AVAILABILITY OF DRUGS: WHAT DOES IT MEAN IN UGANDAN PRIMARY CARE?

1. AVAILABILITY OF DRUGS: WHAT DOES IT MEAN IN UGANDAN PRIMARY CARE? Jessica Jitta, S. R Whyte, N. Nshakira Child Health Development Center Makerere University Uganda & Institute of Anthropology University Copenhagen Denmark

2. ABSTRACT Presentation covers areas below: • Introduction/background • Objectives • Methods • Findings • Conclusions

3. INTRODUCTION • Uganda public- 40%, PNFP 25% and PP 35% • Health reforms Ugandan HS initiated 1990s as central efforts to rebuild the health system • Reforms assume rational drug management ensures drug availability &quality care • Tension assumption- reality HWs responsive to users’ demands& being rational drug manager • Introduction user fees -health as commodity and users demanding value for money

4. OBJECTIVES • To examine drug availability at primary health care level, with a focus on the inconsistencies in drug supply policy and the gap between policy and practice.

5. METHODOLOGY • Cross-sectional qualitative and quantitative KI, FGD,observe consultations and records review • 6 units- a public rural hospital OPD, 3 HCs, a sub-dispensary and an church NGO dispensary • Policy makers/administrators (KI 67); users (54FGD)observed consult(140) exit interviews (160) entries patient registers (600) • Analysis -significance drug availability HCW, users and planners/administrators -realities that HCWs and their patients face -district context national policy • Supply, utilization and expectations/demand for inj chloroq, penicillin & availability of needles/syringes.

6. FINDINGS- Sources of drugs • Public units- EDMP pre-packed kits quarterly to districts , district buy suppl drugs, special vertical programs (TB, STD) & h/units procure drugs &needles and syringes • Patients referred to drugshops buy drugs- 40% • NGO depend only procuring drugs-not limited • Planners concerned EDMP, no policy on drug supplements by units • To users most important- obtain needed drugs

7. FINDINGS- Types drugs available • Volume and range services at unit determine EDMP kits supplied and National Standard Guide available for rational drug use • Most used drugs anti-malaria, antibiotics and analgesics • Inj medicines on high demand, went o/s first • Units put user fees to supplement stocks to overcome chronic o/s & increase range of drugs, needles & syringes and IV fluids • Health unit records on supplements poor

8. FINDINGS- Diagnosis & prescript • Varied with cadre and number of h/providers- skills vary with level health units • Symptomatic diagnosis lack of support facilities • Very sick patients (children vomiting) injections prescribed • High rate use of combination antibiotics and anti-malaria- many drugs (poly-pharmacy) • Very high injection rates 35-85% compared to recommended 15%-providers respond users demands- previous oral form taken no response

9. FINDINGS- Drug suff/adequacy • New kits open only exhausting contents • Drugs used at different rates • Injection drugs run out first unit supp • 40% exit interviews referred drug shop • Planners/admin EDMP adequate in units • Providers unsatisfied injection drugs antibiotics and anti-malaria • Users concerns drug availability at unit,get injections, affordable and adequate dosage

10. FINDINGS- Availability issues • Health sector reforms have changed the conditions for managing, supplying and using drugs through decentralization, user fees and privatization. • Injection drugs in kits ran out quickly and were purchased by the unit or the patient at nearby drug shops. • Government health units both compete with & use local commercial sources of drugs undermining technical premise rational drug use and supply built into kit system.

11. FINDINGS- Quality care perspt • Drugs availability is fundamental quality of care by all 3 categories of actors PHC, perspective differ& shifting • Plan/admin- securing suppl EDMP kits-delivery, records account/stocktaking, mism’gment/leakages at HU-control & security of drugs-manuals&guidelines rational use drug • H/workers not relate insuff to drug to diagnosis prescription but-inadequate supplies in kits, large numbers infectious diseases and need to satisfy pts with injections- purchase suppl drugs, refer pts buy p/shops • Users- in terms whether all prescribed drugs are good obtainable at HU regardless source, inj preferred form

12. CONCLUSIONS • Problem of drug availability interlinked, so is perspectives and interests of actors • Dialogue and realism are needed in order to create policies that respect both good medical treatment standards and the concerns of frontline health workers and their patients. • Rethinking of the meaning of drug availability in PHC calls for methodologies examining the changing context of h/care & position of diff actors, at national and district levels, to address gaps existing between drug policy and practice