MAKERERE UNIVERSITY

Ensuring Continuous Availability of Trained Accredited Drug Shop (ADS) Sellers A SDSI(MSH)/MakCHS COLLABORATION

Options Analysis Report

October 2012
SUBMITTED TO; SDSI PROJECT TEAM, Management Sciences for Health

Table of Contents
TABLE OF CONTENTS............................................................................2 EXECUTIVE SUMMARY...........................................................................3 ACKNOWLEDGEMENTS..........................................................................4 LIST OF ABBREVIATIONS.......................................................................4 1.0. INTRODUCTION..............................................................................5 2.0.OPTIONS ANALYSIS.........................................................................6 2.1.TRAINING OPTIONS.........................................................................7 3.0.RECOMMENDATIONS:....................................................................11

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EXECUTIVE SUMMARY The ADS training program piloted in Kibaale district presented a unique opportunity for sellers and owners of drug shops to improve their knowledge and skills. The sustainability of the successes achieved under the EADSI program depends highly on the availability of well trained and competent sellers who can provide services in the established outlets. There is a need for exploring more options for sustainability of the training program instead of depending on donor funds. An analysis of the current training model reveals that there a number of strengths and opportunities that can be exploited, and a number of weaknesses and threats that should be mitigated. Based on the situational analysis of training in Kibaale, the different stake holders had pertinent and promising suggestions for ensuring sustainability. Carrying out an options analysis reveals that there a number of merits and demerits for each of options. The options look at who, how, the duration of training. Both pre-service and in service training be opted for ADS sellers training. Refresher courses should also be carried out biannually to ensure knowledge and skills acquisition/ retention. The pharmacy training institutions should carry out the initial/accreditation course and this training should be carried out physically at these institutions. The refresher/on-going courses should be carried out by ADS association and local health teams supported and monitored by the pharmacy training institutions. These on-going courses should be held at venues close to the ADS sellers. To ensure financial sustainability, self-funding by the sellers is the only viable option.

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ACKNOWLEDGEMENTS We wish to acknowledge the contributions of the following towards the successful completion of the options analysis process: Heads of the pharmacy training institutions of Mbarara University of Science and Technology, Kampala International University, Gulu University and Mulago Paramedical Schools. The selected officials from; PSU, NDA, Allied health Professionals Council, SURE project and UHMG Selected government officials from the Ministry of Health and Ministry of Education The SDSI technical team

LIST OF ABBREVIATIONS
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ADS EADSI DHT NDA PSU MSH ADDO

Accredited Drug Shop East African Drug Seller Initiative District Health Team National Drug Authority Pharmaceutical Society of Uganda Management Science for Health Accredited Drug Dispensing Outlet

1.0. INTRODUCTION
Training is one of the key success factors that the ADS program in Uganda in hinged on. Before the ADS was introduced in Uganda, there was no structured training program for
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sellers and owners of drug shops. The ADS training program presented a unique opportunity for sellers and owners of drug shops to improve their knowledge and skills. The training covered several areas that directly impact on the day to day operations of the drug shops. The sustainability of the successes achieved under the EADSI program depends highly on the availability of well trained and competent sellers who can provide services in the established outlets. Currently, the demand for and attrition of sellers has been met through continuous training and retraining of new and old sellers with donor funds. This situation raises concern for program stakeholders, including regulatory authorities, because a more sustainable way of training sellers is needed in order for the program to continue achieving positive results in the short and long term. Objective To analyse the different options for a sustainable ADS sellers training program using pharmaceutical training institutions or other organizations Methods The following methods were utilised for the options analysis process Desk review Review of the situational analysis report Focused group discussion; made up of key stakeholders from ADS association, pharmacy training institutions, allied health professions council, Allied Health Examinations Board, MoH, NDA, and PSU.

2.0. OPTIONS ANALYSIS

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SWOT analysis of the current training model Strengths:

The importance of the training is highly appreciated by both owners and sellers The training of the owners were done separately from that of the sellers It has registered great improvement on the quality of pharmaceutical services provided. It was carried out at venues closer to the sellers making it very convenient for the

trainees.

Weaknesses
The duration of course is short (3 weeks); all the ADS trainees and former trainer found

it very inadequate.
Lack of financial sustainability; all the training activities are funded by MSH. Some of the potential trainees are not able to fit in the time table of the trainings The training sessions are less frequent and regular.

Opportunities
The training is a pre-requisite to accreditation of a class C drugs shop which enables

them handle an expanded list of medicines.

Stake holders appreciation of the need for ADS training

Threats
Communities are not well sensitized , for example, patients insist on single doses of

antibiotics
Non availability of trained ADS sellers in cases of attrition; the current model does not

create a pool of adequately trained personnel.

Opening up of illegal drug shops by trained ADS sellers

2.1. Training Options

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Training Modalities
Option 1: Pre-service Training This encompasses a structured comprehensive training program design for people before they begin working as ADS sellers. This kind of training equips the trainees with knowledge needed to provide quality pharmaceutical services. It is competency based training. Merits
Pre-service training creates a pool of ADS sellers that would be available in cases of

attrition and demand for sellers to work in new ADS sellers.

It is a medium and long-term solution to ensuring availability of trained ADS sellers and

therefore addresses sustainability and continuity issues

There is a career growth path for the individual as they can go on to do a diploma of

pharmacy/nursing Demerits
It does not immediately address the need for adequately trained sellers. Being

competency based, it requires proper selection of trainees; involves longer periods of training and is usually more expensive.
This may be seen by some stake holders as new cadre creation that is not supervised

by a professional council in the Ministry of Health Structure. Option 2: In-Service Training In-Service Training refers to training for sellers who are already working in the class C drug shops. This training is job-related and provides the sellers (most of whom are nursing assistants) with additional knowledge and skills to carry out new job functions or to improve their performance of existing job functions.

Merits
Improvement of quality of pharmaceutical services in the existing class C drug shops Immediately addresses the need for adequately trained sellers
The training durations is usually shorter and is less costly.

Involves also refresher/ on-going training.

Demerits
The training involves getting sellers from their work places which may be difficult. 8|Page

 The minimum requirements for one to be trained are usually more lax and so it does not adequately address the issue of quality. It is a short term strategy; it doesnt create a pool of adequately trained sellers to meet the need for ADS sellers created by attrition.

Who should train the ADS sellers? Option 1: Pharmaceutical Training Institutions These include Mulago Paramedical School, Departments of Pharmacy in Gulu, Mbarara, Makerere and Kampala International Universities. Merits
Resources , in form of human resource and infrastructure, are available for doing the

trainings
All are already running some short courses and so have great expertise and regulatory

systems in-place to ensure quality. Demerits

The minimum entry requirements might be well over those for most sellers The course fees might not be affordable to the sellers Involves travelling and staying at these institutions; which makes it more costly. The trainings have to be fitted into the academic calendars; most pharmacy training

institutions dont have adequate staffing numbers and have very busy program schedules.

Option 2: Other Interested Organizations These are institutions that have carried out such training before. They usually pick a number of professionals and carry out a training of trainers (TOTs). The trainers eventually are the ones

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that train the ADS sellers. These organizations could include ADS association and other private enterprises. Merits
They are able to offer flexible training schedules, hence better for on-going trainings Better acceptability by the trainees if the trainers are some of their fellow locals They are able to run on-site/close to workplace trainings

Demerits
TOTs have to be carried out before every training; making it expensive and non-

uniform.
May lack proper systems in place to check quality and also run initial training. Sustainability/continuity of the program remains a challenge. Need extra support and monitoring from other key stakeholders.

Place of training
Option 1: Distance learning This involves designing modules which are sent to the drug sellers with minimal face to face trainings. This would make the training cheaper but is not appropriate for the level of knowledge of the ADS sellers. Option 2: On job training This involves on job mentoring. It would give excellent results, but it is not practical. Option 3: Training organized in the districts This is what was employed in the ADS pilot in Kibaale. It has had some successes. However it is costly and sellers may not adequately attend the training.

Duration of Training The duration for the current training program is three (3) weeks. The ADDO pilot in Ruvuma was six (6) weeks. These are all in-service training models.
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Option 1: initial training duration This training is can be pre-service or in-service and requires adequate time for the sellers to adequately learn and internalize knowledge and develop the skill required. The in-service trainings involve training of persons already working as sellers, hence with some experience and the philosophy is to improve on practices so the duration of the training must be shorter than that required for Pre-service that is competency based. Options 2: on-going training duration These are refresher courses carried out as often as deemed necessary. They must be regular and focused to given areas of weakness identified and so are short; half to full day. Costs of training Option 1: self-sponsorship This involves the ADS sellers paying for their training, both initial and on-going. This is a very financially sustainable option but could greatly limit the numbers of sellers undergoing the training hence not addressing the great need for ADS sellers to cover gaps caused by attrition. Option 2: drug shop/Owner This option will ensure that enough sellers are trained depending on numbers of the owners who wish to have their drug shops accredited. However, it comes with two great setbacks; firstly, the expense might be passed on to the clients by increasing the selling prices hence limiting access to pharmaceutical services. Secondly, the owners will feel they the sellers owe them a lot and this could lead to disrespect and abuse of human rights. Options 3: external funding This can ensure an adequate number of sellers is trained in the short term, but is not sustainable in the long term.

3.0. RECOMMENDATIONS:
Type of training Both pre-service and in service training be opted for ADS sellers training. The in-service training will address short term ADS seller needs. It should be 4-6 weeks depending on the
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training content. In order to ensure quality pharmaceutical services provision, the minimum education requirements for in-service should be O-level certificate. Pre-service should be considered for the provision of higher cadre (pharmacy assistants) for ADS on Medium and Long term. It should be a nine months certificate course whose minimum entry requirement is A-level with science base. Refresher courses should also be carried out biannually to ensure knowledge and skills acquisition/ retention; it should be a full day long course. Who should carry out the training and how? The pharmacy training institutions should carry out the initial/accreditation course and this training should be carried out physically at these institutions. The refresher/on-going courses should be carried out by ADS association and local health teams supported and monitored by the pharmacy training institutions. These on-going courses should be held at venues close to the ADS sellers. Funding mechanisms To ensure financial sustainability, self-funding by the sellers is the only viable option.

4.0 REFERENCES
Aziz Maija, Saul Kidde, Kate Kikule, Dennis Mwesigwa, Nasser Lubowa, Martha Embrey, Keith Johnson; Increasing access to quality essential medicines and services provided by drug shops in Uganda through accreditation and regulation; Management Sciences for Health EADSI; Situational Analysis for the Pharmaceutical Sector and Access to Medicines in Uganda; 2008. Centre for Pharmaceutical Management; 2003; Defining and Measuring Access to Essential Drugs, Vaccines, and Health Commodities: Report of the WHO-MSH Consultative Meeting, Ferney-Voltaire, France, December 1113, 2000. Prepared for the Strategies for Enhancing Access to Medicines Program. Arlington, VA: Management Sciences for Health. ADRET (2011) Assessment of the transferability and Scalability of the ADS Program in Uganda

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