ADDO PROGRAM PILOT IN RUVUMA
The assessment of the situation of need of essential medicines to people living in rural areas evolved with the inception of ADDO program which started as a pilot project. Ruvuma was the region out of (the then) 21 regions that was identified to host the project. The implementation of the project started in early February 2002 to July 2005. The pilot project was supported by the Bill and Melinda Gates Foundation. In the pilot project, several activities which were part of the rollout process were conducted including sensitization of stakeholders, mapping of DLDBs, preliminary inspection of DLDBs, training of owners, training of dispensers, final inspection, public awareness campaign and CFDC meetings.
The first sixteen (16) ADDO shops in Ruvuma were launched by the former Minister for Health, Honorable Ms. Anna Abdullah (MP), in August 2003 and later 210 ADDO shops were accredited in Ruvuma region.
The accreditation of ADDO shops in Ruvuma was followed by a project evaluation which was conducted in November 2004 and findings of the evaluation were disseminated in the stakeholders meeting which took place in February 2005. Besides the challenges during the implementation of the pilot project, there was a significant reduction of unregistered medicines from 26% (baseline) to 2%, increased availability of Prescription Only Medicines (POM) and over the counter medicines. Other positive findings were improved rational use of medicines- 39% recommended antibiotics for acute respiratory tract infection at baseline compared to 14% at the end of the pilot and also the price of drugs were reported to stabilize as oppose to the prices that was in place the time of unavailability of essential medicines. It was because of these evaluation findings that in May 2005, the Government agreed to roll out the Program to other regions.
Much as ADDO program was a challenging undertaking and complex, the program required a significant financial and technical support from Government and other donors to make it a success. Based on this situation, throughout the program implementation, the Government and implementation partners looked at different options of implementation to ensure that it is realistic and performed in a cost effective manner.
1.0 EVALUATION OF THE PILOT PROJECT
The evaluation of the pilot phase of the ADDO project addressed issues related to whether there is an improved quality of medicines, availability, dispensing services and if the medicines are affordable to majority of people in the pilot area. Besides these areas, the evaluation also looked into operationalization and decentralized regulatory systems and the way the project can be sustained.
Generally, the findings of the project revealed the quality of the medicines improved as the availability of unregistered medicines was reduced from 26% to 2% in Ruvuma compared to Singida which was considered as a control. During the time of project initiation, Singida has a 29% unregistered drugs and after the intervention Singida also has 1 in 10 chances for people to buy unapproved medicines. It was also noted that the availability of prescription medicines in Ruvuma was nearly doubled the average availability in Singida.
During the evaluation of the pilot project, sense of ownership was felt by district and ward level inspectors as the structure recognized them as part of regulators. As the way of sustaining the project, evaluators looked at the investment and profit gains, owners of ADDO shops could not see the importance of investing on ADDO especially because most of the capitals were taken as loans. Despite this, 78% of ADDO ended up with debts in order to finance their accreditation investments and 96% of the owners surveyed claimed not o receive all the benefits they expected.
The pilot project also engage the drug sellers who mostly are the nurse auxiliaries on 35 days training on ADDO regulations, standards and code of ethics, drug quality and other important areas related to good pharmacy practices. The areas reported to have been improved included standardized ADDO premises, dispenser’s hygiene, record keeping and proper documentation. It was further noted that communication skills were improved and there was an increased of compliance on the legal requirements by DLDM.
2.0 ROLL OUT STRATEGY OF ADDO PROGRAM
The ADDO began in early 2005 whereby various options and criteria were put in place to discuss modalities on how the program could be rolled out in other regions in the shortest possible time. The initial thinking was to roll out the program in five (5) years (2005 - 2010) taking into consideration the availability of funds to support roll out activities. ADDO Program implementation continues to be a success following the financial support from the government and other development partners. Much as accreditation of the program was slow, the change of malaria treatment guidelines from SP to ACTs opened up an opportunity to support of program implementation. This was through the support from the Global Fund to Fight AIDS, Tuberculorsis and Malaria (GFATM) with a focus of malaria treatment through the private sector. Few years later, the TFDA had a plan to involve private sector for cost sharing that enabled the sustainability of the program to date. Currently, ADDO training are conducted under the auspicious of identified training institutions and private sector contributes the training costs.
Besides the TFDA implementation plan for ADDO program, in 2011 there was a change of responsibilities that the newly Pharmacy Act, 2011 was enacted which called for all retail business licensing including accreditation of ADDO to be shifted to the Pharmacy Council. In 2012, program implementation continued in collaboration with the Pharmacy Council in Kagera, Tabora, Kilimanjaro, Arusha and Mwanza. From this period onwards, the Pharmacy Council took a lead to oversee the implementation activities and TFDA was a support base for all the remaining activities and sustain the gains.
STAGES INVOLVED IN ADDO PROGRAM IMPLEMENTATION
The implementation steps of the ADDO Program included: mobilization and sensitisation of stakeholders at all levels from national to village level with the purpose of creating awareness, building the sense of ownership and outline the responsibilities of stakeholders. As a matter of fact, stakeholders were taken through the Laws, Regulations and Guidelines for operation of Duka la Dawa Muhimu. The approach used was to conduct seminars and mass media communication at different times.
In addition to upgrading the premises, training of ADDO owners, dispensers, inspectors and supervisors is also a key component in the program implementation. The trainings were designed to suit the need of the targeted groups; 5 weeks for dispensers, one week for owners and inspectors. Training is conducted in order to impart knowledge on principles and standards of operations, business management and laws and regulations governing ADDO business.
Training of Owners and Dispensers
Final Inspection Training of owners and Dispensers were also criteria for establishing an ADDO (Duka la Dawa Muhimu). Owners had to attend a six days training on Business skills and Regulations governing the operation of Duka la Dawa Muhimu. Dispensers had to attend a five weeks training.
BENEFITS OF THE ADDO PROGRAM
Quality improvement in health care services has become an important element in health care delivery in most of developing countries like Tanzania. For one to understand the benefits of ADDO program in Tanzania there should be systematic process to assess the baseline performance, gaps identification in relation to the goals set for program accomplishments.
IMPROVED ACCESS TO ESSENTIAL MEDICINES
Tanzania National Health Policy and Health Sector Reforms aim to improve access to quality health care, including provision of pharmaceutical services, to all population in urban and rural areas in an equitable manner. Since Public Private Partnership initiative is emphasized in order to enable private sector to compliment health services, ADDO program managed to address this initiative.
The existence of ADDOs in rural areas has been convenient to patients who have not been able to obtain medicines in the public health facilities. The statistics shows that approximately 70% of the population that lives in rural and peri-urban communities.
There are 11,356 registered ADDOs, and 22,738 trained dispensers throughout the country so far, thus suggesting increased number of services points as well as the quality of both services and products.
ACCOMODATION OF PUBLIC HEALTH INTERVENTIONS
- NATIONAL HEALTH INSURANCE FUND SERVICES
The National Health Insurance Fund (NHIF) was established in 2001, with the basic objective of providing health insurance to civil servants. Since then, the NHIF has increased coverage by extending its membership to private, informal and semi-formal sectors. In 2009, the NHIF was mandated by the Government to manage the Community Health Funds (CHF) which was initially managed by the local authorities. The main objective of being given this task was to bring about the growth of the CHF scheme in terms of coverage, number of members and quality of health services accessible to its beneficiaries. Since 2007, NHIF has allowed members to fill prescriptions at selected ADDOs in areas without Pharmacies thus expanding its services to all remote areas which are highly covered by ADDOs. To date more than 700 ADDOs provide NHIF services in 26 regions.
- REPRODUCTIVE AND CHILD HEALTH THROUGH IMCI AND FAMILY PLANNING
The Ministry of Health (MOHSW) approved a child health component based on the integrated management of Childhood Illness (IMCI) strategy to be integrated in ADDO so as to increase the number of Children correctly treated for acute respiratory tract infection, Malaria and diarrhea. The child health component consists of package of key interventions including training dispensers in rational medicine use for the key common childhood conditions (Malaria, ARI and diarrhea); creating community demand through mobilization activities. Family planning pills were made available to greater part of the community through ADDO outlets thus facilitating implementation of National agenda upon improving child health.
- FIGHT AGAINST MALARIA
In Tanzania, many people seek malaria treatment from retail drug sellers. The National Malaria Control Program identified the accredited drug dispensing outlets (ADDO) program as a private sector mechanism to distribute subsidized artemisinin-based combination therapies (ACTs) in order to increase access to the first-line antimalarial in rural and underserved areas. The ADDOs have also used to distribute Insecticide Treated Nets (ITNs) for the beneficiaries of discounting vouchers.
SET STANDARDS FOR OTHER NEIGHBOURING COUNTRIES
In the course of implementing the program, there has been noted success and challenges that made other neighboring countries to replicate the ADDO model. Currently, ADDO model is being implemented in Uganda and Liberia, and some other neighboring constrained countries are learning good practices and the potential of the ADDO.