| Summary: | Background: Non-communicable diseases (NCDs) are increasingly prevalent in low-income and middle-income countries (LMIC) and accessibility of medicines is essential for the management of these conditions. In Uganda, although many NCD medicines are now included in the national essential medicines list, sporadic evidence suggests that these medicines are widely unavailable to patients. The prescribing patterns of NCD medicines by providers and the dispensing patterns by dispensers represent important knowledge gaps in efforts to understand the care cascade for NCDs in Uganda. We aimed to describe the prescribing and dispensing practices for medicines used to treat NCDs, particularly hypertension, diabetes, and heart failure in Ugandan health-care facilities.
Methods: Based on WHO methodology, we did a cross-sectional study in which systematic sampling was used to collect data from patients attending outpatient NCD clinics at 15 higher-level public health-care facilities throughout Uganda. Demographic, prescribing, and dispensing information were collected using pre-tested structured questionnaires. Prescribing information was recorded from prescriptions, and dispensing information was obtained from medicine packets. Medicine tablets were counted by data collectors. Patients who reported not receiving all of their prescribed doses were contacted by phone to determine if they obtained the non-dispensed doses elsewhere. The primary outcome, which we term the Prescribing-Dispensing (P-D) Gap, was the percentage of prescribed doses that were not dispensed. Associations were tested using a linear mixed model.
Findings: We analysed data from 477 participants, of whom 454 (71%) were women. The average age was 51·4 years (SD 13·5). The mean number of drugs prescribed per encounter was 2·5 (SD 1·1), of which only 1·4 (0·9) drugs were dispensed. Overall, 82 591 total doses were prescribed, and 35 290·5 doses were dispensed, resulting in a P-D Gap of 57·3%. The P-D Gap was smaller for diabetes medicines than for medicines for cardiovascular diseases (46·2% vs 67·5%; p<0·001). 535 (84%) patients did not receive all of their prescribed doses, although only 442 (69%) patients reported having not received all prescribed doses. Of these, 317 (72%) patients were told this was because drug stocks were low. Upon follow-up, 90 (36%) of 253 patients contacted had not obtained their non-dispensed doses elsewhere.
Interpretation: A large P-D Gap exists for medicines used to treat NCDs in Ugandan public health-care facilities. The P-D Gap differs by medicine class and appears to be driven by medicine availability at public sector pharmacies. Most patients do not close this gap by purchasing medicines at private pharmacies, suggesting that under-treatment of these chronic conditions is widespread in patients who are already linked to care. Future work should explore feasible approaches to decrease this P-D Gap.
Funding: Doris Duke Clinical Research Fellowship.
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