226 I THE
PROPHARMACY AS A MEANS OF MEETING DRUG SHORTAGES
The propharmacy as a means of meeting chronic drug shortages in rural health centres in rural African comm unities
Tropical Doctor, October ](J78
health centre, and the size of the population. This money is used for the bulk purchase of drugs from wholesale drug dealers, free from customs duties and taxes. These drugs are then stocked in the propharmacy and sold to people presenting prescriptions from health centre consultations. The drugs are sold at cost but with a 50() to 10" () profit margin added to cover overhead charges and the salary of a night watchman recruited for the propharmacy. This profit margin is T. C. Nchinda, MD, MFCM, DTPH also used to pay a bonus (as an incentive to honest University Centre for Health Sciences, University of practice) to the nurse or pharmacy assistant who runs Yaounde, Cameroon the propharmacy as well as one or two other medical personnel involved in the smooth operation of the TROPICAL DOCTOR, 1978, 8, 225-228 propharmacy. In the NW Province of Cameroon this One of the important problems confronting all health includes the health worker who goes round the procentres in rural areas of developing countries is chronic pharmacies collecting the reports on drug sales and drug shortage. Health centres generally have to pro- delivering new stock, the pharmacy assistant in charge vide free medical and health care to these rural of the central propharmacy depot at the provincial populations. Although the emphasis is on the health headquarters, and the finance clerk who handles all care aspects which are largely preventive, elementary the financial transactions. I must add that in the NW medical care still remains paramount for those who Province where these propharmacies function well, attend the health centres with common illnesses. there is a centralized system of supervision, control, With their usual financial constraints, developing and accounting of some 30 propharmacies in the area. countries can afford to allocate only a small propor- Bulk orders for drugs are made for all the prophartion of the budget for drugs, much of the budget macies and stored centrally in Bamenda from where being consumed by the hospital-based curative they are distributed to the different propharmacies. Separate accounts and records are kept for each proservices. It is thus common to find a rural health centre with pharmacy. The cash receipts from the sale of drugs drugs available only at the beginning of the financial are once again re-invested to purchase more drugs year; for the rest of the year the health centre has often and so the whole operation continues like a revolving to be run with no drugs at all. The attendance at the fund. health centres thus fluctuates with drug availability. The opening of a new propharmacy needs the It is high when there are drugs but drops rapidly to a authorization of the Minister of Health. The request trickle when the drugs are exhausted. We have to open one is made jointly by the rural health medical attempted to solve this problem in the Cameroon, officer who will supervise the health centre where it is where the system is in operation. located and the local council chairman who will eventually provide the initial capital. Drugs are sold on strict cash terms and receipts are issued for all WHAT IS A PRO PHARMACY ? The propharmacy was established in Cameroon some sales to facilitate accounting and control. ten years ago in selected areas of the country as an experiment to meet the problem of chronic drug DRUGS STOCKED IN A PROPHARMACY shortage in rural health centres. A propharmacy is a Propharmacies are authorized to stock only a small local council-financed and Government- limited range of drugs which have been drawn up instituted drug store, generally located near a health taking into account the disease spectrum of the area, centre. It has so far been established only in towns the ease with which the health centre staff can handle where no private pharmacist's exist. Run by a nurse the drugs, and their cost. Some of the essential drugs or pharmacy assistant and supervised by the rural stocked in the propharmacies in the North-West health medical officer, the propharmacy stocks and Province of Cameroon in 1975/76 and their costs are sells drugs at very low cost. given here. The cost of some of these drugs in the At its inception, each propharmacy is given an private chemist's shop is also given for comparison. initial capital by the local council totalling about 200,000 to 500,000 frs CFA per health centre ($800 OTHER DRUG SUPPLIES TO HEALTH CENTRES to $2,000) depending on the financial strength of the In spite of the creation of propharmacies, which is not local council, the capacity and volume of work at the yet universal for all the health centres in Cameroon,
Tropical Doctor, October 1978 Drng
Tablets Chloroquine sulphate (Nivaquine 100 mg) Aspirin 0.5 g Fersolate Folic acid Multivitamin tablet Hyoscine butylbromide Sulphaguanidine Sulphathiazole Magnesium trisilicate Promethazine hydrochloride
Cmtm propharmacy (per tablet) frs
2 2 2 3 2
THE PROPHARMACY AS A MEANS OF MEETING DRUG SHORTAGES
Cost in private pharmacy (per tablet) frs
5·4 4
6 13 14
10 7 5 2
14 17 14 12
3
12
Injections: frs Bipenicillin 500,000 50 per vial Bipenicillin 1,000,000 6o" " Ergometrine 40"" Triplopen 1,200,000 125" " Penextilline 1,000,000 120" tube DPT vaccine 50" dose 45"" Tetanus toxoid
frs 245 per 275" 8o" 33°" 275" 425" 86 3 " frs
I 227
general consultations as well by health centre staff and are thus rapidly exhausted. The amount provided for each goverment health centre varies. The health centres have been categorized according to their size, range of activities performed, and the population they are expected to serve. The range is from category I which is given a drug budget of 910,000 frs ($2,668) per annum to category 3 given 345,000 frs ($1,380) per annum. COST OF MEDICAL CARE
vial " " " " dose "
Syrups: frs Piperazine compound (Antepar) 30 for 30 ml 100 for 30 ml Iron mixture 50 for 150 ml 250 for 150 ml Mist. mag. trisilicate 50 for 150 ml Mist. kaolin 50 for 150 ml Ointments and others: frs frs Aureomycin eye ointment I 'Ic) 185 per tube 75 per tube Aureomycin skin ointment 3 % 15° " 27°" " " Benzylbenzoate emulsion 8o" 25 cc 50" 25 cc Antenatal clinic card 25 each Plastic bag 5 " Treatment card 10 " Note: One USA dollar is equivalent to 250 CFA francs.
the Government has greatly increased its drug budget for the health centres. This is to permit the health centres to stock enough essential drugs and vaccines for free prophylactic use especially at antenatal and child welfare clinics as well as for vaccinations in keeping with Government policy emphasizing preventive medicine. However these drugs get used for
I have carried out a study to assess the medical care costs for a group of patients attending health centres in the North-West Province of Cameroon. The three health centres in which the study was carried out had propharmacies and all of them usually give free prophylactic antimalarials, folic acid, and iron to pregnant women and free antimalarials and iron mixtures to children attending child welfare clinics. the purpose of the study was to find out how much the people spent for: (a) medical care (payments for drugs purchased from the propharmacy) ; and (b) for transport to and from the health centre including food bought at the health centre. Over a period of about two weeks all the patients attending consultations at the three health centres were interviewed just as they were leaving the health centre premises. Receipts were tendered to justify drug purchases while the cost of transport, where the patient came on foot, was calculated based on the known standard fares. Where food or other snacks were bought the cost was also added. The result of this study showed that the average amount spent by each health centre patient (573 patients interviewed) was 216 frs CFA ($0.90). The average amount spent by each clinic patient for drugs only was 155 frs ($0.65). Looking again at the table of comparative prices of some drugs in the propharmacy and the private chemist's shop one sees that the cost of all drugs is higher in the latter than in the former. Thus if the patients in this study had paid for their treatment in a chemist's shop, they would have spent more for their drugs. In addition, each patient would have had to pay the return fare to the town where the chemist's shop is situated. The creation of propharmacies has thus gone a long way to supplement the hitherto infrequent supply of drugs to rural health centres by ensuring that drugs are available all the time and that the drugs are sold at low prices. People living in large towns, where private chemist's shops are situated, have been known to take their hospital prescriptions to propharmacies situated up to 40 km away in order to take advantage of the lower cost of drugs in the propharmacy.
228
I THE PROPHARMACY AS A MEANS OF MEETING DRUG SHORTAGES
Tropical Doctor, OctoberI978
The main requirements for a successful propharmacy are: (i) There must be good administrative management. Drugs must be ordered regularly without waiting for stocks to run out before orders are made. Also, receipts from drug sales must be collected regularly both to provide cash to pay for drugs ordered and to prevent the propharmacy staff from keeping large sums of money in their possession with its attendant risk of theft or misappropriation. (ii) There must be absolute honesty on the part of the persons who run and supervise propharmacies. This is very important to the very life of the propharmacv.
would appear that the system described has accomplished this task very successfully. Although traditionally the tendency has always been to provide free treatment at the rural health centres, it was argued that the advantage of having drugs available all the time at low cost greatly outweighed that of having free treatment occasionally, with drugs being out of stock most of the time. Also, getting the people to participate in their own care by paying modest amounts for their treatment was an important factor to be encouraged.
CONCLUSION
ACKNOWLEDGEMENT
This paper has tried to describe the organization and functioning of the propharmacy in Cameroon. It was developed to get over the problem of chronic drug shortage that has plagued rural health centres. It
I wish to acknowledge the assistance of a group of fifth year medical students of the 1976/77 set of the UCHS Yaounde who helped to collect much of the data for the study reported in this paper in the course of their senior Community Medicine clerkship which the author was supervising.
Book Reviews Helping the Rural African Mother to Care for her Child By C. Desjardins and S. Desjardins (Published by St. Mary's Hospital, Gulu, Uganda (PO Box 200), 133 pages, Price: IO EA shillings.) This concise, unpretentious, very readable little book is an excellent guide for the education of African mothers in essential health care for their infants and small children. The preface to the text points out that it aims at giving the mother the basic knowledge of how to feed the baby and how to take care of it. It gives some simple and practical advice on dealing with children who have fever or diarrhoea or cough or a skin rash or worms. It also mentions the problems of pregnancy, delivery, breast feeding, etc. It is undoubtedly of great value as an example of primary health care originating with the mother and its low price should make it popular with the population that it proposes to enlighten and to help.
Tropical Leafy Vegetables in Human Nutrition By H. A. P. C. Oomen and G. J. H. Grubben (Amsterdam: Koninklijk Instituut Voor de Tropen, (I977) I36 pp., illus. Price DFI. 22.50.) Green leaves are an essential dietary item in most cultures. They provide vitamins, minerals, and protein; and above all they add variety and interest to staple dishes. A wealth of edible green leaves is grown in tropical countries and this book comprises a short, practical, and in places erudite, account of their availability and use. Topics covered are, the nutritional value of green leaves, ways in which they are cultivated or gathered in the tropics, and ways in which they are cooked and eaten. The authors are clearly enthusiasts about their subject and for any health worker wishing to encourage or practise the increased use of green leafy vegetables, this book is an excellent starting point. ERICA WHEELER
PROPHARMACY AS A MEANS OF MEETING DRUG SHORTAGES
The propharmacy as a means of meeting chronic drug shortages in rural health centres in rural African comm unities
Tropical Doctor, October ](J78
health centre, and the size of the population. This money is used for the bulk purchase of drugs from wholesale drug dealers, free from customs duties and taxes. These drugs are then stocked in the propharmacy and sold to people presenting prescriptions from health centre consultations. The drugs are sold at cost but with a 50() to 10" () profit margin added to cover overhead charges and the salary of a night watchman recruited for the propharmacy. This profit margin is T. C. Nchinda, MD, MFCM, DTPH also used to pay a bonus (as an incentive to honest University Centre for Health Sciences, University of practice) to the nurse or pharmacy assistant who runs Yaounde, Cameroon the propharmacy as well as one or two other medical personnel involved in the smooth operation of the TROPICAL DOCTOR, 1978, 8, 225-228 propharmacy. In the NW Province of Cameroon this One of the important problems confronting all health includes the health worker who goes round the procentres in rural areas of developing countries is chronic pharmacies collecting the reports on drug sales and drug shortage. Health centres generally have to pro- delivering new stock, the pharmacy assistant in charge vide free medical and health care to these rural of the central propharmacy depot at the provincial populations. Although the emphasis is on the health headquarters, and the finance clerk who handles all care aspects which are largely preventive, elementary the financial transactions. I must add that in the NW medical care still remains paramount for those who Province where these propharmacies function well, attend the health centres with common illnesses. there is a centralized system of supervision, control, With their usual financial constraints, developing and accounting of some 30 propharmacies in the area. countries can afford to allocate only a small propor- Bulk orders for drugs are made for all the prophartion of the budget for drugs, much of the budget macies and stored centrally in Bamenda from where being consumed by the hospital-based curative they are distributed to the different propharmacies. Separate accounts and records are kept for each proservices. It is thus common to find a rural health centre with pharmacy. The cash receipts from the sale of drugs drugs available only at the beginning of the financial are once again re-invested to purchase more drugs year; for the rest of the year the health centre has often and so the whole operation continues like a revolving to be run with no drugs at all. The attendance at the fund. health centres thus fluctuates with drug availability. The opening of a new propharmacy needs the It is high when there are drugs but drops rapidly to a authorization of the Minister of Health. The request trickle when the drugs are exhausted. We have to open one is made jointly by the rural health medical attempted to solve this problem in the Cameroon, officer who will supervise the health centre where it is where the system is in operation. located and the local council chairman who will eventually provide the initial capital. Drugs are sold on strict cash terms and receipts are issued for all WHAT IS A PRO PHARMACY ? The propharmacy was established in Cameroon some sales to facilitate accounting and control. ten years ago in selected areas of the country as an experiment to meet the problem of chronic drug DRUGS STOCKED IN A PROPHARMACY shortage in rural health centres. A propharmacy is a Propharmacies are authorized to stock only a small local council-financed and Government- limited range of drugs which have been drawn up instituted drug store, generally located near a health taking into account the disease spectrum of the area, centre. It has so far been established only in towns the ease with which the health centre staff can handle where no private pharmacist's exist. Run by a nurse the drugs, and their cost. Some of the essential drugs or pharmacy assistant and supervised by the rural stocked in the propharmacies in the North-West health medical officer, the propharmacy stocks and Province of Cameroon in 1975/76 and their costs are sells drugs at very low cost. given here. The cost of some of these drugs in the At its inception, each propharmacy is given an private chemist's shop is also given for comparison. initial capital by the local council totalling about 200,000 to 500,000 frs CFA per health centre ($800 OTHER DRUG SUPPLIES TO HEALTH CENTRES to $2,000) depending on the financial strength of the In spite of the creation of propharmacies, which is not local council, the capacity and volume of work at the yet universal for all the health centres in Cameroon,
Tropical Doctor, October 1978 Drng
Tablets Chloroquine sulphate (Nivaquine 100 mg) Aspirin 0.5 g Fersolate Folic acid Multivitamin tablet Hyoscine butylbromide Sulphaguanidine Sulphathiazole Magnesium trisilicate Promethazine hydrochloride
Cmtm propharmacy (per tablet) frs
2 2 2 3 2
THE PROPHARMACY AS A MEANS OF MEETING DRUG SHORTAGES
Cost in private pharmacy (per tablet) frs
5·4 4
6 13 14
10 7 5 2
14 17 14 12
3
12
Injections: frs Bipenicillin 500,000 50 per vial Bipenicillin 1,000,000 6o" " Ergometrine 40"" Triplopen 1,200,000 125" " Penextilline 1,000,000 120" tube DPT vaccine 50" dose 45"" Tetanus toxoid
frs 245 per 275" 8o" 33°" 275" 425" 86 3 " frs
I 227
general consultations as well by health centre staff and are thus rapidly exhausted. The amount provided for each goverment health centre varies. The health centres have been categorized according to their size, range of activities performed, and the population they are expected to serve. The range is from category I which is given a drug budget of 910,000 frs ($2,668) per annum to category 3 given 345,000 frs ($1,380) per annum. COST OF MEDICAL CARE
vial " " " " dose "
Syrups: frs Piperazine compound (Antepar) 30 for 30 ml 100 for 30 ml Iron mixture 50 for 150 ml 250 for 150 ml Mist. mag. trisilicate 50 for 150 ml Mist. kaolin 50 for 150 ml Ointments and others: frs frs Aureomycin eye ointment I 'Ic) 185 per tube 75 per tube Aureomycin skin ointment 3 % 15° " 27°" " " Benzylbenzoate emulsion 8o" 25 cc 50" 25 cc Antenatal clinic card 25 each Plastic bag 5 " Treatment card 10 " Note: One USA dollar is equivalent to 250 CFA francs.
the Government has greatly increased its drug budget for the health centres. This is to permit the health centres to stock enough essential drugs and vaccines for free prophylactic use especially at antenatal and child welfare clinics as well as for vaccinations in keeping with Government policy emphasizing preventive medicine. However these drugs get used for
I have carried out a study to assess the medical care costs for a group of patients attending health centres in the North-West Province of Cameroon. The three health centres in which the study was carried out had propharmacies and all of them usually give free prophylactic antimalarials, folic acid, and iron to pregnant women and free antimalarials and iron mixtures to children attending child welfare clinics. the purpose of the study was to find out how much the people spent for: (a) medical care (payments for drugs purchased from the propharmacy) ; and (b) for transport to and from the health centre including food bought at the health centre. Over a period of about two weeks all the patients attending consultations at the three health centres were interviewed just as they were leaving the health centre premises. Receipts were tendered to justify drug purchases while the cost of transport, where the patient came on foot, was calculated based on the known standard fares. Where food or other snacks were bought the cost was also added. The result of this study showed that the average amount spent by each health centre patient (573 patients interviewed) was 216 frs CFA ($0.90). The average amount spent by each clinic patient for drugs only was 155 frs ($0.65). Looking again at the table of comparative prices of some drugs in the propharmacy and the private chemist's shop one sees that the cost of all drugs is higher in the latter than in the former. Thus if the patients in this study had paid for their treatment in a chemist's shop, they would have spent more for their drugs. In addition, each patient would have had to pay the return fare to the town where the chemist's shop is situated. The creation of propharmacies has thus gone a long way to supplement the hitherto infrequent supply of drugs to rural health centres by ensuring that drugs are available all the time and that the drugs are sold at low prices. People living in large towns, where private chemist's shops are situated, have been known to take their hospital prescriptions to propharmacies situated up to 40 km away in order to take advantage of the lower cost of drugs in the propharmacy.
228
I THE PROPHARMACY AS A MEANS OF MEETING DRUG SHORTAGES
Tropical Doctor, OctoberI978
The main requirements for a successful propharmacy are: (i) There must be good administrative management. Drugs must be ordered regularly without waiting for stocks to run out before orders are made. Also, receipts from drug sales must be collected regularly both to provide cash to pay for drugs ordered and to prevent the propharmacy staff from keeping large sums of money in their possession with its attendant risk of theft or misappropriation. (ii) There must be absolute honesty on the part of the persons who run and supervise propharmacies. This is very important to the very life of the propharmacv.
would appear that the system described has accomplished this task very successfully. Although traditionally the tendency has always been to provide free treatment at the rural health centres, it was argued that the advantage of having drugs available all the time at low cost greatly outweighed that of having free treatment occasionally, with drugs being out of stock most of the time. Also, getting the people to participate in their own care by paying modest amounts for their treatment was an important factor to be encouraged.
CONCLUSION
ACKNOWLEDGEMENT
This paper has tried to describe the organization and functioning of the propharmacy in Cameroon. It was developed to get over the problem of chronic drug shortage that has plagued rural health centres. It
I wish to acknowledge the assistance of a group of fifth year medical students of the 1976/77 set of the UCHS Yaounde who helped to collect much of the data for the study reported in this paper in the course of their senior Community Medicine clerkship which the author was supervising.
Book Reviews Helping the Rural African Mother to Care for her Child By C. Desjardins and S. Desjardins (Published by St. Mary's Hospital, Gulu, Uganda (PO Box 200), 133 pages, Price: IO EA shillings.) This concise, unpretentious, very readable little book is an excellent guide for the education of African mothers in essential health care for their infants and small children. The preface to the text points out that it aims at giving the mother the basic knowledge of how to feed the baby and how to take care of it. It gives some simple and practical advice on dealing with children who have fever or diarrhoea or cough or a skin rash or worms. It also mentions the problems of pregnancy, delivery, breast feeding, etc. It is undoubtedly of great value as an example of primary health care originating with the mother and its low price should make it popular with the population that it proposes to enlighten and to help.
Tropical Leafy Vegetables in Human Nutrition By H. A. P. C. Oomen and G. J. H. Grubben (Amsterdam: Koninklijk Instituut Voor de Tropen, (I977) I36 pp., illus. Price DFI. 22.50.) Green leaves are an essential dietary item in most cultures. They provide vitamins, minerals, and protein; and above all they add variety and interest to staple dishes. A wealth of edible green leaves is grown in tropical countries and this book comprises a short, practical, and in places erudite, account of their availability and use. Topics covered are, the nutritional value of green leaves, ways in which they are cultivated or gathered in the tropics, and ways in which they are cooked and eaten. The authors are clearly enthusiasts about their subject and for any health worker wishing to encourage or practise the increased use of green leafy vegetables, this book is an excellent starting point. ERICA WHEELER
