Pharmaceutical Situation in Barbados -...

Pharmaceutical Situation in Barbados

World Health Organization (WHO)

LEVEL II Health Facility and Household Surveys

Supported by:

February, 2011

PAHO HQ Library Cataloguing-in-Publication

Pan American Health Organization, Ministry of Health of Barbados

“ PHARMACEUTICAL SITUATION IN BARBADOS: World Health Organization (WHO) LEVEL II Health Facility and Household Surveys”.

Washington, D. C.: PAHO, © 2011.

ISBN 978-92-75-13158-9

I. Title

1. ECONOMICS, PHARMACEUTICAL

2. PHARMACEUTICAL SERVICES - standards

3. DRUG AND NARCOTIC CONTROL - economic

4. LEGISLATION, DRUG - organization & administration

5. HEALTH SURVEILLANCE

6. WORLD HEALTH ORGANIZATION

NLM QV 736.DB34

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Acknowledgements

This WHO Pharmaceutical situation assessment, Level II, was conducted with the full support of the Ministry of

Health of Barbados, including its permission from the Institutional Review Board (IRB) and endorsement to conduct

the study, with technical and financial support from Pan-American Health Organization/World Health Organization

(PAHO/WHO) through the European Union (EU)/WHO, Africa, the Caribbean and Pacific (ACP) Project

“Partnership on Pharmaceutical Policies”.

Director of the Barbados Drug Services (BDS), Ministry of Health (MOH) of Barbados coordinated the study and

took the responsibility for obtaining the necessary approval of the University of the West Indies/Ministry of Health

IRB.

The study was made possible by the support of the Chief Executive Officer (CEO) of the Queen Elisabeth Hospital

(QEH), Senior Consultant and Director of the Psychiatric Hospital, Medical Officers of Health and Sisters in charge

of the Policlinics, and heads of all health facilities visited and the householders that cooperated with this study.

The Barbados Statistical Services (BSS) collaborated with the BDS and provided assistance in the designing and the

sampling of the Household Survey. The Government Information Service (GIS) assisted with the public

announcement and press releases for the survey.

PAHO/WHO and the WHO Harvard Collaborating Center in Pharmaceutical Policy provided technical support for

the survey and their assistance is gratefully acknowledged. The support of the following individuals was invaluable

to the study:

Dennis Ross-Degnan and Catherine Vialle-Valentin, from the WHO Harvard Collaborating Center in

Pharmaceutical Policy provided methodological support for data review/analysis. Catherine Vialle-Valentin

facilitated the training of data collectors and is one of the research team members of the project. Maryam Hinds the

Director of the Barbados Drug Service, MOH Barbados, provided technical support and facilitated the conduction of

the survey as the Principal Investigator. Carol Mulder, Senior Lecturer at the University of the West Indies assisted

in the planning of the project and is one of the research team members of the project. She is also the Assistant

principal Investigator. In the absence of Carol Mulder, Jennifer Nunez took over the coordination and overall

management of the project. She coordinated the Household Survey while Cheryl Ann Yearwood coordinated the

facility Survey. Assistance was provided by the staff of BDS, generally, but especially, Pamela Payne-Wilson, Ersie

Chase, Glence Prescod, Debbie Williams, Maylene Dash-Brathwaite, Jackie Mason-Pile, Sandra Brathwaite,

Carmen Standard and Eleanor Thompson.

Data collectors were: For the Health Facility Survey: Daley Mottley, Russell Williams, June Benjamin, Joyce

Lewis, Christopher Scott, Chondelle Dash and Ibrahim Hinds. For the Household Survey: Beverley Beckles, Asha

Drakes, Carolyn Drayton, Sandra Murray, Raphael Greenidge, Carrie Reid, Hasan Patel, Mikaela Stoute, Sabrina

Drayton, Kendi Griffith, Nicole Corbin and Ria Haynes-Howard.

Adriana M. Ivama, Medicines and Biological Sub-regional Advisor, Caribbean Programme Coordination Office

(CPC) of PAHO/WHO provided technical support and reviewed the report. Nelly Marin Jaramillo, Regional

Advisor on Pharmaceutical Policy, PAHO/WHO coordinated the process in the Americas and facilitated the

technical support; Enrico Cinnella, technical officer from the Essential Medicines and Pharmaceutical Policies

Department, WHO, reviewed the report and Tassia Williams, PAHO/WHO CPC intern performed the proof reading.

Acknowledgement/Disclaimer

European Union

This document has been produced with the financial assistance of the

European Union and the technical support of the Pan American Health

Organization/World Health Organization. The views expressed herein are

those of the authors and can therefore in no way be taken to reflect the

official opinion of the European Union or the Pan-American Health

Organization/World Health Organization.

Table of Contents

LIST OF FIGURES ..................................................................................................................................................... 5

LIST OF TABLES ....................................................................................................................................................... 6

LIST OF BOXES ......................................................................................................................................................... 8

ABBREVIATIONS AND ACRONYMS ................................................................................................................... 9

CONFLICT OF INTEREST STATEMENT ........................................................................................................... 10

EXECUTIVE SUMMARY ....................................................................................................................................... 11

BACKGROUND - HEALTH AND PHARMACEUTICAL SECTOR ...................................................................................... 11

STUDY ..................................................................................................................................................................... 12

HEALTH FACILITY SURVEY ..................................................................................................................................... 12

Methods .............................................................................................................................................................. 12

Key results .......................................................................................................................................................... 12

Challenges and Constraints ................................................................................................................................ 13

HOUSEHOLD SURVEY .............................................................................................................................................. 14

Methods ............................................................................................................................................................. 14

Key results .......................................................................................................................................................... 14

Challenges and Constraints ................................................................................................................................ 16

RECOMMENDATIONS ................................................................................................................................................ 16

INTRODUCTION ..................................................................................................................................................... 17

BARBADOS BACKGROUND ................................................................................................................................. 18

HEALTH SECTOR ...................................................................................................................................................... 18

PHARMACEUTICAL SECTOR ..................................................................................................................................... 19

STUDY DESIGN AND METHODS ......................................................................................................................... 25



RESULTS AND DISCUSSION ............................................................................................................................... 32


Issues related to the field work ........................................................................................................................... 32

Health workers at health facilities ...................................................................................................................... 34

Access ................................................................................................................................................................ 36

Affordability ...................................................................................................................................................... 38

Quality of medicines .......................................................................................................................................... 39

Rational Use of Medicines (RUM) .................................................................................................................... 40

Challenges and constraints ................................................................................................................................. 44


Characteristics of surveyed households.............................................................................................................. 45

Geographic access and availability of medicines .............................................................................................. 56

Affordability of medicines ................................................................................................................................. 60

Medicines at home ............................................................................................................................................ 65

Use of medicines during acute illnesses ............................................................................................................. 68

Use of medicines for chronic diseases................................................................................................................ 73

Key indicators of Access and Use of Medicines ................................................................................................ 76

CONCLUSIONS AND RECOMMENDATIONS .................................................................................................. 80

REFERENCES .......................................................................................................................................................... 82

ANNEX 1. LEVEL I QUESTIONNAIRE ............................................................................................................... 83

ANNEX 2. LEVEL II SURVEY FORMS ................................................................................................................ 84

ANNEX 3. HOUSEHOLD SURVEY QUESTIONNAIRE .................................................................................... 85

ANNEX 4. ROUNDED RANGES OF HOUSEHOLD EXPENDITURES ........................................................... 86

ANNEX 5. DESCRIPTION OF INDICATORS- HEALTH FACILITY SURVEY ............................................. 87

ANNEX 6. DESCRIPTION OF INDICATORS- HOUSEHOLD SURVEY ........................................................ 89

List of Figures

FIGURE 1. GEOGRAPHIC LOCATION OF STATISTICAL SAMPLE AREAS, BARBADOS, 2010. ......... 29

FIGURE 2. STRATIFIED RANDOM SAMPLING AREA IDENTIFYING HOUSEHOLDS, BARBADOS, 2010. 30

FIGURE 3. AVAILABILITY OF KEY MEDICINES IN PUBLIC HEALTH FACILITY DISPENSARIES, AND IN

PRIVATE PHARMACIES. PHARMACEUTICAL SITUATION ASSESSMENT – HEALTH FACILITY SURVEY

LEVEL II, BARBADOS, JULY 2010. ..................................................................................................................... 37

FIGURE 4. DISTRIBUTION OF FACILITIES ACCORDING TO THE PERCENTAGE OF PRESCRIBED KEY

MEDICINES THAT WERE DISPENSED OR ADMINISTERED. PHARMACEUTICAL SITUATION

ASSESSMENT - HEALTH FACILITY SURVEY LEVEL II, BARBADOS, JULY 2010. ................................ 37

FIGURE 5. ADEQUACY OF INFRASTRUCTURE OF CONSERVATION CONDITIONS OF MEDICINES,

PHARMACEUTICAL SITUATION ASSESSMENT - HEALTH FACILITY SURVEY LEVEL II, BARBADOS,

AND JULY 2010. ....................................................................................................................................................... 39

FIGURE 6: NUMBER OF SURVEYED HOUSEHOLDS IN EACH REGION, BARBADOS, 2010.. ............. 45

FIGURE 7: AGE OF RESPONDENTS/HEALTH CARE DECISION MAKERS, BARBADOS, 2010. .......... 46

FIGURE 8. HOUSEHOLD ASSETS AND LEVELS OF MONTHLY (4 WEEKS) EXPENDITURES, BARBADOS,

2010. ........................................................................................................................................................................... 48

FIGURE 9. REPORTED SYMPTOMS OF ACUTE ILLNESS, BARBADOS, 2010. ......................................... 54

FIGURE 10. MOST FREQUENT CHRONIC DISEASES BY GENDER, BARBADOS, 2010. ........................ 55

FIGURE 11: PREVALENCE OF ILLNESSES, BARBADOS, 2010. .................................................................. 56

FIGURE 12. HOUSEHOLDS FAR AWAY FROM A PUBLIC HEALTH CARE FACILITY, BARBADOS, 2010. 57

FIGURE 13. SOURCES OF MEDICINES FOUND IN HOUSEHOLDS BARBADOS, 2010. ......................... 58

FIGURE 14. SOURCES OF MEDICINES TAKEN FOR AN ACUTE ILLNESS, BARBADOS, 2010. ........... 59

FIGURE 15. POTENTIALLY CATASTROPHIC EXPENDITURES RELATED TO MEDICINES IN MONTH

PRECEDING SURVEY, BARBADOS, 2010. ......................................................................................................... 63

FIGURE 16. MEDICINES IN HOUSEHOLDS WITH CHILDREN, BARBADOS, 2010. ................................ 65

FIGURE 17. PERCENTAGE OF HOME MEDICINES WITH ADEQUATE LABEL AND PRIMARY PACKAGE,

BY SOURCE, BARBADOS, 2010. .......................................................................................................................... 67

FIGURE 18: PRESCRIBERS OF MEDICINES IN CASE OF ACUTE ILLNESS, BARBADOS, 2010. ........ 69

FIGURE 19. ROUTE OF ADMINISTRATION OF MEDICINES PRESCRIBED FOR ACUTE ILLNESS,

BARBADOS, 2010. .................................................................................................................................................... 71

FIGURE 20. REASONS FOR NOT TAKING PRESCRIBED MEDICINES FOR ACUTE ILLNESS, BARBADOS,

2010. ............................................................................................................................................................................ 72

FIGURE 21. ACTIONS TAKEN FOR CHRONIC DISEASES, BARBADOS, 2010. ......................................... 73

FIGURE 22: REASONS FOR NOT TAKING MEDICINES PRESCRIBED FOR A CHRONIC DISEASE,

BARBADOS, 2010. .................................................................................................................................................. 75

WHO Level II Assessment - Health Facility and Household Surveys Barbados

6

List of Tables

TABLE 1. CHARACTERISTIC OF HEALTH CARE FACILITIES SURVEYED IN BARBADOS, JULY 2010. 33

TABLE 2. CHARACTERISTICS OF OUTPATIENTS INTERVIEWED IN BARBADOS, JULY 2010. ....... 34

TABLE 3. DISPENSER PROFILE AT PSA-HFS LEVEL II IN BARBADOS, JULY 2010. ............................ 35

TABLE 4. PRESCRIBER PROFILE IN THE PUBLIC SECTOR, PSA-HFS LEVEL II IN BARBADOS, JULY 2010.

..................................................................................................................................................................................... 35

TABLE 5. GENERAL INDICATORS FOR AVAILABILITY AND GEOGRAPHICAL ACCESSIBILITY,

PHARMACEUTICAL SITUATION ASSESSMENT – HEALTH FACILITY SURVEY LEVEL II, BARBADOS,

JULY 2010. ................................................................................................................................................................. 36

TABLE 6. NUMBER OF DAY’S WAGES OF THE LOWEST PAID GOVERNMENT WORKER NEEDED TO

PURCHASE STANDARD TREATMENTS. PHARMACEUTICAL SITUATION ASSESSMENT - HEALTH

FACILITY SURVEY LEVEL II, BARBADOS, JULY 2010................................................................................. 38

TABLE 7. GENERAL INDICATORS FOR QUALITY OF MEDICINES, PHARMACEUTICAL SITUATION

ASSESSMENT - HEALTH FACILITY SURVEY LEVEL II, BARBADOS, JULY 2010. ................................ 39

TABLE 8. GENERAL INDICATORS FOR RATIONAL USE, PHARMACEUTICAL SITUATION ASSESSMENT -

HEALTH FACILITY SURVEY LEVEL II, BARBADOS, JULY 2010. .............................................................. 42

TABLE 9. DISTRIBUTION OF PRIVATE PHARMACIES ACCORDING TO THEIR RESULTS ON %

PRESCRIPTION MEDICINES BOUGHT WITHOUT PRESCRIPTION, BARBADOS, JULY 2010. ........... 42

TABLE 10. ADHERENCE OF PRESCRIBERS TO RECOMMENDED TREATMENT GUIDELINES.

PHARMACEUTICAL SITUATION ASSESSMENT - HEALTH FACILITY SURVEY LEVEL II, BARBADOS,

JULY 2010. ............................................................................................................................................................... 43

TABLE 11: EDUCATION OF RESPONDENTS, BARBADOS, 2010. ................................................................ 46

TABLE 12: MONTHLY HOUSEHOLD EXPENDITURES, BARBADOS, 2010. ............................................. 49

TABLE 13. CHARACTERISTICS OF HOUSEHOLDS, BARBADOS, 2010. .................................................... 51

TABLE 14. SOURCES OF INCOME AND THE JOB OF THE MAIN EARNER IN THE HOUSEHOLD

(HOUSEHOLD HEAD), BARBADOS, 2010. ......................................................................................................... 52

TABLE 15: PREVALENCE OF ACUTE AND CHRONIC CONDITIONS, BARBADOS, 2010. .................... 53

TABLE 16: CHARACTERISTICS OF ACUTE AND CHRONIC CONDITIONS, BARBADOS, 2010. ......... 53

TABLE 17: TRAVEL TIME TO CLOSEST HEALTH CARE FACILITY, BARBADOS, 2010. .................... 57

TABLE 18: OPINIONS ABOUT GEOGRAPHIC ACCESS AND AVAILABILITY OF MEDICINE, BARBADOS,

2010. ............................................................................................................................................................................ 60

TABLE 19: COST OF MEDICINES FOR A RECENT ACUTE ILLNESS, BARBADOS, 2010. .................. 61

TABLE 20: MONTHLY COST OF MEDICINES FOR A CHRONIC DISEASE, BARBADOS, 2010. ........... 62

TABLE 21: MEDICINES INSURANCE COVERAGE, BARBADOS, 2010. ...................................................... 64

TABLE 22: OPINIONS ABOUT AFFORDABILITY OF MEDICINES, BARBADOS, 2010. .......................... 64

TABLE 23: MEDICINES FOUND AT HOME, BARBADOS, 2010. ................................................................... 66

TABLE 24. ACTIONS TAKEN FOR A RECENT ACUTE ILLNESS, BARBADOS, 2010. ............................. 68

TABLE 25 MEDICINES TAKEN FOR A RECENT ACUTE ILLNESS, BARBADOS, 2010. ......................... 69

TABLE 26 MOST FREQUENT MEDICINES PRESCRIBED FOR CHRONIC DISEASES, BARBADOS, 2010. 74

TABLE 27. OPINIONS ABOUT QUALITY OF CARE AND GENERICS, BARBADOS, 2010. ..................... 76

TABLE 28: INDICATORS OF ACCESS AND USE OF MEDICINES - ALL HOUSEHOLDS, BARBADOS, 2010.

..................................................................................................................................................................................... 77

TABLE 29: INDICATORS OF ACCESS AND USE OF MEDICINES - HOUSEHOLDS WITH AT LEAST ONE

ACUTE OR CHRONIC CONDITIONS, BARBADOS, 2010. ............................................................................... 78


7

List of boxes

BOX 1. KEY MEDICINES SELECTED FOR THE SURVEY ............................................................................. 26

BOX 2. TRACER CONDITIONS FOR COMPLIANCE OF PRESCRIBERS TO RECOMMENDED TREATMENT

PROTOCOLS/GUIDELINES. ................................................................................................................................ 26

BOX 3: TRACER CONDITIONS FOR AFFORDABILITY ................................................................................ 27

BOX 4. SUMMARY LIST OF INDICATORS AND CORRESPONDING SURVEY FORM USED TO COLLECT

THE DATA ................................................................................................................................................................ 28


8

Abbreviations and Acronyms

% ile Percentile

ARI Acute Respiratory Infection

BBD Barbados Dollar

BDS Barbados Drug Service

BNDF Barbados National Drug Formulary

CEO Chief Executive Officer

DHI Development Human Index

EML Essential Medicines List

GA Geographic Access

GBS General Bureau of Statistics

GDP Gross domestic product

HAI Health Action International

HFS Health Facility Survey

HH Household

Ind. Indicator

Inj Injection

INN International Non-Proprietary Name

IRB Institutional Review Board

M Mixed

MOH Ministry of Health

MSH Management Sciences for Health

Nb Number

NMP National Medicines Policy

OB Originator brand

PAHO Pan American Health Organization

PSF Pharmaceutical Situation Assessment

Q Quintile

QEH Queen Elizabeth Hospital

QL Quality

RUM Rational Use of Medicines

SD Standard Deviation

SES Socio-Economic Status

SF Survey Formulary

STG Standard Treatment Guidelines

UNDP United Nation Development Program

URTI Upper Respiratory Tract Infection

USD United States dollars (also US$)

WHO World Health Organization


9

Conflict of Interest Statement

None of the authors of this survey or anyone who had participated or collaborated in any phase of the planning,

field work, analysis or interpretation of the results has any competing financial or other interests.


10

Executive Summary

Background - Health and Pharmaceutical Sector

Barbados is a one of the most heavily populated Caribbean islands. It is a middle income country with a

population estimated 275,700 as of December 2009. Life expectancy at birth is 75.8 years, with 15.75%

of the population over the age of 60 years. Key contributors of morbidity and mortality are heart disease,

cerebrovascular disease, diabetes mellitus, malignant neoplasm, hypertension, and HIV/AIDS among

adults.

The Ministry of Health is responsible for assuring a functioning health care system. Health care services

are organized in three levels. The public sector works in partnership with the private sector. The Special

Benefit Service (SBS) provides medicines and related items listed in the Barbados National Drug

Formulary free of cost at point of service to the following beneficiaries in both the public and private

sectors:

(1) Persons 65 years of age and over;

(2) Children under 16 years of age;

(3) Persons who receive prescribed Formulary Drugs for the treatment of hypertension, diabetes,

cancer, asthma and/or epilepsy.

It should be noted that patients between 16 and 64 who are eligible to receive prescribed formulary

drugs for the treatment of hypertension, diabetes, cancer, asthma and epilepsy obtain the other formulary

drugs at the subsidised prices found in the ‘Prescription Pricing Guide-Purchasing Guide’. This is so

because all formulary medicines and related items enter the country free of duty and other taxes and

have an agreed mark-up attached to them. It is thus true to say that all Barbadians benefit from the

programmes of the Barbados Drug Service (BDS).

Any Barbadian Citizen or Permanent Resident seeking medical attention within the public sector can

have his/her prescription filled free of cost in one of the private participating pharmacies of the SBS or

BDS pharmacies. Prescriptions originating from private physicians can also be dispensed at the BDS

pharmacies free to beneficiaries or at a similar fixed cost + mark-up to non-beneficiaries. The public

pharmacies located at the Geriatric Hospital and the St. Philip District Hospital is set up specifically for

dispensing in-patient prescriptions only.

It should be noted that patients can obtain formulary medicines at subsidised prices because all

formulary drugs and related items enter the country free of duty and other taxes and have mark-up

attached to them.

In Barbados, a National Medicines Policy (NMP) document has existed in draft form since 2003. The

Barbados Drug Service (BDS) provides pharmaceutical regulatory services for Barbados. It also

implements a policy covering medicines‟ prices for beneficiaries that applies to both public and private

sectors. Medicines prices set up by the government are displayed in the Barbados National Drug

Formulary (BNDF), which was last updated in 2010. Medicines that do not appear in BNDF are sold by

private pharmacies according to market forces.


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Study

An assessment of the pharmaceutical situation was undertaken in Barbados between October, 2009 and

July, 2010 using a standardized methodology developed by the World Health Organization (WHO). The

goal of the assessment was to evaluate the pharmaceutical situation in Barbados. The specific objectives

were to provide data to measure outcomes on affordability and availability of key medicines,

geographical accessibility of dispensing facilities and rational use of medicines, as well as some

indication of the quality of medicines at health facilities and pharmacies. These data would provide

evidence on whether the pharmaceutical policy is achieving its goals.

The Pharmaceutical Situation Level II study has two components: a health facilities survey and a

household survey, both based on indicators. In the first component, data relating to pharmaceutical

policy outcomes are gathered from public and private pharmacies and warehouses that supply public

facilities. The second data comes from a questionnaire applied at the household level.

Health Facility Survey

Methods

The survey was conducted in all the public facilities of Barbados with outpatient services which are

expected to carry a full supply of essential medicines. In addition, 30 private pharmacies were included

based on random selection.

Data entry was performed using standard forms developed by WHO (Annex 2). Analysis was done

using the Excel ® software program.

Key results

Access

Overall access indicators show that the availability of key essential medicines is 100% in public health

facilities and 94% in private pharmacies. The percentage of prescribed key medicines that are dispensed

to patients is 99% in the public sector. Key medicines are those listed in Box 1.

Concerning geographical accessibility, 97% of patients interviewed at public facilities traveled less than

one hour to reach the facility.

Treating common conditions using standard regimens, the lowest paid government worker would need

between 0.02 and 0.05 of one day‟s wages to purchase the lowest priced generic medicines from the

private sector, and between 0.09 and 0.97 of one day‟s wages to purchase originator brands from the

private sector.

Data suggests that treatment for common primary health problems is generally affordable based on the

fact that the financial burden for the lowest paid public servant in terms of proportion of a working day‟s

pay is low.


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Quality and regulation

No expired medicines from the key medicines list were found in the public or private sector. Storage

conditions were rated at 85% with respect to adequacy in the storerooms and dispensing rooms of public

health facilities. The adequacy was slightly better in private pharmacies at 90%.

Most public dispensing facilities and private pharmacies comply with the legal requirements of the

government with regards to the presence or support of the pharmacist; these professionals were found in

most facilities. The profile of health workers dispensing medicines was adequate and followed the law,

with no untrained staff dispensing in the private or public sector. According to the findings, doctors are

the most frequent prescribers, and 78% of prescribers have been recently trained in rational use of

medicines. However, prescribing was inadequate for many of the tracer conditions cases reviewed by

surveyors.

Use of medicines

There is no Essential Medicines List (EML) in Barbados. A comprehensive National Formulary exists

however, and was found in 92% of public health facilities. There are national officially adopted

Standard Treatment Guidelines (STG) for diabetes, hypertension and asthma. However, no STG exist

for other common health conditions. The STG for diabetes, hypertension and asthma were available in

55% of surveyed health facilities. With regards to indicators of rational use, 23 % of patients with tracer

conditions were prescribed antibiotics, and 7 % were given injections. Selling of prescribed medicines

without prescription was observed in several private pharmacies. In 2 visited pharmacies, between 25

and 50% of prescription medicines were purchased without prescription. All patients interviewed at

public and at private pharmacies knew how to take their medicines.

Challenges and Constraints

Despite the presence of the pharmacist in most pharmacies, storage conditions of medicines needs to be

improved. Storage conditions were not optimal for public health facilities and private pharmacies. The

implementation of Best Practices related to distribution, storage and pharmacy practices would improve

this situation.

In Barbados, medicines are generally available based on information about current stock on hand.

However, as there were no stock cards in the polyclinics, stock-out days could not be assessed. At the

Saint Michael Psychiatric Hospital (SMPH) and Queen Elizabeth Hospital (QEH), stock-out cards are

maintained. At the former, the percentage of adequate records was 100% and the average number of

stock-out days was 0. At the QEH, the percentage of adequate records was slightly lower at 93.8%, and

the average number of stock-out days was high: 61 days. It is recommended that the computerized

system in the polyclinics be improved to facilitate retrieval of previous stock-out information.

The International Non-proprietary Name (INN) was used for only 36% of prescription medicines in

public health facilities.

Irrational use in private pharmacies is a matter of concern taking into account that 10 in 26 (38%)

private pharmacies sold at least one prescription medicine without prescription at the time of visits.


13

There are national officially adopted Standard Treatment Guidelines (STG) for diabetes, hypertension

and asthma. The STG for diabetes, hypertension and asthma were not available in half the public

healthcare facilities. No STG exist for other common health conditions.

An important finding of the survey is the inappropriate prescription of antibiotics, which are underused

to treat pneumonia in children under 5, and overused to treat non-bacterial upper respiratory infections.

This and the fact that many children under 5 with diarrhea are not prescribed the appropriate treatment,

strongly suggest the need to intensify training of providers in key areas of primary care prescribing. It

must be noted here that the data with respect to the prescribing patterns of physicians is influenced by

the ability to extrapolate the data from the Health Management System in place at the public health

facilities.

The survey also indicates that managerial policies related to pharmaceuticals need to be improved. The

appropriate use of medicines can be improved by increasing availability and use of STG, and by

encouraging the use of INN for prescribing.

Household Survey

Methods

The survey was conducted in all parishes of Barbados. The survey was conducted using the random

stratified sampling method. A sample of 317 households was drawn out of 44 randomly-selected areas.

The questionnaire collected information about medicines kept at home, used during recent acute illness

and prescribed for chronic diseases. It also collected information on how people behaved when

confronted with acute or chronic conditions, their opinions about medicines, as well as demographic and

socio-economic data. Data entry was performed with EpiData software and analysed with Excel .

Key results

Characteristics of surveyed households

The household member most knowledgeable in health was selected as the survey respondent. The

majority of respondents was over 50 years old and had completed primary or secondary school (7 in 10).

One in four households had incurred health expenditures over the past four weeks. Over half of

households reported at least one chronic condition. The most frequently reported chronic diseases by far

were hypertension and diabetes. Few households (15%) reported at least one acute illness. The most

frequent group of symptoms of acute illness was related to cough, runny nose, sore throat, and ear ache.

The prevalence of both chronic and acute conditions was higher in the group of households with lower

socio-economic status (SES).

Geographic access and availability of medicines

Overall, indicators of geographic access to medicines suggest that the majority of surveyed households

live close to a public heath care facility. However, 11% households in the lower SES group live at more

than one hour from a public health facility. The majority of medicines, either found in households or

obtained for an acute illness, came from a private pharmacy.


14

About half of household respondents agreed that medicines are available at their public heath care

facility, while nine in ten agreed that medicines are available at private pharmacies. More respondents in

the lower SES group had a positive opinion of the availability of medicines in the public sector.

Affordability of medicines

Overall, indicators of affordability of medicines suggest that the price households pay for medicines is

not a major obstacle to accessing medicines. A larger proportion of individuals received free medicines

for chronic diseases than for acute illnesses. An average of 3% of respondents reported spending more

than 40% of their non-food expenditures on medicines over the past four weeks.

Two thirds of respondents agreed that they can usually afford medicines. This proportion was lower in

the lower SES group.

Very few people with acute or chronic conditions reported health insurance coverage for medicines. All

respondents who reported medicines insurance coverage were in the higher SES group.

Medicine use and medicines at home

About 80% of households with children stored medicines at home. The average number of medicines

found at home was 3. Most of these medicines had an appropriate label and a primary package in good

condition, especially when obtained in a public health care facility.

The two most frequent medicines found at home were paracetamol (17% of medicines) and

chlorpheniramine, an antihistaminic (5% of medicines).

Medicine use and acute illnesses

Few households reported acute illnesses. Behavior with regards to seeking care and taking medicines

depended on the perceived severity of the illness. The two most frequently used medicines were

paracetamol (26% of medicines) and chlorpheniramine (22% of medicines), which suggests a high

prevalence of treatment for allergic conditions in July. Half of the medicines for acute illness were

prescribed by a doctor or a nurse, which points to the use of non-prescription medicines for the

remaining cases of acute illness. The use of injections for treatment of acute illness was only observed

in the lower SES group: in this group, 7% of medicines were injections. The main reason for not taking

medicines was that symptoms improved.

Medicine use and chronic diseases

Over half of the households reported a chronic disease. Eight in ten individuals with a chronic disease

were told to take medicines and had medicines at home. This percentage however was halved in the

lower SES group: only four in ten individuals with a chronic disease who had been told to take

medicines had medicines at home. In addition, in this group, the percentage of people with chronic

disease not told to take medicines was much higher than in the higher SES group. This strongly suggests

that in the lower SES group, people under-use medicines for chronic diseases. Metformin was the most

frequently used antidiabetic, and indapamide the most frequently used antihypertensive. The main

reason given for not taking medicines was that symptoms improved.

Opinions about quality of care and generics


15

Overall, over half of respondents (53%) believed that the quality of medicines and services in their

public health care facility were good. More respondents (87%) agreed that the quality of services

delivered by private health care providers in their neighborhood was good. The majority of respondents

could not distinguish between brand name and generic medicines.

Challenges and Constraints

Overall, the household survey results indicate that access to medicines is of good quality in Barbados,

and that it is slightly better in households with a higher SES. They point out to an insufficient use of

medicines to treat chronic diseases in households of lower SES.

Recommendations

The survey indicates that managerial policies related to pharmaceuticals need to be improved. The

findings can be used for updating the National Pharmaceutical Policy and implementation plan.

Regarding the need for improvement of the quality of services, it is recommended to develop and

implement Good Practices in all tiers of the pharmaceutical chain from distribution to storage and

pharmacy practices, which would contribute to improve this situation. Special attention needs to be paid

to the fact that a relatively high percentage of prescription medicines are sold without a prescription.

It is recommended to develop strategies that guarantee the quality and strengthen the use of generic

medicines. These strategies would include the regulation of aspects related to quality, safety, prices and

enforcement of the prescription using the International Non-proprietary Name (INN), and generic

substitution.

Regarding aspects related to rational use of medicines, the Barbados Drug Formulary needs to be

updated using the concept of Essential Medicines, selection with evidence based criteria. Standard

Treatment Guidelines (STG) for the most common conditions should be developed, officially adopted

and widely disseminated to users. Priority can be given to chronic diseases due to their high prevalence

in Barbados, with a holistic approach considering lifestyle and treatment.

It is recommended to develop a strategy to improve knowledge and rational use of medicines by the

population. It would address medicines access, quality and safety of medicines, their management at

home (labeling, storage conditions, etc) adherence to treatment (especially for chronic conditions) and

the use of generics or INN drugs.

It is recommended to design strategies to improve equity in medicines access: tackling the higher

prevalence of chronic and acute conditions in the lower SES group, the under use of medicines in this

group. Equity in access to medicines is one aspect to be further investigated; interventions can be

designed for specifically target people of lower SES.


16

Introduction

Between October 2009 and July 2010, the Ministry of Health (MOH) conducted a nationwide study of

the pharmaceutical situation in public health facilities and private pharmacies in Barbados. The main

goal of the study was to document the degree of success in achieving strategic pharmaceutical

objectives.

This study was conducted using the standardized methodology developed by the World Health

Organization (WHO), named Pharmaceutical Situation Assessment Level II. This is an indicator-based

approach that provides systematic data on access and rational use of quality medicines through a

facility-based survey.

The core indicators measure the most important information needed to understand the pharmaceutical

situation in a country.

The study was intended to answer the following questions:

Are medicines available and affordable in public and private dispensing facilities to treat

common conditions at primary care level?

Do people have adequate geographical access to public and private dispensing facilities?

Are there any expired medicines in public and private dispensing facilities?

Are medicines adequately stored and handled in public health facility dispensaries and

warehouses supplying the public sector?

Are medicines adequately prescribed, labeled and dispensed?

Are patients informed on how to use their medicines?

Are pharmacists present at dispensing facilities according to the law?

Are pharmacists present at dispensing facilities?

Which professionals are prescribing and dispensing?

Do prescribers comply with good prescribing practices?

How does Barbados compare to other countries with regard to access to and use of medicines?


17

Barbados background

Barbados is a small country, covering an area of 430 km2

or 166 square miles and has a population

density of 625 persons per square kilometer (1,619 persons per square mile). It is divided into 11

parishes and the total population is 275,700 (estimate at December 2009), with the majority of

population living in the southern parishes of St. Michael, Christ Church and St. Philip. It is not only one

of the most heavily populated islands in the Caribbean, but also has the highest proportion of people

over 65-years old1,2

.

Barbados is described as a middle income country, with a GDP of US $10,350.00 per capita. Of the

total labor force, approximately 10.6% of persons are unemployed, with 6.4% of these in a state of long-

term unemployment over 3 months (as of the 1st Quarter 2010).

1

Life expectancy at birth is 75.8 years, with 15.7% of the population over the age of 60 years, and 21.5%

of the population below 15 years in 2000 population census. According to the most recent national

census in 2000, the average number of people per household is 3. 1

Key contributors to morbidity and

mortality are heart disease, cerebro-vascular disease (stroke), diabetes mellitus, malignant neoplasm,

hypertension and HIV/AIDS among adults. The information from the polyclinics and out-patient clinics

indicate that in adults (20 to 65 years) the conditions commonly seen and treated are hypertension,

diabetes mellitus and disorders of the circulatory system for the older adults (45-65 years), whereas

among the younger adults there are concerns about the impact of road traffic accidents, violence and

HIV/AIDS. 2

Health sector

In 2008, when the US$1 was equivalent to Bds$2.00), government expenditure on health represented

12.9% of all government expenditures (approximately 4.4% of the GDP).1 Hospital services and primary

care accounted for the bulk of the expenditure, 52 percent and 25 percent respectively based on data

from 2003. 2

The public health sector is composed of 3 levels: primary, secondary and tertiary care.

Primary care is delivered from 8 polyclinics and 4 satellite out-patient clinics that are strategically

located and provide a wide range of preventive, curative services, and rehabilitative services. These

services include maternal and child health, immunization, oral health, general practice clinics,

hypertension and diabetes clinics, nutrition education, physiotherapy, provision of pharmaceuticals,

environmental health and a limited range of mental health services.

1 Statistics provided from Barbados Statistical Services

2 Report of the Chief Medical Officer 2002-2003


18

Secondary and tertiary care is provided by the Queen Elizabeth Hospital (QEH), Psychiatric hospital, the

St. Michael District Hospital, 3 District Hospitals, and specialized institutions that provide care for

persons with disabilities. The QEH is a 600 bed hospital that provides acute, secondary, tertiary and

emergency care on a 24-hour basis.

The Psychiatric care facility is a 627-bed hospital, and an 8-bed unit at the QEH. It provides inpatient

and outreach services with additional out-patient services offered on a limited basis at the 8 polyclinics.

The goal of the St. Michael District Hospital and 3 district institutions is to rehabilitate the elderly to

maximum functional capacity so that they can return to their respective communities.

In excess of 35% of the population is covered by private insurance. The private sector represents

approximately 50% of total health services.

The public health sector is complemented by the private sector. The program involves a partnership

with the private sector whereby specialists provide a wide range of secondary-care services, with

support from private laboratories and pharmacies. The private sector also comprises a 24-bed hospital, a

private renal dialysis provider, a halfway house providing mental health services, two substance abuse

treatment providers, as well as 45 nursing and senior citizens homes, which provide long term care for

older persons.1

Pharmaceutical sector

There are approximately 100 licensed private pharmacies outlets in Barbados and 17 public pharmacies.

Public sector pharmacies account for 27% of medicines dispensed to patients, while the private sector

accounts for the remaining 73%. The Barbados Drug Service (BDS) has responsibility for 14 of the 17

public sector pharmacies located across Barbados. The other 3 are managed by the respective

institutions namely the Queen Elizabeth Hospital, the Psychiatric Hospital, and the Ladymeade

Reference Unit. There are two parishes that do not have a Public Pharmacy, namely St. Lucy and St.

James. These parishes are serviced by the Maurice Byer and Black Rock Polyclinic pharmacies

respectively. The BDS pharmacies provide beneficiaries with drugs and related items listed in the

Barbados National Drug Formulary free of cost at point of service. Non-beneficiaries are charged a fee

for this service based on the pricing mark-up which applies to the private sector. Any Barbadian citizen

or permanent resident seeking medical attention within the public sector can have his/her prescription

filled free of cost in one of the public pharmacies. The only exception to this is the pharmacies located

at the Geriatric Hospital and the St. Philip District Hospital. These two pharmacies are set up

specifically for dispensing in-patient prescriptions with some exception given to dispensing

prescriptions for staff members. Prescriptions originating from private physicians can also be dispensed

at the BDS pharmacies at a fixed cost plus the same mark-up that applies to the private sector.

National Medicines (Drugs) Policy


19

In Barbados, a National Medicines Policy (NMP) document has existed in draft form since 2003. The

primary objective of this document is to ensure access, quality and rational use of medicines by health

care professionals and citizens. The document sets out the goal and guide for action with the expression

of the medium to long term goals set by the government of Barbados for the pharmaceutical sector. The

document provides the framework within which the activities of the pharmaceutical sector can be

coordinated. It covers both the public and private sectors. It was submitted to the Cabinet in 2004 and

was last updated in 2009. This document is an essential part of the health policy and it seeks to promote

equity and sustainability of the pharmaceutical sector. An official implementation plan that sets out

activities, responsibilities, budget and timeline is not in place.

Regulatory system

The Barbados Drug Service provides the regulatory service for Barbados on pharmaceuticals. Routine

inspections are undertaken at all pharmacies and the sole pharmaceutical manufacturing plant operating

in the country. Initial inspections are conducted in the wholesalers‟ facilities but they are not licensed.

These inspections are done primarily to ensure that the pharmacy legislation is upheld and that the

medicines manufactured and the process of manufacturing is in accordance with World Health

Organization‟s (WHO) Good Manufacturing Practice. One hundred and fifty-eight (158) pharmaceutical

samples were analyzed in 2006-07. They were found to be in compliance with Good Manufacturing

Practice techniques and were considered suitable for marketing. The products were granted certificates

of pharmaceutical product on international commerce (CPP) and are commercialized both locally and

regionally.

Registration of medicines is however not yet in place but significant progress has been made in

advancing this process. Currently, analytical testing (identity, purity and dissolution) is carried out on all

new generic medicines before they are placed on the market. No bioequivalence data is analysed. There

is a draft bill amending the Drug Service Act which is being circulated for comments. This amendment

aims to ensure that all medicines are approved and registered before being placed on the market. The

amendments also cover Pharmacovigilance and prevention and combating of counterfeit medicines.

Regulatory provisions are in place for licensing manufacturers of medicines. In accordance with Section

40 and 41 of the Financial Administration and Audit (Barbados Drug Service) Rules, 1980, the Director

of the Drug Service shall prepare and maintain a list of suppliers, approved by the Minister of Health

(MOH), of medicines and related items and may restrict invitations to tender as well as contracts for the

purchase of medicines and related items to those suppliers. Any person may apply in writing to have his

or her name included in the list of suppliers having given such information as the Director of the Drug

Service requires. The Drug Inspectorate processes new applications made by manufacturers to be listed

as approved suppliers of medicines and related items. The certificate from the Regulatory Authority in

the country in which the manufacturing plant is located and the statements which substantiate that the

manufacturer produces medicines for consumption in both the domestic and foreign market must be

properly endorsed by an accredited Notary Public.

Continuous efforts are made to ensure that medicines imported and sold in Barbados are manufactured

in accordance with the United States Pharmacopoeia and the British Pharmacopoeia standards or any

other recognized standards. In this regard, different brands of pharmaceuticals are collected and sent for

testing to the Caribbean Regional Drug Testing Laboratory (CRDTL) in Jamaica, Eurofins, England and

Experchem Laboratories Inc., Canada.


20

In 2009, as part of the routine post market surveillance exercise, twenty six (26) results were received at

the CRDTL from Barbados with 24 Satisfactory Results and 2 Unsatisfactory Results.

Legal provisions are in place for the licensing of pharmacists and pharmacy premises through the

Pharmacy Council. There are legal provisions for licensing nurses and doctors before they can practice

through the Nursing and Medical Councils respectively. Dentists also have the Dental Council for

licensing of dentists. There is a Paramedical Council that takes the responsibility for the registration of

other allied health professionals. The Pharmacy Council with support from the Drug Inspectorate

continues to maintain vigilance over the operation and practice of pharmacy in the country. All

registered health professionals renew their licenses annually. Pharmacists as well as the premises of

private pharmacies are re-certified annually and subsequently registered in accordance with the

provisions of the Pharmacy Act. Pharmacists can only dispense medicines that are prescribed by a

medical practitioner that is registered in Barbados. Barbados does not have a generic policy or specific

regulation; however, generic substitution is performed in both the public and private pharmacies. The

private pharmacies honor the agreement signed between the Director, BDS and the Private Participating

Pharmacies in the acquisition of medicines and related items listed in the Formulary so that an adequate

supply of those medicines and related products are continuously available. Except with the express

authorization of the Director and BDS, they can purchase all such formulary medicines that the

Pharmacy requires for the purposes of the Agreement with the BDS from the designated contractors who

have concluded contracts with the Government of Barbados or the BDS in accordance with the Financial

Administration and Audit (Drug Service) Rules, 1980.

The pharmacies are also obligated to ensure that where a prescribed formulary medicine is not in stock in Barbados the BDS is immediately contacted. BDS shall then instruct the pharmacy as to which alternative medicine or related item in the same generic category to dispense to a beneficiary as the cost of this shall be borne by the Barbados Drug Service.

There are provisions in the medicines regulations covering promotion and/or advertising of medicines as

set out in the Health Service (Control of Drugs) Regulations, 1970. Nevertheless, monitoring of

medicines promotion is not performed.

Medicines supply system

Public and private sector biding is pooled at the national level from the point of view that national

tenders are awarded to local distributors with government guaranteed quantities of purchase and

estimated global quantities to be purchased (public and private sector) annually.

Individual public pharmacies are however responsible for their own medicine orders (procurement)

which are then centrally approved through the Government‟s SMART STREAM accounting system. It

is conducted under the supervision of the BDS, a department of the Ministry of Health. Public sector

medicines distribution is the responsibility of the Ministry of Health through the Barbados Drug Service.

Once the medicines are procured, they are distributed to the public health facilities by the local

wholesalers who have been awarded with contracts.

The tender processes used for public sector procurement are 100% national competitive tender. The

tender is advertised in the two local print media. The Ministry of Health is well on its way to developing

a web page that will include the BDS. Once that is completed, international tendering would be possible


21

since the Tender document will be available for downloading on the website. However, tenderers must

have local agents in Barbados. Except in emergency or exceptional situations, direct negotiations or

direct purchasing is not done. In 2009, direct procurement of Oseltamivir (Tamiflu) in response to the A

H1N1 epidemic constituted about 2% of total public expenditure on medicines, which is quite

significant. There are no regulations for national manufacturers‟ preference in public sector

procurement. Public sector procurement is not limited to medicines on Barbados Drug Formulary

(BDF).

Medicines financing

In 2007-08, the total public expenditure for medicines was US$ 23.49M. In 2009/2010 the total

expenditure for medicines was US $26.36M. The current financial year will probably be similar to

2009/2010 figures.

Barbados provides medicines and related items listed in the Barbados National Drug Formulary free of

cost at point of service, through the Barbados Drug Service, to the following beneficiaries:

(1) Persons 65 years of age and over;

(2) Children under 16 years of age; and

(3) Patients who receive prescribed Formulary Drugs for the treatment of hypertension, diabetes,

cancer, asthma and/or epilepsy.

All other items from the formulary can be obtained at the subsidized prices found in the ‘Prescription

Pricing Guide-Purchasing Guide’. This is so because all medicines from the formulary and related items

enter the country free of import duty, environmental levy and value added tax. Furthermore, they have

an agreed mark-up attached to them.

Revenues from fees or the sale of medicines from non-beneficiaries is never used to pay the salaries

directly or supplement the income of public health personnel in the same facility. Such revenue

collected in the public sector goes into the consolidated account

Prescribers in the public sector never dispense medicines; they may need to administer medicines

occasionally. In the private sector, they occasionally dispense medicines.

There is no public health insurance in Barbados. Some of the population has private health insurance,

which covers prescription medicines.

Barbados has a policy covering medicine prices under the BDS program that applies to both public and

private sectors. Local pharmaceutical distributors are fully involved in the supply process, and direct

overseas purchases are seldom made. The Local Distributors are allowed a 32% trading mark-up on

cost, insurance and freight. They are responsible for importing, warehousing, and distributing the

medicines and related items supplied under the Barbados Drug Service program. The retail private

pharmacies participating in the program use the following markup in preparing their reimbursement

claims to the BDS for payment:

Cost of Drug to Pharmacy Amount to be Charged

$0 - $2.00 Fixed Price of $5.00


22

$2.01 - $10.00 Cost plus $5.00

$10.01 - $20.00 Cost plus $7.00

$20.01 - $40.00 Cost plus $12.00

Over $40.00 Cost plus 30%

The government does not set the price or place any price controls on non-formulary medicines that are

sold according to the market forces. Similarly, there is no price control in place for the sale of formulary

medicines to non-beneficiaries in the private sector.

The Barbados National Drug Formulary (BNDF) displays the prices of medicines contained in it. As

stated earlier, prescriptions originating from private physicians written for non-beneficiaries can also be

dispensed at the BDS public pharmacies at a fixed cost plus mark-up in which applies to the private

sector. This privilege to the non-beneficiaries applies to all BDS pharmacies except those at the two

district hospitals where there is no dispensing of medicines to outpatients. Non-beneficiaries are those

who have seen a physician in the private sector for illnesses other than diabetes, hypertension, cancer,

asthma, and epilepsy, and are between the ages of 16 and 64.

Barbados does not have a national medicine price monitoring system for retail/patient prices and there

are no regulations mandating that the price information should be made publicly accessible. The draft

National Medicines Policy (NMP) and the official written guidelines on medicine donations provide

rules and regulations for donors and provide guidance to the public, private and/or NGO sectors on

accepting and handling donated medicines.

Rational use of medicines (RUM)

The Barbados National Drug Formulary is updated annually, most recently in 2010. Currently, the

BNDF is broader than an Essential Medicines List (EML). It contains approximately 1000 unique

medicine formulations. It is currently being reviewed with criteria based on evidence with the support of

PAHO/WHO and the PAHO/WHO Collaborating Centre on Rational Use of Medicines of the

University of La Plata, Argentina.

The drugs contained in the Tender document guided by selections contained in the Barbados National

Drug Formulary are being used for public and private sector procurement. There is no government price

of medicines in Barbados; the cost from the wholesalers is the same to both public and private

pharmacies. There is a Drug Formulary Committee responsible for the selection of products in the

Barbados National Drug Formulary. This Committee meets monthly.

The Drug Tender Committee is responsible for the actual award of contracts for the provision of drugs

in Barbados. This Committee makes its main adjudication during Primary Tenders and then there is a

Supplementary Tender for those drugs not tendered in the Primary document or those drugs that need

further consideration.

The health ministry produces national standard treatment guidelines (STG) for some major conditions,

namely diabetes, hypertension, asthma and HIV/AIDS. These were last updated in 2006 for diabetes and

hypertension and 2009 for asthma. As there is one specialised treatment centre for HIV/AIDS, the


23

related STG is available at this centre. The policlinics have the STG for prophylactic care for accidental

injury.

Antibiotics should not be sold over the counter without a prescription but they are occasionally sold,

while injections are seldom sold over the counter without a prescription.


24

Study Design and Methods

The model currently proposed by WHO for monitoring country pharmaceutical situations uses a

hierarchical approach with 3 groups of indicators: Level I, Level II, and Level III. Level I indicators are

assessed with a short questionnaire measuring organizational structure and processes of the

pharmaceutical sector. WHO Level II surveys investigate outcomes of the pharmaceutical sector in

public and private health care facilities and in households. Level III assessments evaluate specific

aspects of the pharmaceutical sector.


The survey with Level II indicators is a very important part of monitoring the pharmaceutical sector

because these indicators measure the outcomes and impact of strategic pharmaceutical programs in a

country: improved access, quality and rational use.

Access is measured in terms of availability and affordability of essential medicines. Additionally, there

is an indicator on geographical accessibility. Measuring the actual quality of medicines by testing

samples can be expensive. It is preferable to use indicators measuring the presence of expired medicines

on pharmacy shelves as well as adequate handling and conservation conditions. Finally, rational use is

measured by examining the prescribing and dispensing habits and the implementation of key strategies

such as standard treatment guidelines (STG) and essential medicines lists (EML).

Level II facility indicators are measured in public health facilities, private pharmacies, and warehouses

supplying the public sector.

The WHO level II methodology was adapted to the context of Barbados. The facility sample included

twelve public facilities, corresponding to all public health care facilities with outpatient services and

expected to carry a full supply of essential medicines in Barbados. Thirty private pharmacies out of the

100 operating in Barbados were selected randomly. No public warehouse was surveyed, as Barbados

public sector contracts out storage and distribution of medicines to private wholesalers.

In each facility surveyed, a set of Survey Forms (Annex 2) was applied. This allowed adequate

information gathering to calculate the Level II indicators.

The verification of availability, and expired medicines was based on a key medicines list developed for

the Level II survey, selected according to the first-line therapeutic choice for the most common and

important health conditions at the primary health care level (Box 1).


25

Box 1. Key medicines selected for the survey

Diseases/Symptoms Medicines (INN) dosage form

1. Analgesic/fever Aspirin tab. 81 mg

2. Analgesic/fever Paracetamol syr. 125 mg/ 5 ml

3. Inflammation Ibuprofen tab. 400mg

4. Hyperlipidemia Atorvastatin tab. 10 mg

5. Hyperlipidemia Simvastatin tab. 20 mg

6. Diabetes Glibenclamide tab. 5 mg

7. Diabetes Insulin, NPH vial

8. Diabetes Metformin tab. 500 mg

9. Gastro-intestinal disorders/ diarrhoea Oral rehydration salts granules/pre-mixed

10. Gastrointestinal disorders Ranitidine tab. 150 mg

11. Cardiovascular diseases Atenolol tab. 50 mg

12. Cardiovascular disorders Bendrofluazide tab. 2.5 mg

13.Cardiovascular disorders Enalapril tab. 20 mg

14. Respiratory disorders Beclomethasone inh. 50 mg

15. Respiratory disorders Salbutamol inh. 100 mcg

16. Infections Amoxicillin cap. 500 mg

Affordability of treatment for adults and children as well as compliance of prescribers to recommended

treatment protocols were performed considering tracer health conditions selected by the coordination

team (Box 2 and Box 3).

Box 2. Tracer conditions for compliance of prescribers to recommended treatment protocols/guidelines.

Tracer condition Medicines tracked Rationale*

Non-bacterial diarrhoea in

children under age 5

Oral Rehydration Salts

(ORS), antibiotic,

antidiarrhoeal and/or

antispasmodic

Clinical guidelines specifically refer to

correct rehydration of acute diarrhoea

cases

Mild/moderate (outpatient)

pneumonia in children

under age 5

Amoxicillin Defined as any type of lower

respiratory tract infection that authors

considered needing antibiotics.

Non-pneumonia Acute

Upper Respiratory Tract

Iinfection (UTRI) in patients

of any age

Any antibiotic Defined as any type of URTI that

authors considered not needing

antibiotics.„Common cold‟ and „sore

throat‟ cases were considered viral

URTI, i.e. not needing antibiotics.

* Medicines use in primary care in developing and transitional countries:

Fact Book summarizing results from studies reported between 1990 and 2006


26

Box 3: Tracer conditions for affordability

Tracer condition Medicine Treatment schedule

Total

amount

required

Children <2 yr: For the 1st

2 hr 240 mL; 3 x 240 mL

can be taken daily.

Children 2-5 yr For the 1st 2

hr 3 x 240 mL. Max: 6 x 240

mL daily,

Mild/moderate (outpatient)

pneumonia in children under

age 5

Amoxicillin

125mg/5ml

(millilitre )50mg/kg body mass/daily.

Every 8 hrs

1 week: 4.2 g

for a 2yo child

(weight 12kg*)

Non-pneumonia Acute Upper

Respiratory Tract Infection

(UTRI) in patients of any age

Paracetamol

500mg (cap/tab) 10mg/kg/body mass per

dose. Every 6-8 hours as

needed

5 days: 10.5 g

for an adult

(weight 70 kg)

*http://w w w .cdc.gov/grow thcharts/data/set1clinical/cj41c021.pdf

Oral

Rehydratation

Salts: When

needed for

children less

than 10%

dehydrated

Non-bacterial diarrhoea in

children under age 5

Dependent on

severity of

dehydration:

4 - 6 sachets

Data collection methods included patient and health worker interviews after oral consent, check list

guided observation and clinical and administrative documents review.

The survey was conducted after approval by the Ministry of Health. Local health managers were

contacted for specific approval and cooperation.

The field team consisted of 19 data collectors who were selected based on their qualification as data

collectors, medical students, research assistants, CAPE Students and retired Nurses, and one supervisor

who oversaw the process of data collection.

All data collectors were trained during a training course July, 14 to 17, 2010. Data collection took place

between July 19 and August 6, 2010.

Box 4 summarizes Level II indicators and lists the corresponding survey forms. Information on data

collection and calculation can be found on the respective survey forms. Only forms which applied to the

Barbados situation were used.


27

Box 4. Summary list of indicators and corresponding survey form used to collect the data

Indicator Survey Form

Access

1 Availability of key medicines in public health facility dispensaries, private pharmacies and warehouses supplying the public sector

1, 10, 15

2 % of prescribed key medicines dispensed or administered to patients at public health facility dispensaries

6

3 Average stock-out duration in public health facility dispensaries and warehouses supplying the public sector

4, 16

4 Adequate record keeping in public health facility dispensaries and warehouses supplying the public sector

4, 16

5 Affordability of treatment for adults and children under 5 years of age at public health facility dispensaries and private pharmacies

3, 12

8 Average cost of medicines at public health facilities and private pharmacies 6, 14

9 Geographical accessibility of public health facility dispensaries and private pharmacies 6, 14

Quality

1 % medicines expired in public health facility dispensaries, private pharmacies and warehouses supplying the public sector

1, 10, 15

2 Adequacy of storage conditions and of handling of medicines in public health facility dispensaries and warehouses supplying the public sector

5, 13, 17

Rational use of medicines

1 % medicines adequately labelled at public health facility dispensaries and private pharmacies

6, 14

2 % patients informed on how to take medicines at public health facility dispensaries and private pharmacies

6, 14

3 Average number of medicines per prescription at public health facility dispensaries and public health facilities

6, 7

4 % patients prescribed antibiotics in public health facilities 7

5 % patients prescribed injections in public health facilities 7

6 % prescribed medicines on the essential medicines list at public health facilities 7

7 % medicines prescribed by generic name (INN) at public health facilities 7

8 Availability of standard treatment guidelines at public health facilities 8

9 Availability of essential medicines list at public health facilities 8

10 % tracer cases treated according to recommended treatment protocol/guide at public health facilities

9

11 % prescription medicines bought with no prescription 14

Other information

1 % of facilities that comply with the law (presence of a pharmacist) Section A, C

2 % facilities with pharmacist, nurse, pharmacy aide/ health assistant or untrained staff dispensing

Section A, C

3 % facilities with doctor, nurse, trained health worker/health aide prescribing Section B

4 % facilities with prescriber trained in Rational Medicines Use (RMU) Section B

Data collection was performed on the data forms provided in the WHO survey package. After data

collection, summaries were calculated manually on each survey form. Then, values were entered in the

automated WHO Excel spread sheet of Summary Forms which automatically calculated indicators

presented here.

In this report, results at the national level are expressed as median, followed by percentiles 25 and 75.

With regard to the analysis, the national median was only calculated if there was information from at

least four facilities in each category (public or private). Data from patient interviews were only

considered for health facilities with at least 10 interviews completed, which was the case in all facilities.


28

Limitations of the study

The study was not intended to give a detailed analysis of the pharmaceutical sector but rather to provide

an overview of the national pharmaceutical situation in Barbados. The study represents a tool for policy

analysis and the design of appropriate interventions.

The survey has been designed to draw a picture of the national pharmaceutical situation in Barbados.

The regions and facilities selected cumulatively represent the national situation.

The sample sizes are statistically not large enough to make inter-facility comparisons with some

indicators. This survey uses all facilities in the sample areas. From the data collected, no geographic

comparisons can be made.

Household Survey

This study was conducted using an adaptation of the standardized methodology developed by the World

Health Organization (WHO), which uses health facilities included in Level II survey as nucleus to define

the clusters of the household survey.

Given the Barbados geographic context, the standard method could not be used. Instead, a multi stage

cluster sample design was applied, with cluster sizes of 7 households each. The clusters were drawn in

two stages.

The two stage cluster sample was drawn in the following way:

1. A systematic sample of census enumeration blocks within each parish, with a random start and

an appropriate sampling interval for each parish (figure 2).

2. A systematic sample of 7 households within each census enumeration block drawn in stage 1.

Households were selected through a random start and an appropriate sampling interval for each

census enumeration block. These 7 randomly selected households constitute the cluster.

The distribution of the number of clusters in Barbados is shown on Figure 1. The sample was a stratified

random sampling. The Figure 2 exemplifies one random area to show how households were identified.

Figure 1. Geographic location of statistical sample areas, Barbados, 2010.


29

Figure 2. Stratified Random sampling area identifying households, Barbados, 2010.


30

Interviewers were trained to use judgment in selecting respondents. Respondents were selected if they

met at least three of the following criteria:

Main health care decision maker

Household member most knowledgeable in health

Household member most knowledgeable in household health expenditures

Household member most knowledgeable in household health utilization

Designated care giver for sick household members

The survey team consisted of a survey manager and 19 data collectors. Most data collectors were

medical students of the University of the West Indies and other higher tertiary institutions, mainly

Queens and Harrison College Advanced Level Students. All survey personnel received training in the

standard survey methodology, data collection and data entry procedures at a workshop held on July 14-

16, 2010 in Bridgetown. As part of the workshop, a data collection pilot test was conducted in

households which did not form part of the survey sample.

Data collection took place between 19 July and 6 August 2010. The data collectors were divided in 6

groups for the household group and 4 groups for the facilities group. All households and facilities were

surveyed by two data collectors.

An Excel spreadsheet displaying quintiles of monthly household expenditures by number of household

members in Barbados was distributed to data collectors during the training workshop. (Annex 3, page

85) This spreadsheet was used to describe categories A, B, C, D, and E of Question 37 during interviews

with household respondents. At the end of each day of data collection all completed questionnaires were

checked by the survey manager. Upon completion of the survey, the survey manager managing the

household survey and the BDS staff managing the facilities survey conducted a quality control check of

all completed questionnaires prior to data entry.

Survey data entry was performed by the survey manager with the assistance of the data collectors.

Epidata software was used for data entry. Entry was checked by entering twice 100% of the

questionnaires using the double data entry functions of Epidata; erroneous entries and potential outliers

were verified and corrected as necessary.

Epidata records were exported into an Excel workbook containing macros and formulas that

automatically generated the tables and figures contained in this report.


31

Results and Discussion

First, results from the health facility survey are presented, followed by results from the household

survey. The results are presented in the format of groups of indicators. Key issues are highlighted in

each group.


Issues related to the field work

The location of the facilities surveyed is presented in Table 1.


32

Table 1. Characteristic of health care facilities surveyed in Barbados, July 2010.

Parish Facility Name Facility type Number of

outpatient

interviews

Randal Phillips Polyclinic Public Health Center 30

Elcourt Pharmacy Private Pharmacy 30

Jems Pharmacy Private Pharmacy 20

Pearsons Pharmacy Sheraton Private Pharmacy 23

Glebe Polyclinic Public Health Center 30

Henleys Pharmacy Private Pharmacy 30

Avis Pharmacy Private Pharmacy 30

Felimar Drug Mart Private Pharmacy 15

St. John St. John Outpatient Clinic Public Rural Health Center 30

St. Joseph St. Joseph Outpatient Clinic Public Rural Health Center 30

Queen Elizabeth Hospital Public Hospital 30

Black Rock Polyclinic Public Health Center 30

Psychiatric Hospital Public Health Center 30

Edgar Cochrane Polyclinic Public Health Center 30

Warrens Polyclinic Public Health Center 30

Winston Scott Polyclinic Public Health Center 30

A.P. Jones Private Pharmacy 30

Alpha Pharmacy Eldorado Private Pharmacy 10

Alpha Pharmacy Private Pharmacy 17

Bayview Pharmacy Private Pharmacy 15

Callies Pharmacy Brigade HousePrivate Pharmacy 30

Callies Pharmacy Private Pharmacy 30

Carlton Pharmacy Private Pharmacy 30

Collins Pharmacy Private Pharmacy 30

Cosmopolitan Pharmacy Private Pharmacy 30

DASAE Pharmacy Private Pharmacy 30

Eastern Pharmacy Private Pharmacy 30

Elbethel Pharmacy Private Pharmacy 30

Elbethel Pharmacy Belleville Private Pharmacy 30

Flanders Pharmacy Private Pharmacy 15

Heritage Pharmacy Private Pharmacy 30

Holborn Pharmacy Private Pharmacy 30

Knights Pharmacy Warrens Private Pharmacy 30

Pearsons Pharmacy Private Pharmacy 30

SWM Pharmacy Private Pharmacy 30

Maurice Byer Polyclinic Public Rural Health Center 30

O'Hana Pharmacy Private Pharmacy 11

St. Philip St. Philip Polyclinic Public Health Center 30

Christ

Church

St. George

St. James

St. Michael

St. Peter


33

Key points

The main public hospital of Barbados, Queen Elizabeth Hospital (QEH), was included in the

survey.

In addition, 11 public health care centres and 30 private pharmacies were surveyed. This

represents 65% of existing public dispensaries and 30% of private pharmacies in Barbados.

The majority of surveyed facilities came from the most densely populated capital parish of

Saint Michael.

Some facilities had to be visited several times to interview a sufficient number of outpatients.

No interviews were performed in 4 private pharmacies because they were too small and hardly

any patients were available to be interviewed at the time of the survey.

The sample population for the outpatients‟ exit interviews is presented in Table 2. People were

approached when leaving public dispensaries or private pharmacies. Categories for age were: (1) Under

5 years old; (2) 5 -14years; (3) 15 - 59 years and (4) over 60 years old.

Table 2. Characteristics of outpatients interviewed in Barbados, July 2010.

Category of health facilities

Number of

outpatients

interviewed

%

FemaleAge %

Public health facility pharmacies 360 62% 1) under 5 yrs. 4%

2) older children 5%

3) adults 58%

4) over 60 yrs 33%

Private Pharmacies 666 62% 1) under 5 yrs. 7%


3) adults 46%

4) over 60 yrs 42%

Total 1026 62% 1) under 5 yrs. 6%


3) adults 50%

4) over 60 yrs 39%

Key points

The majority of outpatients interviewed were female: six in ten patients interviewed. This

profile was the same in public health facilities and in private pharmacies.

Half of interviewed patients were adults between 15 and 59 years old, and about four in ten

were over 60 years old.

Health workers at health facilities


34

Dispensing is a technical activity and should be performed by trained people. A direct participation of a

pharmacist in this process is highly desirable.

In Barbados, the law requires for pharmacies to avail themselves of the professional services of a

qualified licensed pharmacist. When the pharmacist is not present, daily operations of reviewing and

preparation of prescriptions, labeling among other tasks should not occur. In Barbados, it is illegal to

operate a pharmacy in the absence of the pharmacist.

During the visit, the qualification of the personnel interacting with patients was checked.

Results about dispenser and prescriber profiles are displayed in Table 3 and Table 4 respectively.

Table 3. Dispenser profile at PSA-HFS Level II in Barbados, July 2010.

Public

sector

Private

sector

Professional dispensing during the visit

pharmacist 100% 96%

nurse 0% 0%

pharmacy aide/ health assistant 25% 15%

untrained staff 0% 0%

Facilities that comply with the law (presence of a pharmacist) 100% 96%

Key points

In all public dispensaries and in almost all private pharmacies, a pharmacist or pharmacy aide

were dispensing at the time of the survey.

No untrained staff were dispensing in any of the facilities at any time during the visits of

surveyors.

Table 4. Prescriber profile in the public sector, PSA-HFS Level II in Barbados, July 2010.

% public facilities where doctor nurse

trained health

worker/health

aide

Professional prescribing during the visit is 100% 8% 0%

The most senior professional present is 100% 0% 0%

The most senior professional attended RDU-

related training within the previous year78%

Key points

Physicians were prescribing in all visited public facilities.


35

The nurses who prescribed (8% of all prescribers) would be in the family planning unit where

they prescribe oral contraceptives.

Eight in ten of the most senior prescribers in the public facilities declared having attended

training related to rational use of medicines in the previous year.

Access

Access to health services or products can be understood as a combination of four dimensions:

availability, geographical accessibility, affordability and acceptability. Acceptability was not addressed

by this assessment. As for availability, since the key medicines list includes first choices for the most

prevalent problems at the primary health care level good results should be close to 100%. Reference for

affordability calculation was the day‟s wage of the lowest paid public worker.

Results for general indicators of access were excellent (Table 5; Figure 2, Figure 3). The median

availability of key medicines was 100% in the public sector and 94% in private pharmacies. The

percentage of prescribed key medicines that were dispensed or administered to patients at public health

facilities was 99%. However, a key indicator of availability, i.e. stock-out periods, could not be assessed

in this survey because of the lack of stock-out cards in public health care facilities. Geographical

accessibility of public health facilities is excellent, with a median of 97% of patients reaching a public

facility in less than 30 minutes.

Table 5. General indicators for availability and geographical accessibility, Pharmaceutical Situation

Assessment – Health Facility Survey Level II, Barbados, July 2010.

IndicatorNational

(Median)

25th

Percentile

75th

Percentile

Availability

Availability of key medicines in

public health facility dispensaries 100% 94% 100%

private pharmacy 94% 94% 100%

% of prescribed medicines dispensed or

administered to patients at public health facility

dispensaries

99% 96% 100%

Geographical accessibility

% patients taking more than one hour to travel to



Average transportation cost in local currency*

public health facility dispensaries BBD 2.81 BBD 2.08 BBD 3.40

private pharmacy BBD 3.18 BBD 2.77 BBD 4.47

Average Transport cost percentage of minimum wage daily salary



*US$1 = BBD$1.96


36

Figure 3. Availability of Key Medicines in public health facility dispensaries, and in private pharmacies.

Pharmaceutical Situation Assessment – Health Facility Survey Level II, Barbados, July 2010.

100%

93.8%

Nat

ion

al M

ed

ian

(%

)

Access - Availability of key medicines

Public Health Pharmacy Private Pharmacy

Figure 4. Distribution of facilities according to the percentage of prescribed key medicines that were

dispensed or administered. Pharmaceutical Situation Assessment - Health Facility Survey Level II,

Barbados, July 2010.

0% 0% 0%

100%

0%

100%

< 25% 25 - 50% 50 - 75% > 75%

% o

f P

ub

lic F

acili

tie

s

% of prescribed medicines that are dispensed or administered

Access - Distribution of facilities according the % of prescribed medicines

that are dispensed or administered


37

Key point on availability and geographical accessibility

Key medicines were fully available in all public dispensaries.

Availability of key medicines was slightly lower in the private sector: 94%.

All public dispensaries dispensed 75% and more of key prescribed medicines.

The average cost of transportation was lower to reach public than private facilities: 2.8 vs. 3.2

BBD respectively.

Affordability

The affordability of treatment for 3 common conditions was estimated as the proportion of one day‟s

wages of the lowest-paid unskilled government worker that would be required to purchase medicines

prescribed at a standard dose (Box 3). For acute conditions, treatment duration was defined as a full

course of therapy. The daily wage of the lowest-paid unskilled government worker used in the analysis

was BBD 63.68 (US$ 32.49).

It should be noted that treatment costs refer only to medicines and do not include the additional costs of

consultation and diagnostic tests. Further, although many people in Barbados earn less than the lowest

government wage, unaffordable treatments are being secured by the Ministry of Social Affairs.

Table 6. Number of day‟s wages of the lowest paid government worker needed to purchase standard

treatments. Pharmaceutical Situation Assessment - Health Facility Survey Level II, Barbados, July 2010.

Lowest

price

generic

Originator

brand

Lowest

price

generic

Originator

brand

0.02 N/A 0.02 N/A

0.03 N/A 0.05 0.09

0.01 N/A 0.02 0.97

Disease condition and ‘standard’

treatmentDay’s wages to pay for treatment

private sector

Condition

(Drug name, strength, dosage form)

public sector

Mild/moderate (outpatient) pneumonia in

children under age 5 (amoxicillin susp.,

125mg/ml)

Non-pneumonia Acute Upper Respiratory

Tract Infection (UTRI) in patients of any age

(paracetamol, 500mg tablets)

Acute diarrhoea in children under age 5

(ORS sachets)

Key points on affordability

Overall, when expressed as the proportion of one day’s wages of the lowest paid government

worker, affordability of generic medicines for 3 selected key conditions was good. Except for

Oral Rehydration Salts, it was better in the public sector. It is to be noted that non-


38

beneficiaries who seek medical service in both the public and private sectors and get the

prescriptions filled in the public sector are required to purchase their formulary medicines.

In private pharmacies, originator brand medicines were much more expensive than generics.

Quality of medicines

Since direct quality assessment of medicines is expensive and difficult to evaluate in such a survey,

some proxy’ indicators were measured. Key medicines selected for verification in the study are

supposed to be frequently used, and with a high turnover. Thus, assessing the quantity of expired

medicines would not provide the adequate results. However, storage conditions verified in this study

meet basic quality standards.

The collected data show that no expired medicines were found. Storage conditions were good but not

optimal in both public health facilities and private pharmacies (Table 7; Figure 4).

Table 7. General indicators for quality of medicines, Pharmaceutical Situation Assessment - Health

Facility Survey Level II, Barbados, July 2010.

IndicatorNational

(Median)

25th

Percentile

75th

Percentile

% medicines expired in


private drug outlets 0% 0% 0%

Adequacy of storage conditions of

medicines in

storerooms of public health facility

dispensaries85% 78% 90%

dispensing rooms of public health facility

dispensaries 85% 80% 90%

storerooms of private pharmacies 90% 73% 90%

dispensing rooms of private pharmacies 90% 80% 90%


39

Figure 5. Adequacy of infrastructure of conservation conditions of medicines, Pharmaceutical Situation

Assessment - Health Facility Survey Level II, Barbados, and July 2010.

85%90%

85%90%

Storeroom Dispensing area

Nat

ion

al M

ed

ian

(%

)

QualityAdequacy of infrastructure of

conservation conditions of medicines

Public health pharmacy Private pharmacy

\zx\zx\\z

Key points on quality of medicines

No expired medicines were found in the public or private sectors.

Adequacy of infrastructure for conservation conditions of medicines in public health

pharmacies was 85% in both the storage and dispensing rooms.

Adequacy of infrastructure for conservation conditions of medicines in private pharmacies

was slightly better than in public pharmacies: 90% in both the storage and dispensing rooms.

Rational Use of Medicines (RUM)

According to WHO3, the target for indicators measuring the extent of adequate labeling, proportion of

prescribed medicines dispensed, adherence to treatment guidelines and availability of key medicines is

ideally 100%. However, internationally valid targets for other indicators, such as average number of

medicines per prescription, and the percentage use of antibiotics and injections, are more complex and

have not been empirically established. Targets may require modification over time and across countries.

A commonly used recommendation is to average 2 medicines per prescription, with less than 30% of

prescriptions including antibiotics and less than 20% including injections. The optimal values for these

indicators largely depend on disease patterns, policies, and treatment guidelines, and therefore may vary

3 WHO, (World Health Organization) (2006). Using indicators to measure country pharmaceutical situations: Fact Book

on WHO Level I and Level II monitoring indicators. Geneva, WHO.


40

from country to country and over time. Average number of medicines per prescription was addressed by

two different methods: patient exit interview (cross sectional approach) and retrospective prescription

review (one year review).

The data concerning rational use of medicines (Table 8 and Table 9) show that the average number of

medicines per prescription is 3. The median percentage of patients prescribed with injections is 7%.

Although the median percentage of patients receiving antibiotics is 23%, the median percentage of

patients with tracer non-bacterial diseases treated with antibiotics is too high: 50%. Although the

majority of pharmacies did not sell prescription medicines without a prescription, surveyors found

several instances of prescription medicines sold by private pharmacies without prescription.


41

Table 8. General indicators for rational use, Pharmaceutical Situation Assessment - Health Facility

Survey Level II, Barbados, July 2010.

IndicatorNational

(Median)

25th

Percentile

75th

Percentile

Prescribing indicators

Average number of medicines per prescription

at public health facility dispensaries and

public health facilities(SF6)

3.00 2.00 3.00

Average number of medicines per prescription

at public health facility dispensaries and

public health facilities(SF7)

3.07 2.82 4.40

% patients prescribed antibiotics in public

health facilities23% 13% 33%

% patients prescribed injections in public

health facilities7% 0% 13%

% prescribed medicines on the formulary at

public health facilities99% 97% 100%

% medicines prescribed by generic name

(INN) at public health facilities36% 25% 48%

Patient care indicators

% medicines adequately labeled at


private dispensaries 100% 96% 100%

% patients know how to take medicines at


private dispensaries 100% 100% 100%

% of prescription medicines bought without

prescription in private pharmacy0% 0% 7%

Facility specific factors for the rational use

of medicines

National

percentage

Availability of standard treatment guidelines at

public health facilities 55%

Availability of formulary at public health facilities 92%

Table 9. Distribution of private pharmacies according to their results on % prescription medicines

bought without prescription, Barbados, July 2010.

% prescription

medicines bought

without prescription

Number of

private

pharmacies

% of private

pharmacies

< 25% 24 92%

25 - 50% 2 8%

51 - 75% 0 0%

> 75% 0 0%

TOTAL 26 100%


42

Key points on rational use of medicines

The average number of medicines per prescription was close to 3 for both the exit interviews

and retrospective review of prescriptions.

In four out of the twelve public health facilities, over 30% of outpatient prescriptions included

an antibiotic.

In three out of twelve public health facilities, over 10% of outpatient prescriptions included an

injection.

Almost all prescribed medicines were on the national formulary.

Prescriptions using INN (generic name) are low, which does not correspond with the intended

policy.

Labeling of medicines was excellent both in the public and the private sector.

Most of the patients knew how to use their medicines.

About half of public health facilities did not have a copy of Standard Treatment Guidelines.

Ten of the 26 private pharmacies where interviews took place sold some prescription

medicines without prescription. In one pharmacy, 46% of prescription medicines were sold

without prescription.

Percentage of tracer cases treated according to recommended treatment protocol is presented in Table

10.

Table 10. Adherence of prescribers to recommended treatment guidelines. Pharmaceutical Situation

Assessment - Health Facility Survey Level II, Barbados, July 2010.

Indicator Information source Median

National

Average

Standard

Deviation

Non-bacterial diarrhoea

in children under age 5

Total number of

cases 99

% ORS 40% 35% 22%

% Antibiotics 20% 18% 14%

% Antidiarrhoeal and/or

Antispasmodic10% 25% 30%

Mild/moderate

pneumonia in children

under age 5

Total number of

cases40

% receiving any one

first line antibiotic32% 34% 37%

% receiving more than

one antibiotic17% 19% 21%

Non-pneumonia ARI in

patients of any age

Total number of

cases96

% Antibiotics 50% 54% 25%


43

Key points on rational prescription of medicines

Overall, results suggest the need for intensifying training of providers on rational prescribing.

Only four in ten children under five with diarrhea were prescribed Oral Rehydration Salts,

the recommended treatment. In addition it was not infrequent for providers to prescribe

unnecessary medicines for diarrhea: two in ten of these children received an antibiotic, and

about one in ten received an antispasmodic.

Few cases of pneumonia in children under 5 were available for review at the time of the

survey. Of the 40 cases reviewed, only a third was prescribed a first line antibiotic, which

appears far too low. However, because suspected cases of pneumonia in children under 5

years old are automatically and immediately referred from polyclinics to Queen Elizabeth

Hospital, the proportion of such cases receiving antibiotics may be higher than is reported in

this survey.

On the other hand, antibiotics were largely overused to treat non-pneumonia Acute

Respiratory Infection. Half of the patients of any age with ARI received antibiotics which is an

unusually high rate suggesting unnecessary use of antibiotics.

Challenges and constraints

Despite the presence of the pharmacist in most pharmacies, storage conditions of medicines need to be

improved as these were not optimal for public health facilities and private pharmacies. The

implementation of Good Practices related to distribution, storage and the Pharmacy Practices would

contribute to this.

In Barbados, medicines are generally available. The computerized system in place in the polyclinics is

quite remarkable and is likely responsible for the good performance in labeling. It can represent an asset

for monitoring the implementation of the proposed recommendations; Nevertheless, at policlinic

pharmacies, the previous stock-out information is not available. As there were no stock cards and only

current stock at hand can be retrieved, stock-out days could not be assessed. At Saint Michael

Psychiatric Hospital (SMPH), the percentage of adequate records was 100% and the average number of

stock out days was 0. At Queen Elizabeth Hospital (QEH), the percentage of adequate records was

slightly lower at 93.8%, and the average number of stock out days was high: 61 days. It is

recommended to improve the stock control in the computerized system to be able to retrieve previous

stock-out information.

International Non-proprietary Name (INN) drugs were used for only 36% of the prescription medicines

in public health facilities. Strategies for promoting the use of INN and incentives for prescribers can

contribute to the improvement of the use of generic medicines.

The rational use of medicines in private pharmacies is a matter of concern since ten of 26 private

pharmacies sold prescription medicines without a prescription.

There are STG for diabetes, hypertension and asthma which were available only in about half of

surveyed health facilities.




44

This and the fact that many children under 5 with diarrhea are not prescribed the appropriate treatment

strongly suggest the need to intensify training of providers in key areas of primary care prescribing.


appropriate use of medicines can be improved by increasing availability and use of STG, and by

encouraging the use of INN for prescribing.

Household Survey

The household survey included data from 317 households, with distribution patterns in different parishes

displayed on Figure 5.

Figure 6: Number of surveyed households in each region, Barbados, 2010..

ParishNumber of

households%

St. Michael 105 33%

Christ Church 48 15%

St. Philip 43 14%

St. James 36 11%

St. George 29 9%

St. John 14 4%

St. Thomas 14 4%

St. Joseph 7 2%

St. Andrew 7 2%

St. Peter 7 2%

St. Lucy 7 2%

Total 317 100%

Key points

A total of 317 households participated in the survey.

The largest parish of Barbados, the capital parish of Saint Michael contributed

33% of households.

Characteristics of surveyed households

Understanding the characteristics of surveyed households is critical for assessing their

representativeness at the country level. Interpretation of survey results depends on the location, size,

composition and socio-economic status of households, as well as characteristics of respondents and

morbidity of the population included in the survey.

Respondents

Respondents were selected by data collectors if they were the household health care decision makers.

Therefore, data on age and education of respondents who provided information about the characteristics


45

of the main health care decision makers in households was collected. In addition, the profile of

respondents is important to interpret their opinions. Figure 6 presents the age of respondents, by gender.

Figure 7: Age of respondents/health care decision makers, Barbados, 2010.

1% 3%

14%

27%

19%

34%

0%

50%

100%

men women

Pe

rce

nta

ge o

f re

spo

nd

en

ts

<25 yo 25 to 50 yo >50 yo

Key points

Data collectors interviewed the person who was the most knowledgeable about matters related

to the health of household members.

Two third of respondents were women.

Over half of respondents were over 50 years old.

Table 11 presents the highest level of education reached by respondents.

Table 11: Education of respondents, Barbados, 2010.


46

Number of respondents

No formal schooling 1 0% 0 0% 1 0%

Some primary school 4 1% 1 1% 2 1%

Completed primary school 69 22% 20 19% 49 24%

Completed secondary school 117 38% 35 33% 80 40%

Completed high school or equivalent 23 7% 7 7% 15 7%

Completed college/preuniversity/university 89 29% 41 38% 45 22%

Completed post-graduate degree 9 3% 1 1% 7 3%

Barbados - All Men Women

308 107 201

Key points

All respondents had received some formal education.

A third of respondents completed education beyond high school. This high proportion was

more evident for men than women: 39% versus 25% respectively.

Household assets

Assets are an indicator of socio-economic status which is complementary to household expenditures.

The medicines survey collects information about 15 different items by asking: “Does anyone in your

household have such an item?” Items are country-specific, i.e. each survey team creates a list of assets

that best discriminates among socio-economic strata in their country. Assets chosen by the Barbados

survey team were: car, cell phone, own house/land, solar water heater, stove, water tank, air

conditioning, computer, dishwasher, dryer, and satellite dish.

Figure 7 presents the percentage of households with assets that discriminate best different socio-

economic levels.


47

Figure 8. Household assets and levels of monthly (4 weeks) expenditures, Barbados, 2010.

2%

10%8%

16%

8%

20%

4%

23%

38%

59%

69%

84%

0%

100%

< 800 BBD 800 BBD and over

Pe

rce

nta

ge o

f h

ou

seh

old

s

Total 4-wk expenditures per person

dishwasher satellite dish dryer air conditioning solar water heater computer

Key points

Assets that best discriminated the socio-economic level of households in the survey were:

dishwasher, air conditioning, dryer, satellite dish, solar water heater and computer

Household expenditures

In the survey direct information on food and health expenditures of households is collected. Providing

an actual value of 4-wk total expenditures is optional. Recall periods of total, food, and health

expenditures are defined as the four previous weeks. Discretionary expenditures are calculated as the

difference between total and food expenditures.

Table 12 presents the mean, 25th

percentile, median, and 75th

percentile of household expenditures by

surveyed households. The mean is the average value, sensitive to outliers, whereas the median is the 50th

percentile, which is less affected by extremely high or low values. The median is the value below which

50% of the observations are positioned. The 25th

and 75th

percentiles are the boundaries of half of the

values around the median. The 25th

percentile is the value below which 25% of the observations are

found. The 75th

percentile is the value below which 75% of the observations are found or, conversely,

the value above which 25% of observations are found. The large difference between means and medians

of expenditures in some cases is due to the presence of extreme outliers at the higher ranges of

expenditures. The valid N represents the number of households that provided information with the

specific expenditure.


48

Table 12: Monthly household expenditures, Barbados, 2010.

Valid N MeanPercentile

25Median

Percentile

75

4-wk hh total expenditures* 122 1,451 813 1,200 1,800

4-wk hh food expenditures* 290 693 400 600 800

4-wk discretionary expenditures

(e.g. total - food)*122 726 300 600 1,000

4-wk hh health expenditures* 82 251 71 128 250

4-wk hh hospital expenditures* 1 200 200 200 200

4-wk hh medicine expenditures* 43 102 20 52 84

4-wk hh other health expenditures* 24 229 70 103 200

4-wk hh voluntary health insurance

expenditures*40 262 90 134 260

* Barbados Dollar (BBD)

US$1=BBD$1.96

Key points

Less than half of households shared their actual total expenditures with surveyors.

One in four households (82/318) reported health expenditures over the past month. For these

households, the median spending on health was 128 BBD.

One in eight households (43/318) reported medicines expenditures over the past month. For

these households, the median spending on medicines was 52 BBD.

One in eight households (40/318) reported health insurance expenditures over the past month.

For these households, the median spending on health insurance was 134 BBD.

One household had spent 200 BBD on hospital expenditures during the previous month.

Household socio-economic status

Socio-economic status (SES) is a key attribute of households, influencing their options and decisions

about health care. In addition to collecting assets and expenditures data, socio-economic status can be

estimated by asking respondents to choose which level of expenditures best matches what their

household spends over a defined period of time.


49

The medicines survey identifies poor households by asking respondents to match their household

expenditures with one of five pre-defined ranges (Annex 4, page 85). In Barbados, the lowest range of

expenditures was range A defined as spending less than 800 BBD per person per month. Range B

corresponded to spending between 800 and 1100 BBD per person per month, range C to spending

between 1101 and 1300 BBD per person and per month, range D to spending between 1301 and 1900

BBD per person per month. Range E was the highest possible range of expenditures, defined as

spending more than 1900 BBD per person per month. Respondents chose one of these five ranges of

expenditures that corresponded to the monthly total expenditures of their household. Very few

respondents identified their household in higher ranges.

Households were classified in two socio-economic categories: lower and higher socio-economic status

(SES) based on assets and expenditures criteria, as follows:

Group 1 called lower SES included all households that reported total expenditures below 800 BBD per

person over the past four weeks, and who did not possess any of the following assets: dishwasher, air

conditioning, dryer, satellite dish, or solar water heater. A total of 112 households belonged to this

group.

Group 2 called higher SES included all other households who reported expenditures directly or

indirectly and possessed at least one on the five most discriminating assets: dishwasher, air conditioning,

dryer, satellite dish, or solar water heater. A total of 160 households belonged to this group.

The remaining 46 households are not included in the analysis by SES presented in this report, because

they did not report their expenditures either by self-selecting a spending range or by providing an actual

total.

Figure 9 presents the distribution of the two SES groups in the survey, by parish.


50

Figure 9. Percentage of households in each SES group, by parish, Barbados, 2010.

0%

50%

100%

Lower SES Higher SES

Table 13 and Table 14 present the characteristics of households and sources of income at different levels

of SES, and in different areas.

Table 13. Characteristics of households, Barbados, 2010.

Barbados - All Lower SES Higher SES

Number of households 317 112 160

Average household size 3 4 3

Total population 1068 421 497

Percentage of households with children 35% 46% 28%

Number of children per household with

children 2 2 2

Number of children < 5 yo per household

with children 1 1 1

% of households where someone earns

money 88.3% 88.4% 90.6%

Mean 4-wk total household expenditures

(BBD)1,451 961 1,814


51

Table 14. Sources of income and the job of the main earner in the household (household head),

Barbados, 2010.


Unspecified 9% 10% 9%

Farmer 0% 0% 1%

Self-employed 11% 8% 14%

Civil servant 12% 16% 10%

Teacher 6% 5% 8%

Office worker 17% 16% 20%

Artisan 4% 6% 3%

Agricultural labor 1% 1% 1%

Non-agricultural labor 3% 6% 1%

Health worker 2% 2% 2%

Retired 31% 28% 30%

Key points

More households in the lower SES group had children: 46% vs. 28% in the higher SES group.

The average 4-week spending of households in the lower SES group was half that of

households in the higher SES group: 961 BBD vs. 1,814 BBD.

Overall, close to a third of the main household earners were retired.

A higher proportion of self-employed was observed in the higher SES group: 14% vs. 8% in

the lower SES group.

Household morbidity

The medicines survey collects information about household morbidity by asking respondents if a

member of the household had acute illness within two weeks preceding the survey and if a member of

the household has a chronic disease. If that is the case, data collectors collect health data on the youngest

member with a recent acute illness and on the oldest member with a chronic disease. They also ask how

many members had or have a recent acute illness or have a chronic disease.

Table 15 presents the prevalence of illnesses in surveyed households and Table 15 displays the average

number of illnesses in households with a sick member, as well as the age and gender of members whose

health information was collected.


52

Table 15: Prevalence of acute and chronic conditions, Barbados, 2010.

Yes No All

26 21 478% 7% 15%

161 109 27051% 34% 85%

187 130 31759% 41% 100%

All

At least one

recent acute

illness

At least one chronic

disease

Yes

No

Table 16: Characteristics of acute and chronic conditions, Barbados, 2010.

Number of households with at least one recent acute illness 47

Average number of recent acute illnesses per household with at

least one recent acute illness1.2

Average age of youngest with recent acute illness 26

Percentage of youngest members with recent acute illness who are

< 1545%

Percentage of youngest members with recent acute illness who are

females45%

Number of households with at least one chronic disease 187

Average number of chronic diseases per household with at least

one chronic disease1.3

Average age of oldest with chronic disease 61

Percentage of oldest members with chronic disease who are above

5076%

Percentage of oldest members with a chronic disease who are

females60%


53

Key points

About a third of sampled households reported no health problems: 35%.

Few households reported a recent acute illness: 15%.

Over half of the households reported a current chronic disease: 59%.

Few household reported both acute and chronic conditions: 8%.

A higher percentage of women than men had chronic conditions.

Figure 8 represents the frequency of different groups of symptoms reported for acute illness

Figure 9. Reported symptoms of acute illness, Barbados, 2010.

Cough, runny nose, sore throat,

ear ache

84%

Fever, headache, hot body

52%

Diarrhea, vomiting, nausea

8%

Pain, aches6%

Could not sleep, could not eat

5%

Key points

The most frequent symptoms reported were cough, runny nose, sore throat, and ear ache,

which were present in 8 out of 10 acute illnesses.

Chronic conditions are documented as the diagnosis recalled by respondents. Figure 9 presents reported

chronic diseases, by gender.


54

Figure 10. Most frequent chronic diseases by gender, Barbados, 2010.

0

0

3

3

6

13

21

32

33

79

112

0

2

0

5

2

5

13

14

25

46

75

0 120

Multiple sclerosis

Epilepsy, seizures, fits

Stroke consequence

Heart disease, chest pain, heart attack

Ulcer, chronic stomach pain

Chronic respiratory disease

Arthritis, chronic body pain

High cholesterol

Diabetes, high blood sugar

Hypertension

All chronic diseases

Number of chronic diseases

Men

Women

Key points

Chronic diseases were frequent, and more often reported in women.

The three most reported diseases were hypertension, diabetes, and hypercholesterolemia.

No case of multiple sclerosis was found in the survey.

Figure 10 presents the percentage of households with acute and chronic conditions at different socio-

economic levels.


55

Figure 11: Prevalence of illnesses, Barbados, 2010.

15%

21%

12%

59%

67%

53%

0%

50%

100%

Barbados - All lower SES higher SES

Households with at least one recent acute illness

Households with at least one chronic disease

Key point

The prevalence of both acute and chronic conditions was higher in households of the lower

SES group.

Geographic access and availability of medicines

Geographic access to public health facilities is an important indicator to measure equity in access to

medicines.

Proximity to health care facilities

The medicines survey records the proximity of each household to different types of health care facilities,

using the time to travel as unit of distance. Facilities are classified into the following categories: public

hospital, private or NGO hospital, public health care center or dispensary, private clinic or physician,

traditional healer, or private pharmacy. For each facility, options to choose from were at less than 15

minutes, between 15 minutes and 1 hour, and over one hour of travel time.

Table 17 displays the proximity of households to any health care facility. Figure 11 presents the

proportion of households at more than 1 hour from a public health hospital or public health care center.


56

Table 17: Travel time to closest health care facility, Barbados, 2010.

Travel time < 15 min 249 79% 79 71% 131 82%

Travel time: 15 minutes to 1 hour 68 21% 33 29% 29 18%

Travel time >1 hour 0 0% 0 0% 0 0%

Travel time < 15 min 178 56% 56 50% 92 58%

Travel time: 15 minutes to 1 hour 136 43% 54 48% 67 42%

Travel time >1 hour 3 1% 2 2% 1 1%

Any health care facility

Any public health care facility

Barbados - All


lower SES higher SES

Figure 12. Households far away from a public health care facility, Barbados, 2010.

6%11%

4%1% 2% 1%

0%

50%

100%


Pe

rce

nta

ge o

f h

ou

seh

old

s

> 1 hour to public hospital

> 1 hour to public health center or dispensary


57

Key points

Overall, geographic access to health care and medicines was excellent.

All surveyed households were at less than 1 hour travel from a health care facility of any kind,

public or private.

Only 6% of households were located at more than one hour of travel time from a public

hospital. This percentage was higher in the lower SES group: 11%.

Sources of medicines found in households

Figure 12 presents the percentage of medicines found in households that were obtained in different types

of health care facilities, by SES group.

Figure 13. Sources of medicines found in households Barbados, 2010.

17%

30%

10%

74%

62%

82%

8% 7% 8%

0%

100%


Pe

rce

nta

ge o

f m

ed

icin

es

Public health care facility Private pharmacy Other

Key points

Three in four medicines found in households came from a private pharmacy.

Less than 10% of medicines found at home were obtained from a private source other than a

pharmacy: private hospital, private provider, or herbalist.

More people in the lower SES group obtained their medicines from a public health care

facility: in this group, three in ten medicines found at home came from a public health care

facility vs. one in ten in the higher SES group.

Sources of medicines in case of acute illness


58

Figure 13 presents the sources of medicines in case of acute illness, by surveyed area.

Figure 14. Sources of medicines taken for an acute illness, Barbados, 2010.

16%19%

0%

76%

58%

74%

29%

23%26%

0%

100%


Pe

rce

nta

ge o

f m

ed

icin

es

Public health care facility Private pharmacy Other

Key points

Like medicines found at home, three in four medicines obtained for acute illness came from a

private pharmacy.

Different from medicines found at home, 29% of medicines obtained for an acute illness came

from a private source other than a pharmacy: private hospital, private provider, or herbalist.

No one in the higher SES group obtained their medicines for acute illness from a public health

care facility.

Opinions about geographic access and availability of medicines

Table 18 presents the percentage of respondents who agreed with statements related to geographic

access and availability of medicines.


59

Table 18: Opinions about geographic access and availability of medicine, Barbados, 2010.

Barbados -

All

Lower

SES

Higher

SES

Barbados

- All

Number of respondents 316 112 160 272

Agree Agree AgreeDon't

know

The public health care facility closest to my

household is easy to reach.87% 87% 88% 9%

My household would use public health care

facilities more if opening hours were convenient.49% 54% 43% 22%

The public health care facility closest to my

household usually has the medicines we need.53% 61% 48% 35%

The private pharmacy closest to my household

usually has the medicines my household needs.88% 84% 91% 9%

Key points

Close to nine in ten respondents agreed that their public health care facility is easy to reach.

Half of respondents would like facilities to have more convenient opening hours.

Overall, respondents felt that the availability of medicines is better in private pharmacies than

in public facilities. Almost nine in ten respondents agreed that their private pharmacy has the

medicines they need.

Only half of the respondents agreed that their public health care facility has the medicines they

need. This proportion was higher in the lower SES group: 61 % vs. 48% in the higher SES

group.


Affordability of medicines is a critical indicator of equity in access to medicines. The level of medicine

insurance coverage and the actual cost of medicines for different conditions are important to consider

when assessing medicines affordability. The percentage of households experiencing potentially

catastrophic expenditures during the month preceding the survey provides a useful account of the

affordability of medicines in the surveyed population.

Cost of medicines for acute illnesses

In addition to collecting monthly household expenditures for medicines, information about the cost of

prescriptions for recent acute illnesses is collected. Table 19 presents the cost of prescriptions for acute

illnesses, by surveyed areas.


60

Table 19: Cost of medicines for a recent acute illness, Barbados, 2010.

Barbados -

Alllower SES higher SES

Number of households with at least one acute illness 47 21 19

Number of persons with recent acute illness who took

medicines40 20 14

Number of housheolds who paid for the medicines 25 13 10

Average number of medicines by acute illness 1 1 2

Average cost of medicines when not free of charge BBD 28 BBD 25 BBD 34

Maximum cost of medicines for one acute illness BBD 170 BBD 100 BBD 170

Barbados Dollar (BBD)

US$1=BBD$1.96

Key points

Overall, a high proportion of people with acute illness took medicines.

Less people with an acute illness took medicines in the higher SES group, but when they did,

they took more medicines and paid more than people in the lower SES group.

The proportion of people with an acute condition who took medicines for this condition was

higher in the lower SES group: 20/21 than in the higher SES group: 14/19.

The average number of medicines per acute illness was 1 in the lower SES group and 2 in the

higher SES group.

For households who paid for medicines, the average cost of medicines for acute illness was 28

BBD (US$14.3). The average cost of medicines was higher for people in the higher SES group:

34 BBD vs. 25 BBD in the lower SES group.

Cost of medicines for chronic diseases

The medicines survey also collects information about the price of medicines taken for chronic diseases.

In this case, the monthly cost of each prescribed medicine is recorded.

Table 20 presents the monthly cost of medicines for chronic diseases, by surveyed areas.


61

Table 20: Monthly cost of medicines for a chronic disease, Barbados, 2010.

Barbados

- All

lower

SES

higher

SES

Number of persons with chronic disease 187 75 85

Number of persons with chronic disease who take

medicines139 54 62

Number of persons who pay for medicines 18 1 16

Average number of medicines for a chronic disease 1 1 1

Average monthly cost of medicines for those who pay for

medicinesBBD 19 BBD 9.0 BBD 177

Maximum monthly cost of medicines for a chronic

diseaseBBD 1,500 BBD 9.0 BBD 1,500

US$1=BBD$1.96

Barbados Dollar (BBD)

Key points

Three in four persons diagnosed with a chronic disease took medicines

The average number of medicines taken for a chronic disease was 1.

Overall, 18/139 (13%) individuals with a chronic disease paid for the medicines they received.

Only one person with a chronic disease paid for medicines in the lower SES group, while 16/62

(26%) in the higher SES paid for their medicines.

The maximum monthly price of 1500 BBD was the cost an unidentified medicine taken by a

patient with cancer.

Even when excluding this outlier value, the monthly cost of medicines for patients with chronic

disease was ten times higher in the higher SES group. (data not shown)

Potentially catastrophic expenditures related to medicines

Potentially catastrophic expenditures are payments that may push people into poverty. They can be

expressed in different ways. In the survey, potentially catastrophic expenditures are calculated as

expenditures higher than 40% of discretionary expenditures.i Catastrophic expenditures could only be

calculated in the subgroup of 122 respondents who disclosed the actual amount of total expenditures by

their household during the month preceding the survey.

Figure 14 presents the percentage of households with catastrophic expenditures related to medicines

during the month preceding the survey.


62

Figure 15. Potentially catastrophic expenditures related to medicines in month preceding survey,

Barbados, 2010.

12%10%

14%

3%2%

4%

0%

50%


Pe

rce

nta

ge o

f h

ou

seh

old

s

Potentiallly catastrophic health expenditures

Potentiallly catastrophic medicines expenditures

Key points

In the survey, discretionary expenditures correspond to the difference between total spending

and spending on food. Expenditures are considered potentially catastrophic when they are

higher than 40% of discretionary expenditures.

Results show that 12% of households experienced potentially catastrophic health expenditures

in the month preceding the survey. A quarter of these were related to medicines expenditure.

Potentially catastrophic expenditures related to health and to medicines occurred more often

in the higher SES group than the lower SES group.

Medicines free-of-charge and insurance coverage

Table 21 presents the percentage of households with medicines insurance coverage for acute and chronic

conditions.


63

Table 21: Medicines insurance coverage, Barbados, 2010.

Barbados -


% persons with recent acute illness and a

health insurance covering medicines3% 0% 7%

% persons with chronic disease and a health

insurance covering at least one medicine5% 0% 9%

Key points

Very few people reported having a health insurance covering for medicines.

All people with health insurance were in the higher SES group: 7% of individuals with acute

illness, and 9% with chronic disease.

Opinions about affordability of medicines

Table 22 presents the percentage of respondents who agreed with statements related to affordability of

medicines.

Table 22: Opinions about affordability of medicines, Barbados, 2010.

Barbados

- All

Lower

SES

Higher

SES

Barbados

- All



know

My household can get free medicines at the

public health care facility. 78% 87% 74% 16%

Medicines are more expensive at private

pharmacies than at public health care

facilities.

59% 54% 64% 38%

My household can usually get credit from

the private pharmacy if we need to.15% 9% 18% 44%

My household can usually afford to buy the

medicines we need.64% 56% 69% 10%

My household would obtain prescribed

medicines if insurance reimbursed part of

their cost.

43% 29% 57% 44%

In the past, my household had to borrow

money or sell things to pay for medicines.8% 4% 11% 7%

Key points

Overall, 78% of respondents agreed that they can obtain free medicines in public health care

facilities. This percentage was higher in the lower SES group.


64

Close to two thirds of respondents agreed that they can usually afford medicines. This

proportion fell to half of respondents in the lower SES group.

More households in the higher SES group reported having to borrow or sell items to pay for

medicines in the past: 11% vs. 4% in the lower SES group.

Medicines at home

The objective of the medicines survey is to understand which medicines people access and use, who

prescribes them, where they can be obtained, how much they cost and why people do or do not take

them. Collecting information on medicines kept at home contributes to answering these questions.

In each household, data collectors ask to see all medicines that are kept at home, and record the name,

source, reason for keeping each medicine, as well as the condition of their label and primary package.

Medicines are entered in the data base with both their originator brand actual and generic names, and a

code derived from the 16th

WHO Model List of Essential Medicines.ii

Number of households where medicines could be found

Figure 15 presents the percentage of households with children where medicines were found.

Figure 16. Medicines in households with children, Barbados, 2010.

73% 71%76%

80% 80% 82%

0%

50%

100%


Pe

rce

nta

ge o

f h

ou

seh

old

s

all households households with children


65

Key points

The proportion of households where medicines could be found was 73%. It was higher when

children lived in the household: 80%.

The percentage of households where medicines could be found was slightly lower in the lower

SES group, regardless of the presence of children in the household.

Medicines found in households

Table 23 presents the number and percentage of most frequent medicines found in households.

Table 23: Medicines found at home, Barbados, 2010.

Number of households 317 112 160

Number of medicines found in households 601 % 208 % 344 %

paracetamol 101 17% 35 17% 54 16%

chlorpheniramine maleate 31 5% 14 7% 14 4%

acetylsalicylic acid 26 4% 5 2% 18 5%

antitussive 24 4% 8 4% 15 4%

metformin 18 3% 6 3% 11 3%

indapamide 15 2% 5 2% 10 3%

ibuprofen 15 2% 4 2% 8 2%

ophthalmological medicine 14 2% 8 4% 3 1%

amlodipine + valsartan 13 2% 6 3% 5 1%

telmisartan 13 2% 6 3% 6 2%

rosuvastatin 12 2% 4 2% 8 2%

unknown 12 2% 5 2% 7 2%

gliclazide 11 2% 5 2% 6 2%

vitamin, multi 11 2% 3 1% 7 2%

amlodipine 9 1% 0% 7 2%


Key points

Overall, the profile of medicines found in households was similar in households of lower and

higher SES.

Chlorpheniramine maleate and ophthalmological medicines were found more often in the

lower SES group.

Amlodipine was only found in households of the higher SES group.

Labeling and packaging of medicines found in households


66

Labels of medicines found in households are considered acceptable by data collectors if they include

medicine name, dose, and expiration date. Similarly, the primary package of a medicine is considered

acceptable if it is an envelope or a closable container which contains only one medicine.

Figure 16 presents the percentage of medicines that had an acceptable label, primary package and

validity, by source of medicine.

Figure 17. Percentage of home medicines with adequate label and primary package, by source,

Barbados, 2010.

82%87%

80%

94%

All medicines found at home

Obtained from a public facility

Obtained from a private pharmacy

Obtained from other source

% o

f m

ed

icin

es

wit

h a

de

qu

ate

lab

elin

g an

d p

rim

ary

pac

kage

Key points

Overall, about eight in ten medicines found in households had a label and primary package in

good condition.

Compared to medicines from private pharmacies, medicines from public health care facilities

were more likely to be appropriately labeled and to be kept in an adequate container

Use of medicines during acute illnesses


67

For each recent acute illness reported, data collectors record name, route of administration, prescriber,

and source of each medicine taken for this illness. Medicines are entered in the data base with both their

actual and generic names, and a code derived from the 16th

WHO Model List of Essential Medicines.

Actions taken when an acute illness occurs

Table 24 presents the actions taken in case of recent acute illness.

Table 24. Actions taken for a recent acute illness, Barbados, 2010.

Sick persons with an acute illness perceived as very severe 1

Went for care and took all prescribed medicines 1 100%

Went for care and took some of the prescribed medicines 0 0%

Went for care but did not take any medicines 0 0%

Did not go for care 0 0%

Sick persons with an acute illness perceived as moderately

severe14





Sick persons with an acute illness perceived as not severe 33





Key points

Overall, how an acute illness was treated depended on its perceived severity.

The person with a severe acute illness went for care and took all prescribed medicines.

Of people who had a moderately severe acute illness, 43% went for care and took all

prescribed medicines. This percentage fell to 18% when the acute illness was considered mild.

Medicines for acute illness


68

Table 25 presents the most frequent medicines taken in case of recent acute illness.

Table 25 Medicines taken for a recent acute illness, Barbados, 2010.

Generic

Count of generic

medicines for acute

illnesses

total 58

paracetamol 15 26%

chlorpheniramine maleate 13 22%

cold medicine 5 9%

loratadine 3 5%

diclophenac sodium 2 3%

Key points

The two most frequent medicines taken for an acute illness were paracetamol and

chlorpheniramine maleate.

Prescribers of medicines in case of acute illness

Figure 17 presents prescribers of medicines in case of acute illness, by different survey areas, Barbados,

2010.

Figure 18: Prescribers of medicines in case of acute illness, Barbados, 2010.

51%

44%

60%

49%

56%

40%

0%

100%

Barbados - All lower SES higher SESPe

rce

nta

ge o

f m

ed

icin

es

pre

scri

be

d f

or

acu

te i

llne

ss

Medicines prescribed by a doctor/nurse

Medicines prescribed by someone who is not a doctor or a nurse


69

Key points

Overall in the case of acute illness, half of medicines were prescribed by doctors or nurses.

This percentage was higher in the higher SES group: 60% vs 44%

Routes of administration of medicines prescribed for acute illness

Figure 18 presents the route of administration of medicines prescribed for acute illness, by different

survey areas.


70

Figure 19. Route of administration of medicines prescribed for acute illness, Barbados, 2010.

87% 85%90%

4%7%

0%

9% 7%10%

0%

100%

Barbados - All lower SES higher SESPe

rce

nta

ge o

f m

ed

icin

es

pre

scri

be

d f

or

acu

te i

llne

ss

Oral Injection Other than oral or injection

Key points

In the case of acute illness, most prescribed medicines were taken orally

The percentage of patients receiving injections was low. Only patients in the lower SES group

received injections.

Reasons for not taking medicines prescribed for acute illness

The medicines questionnaire includes a list of possible reasons that could explain why a person did not

take prescribed medicines. If non-compliance is identified, this list is read to the respondent. The

respondent may choose “yes” for as many of the reasons as they feel to explain why the medicine was

not taken.

Figure 19 presents the number of persons with an acute illness who did not take the medicines as

recommended, and the most frequent reasons chosen to explain non-compliance.


71

Figure 20. Reasons for not taking prescribed medicines for acute illness, Barbados, 2010.

18

6

12

14

3

8

1 10

0

20

Barbados - All lower SES higher SESNu

mb

er

of

pe

rso

ns

wit

h a

cute

illn

ess

wh

o d

id n

ot

take

m

ed

icin

es

as p

resc

rib

ed

Did not follow their prescription Symptoms had improved

Could not afford medicines

Key points

Of the 47 individuals with acute illness, 18 did not follow their prescription.

The most frequent reason (cited by 78% of people who did not follow their prescription) for

not taking medicines as prescribed was that symptoms had improved.


72

One respondent in the lower SES group identified affordability of medicines as a reason for

non-compliance.

Use of medicines for chronic diseases

Over half of households (59%) reported at least one chronic disease. In households with a person

diagnosed with a chronic disease, data collectors recorded the name of each medicine prescribed to the

person with a chronic disease, the condition for which it was recommended, the number of days of

supply usually obtained, the usual cost for one month, and insurance coverage for every person with a

chronic disease.

Actions taken when a chronic disease has been diagnosed

Figure 20 presents actions taken in case of chronic disease.

Figure 21. Actions taken for chronic diseases, Barbados, 2010.

72%68%

71%

19% 17%23%

10%15%

6%

82%

69%

83%

Barbados - All lower SES higher SESWas told to take medicines and takes them as directed

Was told to take medicines and does not take them as directed

Was not told to take medicines

Was told to take medicines and medicines are found at home

Key points

Overall, three in four individuals with a chronic disease were told to take medicines and took

them as directed.

Large differences were observed between individuals in the lower and higher SES groups.


73

More people in the lower SES group were not told to take medicines: 15% vs. 6% in the higher

SES group, making lower SES individual 2.5 times more likely NOT to be told to take

medicines for chronic disease (p=0.06).

Medicines for chronic illness

Table 26 presents the most frequent medicines taken in case of chronic disease.

Table 26 Most frequent medicines prescribed for chronic diseases, Barbados, 2010.

Number of individuals with chronic disease 187 75 84

Number of medicines prescribed 335 153 182

metformin 22 7% 9 6% 13 7%

acetylsalicylic acid 18 5% 8 5% 10 5%

indapamide 16 5% 9 6% 7 4%

rosuvastatin 16 5% 6 4% 10 5%

unknown 14 4% 8 5% 6 3%

amlodipine + valsartan 14 4% 8 5% 6 3%

insulin 13 4% 5 3% 8 4%

telmisartan 13 4% 6 4% 7 4%

gliclazide 9 3% 4 3% 5 3%

amlodipine 8 2% 2 1% 6 3%

salbutamol 8 2% 2 1% 6 3%

atorvastatin 8 2% 3 2% 5 3%

hesperidin + diosmin 7 2% 2 1% 5 3%

acarbose 7 2% 6 4% 1 1%

omeprazole 6 2% 4 3% 2 1%


Key points

Metformin was the most frequently prescribed medicine for chronic diseases.

The most frequent medicines prescribed for chronic diseases were antihypertensive and anti

diabetics, which corresponds to the profile of chronic diseases reported in the survey.

Prescribed medicines were similar in the lower and higher SES groups.

Reasons for not taking medicines prescribed for a chronic disease

Figure 21 presents the number of persons with chronic disease who did not take prescribed medicines as

recommended.


74

Figure 22: Reasons for not taking medicines prescribed for a chronic disease, Barbados, 2010.

32

13

19

9

6

31 0 1


Nu

mb

er

of

ind

ivid

ual

s w

ith

ch

ron

ic d

ise

ase

Did not follow their prescription Symptoms have improved

Can not afford medicines

Key points

Of the 187 surveyed individuals with a chronic disease, 32 (17.1%) did not take the prescribed

medicines.

The reason given most often for non adherence was the improvement of symptoms.

One person in the higher SES group identified affordability as a reason for non-adherence.


75

Opinions about quality of care and generics

The medicines survey collects opinions of respondents about quality of care and generics. Statements

describing opinions are read to respondents who are asked if they agree or disagree. Data collectors are

instructed to tick the option „do not know‟ only if respondents are not sure or do not want to answer a

particular question. Table 30 presents opinions of respondents about quality of care and generics.

Table 27. Opinions about quality of care and generics, Barbados, 2010.

Barbados

- All

Lower

SES

Higher

SES

Barbados

- All


know


The quality of services delivered at public

health care facilities in my neighborhood is

good.

53% 61% 47% 23%

The quality of services delivered by private

health care providers in my neighborhood is

good.

87% 83% 91% 10%

Brand name medicines are better than generic

medicines27% 26% 29% 51%

Imported medicines are of better quality than

locally manufactured medicines.15% 12% 19% 70%

Key points

53% of the respondents reported that the quality of services delivered in public facilities was

good, while 87% of respondents agreed that the quality of services delivered by private

providers was good.

About half of respondents did not have an opinion about the quality of brand name medicines

versus generic medicines.

Very few respondents chose not to express their opinion on the quality of imported medicines.

Key indicators of Access and Use of Medicines


76

Table 28: Indicators of Access and Use of Medicines - All households, Barbados, 2010.

Geographic access of medicinesBarbados -

AllLower SES

Higher

SES

% households who have to travel > one hour to reach the

closest public health care facility1% 2% 1%

% respondents who agree that the location of public health

care facilities is convenient87% 87% 88%

% respondents who agree that they would use public health

care facilities more if opening hours were convenient49% 54% 43%

Availability of medicines

% respondents who agree that medicines are usually

available at their public health care facility53% 61% 48%

% respondents who agree that medicines are usually

available at their private pharmacy88% 84% 91%


% households whose monthly medicines expenditures

represent > 40% of discretionary spending3% 2% 5%

% respondents who agree that they can get free medicines at

their public health care facility78% 87% 74%

% respondents who agree that medicines are more

expensive at private pharmacies than at public health care

facilities

59% 54% 64%

% respondents who agree that they can get credit from the

private pharmacy if need be15% 9% 18%

% respondents who agree that they can usually afford to buy

the medicines they need64% 56% 69%

% respondents who agree that they would obtain prescribed

medicines if insurance reimbursed part of their cost43% 29% 57%

% respondents who agree that they had to borrow money or

sell things in the past to pay for medicines8% 4% 11%

Access to medicines - Mixed indicators

% households with medicines at home 73% 71% 76%

% households with children and medicines at home 80% 80% 82%

Average number of medicines kept at home 3 3 4

% medicines found at home and obtained from a public

health care facility17% 30% 10%

% home medicines obtained from a public health care facility

and with an adequate label and primary package87% - -

% respondents who agree that the quality of services

delivered in public health care facilities is good53% 61% 47%

% respondents who agree that the quality of services

delivered by private health care providers is good87% 83% 91%

% respondents who do not know if brand name medicines

are better than generic medicines51% 58% 48%

% respondents who agree that brand name medicines are

better than generic medicines27% 26% 29%

% respondents who agree that imported medicines are of

better quality than locally manufactured medicines15% 12% 19%


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Table 29: Indicators of Access and Use of Medicines - Households with at least one acute or chronic

conditions, Barbados, 2010.

Geographic access to medicinesBarbados -


% respondents who say that distance from source of

medicines is a reason for not taking medicines prescribed

for a recent acute illness

0% 0% 0%

% respondents who say that distance from source of

medicines is a reason for not taking medicines prescribed

for a chronic disease

0% 0% 0%

Availability of medicines

% respondents who say that availability of medicines in

their public health care facility is a reason for not taking

medicines prescribed for a recent acute illness

0% 0% 0%

% respondents who say that availabity of medicines in

their public health care facility is a reason for not taking

medicines prescribed for a chronic disease

0% 0% 0%


% households where someone with a recent acute illness

obtained medicines free-of-charge38% 35% 29%

Average cost of a prescription for acute illness for those

who did not obtain medicines free-of-chargeBBD 28 BBD 25 BBD 34

Maximum cost of a prescription for acute illness for those

who did not obtain medicines free-of-chargeBBD 170 BBD 100 BBD 170

% households where someone with a recent acute illness

had medicines completely covered by a health insurance3% 0% 7%

% households with a chronic disease who obtain

medicines for this disease free-of-charge87% 98% 74%

Average monthly cost of medicines for a chronic diseases

when not obtained free-of chargeBBD 19 BBD 9 BBD 177

Maximum monthly cost of medicines for a chronic

diseases when not obtained free-of chargeBBD 1,500 BBD 9 BBD 1,500

% households with someone with a chronic disease who

has at least one medicine covered by a health insurance5% 0% 9%

Access to medicines - Mixed indicators

% households reporting a member with a recent serious

illness who sought care outside home and took all

prescribed medicines

100% - -

% households where someone with a chronic disease was

told to take medicines and takes them as directed73% 69% 96%

% households where someone with a chronic disease was

told to take medicines and where medicines are found81% 38% 89%


78

Overall, the household survey results indicate that access to medicines is of good quality in Barbados,

and that it is slightly better in households with a higher SES. Geographical access and availability of

medicines do not seem to represent a barrier for access to medicines.

Nevertheless, they point out to an insufficient use of medicines to treat chronic diseases, mainly in

households of lower SES. Treatment management, especially non-adherence is also an issue to be

addressed. This is especially true in the group of surveyed individuals with a chronic disease. The

reason given most often for non adherence in this group was the improvement of symptoms. For

chronic conditions, this is neither a valid nor safe reason for suspending treatment.


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Conclusions and recommendations

The data from this survey provide a baseline for future interventions and the same indicators can be used

for monitoring the progress as well as to establish benchmarks, once they are standardized, it allows

comparing the national situation with results obtained in countries from Caribbean and other parts of the

globe.

In Barbados, medicines are generally available. Nevertheless there are several areas to be addressed to

improve the overall pharmaceutical situation. Despite of the existence of a draft national pharmaceutical

policy, the document was not implemented. The review of this draft and the development of an

implementation plan based on the outcomes of the survey and the proposal of the Caribbean

Pharmaceutical Policy is strongly recommended.


appropriate use of medicines can be improved by the review of the National Drug Formulary, with

selection criteria based on evidence, together with the development, availability and use of STG. It is

also recommended to establish a strategy for strengthening the use of generics, and by enforcing the

current regulations and encouraging the use of INN for prescribing and increasing generic substitution.



This and the fact that many children under 5 with diarrhea are not prescribed the appropriate treatment,

strongly suggest the need to intensify training of providers in key areas of primary care prescribing.

It is recommended to increase the regulation of medicines and pharmaceutical services, including the

economic regulation as prices of the treatments in the private pharmacies were much higher than in the

public pharmacies. Despite the presence of a pharmacist in most pharmacies, storage conditions were

not optimal for public health facilities and private pharmacies and dispensing of prescription medicines

without prescription was also found. The development of national guidelines of Good Practices related

to distribution, storage and pharmacy practices as well as the strengthening of the pharmaceutical

services based on the renewal of primary health care, according to the PAHO/WHO recommendations

and guidelines are recommended as part of the strategies for improving the situation.

A strategy related to improving the knowledge and the rational use of medicines for the population can

be developed. Among the aspects to be included are medicines access and management at home

(labeling, storage conditions, etc), quality and safety issues and generic medicines and the importance of

adherence to treatment, especially in the management of chronic conditions.

It is recommended to design strategies to improve the situation related to the lower SES Group, tackling

the barriers for access, such as geographical barriers (11% households in the lower SES group live at

more than one hour from a public health facility) and the higher prevalence of both chronic and acute

conditions. The data suggests there is an under-use of medicines in this group, with individuals in lower

SES households 2.5 more likely NOT to be told to take medicines for chronic conditions.

Considering the high prevalence of chronic diseases in the country, it is recommended to strengthen the

holistic approach to tackling them, considering as a priority the promotion of healthy life style and other


80

non-pharmacological aspects. Treatment management, especially to strengthen adherence is an

important aspect to be highlighted. Specific interventions can be designed.


81

References

1. Pharmaceutical Assessment Level II of Barbados, June 2009

2. WHO Operational package for assessing, monitoring and evaluating country pharmaceutical

situations; Guide for coordinators and data collectors, December 2007

3. Xu, K. et al., 2003. Household catastrophic health expenditure: a multi country analysis. Lancet,

362(9378), 111-117. 4. WHO Model Lists of Essential Medicines. Available at:

http://www.who.int/medicines/publications/essentialmedicines/Updated_sixteenth_adult_list_en.pdf [Accessed August 26, 2010].

http://www.who.int/medicines/publications/essentialmedicines/Updated_sixteenth_adult_list_en.pdf


82

Annex 1. Level I Questionnaire

This filled out Level I questionnaire has to be adjusted and improved.

i Xu, K. et al., 2003. Household catastrophic health expenditure: a multi country analysis. Lancet,

362(9378), 111-117.

ii WHO | WHO Model Lists of Essential Medicines. Available at:

http://www.who.int/medicines/publications/essentialmedicines/en/ [Accessed August 18, 2009].

http://www.who.int/medicines/publications/essentialmedicines/en/


83

Annex 2. Level II Survey Forms


84

Annex 3. Household Survey Questionnaire


85

Annex 4. Rounded ranges of household expenditures

BarbadosJuly 10 2010

Expenditure Ranges in Barbados Dollars (BBD) for Four Weeks by Household Size

Number of

Household

Members

Range A Range B Range C Range D Range E

1 <800 800-1100 1101-1300 1301-1900 >1900

2 <1600 1600-2100 2101-2600 2601-3800 >3800

3 <2400 2400-3200 3201-3900 3901-5600 >5600

4 <3200 3200-4200 4201-5100 5101-7500 >7500

5 <4000 4000-5300 5301-6400 6401-9400 >9400

6 <4900 4900-6300 6301-7700 7701-11300 >11300

7 <5700 5700-7400 7401-9000 9001-13200 >13200

8 <6500 6500-8400 8401-10300 10301-15000 >15000

9 <7300 7300-9500 9501-11600 11601-16900 >16900

10 <8100 8100-10500 10501-12900 12901-18800 >18800

11 <8900 8900-11600 11601-14100 14101-20700 >20700

12 <9700 9700-12600 12601-15400 15401-22500 >22500

13 <10500 10500-13700 13701-16700 16701-24400 >24400

14 <11300 11300-14700 14701-18000 18001-26300 >26300

15 <12100 12100-15800 15801-19300 19301-28200 >28200

16 <12900 12900-16800 16801-20600 20601-30100 >30100

17 <13800 13800-17900 17901-21800 21801-31900 >31900

18 <14600 14600-18900 18901-23100 23101-33800 >33800

19 <15400 15400-20000 20001-24400 24401-35700 >35700

20 <16200 16200-21000 21001-25700 25701-37600 >37600

21 <17000 17000-22100 22101-27000 27001-39500 >39500

22 <17800 17800-23100 23101-28300 28301-41300 >41300

23 <18600 18600-24200 24201-29600 29601-43200 >43200

24 <19400 19400-25200 25201-30800 30801-45100 >45100

25 <20200 20200-26300 26301-32100 32101-47000 >47000

26 <21000 21000-27300 27301-33400 33401-48900 >48900

27 <21800 21800-28400 28401-34700 34701-50700 >50700

28 <22700 22700-29400 29401-36000 36001-52600 >52600

29 <23500 23500-30500 30501-37300 37301-54500 >54500

30 <24300 24300-31500 31501-38600 38601-56400 >56400


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Annex 5. Description of indicators- Health facility survey

Indicator Purpose/ Rationale

Availability of key medicines in public

health facility dispensaries, private

pharmacies and warehouses supplying

the public sector

To measure current availability of key medicines to treat common

health problems in public health facility dispensaries, private

pharmacies and warehouses. Essential medicines to treat common

diseases should be available in all these facilities, especially in public

sector facilities providing health services for the poor. Physical

availability is a basic measure of access to essential medicines. See

pages 29–30 for guidance on selecting key medicines for this study.

% of prescribed key medicines

dispensed or administered to patients at

public health facility dispensaries

To measure the degree to which facilities are able to provide needed

medicines

Stock out duration at public health

facility dispensaries and warehouses

supplying the public sector

To measure availability over the past 12 months of key medicines to

treat common health problems. An adequate logistic system ensures

that essential medicines remain in stock at all times.

% Adequate record keeping at public

health facility dispensaries and

warehouses supplying the public sector

To determine the extent to which stock records are maintained. The

presence of adequately maintained and accurate stock records

contributes to proper management, estimation of needs and the

reorder of medicines.

Affordability of treatment for adults and

children under 5 years of age at public

health facility dispensaries and private

pharmacies

To measure affordability of basic pharmaceutical treatment as an

indicator of access to essential medicines. In most developing

countries, a majority of the population pays for treatment out-of-

pocket. Affordability is expressed as the ratio of the cost of treating

moderate pneumonia another condition to a standard unit of measure.

For this survey, the lowest daily government salary is used. Countries

may also identify an optional second unit of measure (e.g. poverty

line, basket of food, etc.).

Average selling cost of medicines

public health facilities and private

pharmacies

To measure average cost paid by patient for medicines at public

health facilities and private pharmacies as an indicator of access to

essential medicines. In most developing countries, a majority of the

population pays for treatment out-of-pocket.

% patients taking more than one hour to

travel to the facility

To assess geographic accessibility in terms of how long does it take

the patients to get to the pharmacy they get their medicines

Average transportation cost to the

facility

To assess geographic accessibility in terms of how much does it cost

to the patients to get to the pharmacy they get their medicines

Presence of expired medicines in public

health facility dispensaries, private

pharmacies and warehouses supplying

the public sector

To determine if expired medicines are being distributed or sold. In

some countries, expired medicines are distributed or medicines are

allowed to go out of date on pharmacy shelves. See page 29–30 for

guidance on selecting key medicines for this study.

Adequacy of conservation conditions

and handling of medicines in public

health facility pharmacies/dispensaries,

private pharmacies and

central/regional/district warehouses

supplying the public sector

To determine status of conservation conditions and handling of

medicines in public sector facilities, both of which are factors that

affect quality of medicines

% medicines adequately labeled at

public health facility dispensaries

To assess quality of dispensing practice. If medicines are to be used

properly, they should be labeled appropriately by the person

dispensing them.


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% patients know how to take medicines

at public health facility dispensaries

To assess if patients have adequate knowledge of how to take their

medicines.

Average number of medicines

prescribed in public health facilities

To determine prevalence of polypharmacy, which is one measure of

unnecessary prescribing

% patients prescribed antibiotics in

public health facilities (Survey Form 7)

To determine prevalence of antibiotic prescribing, since over-

prescribing of antibiotics is one common type of inappropriate

medicine use

% patients prescribed injections in

public health facilities

To determine prevalence of injection use, since over-prescribing of

injections is one common type of inappropriate medicine use

% prescribed medicines on the essential

medicines list at public health facilities

To measure the degree to which prescribing practice conforms to the

national essential medicines list (EML). The essential medicines

concept is one of the main strategies being promoted in medicines

policy. More and more countries are formulating national EMLs. For

most, this should be the basis for all public medicines procurement

and prescribing.

% medicines prescribed by generic

name (INN) at public health facilities

To measure the degree to which prescribing practice conforms to the

principles of generic prescribing.

Availability of standard treatment

guidelines at public health facilities

To determine if prescribers have available to them the key source of

therapeutic information they need in daily practice.

Availability of EML at public health

facilities

To determine if prescribers and/or dispensers have available to them

the key source of pharmaceutical information that should be the basis

for all medicine prescribing and dispensing.

% tracer cases treated according to

recommended treatment protocol/guide

To measure quality of care for common conditions with clear

recommended treatment protocols. Adherence to recommended

protocols can be measured by checking if tracer diseases are treated

appropriately. Such recommendations might include use of ORS for

watery diarrhea in children, use of the recommended antibiotic for

mild pneumonia or non-use of antibiotics for simple ARI. The survey

form has space for countries to track additional conditions, if desired.

% of prescription medicines bought

without prescription

To determine if costumers are purchasing and dispensers are selling

prescription medicines without prescription. The existence of a

prescription (and therefore a medical encounter) as the source of

(prescription) medicine seeking behavior should be the basis for all

medicine dispensing as a way to promote rational use of medicines.

% of facilities that comply with the law

(presence of a pharmacist)

To determine if facilities comply with the law (presence of a

pharmacist where the law requires).

% facilities with pharmacist, nurse,

pharmacy aide/ health assistant or

untrained staff dispensing

To determine the profile of the health professionals that dispense

medicines in health facilities and private pharmacies.

% facilities with doctor, nurse, trained

health worker/health aide prescribing

To determine the profile of the health professionals prescribing in

health facilities.

% facilities with prescriber trained in

RDU

To determine if the most senior health professionals prescribing in

health facilities were trained in RDU.


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Annex 6. Description of indicators- Household Survey


Percent of households with no

medicines at home

To investigate aspects of access to and use of medicines at home.

An excessive amount of medicines at home may lead to irrational

use of them. By the other side, the absence of medicines may be

linked to lack of access, what may be better evidenced when

stratified by income level. Differences among quintile allow

inferences on inequity.Generally elderly people use a higher

number of medicines.Households with children are more likely to

keep medicines for future use, and, because of this to have

medicines at home even if no one is sick.

Percent of household medicines

from different sources

To investigate the relative importance of different sources of

medicines to households.

Is expected the predominant sources fit with the NMP orientations.

Also, to find out the main sources orients the need of policies (p.

eg inspection, definition of functioning standards, training of staff)

focusing them.

Percent of households reporting a

serious acute illness who did not

seek care with a health professional

and did not take any medicines

To assess access to medicines among those who did not seek for

health care at the time of a serious acute illness, what indicates

lack of access to health care and lack of access to medicines.

Percent of households reporting an

acute serious illness who sought and

received care outside with a health

professional the home but did not

take any medicines

To assess access to medicines among those who sought and

received care at the time of a serious acute illness.

Percent of households reporting an

acute serious illness who sought and

received care outside the home with

a health professional but did not

take all medicines as

recommended/prescribed

To assess appropriate use of medicines among those who had

access to medicines at the time of a serious acute illness

Percent of respondents who agree

that opening hours of public health

care facilities are convenient

Perception about convenience of opening hours may influence

utilization and access to care and medicines


that sick person/care giver decided

against taking medicines as

prescribed for an illness (acute,

chronic, by illness) for one or more

reasons related to acceptability

To measure how acceptability may influence medicine utilization,

what means behavioral or cultural reasons.


that previous adverse effects is a

reason for not taking a medicine as

prescribed for a reported illness

(acute, chronic, by illness)

To measure how tolerability influence medicine utilization.

This indicator allows estimate of the magnitude of the problem

according to people perception, since they declare not to take

medicines for this reason.


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Percent of persons with reported

illnesses (acute by illness) who are

treated with injections

To evaluate one aspect of rational use of medicines. The injectable

administration via is always more dangerous then others and

should only be used when really indicated.Since current standard

as 20% proposed by WHO refers to primary health care and here

any level of care may be addressed interpretation should be done

with caution. Indeed, in this moment it is very important to

calculate this indicator at household level in order to create

evidence to establish adequate standard concerning this approach.


that quality of medicines purchased

at medicine retailers (private

pharmacy, medicine seller) is better

than at public health care facilities

Perceptions about quality of medicines may influence utilization.

In many middle and low countries medicines provided by the

public system are perceived of low quality by general people, what

may influence medicines use and medicines seeking behavior.


that locally made medicines are of

lesser quality

Perceptions about quality of medicines may influence utilization.

In many middle and low countries medicines locally made are

perceived of low quality by general people, what may influence

medicines use and medicines seeking behavior.

Average number of medicines at

home

To investigate aspects of access to and use of medicines at home.

An excessive amount of medicines at home may lead to irrational

use of them. By the other side, the absence of medicines may be

linked to lack of access, what may be better evidenced when

stratified by income level. Differences among quintile allows

inferences on inequity.

Generally elderly people use a higher number of medicines.

Households with children are more likely to keep medicines for

future use, and, because of this to have medicines at home even if

no one is sick.

Percent of household medicines by

category of person who prescribed

or recommended them

To investigate who prescribed or recommended medicines

available at home.

Data allows identifying origin of prescription/recommendation

according to sectors (public/private) and authorized

professionals/lay people. Importance of specific informal

prescribers that constitutes problems in some countries, e.g.,

private pharmacies may also be identified.

Stratification allows assessing differential behavior among these

prescribers in relation to OTC and medicines from the EML (e.g.

are authorized prescribers more adherent to EML? are lay people

prescribing prescription medicines?). Severe acute and chronic

health problems are more likely to require professional care and

less likely to be solved with OTC medicines.

Percent of antibiotics kept for future

use

To investigate aspects of rational use of medicines available at

home.Systemic use antibiotics are always prescription medicines

and the incorrect use is linked to emergence of resistance and

treatment failure.

Percent of antimalarials kept for

future use

To investigate aspects of rational use of medicines available at

home.

National epidemic level for malaria and national guidance on

treatment should be considered to interpret the indicator.

Depending on the epidemic level it is advisable that people keep

first line treatment at home.


with adequate label

To investigate on aspect of rational use of medicines and quality of

care.

Items verified are the minimum to assure medicines identification

and validity.


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with adequate primary packaging

To investigate one aspect of rational use of medicines and quality

of care.

Despite other conditions are also important, primary package is

fundamental to preserve medicines specifications and

identification

Percent of households with a

chronically ill person who was never

told to take medicines (overall, by

illness)

To investigate overall access to care and medicines for chronic

illnesses.

As chronic ill people are only consider in this approach if they

have already been told by a doctor to have the illness, a high

percentage of people never been told to take medicines indicates

lack of access or quality of health care.

Percent of households with a

chronically ill person prescribed

medicines who does not take

recommended medicines regularly

(overall, by illness)

To investigate regular access to and use of medicines in chronic

illnesses.

Not to take medicines regularly may be linked to access or

adherence.

Percent of medicines taken for a

reported illness (acute, chronic, by

illness) that were recommended by a

doctor or other qualified healthcare

provider

To investigate rational use of medicines in various conditions. The

performance of this indicator may be linked to access to health

care and prescription behavior.

Percentage of people referring the

use of herbal for a reported illness

(acute, chronic disease)

This indicator allows to estimate the importance and acceptance of

herbal medicines by the population

Average household medicine

expenditures as percent of total

expenditures

To determine the overall financial burden of medicines on

households, in relation to total expenditures. The indicator allows

assessing the magnitude of total household expenditures

committed with medicines.


expenditures as percent of non-food

expenditures

To determine the financial burden of medicines as a proportion of

non-food (discretionary) expenditures in households.

This indicators allows to calculated catastrophic expenditure on

medicines


expenditures as percent of total

health expenditures

To determine the financial burden of medicines as a proportion of

health expenditures in households.

Differences among quintiles express inequity level. Different

policies targeting different groups of population should be

considered t the interpretation.

Average annualized health

expenditures per person

To determine the annual level of health expenditures per person.

Differences among quintiles indicate inequity.

Average annualized medicine

expenditures per person

To determine the annual level of medicine expenditures per

person.

Differences among quintiles indicates inequity


expenditures for a reported illness

(acute, chronic, by illness) as

percent of total expenditures in a

4-week period

To determine financial burden of expenditures on medicines for a

reported illness

Percent of households with

insurance coverage for any of the

medicines prescribed for a reported

illness (acute, chronic, by illness)

To determine the extent of insurance coverage of medicines in

households


91



that price is a reason for not taking



To measure cost as a barrier to medicines access.

Percent of households who can get

free medicines at public health care

facilities

Free medicines may increase access. Differences among quintiles

allows to assess if goals established in the NMP are being met.

Percent of households who agree

that medicines are more affordable

at public health care facilities than at

private pharmacies

Perception about affordability may influence utilization

Percent of households who can get

credit for medicines at medicine

retailers (private pharmacies,

medicine sellers)

Possibility of getting credit to buy medicines may influence

patterns of utilization and access

Percent of households who had to

borrow money or sell assets in the

past to pay for medicines

To assess how the cost of medicines affects household economic

status and poverty risk


that lack of availability of medicines

at point of distribution (public

health care facility, private

pharmacy or medicine seller) is a

reason for not taking medicines as

prescribed for a reported illness

(acute, chronic, by illness)

To measure perception about availability of medicines.

This indicator intend to assess if availability is perceived by

people as problem not to take medicine and if the problem has

different magnitude concerning to acute or chronic conditions.


that medicines are available at point

of distribution (public health care

facility, private pharmacy, medicine

seller)

Perceived availability of medicines in health care facilities may be

a barrier to utilization and access

Percent of households located > 1h

5km from the closest provider of

medicines

To measure the distance to public health care facilities. Living

more than 1 hour walking distance from a public health care

facility may impact access to medicines.

Catherine, do you have any evidence on this distance? Why 1h. In

Brazil we found people start be concerned to distance over 30

minutes travel

Percent of households located > 1h

from the point of distribution of



To measure distance from the actual source of medicines. Having

to travel more than 1 hour walking distance to obtain medicines

may impact access to medicines.

Percent of respondents who declare

that distance from source of

medicines is a reason for not taking

a medicine as prescribed for a

reported illness (acute, chronic, by

illness)

To measure geographic access as a perceived barrier to not access

all needed medicines.Results according to kind of illness (acute,

chronic, specific illness) have different potential hazard. In serious

acute illness people probably were in need to access medicines

quickly, may be in life threatening situations. In chronic

conditions people generally requires the same medicines

continuously and any barrier to access declared is probably faced

frequently.


that location of public health care

facilities is convenient

Perception about convenience of health care facilities may

influence utilization and access to medicines


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Percent of households who visited a

formal source of health care at the

time of acute illness

To assess access to and utilization of public health care facilities

during acute illness.

The indicator allows assessing how much are acute ill people

looking for care and if they are doing this in facilities as planned in

national health policy.

Percent of respondents who are

satisfied with quality of services

delivered by local health care

facilities

Perception of quality of care may influence utilization

Percent of respondents who prefer

private health care providers over

public health care facilities

Preferences related to private vs. public providers may influence

utilization. Which question is this?

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