Change in malaria treatment policy: A study of its immediate effects on hospital malaria drug management, utilization of hospital facilities and prescription behavior in District Hospitals of Uganda Waako, P., Ogwal-Okeng, JW., Aupont O. , Ross-Degnan, D. International Conference on Improving Use of Medicines Chiang Mia, Thailand March 31, 2004 INRUD Uganda and Makerere University Project supported as part of the Joint Initiative on Improving Use of Medicines under a grant from RPM Plus

Abstract Problem statement: Increased reports of malaria treatment failure in hospitals and health units led the Uganda Government to change the first line treatment for malaria from chloroquine to sequential use of chloroquine and sulfadoxine/Pyrimethamine in the middle of 2001.Chloroquine is generally considered safe and affordable by most prescribers and hospital administrators in Uganda. There was a lot of scepticm on the affordability of the new regimen, which appeared to have doubled the cost of treating an episode of uncomplicated malaria. It generally took close to a year to generate a consensus for this change. Objectives: A study has been designed to explore the effects of policy change on the utilization of hospital services, malaria treatment practices, and treatment outcomes in hospital settings in Uganda. Study design: : Retrospective time series study, with a survey research design in district hospitals over a time frame of 36 months. Study setting and population: The study focuses on 6 district hospitals: 2 Government, 2 Private, and 2 religious-based, selected from the four regions of Uganda. Outcome measures: Awareness of the new policy by administrators and prescribers; trends of mid-month antimalarial stocks; prescription levels and proportion of correct dosing of new regimen; monthly malaria outpatient attendance and admissions. Results: There was 97% awareness among the prescribers and 100% among administrators. Prescribers in the public sector were more compliant to the policy change than in mission and private hospitals. Drug stock adjustment were inadequate in all hospital settings despite the level of policy awareness and knowledge. There is increased prescription of SP alone in mission hospitals in preference to the recommended treatment. There is increased stocking and prescription of Artemisinnin derivatives in the private sector in preference to the recommended treatment. Mission hospitals that used SP alone were able to control hospital admissions against the increasing outpatient attendance. The public sector that had a high rate of compliance to the new policy did not contain the increasing rate of admissions possibly due to inadequate stock adjustments Conclusions: Source of funding, administrative structures and style in a health facility affect compliance to national treatment policy

BACKGROUND Malaria is a leading health problem worldwide: Over 100 million people are affectd annually. Major burden in Uganda: Leading cause of death, High levels of hospital admission (nearly 25%) and outpatient attendance (25-40%). Parasite resistance and limited access to effective treatment are major constraints to malaria control. Treatment failure  change in treatment Policy (from chloroquine to chloroqine + SP) Problems with implementation and adoption of the new treatment policy

OBJECTIVES To explore the effects of the policy change on the utilization of services, drug management and treatment practices for malaria at the hospitals over a three year transitional period. Specific Objectives To assess awareness and knowledge of hospital administrators and prescribers of the existence of the policy change To assess the variations in hospital utilization over time during the transition of the policy To analyze the adjustment of hospital drug management to the new policy To determine the effect of the policy on the prescription practices for malaria patients during the transition

METHODS Retrospective study using a survey research design combined with longitudinal data analysis. Setting : 6 Hospitals (2-mission, 2-public , 2-private) Survey of 38 hospital administrators and providers Analysis of monthly hospital records (attendance, drug stocks and malaria prescriptions) over 36 months. Time periods 12 months before policy announcement 12 months of transition / debates 12 months after pronouncement --------------- I --------------- I ---------------

Results Awareness and Knowledge Of all administrators and prescribers surveyed, only one did not know about the change in malaria treatment policy Prescription practices An improvement in prescribing of new regimen in the Public hospitals Smaller improvement in prescription of new regimen in Mission Hospitals, with increased use of SP alone over the study period No change in level of CQ+SP prescription in the Private Hospitals rather a steady increase in prescription of Artemisinnin derivatives

Results:

Results (continued) Drug availability: Steady decrease in availability of CQ and SP in Public Hospitals Increase in SP stocks in Mission facilities (CQ availability decreased) Increased stock of Artemisinnin derivatives in the Private Sector (CQ and SP stocks remain stable) Facility Utilisation No variation in admissions despite increased out-patient attendance in the 3 hospital types

Results (continued) Utilisation of Public, Mission and Private facilities

Results (continued) Drug availability in public, mission and private Hospitals

Summary and conclusion Prescribers in the public sector were more compliant to the policy change Drug stock adjustment were inadequate in all hospital setting despite the level of policy awareness and knowledge There is increased prescription of SP alone in mission hospitals in preference to the recommended treatment There is increased stocking and prescription of Artemisinnin derivatives in the private sector in preference to the recommended treatment

Summary and conclusion Mission hospitals that used SP alone were able to control hospital admissions against the increasing outpatient attendance The public sector that had a high rate of compliance to the new policy did not contain the increasing rate of admissions possibly due to inadequate stock adjustments Source of funding, administrative structures and style in health facilities affect compliance to national policy