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Year : 2019  |  Volume : 22  |  Issue : 2  |  Page : 232-237

Drug pooling: A cost-saving strategy to enhance antibiotics availability for pediatric in-patient in Nigeria

1 Department of Paediatrics; Health Administration and Management, University of Enugu Campus, Enugu, Nigeria
2 Department of Banking and Finance, University of Enugu Campus, Enugu, Nigeria
3 Department of Health Administration and Management, University of Enugu Campus, Enugu, Nigeria
4 Department of Paediatrics, Irrua Specialist Teaching Hospital, Irrua, Edo, Nigeria

Date of Acceptance28-Nov-2018
Date of Web Publication7-Feb-2019

Correspondence Address:
Dr. I C Nwakoby
Department of Banking and Finance, University of Nigeria Enugu Campus, Enugu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njcp.njcp_206_18

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Background: Antibiotic use is common but has a lot of challenges. Implementation of an efficient and cost-effective policy, which can improve the availability and sustainability of pediatric antibiotic use, is required. In this study, we explore the concept of antibiotic drug pooling (DP) as a means to overcome challenges often associated with antibiotic use. Materials and Methods: The study was undertaken in three public tertiary hospitals in Southeast Nigeria using a mixed-methods approach. Three focus group discussions with caregivers of in-patient children and 16 in-depth interviews with physicians, nurses, and pharmacists provided the data for the study. In addition, the medical records of patients on admission were examined. Information collected centered mainly on antibiotic use and challenges, participants' perception of antibiotics pooling, as well as possible ways to improve on antibiotic availability and sustainability. Results: Out of 53 children on admission, antibiotics were prescribed for 45 (84.2%) of them children. Seventeen (37.8%) of the 45 on antibiotics had their initial antibiotics changed. The major challenges encountered by all the caregivers interviewed were the cost of the antibiotics (85%). None of the caregivers was willing to submit their purchased drugs for pooled use by other in-patients. Health-care providers, however, lauded the concept of DP and made the following suggestions on ways the proposed concept could be improved: harmonized prescription, billing, and unit-dose dispensing for the first 72 h antibiotic treatment. Conclusion: The adoption of a harmonized prescription pattern and billing as well as unit-dose dispensing for the first 72 h antibiotic treatment will provide a cost-effective means of ensuring antibiotic availability and sustainability. The drug-pooling concept will not only enhance prompt commencement and discontinuation of antibiotic treatment but will also reduce waste and improve time-out policy.

Keywords: Antibiotic stewardship, cost sharing, drug pooling, time-out

How to cite this article:
Ughasoro M D, Nwakoby I C, Onwujekwe O E, Odike A I. Drug pooling: A cost-saving strategy to enhance antibiotics availability for pediatric in-patient in Nigeria. Niger J Clin Pract 2019;22:232-7

How to cite this URL:
Ughasoro M D, Nwakoby I C, Onwujekwe O E, Odike A I. Drug pooling: A cost-saving strategy to enhance antibiotics availability for pediatric in-patient in Nigeria. Niger J Clin Pract [serial online] 2019 [cited 2019 Oct 14];22:232-7. Available from:

   Introduction Top

The timely initiation of antibiotic treatment can reduce both morbidity and mortality.[1] Similarly, failure to continue prescribed antibiotics or change to appropriate antibiotics can adversely affect treatment outcome. The ability to achieve the former and avoid the latter are the aims of antibiotic stewardship (ABS) which seeks to ensure appropriate antibiotic use and avoid antibiotic resistance.[2],[3],[4],[5]

The implementation of ABS in many resource-poor countries is plagued with challenges.[6],[7],[8],[9],[10],[11],[12] A strategy that could ameliorate these challenges is the concept of “antibiotics drug pooling (DP).” Antibiotic DP requires all in-patients on antibiotics to contribute their procured antibiotics toward a common stock and have their treatment administered from this source. This will hasten the commencement of antibiotic treatment, facilitate easy switch from one antibiotic treatment to another, and reduce waste.

Notwithstanding the potentials of DP, it is still an untested ideology, which requires the support of parents/caregivers and health-care workers (HCWs) in order to succeed. This study, therefore, seeks to determine the feasibility of antibiotic DP among pediatric in-patient in southeast Nigeria, as well as solicit suggestion that can ease its adoption. It is our belief that the findings will contribute to improve ABS practices in these resource-poor countries.

   Materials and Methods Top

Study area

The study took place in three out of five states in the southeast zone of Nigeria: Enugu, Abia, and Ebonyi. One tertiary health facility was selected from each of these states using simple random sampling technique. They are all government-owned and national health insurance scheme-accredited health facilities. However, majority of patients pay out of pocket for health-care services rendered.[12],[13],[14]

Study design and population

The study was cross-sectional in design with both quantitative and qualitative aspects. The qualitative aspect of the study involved doctors, nurses, and pharmacists of all cadres who were randomly selected from workers in the pediatric ward and parents/caregivers of in-patient children receiving antibiotic treatment who expressed willingness to participate in the study. The secondary data were generated from the review of the medical records of children on admission. Permission to review the medical records of children on admission was obtained from the Head of Medical Records Department. Information that could be traced to any patient were excluded from the review.

Data collection

Qualitative data were collected using 3 focus group discussions (FGDs) for caregivers and 16 in-depth interviews (IDIs) with HCWs. Different interviewer's guides were used for IDIs and FGDs. The FGD guide was translated to the local language (Igbo) and reviewed by native speaker for better comprehension. The Igbo version was translated back to English to ensure that the original meaning was not lost. The guides were designed to obtain information on HCWs' use of antibiotics, challenges encountered in rendering services, and possible solutions to those problems. A descriptive summary of the concept of DP was provided in an interactive manner to the respondents.

The IDIs: Participants for IDI include doctors, nurses, and pharmacists. Three to four doctors, one nurse, and one pharmacist that were identified in the pediatric ward were selected through random sampling irrespective of their administrative roles in the department. Information sheets were provided for them prior to the commencement of the interviews. Sixteen IDIs were conducted in total. Their experiences with antibiotic use, challenges, and solutions were discussed. The concept of DP was introduced and suggestions were made.

One FGD was conducted in each of the selected facilities and each FGD involved 8–10 caregivers. Each group consisted of both male and female caregivers. The decision to combine both genders in one group was born out of the fact that the proportion of fathers who care for their children in the hospital while on admission was few and could not form a proper group. Biodata forms were filled and signed by the participants before commencing each of the FGDs. The biodata form contained a brief description of the study, and space to fill-in their age, gender, occupation, place of residency, as well as provision for signing of consent. Thereafter, each participant was assigned a number, which had to be mentioned before responding to any question. This was for easy linkage of responses to the responder and to enable the quantitative analysis of certain responses. During the course of the interview, effort was made to ensure that each participant contributed in the discussion by routinely calling out their assigned numbers to prompt comment. However, for some direct questions, such as willingness to contribute and participate in DP if implemented and the feasibility of DP, they were called upon individually to respond to the question.

Quantitative data were collected from the medical records of patients on admission. A profoma was filled from the information obtained from the patients' folders. The data collected were whether antibiotic was prescribed, which antibiotic was prescribed, how many antibiotics were prescribed, the dosage prescribed, was there documented laboratory result before commencement of antibiotic therapy, and any change in prescribed antibiotic within 72 h it was commenced.

Data analysis: The audio recordings of the IDIs and FGDs were transcribed verbatim into Microsoft Word documents (Microsoft Redmond, Redmond, WA) for analysis. To ensure transcription quality, all transcripts were independently checked against the original audio recordings and grammar errors corrected. The transcripts were anonymized. The qualitative data from IDIs and FGD were analyzed separately. Since IDI was used exclusively for the HCWs and FGD used for caregivers, the guides used for both interviews were structured to achieve the set objectives: feasibility of DP and willingness to contribute to the drug pool. Coding of transcripts was performed by two independent persons to ensure consensus resolution of inconsistences. Identified thematic headings, such as knowledge of DP, willingness to contribute to the drug pool, feasibility of DP, and suggestions on how to improve the concept, were used to develop the parent nodes and child nodes imported into NVivo software (QSR International, Melbourne, Australia). The information extracted through the coding framework was then analyzed. Frequency and percentages were calculated for few of the direct questions using the proportion of individual responses to each of the question.

Ethical consideration

The Health Research and Ethics Committee of University of Nigeria Teaching Hospital Ituku-Ozalla gave the ethical approval before the study was commenced. The ethical approval was thereafter used to obtain permission from the other institutions. Written consent was obtained from the participants before participation in the study. Approval was also obtained from the Chief Medical Record Officer before access was given to the medical records of the subjects.

   Results Top

Antibiotics prescription pattern

Overall, 53 folders of patients on admission on the day of interview were reviewed; out of these, 45 (84.2%) received parenteral antibiotics, and in all cases (100%), the initial antimicrobials were prescribed empirically without any microbiological evidence. Majority (82.2%) were on a monotherapy regimen. Of those on antibiotics, 17 (37.8%) had their antibiotics changed within the first 72 h; it was commencing treatment [Table 1]]. Of the antibiotics prescribed: cephalosporin was the most (62.2%) frequently prescribed, followed by penicillin-based antibiotics (17.8%). The mean cost for a 48-h antibiotic treatment regimen was USD 36.3.
Table 1: Sociodemographic characteristics of pediatric in-patients (profoma)

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   Focus Group discussion Results Top

Willingness to contribute and share antibiotics (caregivers)

The respondents' reactions to the concept of antibiotic DP were mainly negative. In their response to the question, “Are you willing to contribute your procured antibiotic to a common pool along with other patients such that all on antibiotic will get their treatment from the same source?,” the participants were to answer either “yes” or “no” before giving their reason(s) for their responses. Majority (n = 24, 88.9%) were skeptical about how such a concept would work. They were not in support of the idea but preferred to keep their drugs with them to be used for their children's treatment. Some of the responses dwelt on concerns about the reluctance of other caregivers to contribute to the pool particularly if their children have started receiving treatment despite not providing any drug. In addition, they were also concerned that others may obtain fake or cheap and less potent brands of the medication. They were more comfortable with keeping their medication within sight and have their children's medication given from theirs. Some of the responses were as follows:

”One of the challenges is for parents to agree … I want my drugs to be used for my child; I don't want that mixture.” Male, banker

”Some might be reluctant to buy…, they are giving my kid drug, why will I want to buy.” Female, businessman

”Two or three patients are going to be sharing one vial. So how comfortable are they going to be?”

Only three (11.1%) accepted to contribute to a pool on the provision that it will be in safe hands and someone held accountable:

”It is a good proposal. If it works out, it will save a lot of money for the patient.” Female, civil servant

”So let's have it while coming to the hospital that why you are a caregiver to your own ward, you are still a caregiver to some other persons.” Male, civil servant

Identified benefits/challenges of the drug-pooling model (caregivers and health-care workers)

Despite their reluctance to pool their procured drugs, in their response to the question, “Do you have any suggestion on how this concept of drug pooling can be improved?”, they were of the opinion that such an innovation will reduce the burden of antibiotics cost and resultant wastages familiar with individual provision and usage, only if it works. In their responses:

”It will cut down lots of wastage.” Male, civil servant

”Children will keep on getting their drugs. At that time the child doesn't have or the parents have not bought and the drug is due…. So there will be continuity.”Female, businesswoman

”The stress of going to look for the drug … it is already in the pool.”Female, trader

Challenges in antibiotics usage (health-care workers)

All the respondents considered antibiotic use among children to be a common practice. In their response to the question, “Do you experience challenges in the use of antibiotic in pediatric practice?”, the respondents attested that there are several challenges experienced with antibiotic use, especially prescribing on empirical bases.

”You will know the right antibiotic to use for a particular illness, but you find that the patient cannot buy.” Pediatrician, FETHA Abakiliki

”You may discover that 12 hours or 18 hours out of the 24, the drugs haven't even been provided.” Nurse, FETHA Abakiliki

”50% times you prescribe antibiotics, you may need to change.” Pediatrician, UNTH Enugu

Modifications to the drug-pooling model (health-care workers)

After their comments on the concept of DP, they were asked to make suggestion on how the concept can be modified or improved before implementation. The question they responded to was, “Can you suggest how this drug pooling can be improved?” Some of the suggestion made were as follows:

”Hospital's supply will be charted in milligram and costed in milligrams.” Pediatrician, UNTH Enugu

”Normally works if the hospital provide drug, and the patient will pay at the end of admission.” Pharmacist, UNTH Enugu

”Unit Dose Dispensing System … the cost for that patient.” Pharmacist, FMC Umuahia

   Discussion Top

The study revealed that majority of the respondents viewed the antibiotic DP concept as not being feasible. Their major concerns were on issues like (a) lack of transparency, (b) inequity and unfairness in contributions, (c) caregivers unwillingness to relinquish their procured drugs to the pool, (d) caregivers withholding contribution once their children have started receiving treatment, and (e) the fear of others contributing fake or substandard drugs to the pool. All the respondents accepted that the DP concept will ease the burden of antibiotics cost, improve availability, and reduce antibiotic wastage. However, for these benefits to be achievable, the concept needs to be refined and modified in line with the identified challenges. Several suggestions were made on how to do this.

On ways to improve caregivers' willingness to contribute and share antibiotics, the key suggestions made were (a) that the hospital pharmacy should be involved in the administration and management of the DP system, and (b) there should be a standardized prescription pattern for antibiotics use based on approved guidelines. The former will restrict the choice of empirical antibiotics to a stipulated few, based on the spectrum of activity and cost.[15] This ensures that the pediatric ward pharmacy stocks these antibiotics for the empirical treatment of most suggested infection cases for the critical first 72 h of admission. This will be supported by routine audit and feedbacks, as well as case reviews by an independent expert, different from the treating team, to advise on the suitability of these antibiotics.[16],[17],[18] The aim will be to ensure replenishment of hospital stock of the commonly prescribed antibiotics to facilitate the prompt commencement of treatment. Furthermore, in a situation where the empirical antibiotic is changed within 72 h of commencement, the newly prescribed antibiotics will be easily obtained from the emergency stock, thereby saving caregivers the stress of buying from external sources.

Second, the adoption of a standardized prescription pattern for antibiotic involves a first 72 h antibiotic billing policy. The proposed policy will cover the cost of antibiotic treatment, irrespective of type of antibiotic prescribed, so long it is among the selected broad-spectrum antibiotics outlined for use for empirical treatment. This will be based on the pre-calculated average cost of the antibiotics used in the first 72 h, weighted according to age and weight. The benefit this has is that it will transfer the responsibility of providing the antibiotics to the prescriber and downplay the power the caregivers have over their antibiotics. In this study, the proportion that received cephalosporin was high compared to those that received penicillin and ciprofloxacin. This is similar to the finding of Di Pietro et al.[19] but in contrast with that of Buccellato et al.[20] The high use of antibiotics irrespective of the type could be attributed to parental pressure to receive antibiotic.[21] Furthermore, the observed relatively wide range in cost obtained could be due to multiplicity of antibiotic options available for treatment common pediatric illnesses. Adherence to a specified guideline could reduce this. However, before implementing the first 72 h billing policy, a review of antibiotic prescription pattern and adopt treatment guideline for common pediatric infectious diseases needs to be performed. Effort should be made to promote the use of effective antibiotic generics and brands for further reducing the cost of antibiotic therapy.

The proposed “ first 72 h billing” policy may be combined with a unit-dose dispensing scheme (UDDS) to ensure that patients can get a refund for any drugs not used in case of drug discontinuation before the 72-h window elapses. Furthermore, the transfer of the custody of the antibiotics to the prescriber through the average billing will facilitate the implementation of DP. This ensures that no more than one vial of similar antibiotics is opened at a time, irrespective of the number of patients on it. This has the advantage of preventing waste that could have occurred when individual patients reconstitute their antibiotics. It will equally enhance the smooth transition from one antibiotic to another or discontinuation within the first 72 h. This will indirectly save the cost of transportation and the intangible cost of time and anxiety involved to procure the drugs, as well as reduce the risk of buying substandard antibiotics. The current decentralization of pharmacies to the wards and clinics obtainable in most tertiary hospitals will make implementation of this policy feasible. The major benefit of combining 72 h billing and UDDS is that it will offer an opportunity to monitor drug use and cost, thereby facilitating accountability and transparency.

Although the aforementioned objectives are laudable, they are not without challenges. Determining the choice of antibiotic, which is likely to vary among the HCWs, is a major problem, further compounded by the potential pressure from the pharmaceutical companies. However, this can be ameliorated by the use of a review committee who decides on both antibiotic generic and brands, based on sensitivity and observed response pattern. Another challenge is the possible resistant from the pharmacy with regards to restrictions on the choice of antibiotic to stock, particularly when one considers the fact that most units in the tertiary hospitals are profit-centered. This will require extensive advocacy and deliberation for the proposed policy to be accepted. Finally, the implementation of this policy requires extensive monitoring and cataloging, and it is doubtful whether the needed manpower with the requisite knowledge and experience exists in the health institutions.

The nonextension of the study to outpatients and preventive care (immunization clinics) is a limitation. This denied the opportunity of sampling the opinion of caregivers of children who are not at immediate need of admission. Bias may arise when in-patient pediatric caregivers' responses are influenced by fears that their suggestions are likely to be implemented in their children's care. Therefore, involvement of outpatient caregivers may have provided a more balanced view. The unavailability of studies on drug pooling is another limitation in this study. Although this can be attributed to the related newness of the concept of DP, it is hoped that with the increased awareness of ABS, the future prospect for similar studies has been improved.

   Conclusion Top

This study revealed that the implementation of the concept of DP as proposed is not feasible. It may be possible to implement if some of the suggested modifications are made: (1) the adoption of a harmonized prescription pattern (prior authorization) and billing; (2) implementation of unit-dose dispensing of antibiotics for the first 72 h.

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Conflicts of interest

There are no conflicts of interest.

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