1. 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

2. Acknowledgements 1.Applied Research for Child Health 2.Management Sciences for Health/RPM Plus 3.Makerere University, Kampala, Uganda 4.INRUD-Uganda 5.Uganda National Council of Science and Technology 6.Mulago Hospital, Kampala, Uganda 7.Mbale Hospital, Uganda 8.Kamuli Mission Hospital, Uganda 9.Nkozi Mission Hospital, Uganda 10.Bugolobi Hospital, Kampala 11.Mayanja Memorial Hospital, Mbarara, Uganda

3. Background ─ Malaria is a leading health problem worldwide: Over 100 million people are affected 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 chloroquine + SP) ─ Problems with implementation and adoption of the new treatment policy

4. 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

5. Methods Retrospective study using a survey research design combined with longitudinal data analysis. Setting : 6 Hospitals (mission, public, 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 proposal - 12 months of transition / debates - 12 months after pronouncement --------------- I --------------- I ---------------

6. Results Awareness and Knowledge - Of all administrators and prescribers surveyed, only one did not know about the change in malaria treatment policy Prescription practices - Improvement in prescribing of new treatment regimen observed in the public hospitals - Smaller improvement in prescribing of new treatment regimen observed in Mission Hospitals, with increased use of SP alone over the study period - No changes in level of CQ+SP prescriptions noted for Private Hospitals. Rather steady increases in prescriptions of Artemisinin derivatives can be observed

7. Results

8. 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 Artemisinin derivatives in the Private Sector (CQ and SP stocks remain stable) Facility Utilization - No variation in admissions despite increased out-patient attendance in the 3 hospital types

9. Results (continued) Variations in drug availability at the hospitals

10. Results (continued) Variations in malaria attendance and admissions

11. 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 prescriptions of SP alone in mission hospitals in preference to the recommended treatment ─ There is increased stocking and prescription of Artemisinin derivatives in the private sector in lieu of 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 ─ Source of funding, administrative structures and style of administration of health facilities affect compliance to national policy