Storage Management and Wastage of Reproductive Health Medicines in Public Health Facilities of West Wollega Zone, Ethiopia: Mixed Study


 Background: Keeping proper storage conditions at health facilities is important to reduce pharmaceutical wastage caused by environmental factors. The expiration of medicines at the health facilities led to wastage of potentially life-saving drugs and unnecessary expenditure on the disposal of those expired medicines. Therefore, the aim of this study was to assess pharmaceutical stores and wastage of reproductive health medicines due to expirationMethod: A facility-based descriptive cross-sectional quantitative and qualitative study was conducted using a checklist, structured and semi-structured questionnaires.Results: Among 23 health facilities assessed, 17 (73.91%) (4(100%) hospitals and 13(68.42%) health centers) fulfilled desirable storage conditions. The total value of reproductive health medicines wasted due to expire in surveyed facilities was 357,920.52 ETB (12,323.81 US dollars) and the Percentage of Stock Wasted due to Expiration was 8.04%. Levonorgestrel 0.75mg tablet contributed highest percentage to expired medicines.Conclusion: Pharmaceutical stores in hospitals had equipment and furniture, fulfilled desirable storage conditions, whereas, significant number of the health centers’ medical store did not comply with the recommended storage conditions. Challenges of store management identified were poor infrastructure, administrative challenges, and shortage of human resource. Stock wasted due to expiration was high and the contributing challenge was non-need-based supply. So Ethiopian pharmaceutical Supply Agency should supply reproductive health medicines based on need and concerned government bodies should avail pharmaceutical store infrastructures, hire professionals, and follow health facilities administrations.


Introduction
Store management is the management of storehouses and stock information, holding and storage of medicines, and the safe custody and protection of stock.
Store is a place where we keep stock in the supply chain. Keeping products in store, guarantees satisfying the future customer demand. Therefore, every business stores a quantity of products for future customers' demand. Store management includes broader activities such as holding; quality control; training of stores staff; and clerical administration of stores operation (1).
Keeping proper storage conditions at health facilities is important to reduce pharmaceutical wastage. Pharmaceutical products stored in pharmacies with good storage facilities maintained their potency. The regulatory authorities and pharmaceutical organizations should emphasize the importance of preserving good storage conditions in the facilitation of health care (2). The management of the store should help the ow of supplies from the source to the end-user in the most reliable and economical way without a signi cant loss of quality, wastage, or theft (3) The expiration of medicines at the health facilities is a big concern due to its double burden. Firstly, it leads to wastage of potentially life-saving drugs. On the other hand, it causes unnecessary expenditure on the disposal of those expired medicines (4). It was estimated that about 70% of funds spent on medicines could be lost or wasted. By improving the basic management, it is possible to reduce these losses signi cantly. For example, it is possible to reduce medicines lost by expiration by 3%, medicines lost by improper storage by 4% (5).
Studies conducted in Ethiopia, revealed that the medicine wastage is a persistent problem of public health facilities. Poor storage facilities, improper store utilization, inadequate space, stocking expired medicines with usable products, and poor stock rotation, which led to expiry of medicines. Another study also mentioned; guidelines for the storage and disposal of medicines were not available and not followed at lower levels, the available space was not always well utilized or organized, and the practice of rst-to-expire-rst-out was followed. It also revealed the problem of expired products at all levels, although did not quantify it. The reproductive health (RH) medicines were emphasized because of their nature supply system. The supply chain system for maternal, neonatal, and child health (MNCH) (which are a major constituent of RH) medicines is inconsistent and had not been integrated into the Integrated Pharmaceutical Logistics System (IPLS) (6)(7)(8). Since IPLS was thought to increase store management performance and decrease value of expired medicines, being not integrated into IPLS could affect the store management and wastage due to expire. As far as the knowledge of investigators is concerned there is no research conducted on the store management and value of expired medicines in Ethiopia. Therefore, the aim of this study was to evaluate pharmaceutical stores and wastage of reproductive health medicines due to expiration at west Wollega zone. This will be a baseline study for stakeholders and academicians to take corrective action and conduct further studies.   and Resupply Forms (IFRRs) were available and being used by all health facilities. All assessed hospitals were using electronic-LMIS during the study period, while only 6(31.58%) of HCs were using electronic-LMIS (Table 4)
The storage condition criteria ful lled by all the facilities include; stacking products at proper height, store products separately from chemicals and insecticides, protecting products from direct sun light (100%), protecting cartoons from humidity (100%), and securing storage area with lock and key (100%).
On the other hand, all the assessed facilities had no functional modern re safety equipment. However, two (8.70%) of health centers made local re extinguishers from sand. In majority (52.17%) of the facilities, the storage area is not su cient (Table 5).   Pharmaceutical store management challenges The challenges of warehouse mismanagement and factors contributing to wastage of reproductive health medicines were identi ed through in-depth face-toface interview with relevant key informants and the results were summarized under the following themes.

i. Infrastructure Related
Most of the KIs raised infrastructure related problem. Especially, most KIs from the HCs complained that the medical store was a simple room not built for the purpose of medical store. Especially, they explained these factors as a major reason for poor medicines storage. For example, one of the store managers explained the problem as follows: As you see, the store is very congested. The roof is too short and it is di cult to clean daily. The roof needs maintenance. During rainy season, the water penetrates. I have reported to the management and they are discussing. It is long time since I told them. But they complain shortage of budget for maintenance.
In addition to the problem of the storeroom, KIs also complained lack of equipment and furniture used in store. Most of KIs from raised that lack of equipment like refrigerator, freezer, and insu cient shelves. This problem is stated by one of the KIs as follows: We are putting cartoons on the ground due to lack of shelves. We have no refrigerator and freezer in our store. Therefore, we store cold chain products in another unit. Since I am not there, I do not know how much the temperature is and they do not record the temperature daily. Since there is frequent electric power interruption, the refrigerator there is not always functional.
ii. Human power Related Another challenge identi ed by most KIs, especially in Health centers was, worker problem. They complained that due to insu cient pharmacy professional at their facility they assigned other professionals to manage pharmaceutical store. For example, one of the KIs expressed it as: We have only one druggist in our facility. He does all pharmacy duties. We assigned him at dispensary. He also does procurement. So, we assigned midwife nurse at store and the druggist oversees it. Another KI also stated: I'm nurse. I have not taken any drug management related course during my college study, except pharmacology. However, due to lack of druggists in our facility, they assigned me as store manager. Most of the works are strange for me. I am just trying to manage all the works, but sometimes even, I encounter new terms. In addition, I have not taken any training.

Factors Contributing to Drug Expire i. Supplier Related factors
Most of the KIs were complaining the problem of the supplier. They stated that the supplier pushes medicines in bulk without their request.
Most of the time PSA and partners dumps a huge amount of family planning medicines with short expire date. We do not need most of these medicines. So, they expire in bulk at our facility.
Another KI also explained the problem as: PSA sends near expiry drugs with very essential drug we need, to a driver. If we want to return those near expiry medicines, the driver does not allow us. He obliges us either to receive all products or return all the products. Since some products are very important, we cannot return them; we are obliged to receive those near expiry drugs.
ii. Demand related Most KIs raised less customer demand for some family planning methods as contributing factor for expiration. One of the KIs explains this as; Most of our customers prefers medroxy-progestrone (Depo-polivera) over other long-term methods. I think that could be due to its convenience for them. Since the supply from the partners is not need based, the bring other medicines with low demand. Then, those medicines will expire at our facility.

Discussion
Availability of equipment and furniture Basic equipment and furniture are important for properly arranging, putting, and keeping medicines at speci ed temperature and humidity. It also facilitates rst expiry rst out (FEFO) principle. The current study revealed that all the hospitals had all basic equipment and furniture used in pharmaceutical store.
However, majority of the health centers had no refrigerator, freezer, su cient shelves, and o ce table with chairs. These results are better than the study conducted in East Hararge, Ethiopia (12). The probable reason for difference may be the study setting. The previous study was conducted in woreda stores, while the current is in hospitals and health centers. Lack of these equipment and furniture had contributed to poor storage management in health centers as, revealed by qualitative result.

Storage Condition
Warehouses used for storage of medicines should ful ll good storage condition criteria to keep the integrity and smooth ow of medicines. Among assessed facilities, 17(73.91%) ful lls ≥ 80% of acceptable storage conditions. This is slightly lower than the study conducted in Nigeria, where all facilities met acceptable storage conditions (13). The difference might be due to the difference in study setting. The previous study included central medical stores in 279,522.52(9,624.4 USD) in assessed HCs. The result was higher than the results of the study done by Gurmu and Ibrahim in east Shewa, Ethiopia (7). The difference could be because, the current study was done on program drugs, unlike the previous that was done on key essential medicines, which contains non program drugs. As revealed by qualitative result, program drugs were supplied in bulk. Again, the supply chain system for MNCH commodities (a major portion of RH medicines) is inconsistent and has not been integrated into the Integrated Pharmaceutical Logistics System (IPLS). Therefore, their supply does not need based (8).
The overall wastage rate due to expire was 8.04 % (3.92% for Hospital and 11.39% for HCs). Wastage rate due to expiration ranges from the highest wastage rate for Levonorgestrel 0.75 mg tablet (33.08%) followed by Zinc sulfate 25 mg dispersible tablet (25.38%) to the lowest wastage rate for contraceptive pills (3.51%). The result was higher than Ethiopian health sector plan for 2018/2019 that is 2% (15). The probable reason for this high wastage rate might be receiving bulk and near expiry medicines, which had low customer demand, as revealed by qualitative method.
Since wastage rate in hospitals were lower than that of HCs, it might be due to professionals' skills assigned in store management. All store managers are pharmacy professionals in hospitals and majority of them took training, while store managers are in HCs were non-pharmacy professionals and not trained.

Limitation of the study
The study only included reproductive health medicines and health facilities. Pharmaceutical supply agency, the upper stream of supply chain was not included.

Conclusion
From this study, we concluded that pharmaceutical stores in hospitals had equipment and furniture, had desirable storage condition, and had less percentage of reproductive health medicines expired. Nevertheless, signi cant number of the health centers' medical stores do not comply with the recommended storage conditions, lack equipment and furniture, and had greater percentage of medicines expired. Infrastructure related, administrative, and human power related factors were identi ed as store management challenges. A major factor contributing for expiration was dumping huge amount of medicines with short expire date. So, the supplier should supply medicines based on their need, concerned government and non-government organizations try to avail equipment and furniture, and emphasis should be given to the impact of wastage of medicines due to expire.