Transcript Poster presentation

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
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In 1990, introduction of cost sharing policy in Uganda.
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Objectives
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-
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to encourage patients/caretakers to contribute to health care costs
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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.
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
Policy abolished in March 2000
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
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Overall average attendance increased, particularly for
children under five years old.
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Moderate increase in attendance observed for children
aged 6 – 10 years old.
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Significant improvement observed in the availability of SP
and ORS after the removal of the policy.
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Changes in drug availability did not seem to be associated
with variations in attendance
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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.
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No clear correlation identified between availability ED and
prescription pattern.
Results (continued)
Changes in Attendance over time
800
Average monthly attendance
700
Removal of cost
sharing policy ->
600
500
Under 1yr
1-5 years
400
6-10 yrs
300
200
100
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36
Tim e
Before
After
Results (continued)
Variations in ED stock out
25
Removal of cost sharing
policy
Stock out days
20
15
Cqtab
SP
ORS
CoT
10
5
0
Q-4
Q-3
Q-2
Before
Q-1
Q1
Q2
Q3
Time in Quarters
Q4
After
Q5
Q6
Q7
Q8
Results (continued)
Variations in number of drugs per prescription
Summary and conclusion
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Attendance increased with the removal of the cost sharing policy,
particularly in for the under-fives.
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Availability of Essential Drugs increased with the removal of the
policy
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Changes in attendance did not affect the availability of the drugs
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Policy changes did not markedly affect general prescriptions
characteristics.
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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