THE RELATIONSHIP BETWEEN DRUG SUPPLY AND PRESCRIBING PATTERNS IN DISTRICT HOSPITALS IN UGANDA Ogwal-Okeng JW, Obua C, and Anokbonggo WW. International Conference on Improving Use of Medicines Chiang Mai, Thailand April 1, 2004 INRUD Uganda and Makerere University Project supported as part of the Joint Initiative on Improving Use of Medicines under a grant from ARCH

ABSTRACT Problem Statement: In Uganda, the supply and availability of essential drugs have continued to be a problem even after the passing of a Local Government Act (LGA) in 1993, which shifted responsibilities for health services delivery from the Central Government to district level decision-making. The new policy was intended to enhance the quality of health services, improve pharmaceutical supplies, and increase the patronage of health facilities. INRUD-Uganda recently conducted a study on the effect of the policy on drug stock levels in two district hospitals. It was found that resource constraints and an erratic supply system prevented either district from achieving a full supply of drugs in the hospitals. Drugs tended to cycle through periods of adequate stocks and stock outs. We do not know how the prescribing behavior of the prescribers is influenced by the drug supply situations. This study therefore proposes to study the relationship between drug supply level and prescribing decisions for treatment of acute respiratory infection (ARI), diarrhoea and malaria in the two districts. Our hypothesis is that rational prescription may not be affected by changes in pharmaceutical supply levels. Objectives: 1). To explore the prescribing patterns for malaria, ARI and non-infective diarrhoea when there are fluctuations in drug supply; 2). To establish the overall distribution of drugs prescribed to treat malaria, ARI and diarrhoea; 3). To investigate the effects of change of drugs recommended in the Uganda STG on prescription adherence to the guideline recommendation; 4). To investigate the effects of the availability of non-first line drugs on the prescribing adherence to recommended guidelines for malaria, ARI and diarrhoea; 5). To investigate the effects of the non-availability of recommended drugs on prescribing behavior for malaria, ARI and diarrhoea. Study Design: Analytical and descriptive study. It will be a retrospective evaluation of the prescriptions at various levels of stocks in the two hospitals using interrupted time series analysis. Outcome measures will be the selection of drugs for malaria, ARI and non-infective diarrhoea, and stock levels over a period of time. Study Setting and Population: Prescriptions will be collected for malaria, ARI and non-dysenteric diarrhoea in Lira and Apac hospitals in the period extending one year before and two years after decentralization. Outcome Measures: 1). Drug selection/choices for malaria, ARI and diarrhoea when the guideline recommended drugs increase or decrease in stock; 2). Overall distribution of drugs prescribed for malaria, ARI and diarrhoea during this period. Data will be collected retrospectively from outpatient records and hospital stock records. Results: This paper will present the prescription choices for ARI, malaria and diarrhoea during periods when the recommended drugs are in stock and when there are stock outs. Study Funding: International Network for Rational Use of Drugs (INRUD) through a grant from the United States Agency for International Development (USAID).

BACKGROUND Inadequate and uncertain availability of essential drugs is a common phenomenon in Uganda health units. The decentralization policy operates on a pull system of procurement of health supplies. Resource constraints contributed to erratic supply of drugs in two district hospitals studied. Drug supply tended to cycle through periods of adequate stocks, low stocks, and stock-outs. Need to know (compare) how prescribing was influenced by drug supply (stock levels).

OBJECTIVES To explore the relationship between availability of drugs and prescribing patterns for malaria and ARI during when availability was changing rapidly and to assess if fluctuations in drug supply is a determinant of inappropriate prescribing patterns. Specific Objectives To establish the over all distribution of drugs prescribed to treat malaria, ARI and diarrhoea. To explore the prescribing patterns for malaria, ARI and non-infective diarrhoea when there are fluctuations in drug supply. To investigate the effects of the non-availability of recommended drug on the prescribing behavior for malaria, ARI and diarrhoea. To investigate the effects of the availability of non-first line drugs on the prescribing adherence and behavior to recommended guidelines for malaria, ARI and diarrhoea.

METHODS Retrospective interrupted time series analysis of prescriptions at various levels of stocks in two district hospitals in Uganda. Prescription data collected retrospectively one before and two years after decentralization from the district hospitals of Apac and Lira, Uganda. Outcome measures being drug selection choices for malaria, ARI and non- infective diarrhoea and stock levels over a period of time, with reference to national guidelines. Overall distribution of drugs prescribed for malaria, ARI and diarrhoea.

METHODS CONT. Specific Variables: Level of stocks – actual counts by the middle of each month Prescription - # of drugs per case, - drug distribution as frequency of prescribing of individual drug per condition - # drug choices conforming with national guidelines by middle of each month - # drug choices outside the national guidelines by middle of each month

Figure I: Drug Choices and Stock Levels of Chloroquine- Lira Hospital

Figure II: Drug Choices and Stock Levels of Chloroquine- Apac Hospital

RESULTS Figure I, relationship between choices antimalarial drugs and stock levels of chloroquine. Lira -Chloroquine choice not vary with stock level. - Prescription of other antimalarials left chloroquine stock levels high.

RESULTS (CONT). Apac-Chloroquine stock levels were influenced by prescribing choice. -Prescribing alternative drugs led to less choice of chloroquine and this left the stock levels high.

CONCLUSIONS Stock levels of chloroquine did not influence the choice of antimalarial drugs. Stock levels were influenced by prescribing choices. Drugs were prescribed because of availability. Chloroquine seems to have been supplied with the other antimalarials, so they became available at the same time.