Coping without money to buy medicine

Twenty-seven year old Jackline Namande, a mother of three, visited Uganda’s largest referral hospital, Mulago, to seek treatment for a stubborn respiratory infection and was given a prescription for antibiotics, only to be told she had to pay for each capsule and she needed 10.

"Where could I get money to buy these drugs?" she asked. "My husband could not afford the medical bill, so he advised that we go for a cheaper antibiotic and complement it with local herbs. It worked out well because I am now feeling much better and I am back to work."

Other people say they either try to look for more money to buy the prescribed medicines or resort to alternative drugs that are cheaper but of poorer quality. "If the sickness is not the acute type, I will look for more money to buy the prescribed drugs because you never know why a doctor makes that prescription, but if my health situation is really bad and I require the medicine immediately, I will rather look for a remedy that is affordable," said Daniel Okum, a hawker in Kampala.

Traditional healers

The lack of affordable essential medicines in Uganda is driving poor people to traditional healers, say health activists. In some of the underserved regions of the country, badly needed medicines are regularly out of stock for up to three months every year, leaving open the question of what patients should do in the absence of treatment.

A drug-access campaigner told IRIN that making a link between the inadequacy of drugs and mortality levels was difficult but described the sociological impact that sees people turning to spiritualism in the belief that their health problems are no longer biomedical.

"Drugs are the main reason people go to hospitals and once there are no drugs, they stop going there," said Rosette Mutambi, the co-ordinator of the Coalition for Access to Essential Drugs. "Uganda meets only a third of its drug requirements. Without drugs, people turn to traditional healers because they believe the hospitals cannot deal with their problem."

According to a study by Health Action International (HAI), the World Health Organization (WHO) and the Ugandan Ministry of Health, even when the medicine is available, a large percentage of sick people in Uganda cannot afford to buy drugs. Researchers and pharmaceutical insiders in the country say factors ranging from public policy, poverty, management and the structure of the international pharmaceutical industry were preventing the very poor from receiving treatment.

A senior official in the health ministry, Dr Sam Okware, confirmed that access to drugs was a problem in Uganda but blamed inadequate resources, saying that though the ministry sought per capita expenditure of $3.60/year for drugs, only $1.68 was allocated.

"It is true that drugs are a problem in the country. The resources available cannot respond to the demand that has increased in the recent past," he said.

With geographic access to health services increasing from 49 to 74 percent in the past five years through the establishment of health centres, the out-patient wards in these centres had also seen the number of patients doubling, he said.

The availability of essential drugs – for the treatment of such common illnesses as malaria – is said to stand at 75 per cent of need. However, these tended to be clustered around the richer urban areas. The study, Uganda Medicine Pricing Survey Report, found that in the far-flung and under-served districts, only 55 per cent of the drugs needed were in stock.

The trend in district health centres – as generally in public hospitals even in urban areas – was for most patients to go home without the medicine prescribed to them.

Okware said management of drug issues at district level was also to blame: "Under the PAP [Poverty Alleviation Programme], we give districts up to 40 million shillings every month [$22,000], 50 percent of which is meant for drugs, but there is a problem in the utilisation of these funds," he said.

Poverty played a role, for, while private drug outlets tended to be better stocked, they cost five times more than public health centres. Hence, 26.6 per cent of the patients who did not receive treatment said they had no money to pay the pharmacist.

The number of outlets is another factor: 247 serve 27 million people. This ratio, says the secretary of the Uganda Pharmacists’ Association, James Tamale, could contribute to the prices charged for drugs.

Branded drugs from licensed producers are in short supply. Out of 45 essential drugs available in pharmacies, only 11 were branded drugs while generic copies accounted for the rest. This means that on average a Ugandan paid 13.6 times the international charge for branded drugs.

As an illustration, the study says the lowest-paid government workers needed four days’ wages to pay for a single treatment of pneumonia against only 4.8 working hours for a generic version.

Even so, Tamale says there has been a relative improvement in the drug situation. "For the rural areas, the drugs may be there but it is the purchasing power of the people that remains the biggest hindrance."

Government medical facilities are another factor, with numbers of patients far outnumbering available capacity. Dr Isaac Ezati, deputy head of Mulago hospital, said it had only 1,500 sickbeds but admitted 500,000 patients a year.

Ezati said the hospital’s 3,000 health workers could not efficiently handle all the cases referred to Mulago. "The budget is tight for Mulago hospital. We have to prioritise our needs. More workers are still needed," he said, adding that training more personnel could bridge the gap faced by the country’s main hospital.

vm/mw/eo