2. A COMPARISON OF PRESCRIBING PRACTICES BETWEEN PUBLIC AND PRIVATE SECTOR PHYSICIANS IN UGANDA Obua C, Ogwal-Okeng JW, WaakoP, Aupont O, Ross-Degnan D International Conference on Improving Use of Medicines Chiang Mia, Thailand April 1, 2004 INRUD Uganda and Makerere University Project supported as part of the Joint Initiative on Improving Use of Medicines under a grant from ARCH

3. ABSTRACT A COMPARISON OF PRESCRIBING PRACTICES IN PUBLIC AND PRIVATE SECTORS IN UGANDA Obua C*, Ogwal-Okeng J.W*, Waako P*, Aupont O** and Degnan D.R**. *Department of Pharmacology and Therapeutics, Makerere University, Uganda. **Drug Policy Research Group, Harvard Medical School, Boston, USA. Problem Statement: Studies done in Mulago hospital, the referral hospital and at other public health institutions in Uganda showed that drug use problems such as polypharmacy and irrational prescription of antibiotics and injections are indications of irrational prescribing practices. The frequent lack or low stocks of medicines in the public institutions may lead many private practitioners to capitalize on this situation and prescribe irrationally, as there is little government regulation in this sector. The introduction of policies such as the Uganda National Standard Treatment Guidelines (UNSTG) was expected to improve prescribing practices in the public and private sectors. Objectives: To compare the prescribing practices in the public and private sectors in the treatment of Acute Respiratory Infections (ARI) and malaria. Design: Treatment records from public health units were randomly selected retrospectively; prescriptions from the private physicians were collected prospectively using surrogate patients. Setting and Population: 30 Prescription records for each condition were collected from 10 public health units, and a prescription for each condition was collected from 119 private clinics in Jinja, Masaka and Kampala urban areas. Outcome measures: % of drugs appropriately prescribed in each condition, % injection prescription, % antibiotics prescription, average number of drugs/case, and standardized mean cost/prescriptions. Results: The overall appropriateness of prescriptions for ARI and malaria in both public and private sectors were poor. Prescriptions for malaria were significantly poorer in the public sector compared to the private sector (14% vs. 27%, p=0.002). Antibiotic prescribing in ARI including expensive and unsafe ones was very high in both sectors, some prescriptions contained up to three antibiotics. Injection use was significantly high in malaria treatment in the public sector (61%) compared to private sector (26.9%) p=0.0001. Polypharmacy and irrational prescription of vitamins and other combination preparations was common in both conditions and both sectors. The standardized mean cost of prescriptions was high in ARI prescriptions in the private sector compared to high cost of malaria treatment found in the public sector. Conclusions: Prescribing practices by both private and public practitioners were highly irrational and did not conform to the treatment guidelines. The extensive inappropriate prescribing for malaria amongst public prescribers calls for explanatory models for the motives and educational intervention. Study Funded by: ARCH through a grant from USAID.

4. ICIUM2004 - CHIANG MAI, THAILAND3 BACKGROUND Private sector physicians contribute significantly to health services in Uganda Governments overseers of health services in both private and public sector. Practices in both sectors characterized by alarming gaps in prescribing. Inappropriate prescribing practices likely to be a serious problem among private sector physicians

5. ICIUM2004 - CHIANG MAI, THAILAND4 OBJECTIVES To analyze and compare prescribing practices between public and private sector physicians for ARI and malaria in Kampala, Masaka and Jinja. Specific Objectives To analyze the overall quality of prescribing for ARI and malaria in the 2 sectors. To compare the prescribing patterns between the two sectors To assess overall difference in cost of prescriptions between the two practices.

6. ICIUM2004 - CHIANG MAI, THAILAND5 METHODS  Survey research design involving both quantitative and qualitative methods.  Prospective survey of 119 private practices randomly selected from the study sites  Use of surrogate patients in private sector data collection  Retrospective survey of 595 prescription records randomly selected from 10 public health units.  Only single-diagnosis prescriptions selected

7. ICIUM2004 - CHIANG MAI, THAILAND6 METHODS (continued) Prescription indicators: Types and number of drugs prescribed Duration of treatment Levels of antibiotic and injection use Appropriateness of prescribing Appropriateness of prescribing:  Indication  Regimen  Route of administration  Use of generic names.

8. ICIUM2004 - CHIANG MAI, THAILAND7 Results  Low levels of overall appropriateness of prescribing in the two conditions by both sector.  High use of injections – twice as much in malaria by public sector compared to private sector.  High use of antibiotics by both sector – in some cases up to 3 prescribed.  Number of drugs per prescription generally more than 2. On average 3.1 and 3.3 drugs in malaria by private and public sectors; 3.1 and 2.9 in ARI by Private and public sectors – evidence of polypharmacy  Comparatively high use of medicines of doughtfull benefits – i.e.vitamins, steroid anti-inflammatory, brand combination drugs by private sector.  Prescription costs too high both sector.

9. 8 Results(Cont.) Table 1: Prescription patterns for treating adult cases of ARI in urban private practices public health facilities Prescribing Practice Private n=117 ( S.E.) Public n=300 (S.E.) Private vs. Public DifferenceSignificance All drugs prescribed appropriately 18.8% (3.6%) 24.3% (2.5%) -5.5%n/s Injection prescribing rate 7.7% (2.5%) 14.3% (2.0%) -6.6%p=0.07 Antibiotic prescribing rate 88.0% (3.0%) 91.3% (1.6%) -3.3%n/s Prescribed more than one antibiotic 11% 9%+2%n/s Average number of combination drugs prescribed 1.1 (0.08) 0.8 (0.0)+0.3p=0.002 Average number of drugs prescribed 3.1 (0.09) 2.9 (0.0)+0.2n/s Standardized cost per prescription 4986 (247) 3165 (127)+1821p=0.01 S.E. – Standard Error

10. 9 Results (cont.) Table 3: Prescription patterns for treating adult cases of malaria in urban private practices and public health facilities Prescribing Practice Private n=119 (S.E) Public n=295 (S.E) Private vs. Public DifferenceSignificance All drugs prescribed appropriately 27.7% (4.1%) 14.6% (2.1%) +13.1%p=0.002 Injection prescribing rate 26.9% (4.1%) 61.0% (2.8%) -34.1%p<0.001 Antibiotic prescribing rate 11.8% (3.0%) 14.9% (2.1%) -3.1%n/s Average number of antimalarials prescribed 1.4 (0.05)1.7 (0.04)-0.34p<0.001 Average number of combination drugs prescribed 1.2 (0.06)1.2 (0.04)+0.06n/s Average number of drugs prescribed 3.1 (0.10)3.3 (0.05)-0.19p=0.06 Standardized cost per prescription 3629 (203)3957 (149)-328n/s S.E. – Standard Error

11. 10 Results (cont.) Fig.1: Overall Appropriateness of Prescribing by Private and Public Sector Fig.2: Prescribing of Injections in Private and Public sector Fig.3: Selection of Antibiotics Prescribed to Patients Treated for ARI P=0.07P=0.0001 P=0.002 p>0.05

12. ICIUM2004 - CHIANG MAI, THAILAND11 DISCUSSION  UNSTG perceived by prescribers as irrelevant to practices hence rarely referred to – a problem of ownership?  The overall low appropriateness and poor prescribing in Malaria by public sector indicator of extensive irrationality in practices – is govt. strategy wrong?  While prescribing in the private sector could be underscored by economic reasons - What motives explain the pattern of prescribing in the public sector?  In Uganda the average family survives on less than $1 a day – negative impact on the health and financial implications by the prescription costs?

13. ICIUM2004 - CHIANG MAI, THAILAND12 CONCLUSION & POLICY IMPLICATION  Prescribing patterns in both sector were not in conformity with the UNSTG recommendations – timely reviews needed.  Exploratory and educational Interventions urgently needed to address non-use of UNSTG and improve the prescribing practices in both sector.  Prescribing in both sectors require qualitative and quantitative educational interventions with continuous monitoring and evaluation to improve practices.  Govt. to actively promote National Treatment Guidelines for effective impact on health and economic outcomes.  Periodic evidence based CME using the National Treatment Guidelines is recommended.