1. 15 March 20041 Managing the Dynamics of Drug Supply, Demand, and Health Services Utilization A New Multi-Purpose Tool for Forecasting Drug Requirements and Resource Management Hanif Nazerali, Khalid Mohamed, Martin Oteba, and Joseph Mwoga Ministry of Health, Uganda

2. 15 March 2004 2 Challenges in the Uganda setting Uganda is changing from a drug kit system (push) to an order-based system (pull) Drug funding is decentralized and increasing rapidly through a SWAp* but management capacity is still limited Health services are utilized only when drugs are available, and this depends on good forecasting, a responsive supply system, and efficient resource management Forecasting in this dynamic environment requires innovative approaches *Sector-wide approach

3. 15 March 2004 3 New multi-purpose tool 1. Reports drug use indicators and other performance indicators 2. Identifies most common outpatient conditions and the most prescribed drugs 3. Forecasts PHC drug requirements and costs for 1000 outpatient cases using dual methods (prescription demand and stock consumed) 4. Quantifies gaps between current demand and actual supply per 1000 cases (or oversupply) 5. Validates records and accounts for resources

4. 15 March 2004 4 Study design and methods Retrospective review of outpatient registers, stock records, and service statistics for a specified period in a cross-section of health facilities Data entered into a customized database, with defined lists of diagnoses, drugs, and current prices (MS Access and linked Excel spreadsheets) Performance indicators analyzed by individual facility, level, district

5. 15 March 2004 5 Study sample A systematic sample of 200-400 encounters per health facility depending on level, at intervals over a 12-month period Total 6,400 outpatient encounters at 24 health facilities in 4 districts Comprehensive stock record review for all drugs issued during the 12- month period Consumption data was obtained from 21/24 health facilities, and for 9 of the top 12 drugs, on average, from the 21 facilities.

6. 15 March 2004 6 Customized Database Inputs Outputs 1. Demographic data, diagnoses, & prescriptions for each encounter 2. Consumption data for a specified period from stock records 3. Health facility service statistics (e.g. OP encounters in the study period) 1. Drug use indicators including average cost per case 2. Ranked diagnoses and drugs by frequency per 1000 encounters 3. Comparison of standardized drug requirement per 1000 cases based on prescriptions (demand) and consumption (supply)

7. 15 March 2004 7 RESULTS (1) Prescribing indicators CategoryNum of enctrs Avg Drugs per enctr % with INJ % with AM % with AB Avg cost* per enctr Age < 5 15753.248%77%59% Age > 5 or not specified 48212.929%51%56% HU level II 15973.140%65%56%1039 HU level III 15992.933%62%54%772 HU level IV 23992.832%53%57%992 Hospital 8013.426%48%61%1088 District KAM 15992.830%57%63%1079 District LUW 16002.739%52%54%864 District MAS 15973.244%64%48%1150 District RAK 16003.222%57%62%675 ALL63963.034%57% 942 Cost in Uganda Shillings (approx 2000 USh = 1 Euro = 1 US$)

8. 15 March 2004 8 RESULTS (2) P rescribing in malaria/ARI DIAGNOSIS frequency% encounters prescribed: N%Cum % AMABAM+ AB Malaria only170628% 98%17%16% Malaria + ARI (No pneumonia) 5829%36%97%90%87% Malaria + ARI (Pneumonia) 4727%43%97% 93% ARI only (No pneumonia) 3175%48%10%90%9% ARI only (Pneumonia) 1773%51%14%97%14% Other diagnoses 314249%100%29%60%11% Total6396100%57% 25%

9. 15 March 2004 9 RESULTS (3) Most prescribed drugs RankDrugTimes Rx per 1000 enctrs % total RxCum % Rx 1Paracetamol oral53217.8% 2Chloroquine oral43614.6%32.4% 3Co-trimoxazole oral2257.5%39.9% 4Acetylsalicylic acid oral2006.7%46.6% 5Mebendazole oral1806.0%52.6% 6Chloroquine inj1444.8%57.4% 7Procaine Penicillin inj1364.5%61.9% 8Sulphadox/Pyrim (SP) oral1183.9%65.8% 9Metronidazole oral983.3%69.1% 10Chlorpheniramine oral712.4%71.5% 11Amoxy(ampi)cillin oral682.3%73.8% 12Doxy(tetra)cycline oral612.0%75.8% 13Ferrous sulph. oral602.0% 14Penicillin V oral592.0% 15Ibuprofen oral432.0% 16Mag. Trisil. oral381.4%

10. 15 March 2004 10 RESULTS (4) Demand and supply Rank Drug and dose unitDemand per 1000 Mean (±95%CI) ED Kit Supply per 1000 Total Supply per 1000 Mean (±95%CI) % Stock- out Time 1 Paracetamol 500mg oral 6165(±782)20005309(±1411)17% 2Chloroquine 150mg base oral3009(±428)30004912(±1050)6% 3Co-trimoxazole 480mg oral2991(±481)2503214(±854)29% 4Acetylsalicylic acid 300mg oral3398(±540)20003080(±726)25% 5Mebendazole 100mg oral1511(±279)10002096(±506)23% 6Chloroquine 200mg/5ml inj (a ) 260(±133)7157(±57)22% 7Procaine Penicillin 4MU inj (a ) 259(±93)2078(±27)16% 8Sulphadox/Pyrim (SP) 525mg oral 272(±70)0622(±230)37% 9Metronidazole 200mg oral1783(±524)3001747(±575)32% 10Chlorpheniramine 4mg oral604(±187)200943(±337)26% 11Amoxycillin 250mg oral (b) 1079(±379)01211(±413)30- 44% 12Doxycycline 100mg oral (c) 575(±210)75425(±113)39% Notes: (a) Demand for CQ inj and Procaine inj is overestimated due to known errors in interpretation of dose units. (b) Includes for ampicillin 250mg at factor 3/8 (c) Includes for tetracycline 250mg at factor 1/4

11. 15 March 2004 11 Discussion – Key Findings Over-prescribing of injections and antibiotics overall, but some facilities are within the expected norms for injections Cost per case is associated with high use of injections, AB, no. of drugs Malaria with ARI is common, and ARI is treated with antibiotics regardless of classification (pneumonia or not) 10-16 Core drugs account for 75% of prescriptions and overall cost Demand per 1000 provides a precise forecast for core requirements while supply is unstable and consumption data are missing or unreliable

12. 15 March 2004 12 Conclusions and recommendations This is a useful and robust tool that will focus available resources towards meeting demand for core drug requirements The same tool highlights potential cost savings ensuing from better specificity of diagnosis and improved prescriber behaviour e.g. reduced injection use A more expensive anti-malarial treatment regimen will have a dramatic impact on resource use Repeat assessments will measure the effect of interventions, changes in resources, systems or management

13. 15 March 2004 13 Abstract