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Pharmaceutical Management for Maternal Health: Assuring access to quality medicines and supplies

Beth Yeager May 4, 2012 Dhaka, Bangladesh

Dimensions of Access to Medicines

Accessibility and Availability

Country % births attended by skilled attendant1 14.3% Stock-outs of oxytocin in public facilities?2 Yes, rarely


India Indonesia Nepal

47% 73% 19%

Yes, regularly
Yes, frequently No Yes, occasionally

WHO Global Health Observatory; Births Attended by Skilled Health Personnel Interactive Map; http://gamapserver.who.int/gho/interactive_charts/mdg5/atlas.html, accessed 4/11/2012 2 USAID/MCHIP Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia Status Report 2011

Example from Bangladesh:
Location of delivery Total cost of health care during pregnancy, delivery, and postpartum period as percent of average annual income 15%


Basic obstetric facility

Comprehensive obstetric facility


Borghi, J. et al. 2006. Household Costs of Healthcare during Pregnancy, Delivery, and the Postpartum Period: A Case Study from Matlab, Bangladesh. Journal of Health, Population, and Nutrition 24 (4) 446455.

Policy Makers



Elements of Pharmaceutical Management to Assure Quality of Products

Protocol for case management based on consensus of experts and internationally recognized best practices Criteria should include:
Consideration of types of health providers at different levels of the system Cost Safety and efficacy Are appropriate storage Quality and stability conditions for oxytocin present? Registration status Is misoprostol included in Availability for procurement EML for ob/gyn indications?
Who is allowed to prescribe misoprostol?

Agreement between STGs and EML

Quantity needed
Management information system to monitor consumption; supply data

Quality standards Packaging Storage conditions/capacity Shelf life of products Supplier performance Centralized vs. decentralized

Procurement (2)
Do tender documents provide sufficient specificity on characteristics that may affect quality? (e.g. packaging for misoprostol) Will re-packaging be necessary? What data are used for quantification? Is data on morbidity available? Have needs of lower levels of the health system been considered? Have multiple uses of medicines (e.g. oxytocin) been considered?

Distribution network and transportation
Vertical vs. integrated Frequency

Conditions during transport

Cold chain; light; protection from weather

Quality assessment at distribution points

Are appropriate conditions maintained during distribution (e.g. oxytocin)? How are medicines distributed to lower levels of system (e.g. community-based distribution of misoprostol)? Is this system really working?

Inventory Management
Stock cards and registers FEFO; stock rotation Reporting Physical inspection Disposal of expired products

Is consumption recorded at all levels? Are records reconciled (e.g. pharmacy vs. delivery room)?

Temperature monitoring Cold chain (oxytocin) Humidity (misoprostol) Light Ventilation Clean environment/absence of insects/rodents Security

Service delivery protocols
Who is allowed to prescribe? Indications, dose, contraindications Management of side effects

Job aids Product availability Dispensing

Labeling Packaging Counseling

Management Support
Standard operating procedures Management information system Human resources Financing Monitoring and supervision

Policy, law and regulation

EML; STGs Registration Importation Financing mechanisms Human resources