THE IMPACT OF DECENTRALIZATION ON HEALTH SERVICES IN UGANDA: A LOOK AT FACILITY UTILIZATION, PRESCRIBING, AND AVAILABILI

1. THE IMPACT OF DECENTRALIZATION ON HEALTH SERVICES IN UGANDA: A LOOK AT FACILITY UTILIZATION, PRESCRIBING, AND AVAILABILITY OF ESSENTIAL DRUGS Ogwal-Okeng JW, Anokbonggo WW, Obua C,Ross-Degnan D, Aupont O. 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 Medicine under a grant from ARCH

2. Abstract Problem Statement: Uganda started implementing a structural adjustment program, which resulted in the decentralisation of health services to district level, in July 1994. It was intended to improve the quality of health services and pharmaceutical supplies in the hospitals, with resultant increases in the level of utilization of health services. Objective: To assess the impact of this policy on facility utilization; prescribing patterns for ARI, diarrhoea, and malaria; and on availability of essential drugs in hospitals in Uganda. Design: Mixed evaluation study design using both qualitative and quantitative methods. With time series analysis of indicators before and after the policy. Setting and Population: The study was done in two district hospitals in northern Uganda. Patient records in the hospitals were analyzed retrospectively. In-depth interviews were conducted with politicians; open-ended questionnaires and focus group discussions were administered to patients and health workers respectively. Outcome Measures: Facility utilization was evaluated by average monthly attendance in the outpatient department and pediatric ward admissions. Prescribing indicator outcomes were: average number of drugs prescribed per case; % drugs given by injections; % antibiotics prescribed; % chloroquine tablets for malaria; % chloroquine injections prescribed for malaria; and % anti-diarrheal drugs prescribed for non-infective diarrhoea. Availability was assessed as average percent availability of nine essential drugs and number of drugs whose availability was more than 40 %. Results: There was a general increase in patient attendance in both hospitals, although the initial increase later declined in Apac district. Drug availability was erratic and not always adequate in both districts. This was much better in Lira district, where funding for drug procurement was more accessible. Prescribing patterns varied, with improvement in some indicators, while other indicators showed no change or even worsened. Conclusions: The decentralisation policy increased health facility utilization. All stakeholders considered the policy to be good. However, it has so far failed to solve drug shortages, inefficient utilization of resources, and general low morale among hospital staff. Staff should be retrained and better remunerated in order to cope with the implementation of the policy. Local politicians should clearly understand their roles and responsibility under the new policy. Efficient utilization of funds at all levels of the district administrative structures should be ensured. Study Funding: Applied Research in Child Health (ARCH) through a grant from the United States Agency for International Development (USAID)

3. Introduction • Decentralization advocated to improve access to health and family planning services, and quality and efficiency of public sector. • Uganda adopted a structural adjustment program (SAP) in 1994 in two phases. Lira was in the first phase that implemented the policy in 1994 and Apac started in 1995. • These changes took the level of decision-making nearer to the people and involved the community and their local leaders in their health matters. • This study examined the impact of the policy on monthly health facility utilization; availability of essential drugs and prescribing patterns for ARI, diarrhea, and malaria in two district hospitals in Uganda.

4. General Objective To assess the impact of decentralization policy on quality of health care services in Uganda based on levels of facility utilization, prescribing behavior and stock levels of essential drugs

5. Specific Objectives • To assess the average monthly patient attendances in the out patient, maternity and pediatric units in Apac and Lira District Hospitals before and after introduction of decentralization policy in Uganda. • To assess the stock levels of some essential drugs in Apac and Lira Hospitals before and after introduction of decentralization policy in Uganda. • To assess the prescription patterns for non-complicated malaria, non-dysenteric diarrhoea and acute respiratory infections (ARI) in Apac and Lira Hospitals before and after introduction of decentralization policy in Uganda.

6. Methods Design and setting • Study conducted in Lira and Apac district hospitals • Retrospective study design covering 2 years before and 5 years after policy implementation • Mixed evaluation methods using both quantitative qualitative approaches. - Analyses of facility utilization records, Phamacy stocks, and prescriptions. - Key informant interviews and focus group with 351 Stakeholders Data sources • Facility utilization: Monthly attendance records of study hospitals from 1992 – 1999 • Drug availability: Mid-month hospital drug availability for specific tracer drugs during 1992 - 1999 • Prescribing Patterns: Analysis of 5040 patients records (prescriptions).

7. Variations in Facility Utilization

8. Mid-month availability of tracer drugs before and after decentralization Results

9. Mid-month availability of tracer drugs before and after decentralization Results

10. Prescribing Patterns for Malaria Results

11. Summary • Increased facility utilization observed with decentralization policy • Drug shortages persisted, and even worsened in some facilities • Drugs stocks increased but quantities remained inadequate • Prescribing behavior remained poor fater decentralization • Health staff had mow morale and lacked of training opportunities • Poor relationship between health staff and political leaders hampered successful implementation of decentralization policy