Message from the MeTA Council Co-chairs

MeTA Activities Moving on more Consistently – Mr Martin Oteba, Ass. Commissioner Pharmacy Division, MOH (Co-chair: Gov’t)

The first achievement is largely reconvening the stakeholders and including new members to share in MeTA’s cause. Phase 2 of MeTA saw four new members join including the PPDA representative. This rekindled the confidence in the pursuance of its activities.

In terms of activities, there is ongoing work in MeTA phase 2 to conduct surveys. Three surveys are complete and due for dissemination. These are; Screening Drug Quality project, Monitoring Medicines prices and Availability in Uganda and Operationalizing Medicines and Therapeutic Committees in Uganda.

Phase 2 saw MeTA bringing on board new staff on the secretariat. This ensured that MeTA activities started moving on more consistently such as meetings, follow-up activities and publicity. There is renewed commitment from the co-chairs; at least one or more of the co-chairs is always present for consultations and or meetings.

The MeTA Uganda Newsletter

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“I see that MeTA is engaging in a number of sector activities than before, the other partners are doing their best, there’s additional trust among supporters and I can see the likelihood that in future MeTA will be a group that can put informed pressure to both governments and parties involved in medicines, through various arms and institutions,” said Mr. Martin Oteba

However, the issue of communication to sustain public awareness needs to be done a lot more. The MeTA group will have to cast its net wider in the coming years to get more players to support this cause. There’s need for additional support from for example USAID and other donors to help MeTA carry out its role.

Increasing Access to Affordable Medicines - Mr. Nazeem Mohammed, MD KPI (Co-chair: Private)

In the last year, MeTA achieved a number of objectives;

• We managed to gather a committed multi-stakeholder council to drive the projects under good governance.

• Most projects have made a good start and will continue to develop in the coming year.

• Several new tools have been developed to promote rational

use of medicines

However, it is important to ensure that we have continuous support from the Ministry of Health and keep the multi-stakeholders involved in the projects.

By the end of MeTA phase 2 we would hopefully have made a difference in increasing access to affordable medicines through creating transparency. We also want to make sure that different stakeholders work better together.

“MeTA is a wonderful opportunity for stakeholders to work alongside each other to make a real difference to increase transparency in access to essential medicines,” said Mr. Nazeem Mohammed, the Managing Director, Kampala Pharmaceuticals Industries (KPI).

Quality of Medicines is Key - Rosette Mutambi, Executive Director HEPS (Co-chair: CSO)

MeTA is all about quality of medicines, prices and availability. This calls for the three-way partnership between the private sector, civil society and government.

“Ordinary people cannot tell the quality of medicines so we rely on the technical people.” This means that the private sector who import medicines have got to be responsible. Local manufacturers have to produce quality but also government through the National Drug Authority has to do its job. Therefore government and NDA should work together to sensitize ordinary people about drug quality and where to get them, not only in the public health centres but also in the private sector.

“I would like to see the MeTA initiative adapted by others especially at the lower levels such as at the regional level,” says Rosette Mutambi, Executive Director, HEPS Uganda.

SURVEYSIn order to support the government of Uganda carry out its role, MeTA Uganda conducted four studies to help inform policy in Phase 2. Studies were conducted on medicines prices and availability, drug quality, operationalizing drug committees and client satisfaction survey in Uganda’s public health facilities. The studies are summarised below:

Monitoring Medicines Prices and Availability in Uganda (July – September, 2013)Price of medicines has been noted as a major determinant of access to essential medicines. According to previous surveys, universal access to medicines was not achieved in Uganda and medicines remain unaffordable for a significant proportion of the public. As a follow up to the last survey conducted three years ago in 2010, MeTA with funds from International MeTA Secretariat conducted this year’s Monitoring Medicines Prices and Availability survey from July to September 2013.

The main objectives were to determine availability of medicines in the public, private and mission sectors; compare prices between the private and mission sectors and assess the affordability of treating key conditions by the ordinary Ugandan.

The survey led by Gildo Okure, Survey Manager HEPS Uganda was conducted in four geographic regions of Uganda targeting three health sectors. A total of 120 health

facilities were surveyed in both rural and urban centres. In each sector, a regional referral hospital was purposively selected, while district hospitals and health centre 4s were randomly selected in the public sector. In the private sector, five pharmacies were purposively selected; three drug shops and two clinics within 5kms of the selected facilities. The mission sector followed similar selection criteria with the public sector. Forty essential medicines were selected during this study.

An advisory group with representatives from KPI, JMS, HEPS, NDA, WHO, MOH, PSU, MAK and MeTA supported the survey manager and a team of 30 experienced data collectors to carry out the study successfully.

The findings revealed that overall; availability of medicines is highest in the mission sector at 74%, followed by the public sector at 68% and 65% in the private sector. Medicines were more available in the urban compared to rural and that 89% of all mission facilities had Artmether/Lumenfantrine 20/120mg tablets compared to 75% of the private facilities.

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Figure 1: Comparison of Overall Availability of Paediatric Formulations Across Sectors.

Source: Medicines Prices and Availability Report October 2013.

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Generally public facilities had very low availability of paediatric formulations according to the survey. Prices of medicines were comparable between urban and rural in the private sector but medicines were 12 percent more expensive in urban than rural mission

facilities; and there was no difference in prices in 25 out of the 40 essential medicines surveyed between the private and mission facilities.

The study results will inform policy decisions on medicines availability and prices in Uganda.

Screening Drug Quality ProjectThe drug quality screening project was conducted to support the Ministry of Health and the National Drug Authority (NDA) ensure drug quality assurance in Uganda from August 29 - November 10, 2013.

Counterfeit and substandard medicines are still prevalent on the Ugandan market due to the limited capacity of the mandated institutions to analyse medicines. MeTA proposed the screening drug quality project to reinforce existing regulatory and oversight infrastructure of the Uganda Ministry of Health and National Drug Authority.

The screening drug quality project also aims to determine the proportion of the sample medicines that has not been granted marketing authorization by NDA, verify the identity and quantity of active ingredients with that stated on the product label and establish a mechanism of sharing information about quality of medicines between reputable pharmaceutical distributors and the drug regulatory authority.

Medicine samples of the most used drugs such as co-trimoxazole 480mg tablets, ciprofloxacin 500mg tablets, amoxicillin 250mg or 500mg capsules and artemether/lumefantrine tablets were collected from a stratified random sample of drug outlets in Mbarara, Arua Iganga and Mayuge districts.

Working closely with the District health

Officers in the sentinel districts, the screening drug quality project followed careful WHO guidelines in selecting the samples, sample handling, assessment and validation of results.

Due to the sensitive nature of drug quality and monitoring and possible conflict of interests, no DATA or results of any preliminary data obtained will be shared with third parties until it had been verified and discussed among relevant agencies including NDA, MOH, distributors and if applicable WHO.

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Figure 2: Availability in Urban versus Rural facilities, Jul-Sept. 2013

Source: Monitoring Medicines Prices and Availability in Uganda (July – September, 2013)

Source: Screening Drug Quality Project

Figure 3 shows a Summary of the Drug Handling Process

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Operationalizing Medicines and Drug Committees in UgandaMeTA Uganda proposed a study to re-invigorate Medicine and Therapeutic Committees (MTCs) in selected hospitals in Uganda in order to promote rational use of medicines

In Uganda, MTCs were set up to advise on medicines management and use in hospitals but have remained largely dormant. MeTA Uganda conducted a research study in three regional hospitals to:

• Assess the state of pharmaceutical management and rational drug use in selected regional referral hospitals using a modified rapid pharmaceutical management assessment tool.

• Assess the utilization of parenteral antimicrobial agents at the selected hospitals and;

• Design and implement interventions which involve mentoring and participatory health worker orientation to improve functioning of medicine and therapeutic committees.

The study targeted regional referral hospitals because of the level of care provided, the extent of medicines handled and the fact that health professionals at these hospitals are mandated to periodically conduct support supervision to other lower level hospitals and health facilities. Therefore successful implementation of MTCs at this level to improve use of antimicrobials at these facilities will result in a ripple effect to lower level hospitals.

A specific questionnaire was administered to 10 prescribers and a second to 50 nurses involved in handling, dispensing and administering the

prescribed medicines to patients. Other methods included in depth interviews with hospital staff, observation, document reviewing medicines stock and consumption records and focus group discussions with MTCs. The latter was mainly to determine underling opinions and attitudes regarding the implementation of MTCs.

Study results show that although all hospitals of Mbale, Gulu and Mbarara have proposed structures for MTCs, these remain inactive. All the MTCs had not had a meeting or activity in the last one year. Reasons cited for non-functionality include lack of clarity on selection and appointment of members; failure to understand the terms of reference and lack of operational funds.

Regarding the utilization of parenteral antimicrobial agents, the study found that ceftriaxone injection, Benzyl penicillin and gentamycin are the most utilized drugs. And quinine is still the preferred treatment option for severe malaria despite the revised treatment guidelines.

Recomendations

• The study recommends training and symposia for MTC members at hospitals in rationale and operationalization of MTCs, low-cost interventions and drug utilization reviews.

• The study also recommends development of treatment protocols for priority drugs such as ceftriaxone, gentamycin and benzyl-penicillin and training of health workers, particularly nurses, on the same.

• There is also need for continuing medical education for clinicians on the new malaria treatment guidelines.

Generally, the study found that though MTCs were not functional at selected hospitals, prescription of parenteral AMDs less than optimal and that nurses had low to moderate knowledge of key aspects of use of AMDs, there is overwhelming willingness among prescribers, nurses and MTC members to improve.

Evidence has shown that MTCs can significantly improve drug use and reduce costs in hospitals and other health care facilities by providing advice on all aspects of drug management and by developing drug policies. They also help in drug evaluation and selection for the hospital formulary. In countries where they have been successfully used, MTCs have supported the development and implementation of standard treatment guidelines as well as manage adverse drug reactions and possible medication errors.

Promoting Transparency in Access to Essential Medicines by Sensitising Communities on Medicines Transparency and Accountability As part of MeTA’s role of increasing transparency in Uganda’s medicines market, MeTA in partnership with HEPS Uganda conducted three trainings to sensitize both health centre staff and communities in Pallisa, Mbarara and Lira districts. The key issues raised in these trainings are summarised below:

PALLISA – In line with its role of increasing transparency in the medicines supply chain, Medicines Transparency Alliance (MeTA) in collaboration with HEPS-Uganda conducted a successful training to promote transparency in access to essential medicines in Pallisa district on September 17, 2013. The 42 participants included Health Unit Management Committee chairpersons, Village Health Team (VHT) coordinators and policy makers among others.

The main objectives were to develop community accountability platforms at the district level, facilitate community reporting on health service delivery as well as identify barriers to access to essential medicines in the district. Participants were told their health rights and responsibilities such as the rights to information, free choice and participation, privacy and confidentiality and right to complain and get redress.

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The push system of drug distribution where unwanted medicines are distributed particularly at lower health facilities, inadequate supply of much-needed medicines and sale of public drugs were top on the list of barriers to access to essential medicines.

Participants agreed to sensitize the communities with the information they attained from the training and formed a committee composed of five members to coordinate community medicine monitoring in the district. The committee will report its findings to HEPS.

MBARARA – Participants said that some of the issues affecting access to medicine included among others; high cost of medicines, out-of-pocket payment by citizens, prices of medicines differ in the private sector, and irrational use of medicine.

They called for stronger government regulation of the private sector and more awareness about availability of medicines and services at public health facilities.

The District Health Educator Lubega Kazooba pledged to work with the community and HEPS to increase awareness on access to medicines.

‘Let the communities know that most essential medicines are available at the government health facilities. Let people know about what services are available,” said Lubega Kazooba. The training held on 26th July 2013 at Kashari county headquarters in Bwizibwera, Mbarara district and 52 people participated.

Key Issues Raised in the Trainings• Understaffing of facilities

• Push system used by NMS

• Inadequate equipment

• Health workers need training on rights of patients and their responsibilities

• Private sector had no referrals yet over charges.

• Poor or no supervision by government

• Lack of water facilities at the health units

• Lack of health literacy

• Low motivation for health workers

LIRA – In Lira, participants identified the main obstacles to access to medicines in the area as; the push system of drug distribution, absenteeism of health workers and inadequate supply of drugs. Participants pledged to share the information with local leaders at community level to address some of the issues. A total of 35 people participated including health unit management committee chairpersons, village health team coordinators and policy makers.

Public Health Services in Uganda: Landmark Study on Citizen Empowerment, Medicines Availability and Client SatisfactionThe study was conducted by UNHCO on behalf of MeTA with support from the World Bank to establish the level of client satisfaction, medicines availability and citizen empowerment regarding the public health sector.

Data was collected from households and public health facilities in 10 districts of Uganda. The study findings show

that client satisfaction with the public health sector is low at 47% as seen below:

• Client satisfaction 47%

• Citizen empowerment 27%

• Medicines availability 63%

• Satisfaction with complaints handling 29%

• Satisfaction with laboratory services 35%

• Satisfaction with other services 30%

• Satisfaction with medicines availability 76%

• Limited power among citizens to take action

• Limited logistics management competence at facility and district levels

Participants pose for a photo after the training in Mbarara A cross-section of council members during the Council Meeting held on December 3, 2013 at WHO offices in Kampala

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Table showing Client Satisfaction Levels

The study recommends a review of linkages between providers and communities-at local government level, eestablishment of quality improvement committees at facility level-MOH and closes monitoring of stock status at facility level and redistribute or raise emergency orders when necessary. The report also urges government and partners to provide mentorship to facilities and raise health literacy levels among citizens.

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MeTA Council Members

MeTA Uganda Secretariat

NO. NAME ORGANISATION1 Joanita Namutebi Lwanyaga Joint Medical Service (JMS)2 Sowedi Muyingo MEDICAL ACCESS (MAUL)3 Hellen Ndagije National Drug Authority (NDA)4 Sam Opio Pharmaceutical Society of Uganda PSU)5 James Tamale World Bank International (WBI)

6 Moses Ojambo Public Procurement Disposal of Assets Authority (PPDA)

7 Kinny Nayer Surgipharm Uganda Limited (SUL)

8 Robbinah Kaitiritimba Uganda National Health Consumers Organisation (UNHCO)

9 Rosette Mutambi HEPS-UGANDA - Coalition for Health, Promotion and Social Development

10 Nazeem Mohamed Kampala Pharmaceuticals Industries (KPI)11 Martin Oteba MoH - Ministry of Health12 Joseph Mwoga WHO - World Health Organisation

# Name Designation1 Denis Kibira Coordinator, MeTA Uganda2 Fred Kitutu MeTA Uganda Secretariat (Academia)3 Morries Seru MeTA Uganda Secretariat (MoH)4 Catherine Nyadoi Administrator, MeTA Uganda5 Annah Natukunda Communications Consultant, MeTA

Medicines Transparency AlliancePlot 93, Buganda Rd, NDA Annex

P. O. Box 23096, Kampala - Uganda.www.medicinestransparency.org/meta-countries/