• Pharmaceutical Coding

• Introduction
• Coding is a system of assigning a unique identifier for a
product
• A code is used to represent a product using letters, numbers,
or their combinations to transfer messages for identifying a
product
• Coding has two parts; the base code and detail codes
• The detail codes include, batch codes, expiry dates, country
of origin, receiving date and internal price coding
• The internal price coding refers to the process of assigning
codes to pharmaceutical products within the health facility to
uniquely identify the price
• So, coding makes cost follow-ups of each medicine in a health
facility easier
• So, any person who performs one or more of the
functions stated above must be covered by indemnity
insurance from the employer
• So, the regional health bureau or Federal Ministry of
Health should develop and issue appropriate indemnity
policy:
• based on the volume and value of transactions that are prone
to deserve indemnity coverage for use under respective
hospitals
• All of the following should be coded
• Medicines
• medical supplies
• Laboratory reagents and raw chemicals
• raw materials for extemporaneous preparation
• radiology chemicals
• sanitary chemicals (antiseptics and disinfectants)
• consumable instruments should be coded in health
facilities
• The purpose of this coding is:
• to ensure traceability of medicines and transactions at any
point in the supply chain system and service delivery
• It also makes all types of pharmaceutical transactions
transparent, understandable for non-health professionals and
auditable
• Unless medical products are coded, it would be very
difficult to trace them, to audit, especially by non-health
professionals (auditors)
• It helps to uniquely identify products during adverse
drug events (ADE)
• Case study
1. If Amoxicillin 125 mg /5ml suspension is sold at 25 Birr and
another one received at different price of 19 Birr, is it possible
to shelve all of them at same time and sell without
committing price errors?
• If an auditor requests you an evidence for Amoxicillin 125 mg/ml
suspension sold on cash on birr 19 per bottle, how do you
convince the auditor that 19 birr is the real price and not birr 25?
2. If a store keeper receives 10 boxes of Amoxicillin 500 mg
capsule at 260 Birr /box from
• PFSA and other 2 boxes with a different price from other source at
300 Birr on the same date, what are the activities required of a
store keeper to record on model 19/health and issue with model
22/health so that there will not be price mix-up?
3. You have been dispensing by recording diphenyl hydantoin and sometimes recording
phenytoin to patients prescribed with phenytoin; what evidence do you present they are the
same generic names standing for the same medicines in case of legal question is raised or
asked by auditors
 Example, look the case of Dessie Referral Hospital. The CEO of Dessie Hospital wanted
hydrochlorothiazide to be audited through product audit in 2015. The auditors collected
sold hydrochlorothiazide as evidence of sold items.
 The auditors then reported audit deficit of 60,000 Birr. The professionals resisted to
acknowledge the deficit and instead assisted the auditors to collect the sold items again.
 This resulted in no deficit
 The cause of deficit was the fact that the auditor by-passed HCT but collected
hydrochlorothiazide. Which of the following was the best tool that should have been used
by the auditor to prevent such a big mistake?
i. use “hydrochlorothiazide 25mg tablet”?
ii. use “HCT”
iii. thiazide diuretic
iv. use a unique code that represents all naming of hydrochlorothiazide like
“Thia-10-1”
4. If a patient comes with complaints of an ADE after 6
months having sales tickets indicating that it was
dispensed from pharmacy of this hospital and EFMHACA
wanted to recall this product, how can you trace back
which specific medicine was dispensed?
• Types of coding system
• The type of characters majorly classifies coding systems they use for
representing pharmaceuticals
• They can also be further sub classified by whether they are fixed or
variable
• Generally, there are two coding systems.
• Alpha-numeric coding system
• Numeric coding system.
1. Alpha-numeric coding system
• This is a type of coding that uses letters and numbers. Alpha numeric
code is constructed from 7 characters
• The first 4 are letters taken from the generic name of the product
followed by three digits
• Therefore, we use the alpha-numeric coding system by using 4 letters
and three-digit numbers
• Next to the four letters, numbers are assigned based on the strength,
dosage form and/or cost of the product
• Numbering starts from the smallest strength and continues to the
highest
• The two numbers that come immediately after the letters refer to the
dosage form and strength of the product
2. Numeric Coding System
• This is a coding system using numbers that starts from one
and can increase until the maximum number of items
• Products with different strength and dosage form will have
different codes
• To give codes using this system, arrange all the products
(segregated by dosage form and strength) in alphabetic order
• Assign number 1 to the first product in the list and continue
numbering until the end
• With this coding system, products of same strength and
dosage form with varying costs cannot be hand led at the
dispensary at the same time
• Therefore, this system requires a cost variation
announcement every time when the cost varies
• Note:
• The numeric coding system is very old model
• It becomes difficult to identify the product using this
code specially when there is a long list of products and if
sources are missed
• Therefore, APTS recommends the use of alpha-numeric
coding system
3. Alpha-numeric variable coding and its application
• This is a type of coding that uses letters and numbers
• As mentioned above, alpha numeric code is constructed
from 7 characters
• The first 4 are letters taken from the generic name of the
product followed by three-digit numbers
• Alpha numeric code possesses less burden of
memorization on the pharmacy professionals
• The alpha components of the code gives clue about a
medicine under question
4. Four letters for codes
• See the following scenario cases how to give letters
for the codes:
• Scenario 1:
• In cases where the drug contains only one compound,
take the first four letters of the generic
• name of the compound:
• Example:
• Amox------ for amoxicillin
• Para-------- for paracetamol
• Scenario 2:
• If drug is a combination of two separate drugs, take the first two
letters from each generic drug
• name.
• Example:
• Amcl -------for Amoxycillin + Clavulanic acid,
• Arlu --------for Artemether + lumefantrine
• Scenario 3:
• If the drug is a combination of three separate drugs, take the first
two letters from the first drug name and the first letter from the
second and third drugs.
• Example 1: Oxhp--------for oxytetracycline + hydrocortisone +
polymyxin B
• Example 2:
• Alms ---------for Aluminum Hydroxide + Magnesium Hydroxide +
Simethicone
• Scenario 5:
• In cases of product names with adjectives in the form of
halogenations, methylations, acetylation, etc.… the first
four letters of the name of the parent compound is
taken.
• Example:
• Sali -----------for acetyl salicylic acid
• Phen-------- for chlorpheniramin
• Zepa ---------for Bromazepam
• Scenario 6:
 In case of products which have, the same letters that
should be selected for codes based on the above
criteria due to same parent compound, the first
adjunction letter of the product which overlapped with
other is taken for codes to differentiate them
• Example:
• Quin---will be the code for both chloroquine and quinine
• In this case, we use:
• Quic------for chloroquine and Quin--- for quinine
 In case of medicines with one base parent compound
or with common name but with multiple combinations;
like; dopa, levo, dextro, cis and trans molecules,
classifications, substituents and adjunctions
• take three letters from the parent compound and one
letter from the adjunctions, substituents or
classifications
• Example 1- Dopa could be the common letter. But, only
Dop is taken and one letter is taken from the isomers
• Dopc---- for Carbidopa
• Dopl -----for Levodopa
• Dopm ------for Methyl dopa
• Dopa--------- for Dopamine
• Scenario 7:
• In case of a product is found having two generic names, one
of the name is taken which is usually used in Ethiopia and the
other name of a product is recorded in bracket
• Example 1:
• Para-- for Acetaminophen and Paracetamol; the product will be
recorded as
• Paracetamol (acetaminophen)
• Example:
• Hyda---- for Phenytoin and Diphenylhydantoin;
• The product will be recorded as Phenytoin (diphenyl hydantoin).
• Note: the name is taken from Diphenyl Hydantoin
• Salb ---for albuterol and salbutamol
• Hyos--- for Hyoscine and Scopolamine
• Example 2-
• Vita---- for Vitamin A (retinol)
• Vitc---- for Vitamin C (Ascorbic Acid)
• Vitk ----Vitamin K1, (Phyto menadione)
• Scenario 8:
• In case of a product were a product is found with more
than one salt forms, take three letters from a parent
compound and take one letter from the salt
• Example:
• Dics---- for Diclofenac sodium
• Dicp ----for Diclofenac potassium
• Scenario 9:
• In case of a special products like
• laboratory raw chemicals
• raw materials for extemporaneous preparation
• sanitary chemicals (antiseptics and disinfectants)
• consumable instruments
• code by taking three letters from the product and take
three fixed numbers
• Example 1:
• Sal1-01 ---for Salicylic Acid powder (the 1 number which
is “1” indicates raw chemical or raw material)
• Example 2:
• Sul1-01 for Sulphur precipitate pure (the 1st number
which is “1” indicates raw chemical or raw material)
• Example 3:
• Cet2-01 for Cetrimide (the 1st number which is “2”
indicates the product is antiseptics or disinfectants)
• Example 4:
• Cyl3-01 for Measuring Cylinder (the 1st number which is
“3” indicates consumable instruments)
• Two numbers for codes
• Next to the four letters, numbers that come immediately
after the letters refer to the dosage form and strength of
the product
• Numbering starts from the smallest strength and
continues to the highest in ascending order
• The two numbers are assigned starting from 01 to 99
using the following agreements
• For chemicals, it is agreed to use 1-01 to 4-09
• See the following table and refer the national code: -
• The six digits of the codes (4 letters and two
numbers) are considered as a base code
• The base code of the product represents
• Generic name of the product
• Dosage form of the product
• Strength or volume or size of the product
• Example 1: Amox-02. This shows “Amox” indicates
amoxicillin, “0” indicates capsule, and “2” indicates
that the 2nd strength
• Therefore, the product is Amoxicillin 500mg
Capsule.
• Oral suspensions are assigned codes of numbers from
26-29
• However, if there are no suspension and syrup for a
single product, all will start from 20.
• Example:
• Ampi-20 Ampicillin suspension 125 mg
• Ampi-21 Ampicillin suspension 250 mg
• Ampi-26 Ampicillin oral drop 100 mg
• The coding for medical supplies and laboratory
reagents & chemicals is based on their size, strength
and volume
• Note: assignment of base code is like the above
• Price code (the seventh characters-(number)
• For a drug having the same generic name, dosage form
and strength but with different cost, the codes vary by
using variable coding system
• The variable code is the last numerical digit of the Code
of the product
• it varies according to the cost of the product by
increasing the last digit sequentially starting from
number 1 for the first price
• The code of Amoxicillin 250 mg capsule with a cost of 10
Birr is Amox-01-1
• The cost of Amoxicillin 250 mg capsule changes to 20
Birr, the code will be Amox-01-2
• In cases where we use fixed coding, the code remains
the same irrespective of variations of the cost
• In such situation, a product with a revised price
cannot be shelved for dispensing prior to finishing
the already existing one
• When the product with the old price is completed,
announcement of cost variation is mandatory
before initiating of dispensing from the product
with the revised price
• All dispensers should immediately note the change
in price
Example of cost code (variable and fixed coding)
• Using price code for price control sheet
• The price code is an additional number to be coded in a specific
health facility per the cost of the product
• whereas the base codes are prepared nationally
• After the base code for a specific product is assigned, the price code
is also assigned for price controlling
• Auditors uses the price control sheet for auditing as a reference
• The price code is assigned by store manager with pharmacy
coordinator/dispensing head
• The copies of price control sheet should be available at all
dispensing units, accountant office, audit office and store
• All shall sign at the price control sheet while receiving
• The price code should be recorded in Model 22/health, sales
tickets, credit/free registers, price control sheet and physical
inventory forms
• A specific product with similar dosage form and
strength but different batch, expiry and price
• Is registered in a separate row in both physical inventory
and model 19;
• But it should be registered in one row in price control
sheet but with specific price codes
• When there is a need to trace/identify the batch
number, expiry date of a specific product
• the price control sheet should be reconciled with the physical
inventory sheet and model 19/health
• Example: - if a patient comes with a sales tick containing
Amox-02-3 code with some adverse drug reaction
• We need to identify the batch number and expiry date of the
specific product dispensed, one can reconcile the batch and
expiry date of the Amox-02-3 from the model 19/ Physical
inventory sheet in a row which contains amoxicillin with the
corresponding cost or price and specific batch and expiry
• However, whenever there is software, the batch and expiry
dates of the product should be recorded in model 19/health,
model 22/health, sales tickets generated from the software,
and free/credit registers
• when using manual vouchers, sales tickets and registers, it is
to reduce workload that recording of batch and expiry is not
recommended in the model 22/health, sales tickets and
credit /free registers.
• Note: the price code like 0.1 and 14.85 which have been
strikethrough indicates that medicines with such prices
are finished
• Instead same medicines with another price (0.20 and
14.70) are available
• Advantages of coding system
• Coding is used for:
• Price controlling
• To simplify health insurance implementation and settlement
• To serve as an input for general specification (GS1) standard barcodes
for the country
• Since globally medicines are going to be coded and the national
procurement list and product directory for all pharmaceuticals are
needed.
• Auditing of pharmaceuticals specially by non-health professionals
(auditors)
• To simplify software development and use
• To uniquely identify products during ADR, ADE
• To calculate some WHO indicators
• Example % of injectable from the other dosage forms can be
automatically calculated by selecting codes that starts from 30 to 39 as
a numerator and all medicines codes as a denominator x 100
• This is observed to simple specially when software is being applied
• When the price control sheet is used (variable coding
system is used), price variation announcement is not
needed since it will be indicated in the price control
sheet
• When using price control sheet, a product with various
costs can be shelved in the dispensary at the same time
• Pharmaceutical Physical Inventory
• Enabling objectives:
• By the end of this chapter, participants will be able to:
• Explain physical inventory in APTS
• Describe the steps for conducting physical inventory
• Use the physical inventory formats
• Interpret results of the physical inventory
• Report results of the physical inventory
• Physical inventory is one of the pharmaceutical inventory
management methods
• It refers to physically counting the actual number of
pharmaceuticals in a health facility
• The purpose of inventory control system is to inform
personnel when and how much of a product to order
• It is used to maintain an appropriate stock level to meet the
continuous needs of patients
• It helps to ensure continuous availability of essential
medicines always in adequate quantities
• It is also used to monitor losses through expiry, pilferages, or
other reasons
• It also avoids over and under stock
• During physical inventory, all items in pharmaceutical stores,
various dispensaries and other service delivery units are
counted
• Steps for Conducting Physical Inventory
• Conducting physical inventory has three steps:
• Preparatory
• actual physical count
• Analysis
• Interpretation
• reporting
• The preparatory Step (Before physical count)
• The first step is preparation for physical inventory
• In preparation for inventory, the stock at the pharmacy
store and dispensary should be arranged and recorded
to facilitate physical count
• Activities in the preparatory phase include:
• Group all products per expiry dates, batch number, codes,
and unit, unit cost in the store and retail price in the
dispensary units
• Separate expired medicines
• Rearrange and shelve as per the above grouping
• Shelving the regrouped products is better if its starts from
bottom up and then to the side way
• Register medicines in the store and dispensaries in the
‘before’ parts of the respective formats
• Useable stocks: should be recorded in a separate physical
inventory-format-page
• All damaged and expired stocks should also be recorded in
another separate physical inventory-format-page
• Products with different expiry dates, cost or price and batches
should be recorded in separate rows of the physical
inventory-formats
• All recorded items should be coded by each row
• All medicines with different cost will have variable codes
• Please refer price code at price control sheet and roles of
auditors’ (product and finance auditors) used to identify
specific products.
• Sign in the signature spaces and record name of the
recorder
• Inform all pharmacy professionals working in the store
and dispensaries about the physical inventory plan, so
that everyone will avail themselves during physical
inventory
• An internal auditor will be available to cut off the
vouchers, registers and sales tickets before taking
physical inventory
• Please refer the details in roles and responsibilities of
auditors, bin owners and store managers
• The reasons why all pharmacy professionals working in
the HF should participate in the inventory are:
• All those who worked in these units are responsible for the
shortage and overages.
• So, they should sign observing the inventory
• Professionals may be reassigned from one dispensary to
another and from one store to another
• So, everyone should be aware of what is happening during
physical inventory
• Physical inventory will be finished within short period when
all staffs participate in the physical inventory
• Therefore, the CEO should delegate all pharmacy personnel
whenever physical inventory of one unit is conducted so that
the inventory time will be minimized and patient service will
not be compromised
• Inventory should never be conducted in the
absence of the responsible persons (those
personnel who have been working in the unit)
• Note: a member of few committees delegated to
take physical inventory will not be as effective and
efficient
• Therefore, in APTS principles, committees for
physical inventory are discouraged
• Actual Physical Counting Step (During physical count)
• During this step, actual physical count of pharmaceuticals is
undertaken
• Physical inventory of stores is carried out every quarter
• The time for inventory should preferably be at the end of
September, December, March, and June of the budget year
• The inventory should be taken on weekends whenever
possible
• Where as physical inventory of dispensaries is carried out
every month
• This should be conducted preferably in the weekends too
since patient service will not be compromised
• The hospital management should consider the weekend part-
time works using the rules and regulations of the country
• When the last day of the moth is either on Tuesday,
Wednesday or Thursday
• Then physical inventory may be conducted either the
previous weekends or in the coming weekends
• Then the report will start from the date of the physical
inventory regardless of the end of the month
• Actual physical count should be carried out in the
presence of the responsible persons in the respective
locations (e.g. store manager, dispensers, etc.)
• Members of the physical counting group, that includes
most of the staffs, are assigned by the head of the
health facility
• Activities in the second phase (during physical inventory): -
• The assigned professionals should be grouped into teams of
2 persons
• Every two personnel should be assigned in separate shelves
• The first person should count physically starting from
bottom up as per the registered products serial number
• The second person will record the quantity and both will
sign on the signature space for ‘counted-by’
• Exchange: When the team finished the shelve, the
coordinator of the physical inventory will exchange the team
with other team who also finished counting of medicines in
another shelve
• Recount: The exchanged team will also recount the already
counted medicines by the other group and sign on the
signature space for ‘recounted-by’.
• Discrepancy: If there is discrepancy, the team will inform to
the first counter team and will repeat the shelf for the third
time together with the first team
• Whenever, there is shortage or overage when compared
with bin cards and stock cards
• the responsible person should be communicated immediately and
asked for justification for the discrepancy
• Once the responsible person believes that the physical count is
counted amount, then the difference will be recorded. This process
increases transparency and accountability
• Signature: the team will sign on the counted-by-space and
recounted-by-space accordingly
• Analysis, Interpretation, and Reporting Steps (after physical
count)
• This step describes activities after physical count
• The pharmacy accountant, who should always be part of the group,
must complete the section to be filled after the inventory
• The inventory at the pharmacy store is valued based on the cost of
medicines
• Whereas the inventory at the dispensary is valued based on retail
prices of medicines.
• To balance
• the cost of medicines at the pharmacy store and dispensing outlets
including service units should be added up together
• In doing so, the monetary values (total selling price) of the physical
inventory at the dispensing outlets should be converted into cost to
bring the values at the store and dispensary into same unit
• The formula is; -Selling price =cost + profit margin;
• Example: If the selling price of the medicines is 120 birr
at dispensary, with a profit margin of
• 20%, what is the cost of the medicines?
• Formula 120 birr = cost + 20%xcost
• 120 birr =cost (1+0.2); 120=1.2 cost and 100=cost
• To simplify, the formula will be cost= selling price /
(1+ profit margin)
• Cost =120/1.2=100
• The result of inventory will be incorporated in the
monthly and quarterly report of APTS at the
• Store and dispensaries separately: -
• Beginning inventory plus received minus issued should be
reconciled with the ending inventory
• If the calculated ending inventory is equal to the physical
ending inventory, it means there is no overage or shortage
• The ending inventory should be divided into two;
• Useable stocks
• Wasted stock (expired and damaged)
• The internal auditor should verify all the findings of the
physical inventory
• After completing the verification, the pharmacy head
should report to the head of the health facility
• The results of the inventory should be further analyzed
and interpreted by methods such as stock status and
consumption methods and ABC analysis
• The results of the analysis should be used to make
informed decision that contributes to continuous
availability of essential pharmaceuticals
• Managing Pharmaceutical Transactions
• At the end of this chapter the participants will be able to
will;
• Explain the process of products transaction; receiving,
requesting and issuing
• Describe the criteria for physical inspection
• Implement/fill the forms for pharmaceutical transactions in
health facilities
• Introduction
• Pharmaceuticals Transactions in health facilities are
process of:
• Receiving of pharmaceuticals in the store
• Issuing to various dispensing outlets and service delivery units
• Dispensing of products to clients on cash, credit and for free
• These transactions should be conducted using legally
approved and serially numbered by Ministry of Finance
documents including:
• Receiving
• Issuing models
• Sales ticket, pad registers
• In these models the numbers;
• 19/health– receiving voucher
• 20/health (IFRR)---- requesting voucher
• 22/Health---- issuing voucher
• The word health indicates that this voucher is
specific to drugs, reagents, medical supplies and
equipment
• The sales of pharmaceuticals should be
summarized:
• daily using appropriate daily summary forms
• all transactions should be reported monthly using
financial and service reporting forms
• Receiving of Pharmaceuticals at Health Facilities
• The receiving of products involves:
• Physical inspection
• physical counting
• Recording of products with costs and codes using standard
formats
• After receiving, prices should be set before issued to
service delivery units
• Physical Inspection
• Physical inspection is the process of checking product
quality and quantity during receiving of medicines in
health facilities
• This is the key step to identify product defect if any
• Steps of physical inspection of medicines:
• The process of physical inspection by store manager and
DSM officer is as follows:
• Compare list of names of medicines with the supplier’s
invoices and original purchase order and check: -
• Number of containers/ packages delivered is correct
• Quantity in each package is correct
• Quality of each batch is correct
• Medicine (generic and brand names, country of origin
etc.) and dosage form (tablet liquid, other form) are
correct
• The strength of the medicine is correct (milligrams,
percent concentration, other measurements)
• Physical inspection is better to be made based on dosage forms as follows:
A. Physical inspection for tablets/capsules during receiving, please check samples
that:
• Tablets/capsules are identical in size and in shape and in colour
• Coloured spots, hollows, fragments/ breaks/friability behaviour, uneven edges, cracks,
embedded or adherent foreign matter, stickiness may show poor quality
• Variation of shade of colour from batch to batch may be normal
• However, if it is within the same batch it may be an indicator of poor quality
• Tablet markings are identical:
• example; scoring, lettering, numbering and unique identifiers are present if required (example:
article code, ministry of health stamp, not for sale stamps, only for promotion stamps, specific
facility stamps)
• No odour after tablets/capsules have been exposed to room air for 20 -30 minutes and no
odour when a sealed bottle is opened except for flavored tablets
• Counterfeit/ fake/ products may not be labelled by uniform spell, logos and label layouts.
B. Physical Inspection for Intravenous preparations
• During receiving of parenteral (IV liquids in bags,
ampoules, dry solids for reconstitution, suspension for
injections) should be inspected physically as follows:
• Clear solutions -free from un-dissolved particles
• Dry solids for use in injection free from visible foreign particles
• There are no leaking containers (bottles, vials, ampoules and
bags
C. Physical inspection for Oral liquid/semisolid
dosage forms
• During receiving of oral dosage forms, check that:
• The bottle size/shape of containers is uniform
• No gas evolves when bottles are opened that indicates
fermentation (puff sound)
• No leakages, breakages, label deformities, no colour changes in
the same batch and no foreign particles are found
• After inspecting of medicines, receiving using voucher 19
/health shall follow.
• The process of recording
• Receiving of pharmaceuticals takes place using a
receiving voucher (Model 19/health
• Model 19/health is a serially numbered official receiving
voucher prepared in four copies and published by the
Ministry of Finance and Economic Development
• It is used to receive pharmaceuticals that come into the
health facility through procurement, transfer, donation
• Steps of recording:
• The store manager receives the issue voucher/ or
delivery invoice from various suppliers and other
sources
• He/she crosschecks the physical count with the items
and quantities stated in the delivery invoice
• supplier sales invoice
• Model 22/health or
• Model 22/health donation certificate/shipping document, etc
• The store manager transcribes the list from the issue vouchers
or delivery note into the receiving voucher (Model 19/health)
• The store manager records base-code for each item, shelves
and updates the bin card accordingly
• The store manager distributes
• the original model 19/health along with the delivery
note or issue voucher of supplier, to finance
• second copy to the deliverer
• third copy to the stock card clerk
• the last 4th copy remains with the pad
• The third copy will be recorded by the stock card clerk
and then shared to pharmacy accountant so that the
accountant will file and use to produce monthly reports
 • For sponsored products, when receiver health facility
doesn’t want the original for finance settlement
• the original can be given to the deliverer /sponsor for
settlement
• The other copies will continue the same as above
• For those pharmaceuticals that are received
without cost
• the facility drug supply management officer or head
pharmacist estimates the cost in consultation with the
finance office and store manager
• The management of the health facility should approve
cost estimation procedures
• Setting Price
• The provisions of Health Care Financing Reform
Legislation enable hospitals to raise and retain revenue
• The sale of pharmaceutical products is an important
source of hospital income
• Except for exempted health programs (e.g.
immunization, TB, ART, Family planning etc.)
• Pharmaceuticals should be sold at a price that covers
the actual cost of the medicine plus a service charge
• Both free and budget products should be dispensed
with retail prices
• The difference will be:
• For cash sales, products are recorded and sold at retail prices
and the health facility receives money
• For free sales, the products are also recorded and dispensed
with retail prices however, the health facility will not receive
money
• the setting of price on medicines should be based on:
• cost of medicines, expenses incurred because of managing
medicines (e.g. holding, transportation cost and printing cost of
vouchers)
• provision of pharmaceutical services (e.g. personnel cost)
• Some others have 25% fixed profit margin
• As a result, the price of medicines will be determined by
adding an agreed up on profit margin (e.g. 25%) on the
cost of medicines
• For example, if the cost of one box of Ampicillin 500mg
is 200birr, then the selling price using 25% will be 250
birr
• The intention of this margin is to:
• cover the expenses incurred & unavoidable losses
• retain minimum profit to ensure sustainability of the supply of
essential medicines and provision of optimal pharmaceutical
services without compromising social responsibility
• The rounding up and rounding down:
• The price of medicines can be roundup or round down.
• Most health facilities are rounding up medicines since
the total price doesn’t significantly affect customer
• The value of Ethiopian cents is becoming very low and
10 cents, 25 cents and 50 cents are not available in the
market
• Therefore, health facilities can round up all products to
Birr
• However, if health facility wants to both round down
and round up for retail price that cost above 5 cents, it
is possible to do as follows
• If the additional rounding up and down of the retail
price is:
• Equal to or greater than 2.5 cents; round up to 5 cents
(only for prices greater than 10 cents). E.g. 12.5 cents
• The additional one 2.5 cents can be 5 cents and round
up to 15 cents.
• Less than 2.5 cents; round down to 0 cents (only for prices
greater than 10 cents). E.g. 11.15 cents
• Equal to or greater than 7.5 cents; round up to 10 cents
• Less than 7.5cents; round down to 5 cents
• Less than 5 cents; round up to 5 cents
 • Example: - If the retail price of Amoxicillin is birr 1.78, it
means the price will be rounded up to birr 1.80
• However, if the retail price were 1.72, it would be
rounded down to birr 1.70
• Note:
• For those health facilities that decided to round up all
cents to birr, they can round up 5, cents, 10 cents, 25
cents and 40 cents: all to 50 cents.
• Example:
• If the retail price of Amoxicillin is birr 1.78, it means the
price will be rounded up to birr 2:00
• if the retail price were 1.72, or 1.65 or 1.80 or 1.90; all
will be rounded up to 2 Birr
`
• Requesting Medicines from Pharmacy Store
• The requisition of medicines by different dispensing
outlets and other service units from the pharmacy store
should be carried out using
• An internal facility reporting and resupply form /IFRR (Model
20/health)
• Model (20/health) is an official requesting form
prepared in double copy and printed and distributed by
the health facility
• It is used to request pharmaceuticals from the pharmacy
store by :
• filling in and reporting all relevant information indicated in the
internal facility reporting and requisition form Model
(20/health)
• The process of requesting medicines within the health
facilities includes the following:
• The responsible person from dispensing outlets and service
units completes part of Model20/health, approved by head
pharmacy, and submit it to the store manager
• In situations where there are more than one bin owners, each bin
owner should identify items to be requested and stocked in their
respective bin locations
• The pharmacist responsible for coordinating bin owners
(dispensers) ensures the proper completion of Model20/health
• The store manager calculates consumption, the amount needed to
arrive at maximum for the requisition period, fills in the quantity to
be approved and submits it to the chief pharmacist of the facility
for approval
• The store manager transcribes the list from the approved
Model20/health into the issuing voucher Model 22/health
• Note: This form is used for normal consumption trend only
• The formula in this form is not applicable in situations
where: -
• There is a dramatic change in morbidity or utilization patterns
• when change in treatment guidelines, regimen,
• In cases of disease outbreaks or initiation of new
programs/new products
• In such situations, previous consumptions may not apply
and therefore dispensers should put requests based on
the current needs
• Issuing of Pharmaceuticals
• The issuing of medicines from the pharmacy store to various
dispensing outlets and other service units– is done using an
issuing voucher (Model 22health)
• Model 22healthis a serially numbered official issuing voucher
prepared in four copies
• It is used to issue pharmaceuticals from the pharmacy store
• The process of issuing drugs, supplies, reagents and
equipment within the health facilities includes the following:
• The store manager receives and transcribes the incoming
approved requisitions and proceeds with the processing of issuing
vouchers
• In this level, the medicines code should carry price code in
addition to base codes
• The store manager signs on the voucher and delivers the
requested items to the dispensing outlets and service units
• The responsible person from the requesting unit reconciles the
dispatched items with those listed in the issue voucher and
confirms receipt of product by signing on the issue voucher
• In addition to the receiver, as part of confirmation of receipt of
products:
• The other pharmacy professionals in the dispensary will sign on the spaces
in the issue voucher as a witness for issued items
• Staffs from service units (wards, TB clinic, MCH clinic, laboratory,
radiology, etc.) should sign on the space issuing voucher as a witness for
issued items
• This voucher should be prepared in quadruplicate;
• the first copy (original) will be sent to the accounting unit of the pharmacy
• the second copy to the receiver
• the third copy to the stock card clerk
• the fourth will remain with the pad
• The approved request should be field properly with the issuing voucher
• The store manager updates the bin card accordingly from the copy
which remains attached to pad.
• The stock card clerk updates the stock card from the third copy of
the issue voucher
• Sales Management
• Objectives:
• The trainees will;
• Receive sales tickets, prescriptions, registers and formats
• Utilize APTS sales tickets, prescription, registers and formats
• Document APTS formats and sales tickets used for selling and
dispensing of medicines
• Introduction
• Selling of medicines refer to the transactions between the
client/patient and the service provider at dispensing outlets
and service delivery units
• This transaction involves sales of medicines on cash or credit
or free including exempted health programs (e.g. TB, ART,
Immunization, etc
• These transactions should be carried-out using the official
forms and tools
• Sales ticket pad register, cash sales tickets and credit sales tickets
used for cash and credit sales
• Whereas, the credit/free registers will be used for credit or
free sales
• Note: credit sales can be managed either using credit sales
tickets or credit register
• Sales management of pharmaceuticals
• Sales Ticket Pad Register
• It is a register with pages or serial number
• It is used for controlling the movement of sales ticket
pads issued to and returned from dispensers
• It identifies sales ticket pads by their serial numbers
• The pharmacy accountant should distribute sales ticket
pads to all dispensing outlets and service units after
recording all the details in the register
• The steps involved in managing the movement of sales
ticket pad should be as follows:
• The pharmacy accountant requests and receives sales ticket pads
from the hospital property administration store
• Every service provider at dispensing outlets and service unit
requests sales ticket pads from a pharmacy accountant
• The accountant issues every sales ticket pad to service providers
after registering all details on the sales ticket register
• The accountant receives used sales ticket pads after checking and
segregating it by used, lost, voided and/ or damaged pages and
getting the signature of the returnee and or responsible person
• Note:
• Service providers are accountable for lost, damaged, voided sales
ticket leaves and therefore, must confirm such incidences with
their signature on the sales ticket pad register
• Sales ticket pad register doesn’t need copies
• Cash Sales Ticket
• Cash sales ticket is a receipt delivered to clients/patients
in exchange of payment of cash
• It is often a serially numbered triplicate copy consisting
of 50 pages per pad
• Each page bears the name and address of the health
facility
• It serves both as a sales ticket and a legal receipt of the
health facility for medicine sales
• Credit Sales Ticket/Credit Sales Dispensing Register
A) Credit Sales Ticket:
 it is a receipt delivered to clients/patients in exchange of
presenting a prescription paper, identification card and
prior notification of credit sales agreement from the
sponsoring organization
 It is the same as the cash sales ticket except the name
“Credit Sales Ticket”
 It serves both as a credit sales ticket and a legal receipt
of the health facility for credit sales of medicines
 Health facilities are advised to use credit sales ticket for
all credit patients
B) Credit Sales Dispensing Register
• This register is a recording tool to keep track of clients
served by the pharmacy based on:
• a credit agreement entered between the health facility and
sponsoring organizations, such as kebele/woreda and private
institutions such as banks, factories, etc., to which the
beneficiary belongs
• Free Medicines Dispensing Register
• It is a recording tool to keep track of clients served
by the pharmacy for free of charge
• based on evidence of confirmation of being
beneficiaries of exempted programs
• This register should be applied at the outpatient
pharmacy, inpatient pharmacy, emergency
pharmacy, radiology, laboratory, and nursing
stations
• Daily Summary and Monthly Reports
• Enabling Objectives
• At the end of this chapter the participants will be able to
• Prepare formats for daily summary and monthly report
• Identify the transaction made on cash, credit and for free on
daily basis
• Produce the daily summary of services delivered, medicines
sales on cash, credit and for free; using the formats
• Analyze the shortages, overages and adjusted sales of
pharmaceuticals
• Identify the key information obtained from the daily summary
and monthly reports which will be used for decision making
• Introduction
• To do daily summary and monthly reports for pharmacy
services and transactions, various forms are used
including;
• Model 19/health
• Model 22/health
• cash sales tickets
• cashier delivery note,
• Model 64
• dispensing registers,
• daily summary forms for credit /free and cash
• Monthly financial and service reporting forms
• Model 19/health and Model 22/health:
• These models are serially numbered tools
• All products received and issued during the month should be
summarized using a copy of model 19/health model 22/health
• Cash Sales Ticket/Credit Sales Tickets
• These tickets are serially numbered tools
• All products sold either on cash or credit should have a copy of
cash/credit sales ticket documented at the accountant office being
summarized by cashier’s delivery note
• Cashiers delivery note:
• Is a single page sheet used for delivering of cash sales tickets and
cash to the accountants
• The form summarizes the names of dispensers and serial numbers
• Model 64:
• Is the serially numbered model used as an evidence for transferring
of cash sales tickets with cash to the account or main cashier
• Credit/Fore free Register:
• This is a serially numbered/page numbered register
• The credit or for free register is a pad used for recording of all the
products dispensed either for free or on credit
• Daily summary:
• Daily summary format is single copy sheet that used to summarize
the daily sales on cash, on credit and for free and services given by
dispensers and other health service providers
• It is also used to monitor the daily financial flow and transactions of
medicines and medical supplies within the health facility
• The daily summary will be prepared by the pharmacy accountant on
daily basis, documented properly
• Daily summary for free dispensed medicines and services
• Preparation of Daily Summary for medicines dispensed for free:
• The accountant receives the free medicines dispensing register from the
dispenser
• The pharmacy accountant crosschecks the pricing of each medicines
dispensed to the client
• Complete the daily summary sheet for free medicines properly
• If the accountant discovers that a client served on free basis is over or
under priced, he/she should report to the appropriate authority for further
correction of the discrepancies
• Calculate the total compounding fee/other services fee, if any, and
segregate from each pages of the register
• Deduct the overages and compounding/service fee from the daily total
freely dispensed medicines and services
• To calculate the daily total adjusted freely dispensed for medicines:
• Deduct the total daily compounding/services fee from the total daily freely
dispensed of medicines and services
• The result is a daily adjusted total freely dispensed of medicines and this
will be used by the
• internal and external auditors to calculate the total cost of freely
dispensed medicines for the day
• Notes:
• The total number of drugs dispensed or count of internal
drug codes is approximately equal to the total number
of counseling made to clients per day by all dispensers
• The total number of patients can be obtained by
counting the list from the register
• Monthly Pharmaceutical Transactions and Service
Reports
• There are two types of reports produced from APTS
• They are Monthly Financial Reports and Monthly Service
Reports
• They are the summary information compiled on monthly
basis on monetary values of the pharmacy transactions
and the number and quality of services rendered
• The management of the health facilities should make
appropriate evaluation of the contents of the monthly
reports and take timely decisions on matters that
require interventions
• Monthly report
• It is the compilation of the daily summary of activities
and analyzing various data gathered to produce
information for decision making on:
• Finance
• product transacted
• service rendered
• Monthly financial report
• A report compiled every month from the daily summary
of dispensed transactions on cash, credit and for free
and services rendered by the pharmacy outlets in the
health facility
• It also shows the store transaction indicating the amount
of beginning and received stock, transferred and
expired stocks
• The report should be prepared using the monthly
financial reporting form (MFRF).
• Data Sources for the Monthly Financial Transactions are
the monetary values of:
• Receiving voucher records
• Issuing voucher records
• Daily summary of dispensed medicines on cash, credit and for
free
• Physical Inventory of medicines at the end of the month
• Expired and transferred medicines
• Records of overages and shortages
• Records of services rendered in every dispensing outlets and
service delivery unit
• Monthly Service Report
• A report compiled every month concerning the various
types service information recorded during the month
like the :
• number of drug use counseling
• number of patients serviced
• availability of medicines
• affordability of prices
• Data Sources for the Monthly Services Reports includes
the following:
• Records of the daily summary about the number of patients
served on cash, credit and free on daily basis
• Records of daily summary about the number of drug use
counseling made for cash, credit and free patients
• Records of other various services rendered by the pharmacy
during the month
• Analysis and interpretation
• Analysis and interpretation of monthly service and
transaction reports should be made after the report is
compiled
• To do the analysis, inventory of the store and dispensary
should also be available.
• Steps of analysis of monthly financial report:
• Take begining stock from the first physical inventory and add all
received stocks in the facility
• Record all dispensed, expired, damaged, transferred medicines in
a separate inventory format
• Subtract all dispensed, expired, damaged, transferred medicines
• Take physical inventory again and calculate by value
• Covert all the data into monetary forms
• Reconcile the remaining physical inventory with the calculated
ones
• Steps of monthly product analysis report:
• Conduct physical count as above and identify the over and under
stocks
• Take expert opinions and bin managers’ report to analysis each
product status
• Calculate consumption to stock ratio analysis and stock turnover
ratio analysis.
• Use the result as a general indicator for decision making that the monthly
consumption is in acceptable range or not
• If not, identify specific medicines that contribute for abnormal range and
do stock status analysis for all identified specific products.
• Calculate the expiry rate of the month and identify the causes if it is
out of the range and take measures
• Identify high value medicines in the inventory, near expiry, and
obsolete (nonmoving) medicines, and drugs that cause low
consumption to stock ratio should be subjected to stock status
analysis
• Measure should be taken as per the stock status analysis and
monthly reports
• Steps of analysis of monthly Service report:
• Workload analysis:
• Number of patient served, number of counseling made and
patient knowledge on prescribed medicines etc. are performance
indicates of the facility.
• Intervention should be taken to improve quality of pharmacy
services and the number of professionals needed should be
adjusted based on the analysis
• WHO indicator analysis:
• Number of drugs per prescription, % of injectable (Note: only
when using software, you can calculate using base loads 30-39 as
numerator and other dispensed as a denominator), affordability,
and taking measures based on the findings example sources of
procurement may be checked for unaffordable products,
producing all the necessary data by graphs.
• Then totally summarize all analysis’s using graphs tables and
summarized wordings to present to the decision makers
• Service analysis
• Service delivered in APTS can be analyzed
• Financial analysis
• Financial transactions of medicines in APTS can be
analyzed
• Rational Drug use: definition WHO
• Patients receive
• medications appropriate to their clinical needs
• in doses that meet their own individual requirements
• for an adequate period of time, and affordable to them
and their community." (WHO, 1985).
• DW---daily wage
• Good Dispensing Practice in APTS Workflow
• Enabling Objectives
• By the end of the session, participants will be able to:
• Describe pre-dispensing activity
• Describe the six steps of dispensing
• Implement the cautionary/advisory labels
• Counsel patients on the rational use of dispensed medicines
• Case study
• W/ro Bizunesh Tessema is a 39 years old female who is a
mother of 5th children and she is expecting her 8th
child. She is now in the 2nd month of pregnancy. She was
a 5th grade student when she got married. She and her
husband are daily laborers. W/ro Bizunesh was
diagnosed with osteomyelitis, vaginal candidiasis and
minor skin infection. She presents to the dispensary with
the following prescription.
• Discuss on:
• How a dispenser is going to counsel or give advice on
her
• When you ask her, she discloses that there were
occasions where she discontinued medicines
(Amoxicillin) given her for UTI as she became symptom
free within a few days of starting treatment
• She confesses that she would take medicines at any time
of the day doubling their amount to save time and
reduce burden of taking medicines many times a day
• The client confidently speaks that when her UTI symptoms
relapsed, she used 6 tablets of medicines left over by her
husband before 2 years
• She said that if she had any such left over medicines at home
or had been available at nearby shop, she would not have
wasted her time and money coming to the hospital
• W/ro Bizunesh still worries that she may not complete all
medicines now given to her
• Moreover, she reported that she feels stomach pain when
using the pain killer Diclofenac enteric coated tablet with
antacids
• She took it chewed/crushed assuming that the pain killer
would work faster but the pain becomes worse
• Answer the following questions based on the case:
• List the problems with the prescription in the introductory
case?
• Do you think all her drug therapy needs are adequately
addressed?
• How do you manage the problems of the introductory case
prescription?
• What could be the problem if this prescription was dispensed
as it is now?
• What counseling points do you consider?
• NB: The problems of the introductory case prescription
can be captured if the six steps of dispensing are strictly
and consistently followed
• Introduction
• There are evidences that show the current practice of
dispensing practices are not satisfactory
• It is well studied that irrational dispensing practices
contributes to irrational use by patients
• Pre-dispensing preparations
• Before the dispensing process begins, prepare yourself and
the working environment to make it professionally appealing
and aesthetically attractive for dispensing
• Wear a clean and white gown with a name tag on it.
• Make sure that the room, shelves, and dispensing counter are
clean and organized.
• Avail all the materials necessary for dispensing activities. This
include but not limited to:
• A clean dispensing counter of adequate size having a smooth,
impervious working surface.
• Tablets and capsules counter
• Avail labeling materials, if possible pre-printed ones
• Adequate copies of relevant up-to-date reference manuals
should be available for quick reference during dispensing
• The six dispensing steps
• The following steps should always be followed during
dispensing of medicines to patients or their care givers
• However, these steps shall be contextualized depending
on the type of drug, the patient status and condition and
the type of dispensary unit
1. Receiving, interpretation and evaluation of a prescription
2. Billing and recording transactions
3. Selection, manipulation or compounding of the medicine
4. Packaging and labeling of the medicine
5. Provision of medicines to the patient with counseling
6. Filing the prescription and transaction documents
• Medicines Use counseling guide (MUCG)
• Medicine Use Counseling Guide (MUCG)
1. Check for any allergies in general and this medicine in particular
• Ask for any allergies
• Obtain past medicines use history
2. Tell name and indication of the medicine:
• Name is important in case of emergency and visit to more than one
provider
• Indication reinforces diagnosis and creates confidence
3. Tell route and frequency of administration:
• Prevents taking by the wrong route
• Inform if first time or reinforce what they know
• Note: ‘take one tablet after meals” may not work since not everyone eats
three meals a day
4. Discuss on what to do if clients miss a dose or if the dose is vomited
5. Tell the client how long to take the medicine:
• Helps to eliminate unrealistic expectations
• Ensures reaching treatment goals
• Prevents emergence of microbial resistance (for antibiotics)
6. Tailor medicine regimen to daily routine:
• Ask the daily routine before suggesting a plan
• Link taking a dose with regular daily task and effect of the
medicine
• Should not assume a common routine (e. g. eating three
meals a day, sleeping night times, etc. which do not have fixed
times)
7. Ask if the client has problem taking this medicine:
• Complexity to the dosage regimen affects adherence:
• Is there special preference for a dosage form when for
example there is swallowing difficulty due to esophageal ulcers
• Consider total cost of care not just the cost of the drug alone
8. Tell how long it will take for the medicine to show an effect:
• If not told, the client may believe the medicine is not working and
may stop taking or increase dose with subsequent toxicity
9. Tell how many times and when to refill:
• Number of refills: Check if there is incontinence
10. Emphasize benefits of the medicine:
• Discuss benefits before potential side – effects
11. Discuss major side effects of the medicine:
• Side effects that are common and how long they will stay; those
that disappear with time using reassurance can help to cope with
them.
• Measures to recognize, prevent, or manage side effects and adverse
effects:
 • Tell what to do if side effects don’t go away or become intolerable
• Encourage the patient to report side effects or adverse effects of the drugs
12. Discuss drug – drug, drug –food, drug- disease, drug – herb
interactions
• Ask if client is taking other medicines, discuss interference of other drugs, food
or medical conditions with current medicine and /or condition being treated
13. Inform clients of devices that can assist them in taking their
medications regularly andthereby improve adherence
• Alarm devices (wrist watch or cell phone alarms), pill boxes, associating doses
with daily activities, leaving medications out where they can see them, etc.
14. Discuss precaution and measures to improve treatment outcome
• Decreased salt intake, dietary requirement, self-monitoring, exercise, activities
to be avoided-
• Don’t assume the client may have prior information. It is good to repeat and
discuss precautions
• 15. Discuss storage recommendation supplementary
instructions:
• Shake well, refrigerate, avoid heat and humidity, etc.
• Duration of use after opening container
• 16. Discuss religious and cultural issue that may affect
medicines use
• Fasting and holy water,
• Dosage forms preferences
• The ill consequences of hoarding medicines at home and sharing of
such medicines with other people, etc.
• 17. Demonstrate and provide adequate information about
special dosage forms:
• Metered dose inhalers, suppositories, eye drops, ear drops, topical,
transdermal patches, injections, sublingual tables, nasal sprays,
sustained-release tablets/capsules, etc.
18. Educate techniques for self – monitoring; Examples:
• Diabetes signs and symptoms of hypo- and hyper – glycaemia
or use of blood glucose monitoring devices
• Watch for excessive bleeding in warfarin therapy
• Hypertension: use of blood pressure meters
19. Ask if there are any additional concerns or questions;
listen respectfully and carefully
20. Ask client to repeat key information to check how
instructions are understood:
• Could you tell me how you are going to take your medicine?
• Praise good medication taking behavior to reinforce
adherence
21. Provide your telephone number and encourage to
contact you, if the need arises
• Wordings used for cautionary/advisory labels when
counseling and labeling
• When advising the patients using the counseling checklist
mentioned above, care need to be exercised regarding the
content of wordings used with patients?
• For example, to advice patients about the need to take on an
empty stomach for a better absorption
• the better term to use is “take 2 hours after or before meal”
than say “take in an empty stomach” because patients may
assume,
• for example, “30 minutes before meal” as an empty stomach
which is not the case physiologically
• Therefore, it is advisable to use standardized wordings for
advisory/cautionary labels when counseling patients or give
them written instructions.
• The cautionary/advisory labels can be of 2 types depending:
• if they are drug specific or
• common for most medicines/dosage forms
• Examples of advisory/cautionary labels common to most
medicines/dosage forms
1. 'Shake the bottle',
2. Use freshly boiled and cooled water
3. 'For external use only',
4. 'Discard days after opening' (applied to eye preparations dispensed in
multiple dose containers)
5. 'Do not use after' (apply particularly to antibiotic mixtures, diluted liquid
and topical
preparations, and to eye-drops)
6. 'Keep out of the reach and sight of children'
7. “Stains cloths or the skin”
8. “Take the tablets with water or other liquid”
9. “Do not share with any other person”
10. Do not take more/ less than recommended
11. “Do not use medicines not given you by an authorized
health professional
12. “Do not transfer into another container”
13. Store tightly closed in a cool and dark place 'Store in a cool
place',
14. “Do not use medications which have become damaged or
shown signs of damage or
expiration”
15. inform the provider medications you bought from
pharmacy by yourself or another doctor has prescribed you or
you completed before sometimes”
• Examples of advisory/cautionary labels specific to a
drug or its family /dosage form
1. Take this medicine with ____________ hrs. gap separated
from other medicines
2. Take this medicine with ____________ hrs. gap separated
from milk.
3. Take with or after food
4. Take half to one hour before food.
5. Take 2 hours before or after food or on an empty stomach
6. To be sucked
7. To be chewed
8. Swallowed whole, not chewed
9. Dissolved under the tongue
10. With plenty of water
11. Do not take more than 2 at any one time. Do not take
more than 8 in 24 hours
12. Do not take more than . . . in 24 hours
13. Do not take more than . . . in 24 hours or . . . in any
one week
14. This medicine may color the urine
15. Dissolve or mix with water before taking
16. Avoid exposure of skin to direct sunlight or sun lamps
17. Take at regular intervals. Complete the prescribed
course unless otherwise directed.
18. Warning. Avoid alcoholic drink
19. Warning. May cause drowsiness. If affected do not
drive or operate machinery. Avoid
alcoholic drink
• Counseling Points for Selected Dosage Forms
• There are multitudes of factors affecting counseling
• Age, background of the patient, literacy level and the
like are to be mentioned
• Some dosage forms require specialized counseling.
Some of the commonest are listed below
A. Tips for Proper Dispensing of Pediatric Powder for
Suspension for Oral Use
1. Use freshly boiled and cooled water (FBC)
2. Add the FBC gently bit by bit shaking each time after each bit and
finally exactly to the mark on the bottle
3. FBC is added only once to each bottle
4. Do not add water (FBC) to all bottle sat the same time, meaning
this has to be only after the first reconstituted bottle is completed
6. Shake each time before use
7. Use only volume measuring device recommended by the dispenser
to dispense the
accurate dose
8. “Do not use after recommended days of each product!”
9. Provide the general warnings and find recommended warning
label wordings that
apply to a specific drug
10. Praise your child for becoming willing to take the dose and the fact
syrups are not
candies but harmful medications if taken inappropriately
• B. Counseling Points for Administration of Eye Drops
1. Wash your hands.
• Emphatically advice the need for thorough hand washing before
application and importance of eye hygiene in prevention of
contamination of there remaining doses and avoidance of re-
infection and relapse of the problem
2. Open the closure. Do not touch the dropper opening
3. Look upward.
4. Pull the lower eyelid down to make a ‘gutter’.
5. Bring the dropper as close to the `gutter' as possible
without touching it or the eye
6. Apply the prescribed number of drops in the ‘gutter’.
• Be vigilant on the issue of systemic side effects after application
into the eye educating the patient on the needs to close the tubes
immediately after each use
7. Close the eye for about two minutes. Do not shut
the eye too tight; excess fluid can be removed with a
tissue.
8. Eye-drops may cause a burning feeling but this
should not last for more than a few Minutes
• If it does last longer consult a doctor or dispenser.
9. If more than one kind of eye-drop is used wait at
least five minutes before applying the next drops.
10. When giving eye-drops to children:
• Let the child lie back with head straight.
• The child's eyes should be closed.
• Drip the amount of drops prescribed into the corner of
the eye.
• Keep the head straight.
• Important!
• Identify the type of eye preparation (lotion, solution,
ointment, etc.)
• Eye drops are generally instilled into the pocket formed by
gently pulling down the lower eyelid and keeping the eye
closed for as long as possible after application;
• One drop is all that is needed. A small amount of eye
ointment is applied similarly; the ointment melts rapidly and
blinking helps to spread it.
• When two different eye-drop preparations are used at the
same time of day, dilution and overflow may occur when one
immediately follows the other
• The patient should therefore leave an interval of at least 5 minutes
between the two
C. Counseling Points for Administration of Eye ointment
1. Wash your hands.
2. Tilt the head backwards a little.
3. Take the tube in one hand, and pull down the lower eye lid
with the other hand, to make a ‘gutter’. Do not touch anything
with the tip of the tube.
4. Bring the tip of the tube as close to the ‘gutter ‘as possible.
5. Apply the amount of ointment prescribed.
6. Close the eye for two minutes.
7. Remove excess ointment with a tissue.
8. Clean the tip of the tube and close it.
D. Counseling Points for Administration of Eardrops
1. Warm the ear-drops by keeping them in the hand or the
armpit for several minutes. Do not use hot water tap, no
temperature control!
2. Tilt head sideways or lie on one side with the ear upward.
3. Gently pull the lobe to expose the ear canal.
4. Apply the number of drops prescribed.
5. Wait five minutes before turning to the other ear.
6. Use cotton wool to close the ear canal after applying the
drops ONLY if the manufacturer explicitly recommends this.
7. Ear-drops should not burn or sting longer than a few
minutes. If it does last longer consult a doctor or dispenser.
E. Counseling Points for Administration of Nasal drops
1. Blow the nose.
2. Sit down and tilt head backward strongly or lie down with a
pillow under the
shoulders; keep head straight.
3. Insert the dropper one centimeter into the nostril.
4. Apply the number of drops prescribed.
5. Immediately afterward tilt head forward strongly (head
between knees).
6. Sit up after a few seconds; the drops will then drip into the
pharynx.
7. Repeat the procedure for the other nostril, if necessary.
8. Rinse the dropper with boiled water.
F. Counseling Points for Administration of Nasal spray
1. Blow the nose.
2. Sit with the head slightly tilted forward.
3. Shake the spray.
4. Insert the tip in one nostril.
5. Close the other nostril and mouth.
6. Spray by squeezing the vial (flask, container) and sniff slowly.
7. Remove the tip from the nose and bend the head forward
strongly
8. Sit up after a few seconds; the spray will drip down the
pharynx.
9. Breathe through the mouth.
10. Repeat the procedure for the other nostril, if necessary.
11. Rinse the tip with boiled water
G. Counseling Points for Administration of Aerosol
1. Cough up as much sputum as possible.
2. Shake the aerosol before use.
3. Hold the aerosol as indicated in the manufacturer's
instructions (this is usually upside down).
4. Place the lips tightly around the mouthpiece.
5. Tilt the head backward slightly.
6. Breathe out slowly, emptying the lungs of as much air as
possible.
7. Breathe in deeply and activate the aerosol, keeping the
tongue down.
8. Hold the breath for ten to fifteen seconds.
9. Breathe out through the nose.
10. Rinse the mouth with warm water.
H. Counseling Points for Administration of Suppositories
1. Defecate and wash your hands.
2. Remove the covering (unless too soft).
3. If the suppository is too soft let it harden first by cooling it
(fridge or hold under cold
running water, still packed!) then remove covering.
4. Remove possible sharp rims by warming in the hand.
5. Moisten the suppository with cold water.
6. Lie on your side and pull up your knees.
7. Gently insert the suppository, rounded end first, into the
back passage.
8. Remain lying down for several minutes.
9. Wash your hands.
10. Try not to have a bowel movement during the first hour.
I. Counseling Points for Administration of Vaginal tablet with
Applicator
1. Wash your hands.
2. Remove the wrapper from the tablet.
3. Place the tablet into the open end of the applicator.
4. Lie on your back, draw your knees up a little and spread them
apart.
5. Gently insert the applicator with the tablet into the vagina far as
possible, do NOT use force!
6. Depress the plunger so that the tablet is released.
7. Withdraw the applicator.
8. Discard the applicator (if disposable).
9. Clean both parts of the applicator thoroughly with soap and
boiled, lukewarm water (if not disposable).
10. Wash your hands.
J. For vaginal tablets without applicator
1. Wash your hands.
2. Remove the wrapper from the tablet.
3. Dip the tablet in lukewarm water just to moisten it.
4. Lie on your back, draw your knees up and spread them
apart.
5. Gently insert the tablet into the vagina as high as
possible, do NOT use force!
6. Wash your hands.
• K. Counseling Points for Applying vaginal creams ointments
and gels (Most of these drugs come with an applicator)
1. Wash your hands.
2. Remove the cap from the tube containing the drug.
3. Screw the applicator to the tube.
4. Squeeze the tube until the required amount is in the applicator.
5. Remove the applicator from the tube (hold the cylinder).
6. Apply a small amount of cream to the outside of the applicator.
7. Lie on your back, draw your knees up and spread them apart.
8. Gently insert the applicator in to the vagina as far as possible, do not use
force.
9. Hold the cylinder and with the other hand insert the drug into the vagina.
10. Withdraw the applicator from the vagina.
11. Discard the applicator if disposable or clean thoroughly (boiled water) if
not.
12. Wash your hands.
• Filing the prescription and transaction documents
• All registers and prescriptions, patient and medication related
records should be documented and kept in a secured place that is
accessible only to authorized personnel. Filing will include:
• The receipts for requisition, receiving and prescription movement control
should be kept properly.
• Blank prescription should be kept carefully. Only permitted individuals
have access to them.
• At the close of each day all dispensed prescriptions should be organized
into normal or special prescriptions (e.g. Narcotic drugs) and filed
separately.
• Prescriptions should be filed sequentially by date in a single
container/carton for each month. The container should be labeled with
the month and year.
• Containers should be arranged on a monthly basis.
• Normal prescriptions should be filed securely for two years and special
prescriptions for five years. Thereafter, they should be disposed carefully
in the presence of appropriate body.
• Free and credit registers should be filed for at least two years
• Pharmaceutical Stock and Consumption Analysis
Methods
• Pharmaceutical stocks at the facility should be analyzed
periodically to see whether the stock is being sold or
consumed at the expected levels
• The results of the analyses help relevant professionals at
health facilities to take appropriate action on current
stocks of medicines or on future procurements
• The stock is analyzed in terms of cost or volume of
medicines sold/consumed during the specific time-
period using the following analysis methods:
• Stock turnover ratio (STR)
• Stock consumption ratio (SCR)
• Stock status analysis (SSA)
• STR and SCR use aggregate data and are used as some
general consumption indicators whereas SSA indicates
the movement of a specific product
• Stock Turnover Ratio (STR)
• Stock turnover ratio or inventory turnover ratio is a
relationship between the cost of medicines sold during a
period and the cost of average inventory during that period
• It is also called inventory turnover ratio
• It indicates the number of time the stock has been turned
over during the period and evaluates the efficiency with
which the health facility can manage its stock of medicines
• STR measures the rate of conversion of stock into sales (cash,
credit, sales)
• In other words, it measures the number of times stock is sold
or used during a specified time
• It indicates profitability of the business.
A low STR indicates an inefficient management of stock.
A low STR implies: over investment in medicines stock, stock
accumulation, accumulation of obsolete and slow-moving medicines
and low profit as compared to total investment.
• Consumption to Stock Ratio (CSR)
• Consumption to stock ratio indicates the value of
pharmaceuticals sold against the stock available for sale
• In other words, it is an indicator of the stock at hand
versus stock sold during the period
• It simply measures the amount of dispensed medicines
in relation to the stock available for sale during the
period
• However, it doesn’t indicate that whether the stock
movement is profitable or not
• Stock available for sale=beginning + received during the
month
• Example: If CSR is 25 percent in a certain period, it
indicates that the pharmacy dispensed a quarter of the
stock available for sale during the period
• The pharmacy remains with 3/4th of the stock available
for sale
• The information from CSR is used to show the stock
movement is within the period of refill
• Note: Both stock turnover ratio and consumption to
stock ratio analysis can be generated automatically from
the APTS monthly report while we use excel sheet or
other modern software
• Stock Status Analysis (SSA)
• Stock status analysis is a method used to analyze the
consumption pattern of a product in the past and
predict utilization of available stock
• It identifies whether products are fast moving, slow
moving, or non-moving
• This information in APTS principle is used to get
readiness, take action before pharmaceuticals are near
expiry, expired or stocked out ahead of time
• The principle doesn’t necessarily need near expiry
products for analysis
• The principles advise to do analysis both for short expiry
and long expiry products
• Any product with long expiry can also be found
overstock but would be easier to take actions like to
transfer and use somewhere else
• The analysis allows evidence based decision making on
utilization of current stock and future procurements
• This process enables the health facility to minimize
wastages and ensure effective and efficient utilization
of budget and continuous availability of essential
medicines
• The main purpose of assessing stock status is to
determine how long the pharmaceuticals we have on
hand will last and how much of it can be used
• To conduct effective stock status analysis, pharmacy
personnel in charge should understand the concept of:
• maximum stock level
• reorder level
• minimum stock level
• lead time
• average monthly consumption
• safety stock (emergency order level) and morbidity data
 • Stock status analysis can be performed by the pharmaceuticals
supply management officer or chief pharmacist of the health facility
as follows:
• Step1: Identify medicines that are candidates for the stock
status analysis (SSA).
• By conducting ABC/VEN analysis identify:
• o Those that fall in A category in the ABC analysis
• o Those that are non-essential and fall in A category in ABC/VEN
reconciliation
• Medicines with near expiry regardless of its category
• Form stock turn over analysis, if the turnover is very slow, those
products with highest cost or bulk volume
• During a quarterly physical inventory, if a product is found to have
very high total cost or those with the highest volume
• Use expert opinion specially store managers and bin managers
• From software that are reported as over stock
* Note: If another stock is being coming but not yet arrived at the
facility, it is suggested to be included in the numerator of the above
equation.
• For medicines used for seasonal diseases such as
malaria, it is advisable to take consumption data of the
season in preceding years
• In situations where the monthly consumption is
increasing with time
• use last month’s consumption instead of average monthly
consumption as a denominator to calculate months of stock
• This calculation is valid only when the remaining shelf
life of the product is greater than the months of stock
• Step 4: Calculate the amount of stock that can be consumed
before the product expires.
• This is calculated by multiplying the average monthly consumption with
the remaining shelf life in months.
• Step 5: Calculate the presence of over stock of a product.
• Over stock is calculated by subtracting the amount of stock that could
be consumed until expiry from the total stock.
• Step 6: Calculate the additional stock needed to reach the
maximum stock (i.e. for the 4 months).
• This is calculated as:
• Additional stock needed to reach to the maximum = AMC x (4 - Months
of usable stock)
• If the result is negative, it indicates the presence of over 4 months of
stock
• Step 7: Covert the additional months of stock in months; This is
calculated as: -
 • If the result is negative, the interpretation is the same as
above.
• Step 8: Take measures based on the findings
• That is, if under stock, immediately refill the product
• However, if over stock: -
• Present to the management for decision making
• Discuss with prescribers to identify any opportunity to use the
medicines
• Reverse to the suppliers if possible
• Sell, transferor donate to other health facilities
• VEN and ABC Analysis, and ABC-VEN Reconciliation
• Enabling Objectives:
• At the end of this session, participants will be able to:
• Practice how medicines are prioritizing into Vital, Essential and
Non-essential
• Classify medicines by using ABC analysis methodologies
• Reconcile the ABC/VEN analysis
• Use the analysis for procurement
• VEN Analysis
• VEN analysis is a method that is used to classify medicines
into Vital (V), essential (E) or nonessential/less essential (N)
per their clinical importance
• It is important that the health facility DTC should classify the
pharmaceuticals list by VEN
• This categorization should guide the
• Forecasting
• Procurement
• inventory management decisions of the health facility
• Medicines can be categorized in to VEN according the
catchment areas or disease morbidity
• Vital medicines are critically needed for the health facility to
save lives
• The criteria for prioritization of medicines into VEN
are as follows:
• Vital (V)
• Vital medicines are very essential medicines that fulfil one or
more of the following criteria:
• Potentially life-saving,
• without which it is impossible to save patient's life, and
• patient may die or may be harmed or disabled due to lack of
these medicines
• Crucial to provide basic health services, without which it is
impossible to deliver the basic services in the specific
catchment area (in its absence service may be discontinued)
• It is mandatory for these medicines to be available 24 hours of
a day, 7 days of a week, and 12 months of a year.
• Essential (E)
• Essential medicines are those that fulfil one or more of
the following criteria:
• Effective against less severe but significant illnesses (it is
between vital and less essential)
• Important to provide basic health services without which
patients can face difficulty
• May be somehow substituted
• Essential to the service without which it is difficult to provide
health service
• It is mandatory at least once a day, or at least once in a week,
or at least once in a month or once in a quarter of the year, but
not as highly mandatory as vitals
• Nonessential (N)
• Non-essential medicines are less essential medicines that are:
• Effective for minor illnesses and have low therapeutic advantage
• Important to patients; however, patients will not die due to the absence of
such medicines
• Necessary to give the health service; however, health service delivery will
not be discontinued in the absence of these medicines
• Note: Assignment to the non-essential/less essential category does
not mean that the medicine is no longer on the health facility’s
medicine list
• But low priority
• During medicines procurement, priority should be given for vital
and essential medicines
• In situations of budget limitation, less-essential medicines are the
first to be adjusted in reconciling requirements with the budget
• Steps in VEN Analysis
• For the VEN analysis to takes place, facility specific
medicines list should be available
• the categorization should be done by the health facility’s
Drug and Therapeutics Committee (DTC)
• as part of the medicines list preparation process
• Each medicine, medical supplies, laboratory chemicals
and reagents included in the list should then be
categorized as V, E or N by the DTC
• ABC Analysis
• ABC analysis is a method for determining and comparing
pharmaceutical costs within a health facility
• It follows the Pareto principle “separating the vital few
from the trivial many” in terms of budget
consumption/allocation
• ABC Analysis can be explained in terms of budget
consumed and number of medicines in the budget list as
follows:
• “A” medicines:
• High percentage of funds spent on large-volume or high-
cost items
• Greatest potential for savings
• Greatest potential for identifying expensive medicines
that are overused
• “B” medicines:
• Moderate cost and moderate number of items;
important items
• “C” medicines:
• Small amount of funds spent on most of the inventory
• Steps for Conducting ABC Analysis
• Note the following points before conducting ABC value
analysis.
• Exclude medicines received by donations and capital goods like
medical equipment from ABC analysis.
• If a single medicine is supplied both by donation and purchase in a
particular year and the donation is not continuous, then this
donation may have impact on medicines budget allocation by the
facility this case
• donated medicines have to be accounted together with purchased
medicines during ABC analysis
• ABC analysis can be conducted separately for donated medicines, if
necessary.
• Received data for ABC analysis can be obtained from receiving/ bin
card if it has cost/stock cards, or databases (if available)
• Note:
• Consumption data for ABC analysis can be obtained from:
• issuing vouchers, bin/stock cards, and databases (if available) and
can be used for forecasting purpose specially to see prescribing
pattern
• But this analysis does not show budget consumption.
• When performing ABC value analysis for the first time, it is
advisable to analyze three years’ data from receiving voucher
• For the subsequent years, the facility should conduct ABC
value analysis on annual basis
• Then, the health facility must conduct trend analysis of the
present year by including the analysis done during the
previous two years
• The necessary data for ABC analysis should be recorded and
analyzed using Excel sheet.
• While conducting ABC Analysis, follow the steps below
• BC/VEN Reconciliation and Interpretation of Findings
• ABC/VEN Reconciliation
• ABC/VEN reconciliation is made from ABC and VEN analyses
• It involves categorizing the class of medicines generated from ABC
analysis by VEN to identify if there is relatively high expenditure on low
priority medicines (N category items in Class “A”)
• Medicines in Class A should be further analyzed in relation to their
importance in the management of top ten diseases/conditions in the
health facility
• Follow the steps below to take the necessary action based on ABC-VEN
reconciliation:
• Present results of the reconciliation to DTC to discuss whether products in Class
“A” reflects public health problem of the area.
• Undertake drug use evaluation (DUE) on medicines suspected to be overused
that fall under class “A”.
• Determine the % of drugs purchased according to the medicines list of the
facility
• Take appropriate measure on N items that fall in A class.
• Note:
• It is very important that ABC-VEN reconciliation should
be conducted not only for medicines purchased or
consumed but also for medicines that are about to be
purchased
• This should be done on both the annual forecast data as
well as prior to each procurement to ensure appropriate
utilization of budget by focusing on the priority
medicines as per the analysis.
• Auditing for Product, Finance and Services
• Enabling Objectives
• To attain the primary objective, the trainees will be able
to;
• Define product, finance, and service auditing
• List data source for auditing
• Explain random and periodical auditing
• Apply product, finance, and service auditing using
random and periodic auditing methods
• Introduction
• Auditing is a systematic, independent examination and
evaluation of:
• data
• Statements
• Records
• a person
• an organization
• a system
• a process
• an enterprise
• project or product operations and performances
• The inventory management, accounting, and
information system must provide comprehensive
evidence on medicine transactions and service delivery
for effective auditing
• Auditing provides reasonable assurance that reported
statements of transactions and services are free from
error
• In practice, because of lack of transparent system,
auditing of the pharmacy transactions and services in
Ethiopia was found to be difficult
• This is due to lack of clear responsibility and
accountability, lack of documentation, incomplete and
unreliable information, and nontransparent
transactions
• The implementation of APTS facilitates the practice of
effective auditing system in health facilities
• There are three major types of auditing in APTS
• They are
• Financial
• product
• Service /performance auditing.
• Financial auditing
• It is a formal examination, correction, and official endorsing
of financial accounts, especially those of a business,
undertaken by an accountant
• It is endorsing that the statement or report is tru
• Auditing pharmaceutical transactions with respect to finance
is used to check and endorse the daily and monthly financial
transactions reports
• The daily financial auditing includes; - the amount of cash
collected, submitted to main cashier /or deposited in bank,
the cashier’s delivery note recording, the cash sales ticket pad
(ticket flow) etc.
• The monthly financial includes; - evaluation of the received
items by vouchers with costs, issued items with
• costs, dispensed items with prices
• Service/Performance Auditing:
• It is a systematic check or assessment, especially of the
efficiency or effectiveness of an organization, a process,
an activity, or a person’s mission
• when typically carried out by an independent assessor
• When service is audited, quality of service, performance
of individuals and the health facility will be evaluated
• Service auditing includes; measuring workload and
analysis with the APTS standards, the patient served, the
number of counseling, the DTP identified etc.
• Product Auditing
• It is a systematic, independent examination of data,
statements and records of products in quality and
quantity
• It is endorsing of the statement concerning the quality
status and quantity of the physical inventory of items is
true by checking the actual items physically
• The product auditing includes:
• checking of products received with expiry dates and batch
number, the number of expired items with records
• the stock on hand, received, issued, dispensed against the
ending stock of specific products
• Data Source and Steps for Financial & Product
Auditing
• Data Source and Steps for Services Auditing