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AVAILABILITY OF DRUGS: WHAT DOES IT MEAN IN UGANDAN PRIMARY CARE? Jessica Jitta, S. 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 1

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

INTRODUCTION • Uganda public- 40%, PNFP 25% and PP 35% • Health reforms Ugandan INTRODUCTION • Uganda public- 40%, PNFP 25% and PP 35% • Health reforms Ugandan HS initiated 1990 s 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 3

OBJECTIVES • To examine drug availability at primary health care level, with a focus 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. 4

METHODOLOGY • Cross-sectional qualitative and quantitative KI, FGD, observe consultations and records review • METHODOLOGY • Cross-sectional qualitative and quantitative KI, FGD, observe consultations and records review • 6 units- a public rural hospital OPD, 3 HCs, a subdispensary and an church NGO dispensary • Policy makers/administrators (KI 67); users (54 FGD)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. 5

FINDINGS- Sources of drugs • Public units- EDMP pre-packed kits quarterly to districts , 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 6

FINDINGS- Types drugs available • Volume and range services at unit determine EDMP kits 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 7

FINDINGS- Diagnosis & prescript • Varied with cadre and number of h/providersskills vary with FINDINGS- Diagnosis & prescript • Varied with cadre and number of h/providersskills 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 8

FINDINGS- Drug suff/adequacy • • • New kits open only exhausting contents Drugs used 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 9

FINDINGS- Availability issues • Health sector reforms have changed the conditions for managing, supplying 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. 10

FINDINGS- Quality care perspt • Drugs availability is fundamental quality of care by all 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 11

CONCLUSIONS • Problem of drug availability interlinked, so is perspectives and interests of actors 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 12