The availability of drugs: what does it mean in Ugandan primary care
Introduction
The ongoing health reforms make two common assumptions on availability of drugs. The first is that rational drug management will ensure availability of drugs. If need is calculated on the basis of morbidity patterns, if essential drugs are supplied and managed effectively, and if medicines are prescribed according to rational professional standards, then drugs will be available. This technical or knowledge-based premise is often the position of national ministries of health and international organisations such as World Health Organisation. The second assumption is that quality of care, especially drug availability, will improve with user fees and that it must do so to justify them and increase user satisfaction. When users become customers, their expectations must be recognised. Thus, availability of drugs can be influenced by user demands. This is the market-driven premise, promoted by principals in ongoing health reforms. There is a logical tension between these two premises and health workers are often squeezed between them. If they are responsive to user demands, they may not be ‘rational’ drug managers according to technical standards.
This article examines drugs policy and practice at primary health care level, with a focus on the inconsistencies in the policy and the gap between policy and practice. It does so by describing the contrast in perspectives between different kinds of actors—policy makers, health workers and service users—in the context of the actually existing situation at one point in Uganda's health care history. The underlying question is: how appropriate and consistent is Uganda's drug policy? We believe that this question is best answered by considering the significance of drugs for people at different positions in the health care system, with emphasis on the realities that health workers and their patients face.
The problematic balance between supply, utilisation, and expectations/demand emerged during a larger study of quality of care in rural primary health care units in southeastern Uganda. Special attention is given to two kinds of injectable drugs, chloroquine and penicillin, because they provide such a powerful and concrete example of the issues involved in that simple phrase, availability of drugs. Examining injections as part of the more general issue of availability of drugs also contributes to the recent debate on injections in developing countries [1], [2].
Several recent studies have pointed to the central role of drug availability in community perceptions of quality of care in African settings [3], [4], [5]. Community satisfaction with government health services, and thus utilisation, was found to depend highly on whether drugs were obtainable. As fees are introduced, drug availability becomes even more crucial. As Van der Geest and colleagues [5] reported from Zambia, people want medicine for their money, and they are ‘rational’ consumers in wanting more medicine for less money.
A few studies have examined drug availability in terms of different categories of actors. Asenso-Okyere et al. [6] showed how Ghanaian health workers dealt with availability in the new era of ‘cash and carry’ (fees for drugs). Some made the available drugs more accessible to poor patients by reducing the amount prescribed (and thus the price); others over-prescribed the readily available drugs in order to generate income. In Zaire, Haddad and Fournier [7] concluded that the ‘technocratic’ concerns about drug supply and distribution were not necessarily congruent with public perceptions of drug availability and accessibility. Gilson [8], working on health care reform in Tanzania, identified problems in supply, prescription, wastage and community demand, all affecting availability of drugs. Her analysis, like ours, included the perspectives of health managers, providers, and users.
Section snippets
Background
Reforms in the Ugandan health care system were initiated during the early 1990s. They were a central part of efforts to rebuild the health services following years of decay resulting from civil conflict and economic difficulties of the 1970s and 1980s [9]. Structural adjustment policies included restructuring and rationalizing the staffing of government health services, and decentralizing decision making and administration in order to bring control and responsibility closer to the people
Methodology
The study, carried out in 1996, elicited views on quality of care held by planners/administrators, health care workers, and users of services in one rural district. It documented actual practices of care in six health units. After analysis of the material, meetings were held with the District Health Management Team (DHMT) and the staff of each of the six health units to discuss the findings and suggest recommendations for improving quality of care. The study was part of an ongoing
Findings
Availability of drugs at primary health care units was influenced by a variety of factors, according to the study findings. Fig. 1 summarises the interrelationships at work and can serve as a framework for presenting the results of the study.
Discussion
The issue of drug availability is seen as fundamental for quality of care by all three of the categories of actors involved in primary health services. However, their perspectives were different and this must be acknowledged clearly in order to understand the current situation and find ways to improve care. We need to know how different concerns about drug availability play into one another. We also need to consider how the different positions on drug availability are shifting as health care
Conclusions
Health care reforms, including cost sharing, meant to reduce drug inadequacies by making care demand-driven, increase flexibility in supply and use of drugs. Greater autonomy of health units and greater ‘participation’ of users through cost sharing, changes the balance with effects on drug availability. When government health units are unable to supply drugs and the private sector is not well regulated, users ‘participate’ in their own health care by buying on a private market that is even more
References (26)
- Simonsen L, Kane A, Lloyd J, Zaffran M, and Kane M. Unsafe injections in the developing world and transmission of...
- Reeler AV. Anthropological perspectives on injections: a review. Bulletin of the World Health Organization,...
- Haddad S, Fournier P, Machou N, and Yatara F. What does quality mean to lay people? Community perceptions of primary...
- Gilson L, Kitange H, and Teuscher T. Assessment of process quality in Tanzanian primary care. Health Policy,...
- van der Geest S, Macwan'gi M, Kamwanga J, Mulikelel D, Mazimba A, Mwanglewa M. User fees and drugs: what did the health...
- Asenso-OkyereWK, Osei-Akoto I, Anum A, and Adokunu A. The behaviour of health workers in an era of cost sharing:...
- Haddad S, Fournier P. Quality, cost and utilization of health services in developing countries: A longitudinal study in...
- Gilson L. Management and health care reforms in Sub-Saharan Africa. Social Science and Medicine,...
- Macrae A, Zwi AB, and Gilson L. A triple burden for health sector reform: ‘post’-conflict rehabilitation in Uganda....
- MoH, 1993. White paper on health policy, update and review. 1993. Ministry of Health,...
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