Obua C, Ogwal-Okeng JW, Waako P, Aupont O , Ross-Degnan D International Conference on Improving

1. A COMPARISON OF PRESCRIBING PRACTICES BETWEEN PUBLIC AND PRIVATE SECTOR PHYSICIANS IN UGANDA Obua C, Ogwal-Okeng JW, Waako P, 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

2. 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 ICIUM2004 - CHIANG MAI, THAILAND

3. 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. ICIUM2004 - CHIANG MAI, THAILAND

4. 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 ICIUM2004 - CHIANG MAI, THAILAND

5. 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. ICIUM2004 - CHIANG MAI, THAILAND

6. 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. ICIUM2004 - CHIANG MAI, THAILAND

7. Prescribing Practice Private n=117 ( S.E.) Public n=300 (S.E.) Private vs. Public Difference Significance 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) +0.3 p=0.002 Average number of drugs prescribed 3.1 (0.09) 2.9 (0.0) +0.2 n/s Standardized cost per prescription 4986 (247) 3165 (127) +1821 p=0.01 Results (Continued) Prescription patterns for treating adult cases of ARI in urban health facilities  S.E. – Standard Error

8. PrescribingPractice Private n=119 (S.E) Public n=295 (S.E) Private vs. Public Difference Significance 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) -0.34 p<0.001 Average number of combination drugs prescribed 1.2 (0.06) 1.2 (0.04) +0.06 n/s Average number of drugs prescribed 3.1 (0.10) 3.3 (0.05) -0.19 p=0.06 Standardized cost per prescription 3629 (203) 3957 (149) -328 n/s Results (continued) Prescription patterns for treating adult cases of malaria in urban health facilities S.E. – Standard Error

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

10. 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? ICIUM2004 - CHIANG MAI, THAILAND

11. Conclusion and Policy implications • Prescribing patterns in both sector were not complying with the UNSTG recommendations – timely reviews needed. • Exploratory and educational Interventions urgently needed to address prescribing issues in both sector. • Providers in both sectors need training and continuous monitoring and evaluation of their activity in order 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. ICIUM2004 - CHIANG MAI, THAILAND