Research Report No. 1 GOVERNING HEALTH SERVICE DELIVERY IN UGANDA: A TRACKING STUDY OF DRUG DELIVERY MECHANISMS RESEARCH REPORT BY ECONOMIC POLICY RESEARCH CENTRE JANUARY 2010 Abbreviations/Acronyms AG Auditor General ART Anti Retroviral Treatment ARVs Anti-Retroviral Drugs bn Billion CAO Chief Administrative Officer CIPLA Chemical, Industries and Pharmaceutical Laboratories CMS Central Medical Stores DHO District Health Officer DHT District Health Team FGDs Focus Group Discussions FY Financial Year GoU Government of Uganda HMIS Health Management Information System HSC Health Service Commission HSD Health Sub-District HSSP Health Sector Strategic Plan HUMC Health Unit Management Committee JMS Joint Medical Stores Km Kilometre LoGs Local Governments m Million MO Medical Officer MoFPED Ministry of Finance, Planning and Economic Development MoH Ministry of Health MoLG Ministry of Local Government MoPS Ministry of Public Service MP Member of Parliament MS Medical Superintendent MTEF Medium Term Expenditure Framework NCDs Non-Communicable diseases NDA National Drug Authority NDP Nation Development Plan NGO Non-Government Organisation NMS National Medical Stores OPD Out Patient Department ORS Oral Rehydration Solutions PAC Public Accounts Committee PEAP Poverty Eradication Alleviation Plan PETS Public Expenditure Tracking Surveys PHC Primary Health Care i PNFP Private Not-for-Profit PPPs Public-Private Partnerships QCIL Quality Chemical Industries Limited RDC Resident District Commissioner RDTs Rapid Diagnostic Tests RTI Respiratory Tract Infections TBA Traditional Birth Attendant TRIPS Trade-Related Intellectual Property Rights UBoS Uganda Bureau of Statistics UCMB Uganda Catholic Medical Bureau UJAS Uganda Joint Assistance Strategy Ushs Uganda Shillings UNMHCP Uganda National Minimum Health Care Package UPMB Uganda Protestant Medical Bureau WTO World Trade Organisation US$ United Stated Dollars WHO World Health Organisation ii Table of Contents 1. Executive Summary ..................................................................................................... viii 2. Introduction .................................................................................................................. 1 3. Analytical Approach and Methods ................................................................................. 7 4. Institutional Partnerships in the Delivery of Medicines ................................................ 12 5. Procurement, Disbursement and Tracking of Supplies of and Funds for Medicines ..... 27 6. Health Facilities and the People --‘Responsiveness’ to the Drug Delivery Systems ....... 40 7. Challenges in Acquisition, Distribution and Utilisation of Medicines ............................ 47 8. Conclusions and Emerging Issues................................................................................. 54 iii List of Tables Table 1: National Budget Estimates on Medicines, FY2008/09 ............................................ 28 Table 2: Budget Allocations of the Funds for Medicines and Health Supplies, FY2008/09 .... 28 Table 3: Committed Funds to NMS by MoH, May 2008 to April 2009 .................................. 29 Table 4: Credit Line Medicines and Health Supplies Funds, May 2008-April 2009 ................ 31 Table 5: Primary Health Care Releases to Referrals Hospitals- July 2008-June 2009, Ushs ... 33 Table 6: PHC Funds on Drugs and Health Supplies during July 2008-March 2009, Ushs ....... 34 Table 7: Source of Medicines by Facility Level, July 2008 – March 2009, Ushs ...................... 35 Table 8: PHC Releases and Actual Expenditures to Districts, July 2008 to March 2009, Ushs 36 Table 9: Distribution of coartem by type, July 2008 – May 2009 .......................................... 38 Table 10: Stock Management in the Main Stock Rooms at Health Facility Level .................. 43 iv List of Figures Figure 1: Ideal Accountability Relationships in Public Service Delivery ................................... 8 Figure 2: Accountability Relationships in the Ugandan Medicines Sub-sector ........................ 9 Figure 3: Key Institutional Players in Drug Delivery in Uganda ............................................. 14 List of Appendices Appendix 1: List of Government facilities visited .............................................................................. 61 Appendix 2: Survey Instruments Used in data collection .................................................................. 63 v Acknowledgements The Economic Policy Research Centre would like to thank all of those who took part in the consultative meetings, fieldwork and validation workshop for their efforts in rendering the successful completion of this study. Particular thanks are due to: the officials in the Ministry of Health, Ministry of Finance, Planning and Economic Development, National Medical Store, Joint Medical Store, National Drug Authority; officials in the districts of Apac, Hoima, Kamuli, Mubende and Rukungiri; in-charges of the various health facilities visited for their effective and constructive participation during the field visits. The National Validation Workshop was held on July 28, 2009 at the Economic Policy Research Centre, Conference Room in Kampala and was attended by stakeholders from government ministries, departments and agencies; World Health Organisation, and officials from the sampled districts of Apac, Hoima, Kamuli, Mubende and Rukungiri. This report has incorporated the outcomes of the Validation Workshop Discussions. The Centre is very grateful to all those that participated in the workshop. vi About the Authors Sarah Ssewanyana (PhD) is the Executive Director of the Economic Policy Research Centre (EPRC) and she specialises in Micro Economics. She is the Government of Uganda expert on poverty analysis and has extensive experience in food security, health, education, labour related issues, and social service delivery. Lawrence Bategeka and Fredrick Mugisha (PhD) are both Senior Research Fellows at EPRC. Lawrence heads the Trade and Regional Integration department and specialises in Public Sector Policy and Institutional Economics, while Fredrick heads the Sectoral department and specialises in Health Economics. Julius Kiiza (PhD) is a Senior Lecturer at the Faculty of Social Science and is a Research Associate with EPRC. Fredrick Muwanika is a Research Fellow in the Micro Economics department at EPRC specialising in Bio-Statistics. James Wokadala is an Assistant Research Fellow in the Micro Economics department as well, with specialisation in Poverty Analysis and Economic Planning. vii 1. Executive Summary Purpose and Study Objectives 1.1. The study set out to produce evidence that will help the Government of Uganda (GoU) and other relevant stakeholders understand (a) the challenges facing the health sector; (b) the obstacles that limit the efficient, effective and timely procurement, distribution and usage of medicines; and (c) what reforms (or changes) are needed to improve access to medicines to all Ugandans. 1.2. The study focuses on five issues. First, the viability of the institutional partnerships crafted between the different stakeholders in the medicines sub-sector. Second, the issue of procurement and disbursement of medicines and health supplies. The study tracks the flow of funds for, and the supplies of the drugs/medicines with a view to determining the pattern of expenditure allocation, and whether all resources allocated to the medicines sub-sector reach their intended beneficiaries. Third, the transportation of medicines from the District Health Office (DHO) and Health Sub-Districts (HSDs) to the lower heath centres is highlighted. Fourth, the management of stocks at the facility level, the problem of drug stock outs, and the perception of service users based on the Focus Group Discussions (FGDs) and exit interviews covering 252 patients are documented. Fifth, the challenges encountered in the acquisition, distribution and utilisation of the medicines are discussed. Finally, the conclusions and recommendations are presented. Rationale of the Study 1.3. The rationale for this study is three-dimensional. First, the dramatic rise in the health needs of Uganda’s population, which is growing at a rapid rate of 3.2 percent. Uganda’s population will rise to 32 m in 2010 and to 43.9 m by 2020. Thus, in 10 years, the health system must cater for an additional 12 m people. The population below 18 years of age is over 50 percent of the national population and has health needs that must be catered for. 1.4. The second concern of the study was the apparent mismatch between Uganda’s high health needs and the small budget allocated to the health sector. Public health-sector spending was US$8.2 per capita in 2007/2008, which is equivalent to 9.6 percent of government total expenditure. In fact, health expenditure as a proportion of government’s discretionary expenditure has stagnated at this level (9.6 percent) since 2000/2001. This falls below the Abuja Declaration target of 15 percent. Health sector funding is inadequate to provide the Uganda National Minimum Health Care Package (UNMHCP) in all facilities. The per capita cost was roughly US$41.2 in 2008/09 and will rise to US$47.9 in 2011/12 (MoH, 2009b). Yet, the Medium Term Expenditure Framework (MTEF) estimation was US$12.5 in 2008/09, signifying a shortfall of about US$29 (MoH, 2009b). At the time of the field research, government was contributing only 20 percent of the drugs, which covered 50 percent of the health needs. The third