International Conference on Improving Use of Medicines ASSESSING THE EFFECTS OF COST SHARING ON AVAILABILITY OF DRUGS AND UTILIZATION OF SERVICES IN PUBLIC HEALTH FACILITIES IN UGANDA Tumwikirize WA., Ogwal-Okeng JW., Mohammed K., Aupont O. International Conference on Improving Use of Medicines Chiang Mia, Thailand 2004 INRUD Uganda and Makerere University Project supported as part of the Joint Initiative on Improving Use of Medicine under a grant from RPM Plus

Abstract Background: In Uganda, the strategy of cost sharing in public health facilities was introduced in 1990. The policy provided special considerations for specific categories of people, among whom were children aged less than five years. In March 2001, the Government abolished the policy. However, reports on the actual impact the policy give conflicting pictures. Objectives: i. To assess the effect of the changes in the cost sharing policy on facility utilization, drug availability and prescribing for the most common ailments in specific pediatric populations in the regional and district public hospitals. Study design: This study used a retrospective longitudinal research design to analyze data covering 12 months before the removal of the policy and 24 months after the abolition. Study site: Reginal and district hospitals located in Jinja, Masaka, Kawolo, and Conde communities of Uganda. Methods: Sampling of four public facilities including 1 regional and 3 district hospitals. Selection of records for 3 strata of pediatric patients (under 1 year, between 1 and 5 years, and between 5 and 10). Data collection from outpatients pediatric records, and pharmacy stock book at participating hospitals, covering 36 months. Time series analyses of drug availability, attendance, and prescribing. Outcomes: These included total number of cases seen per month; availability of essential drugs for common childhood illnesses (st and 2nd line drugs for Malaria, ARI, and diarrhoea, drugs for intestinal infestations and paracetamol) as reflected by number of days of stock-out, amount procured per month for each drug; and prescription characteristics in terms of average number of drugs per prescription, antibitic use and injection per prescription. Results: Overall average attendance increased, particularly for sick chidlren aged between 1 and 5 years who were subject to pay half of the regular consltation fee under the policy. Increases in the availability of the essential drugs were very significant for SP and ORS at those hospitals. No major variations in the prescribing pattern. Conclusions: Removal of the cost sharing policy resulted in increase in utilization of services in the public hospitals, and improved availability of the essential drugs. There was no effect on prescription practices. There is no clear evidence that the increase in the availability of certains specific drugs is associated with the removal of the policy. Other government policies took place shortly after the abolishment of cost-sharing. There is need for further exploration of the variations of facility attendance of a specific age grup as well.

BACKGROUND In 1990, introduction of cost sharing policy in Uganda. Objectives to encourage patients/caretakers to contribute to health care costs To generate revenue to supplement financial based of public institutions in addition to funding from the central government. Policy provided special considerations for specific categories of people, including children under five years. Policy abolished in March 2000 Children under 1 year and Pre-natal care Paid No fee Children between 1-5 years Paid half fee Children over 5 yrs, and adult patient Paid full cost for services

OBJECTIVES General objective: To assess the effect of changes in cost sharing policy on availability of drugs and utilization of services in public hospitals in Uganda. Specific Objectives: - To evaluate the effect of the policy changes on outpatient clinic attendance of three pediatric age groups who were differently affected by the policy. - To analyze changes in the availability of Essential Drugs for common illnesses affecting those age groups. - To determine the variations in prescription practices for specific pediatric patient populations.

METHODS - Use of a longitudinal retrospective research design with stratified study cohorts. - Stratification of pediatric records from 3 district and 1 regional hospitals into 3 study groups. - Data collected from pediatric outpatient clinics and stock cards at the hospital pharmacies covering a 36-month period (12 before and 24 months after removal of policy. - Time series analyses of variations in attendance, drug availability, and prescription characteristics over time

Results Overall average attendance increased, particularly for children under five years old. Moderate increase in attendance observed for children aged 6 – 10 years old. Significant improvement observed in the availability of SP and ORS after the removal of the policy. Changes in drug availability did not seem to be associated with variations in attendance No major variations in prescribing patterns with policy changes.

Results (continued) Modest changes observed in prescription characteristics after the policy change: - Average # of drugs per prescription barely changed - Use of antibiotics per prescription remained constant (70%) throughout the study period. - Slight increase in the proportion of prescriptions with an injection. No clear correlation identified between availability ED and prescription pattern.

Results (continued) Before After

Results (continued) Before After

Results (continued) Variations in number of drugs per prescription

Summary and conclusion Attendance increased with the removal of the cost sharing policy, particularly in for the under-fives. Availability of Essential Drugs increased with the removal of the policy - Changes in attendance did not affect the availability of the drugs Policy changes did not markedly affect general prescriptions characteristics. It is possible that the increase in attendance occurred because there was no cost involved or because of consumers’ awareness of drug availability Limitations : The study did not look at disease specific prescribing patterns, but it is possible that the prevelance of specific disease at a specific point in time affects drug availability and the prescribing patterns for a particular age group