19720en PDF

UNHCR
DRUG
MANAGEMENT
MANUAL 2006
Policies
Guidelines
UNHCR List of
Essential Drugs
UNHCR
DRUG
MANAGEMENT
MANUAL 2006
l Policies
l Guidelines
l UNHCR Essential Drugs List
i
Prepared by Ans Timmermans (Pharmacist) and
Anu Sharma (Medical Doctor).
2006 UNITED NATIONS HIGH COMMISSIONER FOR REFUGEES
These guidelines have been prepared by the Office of the United Nations High
Commissioner for Refugees for use by their staff and the staff of Implementing
partners in the field. Reproduction is authorized, except for commercial purposes,
provided that the source is acknowledged.
Suggestions for corrections or improvements can be sent to:
Technical Support Service, UNHCR, Geneva

([email protected])
UNHCR, 94 rue de Montbrillant, PO Box 2500, 1211 Geneva 2, Switzerland.
Cover design and printing by ILO Turin Centre.

PREFACE
In 2005, UNHCR provided protection to approximately 20 million
refugees and other persons of concern. Provision of comprehensive
health care services in refugee settings is essential as population
displacement and overcrowding are associated with increased risk of
communicable disease transmission and excess mortality. Refugee
health care systems are based on the concept of Primary Health Care
(PHC) through which essential health care is made accessible to
individuals, families and the community.
Health service provision is provided to refugees and other populations

of concern through Implementing Partners (IP’s, directly funded by
UNHCR) and Operational Partners (OP’s, with other sources of funding).
Provision of supplies and equipment necessary for preventive and
curative health care is carried out through a variety of mechanisms:
centrally through UNHCR headquarters (HQ), nationally through Ministry
of Health central pharmacies, and on the local market.
Drug ordering from countries in which UNHCR works is not always

appropriate or efficient. There are many examples of poor prescribing
practices, purchase of drugs of dubious quality, orders unrelated to actual
needs, poor drug storage and distribution, and irrational drug prescribing.
In addition, local purchase may not be indicated, and there is limited data
on stock ruptures, wastage, and other supply management elements.
Centrally, UNHCR has developed an Essential Drugs List (EDL) to

meet the immediate minimum drug needs for a basic refugee health care
system. With an annual expenditure of more than $2 million US, there is
an urgent need to address essential drugs management in UNHCR.
This has led to an updating of the UNHCR EDL and to this manual. The
2006 UNHCR EDL is based on the 2005 WHO Model List of Essential
Medicines and will be updated every 2 years as is the WHO list. This
manual is a revision of the UNHCR Essential Drugs Manual (1989) and is
the result of literature research, field visits, participation at conferences,
and correspondence with experts. The manual is for the use of UNHCR’s
health partners, and for UNHCR health programme officers who
supervise drug procurement in the field. It is meant to be a practical tool for
i
field staff of UNHCR and partners with the aim of improving drug
management in all parts of the drug management cycle.
Given that drug management is not a new concept, this manual is not
meant to introduce new ideas. It is, rather, a compilation of best practices
based on references from other sources. The majority of materials are
taken from: the second edition of Managing Drug Supply (MSH in
collaboration with WHO), Guidelines for the Storage of Essential
Medicines and Other Health Commodities (John Snow, Inc./DELIVER in
collaboration with WHO) and various WHO publications. A complete list of
references is given at the end of each chapter.
The manual consists of: 1. Guidelines that explain drug management

concepts and their rationale, and 2. Standard Operational Procedures
(SOPs) that are action-oriented and guide users step-by-step through
certain drug management questions such as consumption-based
quantification.
The essential drugs policy should be a standard document available

for all staff of UNHCR and partners. It indicates minimum standards in
drug management and the institutional commitment of UNHCR.
The chapter on drug selection aims to assist senior staff of UNHCR

and health partners with the selection of the most cost-effective medicines
relevant to the local situation. The development and use of an essential
drugs list and treatment guidelines are hereby emphasized.
The drug procurement chapter seeks to provide insights into best

practices in drug procurement by UNHCR and by partners. Although
classic procurement principles apply, issues that make drug procurement
different from procurement of other commodities are listed in the 12 drug
procurement principles. Obtaining medicines of good quality at an
affordable price in a timely fashion is the key objective of drug
procurement. General UNHCR procurement regulations also apply to
drugs and medical supplies and hence need to be used in conjunction with
these specific drug procurement guidelines.
The drug distribution chapter includes a section on medical store

management which is probably the most practical and straight-forward
chapter and can be used to train storekeepers with various educational
backgrounds in a variety of settings.
ii
The chapter regarding rational drug use aims to introduce concepts
of investigating and improving drug use rather than providing a
comprehensive “how to” manual.
The chapter on quality assurance applies to the whole drug

management cycle as drug quality assurance is a cross-cutting issue,
which applies not only to procurement (Obtaining good quality drugs), but
also to distribution (Verifying and maintaining quality of drugs) and use
(Monitoring drug quality). Everyone can contribute to drug quality
assurance, regardless of one’s job description or situation. The quality
assurance chapter is the most technical chapter with specific details
outlined in the corresponding Standard Operational Procedures at the end
of the manual.
Our aim in UNHCR is to always emphasize the importance of sound

drug management in health programs for the benefit of the organization
and staff, but most of all, for the beneficiaries.
iii
ACKNOWLEDGEMENTS
Special thanks go to Dr. Richard Brennan (IRC) and Dr. Nadine Ezard
(UNHCR) for their commitment to drug management in their respective
organizations and for providing comments to this document. Nabil Makki
and Dr. Mohammed Qassim (UNHCR) also need to be acknowledged for
sharing their experiences with drug management within UNHCR. The kind
assistance of all branch office, sub-office and health partner staff where
field visits and testing of the manual were carried out is also greatly
appreciated.
Sincere thanks to Dr. Hans Hogerzeil and Dr. Robin Gray (WHO) for
making time to meet for discussion at WHO Headquarters in Geneva.
A special thanks also goes to Dr. Souly Phanouvong (US Pharmacopeia)

for reviewing the drug quality assurance chapter.
iv
TABLE OF CONTENTS
Preface....................................................................................................iii
Acknowledgements.................................................................................iv
Acronyms ...............................................................................................vii
1. DRUG POLICY ............................................................................1

UNHCR Essential Medicines and Medical Supplies Policy............3
2. DRUG SELECTION ..................................................................11

Selecting the Most Appropriate Drugs............................................13
3. DRUG PROCUREMENT ...................................................... 27

1. Drug Procurement Guidelines ....................................................29
2. Quantification – Guidelines .........................................................40
3. Receipt and Inspection Guidelines .............................................43
4. DRUG DISTRIBUTION ......................................................... 51

Medical Store Management Guidelines .........................................53
5. RATIONAL USE OF DRUGS ...............................................87

1. Introduction to Rational Drug Use ...............................................89
2. Good Drug Dispensing Practices ..............................................105
3. Use of Drugs in Children, the Elderly and Pregnant Women ...110
6. DRUG QUALITY ASSURANCE ............................................113

Drug Quality Assurance Guidelines .............................................115
v
GLOSSARY OF TERMS ..................................................................125
ANNEXES .................................................................................... 135

Annex 1 UNHCR Essential Drugs List...........................................137
Annex 2 Order form: Request for drugs not on the
UNHCR Essential Drugs List ..........................................147
Annex 3 Contents of the New Emergency Health Kit .....................149
Annex 4 Standard Operational Procedures (SOPs) ......................157
SOP P1: Consumption-based quantification ..................158
SOP P2: Morbidity-based quantification.........................163
SOP P3: Ordering Procedures for International
Procurement ....................................................168
SOP D1: Physical Inventory ...........................................170
SOP D2: Issuing items that expire first (FEFO)................173
SOP D3: Filling out stock cards .......................................174
SOP D4: Storage of drugs and medical supplies .............178
SOP D5: Removing damaged and expired stock.............182
SOP Q1: Obtaining good quality drugs ............................183
SOP Q2: Verifying the quality of shipped drugs ...............197
SOP Q3: Monitoring and maintaining
the quality of drugs ..........................................202
SAMPLE FORMS AND RECORDS.................................................207

Form F1: Daily consumption tally sheet ..........................................209
Form F2: Monthly requisition and consumption reporting form .......210
Form F3: Stock record sheet...........................................................211
Form F4: Periodic inventory report form..........................................212
Form F5: Problem reporting form for pharmaceutical products .......213
vi
Acronyms
ADR Adverse Drug Reaction
API Active Product Ingredient
DRA Drug Regulatory Authority
EDL Essential Drugs List
FEFO First Expiry First Out
GMP Good Manufacturing Practice
HQ Headquarters
ICRC International Committee of the Red Cross
IDA International Dispensary Association
INGO International Non-governmental Organization
INN International Nonproprietary Name
INRUD International Network for Rational Use of Drugs
IP Implementing Partner
IRC International Resue Committee
MDR Multi-drug Resistant
MIS Management Information System
MSF Médecins Sans Frontières
MSH Management Sciences for Health
NEHK New Emergency Health Kit
NGO Non-governmental Organization
OP Operational Partner
PHC Primary Health Care
PSF Pharmaciens Sans Frontières
SMS Supply Management Service
SOP Standard Operational Procedure
vii
UNHCR United Nations High Commissioner for Refugees
UNICEF United Nations Children’s Fund
USD United States Dollar
USP United States Pharmacopeia
WHO World Health Organization
viii
UNHCR DRUG MANAGEMENT GUIDELINES
CH. 1: UNHCR
ESSENTIAL MEDICINES
AND MEDICAL
SUPPLIES POLICY
CH. 2: DRUG
SELECTION
UNHCR Essential Drugs Responsible: Implementing
List (Annex 1) partner, UNHCR health
coordinator
CH.3: DRUG
PROCUREMENT
Responsible: Programme Procurement (SOP P3)
Quantification (SOPs P1, P2)
officer, UNHCR health Receipt & Inspection (SOP Q2)
coordinator, Supply officer,
SMS
Medical Store Management CH. 4: DRUG

(SOPs D1-D4) DISTRIBUTION
Medical Waste Management and Responsible: Supplier, Supply
Drug Disposal Guidelines officer, Storekeeper,
(SOP D5) Dispenser
CH. 5: RATIONAL
DRUG USE Rational Drug Use Guidelines
Responsible: Implementing (Ch. 5)
Drug Dispensing Guidelines
partner, UNHCR health (Ch. 5)
coordinator
CH. 6: DRUG QUALITY

ASSURANCE
OBTAINing quality drugs (SOP Q1) Responsible: Programme
VERIFYing drug quality (SOP Q2)
officer, UNHCR health
MONITORing & MAINTAINing
drug quality (SOP Q3)
coordinator, Supply officer,
Supplier
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1. DRUG POLICY
1. DRUG POLICY
UNHCR ESSENTIAL MEDICINES AND

MEDICAL SUPPLIES POLICY
INTRODUCTION
Essential drugs play a crucial role in the prevention and control of
diseases. After immunization for common childhood illnesses,
appropriate use of essential drugs is one of the most cost-effective
components of modern health care.
The primary objective of an essential drugs policy is:
To ensure that a selected number of high-quality essential

drugs are available, affordable, and used rationally.
Source: MSH 1997
Drugs are of particular importance because:
þ Drugs save lives and improve health.

þ Drugs promote trust and participation in health services.
þ Drugs are costly (they represent the major part of a health program’s
budget after salaries and vehicles).
þ Drugs are different from other consumer products: 1. neither the
average medical practitioner nor the average pharmacist is
equipped to independently assess the quality, safety or efficacy of
each new drug, and 2. most often, the consumer does not choose the
drug, and if so is not trained to judge its appropriateness, safety, quality
or value for money.
þ Substantive improvements in supply and use are always possible.
Despite the potential health impact of essential drugs and despite

substantial spending on drugs, lack of access to essential drugs, irrational
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UNHCR DRUG MANAGEMENT MANUAL 2006
use of drugs, and poor drug quality remain serious global public health
concerns. Consider the following facts:
l Today over one-third of the world's population still lacks access to

essential drugs in the poorest parts of Africa and Asia.
l Up to 75% of antibiotics are prescribed inappropriately.
l Worldwide an average of only 50% of patients take their medicines
correctly.
l Anti-microbial resistance is growing for most major infectious
diseases, including HIV/AIDS, tuberculosis and malaria.
l Quality & safety issues:
n Less than 1 in 3 developing countries have fully functioning drug
regulatory authorities.
n 10 to 20% of sampled drugs fail quality control tests in many
developing countries.
n Failure in good manufacturing practices too often results in toxic,
sometimes lethal, products.
n Expanding global trade is making it increasingly difficult to
implement quality assurance.
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1. DRUG POLICY
WHAT ARE ESSENTIAL DRUGS?

The concept of essential drugs was established in 1977. Every two years
an expert committee updates the WHO Model List of Essential Medicines.
The list serves as a model for countries to adapt to their own specific
needs.
Box 1. The essential drugs concept

First introduced in 1975, the essential drugs concept is now widely accepted
as a highly pragmatic approach to providing the best of modern,
evidenced-based and cost-effective health care. It is as valid today as it was
25 years ago when first introduced. The essential drugs concept does not
exclude all other drugs, but rather focuses therapeutic decisions,
professional training, public information, and financial resources on those
drugs that represent the best balance of quality, safety, efficacy and cost for
a given health setting.
The essential drugs concept is also a global concept. Health systems of all
types, from basic health systems in the poorest countries to highly
developed national health insurance schemes in the wealthiest have
recognized its therapeutic and economic benefits. Moreover, the concept is
forward-looking. It promotes the need to regularly update drug selections in
light of new therapeutic options and changing therapeutic needs, the need to
ensure drug quality, and the need for continued development of better drugs,
drugs for emerging diseases and drugs for coping with changing resistance
patterns.
Source: WHO Essential Medicines Strategy 2000-2003
The essential drugs concept can be applied in all countries and at various
levels (national, provincial, district, hospital). The essential drugs concept
is especially valuable in resource-poor settings, as it allows one to get the
best medicines for the resources available. The concentration on a few
essential drugs has also lowered prices, due to economies of scale.
SCOPE
The UNHCR Essential Medicines and Medical Supplies Policy aims to

give guidance on how to ensure provision of good quality essential drugs
and medical supplies in all phases of the relief cycle.
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POLICY STATEMENT
The United Nations High Commissioner for Refugees (UNHCR) shall:
1. Ensure implementation of the essential drugs policy in all

UNHCR-supported health programs where drugs and supplies are
selected, procured, distributed or used. It is UNHCR’s role to ensure
that partners:
1.1. Base selection of drugs and medical supplies primarily on the
UNHCR Essential Drugs List which is adapted to national
standards. The UNHCR list is developed after cross-
referencing with the WHO Model List of Essential Medicines
and will be updated every 2 years.
1.2 Use the international non-proprietary names (generic) in
drug selection, procurement, and distribution.
1.3 Adopt a procurement strategy that ensures the availability of
drugs of good quality, safety and efficacy at the lowest possible
price.
1.4 Use Emergency Health Kits in the acute emergency phase
to meet the needs of a population with disrupted or no medical
facilities. The latest update from UNHCR’s Handbook for
Emergencies or the health chapter of the latest SPHERE
handbook should also be used to ensure that minimum
standards are met. MSF provides clinical guidelines and
minimum guidelines in pharmacy management during the
emergency phase.
1.5 As soon as the acute emergency phase is over, assess specific
health needs to set-up a solid drug management system that
includes the establishment of an essential drugs list,
treatment guidelines, a solid drug procurement system and
proper drug distribution procedures. The same applies in the
reconstruction/rehabilitation phase. This will require
information about the morbidity profile, high risk groups,
demographic pattern, seasonal variation of morbidity and
mortality, the impact of improved public health measures, local
availability of drugs and other supplies, drug resistance, usual
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1. DRUG POLICY
medical practice in the country, capabilities of the health

workers and effectiveness of the referral system.
1.6 Assure drug quality during the procurement process through
ensuring:
1.6.1 The quality of the manufacturer (respect for Good

Manufacturing Practices-GMP).
1.6.2 The quality of the product (registration status, Certificate

of Pharmaceutical Product,).
1.6.3 The quality of the batch (Certificate of analysis, labeling,

appearance, packing and shelf life inspection, chemical
analysis). It is the responsibility of the drug distributor to
sell only drugs from GMP-compliant manufacturers and
drugs that are registered in the country of destination.
1.7 Implement proper drug storage and distribution procedures

throughout every level of the supply chain in order to ensure
adequate quality of drugs and supplies at the end user level.
1.8 Take appropriate measures complying with national and/or
international guidelines for the timely disposal of expired and
unwanted drugs in a manner that does not jeopardize public
health.
1.9 Support the rational use of drugs through the promotion of
rational prescribing, dispensing and consumption of
pharmaceuticals at all levels. To this effect, formulate the
necessary guidelines and organize training activities for both
health workers and consumers from the community.
1.10 As an integral part of rational drug use, seek to strike a
balance between preventive and curative components of its
health programs through hygiene promotion and health
education.
2. Request donors to observe the obligation of providing good quality

essential drugs with an acceptable range of shelf life and to adopt the
WHO guidelines for drug donations.
7
3. In order to hold the drug management cycle together, the following

management support measures will need to be taken:
3.1 Aim to incorporate sustainability through a steady and reliable
drug budget and through local capacity-building and staff
development.
3.2 Provide training options in managing drug supply for UNHCR
staff and NGO-partners through conferences, field visits, staff
exchange and short training courses.
3.3 Collect and disseminate drug management lessons learned
from the field to build institutional memory and as a commitment
to the development of the field of drug management and
humanitarian assistance.
3.4 Ensure that important logistical data like inventory and
consumption data are integrated in the health information
system and used for proper procurement planning.
3.5 Ensure that all staff and partners are well oriented to the
rationale and content of this policy.
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1. DRUG POLICY
References:
1. IDA, IDA’s Quality Assurance and Quality Control, brochure.
2. International Federation of Red Cross and Red Crescent Societies

(IFRC), Essential Drugs and Medical Supplies Policy,
www.ifrc.org/who/policy/drugs.asp, October 1999.
3. International Resue Committee, Good Pharmaceutical Procurement

Guidelines, first draft, September 2003.
4. Interagency Pharmaceutical Coordination Group, Operational

principles for good pharmaceutical procurement, Essential Drugs
and Medicines Policy, Geneva, 1999.
5. Management Sciences for Health, in collaboration with the World

Health Organization. Managing Drug Supply. 2nd ed., revised and
expanded. West Hartford, CT: Kumarian Press. 1997. Used by
permission.
6. Medecins Sans Frontieres (MSF), Essential Drugs-Practical

Guidelines, 3rd ed., 2001.
7. The Sphere Project, Humanitarian Charter and Minimum Standards

in Disaster Response, Oxfam Publishing, Oxford, 2004. Also
available at: http://www.sphereproject.org/handbook/index.htm.
8. UNHCR, UNHCR Handbook for Emergencies, 1999.
9. WHO, Caritas, IFRC, ICRC, UNAIDS, UNICEF, PSF et al.,

Guidelines for safe disposal of unwanted pharmaceuticals in and
after emergencies, WHO/EDM/PAR/99.4, 1999.
10. WHO, Caritas, IFRC, ICRC, UNAIDS, UNICEF, PSF et al.,

Guidelines for drug donations, WHO/EDM/PAR/99.4, 1999.
9
11. WHO Essential Medicines Strategy 2000-2003, 1. The impact of

essential drugs.
12. WHO, The 14th Model List of Essential Medicines, 2005,

http://www.who.int/medicines/organization/par/edl/eml.shtml.
13. WHO, The New Emergency Health Kit, 2nd ed., 1998.
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2. DRUG SELECTION
Contents
SELECTING THE MOST APPROPRIATE DRUGS ........................13
1. Introduction .......................................................................13
2. Benefits.............................................................................14
3. Criteria for drug selection ..................................................15
3.1. Emergencies ..............................................................15
3.2. Post-emergency settings ...........................................18
4. Implementation issues......................................................21
4.1. Developing a local Essential Drugs List ......................21
4.2. Organization of the UNHCR Essential Drugs List .......22
4.3. Developing local Standard Treatment Guidelines ......25
References........................................................................26
12
2. DRUG SELECTION
SELECTING THE MOST APPROPRIATE

DRUGS
1. Introduction
Rational drug selection leads to a better supply, lower

costs, and a more rational prescribing and use of drugs.
Selection of drugs and medical supplies should primarily be
based on the UNHCR Essential Drugs List which is adapted to
national standards. The UNHCR list has been developed after
cross-referencing with the WHO Model List of Essential
Medicines and is updated every 2 years. Selection should be
based on the basic health needs of the target population. A
transparent and regular review of the essential drugs list is
a key intervention in improving quality of care in health
programs. In addition, the introduction of standard treatment
guidelines, reflecting the essential drugs list, should be used in
conjunction with standard symptom/disease definitions.
Sources: IRC 2004, MSH 1997, UNHCR 1989
Drugs are expensive. In developing countries, pharmaceuticals constitute

up to 40% of the health care budget and up to 90% of the household
budget. For an NGO implementing health programs, drugs are the largest
expenditure after salaries and vehicles.
No program can afford to purchase all drugs circulating in the market

within its given budget. Resources are limited and choices have to be
made. A limited list of drugs for procurement, based on an essential drugs
list or drug formulary, defines which drugs will be regularly purchased and
is one of the most effective ways to control drug expenditure and overall
health program expenditure. Other than the economic implications due to
improved drug therapy, an effective drug formulary system will also have
clinical implications.
13
2. Benefits
The rationale for selecting a limited number of essential drugs is that it
may lead to:
1. a better supply:
a. easier procurement, storage and distribution
b. adequate stocks
c. better quality assurance
d. easier dispensing
2. more rational prescribing:

a. more focused training
b. more experience with fewer drugs
c. no irrational treatment alternatives available
3. Lower costs (more competitive prices through increased

competition).
4. more rational patient use:

a. focused education
b. reduced confusion and increased adherence to treatment
c. increased availability
An Essential Drugs List (EDL) names the drugs considered optimal

treatment choices to satisfy the health care needs of the majority of a
target population at a cost the program can afford. An essential drugs list
is the guiding model that indicates priorities in drug needs to make sure
that a regular supply of safe and effective drugs is continuously
available in sufficient quantities in a health system.
It should be emphasized to prescribers that an essential drugs list is not

designed to restrict prescriber freedom but to increase access to essential
drugs in settings with limited resources. A certain degree of flexibility for
deviation is possible as long as this has an exceptional character and is
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2. DRUG SELECTION
justified and documented. Drugs not included on the UNHCR Essential

Drugs List (see Annex 1) can be requested using a special form (see
Annex 2).
3. Criteria for drug selection
3.1. Emergencies
Often during the emergency phase of a refugee influx (the first two to three
months) drug procurement is streamlined by the immediate provision of
Emergency Health Kits. These standard health kits have been designed,
tested and revised by WHO and several non-governmental organizations.
Even if kits are used, normal non-emergency lines of procurement must
be planned and set up from the beginning of an emergency situation so
that a smooth and timely transition may be effected.
The New Emergency Health Kit (NEHK) (WHO 1998) has been developed
by WHO in consultation with UNHCR, UNICEF, MSF, ICRC, the League
of Red Cross and Red Crescent Societies (Geneva) and the Christian
Medical Commission of the World Council of Churches. It is currently
under revision as some of the drugs, such as antimalarials, are no longer
effective in many settings. The new kit is expected to be available in 2006;
see www.who.int/medicines for updates. The NEHK contains medicines
and medical supplies in quantities sufficient for a population of 10,000
people for approximately 3 months. The NEHK has been designed to
meet the needs encountered in crisis situations such as floods, droughts,
earthquakes or armed conflict.
IDA always keeps sufficient quantities of the

NEHK in stock to supply to relief workers in
areas affected by war or natural disasters.
Composition: One complete NEHK weighs 840

kg and consists of 24 Boxes:
Source: IDA
15
One Basic unit of 10 boxes,

all identically packed. Every
basic box (numbered 1-10)
contains: medicines, renewable
supplies and instruments
destined for use by primary
health care workers with
limited training. Each box
bears an additional green
Source: IDA imprint, with the text “BASIC”.
One Supplementary unit of 14 boxes: This Supplementary unit

contains: 3 boxes of medicines (numbered 11-13), 5 boxes of IV fluids,
including giving sets (numbered 14-18), 3 boxes of renewable supplies
(numbered 19-21) and 3 boxes of equipment (numbered 22-24). It is
destined for use by professional health workers or physicians.
Each box displays an additional green label indicating the content:

medicines, IV fluids, etc. A packing list of the complete Supplementary unit
is included in box number 11. The expiry date of the first item to expire is
mentioned on each kit. The supplementary unit does not contain any
medicines or supplies from the basic unit and can only be used when
these are available as well. It should never be used alone.
Standard manuals in three languages

The kit includes the following standard manuals: Clinical Guidelines
-Diagnostic and Treatment Manual, published by MSF. It is packed in box
24 of the Supplementary unit.
Treatment guidelines exist for the Basic unit as well. A booklet of 11

pages, containing standard diagnostics, prescription for 11 different
diagnostic groups and 4 pages on dehydration/diarrhea are included. The
booklet is packed in every basic box, and includes a list of contents for a
complete kit as well.
For a complete list of contents of the NEHK, see ANNEX 3.
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2. DRUG SELECTION
Reproductive Health Kits
Reproductive Health Kits for Crisis Situations also exist. These have been
designed by members of the Inter-Agency Working Group on
Reproductive Health to complement the Emergency Health Kits. The
Reproductive Health Kits are available through UNFPA (table 1, see
Reproductive Health Kits for Crisis Situations UNFPA updated 2005 or
www.unfpa.org for more details). In many situations UNFPA will provide
these supplies free of charge to UNHCR operations as part of the
Memorandum between UNHCR and UNFPA. Please contact your
national UNFPA office or UNHCR HQ at [email protected].
Table 1: Reproductive Health Kits for Crisis Situations
Block 1 : 10,000 people for 3 months, community and primary health

care level
Kit 0 administration / training supplies
Kit 1A male condoms
Kit 1b female condoms
Kit 2A clean delivery kit (pregnant women)
Kit 2B clean delivery kit (birth attendants)
Kit 3 rape treatment
Kit 4 oral and injectable contraception
Kit 5 treatment of sexually transmitted infections
Block 2 : 30,000 people for 3 months, primary health care and referral
hospital level
Kit 6 clinical delivery assistance
Kit 7 intrauterine device
Kit 8 management of miscarriage and complications of abortion
Kit 9 suture of tears and vaginal examination kit
Kit 10 vacuum extraction delivery
Block 3 : 150,000 people for three months, referral / surgical obstetric
level
Kit 11 referral level kit
Kit 12 blood transfusion kit
17
3.2. Post-emergency settings
The choice of drugs can depend on many factors. The most important
factor is:
1. Relevance to pattern of prevalent diseases among refugees.
An essential drugs policy should focus on the public health needs of

the population of concern.
In primary health care settings, a disease or health problem based

approach is more practical than a drug-based approach where all
drugs currently used are listed, sorted by therapeutic category and
drug class reviews are performed to revise the list, taking cost, safety
and efficacy into consideration.
The design of local treatment guidelines and the design of the

essential drugs list are interdependent procedures; a first step is to
prepare a list of common health problems. A first-choice treatment
for each health problem on the list may be limited to one or more
drugs or to various forms of non-drug treatment. This choice of
treatment can be the basis of two important documents: the
essential drugs list for that level of care (health post, clinic,
hospital), which is a direct result of the selection, and a set of
treatment guidelines for that level of care, which requires additional
clinical information (diagnostic signs and symptoms and treatment
algorithms).
18
2. DRUG SELECTION
Figure 3 The list of common health problems guides the formulation of clinical guidelines, the
list of essential medicines, training financing, and supply – leading to improved patient care
List of common diseases and complaints
Treatment choice
Clinical guidelines List of essential medicines

National formulary
Financing and
Training and Supervision
Supply of medicines
Patient care and Information
Source: WHO Policy Perspectives on Medicines – The Selection of Essential

Medicines 2002
Other factors:
2. Suitability for use by health workers in the types of treatment

facilities established in refugee settings.
Figure 2 The essential medicines target: the national or institutional list of essential medicines
is a subset of registered medicines, divided by level of care
Registered medicines
All the
medicines National list
in the world of essential
medicines
Levels of use
CHW
S dispensary S
Health centre
Supplementary
Hospital specialist
medicines
Referral hospital
Private sector
Source: WHO Policy Perspectives on Medicines – The Selection of Essential

Medicines 2002
19
The choice of drugs available depends on the staff’s capacity to use them
effectively. Consequently, it is important to know the extent of staff training
and the availability of support facilities for each level of the healthcare
system before deciding where individual drugs will be made available.
Every program should have an essential drugs list, but this does not mean
that all drugs should be made available at every level of care (health post,
clinic, referral hospital). Under normal conditions, the number of drugs
available at a health facility increases with the level of health services
provided. In many settings, health facilities are operating beyond their
capacity (e.g. a health post functioning as a health center) due to lack of
resources, need, and poor geographical planning. In this case, a
pragmatic approach based on the staff’s capacity should be used to
ensure sufficient access to essential drugs.
3. Local considerations.
n The effects of local diseases or conditions on drug effectiveness
(e.g. malnutrition, liver disease);
n Local or regional differences in sensitivity and resistance of
microorganisms, in the case of anti-infective drugs;
n Regional differences in climate, topograpy, and other environmental
factors;
n Health requirements specified by countries of asylum/
resettlement for particular refugee groups (e.g. resettlement-
related health procedures);
n Level of services available locally in the host country;
n Anticipated local storage conditions (stability).
Think twice before including drug products that are sensitive to heat, light
or humidity in a setting where these factors are difficult or impossible to
control (e.g. in remote health centers in Sudan). Choosing the most
stable dosage form for a particular setting is part of the overall drug
quality assurance system. Choosing tablets rather than capsules,
ointments rather than creams, powder for reconstitution rather than
injectable solutions and avoiding syrups is a low-cost, high impact
intervention in maximizing the therapeutic lifespan of medicines in
extreme climatic conditions. See Chapter 6 “Drug Quality Assurance”.
20
2. DRUG SELECTION
4. Implementation issues
4.1. Developing a local Essential Drugs List
The essential drugs list developed for a refugee health program should be
based on the UNHCR Essential Drugs List (see Annex 1) which is
adapted to national standards. National standards are those established
by the lead health authority which is usually the national Ministry of Health.
A national standardized essential drugs list may have been established.
Some countries do not allow importation of drugs that are not included in
the national essential drugs list.
Where a national list is not available or incomplete (frequent in

post-conflict settings), the UNHCR Essential Drugs List is the most
appropriate reference. The UNHCR list has been developed after
cross-referencing with the WHO Model List of Essential Medicines and is
updated every 2 years. Any deviation from the national essential drugs list
should be discussed with the local health authorities. The national drugs
list has legal status, whereas UNHCR or WHO essential drugs lists only
remain a guideline until a country’s health authorities officially adopt it. As
far as possible, essential drugs lists (and also clinical treatment protocols
or guidelines) should be standardized across health agencies.
The UNHCR Health Coordinator, working with senior health staff of

partner agencies, should take the lead in the development or review of the
essential drugs list and standard treatment guidelines, and in the
coordination process with the local authorities and other agencies. Where
there is no UNHCR health coordinator, senior health staff of partner
agencies should assume this responsibility in coordination with the
Regional UNHCR Health Coordinator.
21
4.2. Organization of the UNHCR Essential Drugs List
As mentioned above, apart from developing a local essential drugs list,

levels of use should be established based on the level of supervision
needed for their safe and proper use. UNHCR classifies drugs as follows:
l Basic List
l Supplementary List
l Specialized List
The inclusion of a particular drug on the basic as opposed to the

supplementary list is only intended for guidance: the senior health
coordinator in any given situation will have to decide which medicines the
different levels of health workers are able to use. This will vary according
to the situation.
Basic List
This is the basic list of drugs from which a general distribution for
dispensaries and health centers can be chosen. The drugs are
considered appropriate for use by health workers who have completed a
satisfactory training program as approved by the senior health
coordinator, and for whom adequate and clearly defined supervision
exists.
As a matter of principle, the Basic List does not contain any injectables.
Most simple conditions can be managed with oral regimens. Choice of
particular antibiotics and anti-malarials to be used by first-level health
workers will be made by the senior health coordinator in consideration of
local endemicity and sensitivity patterns.
Supplementary List
This list contains drugs for use by more qualified personnel such as
physicians or other staff as approved by the senior health coordinator.
These drugs are for use only in more elaborate health facilities such as
camp health centers/clinics, which:
22
2. DRUG SELECTION
l are directly supervised by a physician or senior health worker;

l allow for the care and close monitoring of in-patients whenever
necessary;
l are adequately equipped to deal with reactions to the drugs listed.
Clearly, drugs used by more highly trained personnel also include those
specified in the Basic List.
Specialized List
These items are intended for use in the management of specific

conditions such as:
l Leprosy
l Leishmaniasis
l Contraceptive needs
l Yellow Fever
l Tuberculosis
l Malaria
l Snake bite
l Rabies
l Filariasis
l Meningococcal meningitis
l Schistosomiasis
Because many of the drugs specified in this list require careful supervision
and may have serious side effects, they must be administered only:
l after a protocol for safe and proper use has been approved by
appropriate supervisory personnel;
l when the approved protocol is understood and adhered to by field
personnel;
l when there is access to advice from qualified health personnel who are
experienced in the safe and appropriate use of the drugs listed;
23
l when provision exists for patients to be followed systematically to

ensure:
n adequate compliance with treatment,
n careful monitoring of each individual's response to medication,
n prompt recognition of side-effects.
Please note: Anti-retroviral medications (ARVs) for HIV/AIDs are

considered essential drugs and refugees should have access to them.
They are not, however, included on the general EDL list due to
complicated issues surrounding their use. They can be ordered using the
special request form (see Annex 2) after appropriate discussion with your
Regional HIV/AIDS coordinator and/or Technical Officers at HQ, and after
ensuring that the above criteria for the use of specialized drugs have been
met.
Summary Chart of Essential Drugs List

Who can
List Where to use? Needs?
use?
l Home visiting l Training
Nurse's aid, l Simple health clinics l Supervision
Basic List Community
health worker l Basic camp
dispensaries
l Larger health l Close supervision by
centres senior health worker
Basic & Doctor,
Suppl. Lists Senior nurses* l Camp health centres l Monitoring of
providing in-patient
in-patients
care
l Larger health
l Approved protocol
centres
l Camp health centres l Adherence to
Specialized Doctors, providing in-patient protocol
List Senior nurses* care in regions
l Access to specialist
where the specific
advice
disease entity or
need exists l Patient supervision
*Under the direction of the supervising physician

Source: UNHCR 1989
24
2. DRUG SELECTION
4.3. Developing local Standard Treatment Guidelines
The introduction of standard treatment guidelines, used in conjunction

with standard symptom/disease definitions, must be compulsory in all
refugee health programs. This is particularly necessary given the
numbers of agencies and personnel providing refugee health services,
the rapid turnover of staff, and the wide range of health workers involved.
These guidelines should cover the most common diseases and
complaints, be differentiated for the different levels of health care, and be
adapted to the competence of the health workers. For implementation of
standard treatment guidelines, see Chapter 5 “Rational Drug Use”.
25
References:
1. IDA website, www.ida.nl.
2. Interagency Pharmaceutical Coordination Group, Operational

principles for good pharmaceutical procurement, Essential Drugs
and Medicines Policy, Geneva, 1999.
3. International Rescue Committee, Essential Drugs and Medical

Supplies Policy, June 2004.
4. Management Sciences for Health, in collaboration with the World Health

Organization. Managing Drug Supply. 2nd ed., revised and expanded.
West Hartford, CT: Kumarian Press. 1997. Used by permission.
5. Medecins Sans Frontieres (MSF), Essential Drugs-Practical Guidelines,

3rd ed., 2001.
6. UNHCR, UNHCR Essential Drugs Manual-Guidelines for Use of

Drugs in Refugee Settings and UNHCR List of Essential Drugs,
Geneva, 1989.
7. WHO, Combination therapies and formulation of anti-malarial drug

policy, Tutor’s Guide, Trial Edition, July 2003.
8. WHO, Stability of Essential Medicines in Tropical Climates: Zimbabwe,

WHO/DAP/94.16. 1996,
http://www.who.int/medicines/library/dap/who-dap-94-16/.
9. WHO, The 14th Model List of Essential Medicines, 2005,

http://www.who.int/medicines/organization/par/edl/eml.shtml.
10 WHO, The New Emergency Health Kit, 2nd ed., 1998.
11. WHO, The Selection of Essential Medicines, WHO Policy Perspectives

on Medicines, June 2002.
12. WHO, WHO Expert Committee on the Use of Essential Drugs, WHO
Technical Report Series 914, World Health Organization, Geneva,
April 2002.
26
3. DRUG PROCUREMENT
Contents
I. GENERAL PROCUREMENT GUIDELINES FOR THE
UNHCR SUPPLY SYSTEM..............................................................29
1. Introduction .......................................................................29
2. Strategic objectives for good pharmaceutical
procurement......................................................................30
2.1. Procure the most cost-effective drugs in the right
quantities ...............................................................31
2.2. Select reliable suppliers of high-quality products ....31
2.3. Ensure timely delivery ............................................31
2.4. Achieve the lowest possible total cost .....................31
3. Operational principles for good
pharmaceutical procurement ............................................32
3.1. Efficient and Transparent Management .................32
3.2. Drug Selection and Quantification..........................32
3.3. Financing and Competition.....................................32
3.4. Supplier Selection and Quality Assurance ..............33
4. Drug procurement in UNHCR ...........................................33
4.1. Ordering Procedures for International Procurement...35
4.2. Estimating Drug Budget..........................................36
II. QUANTIFICATION ..........................................................................40
III. RECEIVING AND INSPECTING HEALTH COMMODITIES .......43
References .......................................................................................49
28
3. DRUG PROCUREMENT
I. GENERAL PROCUREMENT
GUIDELINES FOR THE UNHCR SUPPLY
SYSTEM
1. Introduction
Pharmaceutical procurement is a complex process that involves many
steps and people. Efficient procedures should be in place: to select the
most cost-effective essential drugs to treat commonly encountered
diseases; to quantify the needs; to pre-select potential suppliers; to
manage procurement and delivery; to ensure good product quality; and to
monitor the performance of suppliers and the procurement system.
Failure in any of these areas leads to lack of access to appropriate drugs
and to waste. In many supply systems, breakdowns regularly occur at
multiple points in this process due to:
l inadequate rules, regulations and structures;

l absence of a comprehensive procurement policy;
l internal procurement regulations conflicting with local regulations;
l lack of unbiased market information;
l lack of trained procurement staff.
Drug procurement for humanitarian agencies is further complicated by the

following specific constraints:
l Funding which is insufficient and/or released irregularly;

l Lack of timely access to reliable logistical data (inventory and
consumption data) for budget and procurement;
l Remote work settings in terms of communication, transport and
staff recruitment;
l Uncertainty regarding quality of locally purchased drugs;
l Delivery (logistics, long lead-times, geographical accessibility,
importation and customs procedures);
29
l Quantification (unstable population, seasonal morbidity patterns);

l Irrational use of drugs complicating forecasting of needs.
It needs to be emphasized that these drug procurement guidelines do not

aim to replace UNHCR’s general procurement guidelines (Chapter 8,
UNHCR Manual). They need to be used as a supplement since the
emphasis is not on compliance with internal accounting and procurement
guidelines, but on the more technical aspects inherent to highly specific
commodities such as drugs.
Also note that the procurement guidelines below do not apply to

humanitarian operations in emergency or disaster settings. Other
procurement mechanisms such as Emergency Health Kits apply in this
case. They are discussed as a special topic in this manual in Chaper 2,
Section 2.1 “Criteria for Drug Selection, Emergencies”.
2. Strategic objectives for good pharmaceutical

procurement
The twelve operational principles for good pharmaceutical procurement
are based on four strategic objectives.
Four strategic objectives of pharmaceutical procurement
2.1. Procure the most cost-effective drugs in the right quantities.

2.2. Select reliable suppliers of high-quality products.
2.3. Ensure timely delivery.
2.4. Achieve the lowest possible total cost.
Source: WHO 1999
30
3. DRUG PROCUREMENT
2.1. Procure the most cost-effective drugs in the right

quantities.
The first strategic objective is to develop an essential drugs list to make

sure that only the most cost-effective drugs are purchased. Procedures
must also be in place that accurately estimate procurement quantities in
order to ensure continuous access to the products selected without
accumulating excess stock.
2.2. Select reliable suppliers of high-quality products.
The second objective is that reliable suppliers of high-quality products

must be (pre-) selected, and that active quality assurance programs
involving both surveillance and testing must be implemented wherever
possible.
2.3. Ensure timely delivery.
The third strategic objective is that the procurement and distribution

systems must ensure timely delivery of appropriate quantities to central
stores and adequate distribution to health facilities where the products are
needed.
2.4. Achieve the lowest possible total cost.
The fourth objective is that the procurement and distribution systems must
achieve the lowest possible total cost. Every program can minimize the
total purchasing costs by choosing the optimal purchasing model for
their particular situation (e.g. annual or quarterly), taking into
consideration order interval, safety stock and the re-order formula used.
The quality of the drugs purchased should not be compromised

under any circumstances. Unlike other commodities, drugs must always
be purchased using VFM (Value For Money) criteria instead of Low Bid
criteria.
31
3. Operational principles for good pharmaceutical

procurement
3.1. Efficient and Transparent Management
1. Separation of key functions that require different expertise.
2. Transparency, written procedures and using explicit criteria to award

contracts.
3. Procurement should be planned properly and procurement

performance should be monitored regularly; monitoring should
include an annual audit.
4. Drug procurement should be limited to an essential drugs list defined

by the recognized lead health authority, or based on the UNHCR
Essential Drugs List adapted to national standards.
3.2. Drug Selection and Quantification
5. Procurement and tender documents should list drugs by their

International Nonproprietary Name (INN), or generic name.
6. Order quantities should be based on a reliable estimate of actual

need.
3.3. Financing and Competition
7. Ensure reliable payment and good financial management.
8. Procurement in bulk.
9. Competitive procurement methods- Authorized vendors.
10. Sole-source commitment in case of authorized vendors.
32
3. DRUG PROCUREMENT
3.4. Supplier Selection and Quality Assurance
11. Formal supplier qualification and monitoring.
12. Product Quality Assurance Program.
More detailed information is given in the Standard Operational

Procedures (see Annex 4, SOP Q1).
4. Drug procurement in UNHCR

It is UNHCR’s policy to principally purchase medical products
through international suppliers. These procurement agencies have
developed the expertise to ensure controlled quality at reasonable prices.
Local/regional procurement should only be considered where

international procurement is impossible or does not meet programme
objectives (eg. exit strategy enacted and programme in transition to
handover to local partners). Procurement should aim for timely availability
of drugs of good quality, safety and efficacy at the lowest available price.
As mentioned above, quality should not be compromised under any
circumstances and Value For Money criteria should be used, not the
Lowest Bid.
Local/regional procurement requires authorization from the regional

Senior Public Health Officer (or at HQ where no regional officer is
available) and from SMS HQ. Authorization is given for a specific list
of pharmaceuticals from a specific manufacturer in a specific
country for a specific period of time.
Local/regional procurement will only be authorised where specific criteria

are met. In countries where these criteria cannot be met, international
procurement may be the only option and this will need to be emphasized
with local officials who may argue otherwise. The criteria are:
l Approval from a trained quality assurance pharmacist that products

and suppliers are quality controlled. This should be either from a
partner INGO or, where the budget allows, through a UNHCR
consultant.
33
l Selection of supplier is through a transparent bidding process. The

committee deciding on the contract should include technical staff.
Procurement staff can have technical input but should not have voting
rights.
l Local suppliers have been pre-qualified by a committee of managers,
technical staff and a pharmacist before being eligible to bid, where the
annual budget is sufficient (See Ch.8, Sect. 2.4.3.5, UNHCR Manual).
Where the budget is insufficient or adequate technical expertise is not
available locally, collaboration with other health agencies (WHO,
UNICEF, ICRC, and health INGOs with capacity for verification of drug
quality such as MSF and PSF) is essential. Pre-qualification should
check: WHO certification scheme, supplier questionnaire, reference
checks, previous record of performance (quality, reliability, timely
delivery of supplies), site inspection, targeted lab testing (if available),
UN prequalified suppliers, test purchases.
l Suppliers are licensed with the government.
l The primary manufacturer is Good Manufacturing Practice (GMP)
certified according to WHO standards and regularly inspected for GMP
standards.
l The product is registered in the country of manufacture, preferably
through the WHO Certification Scheme on the Quality of
Pharmaceutical Products Moving into International Commerce
(http://www.who.int/medicines/organization/qsm/activities/drugregul/c
ertification/certifsc.haplha.html).
l The product is registered in the country of import.
l The product is accompanied by Certificate of Pharmaceutical Product.
l Batch certificates of selected drugs are provided on request.
l Supplies are subject to pre- and post-shipment inspection.
l Analytical testing is conducted routinely on critical products such as
life-saving drugs or IV fluids.
For more information on these points, see the Standard Operational

Procedures (Annex 4, SOP Q1).
The following drugs available from local suppliers are likely to be

automatically approved for purchase:
34
3. DRUG PROCUREMENT
l Drugs also purchased by an INGO with pharmaceutical quality

assurance capacity (such as MSF, PSF or ICRC).
l Drugs from local suppliers that have been purchased from
international procurement agencies.
l Drugs from suppliers that have been approved by the WHO
pre-qualification scheme for HIV/AIDS, tuberculosis and malaria
(http://mednet3.who.int/prequal/).
1
l Drugs from manufacturers that have been approved by PIC/S
countries and that have a market authorization for these countries.
4.1 Ordering Procedures for International Procurement
An order for medicines and medical supplies is prepared in the field by

senior staff of the partner agency, in coordination with the UNHCR health
coordinator where present. Orders must be quantified based on
consumption which is discussed in the next section and in SOPs P1 and
P2 (see Annex 4). The order should then be discussed with the
Programme Officer to confirm the budget. Finally, all orders must be
verified by a UNHCR Senior Public Health Officer. If there are any
concerns it is better to seek technical advice early. The Senior Public
Health Officer must verify by email that the order has been cleared and
this verification must be sent with the order to SMS at HQ through the
respective Desk Officer. Where an order cannot be verified at national or
regional level, the Desk Officer should forward it to the Senior Public
Health Officer at HQ to be cleared. After this, it will go to SMS for
processing.
All orders must be completed on the standard order forms (excel sheets)
which are available from SMS at HQ ([email protected]). The sheets
should not be altered in any way. They include pricing information to assist
with budgeting. Narcotic drugs, such as morphine and diazepam, require
import licenses which must be arranged upon request from SMS. In order
to avoid delays, it is critical that such licenses be completed exactly as
required otherwise the items are cancelled as suppliers cannot hold stock
for extended periods of time.
1 Austria, Denmark, Finland, Iceland, Liechtenstein, Norway, Portugal, Sweden, Switzerland, United
Kingdom, Hungary, Ireland, Romania, Germany, Italy, Belgium, France, Australia, Netherlands,
Czech Republic, Slovak Republic, Spain, Canada, Singapore, Greece and Malaysia.
35
Orders should be accompanied by details of the partner, duration of order,

size of population, and justifications (see Annex 2) for drugs not included
on the UNHCR Essential Drugs List, which generally take longer to
procure. Inclusion of this information will again avoid delays. Clear and
efficient communication is important in order to avoid confusion and to
have the order processed as quickly as possible. For more on this see
Annex 4 SOP P3.
4.2 Estimating drug budget
Operational experience from a variety of field settings has shown that

drug budgets that are less than 2 USD per capita per year are in most
cases insufficient to cover drug procurement for the most essential
primary health care needs. Note that this is the same amount available
as in countries with the lowest pharmaceutical expenditure per capita in
the world in 2000 (Democratic Republic of the Congo, Sierra Leone, etc.).
Using this figure as a benchmark, it means that for a population of 50000
refugees, at least 100000 USD (50000 pers. X 2 USD/pers.) should be
earmarked per year to cover most basic needs. The more efficient the
procurement system and the more rational drug selection is for programs,
the more this budget can be stretched. Note that for more expensive
newer drug treatments such as some anti-malarials (artemisinins) or
anti-retrovirals, special funds should be requested in addition to the basic
amount.
Figure 1 on the following page shows that procurement is really a cycle, as

good completion of one step initiates the next step. Figure 2, which
follows, focuses in more detail on the procurement steps between drug
selection and receipt of drugs.
36
DRUG SELECTION
Implementing partner, QUANTIFICATION
UNHCR health Implementing partner,
CONSUMPTION coordinator, Senior UNHCR health coordinator
INFORMATION Public Health Officer
Implementing partner, (technical advisor)
UNHCR health coordinator
NEEDS FUNDS
Programme officer,
UNHCR health coordinator
DISTRIBUTION
Implementing
partner, UNHCR
health coordinator
THE PROCUREMENT CYCLE CHOOSE PROCUREMENT

METHOD
37
Programme officer, UNHCR
Steps and players health coordinator
WAREHOUSE
STORAGE
Supply officer, Storekeeper
3. DRUG PROCUREMENT
LOCATE + SELECT
SUPPLIERS
Programme officer, Supply
officer, UNHCR health coordinator
RECEPTION + INSPECTION
Country office – Supply
officer, storekeeper FIX CONTRACT TERMS
MONITOR ORDER STATUS Programme officer,
UNHCR health UNHCR health coordinator
coordinator, Supply (technical),
officer, SMS Supply officer
(internationally) (delivery terms)
Figure 2: Drug procurement: Steps and Players
Players
Health, Central
Health, Health, Tender Health, store,
Health Procurement, Procurement Procurement Procurement
Procurement Procurement committee Procurement pharmacist
Finance
Steps
Quantification
Choose Locate and Monitor Reception
and Technical Prepare bid Receive and Award
Selection reconciliation procurement select order and
specifications documents evaluate bids contract
with budget method suppliers status inspection
Pre- Invitation to Compliance Bid- Order Document

* Essential * a. Product Ideally: analysis
qualification: bid with tracking review
drugs list Consumption information based
Restricted contract and system
(1. method on explicit
tender * Product Instructions delivery Regular Visual
national, * b. pre-defined
2. UNHCR) Morbidity Certification with registration to bidders requirements criteria: inspection
38
pre- * WHO communic
* Standard method
qualification Certification Technical 1. Quality ation Lab
treatment c.
Scheme specifications requirements between testing of
guidelines Pharmaco-
peial For smaller * Supplier critical
questionnaire Terms of 2. Technical Procurement products
standards orders: specifications
3 bidding *Reference contract and
and Health
d. Labeling procedure checks contract terms
* Site Product program
e. Packaging inspection quantity and 3. Delivery
* Targeted delivery schedule
lab testing requirements
*UN-pre- 4. performance
qualified
suppliers 5. Payment
terms
6. Lowest
possible
total cost
Supporting documents/standards
Note that some activities can occur in parallel with each other, such as product selection and quantification can occur while suppliers are being selected and
pre-qualified.
3. DRUG PROCUREMENT
Routine procurement tasks:
A suggested minimum frequency of certain procurement procedures is

presented in the table below. Procurement functions that are not
mentioned are either recurrent with every order or can be carried out
according to internal capacity.
Every 2
Annually Quarterly Monthly
years
Revision of essential
X
drugs list
Establish procurement
X
plan
Request budget for
X
drugs and supplies
Tender X
Pre-qualification of
X
suppliers
Collection and
reporting of logistical X
data
Inventory exercise
X
central store
Collection and analysis
of key procurement X
performance indicators
ABC and/or
VEN-analysis of past X
procurement
39
II. QUANTIFICATION
Quantification is the process of estimating the quantities of specific drugs
needed for procurement.
Indicators of poor quantification
The most common indicators of poor quantification of drug requirements

are:
l Frequent shortage of drugs.

l Excess stock or expiry of large quantities of drugs due to
overestimation.
l Irrational and ineffective prescribing:
Prescribers usually either shorten treatments in an attempt to stretch

their insufficient drug supply as far as possible, or substitute with
inappropriate alternative drugs. In extreme cases, the treatment may
be shortened to the point of ineffectiveness.
Note that irrational prescribing can be both the cause, as well as the
result of poor quantification practices.
Quantification methods
The accuracy and quality of an estimation of drug requirements will

depend on the accuracy and quality of the information available.
Past consumption is the most reliable way to predict and quantify future
demand, providing that the supply pipeline has been consistently full and
that consumption records are reasonably accurate. Such consumption
data must be adjusted in light of known or expected changes in morbidity
patterns, seasonal factors, service levels, prescribing patterns and patient
attendance. The downside of basing quantification only on past
consumption is that any existing patterns of irrational drug use will be
perpetuated.
40
3. DRUG PROCUREMENT
An alternative way of calculating needs according to the consumption-

method is to use issue data from the central distribution point (as
opposed to consumption data reported back from the peripheral facilities).
This will give information about the amount of drugs distributed to the
health facilities over a given period. Consumption data is preferred above
issue data because it provides a direct link with the end-users.
In cases where no reliable past consumption information exists (such as

new programs), the morbidity-based technique may be used to
estimate procurement requirements. This technique should also be used
periodically to counter-check the rationality of past consumption, by
comparing actual consumption with the estimated need to treat common
diseases based on standard treatment protocols and epidemiological
data. This combination of consumption and morbidity methods is
also useful in programs with a high seasonal variation in consumption of
certain drugs such as antibiotics or anti-malarials.
Given a well established drug supply system, good stock control,

reliable distribution and rational prescribing practices, the
consumption method provides the most accurate (and easiest)
prediction of future needs.
41
Summary on when to use each method:
Quantification Method Recommended

l When adequate funds are available
l When prescribing patterns are acceptable
l When health facilities have adequate and
uninterrupted drug supply
Consumption Method l When health facilities have reasonably good
stock management, complete and accurate
consumption data and stock out information
l When health facilities have low level of
wastage and losses
l When available data on consumption are
incomplete or unreliable
l When prescribing practices are expensive
and irrational because it provides a
systematic basis for improvement
Morbidity Method
l When the drug budget is unlikely to be
sufficient to meet estimated requirements
l For new or rapidly changing services or
when services are being substantially
reorganized
Sources: ARRA & UNHCR 2002, MSH 1997
For more on how to use these methods, see the Standard Operational
Procedures (Annex 4, SOP P1 and P2).
When funds are not available to purchase all drugs in the quantities that
were estimated to be needed, it is necessary to prioritize the
procurement list to match available financial resources. Various
techniques such as VEN (vital, essential and non-essential) analysis
and ABC analysis can be used to select priority drugs and to reduce the
quantities of less cost-effective drugs. An ABC analysis assembles data
from recent or projected procurements to determine where money is
actually being spent, allowing managers to focus first on high-cost items
when considering ways to reduce procurement costs. In a VEN-analysis,
the drug budget is organized according to health priorities: Vital drugs
(life-saving), Essential (not necessarily life-saving but able to cure severe
42
3. DRUG PROCUREMENT
illness) and Non-Essential (lower therapeutic value). Vital drugs should

always be purchased in sufficient quantity, no matter what, whereas for
Essential and certainly for Non-Essential drugs, there is more leverage. A
VEN priority list should be defined in advance of any decision related to
reducing procurement. These hands-on tools are discussed in detail in
publications listed under References at the end of this chapter.
III. RECEIVING AND INSPECTING

HEALTH COMMODITIES
When you receive health commodities:
1. Ensure there is sufficient storage space (before the shipment

arrives).
2. Prepare and clean the areas used for receiving and storing the
products.
3. Count the number of boxes received and separate damaged
and unsealed boxes from intact and sealed boxes.
4. Inspect all boxes for damaged or expired products. Damaged
and unsealed boxes should be checked immediately and in the
presence of the transporter.
5. Complete and sign the Delivery Note and release the
transporter.
6. Send all necessary documents to Finance for prompt payment.
7. If appropriately trained personnel are available, take product
samples to check for labeling, packaging and product
appearance using the checklist below.
8. Arrange all products on shelves or pallets and record entries in
stock records.
Source: MSH 1997
43
Source: John Snow, Inc./DELIVER 2003
Deliveries by the supplier remain the responsibility of the supplier until

arrival at the warehouse of UNHCR or the partner. The supplier is
responsible for insurance and all costs associated with damaged or
missing goods. Since drugs are very attractive commodities, especially in
developing countries or in countries at war, procedures on receiving the
drugs should be carried out promptly and thoroughly.
In order to ensure a timely payment, Delivery Notes should be sent out

when the goods arrive in-country. In case the goods are still under
clearance, it should be clearly marked on the Delivery Note, “Not
inspected, still in Customs”. UNHCR or partner can pay the supplier, and
still have the option to claim damaged or missing items. A paper trail is
necessary to support the claim that loss or damage took place before
UNHCR took delivery. Hence, it is important to note any damage to boxes,
missing boxes, etc. and have all parties involved sign off. For international
deliveries, the procurement department (SMS) at headquarters should be
informed immediately if anything is missing or damaged.
On reception at the warehouse, the number of boxes and the state in

which they are received should be checked immediately (note any signs of
damage or tampering). If the contents cannot be checked immediately,
44
3. DRUG PROCUREMENT
which is often the case for large shipments, the sealed and undamaged
boxes should be quarantined until inspection. The contents of the boxes
that are damaged or that have a broken seal should be inspected
immediately against the packing list2. Ensure that the items delivered
correspond to the items ordered, and that the quantities conform to those
on the delivery note.
A thorough inspection based on predefined criteria is essential for quality

assurance and as a precursor to any insurance claim. See checklists
below.
Discrepancies, variations, and damage are noted on the invoice. The

annotated invoice is signed and dated by a senior staff member.
Observations are summarized on the delivery report. One copy of the
delivery report is filed according to the purchase order to which it
corresponds (“invoice matching”). Finance can usually only pay a supplier
if the following documents are complete: Purchase Request (PR), a
verifiable vendor receipt, Bid-analysis, Purchase Order (PO) and Delivery
report.
Measures should be taken to ensure that rejected materials and

pharmaceutical products cannot be use. They should be stored
separately from other supplies while awaiting destruction or return to the
supplier. All communication concerning a shipment purchased through
SMS at HQ should be directed to SMS and not directly to the supplier.
After receiving procedures are completed, the drugs must be physically

stored in the warehouse and entered into warehouse documentation
(stock records, inventory list and warehouse register). It is important that
the correct unit appears in all warehouse records, and that the same unit is
used when dispensing to the patient (so tablets instead of boxes).
Received goods are moved to their allocated storage positions in the
warehouse, where they are stored in first-expiry/first out (FEFO) order
(see Chapter 4 “Drug Distribution, Medical Stores Management”). Now is
also the time to document supplier performance in the supplier file (back
order, delivery time, non-compliance with contract specifications).
2 Prepared by the seller, this document describes in detail the contents of each package in a
consignment of drugs, including drug strength, pack size, number of packs per carton, and number of
cartons per package. This helps the buyer check whether drugs actually shipped are in accord with
the packing list and the purchase contract.
45
Inspection Checklist for Drugs Received in the Warehouse:

Labeling:
1. Labeling should be in English and preferably one other official
language of WHO.
2. All labels should display at least the following information:
ð International Nonproprietary Name (INN) of the active ingredients
ð Dosage form
ð Quantity of active ingredient(s) in the dosage form (e.g. tablet,
ampoule) and the number of units per package
ð Batch number
ð Date of manufacture
ð Expiry date (in clear language, not in code)
ð Pharmacopoeia standard (e.g. BP, USP,)
ð Instructions for storage
ð Name and address of the manufacturer
3. A printed label on each ampoule should contain the following:

ð INN of the active ingredient(s)
ð Quantity of the active ingredient
ð Batch number
ð Name of the manufacturer
ð Expiry date
The full label should again appear on the collective package.
4. Directions for use, warnings and precautions may be given in

leaflets (package inserts). However, such leaflets should be
considered as a supplement to labeling and not as an alternative.
5. For articles requiring reconstitution prior to use (e.g. powders for
injection) a suitable beyond-use time for the constituted product
should be indicated.
Packaging:
1. Tablets and capsules should be packed in sealed waterproof
containers with replaceable lid, protecting the contents against light
and humidity.
2. Liquids should be packed in unbreakable leak-proof bottles or
containers.
3. Containers for all pharmaceutical preparations must conform to the
latest edition of internationally recognized pharmacopoeia standards.
4. Ampoules must have either break-off necks, or sufficient files must
be provided.
Source: MSH 1997
46
3. DRUG PROCUREMENT
Expiry date:
At time of shipment the product shall have at least 75% of its shelf life. Write
expiry date on the box in large letters and numbers, also on single containers
put on the shelf. In case that the expiry date is unsatisfactory (calculate
consumption until expiry date), return to supplier.
Appearance of the product:
All shipments:
Compare the goods with the supplier’s invoice and original purchase order or
contract. Note discrepancies on the Delivery Report. CHECK THAT:
n Number of containers delivered is correct
n Number of packages in each container is correct
n Quantity in each package is correct
n Drug is correct
n Dosage form is correct (tablet, liquid, other form)
n Strength is correct (milligrams, percentage concentration,)
n There is no visible evidence of damage (describe)
Take a sample for testing if required.
Tablets:
For each shipment, tablets of the same drug and dose should be consistent.
CHECK THAT:
n Tablets are identical in size
n Tablets are identical in shape
n Tablets are identical in color (shade of color may vary from batch to
batch)
n Tablet markings are identical (scoring, lettering, numbering)
n There are no defects (check for spots, pits, chips, breaks, uneven edges,
cracks, embedded or adherent foreign matter, stickiness)
n There is no abnormal odor when a sealed bottle is opened
Source: MSH 1997
47
Appearance of the product, cont’d
Capsules:
For each shipment, tablets of the same drug and dose should be consistent.
CHECK THAT:
n Capsules are identical in size
n Capsules are identical in shape
n Capsules are identical in color (shade of color may vary from batch to
batch)
n Capsule markings are identical
n There are no defects (check for holes, pits, chips, breaks, uneven edges,
cracks, embedded or adherent foreign matter, stickiness)
n There are no empty capsules
n There are no open or broken capsules
Parenterals:
Parenterals are all products for injection (IV liquids, ampoules, dry solids,
suspensions for injection). CHECK THAT:
Solutions are clear (solutions should be free from undissolved particles, within
permitted limits)
n Dry solids for use in injections are entirely free from visible foreign
particles
n There are no leaking containers (bottles, ampoules)
Source: MSH 1997
48
3. DRUG PROCUREMENT
References:
1. Administration for Refugees and Returnees Affairs (ARRA) and
United Nations High Commissioner for Refugees (UNHCR) in
collaboration with School of Pharmacy, AAU, and Drug Supply
Management Drug Administration and Control Department,
Continuing Education on Drug Supply Management and Rational
Drug Use for Health Professionals Practising in Refugee Camps of
Eastern and Western Ethiopia, 2002.
2. International Rescue Committee, Draft Drug Receipt Guidelines,

2003.
3. International Rescue Committee, Drug quality assurance guidelines,

draft, March 2005.
4. International Rescue Committee, Logistics Technical Support Unit

(LTSU) Manual, Inventory Management, 6. Receipt of materials,
2001.
5. John Snow, Inc./DELIVER in collaboration with the World Health

Organization, Guidelines for the Storage of Essential Medicines and
Other Health Commodities. 2003. Arlington, Va.: John Snow,
Inc./DELIVER, for the U.S. Agency for International Development.

permission.
7. UNHCR, The procurement cycle: Steps and players, comments to

draft, PowerPoint presentation, E. Bogale and N. Makki, First Drug
Management Conference, Nairobi, Kenya, March 1-4, 2005.
8. United States Pharmacopeia Drug Quality and Information (USP

DQI), Ensuring the Quality of Medicines in Resource-Limited
Countries: An Operational Guide, working document (restricted),
March 2005.
49
9. WHO, Estimating drug requirements, A practical manual, Action

Programme on Essential Drugs, Geneva, 1988, reprinted 1990,
1991.
10. WHO, Guide to Good Storage Practices for Pharmaceuticals,

(Annex 9 to the Thirty-seventh Report of the WHO Expert Committee
on Specifications for Pharmaceutical Preparations), 2001.
http://www.who.int/medicines/library/qsm/good_storage.pdf.
11. WHO, Operational principles for Good Pharmaceutical

Procurement, Essential Drugs and Medicines Policy, Interagency
Pharmaceutical Coordination Group, Geneva, 1999.
12. WHO, Practical Guidelines on Pharmaceutical Procurement for

Countries with Small Procurement Agencies, Regional Office for the
Western Pacific, Manila, Philippines, 2002.
13. WHO, The World Medicine Situation, Geneva, 2004.
50
4. DRUG DISTRIBUTION
Contents
I. MEDICAL STORES MANAGEMENT .............................................53
1. Objectives of Good Medical Stores Management..............53

II. ARRANGING HEALTH COMMODITIES ......................................54
1. Stock rotation ....................................................................55

2. Organizing the store room in a logical way ........................56
3. Special storage conditions................................................57
4. Controlled substances ......................................................58
5. Attractive items .................................................................58
6. Flammables and corrosives..............................................59
III. MAINTAINING THE QUALITY OF PRODUCTS ..........................61
1. Stability – Expiry Date – Deterioration-Quality standards ..62

2. Storing health commodities ..............................................65
2.1. Controlling temperature..........................................66
2.2. Preventing damaging and contamination................69
2.3. Protecting against fire ............................................70
2.4. Protecting against pests.........................................72
2.5. Protecting against theft ..........................................74
IV. KEEPING TRACK OF PRODUCTS IN A MEDICAL STORE ......77
1. Stock cards .......................................................................77

2. The physical inventory ......................................................78
3. Summary of forms and records .........................................82
V. REORDERING HEALTH COMMODITIES ...................................83
VI. ROUTINE MEDICAL STORE MANAGEMENT..........................84
References .......................................................................................85
52
I. MEDICAL STORES MANAGEMENT
1. Objectives of Good Medical Stores

Management
1. To guarantee a continuous supply of drugs and medical supplies.
2. To maintain the quality of drugs during the whole distribution

process.
3. To minimize losses through expiration and deterioration.
4. To control theft and corruption.
5. To keep accurate inventory records.
6. To provide stock movement information in order to forecast needs.
7. To use transport means efficiently.
53
II. ARRANGING HEALTH COMMODITIES
Source: John Snow, Inc./ DELIVER 2003
Arrange the storeroom and shelves as follows:
If using pallets (more likely in a central facility than a health center), stack
cartons on pallets:
l at least 10 cm (4 inches) off the floor;

l at least 30 cm (1 foot) away from the walls and other stacks;
l no more than 2.5 m (8 feet) high (general rule).
For all storage:
l Follow the manufacturer’s or shipper’s directions when stacking,

and follow labels for storage conditions.
54
l Place liquid products on the lower shelves or on bottom of stacks.

l Store products that require cold storage in appropriate temperature
controlled zones.
l Store attractive and controlled products in appropriate security
zones.
l Separate damaged or expired products from the usable stock
without delay, and dispose of using established disposal procedures.
l Always store all commodities in a manner that facilitates FEFO (“First
Expiry First Out”) rule for stock management.
l Arrange cartons so arrows point up and identification labels, expiry
dates, and manufacturing dates are visible. If this is not possible, write
the product name and expiry date clearly on the visible side.
Pharmacies without shelves or pallets are not pharmacies!!!
1. Stock Rotation
When issuing products, it is important to follow the FEFO (“First Expiry
First Out”) rule. Following FEFO minimizes wastage from product
expiration.
l Remove regularly all expired items from the store and check for
near-to expiry drugs which cannot be used completely.
l Mark all containers and boxes with the expiration date of the drug.
l Arrange stock according to FEFO to allow stock rotation. Put drugs
with the earliest expiration date in front/on top and drugs with the latest
expiration date in the back/below.
l Do not divide drug stocks for same products over different locations.
l Record the expiration date for every drug during physical inventories
(provide a column for expiration date on the inventory sheet).
Remember that the order in which products are received is not necessarily
the order in which they will expire. Products received more recently may
expire sooner than products received earlier. So, it is extremely important
55
to always check expiration dates and make sure the dates are visible
while the products are in storage.
Source: John Snow, Inc../DELIVER 2003
2. Organizing the store room in a logical way

l Remove all unnecessary items (medical + non-medical) from the
store after a thorough inventory exercise.
l Stock is most easily arranged according to the following
classification:
n oral drugs
n injectable drugs
n infusions
n drugs for external use and disinfectants
56
n reagents and laboratory materials

n small consumable materials classified in subcategories:
o dressings
o injection materials
o sutures
Within each category, products (oral, injectable, external use) are

classified alphabetically.
Each product should have a designated place, well identified by a fixed

label. The label should indicate the generic name, form and dosage, e.g.
AMOXICILLIN 250 MG TABLET.
Provide sufficient space between and for each drug.
Arrangement should allow fast inspection.
It should be possible to note the number of each box and evaluate

in a few minutes, current stock or monthly consumption of a
product.
An empty space behind a label means a stock rupture.
This organizational system is indispensable for easy and efficient

management. Only a few hours should be needed to do a complete
inventory.
3. Special Storage Conditions

Some products need storage in an access-controlled environment. It is
important to identify products that are at risk of theft or abuse or have the
potential for addiction (“controlled substances”), and to provide
increased security for these items. This includes products (“attractive
items”) that are in high demand or have the potential for resale (illicit
markets). Other products such as flammables and corrosives pose risks
of fire, product contamination or bodily injury and should be stored
separately from drugs.
57
4. Controlled Substances
Controlled substances should be kept in a locked cupboard or in a safe
to which only one or two persons have access. Every entry and exit should
be recorded in a register, which can be found in the cupboard or safe.
Narcotic drugs, also called “dangerous drugs” are governed by special
legislation and regulations that control import, export, production, supply,
possession, prescribing, record keeping, and retention of documents.
Typical examples are:
Narcotics: morphine, opium preparations, pethidine, tramadol and

ketamine
Other opioid and strong analgesics: pentazocine, codeine,

dihydrocodeine, dextroproproxyphene
Psychotropic drugs: usually the group of drugs called

“benzodiazepines,” of which diazepam is the best-known example.
Strong tranquilizing medicines, such as chlorpromazine, may also be

found under this heading.
5. Attractive items
Some non-controlled items are particularly prone to theft, abuse, or
misuse. These include expensive drugs (cimetidine, praziquantel, snake
anti-venom, quinine, anti-retrovirals, artemisinin anti-malarials), certain
antibiotics, minor medical equipment such as scissors, dressing sets,
safety razors, hypodermic needles, and rolls of cotton. Such items should
be stored in a separate locked area and require stricter record keeping
and more frequent stock taking than other items. Periodic audits should be
made of consumption (issues) against actual recorded use (outpatient
registers, prescription records, or ward stock records) to expose any theft
or misuse.
58
6. Flammables and corrosives

Bulk supplies of flammables, such as alcohol, ether, acetone, kerosene
must be stored in special buildings or rooms. A separate building is best,
since this greatly reduces the risk of fire spreading to the central store.
Fuel must always be stored in a separate building. The flammables store
must be well ventilated and fireproof, and fitted with an “explosion hatch”,
which may be part of the roof or part of a wall.
A small working stock of flammables may be kept in a steel cabinet in

well-ventilated premises, away from open flames and electrical
appliances. The cabinets should be marked “highly flammable liquid” and
bear the international hazard symbol. In addition, the shelves of the
cabinet should be designed to contain and isolate spillage. Always store
flammables in their original container.
59
Flammable liquids each have a flash point, which is the minimum

temperature at which the liquid gives off vapor in sufficient concentration
to form an ignitable mixture with air near the surface of the liquid. The flash
point indicates the susceptibility to ignition.
l Acetone and anesthetic ether have a flash point of –18°C.

l Undiluted alcohols have a flash point of 18° to 23°C.
l The flash point for kerosene is 23° to 61°C.
It is not necessary to store flammables below their flash point, but it is very
important to store them in the coolest location possible and never in
direct sunlight. It is important to control the evaporation rate and avoid
the build-up of pressure.
Corrosives or oxidant substances, such as trichloracetic acid, glacial

acetic acid, concentrated ammonia solutions, silver nitrate, sodium
nitrite, and sodium hydroxide pellets, should be stored away from
flammables, ideally in a separate steel cabinet. Appropriate industrial-type
protective gloves and face-masks should be used when handling them.
60
III. MAINTAINING THE QUALITY OF

PRODUCTS
1. Stability – Expiry Date – Deterioration-Quality standards.
2. Storing health commodities:

2.1. Controlling temperature – The Cold Chain.
2.2. Preventing damage and contamination.
2.3. Protecting against fire.
2.4. Protecting against pests.
2.5. Protecting against theft.
61
1. Stability-Expiry Date-Deterioration-Quality
Standards
A drug product must retain its properties within specified limits in order to
be useful. The time that a drug’s stability is guaranteed is usually
established by the manufacturer. In most countries, manufacturers are
bound by law to have the stability of their products tested under standard
conditions. They have to be able to ensure a minimum period of
preservation. This period ends with the product’s expiry date.
The stability of a drug product depends on the active ingredient, which can
be affected by its formulation and packaging. Inadequate storage and
distribution can lead to physical deterioration and chemical
decomposition, reduced potency, and occasionally, formation of toxic
by-products of degradation. This is more likely to occur under tropical
conditions of high ambient temperature and humidity. Being well
acquainted with the normal characteristics of every drug, like color, smell,
solubility and appearance, is essential. These normal characteristics or
quality standards can also be found in pharmaceutical references like
Martindale, Merck-Index and pharmacopeia (see Chapter 6). This method
allows qualified staff to detect any changes as soon as they occur. Certain
processes may however occur without any detectable change in the
appearance of the products!
Damaged products should never be issued to facilities or dispensed to

patients. If you are not sure if a product is damaged, check with someone
who knows. Do not issue or dispense products that you suspect are
damaged. Report any defects and send the defective products back to the
facility that issued them to you.
62
Indicators of quality problems:

Products of different types show damage in different ways.
Some indicators you can use to detect damage are
Light-sensitive products (such as x-ray film)
l torn or ripped packaging
Latex products
l dry
l brittle
l cracked
All products
l broken or ripped packaging (vials, bottles, boxes, etc.)
l missing, incomplete, or unreadable label(s)
Liquids
l discoloration
l cloudiness
l sediment
l broken seal on bottle
l cracks in ampoule, bottle, or vial
l dampness or moisture in the packaging
Lubricated latex products
l sticky packaging
l discolored product or lubricant
l stained packaging
l leakage of the lubricant (moist or damp packaging)
Pills (tablets)
l discoloration
l crumbled pills
l missing pills (from blister pack)
l stickiness (especially coated tablets)
l unusual smell
Injectables
l liquid does not return to suspension after shaking
continued
63
Sterile products (including IUDs)

l torn or ripped packaging
l missing parts
l broken or bent parts
l moisture inside the packaging
l stained packaging
l Capsules
l discoloration
l stickiness
l crushed capsules
Tubes
l sticky tube(s)
l leaking contents
l perforations or holes in the tube
Foil packs
l perforation(s) in packaging
Chemical reagents
l discoloration
Question: Can expired drugs be used?
Answer: NO!
Expired drugs should never be used (unless as a last solution in case of

an emergency); not only can their potency be decreased, but more
serious effects like increased allergic reactions (penicillin) or even
formation of toxic substances (tetracycline) can occur. Also changes in
formulation (suppositories, creams) or decrease in solubility (oral
re-hydration salts) can occur.
Note that the expiry date given by the manufacturer is tentative and
marks the end of the period for which safe and effective use of the drug is
guaranteed. Expiry dates are usually based on stability studies done for
moderate climates, so it is fair to assume that many drugs stored in an
extreme climate have lost most of their potency by the expiry date (if not
before this date for some unstable drugs).
64
2. Storing Health Commodities

It is essential to follow the product manufacturer’s storage
instructions as much as possible. The product must be kept in the most
suitable conditions available and used as quickly as possible. The product
manufacturer should be consulted before violating recommended storage
conditions to determine how long the product will remain safe and
effective under the actual storage conditions.
The use of the following labeling instructions are recommended:
On the label Means
“Do not store over 30 °C” from +2 °C to +30 °C

“Do not store below 8 °C” from +8 °C to +25 °C
“Protect from moisture” no more than 60% relative humidity in
normal storage conditions; to be
provided to the patient in a moisture
resistant container.
“Protect from light” to be provided to the patient in a
light-resistant container.
If no specific storage instructions are given, normal storage conditions

apply. Normal storage conditions for drugs have been defined as
“storage in dry, well ventilated premises at temperatures of +15ºC to
+25ºC, or, depending upon climatic conditions, up to +30ºC.
Extraneous odors, other indications of contamination and intense
light must be excluded” (WHO 1990). The +15ºC to +25-30ºC zone is
assumed to be air-conditioned and therefore, humidity controlled. In
temperate climates, this temperature range can be achieved without
air-conditioning, but humidity control (dehumidifiers) may still be
necessary.
65
2.1. Controlling temperature
Humidity
When product labels say “protect from moisture,” store the product in a
space with no more than 60% relative humidity. To reduce the effects of
humidity consider:
l Ventilation: Open the windows or air vents of the storeroom to allow

air circulation. Ensure that all windows have screens to keep out
insects and birds, and that all windows either have bars or are not open
wide enough for anyone to climb in. Put boxes on pallets and ensure
there is space between pallets and the walls of the storeroom.
l Packaging: Secure all lids. Never open a new container unless
necessary.
l Circulation: Use a fan to circulate fresh (outside) air. In bigger
storerooms you may need a ceiling fan. Standing fans are more useful
in smaller storerooms. This requires electricity and some
maintenance.
l Air conditioners: If possible, use an air conditioner. This is costly,
depends on a constant supply of electricity, and requires regular
maintenance. Depending on climatic conditions, a dehumidifier may
be a less costly option. However, they also need a constant supply of
electricity and require regular attention to empty the water containers.
Sunlight
Some health products are photosensitive and will be damaged if exposed

to light. These include multi-vitamins, furosemide, chlorpheniramine
maleate, hydrocortisone, intravenous solutions in plastic bottles, rubber,
cellulose, plastic or latex1 products (such as male condoms), and x-ray
film.
1 Condoms, most sterile disposable medical devices, and surgical products such as syringes, needles,
and catheters require protection from excessive humidity, cold, and strong light. Any of these
conditions may make products brittle, stained, malodorous, and unusable. Sterility cannot be
assured if packaging is damaged. Items remain sterile even after the expiry date as long as
packaging is intact.
66
To protect products from sunlight:
l Shade the windows or use curtains, if they are in direct sunlight.

l Keep products in cartons, especially injectables.
l Do not store or pack products in sunlight.
Heat
Remember that heat will affect many products. It melts ointments, creams
and suppositories and causes other products to become useless.
Following the guidelines listed earlier for protecting products from
humidity and sunlight will also help protect products from heat.
67
Monitoring
Consistently monitor the temperature of the different areas within the

storeroom.
Keep thermometers at the hottest places in the store and check

temperatures during the hottest part of the day. If you do not have
thermometers, you can still monitor the heat. If you feel hot, your products
are probably hot, too. Temperature monitoring of the cold chain is even
more rigorous.
68
Drugs Found to Have Stability Problems under

Tropical Conditions
Oral solids (tablets/powder for suspension) Oral liquids (syrups)

Acetylsalicylic acid Paracetamol
Amoxicillin
Ampicillin Injectables
Penicillin V Ergometrine
Retinol (Vit. A) Methylergometrine
Sources: Sakolchai et al. 1989: WHO/UNICEF 1991; Hogerzeil et al. 1992, 1993
Other drugs that are relatively unstable are: cloxacillin (tablet, capsule or
powder for suspension), nitroglycerine (glyceryltrinitrate) tablets,
phytamenadion (vitamin K) injection, paracetamol tablets (grey or
black discoloration due to molding).
Freezing is as damaging as high temperatures for some items, including

injectable contraceptives, ergometrine, insulin, adrenaline. Loss of
potency in ergometrine injection because of heat has frequently been
found in field studies and may also be detected visually. If the solution
appears colored when compared with water, the injection has less than
90% of stated content and should be discarded.
Short periods at room temperature (during transportation or local

distribution, for instance) are acceptable for many products (such as
ergometrine and insulin), even though such exposure can, to some extent,
reduce shelf life. Other items, such as vaccines, should always be
transported in cold boxes.
2.2. Preventing damage and comtamination
Physical damage
Avoid crushing products stored in bulk. Products should be stacked no

more than 2.5 m (8 feet) high, as a general rule. Heavier or fragile items
(such as those packaged in glass) should be placed in smaller stacks.
69
Bind sharp edges or corners in the store with tape. Most importantly,
ensure that nothing in the store can fall and injure staff members.
Dirt
Write and post the schedule and instructions for cleaning the storeroom in
multiple locations around the facility. Sweep and mop or scrub the floors of
the storeroom regularly. Wipe down the shelves and products to remove
dust and dirt. Dispose of garbage and other waste often, in a manner that
avoids attracting pests. Store garbage in covered containers.
Infrastructure: Ensure the storeroom has easy access to a water outlet

for cleaning.
Cleaning materials: Keep a budget for buying cleaning materials. Use

industrial detergents when possible, particularly for larger facilities,
although imported detergents can be expensive. Try to use locally
available detergents, particularly for smaller or more remote facilities.
Clean with chlorine bleach at least once a month.
Outside the facility: Burn garden rubbish and cardboard cartons, etc.
when garbage collection is not available. Use the necessary precautions
to keep the fire under control, and do not burn materials close to the
building. Make sure the wind is not blowing toward the building.
2.3. Protecting against fire
To prevent damage to products from fire:
l Strictly prohibit smoking in the store.

l Conduct fire drills for personnel every 6 months.
l Clearly mark emergency exits and check regularly to make sure they
are not blocked or inaccessible.
70
l Display fire precaution signs in appropriate places in the storage facility

(especially locations where flammables are stored).
l Minimize the number of flammables stored in the store. Do not allow
flammable trash to accumulate.
l Make standard fire extinguishers available in every storage facility

according to national regulations.
l Visually inspect fire extinguishers every 2–3 months to ensure that
pressures are maintained and that the extinguisher is ready for use.
l Service fire extinguishers at least every 12 months.
l Place smoke detectors throughout the storage facility and check them
every 2–3 months to ensure that they are working properly.
71
l Use sand to extinguish fires where there are no fire extinguishers.

Place buckets of sand near the door.
2.4. Protecting against pests
Prevention inside the storage facility:
l Design or modify the storeroom to facilitate cleaning and prevent

moisture.
l Maintain a clean environment to prevent conditions that favor pests.
For example, store garbage in covered garbage bins. Regularly clean
floors and shelves.
l Do not store or leave food in the storage facility. Do not allow staff to
eat or drink in the storage area. Provide a designated place for eating.
l Keep the interior of the building as dry as possible.
l Paint or varnish wood, as needed.
l Use pallets and shelving.
72
l Prevent pests from entering the facility. Rats are known to consume
certain types of IV-fluids.
l Inspect the storage facility regularly for evidence of pests.
Prevention outside the storage facility:
l Regularly inspect and clean the outside premises of the storage

facility, especially areas where garbage is stored. Check for any rodent
burrows, and ensure that garbage and other waste is stored in covered
containers.
l Check for still or stagnant pools of water in and around the premises,
and ensure that there are no buckets, old tires, or other items holding
water.
l Treat wood frame facilities with water sealant, as needed.
l Use mercury vapor lighting where possible, and locate lighting away
from the building to minimize the attraction of pests.
73
2.5. Protecting against theft
During transport:
l Verify documents.
l Ensure packing seals are used.
l Use strong boxes/containers.
l Provide reliable/well-maintained vehicles.
l Ensure drivers are reliable.
l Ensure rapid clearance at air and sea ports and through on-land
borders.
At storage facilities:
l Limit access to only designated staff.

l Limit the number of keys made for the facility; keep a list of people who
have keys.
l Secure all locks and doors.
l Make unannounced spot checks.
l Provide independent stock count/inventory control.
In health centers:
l Lock the storeroom/cupboards.

l Have stock cards for each product.
l Set maximum dispensing quantities.
l Have dispensers record individual prescriptions and maintain
prescription or dispensing registers (daily dispensing tally sheets,
monthly consumption sheets).
l Limit dispensing to authorized staff members only.
74
Monitor selected products:
As additional protection against theft, monitor items that are fast moving,
chronically in short supply, in high demand by patients, expensive, life
saving, and easy to hide or disguise.
Most common security breaches at the hospital or health center level:
By health staff:
n petty theft (“leakage”) by health staff for personal and family use.
n systematic diversion of larger quantities for illicit markets or for use in
private practice.
n writing of multiple prescriptions to the same person or to false names
(“ghost patients”).
n systematic over-ordering of drugs for use in private practice.
By patients:
n patients faking illness to obtain drugs for resale (refugee camps!) or
home storage.
n visits by patients to several health centers (“drug shopping”) to obtain
popular resale items (especially in refugee camps with multiple health
facilities in close proximity).
Source: MSH 1997
Two techniques for monitoring medicines:
Select medicines which are likely to be stolen or misused (e.g. antibiotics,

narcotics, psychotropics, anti-retrovirals).
1. Check inventory records for stock on hand. Then, conduct a physical

inventory (physically count the quantities on hand) and compare the
results.
2. Alternatively, compare stock records with prescription or dispensing

records:
1. Check the inventory records to determine the consumption
during a specified period.
Example, 8000 tablets were issued during a 3-month period.
75
2. Check medical charts or prescription ledgers and count the

number of treatment courses during the same period.
Example: 101 adults were dispensed 56 tetracycline tablets
each.
3. Convert treatment courses into dose units.
Example: 5656 tablets.
4. Compare this figure with the stock issued from the storage
area.
If you find a significant discrepancy, investigate further.
O Accountability of pharmacy store staff and

supervisors
Security management is as much a part of the job of a storekeeper

as are drug storage and proper record keeping. In case of loss of
drugs through theft or corruption, storekeepers should be held
accountable. This means that they will have to demonstrate:
1. they are not involved actively or passively, and
2. they have done everything possible to have prevented this

from occurring through proper store management.
Supervisors (Health Coordinators and Logistics Coordinators) will

need to demonstrate regular supervision of stores and store
records since security breaches are usually the result of poor
supervision.
76
IV. KEEPING TRACK OF PRODUCTS IN

A MEDICAL STORE
1. Stock cards
The stock card is the most important record for stock management. It
shows stock movement over time and gives an exact figure of the amount
that is available for a certain item at a given point in time.
Stock cards should be updated in the following cases:
l With every stock movement (entry/exit);

l During every physical inventory. The physical quantity verified during
the inventory should be filled out on the stock card. Every difference
between physical quantity and recorded quantity should be explained
under the ‘Remarks’ column;
77
l In case of loss (expiration, waste, theft,).
On the stock card, the following should be mentioned:
l the generic name, the form (tablet, ointment, etc.) and the strength of
the product;
l all movements (entries, exits, origin, destination, stock) and the
dates;
l unit: tablet, tube, bottle, piece, etc. (very important);
l expiry date: in bigger stores, same products with different expiry dates
should have separate stock cards;
l indication of physical inventories and dates.
If stock cards are well kept, there will be no losses.
Very important: update stock cards after every movement. Always use
inerasable ink and never use a pencil. Every correction should be justified
and reported to the supervisor. Never throw away old stock cards.
2. The physical inventory

Before every new drug order, a comparison of the physical stock (what is
counted on the shelf) and the theoretical stock (written on stock cards)
should be carried out. This is called an inventory. An inventory identifies
discrepancies (or differences) between the stock that is available and
the stock that should be available according to stock records. The goal of
the inventory exercise is to determine the physical stock, but also to
identify and explain any discrepancies (due to miscalculation, omission,
theft, unexplainable losses). Other reasons for inventory exercises can
include checking the quality of the stored products, correcting records
where necessary, or organizing the store room.
78
Example of physical inventory form
Inventory for the month of:

Date:
Health center:
Item Expiry Quantity Quantity Difference Remarks
date Stock counted
card
ASA 500 mg tablets 11/2004 2400 2346 54 Calculation
error on
stock card
Amoxicillin 500 mg 10/2005 550 550 0
tablets
To conduct an inventory in a central medical store:
1. Choose a date in advance, and set a cut-off date several days

earlier. Beyond that date, no movement of incoming and outgoing
drugs should be allowed. When there is no alternative, incoming
drugs should be kept aside until after the inventory (not included) and
outgoing drugs should be included.
2. Prepare the inventory area. Make sure that cartons are neatly
stacked so that all commodities are readily accessible, and any
partial (open) cartons are visible and not concealed under full
cartons.
3. Arrange for staff to be present on the day of the inventory if cartons

will need to be moved and restacked. An inventory should be carried
out by the pharmacy staff AND their supervisor.
4. Collect more people if necessary, and explain to non-medical staff

very clearly how to perform the inventory and emphasize the
importance of writing the exact description, unit, package size and
eventually unit price.
5. Count the usable products:

è Begin at one end of the aisle and work to the other end before
starting the next aisle.
79
è Go from top of the shelves to the bottom. Do not skip any stacks
or rows.
è Record all counts in basic units rather than boxes or tins
because the quantity of their contents varies according to
supplier. Basic units are the smallest unit (tablets, capsules,
tubes, syringes, ampoules, bottles) in which drugs can be
dispensed to a patient. Be sure to count the actual quantities in
partial (open) cartons.
è To be accurate, two people should do separate physical counts
and then compare them. If the two counts are not the same, a
recount should be made of the items in question until the cause of
the discrepancy is discovered.
è Any damaged or expired supplies should be recorded on a
separate sheet specifically for this purpose. These supplies are
removed from the stock. Expiry dates for every item should be
recorded and nearly-to-expire drugs should be marked.
6. Update the stock records:

è Record the amounts on the stock cards and write ‘Physical
Inventory’ in the remarks column.
è If the inventory amount is different from the calculated amount,
note in the remarks column that you are making a correction. For
example, “Corrected by physical count” or “Found expired during
inventory”.
è The inventory record form should be signed and dated by the
person(s) who performed the inventory and the Storekeeper. The
form should be filed as a permanent record.
7. Take action based on the result of the physical inventory:

è If no discrepancies are found, congratulate your staff.
è In case a discrepancy is found, the correct physical quantity
should be written on the stock card in a different color. If
discrepancies are large or frequent, further investigation should
be carried out to find the cause and to take action (tighten security
or repeat training in record keeping).
80
Discrepancies could be caused by:

l Miscount during the current inventory or a previous inventory.
l Items previously removed from inventory or received into inventory but
not recorded on the stock cards.
l Missing a carton during the inventory.
l Damaged or expired drugs recorded on a separate sheet but not
deducted from the balance on the stock card.
l Items not in their proper place.
l Theft.
Record the reasons for any discrepancies on the physical inventory form.
In larger warehouses the complete physical inventory process may be

disruptive to the store’s activities. It is always best to choose the least busy
time of the quarter to take a complete physical inventory.
An alternative method is cycle counting or continuous physical inventory.

With this method, one or a few products are counted at a time each day,
week, or month, rather than closing down the warehouse and counting
everything on the same day. The sampling procedure might be simple (for
example, count one product during the first week of each month, so that
everything is counted at least once per year), or more targeted (count all
expensive or fast-moving items twice per year, and count the rest only
once). Cycle counting strategies require more thought, but are less
disruptive to routine warehouse operations.
81
3. Summary of forms and records to keep at

the central and peripheral level
Type of Health center
Central pharmacy
document pharmacy
Records Stock card Stock card
Delivery schedule Daily Consumption Tally
Temperature monitoring sheet Sheet
Forms Waybill Requisition form*

Waybill
Reports Quarterly inventory Monthly Inventory
Monthly Consumption**
* and ** can be combined into one form to increase efficiency
82
V. REORDERING HEALTH COMMODITIES

Drugs and medical supplies should be reordered by the health facilities
based on a regular re-order schedule (e.g. monthly) that will depend on
staff and transportation availability. Quantities to be reordered should be
based on past consumption, remaining inventory and a safety stock (see
Annex 4, SOP P1). Note that in order to avoid emergency orders due to
poor planning, storekeepers at health facilities must be trained in
calculating order quantities. All supplies should be reordered on a
pre-printed requisition form that is prepared by the health facility’s
storekeeper and authorized by the in-charge of the facility. Once the
requisition form is received at the central medical store, approval from
authorized health staff should be requested before releasing the products
to the field. Approval of the supplies will depend on approval and
justification at the health facility level. After approval by an authorized
health officer, the order will be prepared by the central medical store
keeper. Together with the issued supplies, a copy of the approved
requisition form that indicates the issued quantities and a waybill shall be
sent to the health facility. Upon arrival at the health facility, the quantity of
all supplies will be verified by both the storekeeper and the driver. The
waybill and requisition form are signed by both parties. One copy of the
requisition form and the waybill remains at the health facility for their
records, while the other copies return with the driver to be filed at the
central medical store.To reduce the number of forms and records and to
justify re-ordered quantities, the requisition form can include a column that
indicates the quantities that have been used.
See sample Requisition form in Sample Forms and Records.
83
VI. ROUTINE MEDICAL STORE

MANAGEMENT
Every 12
Daily/Weekly Monthly Quarterly
months
Update stock For health For central For central and
records and center/hospital medical stores: peripheral level:
maintain files. pharmacies:
u Monitor stock Conduct physical Conduct physical Conduct complete
levels, stock inventory or cycle inventory or cycle physical inventory for
quantities, and count, and update count, and update Finance and update
safety stocks. stock keeping stock keeping stock-keeping
u Submit emergency records. records. records.
order when Assess stock Assess stock u Reassess
necessary. situation and expiry situation and expiry maximum/minimum
u Update back-up file dates. dates. stock levels, and
for computerized Submit monthly u Use established adjust if needed.
inventory control consumption procedures to
records. information. dispose of expired
u Update bin cards. Fill out requisition to or damaged
central medical products.
u Separate expired
stocks and move to stores. u Visually inspect fire
secure area. For central and extinguishers
peripheral level:
Write monthly stock
report
(in/out/losses/balance)
!! Carry out
supervisory visit
(Health
Coordinator/Logistics
Coordinator)
u Run generator to
ensure the system
is working correctly;
check the level of
fuel and add fuel, if
needed.
u Check for signs of
rodents, insects, or
roof leaks.
u Inspect the storage
structure for
damage, including
the walls, floors,
roof, windows, and
doors.
Source: John Snow Inc./DELIVER 2003
84
References:
1. FSU-MSF 75, Cold Chain guideline, 2002.

permission.
3. Medecins Sans Frontieres (MSF), Essential Drugs-Practical

Guidelines, 2nd revised edition, 2002.
4. John Snow, Inc./DELIVER in collaboration with the World Health

Organization. Guidelines for the Storage of Essential Medicines and
Other Health Commodities. 2003. Arlington, Va.: John Snow,
Inc./DELIVER, for the U.S. Agency for International Development.
5. John Snow, Inc. by Program for Appropriate Technology in Health

(PATH), Pest Management for Warehouses Storing Contraceptive
Products in Developing Countries, Prepared for Family Planning
Logistics Management Project (FPLM),1994.
6. WHO, Guide to Good Storage Practices for Pharmaceuticals,

(Annex 9 to the Thirty-seventh Report of the WHO Expert Committee
on Specifications for Pharmaceutical Preparations), 2001.
http://www.who.int/medicines/library/qsm/good_storage.pdf.
7. WHO, Stability of Essential Medicines in Tropical Climates:

Zimbabwe, WHO/DAP/94.16, 1996.
http://www.who.int/medicines/library/dap/who-dap-94-16/who-dap-
94-16.htm.
8. WHO, Stability of Injectable Oxytocics in Tropical Climates,

WHO/DAP/93.6, 1993.
http://www.who.int/medicines/library/dap/who-dap-93-6.htm.
9. WHO, Stability of Oral Oxytocics in Tropical Climates, WHO/DAP/94.13,

1995.
http://www.who.int/medicines/library/dap/who-dap/94-13/who-dap-
94-13.htm.
85
5. RATIONAL USE OF
DRUGS
Contents
I. INTRODUCTION TO THE RATIONAL USE OF DRUGS ...............89
1. Defining rational drug use.................................................89

2. Types of irrational drug use ...............................................90
3. Impact of inappropriate use of drugs..................................92
4. Factors underlying irrational use of drugs..........................92
5. Strategies to improve drug use ..........................................94
5.1. Investigating drug use ............................................94
5.2. Core strategies to improve drug use........................97
5.3. Achieving patient adherence in refugee
communities .........................................................103
II. GOOD DRUG DISPENSING PRACTICES ..................................105
1. Working environment......................................................105
2. Dispensing process ........................................................106
3. Dispensing staff ..............................................................109
III. USE OF DRUGS IN CHILDREN, THE ELDERLY AND
PREGNANT WOMEN ................................................................110
References .....................................................................................112
88
5. RATIONAL USE OF DRUGS
I. INTRODUCTION TO THE RATIONAL

USE OF DRUGS
1. Defining rational drug use

The aim of any drug management system is to deliver the correct drug to
the patient who needs it. Many gains of efficient selection, procurement
and distribution can be lost by irrational prescribing and by lack of
adherence to treatment by the patient.
The Conference of Experts on the Rational Use of Drugs, convened by the

World Health Organization in Nairobi in 1985, defined rational use as
follows:
“Rational use of drugs requires that patients receive medicines

appropriate to their clinical needs, in doses that meet their own
individual requirements, for an adequate period of time, and at the
lowest cost to them and their community.”
It is clear that there are differences in refugee settings with regard to:
l the numbers of health workers, their levels of competence, and range

of nationalities;
l the specific organization of refugee health services at national levels
as well as in camp settings;
l the particular treatment protocols approved for use by health
authorities, and those used by agency personnel;
l the specific composition of refugee populations by age, ethnicity,
socio- economic and cultural status and illness profile.
However, the effective use of drugs in all refugee settings depends on:
1. Rational prescribing:
n Appropriate indication. The decision to prescribe a drug is entirely
based on medical rationale and the drug therapy is an effective and
safe treatment.
89
n Appropriate drug. The selection of a drug is based on efficacy,

safety, suitability, and cost considerations.
n Appropriate patient. No contraindications exist, the likelihood of
adverse reactions is minimal, and the drug is acceptable to the
patient.
2. Correct dispensing, including appropriate patient information.

Refugee patients are provided with relevant, accurate, important and
clear information regarding their condition and the medication that is
prescribed. Drugs are dispensed in a safe and hygienic manner.
3. Adherence to treatment by the refugees.

Adherence is the degree to which patients adhere to medical
advice, and take medicines as directed. A patient adheres to the
treatment if he/she understands and appreciates the value of taking
specific drugs for specific indications and if drugs are dispensed in a
form that is acceptable to the patient.
2. Types of irrational drug use

Prescribing:
l Multiple or over-prescription (“Polypharmacy”).

l The use of drugs when no drug therapy is indicated,
e.g., antibiotics for viral upper respiratory infections.
l The use of the wrong drug for a specific condition requiring drug
therapy,
e.g., tetracycline in childhood diarrhea requiring ORS.
l The use of drugs with doubtful or unproven efficacy,
e.g., the use of antimotility agents in acute diarrhea.
l The use of drugs of uncertain safety status,
e.g., use of dipyrone (Novalgine etc.).
l Failure to provide available, safe, and effective drugs,
e.g., failure to vaccinate against measles or tetanus, or failure to
prescribe ORS for acute diarrhea.
90
l The use of correct drugs with incorrect administration, dosages, and

duration, e.g., the use of IV metronidazole when suppositories or oral
formulations would be appropriate, not dispensing the full course of
antibiotics.
l The use of unnecessarily expensive drugs (“extravagant prescribing”),
e.g., the use of a third generation, broad-spectrum antimicrobial when
a first-line, narrow spectrum agent is indicated.
l Indiscriminate use of injections,
e.g., in malaria treatment.
l Multivitamins and tonics for malnutrition.
Dispensing:
l Incorrect interpretation of the prescription.

l Retrieval of the wrong ingredients.
l Inaccurate counting, compounding or pouring.
l Inadequate identification and labeling.
l Unsanitary procedures.
l Mistakes in delivery of drugs to patients such as wrong drug, wrong
amount of drug.
l Poor quality packaging materials.
Patient adherence:
Inadequate instructions, poor labeling and difficult treatment regimens

negatively influence adherence in most populations. In refugee settings,
assuring compliance is particularly difficult owing to:
l the presence of language barriers, especially when expatriate or

national staff must diagnose and treat refugee patients.
l lack of familiarity for some refugee populations in the use of
medications, because of:
n limited previous exposure to modern drugs,
n previous reliance on traditional systems of healing,
91
n low levels of education and literacy.

l the degree of mobility in refugee groups - within camp boundaries,
between encampments, and across national borders.
l the frequent disruption of established family structures arising from
relocation to a refugee camp.
l the lack of an orderly household numbering system in many large
refugee communities, which makes effective home visiting difficult.
l inappropriate previous exposure to drugs, e.g. reliance upon
injections.
l Treatments or instructions that do not consider the patient’s beliefs,
environment or culture.
3. Impact of Inappropriate Use of Drugs

The impact of this irrational use of drugs can be seen in many ways:
1. Reduction in the quality of drug therapy and overall quality of health

care leading to increased morbidity and mortality.
2. Waste of resources leading to reduced availability of other vital drugs

and increased costs.
3. Increased risk of unwanted effects such as adverse drug reactions and

the emergence of drug resistance, e.g., malaria or multi-drug resistant
tuberculosis.
4. Psychosocial impacts, such as when patients come to believe that

there is “a pill for every ill.” This may cause an apparent increased
demand for drugs.
4. Factors Underlying Irrational Use of Drugs

Many different factors affect the irrational use of drugs. In addition,
different cultures view drugs in different ways, and this can affect the way
drugs are used.
92
The major forces can be categorized as those deriving from patients,

prescribers, the workplace and the supply system, and combinations of
these factors.
l Prescribers – lack of education and training

– inappropriate role models
– lack of objective drug information
– generalization of limited experience
– misleading beliefs about drug efficacy
– lack of skill or conscientiousness
– inadequate supervision
– incentive to overprescribe
l Dispensers – inability to interpret a prescription

– insufficient training
– insufficient staffing
– lack of equipment and facilities
– lack of packaging materials
– poor attitude about dispensing
l Patients – drug misinformation

– misleading beliefs
– patient demands/expectations
– no labeling or no understandable labeling
– inadequate verbal instructions
– complex treatment regimen or long
– duration
– presentation of treatment
l Workplace – heavy patient load

– pressure to prescribe
– lack of adequate lab capacity
– insufficient staffing
93
l Drug Supply System – unreliable suppliers.

– drug shortages
Personal
Informational Knowledge
Unbiased
Deficits
Acquired
Information
Habits
Influence
Cultural
of Industry
Beliefs
DRUG
USE Interpersonal
Workload & Patient
Staffing Demand
Workplace Infra- Authority &

structure Supervision
Relationships
with Peers
Workgroup
Source: MSH 1997
5. Strategies to improve drug use

Before any strategies are developed it is essential to identify, measure
and understand the problems. There are a variety of tools and methods
available which can help in this.
5.1. Investigating Drug Use
Two methods should be distinguished: quantitative methods, to measure

what is being done, and qualitative methods, to provide information on
94
why it is being done. Sources for quantitative data on drug use include
indicators for health facilities and aggregated consumption and
procurement data. To encourage consistency in drug use studies, the
World Health Organization (WHO) and the International Network for
Rational Use of Drugs (INRUD) have produced a manual for investigating
drug use in health facilities. The manual defines core drug use indicators
and provides a methodology for measuring these indicators. This
standardized method has been used in over 40 countries and allows for a
comparison between countries and regions, and for monitoring the effect
of interventions.
The WHO manual defines twelve core and seven complementary drug
use indicators (see Table 1 below) that measure key aspects of drug
prescribing, patient care, and availability of drugs and drug information at
outpatient facilities. The core indicators are highly standardized and do
not require national adaptation. Although not comprehensive, they
provide a simple tool for quickly and reliably assessing a few critical
aspects of drug use. With these indicators, results should point to specific
drug use problems that need to be examined in more detail. All the
necessary data are collected from medical records or by direct
observation at individual health facilities.
The manual also defines a set of complementary indicators, which are

less standardized and require defining variables specific to the location.
One important complementary indicator measures adherence to
treatment guidelines. This indicator needs clear and explicit criteria to be
reliable and informative.
TABLE 1: WHO Drug Use Indicators (Outpatient Facilities)
Core Drug Use Indicators
Prescribing indicators
1. Average number of drugs per encounter
2. Percentage of drugs prescribed by generic name
3. Percentage of encounters with an antibiotic prescribed
4. Percentage of encounters with an injection prescribed
5. Percentage of drugs prescribed from essential drugs list or
formulary
95
Patient Care Indicators

1. Average consultation time
2. Average dispensing time
3. Percentage of drugs actually dispensed
4. Percentage of drugs adequately labeled
5. Patients’ knowledge of correct dosage
Health Facility Indicators

1. Availability of a copy of essential drugs list or formulary
2. Availability of key drugs
Complementary Drug Use Indicators
1. Percentage of patients treated without drugs

2. Average drug cost per encounter
3. Percentage of drug costs spent on antibiotics
4. Percentage of drug costs spent on injections
5. Prescription in accordance of treatment guidelines
6. Percentage of patients satisfied with the care they received
7. Percentage of health facilities with access to impartial drug
information.
Source: WHO/DAP 1993
The Prescribing indicators (1-5) are easily used checking prescriptions

and the Health Facility indicators (11-12) are also easily verified. These
indicators can be used in a study or preferably, can be included in monthly
reports.
Table 2 shows results from studies using WHO indicators:
96
TABLE 2: Selected Results of Studies Using WHO Indicators
Country Number Number of Percent Percent Percent Consulting Percent Percent

of drugs antibiotics injections generics Time who knew of key
Facilities Prescribed (min) dosing drugs in
stock
Africa
Sudan 37 1.4 63% 36% 63%
Malawi 72 1.8 34% 19% 2.3 27% 67%
Tanzania 20 2.2 39% 29% 82% 3.0 75% 72%

Nigeria 20 3.8 48% 37% 58% 6.3 81% 62%
Ghana 20 4.3 47% 56% 59%
Uganda 127 2.4 53% 36% 86% 4.6 29%
Asia
Indonesia 20 3.3 43% 17% 59% 3.0 82%
Bangladesh 20 1.4 31% 0% 63%
Nepal 20 2.1 43% 5% 44% 3.5 56% 90%
Latin America And Caribbean
Ecuador 19 1.3 27% 17% 37% 38%
El 20 2.2 32% 7% 72%
Salvador
Jamaica 20 2.4 30% 4% 40%
Sources: Management Sciences for Health/INRUD
5.2. Core strategies to improve drug use
It is recommended that a combination of educational, managerial and

regulatory strategies are used. The activities should be planned in such a
way that they act to reinforce one another. Rules and regulations have
little impact if target groups are not educated and informed and if
management and supervision systems are not in place. Complementary
measures and a combination of strategies that work should be identified
for different target groups.
97
Clinical guidelines and essential drugs lists
The starting point for most, if not all, interventions to promote rational drug
use is nationally or institutionally agreed standard treatment guidelines (or
“clinical guidelines”). Clinical guidelines define the desired prescribing
behavior and constitute the core of all educational, regulatory and
managerial interventions. In addition they define the selection of essential
drugs for the supply system, as expressed in the essential drugs list.
Clinical guidelines indicate the most cost-effective therapeutic approach,

on the basis of valid clinical evidence. Their impact is greatest if the
end-users (prescribers and, to a certain extent, patients) are closely
involved in the development. As for implementation, availability of clearly
printed materials, an official launch in the presence of senior health
officials and initial training are key initial interventions.
The point needs to be made that availability of treatment guidelines

alone will not lead to better prescribing and that reinforcement
training, monitoring and supervision are essential to maintain the
rational use of drugs.
A variety of printed materials can be used to further promote rational

prescribing. They achieve maximum impact when used with other, more
interactive interventions, such as discussion groups, problem-based
learning and prescription reviews. Printed reference materials can
include manuals, posters, and training materials. Depending on the
number of treatments involved, printed references may be in the form of
wall charts, pocket handbooks, or larger “shelf-size” reference books.
Some people feel that wall charts provide a better reminder to health
workers, are more permanent, and help the patient better understand the
treatment process. Others feel that a handbook is more effective, provided
it fits into the pocket, is durable, and is well organized. Pocketbooks can
also include information about individual drugs or other reference data.
Drugs and therapeutics committees
Drugs and therapeutics committees are vital structures for implementing

comprehensive and coordinated rational drug use strategies in institutions
and health programs. They should be responsible for developing and
coordinating all policies related to pharmaceuticals (e.g. on the selection
98
of standard treatments, hospital formularies and drug budgets). These

committees should also be responsible for adapting the national clinical
guidelines and essential drugs list to the needs of the program. They
should also perform drug utilization studies and prescription reviews, and
develop educational strategies to improve drug use and management.
5.2.1. Educational strategies
Rational use depends on the knowledge, attitudes and practices of health

care practitioners and consumers. Educational strategies for both groups
are essential. It is critical to consider and to understand the environment in
which drug use takes place when planning educational strategies.
In-service training of health workers
Continuing education, supervisory visits and focused lectures and

workshops can be effective in increasing knowledge and changing
behavior. Experience has shown that the impact on behavior is likely to be
maximized if specific prescribing and dispensing behavior is targeted, if
the groups are small, if known experts are involved in the teaching, and if
the training is followed up with specific feedback on their actual
prescribing. Face-to-face contact between prescribers and dispensers
with trained educators is effective but requires considerable human and
financial resources.
Note that dispensers are usually a neglected group of health staff in terms
of having access to training opportunities. In many refugee settings,
dispensers are refugees themselves, often with moderate education.
Being the last step in the drug supply chain (“where the pill meets the
patient”), dispensers should receive regular training and their
performance should be regularly monitored.
Drug information
An underlying factor in many aspects of irrational drug use is the lack of

access to independent drug information. All prescribers should have
access to standard treatment guidelines, the essential drugs list and a
drug formulary. In the absence of national or local guidelines, the MSF
Clinical Guidelines and WHO Model Formulary can be used. Other
reputable sources of independent drug information (most are available on
99
CD-ROM) are the British National Formulary, Martindale: The Extra

Pharmacopoeia, the United States Pharmacopoeia and Harrison’s
Principles of Internal Medicine.
Consumer information and education
Consumer education is an important area, often neglected in developing

and implementing an essential drugs policy. Most health programs tend to
place greater emphasis on the supply of essential drugs to health centers
and the training of health care practitioners to prescribe properly than on
promoting rational use of medicines by consumers. However, drug use
studies show that people commonly use medicines without health
practitioners’ advice, that their drug use pattern is shaped by their own
experiences with medicines, and that they obtain their medicines from
various sources, including the informal sector. Given this situation, more
attention should be paid to educating consumers on the appropriate use of
drugs.
Consumers in a refugee setting are in a context that is not conducive for

the rational use of drugs. Drugs are available free of charge and are often
being prescribed and dispensed by members of the same community. In
war-affected areas, drugs are the equivalent of hard currency and patients
have an incentive to seek health care only to obtain drugs. “Drug
shopping” is a well known phenomenon in stable refugee settings with a
large concentration of facilities and a lack of solid patient registration
systems. The monotonous life in a refugee camp and the lack of work or
entertainment can also lead to vague psychosomatic complaints that are
often treated with analgesics due to lack of social services.
5.2.2. Managerial strategies to promote rational drug use
Managerial strategies are also important in promoting rational drug use

and in discouraging waste. Managerial strategies attempt to structure
information, information flow, and decision process to achieve more
cost-effective use of pharmaceutical resources. The most important
strategies are discussed below. In all cases, a careful analysis of the
underlying problem, extensive discussions with all staff involved, a careful
introduction, and intensive supervision and follow-up help to ensure
maximum impact of the strategies.
100
Standard treatments, essential drugs lists, dispensing standards
As mentioned above, clinical guidelines should be used to define

institutional or national essential drugs lists, and these should be used to
guide drug procurement and reimbursement. Adherence to clinical
guidelines should also be promoted by involving the end-users in their
development, by introduction and training in their use, and through
supervision and medical audit.
Other possibilities are a systematic review of the procurement according

to and within therapeutic class, introduction of standardized or structured
(pre-printed) order forms, countersigning procedures for antibiotics or
expensive drugs, the use of standardized course-of-therapy packages
(pre-packaging), audits plus feedback to providers, instituting
self-monitoring practices among prescribers, and dispensing the first
doses of treatment at the health facility.
5.2.3. Regulatory strategies to promote rational drug use
There are various regulatory strategies that support educational and

managerial strategies to promote rational drug use.
Regulatory strategies are generally aimed at saving money or preventing

improper use of drugs. Regulatory approaches imply a degree of
arbitrariness. They tend to be focused and rather inflexible. Because of
limited opportunities to make adjustments once a regulatory strategy is in
place, it is important that regulatory initiatives be well-conceived and
well-tested before being launched on a large scale. There are always risks
of unintended adverse effects of such regulations.
Examples of regulatory strategies include the ban of unsafe drugs and

prescribing and dispensing restrictions. Either type of limit is arbitrary and
risks certain negative consequences. For example, a “three-drug rule” in a
setting in which an antibiotic, a vitamin, and an antidiarrheal are the
provider's first three preferences before oral rehydration salts (as is still
the case in some places) would mean no ORS for the patient. As another
example, a “three-day rule” might save money, but also contributes to
underdosing, increased bacterial resistance, and giving patients the false
impression that only three days supply is needed for any medicine.
101
Table 3 summarizes all these strategies:
TABLE 3: Intervention Strategies to Improve Drug Use
Educational strategies: TO PERSUADE
Training of Prescribers
l Continuing education (in-service)
l Supervisory visits
l Group lectures, seminars and workshops
Printed Materials
l Clinical literature and newsletters
l Treatment guidelines and drug formularies
l Illustrated materials (flyers, leaflets)
Approaches Based on Face-to-Face Contact
l Educational outreach
l Patient education
Managerial Strategies: TO GUIDE
Selection, Procurement and Distribution

l Limited procurement lists
l Drug utilization review and feedback
l Drug committees
l Providing cost information on order forms
Prescribing and Dispensing Approaches
l Structured drug order forms
l Standard diagnostic and treatment guidelines
l Course-of-therapy packaging
l Improvements in labeling
l Clinical supervision
102
Regulatory Strategies: TO ENFORCE
Drug selection
l Banning unsafe or ineffective drugs
Prescribing and Dispensing Controls
l Level-of-use prescribing restrictions (health post,
health center, hospital)
l Restrictions on who can prescribe or dispense
l Limits on number of different drugs per patient
(e.g., “3-drug rule”)
l Limit on quantities of each drug (e.g., “3-Day Rule”)
l Requirements for generic prescribing
Source: INRUD 2004
5.3. Achieving patient adherence in refugee

communities
To achieve adherence in refugee communities, measures should be

implemented to ensure there is:
l a basic understanding of refugee beliefs regarding common

illnesses, treatments and the effects of modern drugs. Liaison with
traditional healers and midwives will assist such an understanding;
l adequate patient education in the use of prescribed medicines,
through patient teaching and symbolic labeling for non-literate groups,
for instance (see figure below);
l a mechanism for monitoring actual use of medications in the home
(such as trained community health workers making home visits);
l a standardized individual or family health record card as approved by
appropriate health authorities. (This is particularly important in mobile
refugee populations for whom a centralized record-keeping system is
clearly impractical and ineffective.)
103
l a provision that refugees receive instructions in a language that they

can understand;
l the possibility for illiterate patients to have drugs dispensed in a tablet
bag with a pictogram;
l blister packaging wherever possible, especially for fixed-dose
combinations.
Source: UNHCR 1989
104
II. GOOD DRUG DISPENSING

PRACTICES
Good dispensing means ensuring that an effective form of the correct drug
is delivered:
l to the right patient;

l in the prescribed dosage and quantity;
l with clear instructions;
l in a package that maintains potency.
Dispensing is the last step in the drug pathway between manufacturer and
patient. No matter how many precautions are taken to guarantee and
maintain drug quality during production, packaging, transport, storage,
and distribution, they will all be useless if drug quality is not preserved
during this last step!
Good Dispensing Practices:

n Safe, clean and organized working environment
n Disciplined use of effective procedures
n Qualified and trained staff, regular performance monitoring
n Safe and clean dispensing/ Labeling
n Ensuring patients’ understanding
n Good record keeping
Source: MSH 1997
1. Working environment
Dispensing environments must be clean because most drug products are
taken internally. The working area must be hygienic and uncontaminated.
The environment must also be organized so that dispensing can be
105
performed accurately and efficiently. The dispensing environment

includes:
l Staff
Must maintain good personal hygiene and should wear clean
protective clothing. Facilities to wash and dry hands should be
available.
l Physical surroundings
These must be kept free of dust and dirt, so daily cleaning of floors and
working surfaces is necessary.
l Shelving and storage areas
Cupboards should only contain drugs and should be kept tidy and
clean.
l Surfaces used during work
Spillage of liquids (e.g. syrups) should be wiped immediately. Food
and drinks are not allowed in the dispensing area.
l Equipment and packaging materials
Dispensing equipment is used for measuring liquids (measuring
cylinder) or counting tablets or capsules (spoons, tablet counters).
Equipment should be cleaned between different products, patients and
at the end of the day.
The dispensing area should be safe and large enough to allow staff
movement.
Stock containers (especially in IPD) and pre-packed medicines must be

stored in an organized way. VERY IMPORTANTLY, ALL STOCK
CONTAINERS IN USE MUST BE CLEARLY AND ACCURATELY
LABELED to minimize error. The repacking of one drug in a container of
another drug should be discouraged and if it needs to be done, the name,
dosage and batch number and expiry date should be clearly indicated.
2. Dispensing Process
The consistent and repeated use of a good dispensing procedure is vital in
ensuring that errors are noticed and corrected at all stages of the
dispensing process. The dispensing process:
106
1. Receive and validate prescription
Confirm name of patient, since there might be a risk of mixing-up

prescriptions if many people have the same name.
2. Understand and interpret prescription
Read prescription and make sure that it is complete.
A prescription consists of 7 parts:

1. Name of the patient (eg. Kyaw Htoo)
2. Name of the drug and the strength to be administered (eg.
ibuprofen 200 mg)
Write the full name of the drug.
E.g. Do not write ‘para 500 mg’, but ‘paracetamol 500 mg’
3. Dosage of the drug (eg. 500 mg)
4. Route by which the drug is to be administered (eg. PO)
5. Time and/or frequency of administration (eg. 3 times a day)
6. Date and time when the order was written
7. Signature of the person writing the prescription
If the prescription is not complete, go back to the prescriber and ask

him/her to complete the prescription before dispensing.
n Correctly interpret abbreviations used by the prescriber (e.g. IM,

T.I.D.)
n Confirm that doses are in safe range (check age/sex)
n Correctly perform any calculations of dose and issue quantity
n Identify any common drug-drug interactions
In case of any doubt, check with the prescriber.

This might save a life!
107
3. Prepare items for issue

1. Write label
2. Select stock container
Select by reading the label of the container and check it with the
prescription. Do not keep too many containers open at the
same time.
3. Measure or count quantity from the stock container
Hands must never be in direct contact with the medicine!
Counting can be done with a clean piece of paper and spatula,
tablet counter, lid of the container in use or other clean surface.
Immediately after counting, the container should be closed
again and the container label should be rechecked for the drug
name and strength.
4. Pack and label medicine
Tablets and capsules should be packed in a sealed plastic
dispensing bag. Liquids require clean bottles with effective
caps. Never mix two liquids together.
The label should indicate: name of the patient, drug name and
strength, dose (amount and frequency), quantity dispensed.
Symbols might be necessary to indicate amount and frequency
of dosage (for patients who cannot read).
Check dispensed drug against prescription and against stock
containers used.
Especially in dispensaries with a high patient-load, it is better to work in

teams of two for dispensing in order to double-check prescription
deliveries; the first collects the drugs prescribed, the second then verifies
and gives them to patients with all necessary explanations.
4. Record action taken
5. Issue medicine to patient with clear instructions and advice
Apart from emphasizing the dose, frequency, length of treatment, and

route of administration, the priority is to give the patient information that
will maximize the effect of the treatment. Even when a clinician prescribes
an effective drug, if the patient does not believe in it, does not take it like
prescribed, or even stops treatment, the ultimate goal of improving the
108
patient’s health will not be reached. Advice should therefore concentrate

on:
l When to take the medicine (particularly in relation to food and other

medicines);
l How to take the medicine (chewed, swallowed whole, taken with
plenty of water);
l How to store and care for the medicine.
Common but harmless side effects (nausea, mild diarrhea, urine

changing color) should be mentioned to prevent a frightened patient
from stopping the treatment.
Also important is to explain why antibiotic treatments must be taken

completely, while painkillers (analgesics) should be stopped when the
pain has gone.
Drugs which interact with alcohol should also be mentioned

(anti-histamines, anti-depressants, metronidazole).
In case of a mono-dose treatment, the drugs should be taken on the

spot under supervision. In other cases, the first dose can also be given
on the spot.
Every effort should be made to confirm that the patient

understands the instructions. Remember that some people pretend
they understand, because they are ashamed or in a hurry! To check if a
patient really understands, have them repeat what they were told.
3. Dispensing staff
Although assigned to dispenser positions, dispensing staff often do not
have high levels of education. Nevertheless, they have a huge
responsibility in the distribution of drugs, since most patients do not know
the correct use or cannot judge the quality of drugs received and are
therefore completely dependent on the dispenser.
109
Dispensers should have:
l Knowledge about the medicines being dispensed (common use,

common dose, precautions about the method of use, common side
effects, common interactions with other drugs or food, storage needs);
l Good calculation and arithmetic skills;
l Skills in assessing the quality of preparations;
l Attributes of cleanliness, accuracy, and honesty;
l Attitudes and skills required to communicate effectively with patients.
Dispensers need regular training and performance checks.
III. USE OF DRUGS IN CHILDREN, THE

ELDERLY AND PREGNANCY
Drugs should be used with great care in children, older people and
pregnant women.
Always check the dose for children, since they take up drugs in the blood
differently from adults and because their kidneys and liver have not yet
fully developed. Use dosing schedules based on bodyweight rather than
on age to calculate dosages for children. This is especially important for
malnourished children.
Older people also need adjusted dosages since their liver and kidneys
are not as functional as before. Be careful with several antibiotics (eg.
penicillin, tetracycline), digoxin, cimetidine, furosemide and
psychotropics (eg. antidepressants, sedatives, antipsychotics).
Dispensing drugs to older people should occur with extra care. Clear
information should be given about the dosage, the time of administration,
the way to take the drug, and possible side-effects. Often, older people
need help with taking their drugs.
110
Pregnant women and lactating women also need to be careful with

drugs. In general, pregnant women should avoid using drugs during the
first and last trimesters of the pregnancy to avoid malformations or a
change in metabolism in the unborn baby.
Of course, when the health of the woman is at greater risk from not being
treated, treatment should be given (example: falciparum malaria).
Never give the following drugs during pregnancy:
l Tetracycline (interference with bone and teeth development)

l Doxycycline (interference with bone and teeth development)
1
l Chloramphenicol (‘Grey baby syndrome ’)
l Streptomycin (vestibular and auditory damage, renal impairment)
l Overdose of vitamin A and vitamin D (malformations of urogenital
and nervous system)
l Certain hormones (estrogens, progestagens, androgens, danazol)
l Co-trimoxazole (teratogenesis)
l Ciprofloxacin (interference with cartilage development)
l Certain sulphonamides like certain oral anti-diabetics (not during
entire pregnancy), and co-trimoxazole (not during third trimester)
l Oral anti-diabetic drugs
l Salicylates (aspirin; high risk for bleeding and interference with
delivery)
Drugs that are not mentioned in the above list are NOT automatically safe
for use during pregnancy. A drug formulary should be consulted whenever
prescribing drugs to a pregnant woman.
Through breastfeeding (lactation), a child can receive drugs that may be

dangerous for its development. Certain drugs cannot be given to women
who are breastfeeding. As for pregnancy, a drug formulary should be
consulted when prescribing drugs to lactating women.
1 Grey Baby Syndrome: cardiovascular collapse, respiratory depression, cyanosis in unborn childen,
usually near the end of the pregnancy.
111
References:
1. Algemene Farmacotherapie, Het geneesmiddel in theorie en
praktijk, zevende druk, Wesseling, Neef, de Graeff, e.a., Bohn
Stafleu Van Loghum, 1999.

permission.
3. Medecins Sans Frontieres, Essential Drugs-Practical Guidelines, 2nd

revised edition, 2002.
4. INRUD (International Network for the Rational Use of Drugs),

Framework for changing drug use practices, Session Guide Nr. 9,
PRDU (Promoting Rational Drug Use) Course Materials and
Resources, February 2004.
5. (INRUD) International Network for the Rational Use of Drugs),

Problems of irrational drug use, Session Guide Nr. 3, PRDU
(Promoting Rational Drug Use) Course Materials and
Resources,February 2004.
6. UNHCR, UNHCR Essential Drugs Manual, Guidelines for Use of

Drugs in Refugee Settings and UNHCR List of Essential Drugs,
Geneva, 1989.
7. WHO, How to develop and implement a national drug policy, 2nd

Edition, Geneva, 2001.
8. WHO, How to investigate drug use in health facilities: selected drug

use indicators, WHO/DAP/93.1, Geneva, 1993.
112
6. DRUG QUALITY
ASSURANCE
Contents
I. DRUG QUALITY ASSURANCE ...................................................115
1. Introduction .....................................................................115
2. Objectives of drug quality assurance ..............................117
3. Characteristics of product quality ...................................118
4. Responsibilities of various actors ...................................119
5. Critical Elements in Quality Assurance............................120
A. Procedures to OBTAIN drug products that
meet current quality standards.........................120
B. Procedures to VERIFY that shipped goods
meet the specifications......................................121
C. Procedures to MONITOR and MAINTAIN
the quality of drug products from the moment
they are received until the drug is finally
consumed by the patient ...................................121
6. Additional points in quality assurance..............................121
References .....................................................................................123
114
6. DRUG QUALITY ASSURANCE
I. DRUG QUALITY ASSURANCE
1. Introduction
The health and well being of beneficiaries should be top priority. Quality
assurance of drugs assists the health program in maintaining its
reputation towards beneficiaries and donors.
High world-wide standards may exist for drug regulation and quality, but
implementation and enforcement vary. Consider that:
l less than 1 in 3 developing countries have well-functioning government

drug regulation. Sadly enough, countries with the highest need for
affordable good quality essential drugs are also the countries with the
poorest regulatory capacity.
l global trade brings global quality assurance challenges for drug
purchasers. Drugs manufactured in Europe, Asia and Africa may vary
widely in quality and safety.
l An average of 10-45% of drugs fail quality control testing (20
countries).
l Counterfeit and substandard medicines are “freely” available (see
Figs.1 and 2).
Poor drug quality means poor treatment outcomes and treatment failures,
which in many cases potentially leads to drug resistance which requires
more resources to treat e.g. MDR-TB, malaria. Poor quality drugs also
affect the trust that beneficiaries have in the healthcare system.
Counterfeit drugs and substandard drugs can kill:
l Substandard: e.g. contamination/mixing up glycerol with diethylene

glycol
n Nigeria 1990: 109 children died
n Bangladesh 1992: 223 children died
n Argentina 1992: 23 patients died
n Haiti 1995/1996: 89 children died
115
l Counterfeit: e.g. meningitis vaccine with no antigen

n Niger 1995: around 2500 deaths
e.g. anti-malarial drugs
n Cambodia 1999: 30 deaths (use of fake anti- malarial drugs)
Counterfeit and substandard drugs cost about 22 billion USD per year,
representing about 7% of world-wide pharmaceutical sales.
Figure 1:
API: Active Product Ingredient
116
Figure 2:
% breakdown of drug quality data on 1024 anti-malarial and anti-TB
drugs in selected USAID-assisted countries (1997 - 2003)
2. Objectives of drug quality assurance

The purpose of quality assurance in any drug supply system is to ensure
that each drug reaching a patient is safe, effective, and of standard
quality. For pharmaceutical procurement, drug quality is assessed as
compliance with pharmacopeial specifications concerning a drug’s
identity, purity, potency and other characteristics like uniformity of the
dosage form, bioavailability and stability.
Especially in regard to local drug procurement, quality assurance should

be high on the priority list. A comprehensive quality assurance system
includes both technical and managerial activities, spanning the entire
supply process from drug selection to patient use.
117
Technical activities include evaluating pharmaceutical product

documentation, performing or reviewing quality control laboratory tests,
and monitoring product performance. The GMP-certificate (Good
Manufacturing Practices), batch certificates, and certificates of
registration are good indicators of standardized quality.
Managerial activities include selecting suppliers, preparing contract

terms, monitoring supplier performance, and enforcing drug
inspection procedures throughout the distribution network.
3. Characteristics of product quality

Established quality standards are published periodically in pharmacopeias,
which provide detailed descriptions of drug characteristics and analytical
techniques. The major pharmaceutical manufacturing and exporting
countries publish their own pharmacopeias, for example the British
Pharmacopeia (BP), the US Pharmacopeia (USP), the European
Pharmacopeia and the International Pharmacopeia (published by WHO).
Standards vary slightly from one pharmacopoeia to another, but efforts
are made to harmonize pharmacopeial standards for drug registration.
For pharmaceutical procurement, drug quality is assessed as product

compliance with specifications as described in the pharmacopeia.
Some examples of pharmacopeia:
Source: USP
118
4. Responsibilities of various actors

The dynamic nature of drug products and the cumulative effects of the
production process, right through to packaging, handling, transport, and
storage conditions, require quality assurance at all levels of the drug
supply system.
Ensuring drug quality is the responsibility of all those involved - from the
producers of drugs to distributers to dispensers. Both the public sector
and the private sector have responsibilities.
Manufacturers are responsible for developing and manufacturing a good

quality product and should adhere to Good Manufacturing Practices
(GMP). They should also document their procedures and activities, to
ensure the quality of the product.
The national drug regulatory authority (DRA) must ensure that

drugs approved for marketing in a country are appropriately evaluated
and registered; that manufacturers comply with GMP through
licensing and inspection; that the quality of imported drugs is ensured,
for example through the WHO Certification Scheme (see below); and
that drug quality is maintained in the supply system by ensuring good
storage and distribution practices, and by monitoring the quality of drugs
in the distribution chain. In industrialized countries, regulatory capacity
has evolved in phases over many decades. It is reasonable to expect that
developing countries will also require time to develop effective regulatory
capacity. Such capacity requires a firm legislative basis, trained
personnel, specific technical resources, adequate funding and public
commitment. Although there is noticeable improvement, in most
African countries where UNHCR and partners operate, the DRAs have
limited capacity to regulate and enforce quality, safety and efficacy of
drug products on their market. Only DRAs from PICS/Scheme1
1 PIC/S is the combination of the Pharmaceutical Inspection Convention (PIC) and the Pharmaceutical
Inspection Co-Operation Scheme (PIC Scheme). Together, PIC and PIC Scheme operate under the
umbrella PIC/S. The purpose of PIC/S is to facilitate the networking between participating authorities
and the maintenance of mutual confidence, the exchange of information and experience in the field of
GMP and related areas, and the mutual training of GMP inspectors. PIC/S is a cooperative
arrangement among health authorities, mainly in the European Union and contributes to a more
consistent understanding of Good Manufacturing Practices in these countries. Membership in PIC/S
is not automatic. An authority wishing to join is carefully evaluated to determine its inspection and
licensing system, quality system, legislative requirements and inspector training. A PIC/S delegate
also evaluates how well the authority’s inspectors perform GMP inspections. Note that the US FDA is
not a member of PIC/S. (PIC/S Website: www.picscheme.org, January 2004).
119
and ICH2 countries (EU, USA, Japan, Malaysia, Canada, Switzerland) are
believed to have sufficiently stringent DRA’s.
Those involved in drug procurement should ensure that drugs are

carefully selected, purchased from reliable sources, inspected at the time
of receipt, and transported and stored properly. Mechanisms to report
quality defects and a recall procedure must be in place.
Those involved in distribution and dispensing must ensure the proper

storage of products, and their appropriate handling, packaging and
dispensing. They must also inform patients about the correct handling of
drugs.
5. Critical elements in quality assurance

Quality assurance covers all activities aimed at ensuring that consumers
and patients receive a product that meets established specifications and
standards of quality, safety and efficacy. It concerns both the quality of
the products themselves and all the activities and services that may affect
quality.
A. Procedures to OBTAIN drug products that meet current

quality standards (see Annex 4 SOP Q1):
1. Product Selection
2. Supplier qualification
3. Product qualification
4. Drug Regulatory Authorities
5. Contract specifications
2 ICH: International Conference on Harmonization is a joint initiative involving both regulators and
research-based industry representatives of the EU, Japan and the US in scientific and technical
discussions of the testing procedures required to assess and ensure the safety, quality and efficacy
of medicines.
120
B. Procedures to VERIFY that shipped goods meet the

specifications (see Annex 4, SOP Q2):
6. Batch certification
7. Inspection of Shipments
8. Targeted laboratory testing
C. Procedures to MONITOR and MAINTAIN the quality of

drug products from the moment they are received until
the drug is finally consumed by the patient (see Annex
4, SOP Q3):
9. Appropriate storage, transport, dispensing and use procedures
10. Product monitoring system
Few drug management programs can effectively manage all the possible
quality assurance activities for all the drug products that are procured.
Consequently, realistic goals must be set to identify the combination of
managerial and technical quality assurance activities that will be most
effective under existing conditions.
6. Additional points in quality assurance

1. Quality is a dynamic issue. Drugs produced by a manufacturer may
comply today but may not comply in six months. Manufacturers and
suppliers should be constantly monitored and periodically
re-evaluated. Quality problems detected by the monitoring system
should be recorded and considered when re-evaluating a supplier. A
supplier can only keep its approved supplier status for a limited
duration of time after which a re-evaluation needs to take place.
2. Quality is drug or product specific. A manufacturer that complies

with GMP-standards for oral forms (such as tablets and capsules),
may not comply for more critical items such as sterile products
(injectables, infusions).
121
3. Quality is manufactured, not controlled. This means that one can

not simply judge the quality of a drug by testing the end product
(“quality control”), but that the production process needs to be
validated. One has to know the circumstances in which the drug was
manufactured through inspection of Good Manufacturing Practices
(GMP). Not only the finished product should be GMP-compliant, but
also the raw materials used to manufacture the product. The latter is
often difficult to control as most raw materials are purchased in Asia,
far away from manufacturers of finished drug products or through a
number of various middle-men.
122
References:
1. ICH Global Cooperation Group, Questions and Answers about ICH,
October 2000.
2. International Rescue Committee, Draft Quality Assurance

Guidelines, 2002.

permission.
4. MSF, Policy for the procurement of medical products, Policy paper

written by Jacques Pinel and Myriam Henkens, Francine Matthys,
Christine Chevalier, Gloria Bassets, Lucie Blok, Marc Gastellu,
Dounia Bitar, May 2000.
5. O. AndrioIlol, L. Machuron, J.Y. Videau, C. AbeIIi, S. Plot and D.

Muller, Supplies for humanitarian aid and development countries:
the quality of essential multisource drugs, S.T.P. PHARMA
PRATIQUES 8 (2) 137-155 1998.
6. Pharmaciens Sans Frontieres, Correspondence with Christine

Godefroy, QA Pharmacist, regarding quality assurance procedures
Clermont-Ferrand, France, 2002.
7. Pharmaceutical Inspection Co-operation Scheme website:

www.picscheme.org, January 2004.
8. The Sphere Project, Humanitarian Charter and Minimum Standards

in Disaster Response, Oxfam Publishing, Oxford, 2004. Also
available at: http://sphereproject.org/handbook/index.htm.
9. United States Pharmacopeia Drug Quality and Information Program

(USP DQI), Ensuring the Quality of Medicines in Resource-Limited
Countries: An Operational Guide (draft version for restricted
distribution), April 2005.
123
10 WHO, Drug regulation, Chapter 8, “How to develop and implement a

national drug policy”, 2nd edition, Geneva, 2001.
11. WHO, “Practical Guidelines on Pharmaceutical Procurement for

Countries with Small Procurement Agencies”, Regional Office for the
Western Pacific, Manila, Philippines, 2002.
124
GLOSSARY OF TERMS
Active pharmaceutical ingredient (API) — A substance or compound
intended to be used in the manufacture of a pharmaceutical product as a
pharmacologically active compound (ingredient).
Adverse drug reaction (ADR) — Any unwanted effect produced by a

drug that is harmful to the patient. Onset may be sudden or develop over
time.
Assay — The monograph standard test, with associated method of

analysis, that is designed to determine the strength of a drug product.
Basic tests — Simplified analytical tests that do not require complex

methodologies and equipment. Basic tests may be used in specific
circumstances to verify the identity of a drug or ascertain the absence of
gross degradations or contamination.
Batch (or Lot) — A defined quantity of starting material, packaging

material, or product processed in a single process or series of processes
so that it could be expected to be homogenous or the quantity of a drug
produced in one production run.
Batch certificate — A document containing information which normally

will be issued for each batch by the manufacturer, or will be validated or
issued by the competent authority of the exporting country, particularly for
vaccines, sera, and other biological products. The batch certificate
accompanies every major consignment.
Batch number (or Lot number) — A distinctive combination of numbers

and/or letters that specifically identify a batch on the labels, the batch
records, and the certificate of analysis, etc.
Bioavailability — The rate and extent of availability of an active

ingredient from a dosage form as measured by its concentration/time
curve in the systemic circulation or its excretion in the urine.
Bioequivalence — Two pharmaceutical products are bioequivalent if

they are pharmaceutically equivalent, and their bioavailability, after
125
administration in the same molar dose, is similar to such a degree that

their effects can be expected to be essentially the same.
Bulk product — Any product that has completed all the processing
stages up to, but not including, final packaging.
Certificate of analysis (CA) — Report of the analytical test results

obtained, including the final conclusion of the examination of a sample
issued by the manufacturer, repacker, or trader.
Clinical trial (or Clinical research) — A research study in human

volunteers to answer specific health questions. Carefully conducted
clinical trials are the fastest and safest way to find treatments that improve
health. Interventional trials determine whether experimental treatments,
or new ways of using known therapies, are safe and effective under
controlled environments. Observational trials address health issues in
large groups of people or populations in natural settings.
Counterfeit drug — A pharmaceutical product that is deliberately and

fraudulently mislabeled with respect to identity or source. Both branded
and generic products can be counterfeited. Counterfeit drugs can include
products with the correct ingredient(s), with the wrong ingredient(s),
without active ingredient(s), with insufficient quantity of active
ingredient(s), or with fake packaging. A counterfeit drug can be a
deliberate imitation or a copy of a genuine product.
Disintegration — The breaking up of a tablet or a capsule into granules or

aggregates in an aqueous fluid.
Dissolution — The process by which a solid substance is broken down

into molecules or ions homogeneously dispersed in an aqueous fluid to
form a solution. The rate of dissolution is determined by the interaction
between the substance and the medium.
Dosage form — The form—tablet, capsule, injection—of the completed

pharmaceutical preparation.
Dosage (or strength) — The content of the active ingredient per dosage
unit is determined by the assay of the specific monograph and expressed,
generally, in milligrams or units per dosage unit.
126
Drug — Any substance or pharmaceutical product for human or

veterinary use that is intended to modify or explore physiological systems
or pathological states for the benefit of the recipient.
Drug formulation — The composition of a dosage form, including the

characteristics of its raw materials and the operations required to process
the drug.
Drug interaction — A modification of the effect of a drug when

administered with another drug. The effect may be an increase or a
decrease in the action of either substance or may be an adverse effect
that is not normally associated with either drug. The action of one drug
upon another may be harmful to the patient, depending on the drugs and
the patient’s medical condition.
Drug Regulatory Authority (DRA) — A national body that administers

the full spectrum of drug regulatory activities, including at least all of the
following functions: Marketing authorization of new products and variation
of existing products; quality controlled laboratory testing (although in
some countries, the lab may not be part of the DRA); adverse drug
reaction monitoring; provision of drug information and promotion of
rational drug use; good manufacturing practice (GMP) inspections and
licensing of manufacturers, wholesalers, and distribution channels;
enforcement of operations; and monitoring of drug utilization.
Efficacy (of a drug or treatment) — The maximum ability of a drug or

treatment to produce a result regardless of dosage. A drug passes
efficacy trials if it is effective at the dose tested and against the illness for
which prescribed. For example, in the procedure mandated by the United
States Food and Drug Administration, Phase II clinical trials gauge
efficacy and Phase III trials confirm efficacy.
Expiry (expiration) date — The date given on the individual container of

a drug product designating the date up to which the product is expected to
remain within specifications, if stored correctly. Expiry date is established
by the manufacturer for each batch by adding the shelf-life period to the
date of manufacture.
Excipient —- Any component of a finished dosage form other than the

claimed therapeutic ingredient or ingredients.
127
Finished product — A product that has undergone all stages of

production, including packaging in its final container and labeling.
Fixed-dose combination — A combination of more than one active

pharmaceutical ingredient in one package or single dosage form.
Generic name — The approved or international non-proprietary name of

a drug given by the World Health Organization.
Generic products — A pharmaceutical product—usually intended to be

interchangeable with the innovator product—is usually manufactured
without a license from the innovator company and marketed after expiry of
the patent or other exclusivity rights. The term should not be confused with
generic names for APIs.
Good Manufacturing Practice(s) (GMP) — The part of quality

assurance that ensures that pharmaceutical products are consistently
produced and controlled by the quality standards appropriate to their
intended use and as required by the marketing authorization. These
standards include criteria for personnel, facilities, equipment, materials,
manufacturing operations, labeling, packaging, quality control, and in
most cases, stability testing.
Identity — The correct chemical substance and formula of an active

ingredient in a drug product.
Identity test — The selected test in the monograph to verify that the drug
product has the correct identity.
Indication — A symptom or circumstance that indicates the advisability or

necessity of a specific medical treatment or procedure. Indication could
also refer to the degree indicated in a specific instance or at a specific time
on a graduated physical instrument, such as a thermometer.
Interchangeable pharmaceutical product — A product that is

therapeutically equivalent to a reference product.
Labels (according to GMP) — All finished drug products should be

identified by labeling, as required by the national legislation, bearing at
least the following information:
128
(a) the name of the drug product;
(b) a list of the active ingredients (if applicable, with the International
Non-proprietary Names (INNs)), showing the amount of each present,
and a statement of the net contents (number of dosage units, mass, or
volume);
(c) the batch number assigned by the manufacturer;
(d) the expiry date and manufacturing date in an uncoded form;
(e) special storage conditions or handling precautions that may be

necessary;
(f) directions for use, and any warnings or precautions that may be
necessary;
(g) the name and address of the manufacturer or the company or person
responsible for placing the product on the market.
Lead time — The time interval needed to complete the procurement

cycle. This begins at the time when new stock is ordered and ends when
that stock is received and available for use. Lead time varies depending
on the system, speed of deliveries, availability, and reliability of transport,
and sometimes, weather.
Manufacture — All operations involved in the purchase of materials and

products, production, quality control, release, storage, shipment of
finished products, and related controls.
Manufacturer — A company that carries out at least one step of

manufacture.
Marketing authorization (product license, registration certificate) —

An official document issued by a competent drug regulatory authority for
the purpose of marketing or free distribution of a product after evaluation
for safety, efficacy and quality. The certificate must set out, inter alia, the
name of the product, the pharmaceutical dosage form, the quantitative
formula (including excipients) per unit dose (using INN or national generic
names where they exist), the shelf-life and storage conditions, and
packaging characteristics. The document specifies the information on
129
which authorization is based. The license also contains the product

information approved for health professionals and the public, the sales
category, the name and address of the holder of the authorization, and the
period of validity of the authorization.
Method validation — Demonstrates the suitability of the analytical

procedure for its intended use. The characteristics of the analytical
procedures to be considered in method validation are the accuracy,
precision, robustness, linearity and range, selectivity, limit of detection,
and limit of quantitation.
Monograph — A set of properly selected standardized tests with

associated methods of analysis that can be used to assess the integrity of
drugs (including dosage forms) and starting materials. These standards,
when met, assure the quality of the drug with respect to identity, purity,
strength, packaging, storage, and labeling. Monographs are published in
pharmacopeia.
Multi-source (generic) pharmaceutical — Pharmaceutically equivalent

products that may or may not be equivalent therapeutically. Multi-source
pharmaceutical products that are therapeutically equivalent are
interchangeable.
New drug — A drug that has not been declared safe and effective by
qualified experts under the conditions prescribed, recommended, or
suggested on the label. This may be a new chemical formula or an
established drug prescribed for use in a new way.
Packaging material — Any material, including printed material, used in

the packaging of a pharmaceutical product, excluding any outer
packaging used for transportation or shipment. Primary packaging
materials are those that are in direct contact with the product.
Pharmaceutically equivalent products — Products that contain the

same amount of the same active substance(s) in the same dosage form,
meet the same or comparable standards, and are intended to be
administered by the same route.
Pharmaceutical product — Any medicine intended for human use or

administered to food-producing animals, presented in its finished dosage
form or as an active ingredient for use in such dosage form, that is subject
130
to control by pharmaceutical legislation in both the exporting and

importing states.
Pharmacodynamic — The study of the action or effects of drugs on living
organisms.
Pharmacokinetics — The process by which a drug is absorbed,

distributed, metabolized, and eliminated by the body.
Pharmacopeia — A book containing an official list of monographs and

internationally acceptable standards for the potency, purity, quality,
packaging, and labeling of pharmaceutical products. The major
pharmacopeias in the world are: The International Pharmacopeia, the
United States Pharmacopeia, the British Pharmacopeia, the Japanese
Pharmacopeia and the European Pharmacopeia. Other countries have
their own pharmacopeias.
Pharmacovigilance — All science and activities relating to the detection,

assessment, understanding, and prevention of adverse effects or other
drug-related problems. In general, pharmacovigilance aims to re-evaluate
the safety and efficacy of pharmaceutical product in the market. This
encompasses spontaneous adverse drug reactions, drug information
reporting, promotion of rational use of drugs, risk management, and crisis
preparedness.
Post-marketing surveillance of drug quality — Monitoring the quality of

drugs by inspection and laboratory testing to assure that the storage is
correct and that drugs are stable within their labeled shelf-life.
Potency — The extent to which a drug contains the specified amount of

the active ingredient.
Pre-marketing surveillance — Monitoring the quality of drugs by

inspection and laboratory testing to assure that the drugs conform to the
quality standards and specifications before their marketing authorization.
Primary container — The immediate container in direct contact with the

drug product, such as a jar, bottle, blister, ampoule, etc. The primary
container is designed to meet the specifications for storage and protect
the drug throughout its shelf-life.
131
Product certificate — A document containing the information set out in

Annex 3 of this Guideline. The certificate is validated and issued for a
specific product by the competent authority of the exporting country and
intended for use by the competent authority in the importing country, or, in
the absence of such an authority, by the drug procurement authority.
Purity — The extent to which drugs are free from potentially harmful
contaminants, degradation products, significant quantities of other drugs,
bacteria, or other microorganisms.
Quality (of drug product) — All characteristics—purity, strength,

packaging, labeling—that allow the drug product to deliver its intended
treatment.
Quality assurance (QA) — All matters that individually or collectively

influence the quality of a product. QA’s objective is to ensure that
pharmaceutical starting materials and pharmaceutical products meet
quality standards.
Quality control — All measures taken—including setting specifications,

sampling, testing, and analytical clearance—to ensure that raw materials,
intermediates, packaging materials, and finished pharmaceutical
products conform to established specifications for identity, strength,
purity, and other characteristics.
Quarantine — Physically isolating the starting, packaging, intermediate

or bulk materials or finished products while a decision is awaiting on their
release, rejection, or reprocessing.
Recall — The process of withdrawing a drug from the market because of a

quality, safety, or efficacy problem.
Registration — Any statutory system of approval required at the national

level as a pre-condition for introducing a pharmaceutical product to the
market.
Safety — Not causing harm or injury; having a low incidence of adverse

reactions and significant side effects when adequate instructions for use
are given; and having a low potential for harm under conditions of
widespread availability.
132
Sample — A portion of material collected according to a defined sampling

procedure. The size of any sample should be sufficient to carry out all
anticipated test procedures, including all repetitions.
Sampling procedure — A detailed and complete sampling operation to

be applied to a defined material for a specific purpose. A detailed, written
description of the sampling procedure is provided as sampling protocol.
Sampling unit — Discrete part of a consignment, such as an individual

package, drum, or container.
Secondary container — The external container in which the primary

container is placed.
Shelf-life — The period of time during which a drug product, if stored

correctly, is expected to comply with the specification as determined by
stability studies on a number of batches of the product. The shelf-life
establishes the expiry date of each batch.
Specification — A detailed document describing the requirements with

which the pharmaceutical products or materials used or obtained during
manufacture have to conform. Specifications serve as a basis for quality
evaluation.
Stability — The ability of a pharmaceutical product to retain its chemical,

physical, microbiological and biopharmaceutical properties within
specified limits throughout its shelf-life.
Stability tests — A series of tests designed to obtain information on the

stability of a pharmaceutical product to help define its shelf-life and
utilization period under specified packaging and storage conditions.
Standard — A technical specification that addresses a business

requirement, is implemented in viable commercial products, and, to the
extent practical, complies with recognized standards organizations, such
as ISO (International Organization for Standardization).
Standard Operating Procedure (SOP) — An authorized written

procedure giving instructions for performing operations not necessarily
specific to a given product or material, but of a more general nature (i.e.,
equipment operation, maintenance, and cleaning; validation; cleaning of
133
premises and environmental control; sampling and inspection). Certain

SOPs can be used to supplement product-specific master and batch
production documentation.
Starting material — Any substance of defined quality used in the

production of a pharmaceutical product, excluding packaging material.
Substandard drug — A legal branded or generic drug that does not meet
national or international standards for quality, purity, strength, or
packaging.
Therapeutic equivalence — Pharmaceutically equivalent products

whose effects with respect to both safety and efficacy are essentially the
same, when administered in the same molar dose, as can be derived from
appropriate studies (bioequivalence, pharmacodynamic, clinical, or in
vitro).
Toxicity — An adverse effect produced by a drug that is detrimental to the

patient’s health. The level of toxicity associated with a drug will vary
depending on the condition that the drug is used to treat.
Validated method — A method of analytical performance demonstrated

by experimental data that has proven its suitability as analytical support of
a specification proposed for particular drug. The nature of the method and
the type of drug test determine the characteristics that should be
considered to validate the method.
WHO-type certificate — A certificate of a pharmaceutical product of the

type defined in the “WHO Certification Scheme on the Quality of
Pharmaceutical Products Moving in International Commerce.”
134
ANNEXES
ANNEXES
ANNEX 1 UNHCR ESSENTIAL DRUGS

LIST (2006)
PLEASE NOTE: When drugs are ordered which are not on this list, a
special order form (Annex 2) will need to be completed. Procurement and
delivery times will also generally be longer.
The most up-to-date list can be obtained with prices via SMS HQ
([email protected]).
BASIC LIST
1 Acetylsalicylic Acid 100mg
2 Acetylsalicylic Acid 500mg
3 Acetylsalicylic acid, suppository, 50mg
4 Acetylsalicylic acid, suppository, 150mg
5 Albendazole 400mg
6 Aluminium Hydroxide 500mg, chewable
7 Amitriptyline, 25mg
8 Amoxycillin 250mg
9 Amoxicillin + clavulanic acid, 500mg+125 mg
10 Amlodipine 5mg
11 Atenolol 50mg
12 Beclomethasone oral inhaler, 250mcg/dose, 200 doses
13 Vitamin C 50mg (Ascorbic Acid)
14 Vitamin C 250mg (Ascorbic Acid)
15 Carbamazepine 100mg
16 Carbamazepine 200mg
17 Chloramphenicol 250mg
18 Chlorpheniramine Maleate 4mg
137
19 Chlorpromazine HCl 100mg

20 Ciprofloxacin 500mg
21 Cloxacillin 500mg
22 Cotrimazole vaginal tablet 100mg
23 Digoxin 0,25mg
24 Doxycycline 100mg
25 Enalapril 2.5mg
26 Erythromycin 250mg (as stearate)
27 Ferrous Sulphate 200mg
28 Ferrous Sulph. 200mg + Folic Acid
29 Fluconazole 50mg
30 Folic Acid 5mg
31 Furosemide 40mg
32 Glibenclamide 5mg
33 Glyceryl Trinitrate 0,5mg
34 Griseofulvin 125mg
35 Haloperidol 5mg
36 Hydralazine 25mg
37 Hydrochlorothiazide 25mg
38 Ibuprofen 200mg
39 Iodine 200mg
40 Isosorbide dinitrate 5mg
41 Mebendazole 100mg
42 Metformin 500mg
43 Methyldopa 250mg
44 Metoclopromide 10mg
45 Metronidazole 250mg
46 Niclosamide 500mg
138
ANNEXES
47 Nitrofurantoin 100mg
48 Nystatin 100,000 IU, oral tablet
49 Nystatin 100.000 IU, pessaries
50 Paracetamol 100mg
51 Paracetamol 500mg
52 Paracetamol suppository, 125mg
53 Paracetamol suppository, 250mg
54 Phenoxymethylpenicillin 250mg
55 Phenytoin Sodium 100mg
56 Vitamin B6 50mg (Pyridoxine)
57 Prednisolone 5mg
58 Promethazine HCl 25mg
59 Propranolol 40mg
60 Ranitidine 150mg
61 Vitamin A 10.000 IU (Retinol)
64 Salbutamol oral inhaler, 100mcg/dose, 200 doses
65 Salbutamol 4mg
66 Senna 7,5mg
67 Spironolactone 25mg
68 Cotrimoxazole 480mg
69 Cotrimoxazole 120mg
70 Vitamin B1 50mg (Thiamine)
71 Zinc sulfate 10mg
139
1 Benzoic Acid comp. ointment, 800g

2 Benzyl Benzoate application 25%,
3 Benzyl Benzoate saponated 90%, 1l
4 Betamethasone 0.1% cream, 15g
5 Calamine Lotion 15%, 500ml
6 Chlorhexidine Gluconate 20%, 5ltr
7 Chlorhexidine Gluconate 5%, 1ltr
8 Chlorhexidine 1,5% + Cetrimide 15%, L
9 Fluorescein eye drops 2%, 0,5ml
10 Gentian violet 25g
11 Hydrocortisone ointment 1%, 15g
12 Miconazole 2% cream, 30g
13 Neomycin 5mg/g + Bacitracin 500 IU/g
ointment, 15g
14 Silver sulfadiazine cream 1%, 500g
15 Povidone Iodine 10%, 200ml
16 Tetracaine eye drops 0,5%, 10ml
17 Tetracycline eye ointment 1%, 5g
18 Zinc Oxide ointment 10%, 800g
SUPPLEMENTARY LIST
1 Dextrose 5%, 500ml
Infusion giving set w/air inlet + filter
4 Haemaccel 500ml
5 Potassium Chloride 1g/10ml
140
ANNEXES
6 Ringers lactate 500ml

7 Ringers lactate 1000ml
8 Sodium Chloride 0,9%, 500ml
9 Sodium Chloride 0,9%, 1000ml
10 Oral Rehydration salt 27,9g, WHO
11 Water for inj., 2ml
1 Diazepam 5mg/ml, 2ml

Import license required
2 Morphine HCl 10mg/ml, 1ml
3 Phenobarbitone 50mg
4 Phenobarbitone Sodium 100mg/ml, 2ml
5 Tramadol 50mg/ml, 2ml
Import license may be required
1 Oxytocin 10 IU/ml, 1ml

Cool item, store between 2-8 °C
2 Ergometrine Maleate 0,5mg/ml, 1ml
3 Insulin Soluble Hm 40 IU/ml, 10ml
4 Insulin Soluble Hm 100IU/ml, 10ml
141
5 Insulin Isophane NPH HM 40 IU/ml,

Insulatard HM
6 Insulin Isophane NPH HM 100IU/ml
1 Adrenaline 1mg/ml, 1ml

2 Ampicillin 500mg (as Sodium)
3 Atropine Sulphate 1mg/ml, 1ml
4 Benzathine Penicillin 2,4M IU
5 Benzylpenicillin Sodium 1M IU
6 Benzylpenicillin Sodium 5M IU
7 Procaine Penicillin 3 M IU
8 Procaine Penicillin 4 M IU, fortified
9 Chloramphenicol 1g (As Sodium Suc
10 Chlorpromazine HCl 25mg/ml, 2ml
11 Cloxacillin 500mg
12 Dexamethasone 4mg/ml, 1ml
13 Digoxin 0,25mg/ml, 2ml
14 Furosemide 10mg/ml, 2ml
15 Gentamicin 40mg/ml, 2ml
16 Haloperidol 5mg, 1ml ampoule
17 Halothane inhalation 250ml
18 Hydralazine HCl 20mg (lyophilized
19 Hydrocortisone 100mg (as sod. suc
20 Ketamine 50mg/ml, 10ml
21 Lidocaine 1%, 50ml
22 Magnesium sulphate 500mg/ml, 2ml
23 Metoclopramide 5mg/ml, 2ml
142
ANNEXES
24 Metronidazole infusion 5mg/ml, 100ml

25 Naloxone HCl 0,4mg/ml, 1ml
26 Phenytoin 50mg/ml, 5ml
27 Promethazine HCl 25mg/ml, 2ml
28 Salbutamol 0,5mg/ml, 1ml
29 Spectinomycin 2g w/solvent
30 Vitamin K 1mg/ml, 1ml
SPECIALIZED LIST
1 Ethambutol 100mg
2 Ethambutol HCl 400mg
3 Isoniazid 100mg
4 Pyrazinamide 500mg
5 Rifampicin 150mg
6 Rifampicin 300mg
7 Rifampicin 150mg + Isoniazid 100mg
8 Rifampicin 300mg + Isonazid 150mg
9 Streptomycin 1g
10 Thiacethazone/i.n.h. 50/100mg
11 Thiacethazone/i.n.h. 150/300mg
12 Isoniazid + Ethambutol, 150mg+400mg
13 Rifampicin + Isoniazid + Pyrazinamide, 150mg+75mg+400mg
14 Rifampicin + Isoniazid + Pyrazinamide + Ethambutol,
150mg+75mg+400mg+275mg
1 Ethinyloestradiol 0,03mg +
Levonorgestrel 0,15mg
2 Ethinyloestradiol 0,035mg +
Norethisterone 1mg
143
3 Levonorgestrel 0.75mg
4 Condoms, lubricated
5 Condoms, “Femidon”
6 Intra Uterine Device, Gyne-T 380A
7 Medroxyprogesterone acetate, depot inj, 150mg/ml, 1 ml
8 Multiload (short) cu 250 IUD
1 Amiodiaquine 200mg base

2 Amiodiaquine + artesunate 153mg+50mg, co-blister, (3+3 tabs)
3 Artemether 20mg/ml, 1ml
4 Artemether 80mg/ml, 1ml
5 Artesunate 50mg
6 Ceftriaxone 250mg w/solvent
7 Ceftriaxone 1g
8 Chloramphenicol oily 250mg/ml, 2m
9 Chloroquine 100mg base
10 Chloroquine Phosphate 250mg (unc.)
Eqv. to 155mg Chloroquine base
11 Clofazimine 50mg
12 Clofazimine 100mg
13 CoArtem (artemether 20mg + lumefantrine 120mg)
14 Dapsone 50mg
15 Dapsone 100mg
amilase 2900 IU + protease 330 IU
16 Diethylcarbamazine Citrate 50mg
17 Ivermectin 6mg
18 Mefloquine 250mg
19 Pentamidine Isethionate 300mg
144
ANNEXES
20 Praziquantel 600mg
21 Primaquine 7.5 base
22 Primaquine 15mg base
23 Quinine Sulphate 300mg
24 Quinine diHCl 300mg/ml, 2ml
25 Sodium Stibogluconate 100mg/ml, 3
26 Sulfadoxine 500mg + Pyrimethamine 25mg
27 Suramin 1g
28 Meglumine Antimonate 1,5g/5ml
145
ANNEXES
ANNEX 2 ORDER FORM: REQUEST FOR

DRUGS NOT INCLUDED ON THE
UNHCR LIST OF ESSENTIAL DRUGS
PLEASE COMPLETE ALL RELEVANT SECTIONS OF THIS FORM:
Country: ________________ Location:________________________
Camp: _________________ Refugee population:_______________
1. Generic name: __________________________________________
2. Specify the dosage form and strengths that you wish to include:
______________________________________________________
Dosage form Strength(s) Dosage form Strength(s)
Tablet: ____________________ Capsule: __________________
Syrup:____________________ Oral solution: _______________
Ointment/cream: ____________ Injectable: _________________
Suppositories: ______________ Other: ____________________
3. Recommended dosages and length of treatment:
- Paediatric:
_____________________________________________________
- Adult:
_____________________________________________________
4. Clinical indications for use of drug: __________________________
5. State reasons for request, and explain why UNHCR list analogues
not appropriate:
______________________________________________________
147
6. List contra-indications, precautions and side-effects associated with

use/abuse of proposed drug:
______________________________________________________
7. Specify conditions under which the drug will be used:

- camps( s) where it will be used: ____________________________
- level( s) of health worker( s) authorized to
prescribe drug: _________________________________________
- health facilities in which it will be used: ______________________
- access to personnel skilled in use of drug: ____________________
(Name and title of person making request) (Signature) (Date)

(Organization/Agency)
NB. This form is to be submitted for clearance to the Senior Public

Health Officer through the UNHCR Field Office.
Note: Procurement and delivery time will be longer than EDL drugs.
148
ANNEXES
ANNEX 3 CONTENTS OF THE NEW

EMERGENCY HEALTH KIT
Basic Unit
Drugs:
Acetylsalicylic acid 300mg 3x 1,000 TAB
Aluminium hydroxide 500mg 1x 1,000 TAB
Benzyl benzoate 25% application 1x 1 L
Cetrimide 15%/chlorhexidine gluc. 1.5% (savon) 1x 1 L
Chloroquine phosphate 150mg base (uncoated) 2 x 2x 1,000 TAB
1.000 TAB
Co-trimoxazole 400mg+80mg scored. 2x 1,000 TAB
Ferrous sulphate 200mg / folic acid 0.25mg 2x 1,000 TAB
Gentian violet 4x 25 g
Mebendazole 100mg 1x 500 TAB
Oral rehydration salts for 1000ml water 2x 100 SAC
Paracetamol 100mg 1x 1,000 TAB
Tetracycline hcl eye ointment 1% 5g 1x 50 TUB
Renewable supplies:
Adhesive tape 2.50cm x 5m 4x 8 ROL
Ballpoint, Bic, blue 10 x 1 PCE
Block note A6 10 x 1 PCE
“treatment guidelines ”for basic unit,engl/fr./span. 2x 1 PCE
Clinical thermometer oral /rectal,°C+°F, stubby 6x 1 PCE
Cotton wool absorbent BP /Eur P. 500g zig-zag 2x 1 PCE
Elastic bandage 8cm x 5m (stretched) 1x 20 ROL
Examination gloves latex medium disposable 1x 100 ROL
Gauze compresses 10x10cm 12 ply, non sterile 5x 100 PCE
149
Renewable supplies:
Health card 10.000pers./ kit eng/fr/sp+plastic bag 1x 500 PCE
Hydrophylic bandage selfedged 7,5cm x 5m 10 x 20 ROL
Note book, hard cover A4 100 pages 4x 1 PCE
Soap unwrapped 200g 1X 10 PCE
Tablet bags re usable 60x 80mm mini grip(+pictogram) 4X 500 PCE
Equipment:
Bottle, 100ml plastic (screwcap=872741) 1X 1 PCE
Cap with spout for bottle 100ml, 17 mm 1x 1 PCE
(code 731900)
Bucket, plastic 12L 2x 1 PCE
Dish (kidney) s.s. 24cm 1x 1 PCE
Dressing set (*) 2x 1 SET
Drum for cotton wool and gauze diam.15cm high 15cm 2x 1 PCE
Instrument tray 30x20x2cm 1x 1 PCE
Forceps artery Pean 14.5cm straight 2x 1 PCE
(=Kocher, no teeth)
Gallipot s.s. without lid 300ml 1x 1 PCE
Plastic bottle 1000ml wide neck/screw cap 731700 3x 1 PCE
Screw cap for plastic bottle 1000ml (731800) 3x 1 PCE
Scissors, surgical bl/bl, straight, 14.5cm 2x 1 PCE
Syringe Luer 10ml disp 2x 1 PCE
Surgical scrub brush, sterilisable 2x 1 PCE
Water bag, foldable, 20Ltr strong quality with tap 1x 1 PCE
(*) Each dressing set consists of:
Instrument box with lid, s.s. 20x10x5cm 1 x 1 PCE 1x 1 PCE
Forceps dissecting 14cm (dressing spring type) 1 x 1 1x 1 PCE
PCE
Forceps artery Pean 14.5cm, straight 1 x 1 PCE 1x 1 PCE
Scissors, surgical sh/bl, straight, 14.5cm 1 x 1 PCE 1x 1 PCE
150
ANNEXES
Supplementary Unit
Benzathine penicillin 2.4 miu 1x 50 VLS
Diazepam 5mg/ml, 2ml 2x 100 AMP
Epinephrine 1mg/ml, 1ml (=adrenaline) 1x 50 AMP
Ketamine 50mg/ml, 10ml 1x 25 VLS
Morphine 10mg/ml inj. 1ml 5x 10 AMP
Oxytocin 10 iu/ml, 1ml 2x 100 AMP
Phenobarbital 50mg 1x 1000 AMP
Quinine di-hcl 300mg/ml 1x 100 AMP
Quinine sulphate 300mg film coated 3x 1000 TAB
Silver sulphadiazine 1% cream 50g 30 x 1 TUB
Sulphadoxine/pyrimethamin 500mg/25mg 3x 100 TAB
Water for injection 10ml 20 x 100 AMP
Benzylpenicillin 5 miu 5x 50 VSL
Procaine penicillin 3 miu/benzylpen. 1 miu 15 x 50 VSL
Aminophylline 25mg/ml, 10 ml 1x 50 AMP
Amoxicillin 250mg 3x 1000 TAB
Ampicillin 500mg 4x 50 VLS
Atropine sulphate 1mg/ml, 1ml 1x 50 AMP
Benzoic acid 6%+salicylic acid 3% ointment, 40gr 25 x 1 TUB
Chloramphenicol 250mg 2x 1000 CAP
Chloramphenicol sodium succinate 1g base 10 x 50 VLS
Chlorpromazine hcl 25mg/ml, 2ml 1x 20 AMP
Dextrose 50% 50ml 1x 25 VLS
Doxycycline 100mg (as hyclate) 2x 1000 TAB
Ethinylestradiol/Levonorgestrel 0.05/0.25mg 100 x 4 TAB
Folic acid 5mg 1x 1000 TAB
Furosemide 10mg/ml, 2ml 1x 20 TAB
Hydralazine 20mg (dry pow der for inj.) 4x 5 AMP
151
Hydrochlorothiazide 25mg 2x 100 TAB

Hydrocortisone 100mg (as sodium succinate) 2x 25 VLS
Lidocaine hcl 1%, 20ml 2x 25 VLS
Methyldopa 250mg filmcoated 1x 500 TAB
Metronidazole 250mg 2x 1000 TAB
Naloxone 0.4mg/ml, 1ml 2x 20 AMP
Nystatin 100.000 IU vaginal 10 x 100 TAB
Nystatin 100.000 IU oral non-coated 10 x 100 TAB
Prednisolone 5mg 1x 100 TAB
Promethazine hcl 25mg coated 1x 500 TAB
Promethazine hcl 25mg/ml, 2ml 1x 50 AMP
Pvp iodine 10% solution 10 x 200 ML
Salbutamol 4mg 1x 1000 TAB
Vitamin A 200.000 iu (retinol) 4x 1000 CAP
Vitamin C 250mg (ascorbic acid) 4x 1000 TAB
Supplementary infusions
Hartmann's sol. (ringer lactate) 500ml +set 3x 20 BTL
Hartmann's sol. (ringer lactate) 500ml + set 3x 20 BTL
Dextrose 5% in water 500ml + set 2x 20 BTL
Dextrose 5% in water 500ml + set 3x 20 BTL
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ANNEXES
Supplementary renewable supplies:

Catheter Foley no.12 balloon 5-15ml sterile 1x 10 PCE
I.v. placement unit 22G blue 15 x 1 PCE
Scalp vein infusion set 25g 3x 100 PCE
Spinal needle 20G x 90mm disp. 1x 25 PCE
Spinal needle 22G x 40mm disp. 1x 25 PCE
Surgical gloves size 7.5 sterile 3x 50 PCE
Surgical gloves size 8.5 sterile 1x 50 PCE
Suture vicryl 2/0 , 70cm, + 3/8 ct.ndl. 30mm, V586H 4x 36 PCE
Syringe luer 10ml disp. 2x 100 PCE
Syringe luer 10ml synthetic autoclavable 4x 10 PCE
Syringe luer 2ml disp 4x 100 PCE
Tongue depressor wood 15cmx18mm 1x 100 PCE
724202 Feeding tube ch5 40cm disp. luer 1 x 20 PCE 1x 20 PCE
720903 Feeding tube ch8 40cm disp. luer 1 x 50 PCE 1x 50 PCE
944003 Gauze compresses 10x10cm 12-ply, sterile 22 22 x 45 PCE
x 45 PCE
706300 Needle luer 21g x 1-1/2" (0.8x38mm), disp. 20 20 x 100 PCE
x 100 PCE
840774 Safety box for disp. of used syringe & needle 20 x 1 PCE
5L 20 x 1 PCE
840413 Stomach tube ch16 125cm disp. plastic 1 x 10 1x 10 PCE
PCE
711100 Surgical gloves size 6.5 sterile 1 x 50 PR 1x 50 PCE
901000 Syringe 50(60)ml luer dis p.(also for feeding 10 x 1 PCE
tube) 10 x 1 PCE
719900 Urine collecting bag 2000ml with tap and valve 10 1 PCE
10 x 1 PCE
Autoclave tape,18mmx50mtr (for steam ster.) 2x 1 ROL
153
Supplementary renewable supplies:

Clinical thermometer oral /rectal,°C+°F, stubby 10 x 1 PCE
Examination gloves latex small disposable 1x 100 PCE
Examination gloves latex medium disposable 1x 100 PCE
Examination gloves latex large disposable 1x 100 PCE
Hydrophylic gauze 90cm x 91m BP 13heavy (17g/m2) 3x 1 PCE
I.v. placement unit 18G green 15 x 1 PCE
I.v. placement unit 24G yellow 15 x 1 PCE
Mucus extractor baby disposable 5x 1 PCE
Needle luer 19g x 1-1/2" (1.1x38mm), disp. 10 x 100 PCE
Needle luer 25g x 5/8" (0.5x16mm), disp. 1x 100 PCE
Scalp vein infusion set 21g 1x 100 PCE
Sodium dichloroiso cyanurate 1.67gr (NaDCC) 6x 200 TAB
Syringe luer 5ml disp. 5x 100 PCE
Umbilical cord tie 3mm non-sterile 100m 1x 1 ROL
Supplementary equipment:
Battery for oto/ophth.scope penl. alkal. R6 7205/7139 12 x 1 PCE
Bulb for otoscope mini Heine(7139) XHL 056 2.5V 4x 1 PCE
Drum for cotton wool and gauze diam.15cm high 15cm 2x 1 PCE
Instrument tray 30x20x2cm 1x 1 PCE
Measuring-tape, flexible 1.5m,vinyl-coated,fibregl 5x 1 PCE
Otoscope “mini” with battery handle, small Heine 2x 1 PCE
Scale Salter type 25kg x 100g + 3 trousers 3x 1 PCE
Surgical scrub brush, sterilisable 2x 1 PCE
Water filter (Berkefeld) SS3 with 3 candles 10ltr. 3x 1 PCE
2 razor handles reusable + 100 blades 2x 1 SET
Apron with neckband opaque plastic, disp. 2x 1 PCE
Dish (kidney) s.s. 24cm 2x 1 PCE
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ANNEXES
Supplementary equipment:
Pressure cooker 21 ltr + basket (for EHK) 1x 1 PCE
Scale metric adults bathroom type 1x 1 PCE
Sheeting, plastic, clear 90cm x 180cm Uni 0361020 2x 1 PCE
Sphygmomanometer, anaeroid, simple 4x 1 PCE
Stethoscope foetal metal 1x 1 PCE
Stethoscope, littman type double light weight + spares 4x 1 PCE
Tape for measuring circumference (talc) 10 x 1 PCE
Abcess/suture set (packed in 734200) 2 x 1 SET 2x 1 SET
Blade for surgical knives size 22 1x 100 PCE
Book “guide clinique et therapeutique”(french)MSF 1x 1 PCE
Book “clinical guidelines” (english) MSF 1x 1 PCE
Book “guia clinica y terap eutica” (spanish) MSF 1x 1 PCE
Dressing set (packed in 734200) 5x 1 SET
Forceps artery Pean 14.5cm straight (=kocher, no 2x 1 PCE
teeth)
Midwifery kit (packed in 734200) 1x 1 KIT
Prestige double-rack 7503 PHC-sterilizer + access. 1x 1 PCE
Scissors, surgical bl/bl, straight, 14.5cm 2x 1 PCE
Stove kerosene for sterilizer Hipolito 36 2x 1 PCE
Tourniquet (arm), cotton white with buckle 2x 1 PCE
Towel, huck 430 x 500mm Uni 0575000 2x 1 PCE
Each abscess/suture set consists of:

Instrument box with lid, s.s. 20x10x5cm 1x 1 PCE
Forceps tissue 14.5cm 1/2 teeth (spring type) 1x 1 PCE
Forceps artery Kocher 14cm straight 1x 1 PCE
Scissors, curved, sharp/b lunt 14.5cm 1x 1 PCE
Probe, grooved 14.5cm uni 0759810 1x 1 PCE
Needle holder, mayo-hegar 18cm,straight 1x 1 PCE
155
Each abscess/suture set consists of:

Handle for surgical blade s no. 4 1x 1 PCE
Each dressing set consists of:
Scissors, surgical sh/bl, straight, 14.5cm 1x 1 PCE
Forceps dissecting 14cm (dressing spring type) 1x 1 PCE
Each midwifery set consists of:
Scissors, surgical sh/bl, straight, 14.5cm 1x 1 PCE
Dissecting straight Mayo 16-18 1x 1 PCE
156
ANNEXES
ANNEX 4 STANDARD OPERATIONAL

PROCEDURES
SOP P1: Consumption-based quantification
SOP P2: Morbidity-based quantification
SOP P3: Ordering Procedures for International Procurement
SOP D1: Physical Inventory
SOP D2: Issuing items that expire first (FEFO)
SOP D3: Filling out stock cards
SOP D4: Storage of drugs and medical supplies
SOP D5: Removing damaged and expired stock
SOP Q1: OBTAINing good quality drugs
SOP Q2: VERIFYing the quality of shipped drugs
SOP Q3: MONITORing and MAINTAINing the quality of drugs
157
United Nations High Commissioner for Refugees

Consumption-based quantification of essential drug procurement
Nr. Of pages: 5 Procedure number: SOP P1
Objective:
Estimating the quantities of specific drugs needed for procurement to

avoid shortage and excess stock based on past consumption data,
adjusted for stock-outs, avoidable wastages and projected changes in
drug utilization.
Responsibility:
Health coordinator in collaboration with health and logistics staff.
Resources:
Essential data are:
l general data: location, partner, name of responsible officer with

UNHCR and with partner
l data on population size
l consumption and/or issue data
l data on frequency and duration of stock-outs
l projected drug costs
l review period versus desired coverage period
Consumption data Issue data

l dispensing records l stock records central distribution point
l monthly consumption reports l distribution records
Note that the consumption from a stock record card is calculated by

adding up all the quantities issued. The formula is:
Recorded consumption = Opening stock + Drug Received - Closing Stock.
158
ANNEXES
Procedures:
Step 1: Prepare a list of drugs to be quantified.
Step 2: Determine the period of time to be reviewed for consumption.
The simplest and most practical period for which to calculate consumption
is one year. This ensures that the morbidity variations of all seasons are
covered. If data are available, the longest period of data should be used as
can improve the reliability of the results.
The timing of placing an order is critical in order to avoid stock-outs. It

needs to take into account the lead-time (time for procurement and
delivery). For example, if an order is being placed for January – December
2006, the order must arrive in December 2005. Taking into account an
average lead-time of 3 months, the order must be prepared and sent in
September 2005 (or even earlier if possible).
Step 3: Enter consumption data for each drug.
For each drug, enter:
l The total quantity used during the review period (in basic units).
l The number of days (or months) that the drug was out of stock in the
review period.
l The average lead-time from the last several procurements.
Step 4: Calculate the Average Monthly Consumption and adjust for stock-out.
The average monthly consumption is a key variable in the quantification

formula and should be as accurate as possible. The simple approach is to
divide total consumption by the number of months reviewed. If there were
stock-outs during that period, the average must be adjusted to include the
consumption that would have occurred if stock had been available.
Adjusted average monthly consumption:

CA= CT ÷ [RM – (DOS ÷ 30.5)]
CA = Average monthly consumption adjusted for stock-outs
CT = Total consumption during review period, in basic units
159
RM = Review period in months

DOS = Number of days an item was out of stock during the review period
Note that one must divide by 30.5 to convert to months. If the total
consumption of ampicillin 250 mg capsules for a six-month review period
was 89000 capsules and the drug was out of stock for 34 days during that
period, the (adjusted) average monthly consumption is:
CA = 89000 ÷ [6- (34 ÷ 30.5)] = 18218
Step 5: Calculate the lead-time stock needed for each drug.
This is the quantity of drug consumed during the delivery time. So if delivery
time is 3 months, the lead-time stock is the monthly consumption x 3.
Step 6: Calculate the safety stock needed.
The safety stock is that which is needed to compensate for possible late
deliveries, losses and increases in consumption. It is generally calculated
as half of the consumption of the lead-time stock or about 20% of the total
order. So if the lead-time is 3 months, safety stock is half of that or monthly
consumption x 1.5.
Step 7: Convert the quantity into order pack.

Total quantities required divided by order pack size.
Step 8: Estimate costs for each drug and total costs.
In order to estimate procurement costs, multiply the price by estimated quantity

for each drug by the purchase price. If for example the price per pack of
Amoxicillin 250mg of 1000 capsules is 30 USD and the annual total estimated
requirement is 40 packs then the cost will be =40 x 30 USD= 1200 USD.
Estimate the total cost of all drugs and add everything up.
Step 9: Prepare annual drug budget.
The annual drug budget shall include:
l All the estimated cost of the drugs & medical supplies required.
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ANNEXES
l Estimates of the cost for transportation, procurement & distribution.
Formulas for Consumption-Based Calculations
Formula Objective of Formula Calculations

Number
1 Adjusted average monthly CA = CT ÷ [RM – (DOS ÷ 30.5)]
consumption (preferred)
2 Adjusted average monthly CA = CT ÷ (RM – MOS)
consumption (alternative)
3 Projected average monthly CP = CA x AU
consumption
4 Basic safety stock CP x LT
requirements
5 Quantity to order QO = CP x (LT + PP) + SS – (SI + SO)
CA = Average monthly consumption, adjusted for stockouts

CT = Total consumption during review period, in basic units
RM = Total consumption review period in months
DOS = Number of days an item was out of stock during the review
period
MOS = Estimated number of months an item was out of stock during
the review period
CP = Projected average monthly consumption
AU = Utilization adjustment
LT = Average lead time (for projected supplier or worst case),
in months
QO = Quantity to order in basic units, before adjustment for losses
or program change
PP = Procurement period (number of months to be covered by order)
SS = Quantity needed for safety stock
SI = Stock now in inventory, in basic units
SO = Stock now on order, in basic units
161
Figure 1 Example of a Consumption-Based Forecast
Drug Strength BU Pack Total Days Adjusted Projected Stock Stock on Lead- Sug- Adjusted Order Probable Value of
Size Consump- Out of Average average on Order time gested Order Quantity Pack Proposed
tion Sto ck Monthly monthly Hand (BU) Stock Quantity Quantity (Pack s) Price Order
in Period Consump- Consump- (BU) Level to Order (US$) (US$)
(BU) tion tion (BU) (BU)
(BU) (BU)
Ampicillin 500 mg capsule 1,000 59,500 0 9,917 10,413 32,000 42,000 31,238 50,950 56,045 57 69.30 3,950.10
Ampicillin 250 mg capsule 1,000 89,000 34 18,218 19,129 81,000 58,000 57,387 90,548 99,603 100 35.10 3,510.00
Ampicillin sodium 500 mg ampoule 100 3,879 0 647 679 111 7,600 2,036 435 478 5 29.95 149.75
injection
Ampicillin 125 mg/ bottle 1 4,128 0 688 722 1,513 3,000 2,167 4,156 4,571 4,572 0.75 3,429.00
suspension 100 mL 5 Ml
Antihistamine 250 mL bottle 1 853 29 169 177 351 929 532 849 933 934 1.57 1,466.38
decongestant elixir
Antihistamine (any) tablet 500 50,000 0 8333 8,750 0 62,500 26,250 42,500 46,750 94 12.00 1,128.00
decongestant
Bacitracin — tube 1 2,414 31 484 509 3,400 100 1,526 2,603 2,864 2,864 0.54 1,546.56
antibiotic ointment
Bendrofluazide 5 mg tablet 500 141,500 30 28,208 29,618 142,000 50,000 88,854 163,415 179,756 360 1.90 684.00
Benzathine benzyl- 2.4 M.U. ampoule 50 1,318 0 220 231 1,486 0 692 1,282 1,410 29 25.00 725.00
162
penicillin injection
Cephradine 500 mg ampoule 100 2,695 0 449 472 2,300 1,100 1,415 2,260 2,485 25 75.00 1,875.00
injection
Chlorhexidine 5% Liter 5 302 0 50 53 433 0 159 201 221 45 17.95 807.75
gluconate solution
(Hibitan)
Chlorhexidine/ 5 liter Liter 5 438 0 73 77 418 250 230 252 277 56 14.70 823.20
cetrimide (Savlon)
Chlorpropamide 250 mg tablet 1,000 162,000 0 27,000 28,350 169,000 0 85,050 171,200 188,320 189 8.99 1,699.11
Cimetidine 200 mg ampoule 10 1,090 0 182 191 2,580 0 572 0 0 0 8.36 0
(Tagamet) injection
Cimetidine 400 mg tablet 1,000 24,000 0 4,000 4,200 23,500 25,000 12,600 1,900 2,090 3 42.00 126.00
Cloxacillin 125 mg/ bottle 1 882 0 147 154 1,446 0 463 406 447 447 1.00 447.00
suspension 100 mL 5 mL
Note: BU = basic unit, Consumption period = 6 months, Lead time = 3 months, Procurement Period = 6 months, Utilization
adjustment for 6 months = 2.5%, Losses adjustment = 10%
ANNEXES

Morbidity-based quantification of essential drug procurement
Objective:
l Estimating the quantities of specific drugs needed for procurement to

avoid shortage and excess stocks in new programs or programs where
no past consumption data is available.
l Countercheck procurement quantities as estimated by the
consumption method.
Responsibility:
Health Coordinator in collaboration with health staff.
Resources:
Essential data are:
l data on population and patient attendances

l actual or projected incidence of health problems
l standard treatments (ideal, actual)
l projected drug costs
Procedures:
Step 1: Prepare Average Standard Treatment Schedules (ASTS).
In preparing ASTS the following information should be included:
l The name of the health problem and code number of the diagnosis.
l The patient's age and sex.
l The generic name, strength and dosage form each drug used to treat
the disease.
163
l The average dose, number of doses/day and duration of treatment (the

number of days these doses are given).
l The total average quantity of each drug used for a standard course of
treatment.
ICD Diagnosis Treatment Dose Number Duration Quantity

Code of doses (total for
No. per day treatment course of
days) treatment
Pneumonia Amoxicillin 1 capsule 3 7 21
-adults 500 mg capsules
capsule
-children Amoxicillin 5 ml 3 7 100 ml
250 mg/
5 ml
suspension
Step 2: Estimate number of treatment episodes for each health problem.
A treatment episode is a patient contact for which a standard course of

treatment is required.
The following information helps estimate the number of treatment

episodes:
l Obtaining the total number of patient contacts by diagnosis.

l Recognize the diagnosis according to the health problems defined in
the average standard treatment.
l Within health problems, breakdown the number of patient contacts by
age, sex and severity.
l Determine the proportion of contacts for which standard treatments
are required.
All patient contacts/visits may not give rise to a treatment episode as may
not require a standard course of drug treatment.
A single patient contact or visit may give rise to more than one treatment
episode.
164
ANNEXES
Step 3: Calculate total quantity of each drug required.
a.) Calculate the total quantity of each drug required for each health
problem.
A total quantity of drug for each health problem can be calculated

using the following formula:
Total quantity of each drug = No. of treatment episodes X Quantity of the drug specified
of each health problem for the health problem
for a standard course
If the number of treatment episodes for acute diarrhea treated

annually by a certain health facility was 10,000 of which 65% were
children and cases were treated with ORS, the quantity can be
determined as follows:
ICD Diagnosis Number of Quantity per Total

Code Treatment average Quantity
Episodes (a) standard (a x b)
treatment (b)
Acute diarrhea 10000 x 35%= ORS 2 3500 x 2 =
-Adult 3500 sachets per 7000 sachets
24hrs.
-Children 10000 x 65%= ORS 1 sachet 6500 x 1=
6500 per 24 hrs. 6500 sachets
Total 13500
sachets
b.) Calculate the total quantity of drug required.
When a drug is indicated for more than one standard treatment, add
the quantities required for each treatment to obtain the total quantity
of the drug. These all are combined to project the quantity of each
drug needed for each treatment episode in each standard treatment.
165
Illustrative example
Drug Generic Health Total quantity of all

code name problem treatments
No.
No. of Qty. per Total
treatment average quantity
episodes STS
Metronidazole Amoebiasis
250 mg Adult 600 45 27000
capsule 400 15 6000
Children
Giardiasis 1000 21 15000
1000 8 8000
Trichomoniasis
Total 56000
STS~ means Standard Treatment Schedule
Step 4: Increase the quantity obtained to allow for possible for service
expansion.
Step 5: Convert the quantity into the required order pack.
The quantity can be converted into the required number of order

packs/pack size.
The Formula is:
No. of order packs = Total quantities required

Pack size (counting unit)
N.B: The quantity can be increased by, for example, 5% allowances for changes in
consumption pattern and losses.
Step 6: Estimate the cost of the drug quantities required.
After calculating the total number of packs of each drug required, the next
step is to estimate the total cost of the drug required using the formula
shown below and then adding up the total costs of all drugs.
Total cost of each drug = Number packs required x Price per pack
166
ANNEXES
Step 7: Prepare Annual Drug Budget.
Preparing the annual budget requires:
l Adding up the estimated cost of all drugs required;

l Estimating the cost for transportation, procurement and distribution;
l Estimating costs for preparing/printing of stock cards, bin cards,
consumption reporting forms.
l Prescription Registration Book, and other necessary working
documents.
167

Ordering Procedures for International Procurement
Task: To order medicines and medical supplies for use in the health
centres.
Completed by: Senior health staff of Implementing partner, UNHCR

health coordinator, UNHCR Senior Public Health Officer (to supervise and
clear order), Programme Officer (to ensure budget), Supply Officer (to
receive and transport).
Purpose: To ensure that drugs and medical supplies are appropriately

ordered in terms of type and quantity and to ensure that they are available
continuously without shortages or disruptions.
When to perform: At least once a year, though it could be more

frequently depending on budget availability.
Steps and actions
1. The Implementing health partner must always be aware of how much

stock of drugs and medical supplies it has on hand. When only six
months supplies are left, they should inform the UNHCR health
coordinator (where present) and the Programme officer that more
supplies are needed.
2. The Programme officer should inform the Desk that funds will be
needed for drugs and medical supplies.
3. Senior staff of the partner agency in coordination with the UNHCR
health coordinator (where present) prepare the order for the next
year (or 6 months, depending on budget) based on past
consumption or morbidity methods. The order is placed on the
standard order forms available from SMS.
4. The order is reviewed with the Programme Officer to confirm the
budget.
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ANNEXES
5. The order is then sent to the UNHCR Senior Public Officer to be

reviewed and cleared. An email should be sent to the Programme
Officer that the order has been cleared.
6. The Programme Officer forwards the order and email to the Desk. If
an order cannot be cleared in the field, the Desk sends it to the
Senior Public Health Officer at HQ to be cleared.
7. Once cleared, the order is forwarded by the Desk to SMS for
processing. When the order is ready for shipment, the supplier
notifies the consignee (Country office) and SMS of the estimated
date of arrival. The Supply officer at country level requests from the
supplier, transport company and SMS any additional documents (eg.
purchase order, packing list, final invoice, etc.) needed to start
clearance procedures in-country
8. The Supply officer at country level ensures that the order is cleared
through customs as quickly as possible once it arrives in-country.
Once customs has been cleared, the store-keeper at the warehouse
receives, inspects and stores the materials. Any discrepancies or
damages are reported immediately to the Supply officer. The Supply
officer arranges onward transport to the Suboffice and Implementing
partner as soon as feasible.
9. The Suboffice and Implementing partner receive and verify the order.
Any discrepancies or damages are reported to SMS immediately.
This task is complete when:
l drugs and medical supplies arrive in the health centre and are
available for the population.
169

How To Conduct a Physical Inventory
Nr. Of pages: 2 Procedure number: SOP D1
Task: Conducting a physical inventory
Completed by: pharmacist, storekeeper, clinical officer/medical assistant
Purpose:
1. To verify the quantity of usable stock available for distribution.

2. To identify discrepancies between actual supplies and the stock
balance on the stock card.
3. To detect damaged or expired items.
4. To provide opportunity for store reorganization.
When to perform:
1. Quarterly at a central medical store

2. Monthly at a health center (on the last day of the month)
3. Any time you think there may be discrepancies in the amounts of
usable stocks available
Steps and actions
1. Separate and count any expired or damaged drugs, and other

medical supplies.
Record the amount of damaged or expired product in the
Losses/Adjustments of the stock card. In the Remarks, provide a
brief explanation for the expiry or damage.
2. Count every brand, preparation or dosage form of usable health
commodity by hand.
Include stock held in storerooms, cabinets, or racks. Do not count
stock already issued to health facilities. Always count the smallest
countable unit of the commodity. Example: condoms=piece,
orals=cycle, etc.
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ANNEXES
Count unopened/complete cartons first. Multiply the number of

cartons by the number of units in the carton. This will give you the
total number of commodity units in the carton.
Example: You have 40 unopened cartons, each one containing 200
units.
40 x 200 = 8,000 total units in the unopened cartons.
Count open cartons. If an open carton contains unopened boxes,
count the boxes and multiply the number by the number of units in a
box. This will give you the total number of the commodity units in
unopened boxes.
Example: You have 10 unopened boxes, each one containing 20 units.
10 x 20 = 200 total units in the unopened boxes.
Count all the units that are in open boxes, shelves, drawers, etc., and
add them together.
Example: You have counted 15 units in an open box on a shelf. You
have counted 4 units in a drawer.
15 + 4 = 19 total units from an open box and a drawer.
Add the total units from unopened boxes, open boxes, shelves,
drawers, etc. This will give you the total number of units of the
commodity available in your store (quantity on hand).
8,000 units from unopened cartons
200 units from unopened boxes
19 units from open boxes, etc.
8,219 total units = quantity on hand
3. On the next line of the stock card, write the date of the physical
inventory, the words Physical Inventory, and the quantities counted
in red ink.
Record the quantity counted in the Quantity on Hand. In the
Remarks, provide a brief explanation for the loss or adjustment.
Always enter each transaction on a separate line. After recording a
physical inventory on the stock card, skip a line on the stock card,
leaving it blank, and begin recording the next month's transactions
on the next line.
171
4. Mark the expiry date clearly, with large, dark numbers, on each box
or carton.
5. Reorganize products according to expiry dates to comply with FEFO
distribution.
These steps may have been taken during routine receipt and
management of drugs and other medical supplies. However, if
unmarked stocks are found during a physical inventory, proceed with
these steps.
l The Quantity on Hand units of the commodity have been counted
and recorded on the stock card.
l Losses and Adjustments have been calculated and recorded on
the stock card.
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ANNEXES

ISSUING ITEMS THAT WILL EXPIRE FIRST
Task: Distributing drugs, contraceptives, and other medical supplies

according to FEFO (First expiry First out)
Completed by: medical storekeeper, clinical officers/medical assistant
Purpose: To ensure that products are distributed before they expire
When to perform: Whenever health commodities are issued
Steps and actions
1. Mark expiry dates on outside of cartons or boxes.

2. Place cartons or boxes so that stocks first to expire are stacked in
front on top of stocks that will expire later.
3. Issue stocks from front to back or top to bottom so stocks that expire
sooner will be issued first.
This task is complete when: All health commodities are issued
according to FEFO.
173

Filling Out Stock Cards for Medical Supplies
Task: Filling out the stock card
Completed by: storekeeper, pharmacist, clinical officer/medical assistant
Purpose:
1. To maintain a continuous record of all drugs and other medical

supplies transactions.
2. To record results of a physical inventory.
When to perform:
Each time you:
1. Receive or issue health commodities.

2. Record a loss or adjustment.
3. Conduct a physical inventory.
Note: Complete one stock card for each brand, preparation, or dosage
form of a health commodity. Enter only one transaction on each line. After
recording a physical inventory on the stock card, skip a line on the stock
card, leaving it blank, and begin recording the next month's transactions
on the next line. There should be one stock card for each brand,
preparation, or dosage form of the health commodity you store. When you
have completed both sides of a stock card for a product, attach a new
stock card to the top of the old card and write the words Balance Forward
or B/F on the first line. Write the quantity brought forward from the old card
in the first Quantity on Hand space on the new card.
174
ANNEXES
Steps and Actions
1. Description:
Enter the name of the health commodity. Use one stock card for each
health commodity.
Example: Amoxicillin 250 mg
2. Unit:
Enter the smallest unit in which drugs will be dispensed to the patient
(basic units), instead of packing units. Note that the same basic unit
should be used a every level in the supply chain to avoid confusion.
Example: “tablet” (instead of “tin of 1000 tablets).
3. Batch number:
Enter the batch number mentioned on the product label for quality
assurance purposes. Ideally, it is possible to trace back the batch
number at every level of the supply chain, until the point where the
drug meets the patient.
Example: 0907D
4. Expiry date:
Enter the expiry date as mentioned on the product label. Ideally, and
at least at bigger medical warehouses such as a central medical
store, one stock card for every expiry date should be used per
product to make sure that the FEFO (First Expiry First Out) principle
is being followed. One product can have several expiry dates.
Example: EXP 07/2008
5. Date:
Enter the date of the transaction.
Example: 12/4/2004
6. Issued to/Received From:
Enter the name of the facility (or supplier) that the product is coming
from in case it concerns an entry. Enter the name of the facility to
which the product is being sent to in case it concerns an exit.
175
Example: Nduta Central Camp Pharmacy (for an exit of a product

from a central store)
7. Reference:
Enter the delivery note number of the item received or issued. Get
this from the Requisition for Medical Supplies or issue
voucher/waybill that accompanies the item.
Example: Voucher #: 0039
8. Quantity Received:
Enter the exact amount of the product received on this date in red ink.
This is for stock received at the health centers from the central
pharmacy, and stock received at the central pharmacy from the
suppliers.
Example: Quantity received: 50,000
9. Quantity Issued:
Enter the exact amount of the product issued on any date. This is
stock that has physically left the storage area.
Example: Quantity issued: 6,000
10. Balance:
Add any receipts or adjustments and subtract any issues or losses
from the existing Balance to determine the new Balance (or “quantity
on hand”). Write this figure in the Balance column for this date. This
column should always represent the amount of this item presently in
your store.
When conducting a physical inventory, always record the exact
amount
counted. If the physical count does not match the amount recorded in
this column, review the issues and receipts against the delivery
vouchers, check the math, note Losses and Adjustments in a
separate row (in a different ink color) and update the figure in this
column.
Record the physical inventory on the stock card in red ink.
Example:
Balance = 143,000
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Physical Inventory = 143,000

Note: Losses/Adjustments:
Enter the exact amount of losses or adjustments (additions) to
inventory on this date.
Always use a (-) sign to indicate losses and a (+) sign to indicate
adjustments (additions).
Losses include theft, expiry, damage, or items used for either training
or counselling.
Adjustments include usable stock returned from lower level facilities
or transferred from one facility to another.
Example: (-) 2,000 loss
11. Remarks:
1. When there is a loss or adjustment for an item, provide a brief
explanation.
Example: Damaged by water
2. When updating the stock card, sign your name.
Example: John Makowa
3. When conducting a physical inventory, sign your name.
Example: Physical Inventory: John Makowa
l The Product name or Description, Batch Number, Expiry Date,
Date (of transaction), Reference, Quantity Received, Quantity
Issued, Losses/Adjustments, Balance, and Remarks columns
are correctly completed.
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Storing drugs and medical supplies at medical stores and pharmacies
Task: Storing drugs, contraceptives, and other medical supplies
Completed by: Pharmacist-In-Charge, Pharmacy Technician, Stores

Clerk, etc.
Purpose: To protect quality and package integrity while making products

available for use.
When to perform: When health commodities are being stored.
Storage Guidelines and Notes
1. Clean and disinfect storeroom regularly. Take precautions to prevent

harmful insects and rodents from entering the storage area.
Rodents and some insects (for example, termites and roaches) like
to eat certain health commodities, like oral contraceptives. They also
eat shipping cartons and inner packaging. Pest-proof your store to
stop the pests from getting in. If your store becomes infested with
pests, use appropriate pesticides and use cats, which are effective
against termites, rodents, roaches, etc. After you clear pests from the
store, keep it clean. A clean store keeps pests away. Food and drinks
in the warehouse increase the risk of pests. Eliminating some pests
may be difficult and beyond the storekeeper's means.
2. Store health commodities in a dry, well lit, well-ventilated
storeroom—out of direct sunlight.
A hot store may cause some of the commodity supplies to spoil,
which will decrease shelf life. For example, the shelf life of oral
contraceptives and condoms is generally 4 to 5 years. However, the
shelf life, particularly condoms, will probably be much shorter if the
temperature inside the warehouse rises above 40ºC. Although air
conditioning is ideal, it is expensive. Alternatives are ceiling fans
and/or forced ventilation. Direct exposure to sunlight can also reduce
the shelf life of commodities. Use roofing and windows that shade
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ANNEXES
the interior of the store from sunlight. Store supplies in their shipping
cartons.
3. Protect storeroom from water penetration.
Water can destroy commodity supplies or their packaging. If
packaging is damaged, the product is unacceptable to the client
even if the commodity is undamaged. Repair the warehouse so
water cannot enter.
Other measures include stacking commodity supplies off the floor on
pallets (at least 10 cm off the floor and 30 cm away from walls),
because moisture can seep through walls and floors and into the
commodity supplies.
4. Keep fire safety equipment available, accessible, and functional.
Train employees to use it. Keep fire extinguishers accessible and in
working order. Keep one extinguisher near the door and others
throughout the inside of larger warehouses. Ensure that the right
equipment is available— water works on wood and paper fires but
should not be used on an electrical or chemical fire.
5. Store latex products away from electric motors and fluorescent
lights.
Latex products, including condoms, can be damaged if they are
directly exposed to fluorescent lamps. The lamps and electric motors
create a chemical called ozone, which can rapidly deteriorate
condoms. Move condom boxes away from these sources. Leave
condoms in paper boxes and cartons.
6. Maintain cold storage, including a cold chain, as required.
Cold storage, including the cold chain, is essential for maintaining
the shelf life of certain drugs and vaccines. After these items are
removed from cold storage, they become irrevocably damaged. If
electricity is unreliable, it may be necessary to use bottled gas or
kerosene-powered refrigeration. During immunization campaigns,
cold boxes or insulated coolers may be sufficient for rapid transport.
7. Limit storage area access to authorized personnel. Lock up
controlled substances.
To ensure that all stock movement is authorized, lock the storeroom,
limit access to persons other than the storekeeper and his/her
179
assistants, and verify that both incoming and outgoing stock

matches documentation. Periodically perform a systematic physical
inventory to verify inventory records. More than one key to the
storeroom should be available to ensure that the storeroom can
always be accessed. However, the second key should not be
available for everyone. Keep the key in a centrally located lock box,
under the control of the storekeeper's supervisor.
8. Stack cartons at least 10 cm off the floor, 30 cm away from the walls
and other stacks, and no more than 2.5m high.
Note: This may not be possible in all health centers.
Use pallets to keep products off floors where they will be less
susceptible to pest, water, and dirt damage. Stack pallets away from
walls and far enough apart so an employee can walk completely
around each pallet. This promotes air circulation and facilitates
movement of stock, cleaning, and inspection. Using pallets is usually
more efficient than using shelving, particularly for bulk items
because they:
l Reduce the amount of unpacking for storage and repacking for
delivery.
l Facilitate shipment in lot sizes.
l Are cheaper to construct.
l Hold more stock for the space they occupy.
Health centers are more likely to have shelving than pallets. Correct
stacking of supplies will avoid crushing cartons at the bottom of a
stack. Stack cartons no more than 2.5 meters high. This will also
reduce potential injury to warehouse personnel. Keep commodities
away from walls to promote air circulation and prevent cartons from
moisture damage, which may occur if water condenses or
penetrates walls.
9. Arrange cartons with arrows pointing up, with identification labels,
expiry dates, and manufacturing dates clearly visible.
Arrows indicate that the commodity should be stored with the arrows
pointing up. For example, if Depo-Provera® is stored on its side or
upside down, caking will occur, making it difficult to mix for use. The
identification labels make it easier to follow FEFO, and make it easier
to select the right product.
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ANNEXES
If shipping cartons do not show either a date of manufacture or an

expiration date, the date of receipt of supplies at the receiving
warehouse should be clearly marked on the cartons and bin cards.
Write large, easy-to-read numbers with a marking crayon. If the
original markings are small or difficult to read, rewrite the
manufacturing or expiration dates in large numbers.
10. Store health commodities to facilitate FEFO procedures and stock
management.
Ensure FEFO is followed. Recently received commodity supplies
may sometimes be older than the store's existing stock.
11. Store health commodities away from insecticides, chemicals,
flammable products, hazardous materials, old files, office supplies,
and equipment; always take appropriate safety precautions.
Insecticides and other chemicals may affect the shelf life for many
products. To make the health commodities easy to access, keep
other supplies away from health commodities. Some health
commodities have a relatively short shelf life overall, and they must
move quickly to the end user. Storing old junk may slow down access
to products. Some medical procedures require the use of flammable
products. Bottled gas or kerosene is used to power refrigerators,
alcohol is used in sterilization, and mineral spirits is used to power
Bunsen burners.
These products should be stored away from other products, near a
fire extinguisher.
12. Separate damaged and expired health commodities from usable
commodities, remove them from inventory immediately, and dispose
of them using established procedures.
By separating these products, FEFO is more easily implemented.
By destroying damaged products immediately, more space will be
available.
This task is complete after:
l All health commodities are stored according to these guidelines.
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Removing damaged and expired stock
Task: Handling of damaged or expired drugs and other medical supplies
Completed by: pharmacist, storekeeper, clinical officer/medical assistant
Purpose: To remove unusable products from storage so they are not

distributed to patients.
When to perform: Whenever damaged or expired health commodities

are known or discovered.
Steps and Actions
1. Stack damaged or expired product separately from usable stocks in

an unused box or on an unused shelf.
2. Write Damaged or Expired Stock on the box or shelf.
3. Note the quantity of expired or damaged stock as a loss on the
appropriate stock card and subtract the quantity from the Quantity
On Hand column.
4. If you are: Then:
At the health centre Inform the health facility manager of the quantity
of expired or damaged stock and send the stock to the central
medical store.
At the central medical store Inform the health coordinator of the
quantity of expired or damaged stock and await orders for disposal.
The health coordinator Inform the donor of the quantity and value of
expired stock and request approval for destruction.
l Damaged or expired stock has been separated from usable
stock.
l Stock card has been updated.
l Appropriate authorities have been notified.
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Obtaining good quality drug products
Nr. Of pages: 13 Procedure number: SOP Q1
1. Careful product selection
Objective: selecting safe and efficacious products with adequate stability,

proper labeling and packaging and without bioavailability problems
Impact: medium
Cost: low
Sources:
l Technical documentation provided by the supplier on pharmaceutical

characteristics of the dosage form
l Product samples to check drug product, labeling and packaging
Staff: health coordinator and logistics
Procedures:
* Choose dosage forms with longer shelf-life.
l Powders for reconstitution instead of injectable liquids

l Powders for reconstitution instead of oral suspensions
l Tablets instead of capsules
l Ointments instead of creams
In general: the less water a product contains, the longer its shelf-life.
*Ask for product-specific stability studies from manufacturer whenever

appropriate.
*Avoid products exhibiting potential bioequivalence problems or ask for

studies for a small number of drugs (certain heart, seizure, asthma drugs).
183
Select products with packaging that can withstand rough transport and
extreme climatic conditions.
l Plastic rather than glass containers for intravenous infusions,

disinfectants, etc.
l Plastic tins rather than metal tins for tablets and capsules.
l Blister packages or small pack size containers where cost-effective.
2. Supplier qualification
Objective: To ensure that the company in question is a registered

company, that the products offered are manufactured in compliance with
Good Manufacturing Practices (GMP) and that marketing authorization in
the country of origin has been obtained for the products offered. If the
supplier is known to the procurement agency, evaluation of past
performance is part of the prequalification.
Cost: high
Impact: high
Staff: quality-assurance pharmacist consultant or procurement agency
Procedures:
* Select competitively and transparently by: restricted tender with

pre-qualification if sufficient budget.
* For known suppliers: Analyze information available on supplier reliability.
Information on suppliers’ performance (from a supplier performance

monitoring system) needs to be analyzed, and operational
definitions and criteria must be developed and applied to assess the
reliability of suppliers and avoid subjectivity. For example: suppliers
should ensure that the drugs delivered have a shelf-life of at least 2
years at time of receipt.
Lack of explicit definitions and criteria provides rejected suppliers (as
well as the donors) with the opportunity to question the integrity of the
procurement process.
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ANNEXES
* For new suppliers:
1. Verify if supplier can meet contract specifications such as:

1.1. Purchasing of drugs from strictly GMP-compliant
manufacturers (see under product qualification).
1.2. Check strict GDP (Good Distribution Practices)-compliance of
supplier’s staff, procedures and infrastructure.
2. Follow procedures:
2.1. Assess reputation and reliability according to other clients
WITH A CHECKLIST: if bad reputation: STOP.
If good reputation or no opinion; go to 2.2.
2.2. Assess supplier based on:
2.2.1. Supplier questionnaire (see annex 1 at end of this

section): if unsatisfactory: STOP, if satisfactory; go to 2.2.2.
2.2.2. Technical visit by health and logistics staff that checks

Good Distribution Practices:
Quality Assurance System: registration of the supplier in the

country, organization, technical documents, general Standard
Operating Procedures (SOP's), qualification procedure of the
manufacturers (of raw material), handling of returns,
complaints and product recalls, computerization, traceability,
batch release, self-inspections.
One important aspect of quality assurance is the concept of
“traceability”. The supplier must be able to trace the product to
the finished product manufacturer, and the latter must be able
to trace the ingredients to their producers, all in a transparent
manner.
Personnel: general qualification, job descriptions for key
personnel, training.
Documentation: registration, certificate of analysis.
Warehouse: building, condition, suitability, monitoring
(temperature, humidity), pest control, lay-out, product flow,
distribution and control, labeling.
If all points in 2.2.2 are satisfactory, APPROVED SUPPLIER.
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3. Product qualification
Objective: to ensure that drug products purchased meet internationally

accepted quality standards
Cost: high
Impact: high
Staff: quality-assurance pharmacist consultant or procurement agency
Procedures:
3.1. Evaluate product questionnaire (see annex 1at end of this section):
l Registration status
l Site of manufacture (origin)
l Active ingredients
l Finished product specifications
l Stability data
If available, type of therapeutic equivalence data
3.2. Evaluate certificates:
l Registration: Certificate of a Product
l GMP
l Analytical batch certificate from manufacturer (“certificate of
analysis”)
Many models of product certificates exist: the WHO-type and the
non-WHO type product certificates (see annex 2 at end of this
section). Products Certificates that are needed are based on the
WHO Certification Scheme on the Quality of Pharmaceutical
Products Moving in International Commerce otherwise known as the
WHO Certification Scheme.
These certificates confirm that the products have been
manufactured according to current GMP standards and that the
manufacturer has been inspected by the national DRA and the
products are approved for marketing in the country of origin. It further
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ANNEXES
certifies that all written product information has been approved by the
national DRA. For products not approved for marketing in the country
of origin, the reason(s) must be given.
In addition to the product certificate that provides information
regarding registration status in country of origin, registration status
in country of use should also be verified as it will influence product
selection and quality assurance of a pharmaceutical product.
The analytical batch certificate should be asked for (at least for
critical drugs1) to verify whether the individual batch of the drug that is
purchased complies with the pharmaceutical specifications
mentioned in the registration file.
3.3. Take product samples to check labeling and packaging
Samples that are taken during an audit are taken to look at the
general presentation and labeling, but not for laboratory testing.
Note that many quality problems are detectable on visual
product inspection and do not require testing! E.g. crumbling
tablets, particles in injectables.
Samples that are needed for laboratory testing are taken from the
local market or from another agency having purchased from the
same supplier. Having a supplier send a sample is not the best
option for obvious reasons.
If 3.1, 3.2 and 3.3 are satisfactory, APPROVED PRODUCT.
Depending on: a) these audit results, b) results of possible laboratory
testing, and c) the agreement by the supplier to send all quality
assurance related documents for every batch that is purchased, the
suppliers are either 1. totally pre-qualified, 2. partially pre-qualified
(only for certain dosage forms) or 3. not at all pre-qualified. In the
last case, future pre-qualification is dependent on the supplier’s
response in points to improve.
Pre-qualified suppliers or manufacturers should be audited at least
every 3 years.
1 Critical drugs may include: 1.drugs with the highest public health importance (antibiotics,
antimalarials, infusions,etc), 2. drugs from new or unknown suppliers, 3. drugs with a narrow safety
margin (e.g., digoxin, lithium, phenytoin, theophylline and warfarin).
187
Figure 1 below visualizes the procedures mentioned under 2.

Supplier Qualification and 3. Product Qualification.
Figure 1: Supplier and product qualification (Transfer

Belgium)
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ANNEXES
Note that in addition to procedures explained under Supplier

qualification and Product Certification, an assessment of the host
country’s drug policy and regulation needs to be carried out. See
annex 3 at the end of this section for suggested assessment
questions. Note that WHO can also assist with providing answers. The
publication “The World Medicines Situation, WHO/EDM/PAR/2004.5”
also contains valuable information.
4. Contract specifications
Including specifications in a contract can help ensure that
high-quality drugs are received. It is absolutely VITAL that contract
specifications are made clear to the supplier and that they are
enforced. UNHCR’s quality standards should be clarified and
suppliers made to contractually comply with them. Random checks
can be carried out to verify compliance. For example, it is not realistic
to have health staff of UNHCR (or implementing partners) inspect
registration status of all drug products or GMP-compliance of all
manufacturers. At minimum, they should carry out random checks
and take action in case of non-compliance. This way, the burden of
quality assurance is placed on suppliers, who: 1. should be doing this
in the first place, 2. should have the technical capacity to do so (if not,
UNHCR and partners should not be purchasing from them).
At a minimum, the following specifications should be mentioned in
the contract (see Sample Drug Contract which follows).
l price and currency
l payment terms
l quality: Chemical and physical specifications of finished products
AND raw materials, pharmacopeial standard, registration status
in country of origin, batch certificates, GMP-certificate
l nomenclature, language and labeling
l storage and transport
l delivery
l packaging (suitable and sealed)
l expiry dates/shelf-life
l default
l documentation
189
It is vital that these conditions are not only mentioned in the contract,
but that they are also being verified upon receipt of the shipment.
Example of IDA product specification (1)
S-5064 MC1. REV. no.: 00, Date: Page: 1/2
rifampicin 150 mg + isoniazid 75 mg
Form and strength
Each tablet contains 150 mg rifampicin and 75 mg
isoniazid.
Producer and article code
Manufacturer: Macleods Pharmaceuticals Ltd.,
India
Manufacturing site: Plot No. 1. Near Kuldeep Nagar,
Mahim Road, Palghar (W),
404 Distr. Thane Maharashtra
IDA code: 5064
Specifications
Characteristics
Colour: Brown to reddish brown
Shape: Round, biconvex
Coating: Film coated
Diameter: 8.9mm~0.2mm
Thickness: 5.9mm~0.2mm
Average weight: about 299 mg
Uniformity of Weight: complies to BP
Disintegration: < 30 minutes

Dissolution
(both components): 75% in 45 minutes
(paddle, 100 rpm, 90Oml 0.1 N HCl)
Assay at release
- rifampicin: 95.0 - 107.5 %
- isoniazid: 95.0 - 107.5 %
Assay end of shelf-life

-rifampicin: 90.0 - 107.5 %
-isoniazid: 90.0 - 107.5 %
Related substances:
- rifampicin quinone: NMT 4%
- rifampicin n-oxide: NMT 1.5%
- 3-formyl rifampicin: NMT 0.5%
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ANNEXES
Active raw material

- quality: BP 2000
- Approved source
- Rifampicin:Lupin laboratories [2]
- Isoniazid: Amsal Laboratories
Storage
Store in a dry place below 25°C. Protect from light.
Shelf life
Two (2) years.
[2] Same raw material as was used to proof the

bioequivalence of rifampicin
Annex 1: The Model Questionnaire for Prequalification

of Suppliers consists of four main sections:
MINIMAL information:
Business Information (section I),
Product Information (section 4),
Desirable information (which is a MUST if purchasing from

manufacturer)
l Manufacturing Information (section 2),

l Quality (section 3)
I. Business Information
This section establishes if the company is a manufacturer or a wholesaler.

It contains data to assess the size of the business in terms of staff,
categories of staff, capital value, sales turnover and if the company is
engaged only in export trading. Companies that do not appear viable must
be avoided. It is also important to know the countries the company has
191
been exporting its products to. If a company has exports to countries with
sophisticated drug regulatory systems, this indicates that its products
comply with stringent quality standards. However, if the products are
exported only to developing countries with newly-established drug
regulatory systems, efforts must be directed toward ensuring that the
products being offered meet quality criteria. Sales turnover from export
and domestic sales help to distinguish so called “export only” companies
that manufacture products that are only for export to developing countries.
In such a case, the procurement agency needs to find the reason why
such a company does not market its products in its country of origin. A
description of the company’s quality assurance system provides useful
insights on how the concept of quality assurance is understood and
implemented.
Possible supplier evaluation criteria:
l the supplier holds a valid license as an importer/wholesaler;

l the supplier has been operating as a distributor for drugs and medical
supplies for more than 3 years and has not ceased operations in the
last 3 years;
l the supplier has clients in at least 3 regions of the country;
l sales turnover for drugs and medical supplies in the last fiscal year is at
least 1000000 USD;
l the supplier has provided audited financial statements for the past 3
years;
l the average stock value for drugs and supplies in the last fiscal year is
at least 80000 USD;
l annual sales to at least one customer exceeds 30000 USD;
l the supplier has a staff of at least 10 full-time employees.
II. Manufacturing Information (mainly for manufacturers)
Ideally the manufacturer should be inspected, but for some developing

countries this may not be feasible due to the lack of funds and qualified
inspectors. The WHO Certification Scheme can be used to ensure GMP
compliance and establish if the products intended for export are approved
for sale in the country of origin. It is useful to request additional information
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ANNEXES
related to the manufacture of the products to verify the information

provided through the WHO Certification Scheme. This section provides
information on the number and type of the professional staff involved in
the manufacture of the pharmaceutical products. It discloses whether the
offered products are manufactured by the company or if other
manufacturers are responsible for part(s) of the total manufacturing
process (manufacture under contract). All companies involved in the
manufacturing process will have to submit information under section II
(Manufacturing Information) and III (Quality Control Information). The
information provided should be crosschecked with the description of the
quality assurance system.
Since manufacture of pharmaceuticals involves many steps from

processing of the raw materials to the late stages of packaging and
labeling the products, it is important to know if more than one company is
involved in the whole process and compliance with
GMP must be documented for all the manufacturing plants involved in the
process.
To be able to manufacture products of acceptable quality, such products

have to be produced on a routine basis. Some manufacturers have
product lists containing 2000-3000 different products and it is difficult for
any manufacturer to manufacture such a wide range of products routinely.
Such a wide product range is also not economically viable. For a
medium-sized company the ideal product range may not exceed more
than 80-120 different products. This type of information can be very
helpful as many companies attempt to supply any product requested by
securing the products from third parties or manufacturers such products
for the very first time and therefore does not have the required validation
and stability studies for quality assurance. It is important to establish that
the products offered have undergone bioavailability testing when
required, and stability testing as is routinely required.
III. Quality Control Information (mainly for manufacturers)
This information serves to evaluate the quality assurance system of any

pharmaceutical company. GMP requires companies to have quality
control laboratories. Use of external laboratories is acceptable only for
selected tests that require sophisticated instruments and special skills.
193
Efforts should always be directed towards searching for reliable suppliers

of quality products and therefore, prequalification is a continuous process.
Be alert if:
l The company exports only to developing countries.

l The company’s product list exceeds 200 products.
l The company has less than 100 drugs of the national essential drug list
in stock.
l The company has no components of a quality assurance system
suggested under 2.2.2.
l Stability studies have not been conducted.
IV. Product Information
A useful guide in formulating decisions on drug procurement is the

regulatory status of a product in countries with well-established drug
regulatory systems with adequate resources and capacity.
Products registered for marketing in such countries have complied with

efficacy, safety and quality standards and are acceptable for
procurement. Products not registered in such countries merit further
investigation in light of efficacy, safety and quality issues. Many small
countries require prior registration in selected developed countries as a
prerequisite for the marketing authorization of products.
As previously mentioned, Certificates of Pharmaceutical Products based

on the WHO Certification Scheme establishes that a product has been
registered in the country of origin and its manufacturer complies with
Good Manufacturing Practice (GMP) standards with regular inspections.
Doubt on the authenticity of certificates may be verified by directly
communicating with the issuing agency. Many countries still issue such
certificates using formats different from that recommended by the WHO.
In such cases the issuing agency should be requested to reissue
certificates using the recommended format (see below).
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ANNEXES
Annex 2: Types of WHO and non-WHO Certificates used

in drug procurement
Source: MSH 1997
Annex 3: Assessment of drug policy, regulation and

enforcement in the host-country
Policy, Legislation and Regulation
l Is there a national drug policy approved by the government? When

was it last updated?
l Is there a comprehensive drug law? When was it last updated?
l Is there a functional national drug control authority responsible for the
promulgation of regulations and enforcement?
195
Drug Selection and Registration
l Is there a system for drug registration?

l Is drug registration based on an assessment of a drug’s efficacy,
safety, quality, and truth of packaging information? Are
pharmacological or therapeutic standards used?
l Are there different registration procedures for essential drugs, generic
products, multi-source products, or imported products from selected
countries?
l Is the WHO Certification scheme on quality used systematically by the
drug regulatory authority?
l Is there a system for the collection of data regarding the efficacy and
safety (adverse effects) of marketed drugs?
Licensing, Inspection, and Control
l Do mechanisms exist for the licensing, inspection, and control of

pharmaceutical personnel and for manufacturing, distribution, and
dispensing facilities?
l Do inspectors use a checklist for inspecting different types of
pharmaceutical assessments?
l How many inspections were made during each of the last three years
for the different types of pharmaceutical establishments?
Compliance and enforcement
l What measures exist for enforcement of pharmaceutical laws and

regulations? Are they enforceable administratively or through court
actions? Are statistics available about compliance and enforcement?
l During the last three years, how many drug products were eliminated
from the register? How many batches of drug products were recalled
from the market?
l Is there a system for reporting drug product problems? What type of
and how many complaints were registered in the past three years, and
what corrective actions were taken?
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Verifying the quality of shipped drugs
7. Inspection of Shipment
Purpose: To check:
1. Adherence to contract specifications (labeling, packing).

2. Receipt of necessary quality certificates.
3. Completeness of order.
4. Damage.
5. Quality- Physical inspection of goods (particles in injection,
uniformity of appearance).
Cost: low
Impact: medium
Staff: logistics officer
Procedures:
On Receipt:
1. Count the number of boxes received and separate damaged and

unsealed boxes from intact and sealed boxes.
2. Inspect all boxes for damaged or expired products. Damaged and
unsealed boxes should be checked immediately and in the presence
of the transporter.
3. Complete and sign the Delivery Note and release the transporter.
4. Send all necessary documents to Finance for prompt payment.
5. If appropriately trained personnel is available, take product
samples to check for labeling, packaging and product appearance
using the checklists below.
197
For labelling:
1. Labeling should be in English and preferably one other official

language of WHO.
2. All labels should display at least the following information:
l International Nonproprietary Name (INN) of the active ingredients
l Dosage form
l Quantity of active ingredient(s) in the dosage form (e.g. tablet,
ampoule) and the number of units per package
l Batch number
l Date of manufacture
l Expiry date (in clear language, not in code)
l Pharmacopoeia standard (e.g. BP, USP,)
l Instructions for storage
l Name and address of the manufacturer
3. A printed label on each ampoule should contain the following:
l INN of the active ingredient(s)
l Quantity of the active ingredient
l Batch number
l Name of the manufacturer
l Expiry date
The full label should again appear on the collective package.
4. Directions for use, warnings and precautions may be given in

leaflets (package inserts). However, such leaflets should be
considered as a supplement to labeling and not as an alternative.
5. For articles requiring reconstitution prior to use (e.g. powders for
injection) a suitable beyond-use time for the constituted product
should be indicated.
198
ANNEXES
Packaging:
1. Tablets and capsules should be packed in sealed waterproof

containers with replaceable lid, protecting the contents against light
and humidity.
2. Liquids should be packed in unbreakable leak-proof bottles or
containers.
3. Containers for all pharmaceutical preparations must conform to the
latest edition of internationally recognized pharmacopoeia
standards.
4. Ampoules must have either break-off necks, or sufficient files must
be provided.
All shipments:
Compare the goods with the supplier’s invoice and original purchase
order or contract. Note discrepancies on the Delivery Report. CHECK
THAT:
l Number of containers delivered is correct

l Number of packages in each container is correct
l Quantity in each package is correct
l Drug is correct
l Dosage form is correct (tablet, liquid, other form)
l Strength is correct (milligrams, percentage concentration,)
l There is no visible evidence of damage (describe)
Take a sample for testing if required.
Tablets:
For each shipment, tablets of the same drug and dose should be
consistent. CHECK THAT:
l Tablets are identical in size

l Tablets are identical in shape
199
l Tablets are identical in color (shade of color may vary from batch to
batch)
l Tablet markings are identical (scoring, lettering, numbering)
l There are no defects (check for spots, pits, chips, breaks, uneven
edges, cracks, embedded or adherent foreign matter, stickiness)
l There is no abnormal odor when a sealed bottle is opened
Capsules:
For each shipment, tablets of the same drug and dose should be
consistent. CHECK THAT:
l Capsules are identical in size

l Capsules are identical in shape
l Capsules are identical in color (shade of color may vary from batch to
batch)
l Capsule markings are identical
l There are no defects (check for holes, pits, chips, breaks, uneven
edges, cracks, embedded or adherent foreign matter, stickiness)
l There are no empty capsules
l There are no open or broken capsules
Parenterals:
Parenterals are all products for injection (IV liquids, ampoules, dry solids,
suspensions for injection). CHECK THAT:
l Solutions are clear (solutions should be free from undissolved

particles, within permitted limits)
l Dry solids for use in injections are entirely free from visible foreign
particles
l There are no leaking containers (bottles, ampoules)
200
ANNEXES
8. Laboratory testing
Purpose: screening of drugs before storage (either critical drugs or

suspicious drugs upon receipt from supplier) or after storage.
Cost: low/medium/high (depending on type of testing)
Impact: medium
Staff: consultant pharmacist
Procedure: will not be detailed here. It will have to be developed by the

consultant in consultation with TSS at HQ if any testing is to be carried out.
201

Monitoring and maintaining the quality of drug products
9. Appropriate storage, transport, dispensing and use procedures
9a. Appropriate storage and transport
Purpose: maintaining drug quality as delivered by supplier
Cost: low-medium
Impact: medium-high (higher in extreme climatic conditions)
Staff: medical officer and logistics (supervision), storekeeper
Procedures:
l Ensure that storage premises are clean.

l Protect drug containers from direct sun.
l Temperature not exceeding 25°C (exceptionally 30°C). Install
air-conditioning where necessary.
l Provide adequate ventilation.
l Monitor cold chain – keep EPI-vaccines and cool items between 2 and
8 °C, protect freeze-sensitive vaccines from freezing, check equipment
and supervise staff, etc.
l Avoid overstocking.
l Items stored on shelves or in cupboards.
l All drugs stored in a predefined order (alphabetically, per dosage form,
per therapeutic class).
l Containers with the nearest expiry date lined up first so as to be used
first (First Expiry First Out or FEFO-rule).
l Avoid repackaging unless quality control is in place.
See SOP D4 “Storage of drugs and medical supplies”.
202
ANNEXES
9b. Ensure Good Dispensing Practices
Purpose: avoid contamination and deterioration of drugs by environment,

staff, insufficient packaging method and patients
Cost: low
Impact: medium (higher in extreme climatic conditions)
Staff: medical officer (supervision), drug dispensers
Procedures:
l Safe, clean and organized working environment.

l Disciplined use of effective procedures.
l Qualified and trained staff, regular performance monitoring.
l Safe and clean dispensing/ Labeling.
l Use proper dispensing containers-airtight and/or light resistant.
l Dispensing against prescription only.
l Establish the contents of a drug label (at least patient name, drug
name, strength, expiry date, instructions for storage, use, dispensing
date, and quantity.
l Counseling and ensuring patients’ understanding.
l Good record keeping.
10. Product monitoring system
10.1. Problem reporting system
A formal system should be established which encourages health workers

to report potential problems with poor product quality; ideally using
pre-printed, simple reporting forms. At every level, it should be made clear
who should report the perceived quality problem and to which person at
the next level. All reports should be carefully assessed to establish the
need for laboratory testing and appropriate follow-up action must be
taken, including product recall if warranted. The reporter should be
informed about the results and the action taken, even if products are not
203
defective, in order to encourage continued participation in the reporting

program. Product defect reports and results should be recorded as part of
the supplier monitoring system in both supplier as product files.
See Problem Reporting Form for Pharmaceutical Products in Sample

Forms and Records.
10.2. Product Recalls
1. Rapid communication to facilities for quick product recall

The first step is to recall every batch of the same drug from the
health facilities and the central pharmacy to put this batch under
quarantine.
Drugs under quarantine can never be used. They will be released for
use again, only if formal test results do not indicate any quality
defects about the tested batch.
The recall procedure illustrates the importance of having an
inventory system in place that can trace drugs back according to
their lot or batch numbers (traceability).
2. Immediate notification of the supplier and collection of suspicious
samples
For example, IDA retains samples of all distributed batches until the
end of their shelf-life plus one additional year for products that are not
registered in the European Union (and that are hence checked
internally). This should facilitate the investigation of possible
complaints. A reliable supplier always assumes full responsibility for
his products and will test the suspicious product, even when it may
turn out to be due to poor storage procedures and conditions. A
preliminary condition is to have a functional product problem
reporting scheme that identifies who reports what to whom e.g. a
health worker in a health center reports the insolubility of penicillin
procaine fortified powder for injection to the central medical store
staff who in turn report the problem to the procurement office that
contacts the supplier.
In case the supplier does not accept responsibility to test samples,
samples for laboratory testing are collected and sent to an
acknowledged testing facility, preferably in Europe, although in
certain countries (e.g. Kenya) some private or academic institutions
204
ANNEXES
also have a well-functioning quality-control laboratory. Note that the

value of the stock at risk must justify testing (a relatively lower stock
value in comparison with costs of laboratory testing does not justify
testing). Suspicious drugs that have caused adverse reactions
should always be tested however.
3. The monitoring of adverse reactions in patients that have received
the suspicious drug.
Note that many quality problems are detectable on visual
inspection and do not further require laboratory testing (e.g.
crumbling tablets, particles in injectables, oral suspensions that
harden,).
205
SAMPLE FORMS AND RECORDS
SAMPLE FORMS AND

RECORDS
Form F1: Daily consumption tally sheet
Form F2: Monthly requisition and consumption reporting form
Form F3: Stock record sheet
Form F4: Periodic inventory report form
Form F5: Problem reporting form for pharmaceutical products
207
Form F1: DAILY CONSUMPTION TALLY SHEET
Health Facility: ___________________ Date: _______ Recorded by: ___________________
Drug Total Remai

Initial
Nr. descri Unit Quantity Dispensed Dispen ning
Stock
ption sed Stock
209
Form F2: MONTHLY REQUISITION AND CONSUMPTION

REPORTING FORM
Health facility: _____________________________ Date: ___________
Request period: ____________________ Voucher#: ______________
Closing Quantity Quantity Quantity Quantity

Nr. Item Unit Remarks
balance Used Requested Issued Received
Requested by: _______________ Delivered by: __________________

Name-Position-Signature-Date Name-Position-Signature-Date
Approved by: ________________ Received by: __________________

Name-Position-Signature-Date Name-Position-Signature-Date
Issued by: ________________________

Name-Position-Signature-Date
210
Form F3: STOCK RECORD
Description: ______________________________ Batch#: __________
Unit: ________________________________ Expiry date: __________
Issued
Quantity Quantity Remarks/
Date To/Received Reference Balance
Received Issued Signature
From
211
Form F4: PERIODIC INVENTORY REPORT
Review period: _____________________________________________

Location: __________________________________ Date: __________
Quantity on stock Remarks/

Item Batch# Expiry Date Quantity counted Difference
record Justification
212
Witnessed by: _____________________ ______________________

Name and position Signature
Reviewed by: _____________________ ______________________

Name and position Signature
Form F5: PROBLEM REPORTING FORM FOR PHARMACEUTICAL PRODUCTS
Reported by: _______________________________________________

Sample location: ____________________________ Date: __________
Drug description
Manufacturer or Expiry Conditions and
(generic name + Brand Name Batch number Findings
supplier date duration of storage
strength)
Suggested criteria for drug evaluation:

1. Physical characteristics: e.g. hardness, color, mixing ease for reconstitution
2. Packaging: expiry date, lot or batch number, package insert
213
3. Labeling: language, legibility
4. Patient acceptability: taste, color, size of tablet
5. Health care provider acceptability: e.g. is the ampoule easy to break
Guidelines for sampling:

1. Take samples from previously unopened containers

2. Minimum sample size: Tabs and caps: 100 units. Injectables (liquid and dry forms): 10 units, Syrups (liquid or dry
forms): 5 units, Drugs for External use: 2 units.
3. Tab/caps must be tightly packed in plastic/glass vial (do NOT use plastic dispensing bag)
4. Enclose COMPLETE LABEL (generic name, strength, quantity, manufacturer and supplier names, lot/batch number,
expiry date, date of manufacture)
5. Attach certificate of analysis where possible

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UNHCR

2006 UNITED NATIONS HIGH COMMISSIONER FOR REFUGEES

Suggestions for corrections or improvements can be sent to:

Technical Support Service, UNHCR, Geneva

UNHCR, 94 rue de Montbrillant, PO Box 2500, 1211 Geneva 2, Switzerland.

Cover design and printing by ILO Turin Centre.

Health service provision is provided to refugees and other populations

Drug ordering from countries in which UNHCR works is not always

Centrally, UNHCR has developed an Essential Drugs List (EDL) to

The manual consists of: 1. Guidelines that explain drug management

The essential drugs policy should be a standard document available

The chapter on drug selection aims to assist senior staff of UNHCR

The drug procurement chapter seeks to provide insights into best

The drug distribution chapter includes a section on medical store

The chapter on quality assurance applies to the whole drug

Our aim in UNHCR is to always emphasize the importance of sound

A special thanks also goes to Dr. Souly Phanouvong (US Pharmacopeia)

1. DRUG POLICY ............................................................................1

2. DRUG SELECTION ..................................................................11

3. DRUG PROCUREMENT ...................................................... 27

2. Quantification – Guidelines .........................................................40

3. Receipt and Inspection Guidelines .............................................43

4. DRUG DISTRIBUTION ......................................................... 51

5. RATIONAL USE OF DRUGS ...............................................87

2. Good Drug Dispensing Practices ..............................................105

3. Use of Drugs in Children, the Elderly and Pregnant Women ...110

6. DRUG QUALITY ASSURANCE ............................................113

ANNEXES .................................................................................... 135

SAMPLE FORMS AND RECORDS.................................................207

Medical Store Management CH. 4: DRUG

CH. 6: DRUG QUALITY

UNHCR ESSENTIAL MEDICINES AND

The primary objective of an essential drugs policy is:

To ensure that a selected number of high-quality essential

Source: MSH 1997

Drugs are of particular importance because:

þ Drugs save lives and improve health.

Despite the potential health impact of essential drugs and despite

l Today over one-third of the world's population still lacks access to

WHAT ARE ESSENTIAL DRUGS?

Box 1. The essential drugs concept

Source: WHO Essential Medicines Strategy 2000-2003

The UNHCR Essential Medicines and Medical Supplies Policy aims to

The United Nations High Commissioner for Refugees (UNHCR) shall:

1. Ensure implementation of the essential drugs policy in all

medical practice in the country, capabilities of the health

1.6.1 The quality of the manufacturer (respect for Good

1.6.2 The quality of the product (registration status, Certificate

1.6.3 The quality of the batch (Certificate of analysis, labeling,

1.7 Implement proper drug storage and distribution procedures

2. Request donors to observe the obligation of providing good quality

3. In order to hold the drug management cycle together, the following

2. International Federation of Red Cross and Red Crescent Societies

3. International Resue Committee, Good Pharmaceutical Procurement

4. Interagency Pharmaceutical Coordination Group, Operational

5. Management Sciences for Health, in collaboration with the World

6. Medecins Sans Frontieres (MSF), Essential Drugs-Practical

7. The Sphere Project, Humanitarian Charter and Minimum Standards

8. UNHCR, UNHCR Handbook for Emergencies, 1999.