that cost of medicines in Nigeria is quite prohibitive and would constitute a

barrier to care especially for patients with chronic illnesses .

The government needs to formulate policies and provide interventions to ensure that

medicines are affordable to its citizens. Wider coverage of the National Health Insurance

Scheme (NHIS), formulation, enforcement of a pricing policy for medicines and procurement

of some key essential medicines are some interventions which will improve access to

medicines.

The results show that the most used prescribers are doctors and drug sellers. This confirms that

respondents usually sought care outside the home either in hospitals in the public sector or

with drug sellers in the private sector. This accentuates the fact that the Nigerian health system

needs re-engineering to ensure that different facilities play the role for which they were

established.

Most of the household medicines were properly dispensed using adequate primary packaging

materials; however only half of dispensed medicines were adequately labelled with the name

2

Rational Use of Medicines

26

of the medicine, dosage instruction and expiration date. Since a good number of households

kept medicines for future use, adequate labelling is therefore very important. The results are

congruent with previous studies which show inadequate labelling to be the norm in health

facilities.

The results also indicate that only 10% of acute illnesses were treated with injections. This

shows an improvement in the frequency of use of injections as previous studies showed a high

rate of injection usage . This may be attributed to the change in antimalaria treatment policy

from the use of chloroquine to ACTs which are mostly used in the oral dosage form. It is not

clear how much the populace has embraced the ACT policy as more than half of the

households interviewed had chloroquine available in their homes. The cost of ACTs compared

to chloroquine may be at the heart of this preference.

This is an indicator based assessment which is meant to give an overview of the pharmaceutical

sector in order to determine appropriate interventions required to improve the system. In-depth

studies would be required to understand specific issues in the system.

The proportion of respondents who did not have any education may have been overestimated

due to the fact that in a country with significant proportion of Muslims, Quranic education was

not taken into account. Thus, any person not having the western form of education was

deemed not to have any education. Future assessments should take this type of education into

consideration.

It is doubtful if respondents could appropriately distinguish between primary health care

facilities and hospitals as the local languages refer to all health facilities as “hospitals”. It will be

important in the Nigerian survey to ensure that the two types of facilities are adequately

distinguished using local nomenclatures.

3

Limitations

2FMOH (2005). Prices people pay for Medicines in Nigeria. Published by the Federal Ministry of Health in collaboration with the World

Health Organization, EC & DFID

27

CONCLUSION AND RECOMMENDATIONS

O The results show that despite high accessibility of primary health facilities, the

hospitals are the main source of care and medicines for respondents for both acute and

chronicillnesses. There is therefore need to re-engineer the Nigerian health system to

ensure that different levels of health care play the role for which they were established.

O Drug sellers were important pharmaceutical care providers in the community. In order

to ensure that they provide adequate care to the populace, there is need for them to be

adequately regulated and their capacity built as primary care givers. Of particular

importance is the issue of labelling of medicines which needs to be standardised and

enforced.

O While medicines are geographically available, they are unaffordable to most persons

especially to those with chronic illnesses as a majority could not procure their

monthly medicine supplies. Interventions which will ensure increased access to

medicines especially for the chronically ill should be devised by the government. Such

interventions may include, formulating a pricing policy to reduce prices, providing

free medicines to those with chronic illness and increasing health insurance coverage

especially for the majority of the population who are currently uninsured due to the

limited implementation of the current policy.

28

3FMOH (2002). . Published by the Federal Ministry of Health in collaboration with

the World Health OrganizationBaseline survey of the Nigeria Pharmaceutical Sector