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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:
Compliance to new treatment policy (CQ+SP) at Hospitals in Uganda
50
New treatment
Policy proposed
Percentage prescriptions
45
New treatment Policy
enacted
40
35
30
25
Public
Mission
20
Private
15
10
5
0
Q3-99
Q4-99
Before policy Proposal
Q1-00
Q2-00
Q3-00
Q4-00
Q1-01
Transition and discussion period
Time in Quarters
Q2-01
Q3-01
Q4-01
Policy implementation
Q1-02
Q2-02
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
Variations in Utilisation Of Mission Hispitals
Variations in utilisation of Public Hospitals
1400
2000
New treatment Policy
enacted
New treatment
Policy proposed
1800
New treatment
Policy proposed
New treatment Policy
enacted
1200
1200
Public M O/P attendance
Public Malaria Admissions
1000
800
600
Number of Patients
1400
1000
800
Malaria O/P attendance
Malaria Admissions
600
400
400
200
Before policy Proposal
200
Transition and discussion
period
Transition and discussion
period
Policy implementation
Before policy Proposal
0
Policy implementation
0
Q3-99
Q1-00
Q3-00
Q1-01
Q3-01
Q1-02
Q3-02
Q3-99
Time (Quarters)
350
New treatm ent
Policy proposed
New treatm ent Policy
enacted
300
250
200
Private M O/P attendance
Private Malaria Adm issions
150
100
50
Before policy Proposal
Transition and discussion
period
Policy im plem entation
0
Q3-99
Q1-00
Q3-00
Q1-01
Q3-01
Time (Quaters)
Q1-00
Q3-00
Q1-01
Time(quarters)
Variation in Utilisation Of Private Hospitals
Number of Patients
Number of Patients
1600
Q1-02
Q3-02
Q3-01
Q1-02
Q3-02
Results (continued)
Drug availability in public, mission and private Hospitals
Availability of CQ and SP in Public Hospitals
Availability of CQ, SP and Artemisinnin Derivatives in Private Hospitals
14000
1800
New treatment
Policy proposed
1600
New treatment Policy enacted
1400
8000
Mid-month Drug Stock (X10)
10000
Public CQ
Public SP
6000
4000
1200
1000
Private CQ
Private SP
Private Art
800
600
400
2000
200
0
Q3-99
Q1-00
Q3-00
Q1-01
Q3-01
Q1-02
0
Q3-02
Time(Quarters )
Q3-99
Q1-00
Q3-00
Q1-01
Time(Quarters)
Availability of CQ and SP in Mission Hospitals
9000
8000
New treatment Policy
enacted
New treatment
Policy proposed
7000
Mid- month Drug Stock (x10)
Mid Month Drug Stock (x10)
New treatment
Policy proposed
New treatment Policy enacted
12000
6000
5000
Mission CQ
Mission SP
4000
3000
2000
1000
0
Q3-99
Q1-00
Q3-00
Q1-01
Time ( Quarters)
Q3-01
Q1-02
Q3-02
Q3-01
Q1-02
Q3-02
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