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HPR
doi 10.21859/hpr-0104141
Hosp Pract Res. 2016 Dec;1(4):141-145

Brief Report
Hospital Practices and Research

Drug Supply Chain Management and Implementation of

Health Reform Plan in Teaching Hospital Pharmacies of
Ahvaz, Iran
Reza Shakori1, Masume Bagheri Kahkesh2*
1
Ahvaz University of Medical Sciences and Health Services, Ahvaz, Iran
2
Health Services Management Department, Science and Research Branch, Islamic Azad University, Tehran, Iran
*
Corresponding Author: Masume Bagheri Kahkesh, PhD Student in Health Care Management, Health Services Management
Department, Science and Research Branch, Islamic Azad University, Tehran, Iran. Tel: +98-9169812189; Fax:+986143269652;
Email: masume.bagheri@yahoo.com

Received July 21, 2016; Accepted September 3, 2016; Online Published December 18, 2016

Abstract
Background: Drugs play a strategic role as a health commodity. Thus, the supply chain management of drugs is an important
issue to reducing costs and thereby improving patient health.
Objective: This study evaluated the status of drug supply chain management and health reform in the pharmaceutical sector
of teaching hospitals in Ahvaz, Iran.
Methods: This cross-sectional study was carried out in pharmacies of teaching hospitals in Ahwaz, Iran in 2015. Data was
collected through a checklist extracted from the Evaluation Checklist of the Food and Drug Deputy and related articles. The
study checklist examined six dimensions of the Evaluation Checklist, including drug storage, administrative regulations,
preparation of medicines, drug distribution, taking medication, and implementation of health reforms in the pharmaceutical
sector. The content validity of the checklist was confirmed by experts and pharmaceutical specialists. Data was analyzed for
descriptive characteristics such as frequency and percentage using Excel version 2010 software.
Results: The findings show that hospitals met standards for administrative regulations with 78.5% and preparation of
medicines with 77.25%. The dimensions of drug storage with 74.75%, taking medication with 74.25%, implementation of
health reforms with 71.5%, and drug distribution with 62.5% were in a near-standard state.
Conclusion: Supply chain management systems of medicines in teaching hospitals are near-standard. To improve hospitals,
offering proper training to employees, using the fixed-rate shopping system, and providing facilities to patients are
recommended.
Keywords: Pharmacy, Organization and administration, Hospitals, Health reform

1. Background most imported drugs are expensive, and this increases the
Undoubtedly the status of health is one of the most allocated exchange rate for drug imports and increases
important indicators of social development and progress. costs. Additionally, the resources available in health centers
The provision of healthcare is also a major challenge to are often not properly used, and in most cases, lack of
human life, and the treatment of disease is considered one different resources gathered together, the squandering and
way to achieve community health.1 The management of waste of resources can be observed.4
the drug circulation process to advance the aims of healthy According to the President of the Islamic Republic of
people for sustainable development is an important issue. Iran, Doctor Hassan Rouhani, reforms in the country
Each country should have a national drug policy as a are being run as the health development plan. The health
main part of its health society policy so as to ensure the development plan is a project that improves the way people
provision of effective, safe, qualified, and affordably-priced live in the area of healthcare. In this project, it is hoped
drugs for the government and people.2 Correcting the that a lot of people problems, including the cost to treat
drug policies of developing countries is a main concern in diseases, dissatisfaction with medical centers, time wasted
the healthcare sector, and the World Bank and the World waiting for treatment, etc. will be resolved; troubleshooting
Health Organization (WHO) are in agreement about the is the main advantage of this project.5 Financial challenges
necessity of reorganizing it.3 In developing countries, in hospitals, in other words reducing costs and increasing

Copyright © 2016 The Hospital Practices and Research. This is an open-access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.
Shakori and Bagheri Kahkesh

revenue, are of great importance. After legal personnel

Selection
costs, the hospital pharmacy spends 20% of the total
budget, making up the largest percentage of the health
budget.6 Injuries caused by medical errors occur in over
42% of patients, which contribute significantly to increasing
health problems, social problems, and the healthcare costs Management
of people and the government.7 Use Support Procurement

Among these factors are the roles of people as the main Organizing
component of the drug culture and doctors and medical Finance

personnel as a cultural element. Disregard for this issue

is followed by undesirable consequences, such as patient
and caregiver dissatisfaction, the ruination of the country’s
healthcare systems, prolonged illness periods, medication Storage and
Distribution
side effects experienced by patients, diminished doctor-
patient relationships, and increasing healthcare costs and Figure 1. Medicine Chain Management Concept Model.
drug problems.8
yes, the situation was considered to be substandard. Data
2. Objective was analyzed using Excel version 2010.
Considering all the above-mentioned factors, this study
examined the management of the drug supply chain 4. Results
and the implementation of a health development plan in The results demonstrated that the drugstores of all studied
pharmacies at teaching hospitals in Ahvaz, Iran. hospitals were in a standard situation in terms of software
and hardware (computers, printers, hygrometer), proper
3. Methods shelving, and storage of medicines and serums according
This was a cross-sectional and usability study. The study to the standards promulgated by the Ministry of Health.
population and hospital environment consisted of the The situations of refrigerated storage of medication,
committee members of drugs and treatment in the medical security systems (fire-fighting and fire alarms, anti-theft
teaching hospitals of Ahvaz University of Medical Sciences, systems), the presence of air conditioning and sanitation
which included Shafa, Razi, and Imam Khomeini hospitals. also met standard requirements. About 75% of the hospital
All of the population entered in the study. The data pharmacies did not have a physical space proportional
collection tool for this research was a checklist developed to the number of hospital beds. Additionally, expired
from the checklist of the food and drug departments of the drugs were kept in all pharmacies, and in only two of the
evaluated pharmaceutical sector of hospitals5 and related hospitals (Shafa and Imam Khomeini) were reasons for
articles.2,3 The reliability and validity of the checklist were drugs expiring examined by the Drugs and Drug Treatment
confirmed with a score of 0.79 using Cronbach α and by Committee.
experts and the Pharmaceutical University of Jundishapur, All hospitals met standards for the preparation of
respectively. Data was collected through checklists medicines in pharmacies, except the Imam Khomeini
completed through interviews and direct observations. The hospital in which conditions were near-standard. Seventy-
checklist contained 72 questions regarding 6 dimensions five percent of the studied hospitals distributed drugs as
based on the objectives of the study. The first dimension single doses, and drugs outside the pharmacopoeia were
contained 21 questions regarding drugstores; the second provided for all hospitals under the prescription of the
through sixth dimensions contained 5 questions about physicians, This is why patients were not sent out of the
drug preparation, 9 questions about drug consumption, 10 hospital in order to provide their drugs. All hospitals and
questions related to drug distribution, 9 questions related pharmaceutical companies had a Committee of Medication
to the implementation of healthcare development plans in and Treatment and advertising or contract systems were
the pharmaceutical sector of hospitals, and 18 questions not used for drug purchasing. No independent financial
about the administrative regulations of medication in the relationship between pharmacies and pharmaceutical
hospital, respectively (Figure 1). companies existed in any of the studied hospitals. All
Checklists were completed by technical officials, hospitals other than Imam Khomeini hospital met the
hospital drug store officials, and researchers based on standards for drug consumption. In 75% of hospitals,
their observations. The questions could be answered yes doctors and the pharmacies of the hospitals consulted
or no and were designed for the assessment of drug chain with each other for some drugs, especially new ones. In all
management based on the planned checklist. Based on hospitals, communication existed between departments
divisions by the author in each dimension, if more than and pharmacies regarding drug consumption, prediction of
75% of the questions were answered yes, then the situation the needed amount of drugs (Tralee and hospital emergency
was standard, from 51% to 75% indicated a near-standard departments), sending invocations from departments to
situation, and if 50% or less of the questions were answered pharmacy stores with a mechanized method, and returning

142 Hospital Practices and Research 2016;1(4):141-145

 Drug Supply Chain Management

Table 1. Medicine Chain Management in Hospitals

Golestan Hospital Shafa Hospital Imam Khomeini Hospital Razi Hospital

Drug store state (%) 77 78 76 76
Drug provision (%) 80 80 60 80
Drug consumption (%) 88 77 44 88
Drug distribution (%) 70 52 40 60
Drug implementation criteria (%) 77 66 66 77
Implementation of health development plan (%) 88 72 77 77

medicine that was close to the expiration date. In none of all hospitals, drugs were classified based on three categories
the hospital pharmacies except that of Imam Khomeini (emergency, urgent, normal), and treatment committee
Hospital, was the accuracy of the prescribed dose for and medication committee meetings were held regularly.
the patient examined. The stock of the departments was In only one hospital were medication errors studied and
consistent with the checklist of pharmacies in 50% of the reported on a regular basis.
hospitals, and 75% of transactions between departments Golestan and Razi hospitals were at a standard level for
were recorded in an emergency situate ion in hospital the implementation of health development plans in the
pharmacies. hospital pharmaceutical sectors, and Imam Khomeini
The Drug Distribution Departments of Golestan, Razi, and Shafa hospitals were near-standard. Drugs from
and Shafa hospitals were in a near-standard situation, but outside the pharmacopoeia that were emphasized and
Imam Khomeini hospital was substandard. Seventy-five requested by physicians were found in the drug stores of
percent of hospital pharmacies controlled the dispensing half of all hospitals. All hospitals had a drug monitoring
of medicines as quality, but priority was observed in Iran’s system in place for placing pharmaceutical requests to
drugs (according to the Food and Drug Department). In pharmaceutical distribution companies. In 75% of the
50% of pharmacies, required actions were taken to deal studied hospitals, the insufficiencies of medicines and
with the problem of drugs being 2-tiered. In 75% of the supplies were timely evaluated and essential drugs lists
pharmacies, there were drug savings for emergencies were compiled to preclude patients from going outside
and critical situation proportional to the requirements. the hospital to find the required drug, even if it was not
However, drugs were not distributed in the pharmacies included in the hospital pharmacopoeia. In all studied
based on the single-dose system. Moreover, drug hospitals, medication was prescribed based on early and
distribution from stores to departments within 24 hours final diagnoses. None of the hospitals provided health
was not possible. Doctors of all hospitals were aware supplies for patient caregivers, despite the fact that
of the drugs available in the pharmacies, and the drugs all hospitals provided toiletries for admitted patients
requested by all departments were consistent with patient (shampoo, slippers, toothbrush, and toothpaste). None of
records and medical prescriptions. Seventy-five percent the hospitals received the costs for prescribed drugs during
of the hospitals used the required facilities for transport, treatments from patients. This is while at discharge, the
and in all hospitals, drug requests from departments were cost of the prescribed drugs were received from patients
delivered to the pharmacy in certain hours and with stamp according to the new tariffs of the health development
and complete signatures. plan (6% urban insurance and 3% referral rural insurance)
The implementation status of medical criteria was (Table 1). The overall Medicine Chain Management in the
standard in all hospitals except Shafa hospital, in which study hospitals is shown in Figure 2.
conditions were near-standard. Retraining and training
90%
medical personnel were implemented in 50% of hospitals,
80%
while in half of the hospitals drug services were carried
out 24 hours a day. In 75% of hospitals, there were enough 70%

pharmacists, and medical records for patients were kept 60%

in 50% of hospitals. In 3 hospitals, monthly reports on 50%

the drug status were presented orally to the head of the 40%
hospital. Technical personnel monitored the circulation 30%
of the drugs in all hospitals. In 75% of hospitals, the side 20%
effects of consumed drugs were reported to the Hospital 10%
Pharmaceutical Committee. In all hospitals, the pharmacy 0%
technical personnel monitored the implementation Razi
‫رازی‬ Imam Khomeini
‫امام‬ Shafa
‫شفا‬ Golestan
‫گلستان‬
of the Food and Drug Department rules. An updated Figure 2. The Overall Status of Medicine Chain Management in the
pharmacopoeia was found in 3 of the 4 studied hospitals. In Study Hospitals.

Hospital Practices and Research 2016;1(4):141-145 143

Shakori and Bagheri Kahkesh

drug administration can be avoided with proper planning,

5. Discussion timely and regular coordination with departments, and
The results of the present study showed that the pharmacies continuous communication with doctors and hospital
of all studied hospitals were in a standard condition and sectors.
were consistent with Dinarvand’s study on the necessity The findings revealed that Golestan and Razi hospitals
of education for all medical staff, especially hospital met standards for health development plans, and Shafa
pharmacy personnel to minimize the risk of errors and and Imam Khomeini hospitals were near-standard.
maximize utilization of the equipment.9 Inappropriate and Implementation of a health development plan caused a
insufficient physical space in drugstores has caused many reduction in medical expenses paid by people in hospitals
problems for commuting pharmacy staff, drug storage, and includes all areas of health and medicine. These results
warehousing, and inspection; it has also led to a buildup were consistent with those of a study by Bagheri Kahkesh
of drugs in the warehouse shelves that creates irreparable et al.11 Another effect the health development plan had
damages for the pharmacy. By insuring pharmacies and on pharmacies was the formation of a committee to
drug warehouses against unanticipated and anticipated assess drug costs in order to monitor induced costs, and
risks (fires, earthquakes, floods, etc.) we can lead to to prevent patients from referring outside the hospital for
providing the costs of adverse incidents through insurance medicine. This result was consistent with the findings of
organizations and the government and can somewhat Chandani et al.12
guarantee pharmacies. The presence of stocks of expired
drugs can be dangerous; this issue corresponds somewhat 6. Conclusion
with the results of Berdot et al study.6 It seems that the most important future challenges
The results for drug provision showed that three of the faced by pharmacies regarding health development plan
four studied hospitals met standard levels, while Imam management may include shortages of space due to the
Khomeini hospital was near-standard. Some drugs were overcrowding of patients and the availability of excessive
provided from pharmaceutical companies by the Food amounts of drugs both in pharmacies and stacked on
and Drug Department, and no independent financial warehouse shelves. Another challenge could be the
relationship existed between the pharmacists and the shortage of trained manpower in pharmacies in order to
pharmaceutical companies. Additionally, all of the studied help and advice those patients who refer to them. Another
pharmacies had a committee called the Medicine and problem is excessive consumptions of drugs by patients. All
Treatment Committee. This in itself is interesting, because these challenges and many more should be paid attention
this committee could provide expensive drugs that are to so that it would eventually lead to less consumptions of
not available in pharmacies or are not easily dispensed drugs by patients.
by pharmaceutical companies to pharmacies, thereby
preventing the waste of time by drugstores. Another Authors’ Contributions
benefit observed in these pharmacies is the pharmacopoeia All authors contributed equally to this article.
of drugs prepared for patients which saves patient from
having to refer outside the hospital for drugs. This Conflicts of Interest Disclosures
dimension was consistent with the findings of Berdot et al6 The authors had no conflicts of interest.
and Colella et al.4 In terms of drug distribution, the results
showed that three of the four hospitals were in a standard Ethical Approval
state, while Imam Khomeini hospital was substandard. Not applicable.
Drug distribution should be carried out by pharmacies
(24-hour) according to the single-dose system. Acknowledgments
Additionally, retraining and job training classes should The authors express their appreciation to their colleagues in
be held for hospital pharmacy personnel so they become the teaching hospitals of Ahvaz, Iran for their cooperation
familiar with the methods and principles of drug usage, in the implementation of the plan.
drug distribution, and drug services, including the
principles of distribution and consumption of new and References
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