Ministry of Health
Republic of Uganda
Annual Pharmaceutical Sector Performance Report
2015-2016
OCTOBER 2017
Annual Pharmaceutical Sector Performance Report
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FOREWORD
The Annual Pharmaceutical Sector Performance Report provides us with a valuable
picture of the progress made implementing the National Pharmaceutical Sector
Strategic Plan (2015-2020). The report is disseminated to all stakeholders within the
health sector and discussed in a number of meetings from the Medicines Procurement
Management Technical Working Group (MPMTWG) at central level, Regional and
District logistics meetings in order to guide decision making.
The pharmaceutical sector will use these findings as a starting point to assess the
implementation of the National Medicines Policy and National Pharmaceutical Sector
Strategic Plan 2015.
I therefore, urge all stakeholders to use this information to focus their efforts in
achieving sustainable improvements in the pharmaceutical sector.
I wish to thank all those who have contributed to the preparation of this report and
supported the pharmaceutical sector: the dedicated staff of the Pharmacy Department,
National Medical Stores, Joint Medical Stores, the schools of pharmacy, National Drug
Authority, registrars of health professional councils, district health officers, health
workers, and health development partners.
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TABLE OF CONTENTS
FOREWORD ............................................................................................................................................................. ii TABLE OF CONTENTS ........................................................................................................................................ iii LIST OF FIGURES .................................................................................................................................................. iv LIST OF TABLES..................................................................................................................................................... v LIST OF ANNEXES ................................................................................................................................................. v ACRONYMS and ABBREVIATIONS ................................................................................................................ vi EXECUTIVE SUMMARY ..................................................................................................................................... vii INTRODUCTION ..................................................................................................................................................... 1 METHODOLOGY ..................................................................................................................................................... 1 RESULTS AND DISCUSSION .............................................................................................................................. 2 ANNEXES ............................................................................................................................................................... 22
Annex 1: Summary of Key Performance Indicators for FY 2015/16 ................... ………….22
Annex 2: List of contents of EMHS baskets .................................................................................... 25
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LIST OF FIGURES
Figure 1: Average percent availability of commodity basket items in reporting facilities,
in the previous quarter, April–June, 2016 ............................................................................................ 4
Figure 2: Percentage of facilities that had over 95% availability of a basket of
commodities in the previous quarter, April- June 2016 ................................................................. 5
Figure 3: Percentage of items ordered by facilities not filled by NMS, 2014/15-2015/16
............................................................................................................................................................................... 6
Figure 4: Average percentage of facilities submitting their orders on time and NMS
deliveries on time, 2014/15-2015/16 ................................................................................................... 7
Figure 5: Percent facility performance on stock management Indicators, 2015/16 ........ 10
Figure 6: Percent facility performance on storage management Indicators, 2015/16 .... 10
Figure 7: Percent facility performance on ordering and reporting Indicators, 2015/16 11
Figure 8: Percent facility performance on prescribing quality Indicators, 2015/16 ........ 13
Figure 9: Percent facility performance on dispensing quality Indicators, 2015/16 ......... 14
Figure 10: Comparison of Horizontal Equity Ratio across Levels of Care ............................. 17
Figure 11: Percent of average international price paid for procured essential medicines
by NMS and JMS, 2014/15-2015/16 .................................................................................................... 18
Figure 12: Number of registered pharmacists and ratio to population, 2014/15-
2015/16 ........................................................................................................................................................... 21
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LIST OF TABLES
Table 1: Annual Pharmaceutical Sector Performance Report Data Sources ........................... 1
Table 2: Availability of EMHS indicators, 2015/16 .......................................................................... 3
Table 3: Percent availability of commodity basket items at central warehouse, 2015/16
Commodity basket ......................................................................................................................................... 3
Table 4: Procurement and Delivery indicators, 2015/16 .............................................................. 5
Table 5: Average facility performance on medicines management indicators. 2015/16 . 9
Table 6: Number of facilities visited and average total SPARS score by ownership and
level of care..................................................................................................................................................... 12
Table 7: Appropriate Medicines Use Indicators, 2015/16........................................................... 13
Table 8: Affordability and Financing indicators – FY 2015/16 Performance ...................... 15
Table 9: Per capita GoU expenditure on EMHS, in US$, 2010-2016 ......................................... 16
Table 10: Safety, Efficacy and Quality of EMHS indicators – FY 2015/16 Performance .. 18
Table 11: Number of adverse drug reaction reports submitted to NDA, 2014-2016 ....... 19
Table 12: Pharmacy Human Resources indicators - FY 2015/16 Performance .................. 20
Table 13: Pharmacist (P) and Pharmacy Technician (PT) positions filled in the public
sector ................................................................................................................................................................ 21
LIST OF ANNEXES
Annex 1: Summary of key performance indicators for FY 2015/16 ................................... 21
Annex 2: List of basket of EMHS.…………………………………………………………….…………….. 25
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ACRONYMS and ABBREVIATIONS
ACT artemisinin-based combination therapy ADR adverse drug reactions ARV antiretroviral DHIS District Health Information System EMHS essential medicines and health supplies EMHSLU Essential Medicines And Health Supplies List Uganda GF Global Fund GH general hospital GoU Government of Uganda HMIS HRH
health management information system human resources for health
HSSIP Health Sector Strategic Investment Plan ITN insecticide treated nets IRS indoor residual spraying JMS Joint Medical Store MAUL Medical Access Uganda Limited M&E monitoring and evaluation MoH Ministry of Health MOS months of stock NDA National Drug Authority NDP National Drug Policy NDQCL National Drug Quality Control Laboratory NGO Non-governmental organization NHP National Health Policy NMS National Medical Stores NMP National Medicines Policy NPSSP National Pharmaceutical Sector Strategic Plan NRH national referral hospital OI opportunistic infections PHP private health practitioners PNFP private-not-for–profit PSU Pharmaceutical Society Uganda QCIL Quality Chemical Industries Limited RRH regional referral hospital SPARS Supervision, Performance Assessment, and Recognition Strategy STGs standard treatment guidelines TB tuberculosis UGX Uganda shilling URTI upper respiratory tract infection USAID United States Agency for International Development USD U.S. dollar WHO World Health Organization
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EXECUTIVE SUMMARY
The MoH Pharmacy Division annually tracks performance of the pharmaceutical sector
using a wide range of information that includes published government reports, monthly
reports submitted through the national health information management system, as well
as data collected through routine supervision visits to health facilities. A total of 32
standardized indicators have been measured for the year 2015/16 to assess progress
made towards achieving the objectives and targets set out in the National
Pharmaceutical Sector Strategic Plan (NPSSP) III for 2015-2020.
This report presents results for the first year of the five-year period of the NPSPP III and
compares performance against the last year (2014/15) of the previous five-year period
to identify successes and the areas requiring further efforts to achieve set targets.
The following are highlights from the first year of implementing the NPSSP III.
Availability of essential medicines and health supplies (EMHS): The availability of a
basket of 41 tracer commodities improved this year, with 55% of health facilities having
95% availability of a basket of commodities, up from 49% in 2014/15. During the year,
80% of sampled hospitals and 70% of HCIV facilities submitted their EMHS orders on
time to National Medical Stores (NMS). The NMS lead time from order receipt to
delivery to public health facilities increased slightly, from 41 days in 2014/15 to 48
days in 2015/16, but is still well below the maximum of 60 days. Orders placed with
NMS that are fully filled decreased to 63% from 72% in 2014/15. Average facility
performance was 71% on the Supervision Performance Assessment and Recognition
Strategy (SPARS) indicators, the same as in 2014/15.
Affordability and financing of EMHS: Government financing for all EMHS including
ARV, TB and malaria medicines increased in nominal terms from UGX 219 billion in
2014/15 to 231 billion in 2015/16. The budget allocation to the health sector as a
proportion of the total GoU budget was 6.4% in FY 2015/16, the lowest for over a
decade. Government per capita expenditure on EMHS dropped this year to US$ 1.9, the
lowest since 2010. Both NMS and Joint Medical Store (JMS) continued to obtain generic
products at competitive prices, at 42% and 69% of median international reference
prices, respectively. Donor partners contributed 80% of the total estimated expenditure
on EMHS, posing a risk in the event of funding uncertainties.
Safety, efficacy and quality of EMHS: The percentage of medicines failing NDA quality
tests increased to 13%, up from 6% last year. NDA tested more items this year (175)
than in 2014/15 (118).
Appropriate use of EMHS: Facility compliance to the Uganda Clinical Guidelines (UCG)
in prescribing medicines improved slightly this year with adherence at 82% for
sampled malaria cases (compared to 79% in previous year) and 60% for diarrhea (59%
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last year), but dropped for upper tract respiratory infections from 42% in 2014/15 to
36% this year.
Human resources in the pharmaceutical sector: The number of registered
pharmacists increased by almost 60% compared to last year, increasing the ratio of
pharmacy staff to the population from 2.2 to 2.9 per 100,000 population. Only 40% of
pharmacist and pharmacy technician posts are filled in the public sector.
INTRODUCTION
The Annual Pharmaceutical Sector Performance Report 2015/16 reviews the progress
made towards achieving the targets set in the National Pharmaceutical Sector Strategic
Plan (NPSSP) III 2015/16 - 2019/20. Progress is assessed by examining the trends in
the selected 34 indicators over time and comparing them to targets set for 2015.
The report covers the seven result areas of the NPSSP II which are aligned with the
objectives in the National Medicines Policy 2015:
1. Increased Access and Availability of Essential Medicines and Health Supplies
(EMHS)
2. Increased Affordability and Financing of EMHS
3. Increased Safety, Efficacy and Quality of MHS
4. Improved Appropriate Use of EMHS
5. Strengthened Human Resources in the Pharmaceutical Sector
6. Strengthened Coordination and M&E
7. Strengthened Community Engagement and Private Sector Participation
METHODOLOGY
Data collection. The data collection process follows standardized methods, tools and
procedures outlined in the monitoring and evaluation plan for the NPSSP III. The data
sources include routine sources of data from the District Health Information System
version 2 (DHIS2) using the national data collection tools of the health management
information system (HMIS), the national Supervision, Performance Assessment and
Recognition Strategy (SPARS) reports, document review, Key informant interviews
reports and records from National Medical Stores (NMS), Joint Medical Store (JMS) and
National Drug Authority (NDA). The data are collected on an annual basis, analyzed and
reported by Pharmacy Division M&E specialists.
Table 1: Annual Pharmaceutical Sector Performance Report data sources Result Area Data sources
1. Availability of EMHS NMS and JMS issues and stock on hand reports,
HMIS 105 reports, SPARS reports
2. Affordability and Financing Ministerial Policy Statement and Budget framework
paper, NMS vote 116 health facility resource
allocations
3. Safety, Efficacy, Quality NDA annual performance and activity reports,
Pharmacovigilance quarterly bulletins
4. Appropriate Use SPARS report
5. Human Resources New registration and graduating students pharmacy
technician register, Human Resource register, PSU
and Allied Health licensed pharmacist and registers
6. Coordination and M&E SPARS report, Pharmaceutical Information Portal
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Result Area Data sources
data
7. Community Engagement and Private
Sector Partnership
HMIS 097b report
The selection of indicators was based on the priority strategies outlined in the NPSSP
2015/20. To ensure standardized measurements, operational definitions are clearly
defined for each indicator, with the data source, collection and calculation method, and
data limitations described in M&E plan. Where indicators can be measured through
more than one source of data these are presented together for the purpose of
comparison and validation.
Data Analysis. Data are entered into different Excel workbooks and cleaned to ensure
errors are corrected. Descriptive statistics for each indicator are generated. The focus of
analysis is current performance compared to the previous year’s performance and
against set targets.
Reporting. This report is disseminated through the MoH website1, the Pharmaceutical
Information Portal (PIP)2 and other public channels.
RESULTS AND DISCUSSION
Data on pharmaceutical sector performance in the seven result areas are presented
below. In each section, a summary of the targets and achievement for FY 2015/16 is
provided for all of the Result Area indicators, followed by a more detailed presentation
and discussion of the individual indicators. Data from the previous year (2014/15) is
shown to measure the annual progress made.
Increased availability of essential medicines and health supplies
The National Medicines Policy (NMP) 2015 emphasizes the importance of efficient and
appropriate procurement, storage, distribution and good management of EMHS at all
levels of the system as the foundation for ensuring consistent availability of EMHS for
the effective nationwide delivery of the Universal Health Care Package.3 Result Area I
has five components each of which has a set of indicators to measure progress.
1 http://health.go.ug/publications/reports 2 https://pip.nhdb.ug 3 The National Medicines Policy (NMP) 2015, aims to contribute to the attainment of the highest standard of health by the population
of Uganda, through ensuring the availability, accessibility affordability and appropriate use of essential pharmaceutical products of
appropriate quality, safety and efficacy at all times
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Component 1: Availability of EMHS
Three indicators in Component 1 measure the availability of 41 priority essential
medicines and health supplies at central and health facility level. A summary of the
2015/16 targets and achievements of the indicators is presented in Table 2. The list of
the 41 tracer EMHS is included in Annex 2.
Table 2: Availability of EMHS indicators, 2015/16 Indicator FY15/16
Target FY 15/16
Achieved
1. Percentage availability for a basket of 41 tracer medicines and supplies in last three 3 months (April – June 2016) at central warehouses
65% NMS: 60%, JMS: 67%
2. Average percentage availability of a basket of 41 commodities at all reporting facilities in the previous quarter (April –June 2016) 88% 89%
3. Percentage of facilities that had over 95% availability of a basket of commodities in the previous quarter (April – June 2016)
67% 55%
Note: Data source. NMS stock status data, and DHIS2 data
Indicator 1: Percentage availability for a basket of 41 tracer medicines and supplies in last 3 months at the central warehouses
This indicator measures how many months out of each quarter of the year the quantity
of the product at NMS and JMS is equal to or more than the set minimum of two months
of stock. The indicator is calculated as an average percentage of all the 41 tracer
commodities. If data for the month and commodity is not available from warehouse
records/reports, that month or commodity are dropped from the calculation. In
2015/16, the average percentage availability was 60% at NMS and 67% at JMS; the
target was 65%. At NMS, the ARV and TB baskets had the highest availability, 88% and
100%, respectively; the lowest was for lab items.
Table 3: Percent availability of commodity basket items at central warehouse, 2015/16 NMS JMS
ARV 88% 71%
TB 100% -
Lab 33% 67%
RMNCAH 63% -
EMHS 40% 56%
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Indicator 2: Average percentage availability of a basket of 41 commodities at all reporting facilities in the previous quarter
This indicator measures the number of days out of each quarter (90 days) the 41 tracer
commodities were in stock in government, PNFP and private reporting facilities. Data
for this indicator was obtained from the monthly facility reports (HMIS 105 form)
submitted through the national DHIS2 system. If the commodity is not managed by the
facility, the commodity is dropped from the calculation.
In the quarter April-June 2016, on average the 41 commodities were available on 80 of
the 90 days (89%) in 3,262 reporting facilities (Figure 1). This met the annual target of
88%. No item was available 100% of the time. The ARV and RMNCAH baskets had the
highest availability, 91% and 90%, respectively, while the TB basket had the lowest
availability at 85%4.
The same data are routinely collected on 15 tracer commodities during facility visits by
district Medicines Management Supervisors (MMS). Their reports for the same quarter
(April-June 2016) show that 84% average availability of a basket of 15 commodities on
the day of visit at the 1,266 health facilities supervised during the quarter.
Figure 1: Average percent availability of commodity basket items in reporting facilities, in the previous quarter, April–June, 2016
Indicator 3: Percentage of health facilities that had over 95% availability of a basket of commodities in the previous quarter
The indicator measures the proportion of health facilities that had each item in a
commodity basket on at least 86 of the 90 days (95%) in the previous quarter. The
indicator averages the percent availability of basket items across all reporting facilities.
If the data for the commodity, month or facility is not available, then they are dropped
4 April- June 2016 Facility Tracer Medicines Stock Status Report
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from the calculation. In 2015/16, 55% of reporting facilities had over 95% availability
of the basket of commodities, below the 67% target.
Figure 2: Percentage of facilities that had over 95% availability of a basket of
commodities in the previous quarter, April- June 2016
Component 2. Selection, Procurement and Delivery
NMS procures and distributes EMHS to more than 2,700 government health facilities on
a bimonthly schedule. Before the start of each financial year NMS coordinates annual
procurement planning exercises with higher level facilities (HCIV, general and referral
hospitals) and works with district health officials to revise the district’s essential
medicines kit that are sent to lower level facilities (HCII and HCIII). Facilities must
adhere to their allocated budgets, place orders by established deadlines and adhere to
national guidelines regarding the commodities that can be used at each level of care.
NMS is responsible for procuring adequate quantities of the commodities, correctly
processing facility orders and dispatching them to facilities in a timely manner. Central
warehouses and facilities are encouraged to prioritize the procurement and ordering of
vital, life-saving EMHS to optimize the use of limited resources.
Five indicators are used to measure Component 2. Table 4 provides a summary of
performance in FY 2015/16.
Table 4: Selection, Procurement and Delivery indicators, 2015/16
Indicator FY15/16 Target
FY 15/16 Achieved
4. Percent of health facility orders placed that are fully (100%) filled at NMS
75% Order fill: 63% Nil lines: 37%
5. Average lead-time (days) from ordering by the facility to delivery to the facility
Max. 60 days 48 days
(range 15-164 days)
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Indicator FY15/16 Target
FY 15/16 Achieved
6. Percentage of health facility orders submitted on time as per NMS schedule
80%
74%
7. Percentage of deliveries made by NMS to the facilities within the scheduled delivery date
65% 77%
8. Percent of vital items (medicines, supplies and laboratory items) issued by NMS to facilities
60% Vital (90%),
Essential (4%), Necessary (6%). (n=1,384 items)
Indicator 4: Percent of health facility orders placed that are fully filled at NMS
The order fill indicator measures the percentage of the items ordered and received by
the facility in the correct quantities and products. The indicator here was calculated for
HCIV and hospitals only as they can send orders to NMS to receive supplies. The
opposite indicator is for the proportion of ‘nil lines’, a measure of how many items in an
order that were not supplied at all. Data for the two indicators was obtained from a
sample of 35 hospitals and HCIV facilities using facility orders submitted to NMS and
compared to NMS delivery notes for the sampled facilities.
In 2015/16, an average of 63% of the items ordered by higher level facilities were fully
supplied by NMS, while 37% of the items ordered by the sampled facilities were not
supplied in any quantity (Figure 3). Order fill rates can reflect issues in the adequacy of
financing, inventory management, picking, and shipping procedures; facilities might
also order items that are not appropriate for their level of care. The relatively low order
fill rate and high proportion of ‘nil lines’ is of concern given the negative effects this has
on provision of health services. The increase in proportion of ‘nil lines’ from 28% in
2014/15 to 37% this year is concerning but not unexpected given the stagnation in GoU
funding for EMHS and rapid population growth.
Figure 3: Percentage of items ordered by facilities not filled by NMS, 2014/15-2015/16
Note: The hospital category includes 12 general hospitals and 3 regional referral hospitals
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Indicator 5: Average lead time from ordering to delivery to the facility
The maximum lead time from receipt of facility order at NMS to delivery at the facility is
set as 60 days. The data on lead time was obtained from NMS order records and
delivery notes for a sample of 35 hospitals and HCIVs across the country. In 2015/16,
the average lead time was 48 days, well under the NMS maximum of 60 days. The range
of lead time days was a low of 15 days (this might have been an emergency order) and a
maximum of 164 days (3.6 months). The latter is much higher than the highest number
of days in the baseline year (2.4 months). Data on lead time submitted in routine SPARS
reports showed a lower average lead time of 35 days, with a range of 0 to 120 days.
Indicator 6: Percentage of health facility orders submitted on time as per NMS
delivery schedule and Indicator 7: Percentage of deliveries made by NMS to the
facilities within the scheduled delivery date
Indicator 6 is an average across the year of the percentage of hospitals and HCIVs that
submitted their bimonthly order on time as per the NMS order schedule. Indicator 7 is
the percentage of those orders that NMS delivered on time as per their delivery
schedule. It is helpful to review these two indicators together since NMS cannot deliver
to a facility on schedule unless the facility submits their order on schedule.
In 2015/16, 74% of facilities submitted their orders on time and 77% of NMS deliveries
were made on schedule (Figure 4). The percentage of facilities ordering on time is
below the desired target of 80% and performance dropped slightly (77%) compared to
2014/15. This year, NMS exceeded their on-time delivery target of 65% and their
delivery performance is up from 63% on time deliveries in 2014/15.
Figure 4: Average percentage of facilities submitting their orders on time and NMS
deliveries on time, 2014/15-2015/16
8
Indicator 8. Percent of vital items (medicines, supplies and laboratory items) issued by NMS to facilities
The 2016 Essential Medicines and Health Supplies List of Uganda (EMHSLU) classifies all
of the items according to Vital, Essential, Necessary (VEN) classification5. The data for
this indicator was obtained from itemized NMS sales records issued to health facilities.
The indicator is a percent of VEN items issued from the total issued items (n=1,384
items) by value.
In 2015/16, 20% of the items issued to facilities were classified as ‘vital’, well below the
60% target however, the value of the ‘vital’ items was 90% of the total sales. The
majority of items (55%) ordered by facilities were ‘necessary’ items at a value of 6% of
the total sales. This result is of concern because it suggests that patients may have less
access to life-saving medicines because they are more expensive.
Component 3. Medicines Management
SPARS, the national medicines management systems strengthening and capacity
building program, has been implemented in all 116 districts. More than 2,478 public
facilities and 620 private-not-for-profit (PNFP) facilities have received at least one
SPARS supportive supervision visit by a trained medicines management supervisor
(MMS). Facility performance is assessed and monitored using 25 indicators in five
domains covering stock management, stores management, ordering and reporting,
prescribing and dispensing.
Each of the five domains has a maximum score of five points totaling up to 25 maximum
overall SPARS score. Within each domain, the number of performance indicators varies
but each domain has a maximum score of 5. If an indicator is not assessed for a facility
the indicator score is dropped from the calculation. Performance on the indicator is
calculated as the percentage of the average facility score out of the total possible score.
Data for the indicators was obtained from facility SPARS reports based on the last visit
in FY 2015/16 for 2,334 facilities that were supervised by MMS during the year.
Table 5 shows the average facility performance on medicines management indicators in
2015/16. All indicators include measurements of public and PNFP facilities.
It is important to note that there is wide variation in the length of time that facilities
have been implementing SPARS; some may have only started SPARS in/or shortly
before 2015/16, while others will have been implementing SPARS since the start in
2012.
5 Essential Medicines and Health Supplies List Uganda (EMHSLU) 2016
9
Table 5: Average facility performance on medicines management indicators. 2015/16 Indicator FY15/16
Target FY 15/16
Achieved
9. Stock management 60% 56%
10. Stores management 80% 81%
11. Order and reporting quality score 80% 82%
12. Accuracy of the HMIS report on stock outs of tracer medicines
100% 79%
13. Average percent facility performance on 25 SPARS indicators
72% 71%
14. Cumulative percent of facilities with at least four SPARS visits
No target 62%
15. Prescribing quality 70% 66%
16. Dispensing quality 70% 71%
Indicator 9: Stock management, Indicator 10 store management and Indicator 11 ordering and reporting
Stock management is measured by four sub-indicators stock card availability,
correct filling of the stock card, correct use of the stock book and physical count agrees
with stock card balance. The proper filling and updating of stock cards and stock books
enable health workers to easily track the inventory levels and account for stock
transactions. At the end of each month, key data from the stock cards of all medicines
are supposed to be entered into the stock book. Correctly filling and using the stock
book helps health workers to calculate average monthly consumption rates, assess their
stock card balance and calculate the quantities they need to order each cycle. The
recorded stock card balance is validated whenever a physical count is conducted to
check if the figures agree. These steps are all fundamental to good medicines
management practices and ensuring availability.
In FY 2015/16, the average performance stock management score was 56% (2.8/5).
This performance is below the set target of 60% and the lowest of the five domains.
Availability of stock cards was 19.3% and 20.5% for accuracy of stock balance while the
average score for correct use of the stock book was only 5.8% (Figure 5). Stock books
were introduced in 2013 and although use continues to improve over time, health
facility staff in lower level facilities may not see the need to maintain an updated stock
book because their use is linked to ordering.
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Figure 5: Average facility performance on stock management indicators, 2015/16
Storage management is measured based on five sub-indicatorscleanliness of the
pharmacy, hygiene of the pharmacy, system for storage of medicines, storage conditions
and storage practices of medicines. Good storage conditions and practices ensure that
medicines are stored in a clean, safe, well maintained store protected from heat, light
humidity and pests to ensure the safety, quality and potency of the medicines. Better
resourced facilities, such as hospitals and donor partner-supported facilities, score
higher on the storage management indicators because they often have more space,
shelves, refrigerators, running water, and electricity.
In FY 2015/16, the average performance storage management score was 81% (4.1/5),
slightly higher the set target of 80%. Pharmacy cleanliness and storage system had the
highest average score at 17.6% and 17.8% with pharmacy hygiene scoring the lowest
13.8%. This indicator assesses if a facility has availability of clean and functioning
toilets with toilet paper and hand washing facilities with soap. Figure 6: Facility performance on storage management Indicators, 2015/16
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Ordering and reporting is measured by four sub-indicators reorder level
calculation, timeliness of the ordering, accuracy of stock out data reported in the HMIS
105, and filing of delivery notes and invoices. The accuracy and proper filing of records
is essential for accountability and good stock management and facilities must know how
to correctly calculate order quantities to ensure they maintain appropriate stock levels.
Accurate reporting on product stock outs is important for monitoring availability by
central level program managers.
In FY 2015/16, the average facility performance score for ordering and reporting was
82% (4.1/5), consistent with the set target of 82%. Facilities did well in general in this
area, particularly on the timeliness of ordering (22.8%) and filing (21%). The lowest
performance was on knowledge of reorder level calculation (18.3%), a critical sub-
indicator because facilities need to know how to calculate the right quantity to order
using average monthly consumption and stock on hand (this sub-indicator applies only
to higher level facilities that submit bimonthly orders).
Figure 7: Percent facility performance on ordering and reporting Indicators, 2015/16
Indicator 12: Accuracy of the HMIS 105 reports on stock outs of tracer medicines
Facilities are required to report the number of days of stock out of tracer EMHS in the
monthly HMIS 105 report. MMS compare the number of stock out days recorded on the
stock cards for the tracer medicines with the data submitted in the HMIS facility reports.
In 2015/16, the average facility performance on accuracy of HMIS reported stock out
data was 79%. The result is slight reduction from the previous year (82%).
12
Indicator 13: Average facility performance on 25 SPARS indicators
This indicator measures the overall medicines management performance in
government and PNFP facilities in the five domains. The maximum possible facility
score is 25 (five points in each of the five domains). The indicator is calculated by
averaging the scores of all facilities assessed during the year and dividing it by 25. No
annual target was set for this indicator. The closer to 100%, the better the facility
performance is.
In 2015/16, the average overall facility performance was 71% (Table 6). HCIVs and
hospitals score higher than lower level facilities and regional referral hospitals scored
the worst. There is only a small difference in the average SPARS scores between public
(71%) and PNFP (69%) facilities.
Table 6: Average total SPARS score by ownership and level of care, 2015/16 Ownership Level of Care Facilities visited Average total score
Public
HC2 1063 17.8
HC3 637 17.7
HC4 106 18.9
Hospital 30 18.9
Referral Hospital 11 16.1
PNFP
HC2 252 16.0
HC3 192 17.6
HC4 9 18.8
Hospital 34 18.6
Grand Total 2,334 17.6
Indicator 13: Cumulative percentage of government and PNFP facilities with at least four SPARS visits
To date, over 19,000 SPARS visits have been conducted by 400 trained MMS. Regular
SPARS supportive supervision visits have improved medicines management
performance in facilities, with the most noticeable improvements occurring in the first
four SPARS visits.
In FY 2015/16, 61% (3062) of facilities had implemented at least four SPARS visits a
one percent point difference from 62 %( 2472) in 2014/15. No improvement is seen
because the implementation of SPARS though a national strategy has not been
implemented in a standardized way.
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Improved Appropriate Use of Medicines and Health Supplies
Improving medicines use through proper prescribing and dispensing practices ensures
the best use of limited resources and optimal patient care. Prescribing quality is
measured by three sub-indicatorsrational prescribing (number of medicines
prescribed per encounter, generic name, encounters with one or more antibiotics,
injections and diagnosis recorded), prescription recording system and adherence to
standard treatment guidelines. Dispensing quality is measured by seven sub
indicatorsdispensing time, packaging material, dispensing equipment, availability of
reference materials, services available at the dispensing area, patient care, labelling and
correct filling of the dispensing log.
Performance on both indicators is measured as the average facility score out of the total
possible score of 25. Table 7 shows the targets and results for 2015/16.
Table 7: Appropriate Medicines Use Indicators, 2015/16 Indicator FY15/16
Target FY 15/16
Achieved
14. Average facility performance score for prescribing quality
70% 66%
15. Average facility performance for dispensing quality
70% 71%
In FY 2015/16, the average facility performance for prescribing quality was 66%, with
an average score of 3.3 out of possible score of 5. This was the second lowest score of
the five domain areas.
Figure 8: Percent facility performance on prescribing quality indicators, 2015/16
Annual Pharmaceutical Sector Performance Report
14
Average facility performance was highest for correct use of prescription recording
system (16.8%) and malaria management (15%). The lowest performance was for
management of non-pneumonia cough/cold (8%). The poor score for this sub-indicator
reflects a widespread inability to correctly diagnose this condition and overuse of
antibiotics and polypharmacy6. Despite years of regular MMS monitoring and
mentoring of facility staff on adhere to clinical guidelines on treatment of non-
pneumonia cough/cold and diarrhoea, provider prescribing habits have been proven to
be difficult to change because they require a combination of interventions to improve.
Public facilities had a better average prescribing quality performance score, 71%, than
PNFP facilities, 61% (data not shown).
For dispensing quality, the average facility performance was 71% which meets the
annual target of 70% in 2015/16. Within the dispensing domain, performance was
lowest on the sub-indicators of labelling and dispensing time. Although the medicines
name and dose were usually indicated on the dispensing envelope, other critical
labelling information is often left out, such as medicine strength, quantity, date, patient
name and facility name. PNFP facilities had a higher performance score on dispensing
quality (73%) compared to public facilities (66%).
Figure 9: Percent facility performance on dispensing quality indicators, 2015/16
6 International Bank for Reconstruction and Development/ the World Bank. Education and Health Services in Uganda. Data for results and accountability. 2013
15
Increased Affordability and Financing of EMHS
One of the key priorities of the National Medicines Policy 2015 is to ensure “adequate
financing of required quantities for the people of Uganda with equitable provisions of
the poor and vulnerable, as well as cost effective use of available resources”.7 The main
strategies for achieving this are the sustainable resource mobilization, with the aim of
reducing reliance on donors, and the establishment and maintenance of systems for
efficient utilization of EMHS resources and the equitable allocation of funds for
procurement of medicines and health supplies.
Six indicators are used to assess performance in this Result Area. The annual targets
and achievements for 2015/16 for each indicator is shown in Table 8.
Table 8: Affordability and Financing indicators – FY 2015/16 Performance
Indicator FY15/16 Target
FY 15/16
Achieved
16. Per capita expenditure on EMHS* 1.9 1.9
17. Percentage of GoU funds released for EMHS out of the total health sector funds*
19% 18%
18. Horizontal equity ratio to measure difference in allocation per patient among government owned facilities at the same level of care
0.20
HC4 – 0.19 HC3 – 0.30 HC2 – 0.26
19. Percent of average international price by NMS and JMS for procured basket of EMHS
<100% NMS- 42% JMS- 69%
20. Percent of order-based facility with a PFM score of 80% and above
No target
PFM just started
21. Percent of PHC funds NGO non-wage recurrent funds spent on procurement of EMHS for PNFP sector
50%
50%
*Includes ARVs, TB, ACTs, essential medicines, vaccines, laboratory supplies and reproductive health
commodities.
Data Sources: NMS Vote 116 allocation report, Bank of Uganda exchange rate, Annual Health Sector
performance report 2015/16, UBOS 2016 statistical abstract
Indicator 16: Per capita expenditure on EMHS In the FY 2015/16, an estimated US$1.9 was expended per capita on EMHS, including
ARVs, TB, and ACTs, essential medicines, vaccines, laboratory supplies and reproductive
health commodities. This is lower than past five years where per capita expenditure for
all EMHS stagnated at US$2.3-2.4 (Table 9). The per capita expenditure of US$1.9 is only
7 Source: National Medicines Policy 2015
Annual Pharmaceutical Sector Performance Report
16
6.5% of the per capita need of US$29 calculated as required under the National
Pharmaceutical Sector Strategic Plan 2015-2020. Per capita expenditure reduces to just
US$0.8 with the exclusion of expenditure on ARVs, TB ACTS and vaccines.
Table 9: Per capita GoU expenditure on EMHS, in US$, 2010-2016
2010/11 2011/12 2012/13 2013/14 2014/15 2015/16
Including ARVs, ACTs, TB supplies, and
vaccines
2.4 2.3 2.4 2.4 2.3 1.9
Excluding ARVs, ACTs, TB supplies, and vaccines
0.5 0.96 0.94 0.99 0.97 0.8
Bank of Uganda average dollar rate 2015/16 was 3,402 UGX. The figures above do not include off budget support.
Indicator 17: Percentage of GoU funds released for EMHS out of the total health sector funds Of the total of GoU funds released for the health sector in 2015/16, 18% was allocated
to EMHS, just below the target of 19%. The UGX 231 billion released this year was
slightly higher than the UGX 218 billion released in 2014/15. The budget allocation to
the health sector as a proportion of the total GoU budget was 6.4% in FY 2015/16, the
lowest for over a decade. The health sector budget in 2015/16 was UGX 1,271 billion
(US$374 million), down from UGX 1,281 billion (US$488 million) in 2014/15.
Indicator 18: Horizontal equity ratio to measure difference in allocation per patient among government owned facilities at the same level of care
To achieve equitable access for the population the allocation of EMHS resources should
match the need at the different health facilities where services are being provided.
Horizontal equity means that health facilities at the same level of care receive equitable
allocations of EMHS resources per patient. The Gini coefficient is used to measure the
degree of spread of the resource allocation per patient across facilities at the same level
of care. It ranges between 0%, which represents perfect equality where every facility
has the same per patient allocation, and 100%, which represents extreme inequality
where the facility with highest per capita allocation has all the resources with the other
facilities having zero allocation. Data for this indicator was obtained from NMS Vote116
allocations to selected health facilities and DHIS2 monthly inpatient and outpatient
numbers.
In FY 2015/16, HCIVs had the highest level of equity (Gini=0.19) among the three levels
of care measured. HCIIIs had the lowest level of equity (Gini=0.30) and HCIIs fell
between the two. This pattern is not unexpected given that GoU EMHS resources are
allocated to health facilities based on the level of care not patient load. HCII and HCIII
facilities have widely varying patient loads yet their budget allocations are set by their
level of care. HCIVs have much higher budget allocations than the lower levels of care
Annual Pharmaceutical Sector Performance Report
17
and less variability in patient volumes than the lower level facilities. Inequity increased
in HCII and HCIIIs and decreased in HCIVs compared to 2014/15 (Figure 18).
Figure 10: Comparison of Horizontal Equity Ratio across Levels of Care
Indicator 19: Percent of median international price paid by NMS and JMS for
basket of EMHS
To ensure greater value for money, central warehouses should strive to achieve
competitive prices through a transparent tendering process. Data for this indicator are
obtained from NMS and JMS reported procurement prices for a basket of 51 EMHS. The
procurement prices are compared to the median international prices listed in the
Management Sciences for Health International Drug Price Guide. Performance is
considered good if the procurement agencies are below 100% of the international price.
In FY 2015/16, both NMS and JMS average procurement prices for the basket of
essential medicines were considerably below the average international prices, 42% and
69%, respectively. For NMS, this is a 15 percentage point decrease compared to
2014/15, while the average procurement price paid JMS increased by 6 percentage
points (Figure 11).
Annual Pharmaceutical Sector Performance Report
18
Figure 11: Percent of average international price paid for procured essential medicines by NMS and JMS, 2014/15-2015/16
Increased Safety, Efficacy, and Quality of Essential Medicines and
Health Supplies
Since 1993, NDA has been responsible for assessing the quality, safety, and efficacy of
medicines, inspecting and licensing all pharmaceutical outlets in Uganda and conducting
sensitization on pharmacovigilance. Table 10 shows the achievements in FY2015/16 for
the four indicators used to measure Result Area 3. There are no annual targets for
indicators 24 and 25.
Table 10: Safety, Efficacy and Quality of EMHS indicators – FY 2015/16 Performance Indicator 2015/16
Target 2015/16
Achieved
22. Number of ADR reports submitted per 100,000 people
2.35 1.88
23. Percentage of sampled medicines failing pharmaceutical, chemical or microbiological NDA quality tests
<1% 13%
24. Percentage of pharmacovigilance reports in the previous year due to therapeutic ineffectiveness
No target 7%
25. Percentage of pharmacovigilance reports in the previous year due to substandard products
No target 6%
Indicator 22. Number of ADR reports submitted per 100,000 people Pharmacovigilance is the detection, assessment, understanding and prevention of
adverse effects or any other medicine-related problems. To enhance patient care and
safety in the use of medicines the NDA collects information reported by providers on
Annual Pharmaceutical Sector Performance Report
19
cases of adverse drug reactions (ADR) and other medicines-related issues through their
11 regional pharmacovigilance centers. The reported ADRs include a large spectrum of
clinical manifestations, which are collated based on the WHO Adverse Reaction
Terminology, System-Organ Class. The number of reports submitted are a basic
indication of the functioning of the reporting and surveillance system.
In FY 2015/16, a total of 174 ADR reports were submitted, a 63% decrease in ADR
reports submitted compared to FY 2014/15 (Table 11). The decrease in the number of
reports is not explained.
Table 11: Number of adverse drug reaction reports submitted to NDA, 2014-2016
2014/15 2015/16
Number of ADR reports submitted during the year
471
174
Indicator 23. Percentage of sampled medicines failing pharmaceutical, chemical or microbiological NDA quality tests
NDA’s National Drug Quality Control Laboratory (NDQCL) tests medicines on a regular
basis to detect counterfeit and/or poor quality drugs, some upon entry into the country
and others through post-market surveillance. In 2015/16, the NDQCL tested 175
medicines, of which 23 (13%) failed to comply with pharmacopeia and chemical
standards. This failure rate is double that of the previous year (6%) and the highest
observed since 2010.
Strengthened Human Resources in the Pharmaceutical Sector
The MoH is committed to attaining and maintaining an adequate workforce in the
pharmaceutical sector that is equitably distributed, appropriately skilled, motivated and
productive. A comprehensive human resources for health policy and strategy is in place
and a review is underway of the whole health workforce structure and training of
pharmaceutical and other health workers.
Three indicators are used to track progress in building the pharmaceutical sector
workforce. Data for the indicators is obtained from the pharmaceutical society and
allied health records, pharmacy school registers, the Annual Health Sector Report
2015/16 and MoH Human Resource for Health Information System. The data, however,
are not readily available or updated. The annual targets and achievements for 2015/16
are shown in Table 12.
20
Table 12: Pharmacy Human Resources indicators - FY 2015/16 Performance Indicator FY15/16
Target FY 15/16
Achieved
26. Number of pharmacy students and pharmacy technicians enrolled and graduating per year
No target Enrolled: 106
Graduating: 92
27. Pharmacists/pharmacy technicians per 100,000 population ratio
No target
3.99 per 100,000
Pharmacists - 2.3 Pharmacy technicians - 1.7
28. Percentage of pharmacist and pharmacy technician positions filled in the public sector
No target Pharmacist - 40%
Pharmacy technician - 40%
Indicator 26. Number of pharmacy students and pharmacy technicians enrolled and graduating per year
Information on pharmacy school enrollment and graduation was obtained from the
country’s three pharmacy schools: Makerere University, Mbarara University of Science
and Technology and Kampala University International. In 2015/16, a total of 106
students enrolled in pharmacy school and 92 graduated. Many of the students end up
working in the private sector because of the greater opportunities offered compared to
the public sector.
Indicator 27. Pharmacists and Pharmacy Technicians per 100,000 population
ratio
According to the Pharmaceutical Society Uganda records there were 840 licensed
pharmacists practicing in the public and private sector in 2015/16, producing a ratio of
2.99 pharmacists to 100,000 people. This is higher than the 2.2 ratio in the previous
year with only 527 registered pharmacists. This year there were 621 registered
pharmacy technicians was 621, yielding a ratio of 1.69 pharmacy technicians to 100,000
people. There is no defined target ratio set as optimal for pharmacists8.
8 Global Pharmacy Workforce Intelligence: Trend Report.2015
21
Figure 12: Number of registered pharmacists and ratio to population, 2014/15-2015/16
Indicator 28. Percentage of pharmacist and pharmacy technician positions filled in the public sector The number of public sector posts for pharmacists and pharmacy technicians
(dispensers) has increased significantly since 2011, from a total of 148 to 535 posts in
2015/16. The fill rates for both pharmacist and pharmacy technician posts was 40%
based on data obtained from the Seventh Human Resources for Health audit performed
by the MOH in collaboration with USAID-funded projects implemented by Intra Health
International.
Table 13: Pharmacist (P) and Pharmacy Technician (PT) positions filled in the public sector
2014/15 2015/16
Cadre P/PT/Dispensers P PT
Total no. of posts 307
112
423
Number of posts filled 115
45
169
% of posts filled
37%
40%
40%
Data Source: Annual Health Sector Performance Report
Annual Pharmaceutical Sector Performance Report
22
ANNEXES
Annex 1: Summary of Key Performance Indicators for FY 2015/16
Key Pharmaceutical Indicators
Overall Progress
Baseline 2014/ 2015
Target 2015/16
Achievement 2015/16
Av
ail
ab
ilit
y
Percentage availability for a basket of 41 tracer medicines and supplies in last 3 months at the central warehouses
NMS: 63% Based on 34
tracer medicines
JMS: 85% Based on 16 tracer
medicines
65%
NMS: 60%
JMS: 67%
Average % availability of a basket of 41 commodities based on all reporting facilities in the previous quarter
ALL: 84% EMHS:87% ARV:91% TB:87%
LAB:88% RMNCH:89%
88%
89%
% of health facilities that had over 95% availability of a basket of commodities in the previous quarter
ALL: 49% EMHS:44% ARV:50% TB:62%
LAB:49% RMNCH:38%
67%
55%
Pro
cure
me
nt
an
d D
eli
ve
ry
% of facilities with the current EMHSLU and UCG available
TBD
No Data
% of vital (V) items issued at NMS (medicines, supplies and Laboratory items) to the facilities
TBD
60%
V: 90%
E: 4% N: 6% (n= 1384 items) Total Sales- 916 billion shillings
% of health facility orders placed that are fully filled at NMS
72%
75%
Order fill: NMS: 63%
Nil lines: NMS:
37% Average NMS lead-time (days) from ordering to delivery at the facility
41 days (Range: 8 – 74)
<60 days 48 days (Range: 15-164)
% of deliveries made by NMS to the facilities within the scheduled date
NMS: 63%
65%
77%
% of health facility orders submitted on time as per NMS delivery schedule
77%
80%
51%
Me
dic
ine
s M
an
ag
em
en
t
Stock management- % stock management score for public and PNFP facilities
60%
56%
Storage management- % storage management
80%
81%
Annual Pharmaceutical Sector Performance Report
23
Key Pharmaceutical Indicators
Overall Progress
Baseline 2014/ 2015
Target 2015/16
Achievement 2015/16
score for public and PNFP facilities Ordering and reporting quality- % order and reporting quality score for public and PNFP facilities
80% 82%
Average % score of 25 SPARS indicators for public and PNFP facilities
OVERALL:72% PUBLIC:72%
PNFP:70%
72%
71%
Accuracy of the HMIS 105 report on stock outs of tracer medicines
82%
100%
79%
Cumulative % of government and PNFP with at least four SPARS visits
62%
Aff
ord
ab
ilit
y % of average
international price paid by the central warehouses for procured basket of essential medicines
NMS – 57% JMS – 63%
<100%
NMS – 42% JMS – 69%
Fin
an
cin
g
% of order based facility with a PFM score of 16 and above
Hospital – 63% HCIV – 51%
Hospital-63% HCIV-51%
Hospital – 63% HCIV – 51%
% of GoU funds released for EMHS out of the total health sector funds (Including ARVs, ACTs, TB medicines, Vaccines, Laboratory supplies and Reproductive Health Commodities)
18%
19%
18%
Per capita expenditure on EMHS (including ARVs, TB, ACTs, essential medicines, vaccines, laboratory supplies and reproductive health commodities)
1.7
1.9
1.9
Horizontal equity ratio to measure difference in allocation per patient among government owned facilities at the same level of care
HCIV – 0.26 HC3 – 0.18 HC2 – 0.20
0.20
HCIV – 0.19 HC3 – 0.30 HC2 – 0.26
% of PHC funds spent on procurement of EMHS for PNFP sector
50% of the PHC NGO non-wage
recurrent (NWR) for procurement
of medicines
No Data
Annual Pharmaceutical Sector Performance Report
24
Key Pharmaceutical Indicators
Overall Progress
Baseline 2014/ 2015
Target 2015/16
Achievement 2015/16
Sa
fety
, Eff
ica
cy a
nd
Qu
ali
ty o
f M
ed
icin
es
& H
ea
lth
Su
pp
lie
s
% of sampled essential medicines from post market surveillance tested and failing pharmaceutical, chemical or microbiological NDA quality tests
<1%
<1%
13%
Number of ADR reports submitted per 100,000 people
1.35
2.35
1.88
% of reports in the previous year due to therapeutic ineffectiveness
TBD
7%
% of reports in the previous year due to substandard products
TBD
6%
Ap
pro
pri
ate
u
se o
f M
ed
icin
es
&
He
alt
h
sup
pli
es
Prescribing quality- % prescribing score for public and PNFP facilities
70% 66%
Dispensing quality- % dispensing score for public and PNFP facilities
70% 71%
Hu
ma
n R
eso
urc
e
Number of pharmacy students and pharmacy technicians enrolled and graduating per year
MUK Enrolled – 43
Graduating – 41 MUST
Enrolled – 38 Graduating – 66
KIU Enrolled – 39
Graduating – 08
TBD MUK Enrolled – 55
Graduating – 41 MUST
Enrolled – 51 Graduating – 51
KIU Enrolled –
Graduating – Pharmacist/pharmacy technician to population ratio
1.7 per 100,000 TBD 3.99 per 100,000 (Pharmacists: 2.3
per 100,000; Pharmacy
Technicians: 1.7 per 100,000)
% of pharmacist and pharmacy technician positions fully filled in the public sector
Pharmacists 55%
Number=370
Pharmacy Technician/
Dispenser 55%
Number=420
Pharmacists 40%
Number=112
Pharmacy Technician/
Dispenser 40%
Number=423
Annual Pharmaceutical Sector Performance Report
25
Annex 2: List of contents of EMHS baskets
ARV BASKET
Tenofovir/Lamivudine/Efavirenz (TDF/3TC/EFV)
Zidovudine /Lamivudine/Nevirapine (AZT/3TC/NVP)
Zidovudine/Lamivudine (AZT/3TC)
Tenofovir/Lamivudine (TDF/3TC)
Nevirapine (NVP) 200mg
Efavirenz (EFV) 600mg
Abacavir/Lamivudine (ABC/3TC) 60mg/30mg
Nevirapine (NVP) 50mg
LAB BASKET
Determine HIV Screening test
Stat -pack HIV Confirmatory rapid tests
Unigold HIV RDT Tie-breaker test
CD4 reagent Specify
Malaria Rapid Diagnostic tests
ZN reagent for AFB
Blood 450 ml
EMHS BASKET
Recommended first line ACT (Artemether/Lumefantrine 20/120mg)
Cotrimoxazole 480mg
Thearapeutic milk F75 (75Kcal/100ml)
Thearapeutic milk F100 (100Kcal/100ml)
Ready to use Therapeutic feeds (RUTF)
Cotrimoxazole 960mg tablet
Chlorhexidine 20%
Bendroflumethiazide (Aprinox) 5mg
Propranolol 40mg
Nifedipine tablets 20mg
Captopril 25mg
Metformin 500mg
Glibenclamide 5mg
Insulin short-acting
Cardiac Asprin 75mg
RMNCAH BASKET
Depo- Provera
Sulfadoxine/ Pyrimethamine tablet
ORS Sachets with zinc tablet
Measles Vaccine
Misoprostol 200mcg Tablet
Amoxicillin dispersible 250mg tablet (For children)
Ceftriaxone 1g Injection
Oxytocin Injection
Mama Kit
TB BASKET
RHZE blister strip
RH blister strip 150/75mg