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Background: Uganda was one of seven countries in which the United Nations Commission on Life Saving Commodities (UNCoLSC) initiative was implemented starting from 2013. A nationwide survey was conducted in 2015 to determine availability, prices and affordability of essential UNCoLSC maternal and reproductive health (MRH) commodities. Methods: The survey at health facilities in Uganda was conducted using an adapted version of the standardized methodology co-developed by World Health Organisation (WHO) and Health Action International (HAI). In this study, six maternal and reproductive health commodities, that were part of the UNCoLSC initiative, were studied in the public, private and mission health sectors. Median price ratios were calculated with Management Sciences for Health International Drug Price Indicator prices as reference. Maternal and reproductive health commodity stocks were reviewed from stock cards for their availability for a period of 6 months preceding the survey. Affordability was measured using wages of the lowest paid government worker. Results: Overall none of the six maternal and reproductive commodities was found in the surveyed health facilities. Public sector had the highest availability (52%), followed by mission sector (36%) and then private sector had the least (30%). Stock outs ranged from 7 to 21 days in public sector, 2 to 23 days in private sector and 3 to 27 days in mission sector. During the survey, maternal health commodities were more available and had less number of stock out days than reproductive health commodities. Median price ratios (MPR) indicated that medicines and commodities were more expensive in Uganda compared to international reference prices. Furthermore, MRH medicines and commodities were more expensive and less affordable in private sector compared to mission sector. Conclusion: Access to MRH commodities is inadequate in Uganda. Maternal health commodities were more available, cheaper and thus more affordable than reproductive health commodities in the current study. Efforts should be undertaken by the Ministry of Health and stakeholders to improve availability, prices and affordability of MRH commodities in Uganda to ensure that sustainable Development Goals are met.
A survey measuring the availability, price and affordability of maternal and reproductive health (MRH) commodities at health facilities in Uganda was conducted in September 2015, using an adapted World Health Organisation (WHO) and Health Action International (HAI) standardized methodology [12]. This method was validated [13] and used by others [14–16]. It is based on quantitative techniques to analyse availability and prices of health commodities in the public, private and mission health sectors. Public, private and mission sector health centres of level III or higher participated in the survey. MRH commodity availability on day of survey and in 6 months preceding the survey was assessed and prices paid by patient were collected. The central region which is the largest in the country and has the capital city was selected first. Three regions of Eastern, Western and Northern Uganda within 1 day’s travel from the central region were then selected to provide a realistic representation of the diverse epidemiological, geographical and medicine supply chain characteristics in Uganda. Health facilities from both urban and rural areas were included in the study sample. In each region, the main regional referral hospitals were selected with guidance of the Uganda Ministry of Health list of health facilities; public health centres level III or higher were randomly selected. Then private and mission sector health facilities that were within a three-hour drive radius from the enrolled regional referral hospitals were selected, respectively. Consecutive sampling was done with an intention of having 10 health facilities per sector in each region coming up to a total sample frame of 120 facilities. This was done to ensure that each sector had a minimum representation of 30 health facilities in the survey [12]. Health Centres level III are the lowest level of care at which MRH commodities are delivered according to the Ministry of Health (MoH) scheduling of basic of health services in Uganda [17]. The medicines and commodities surveyed included the six reproductive and maternal health medicines and commodities, which are required either to prevent or manage pregnancy as specified by the “United Nations Commission on Life Saving Commodities for Women and Children” (UNCoLSC). UNCoLSC prioritized a core list of 13 life-saving commodities and medicines for reproductive, maternal, newborn and child health, and it specified their formulation or presentation. All countries, Uganda inclusive, were encouraged to grant marketing authorization to these medicines and commodities. The final list of products measured is shown in Table 1 below. List of medicines and commodities surveyed in Uganda, 2015, based on the standard World Health Organization/Health Action International Medicine Prices and Availability methodology Eight data collectors with previous experience of conducting medicine surveys worked in pairs of a pharmacist and a social scientist under close supervision of a qualified survey manager. Prior to data collection, these pairs were trained on the WHO/HAI methodology of monitoring medicine availability and prices. Data collectors used a semi-structured questionnaire to interview facility managers while ascertaining physical count and stock card records of surveyed medicines. Availability was measured by the physical presence of a product in the outlet at the time of the survey. For each medicine surveyed, data collectors recorded the stated product name for both the highest and lowest priced medicines available, the manufacturer, unit price of the product and number of stock-out days in the previous 6 months. In the public sector where medicines are free of charge to the care seekers, only availability and stock out days were recorded. Once data collection was complete, survey data was entered centrally into the pre-programmed Microsoft Excel Workbook provided as part of the WHO/HAI methodology. Data input was independently checked for errors. Additional quality control measures were executed at various stages throughout the study. An advisory team provided the overall quality assurance by reviewing survey process, tools for data collection and validation of findings. The survey tools were pre-tested before the survey and prior to data collection. In addition, all survey personnel participated in training and field testing of the survey. Each regional/district team had a supervisor who cross checked the data on a daily basis for completeness, legibility and consistency and reported to the survey manager. A survey manager made field visits and follow-up telephone interviews to validate data in 10% of the sampled outlets. Prior to data entry all relayed data was checked for completeness and consistency. The availability of individual medicines was calculated as the percentage of sampled medicine outlets where the medicine was found. Data were reported in aggregate as public, private or mission sector medicine outlets. Overall availability per sector was calculated as median of medicines surveyed. For stock data, facilities that had not stocked a particular medicine for 6 months preceding the survey were expressed as a percentage of total number of facilities. For those that reported to stock the medicine, a monthly average of stock-out days was calculated. Patient prices were collected in Uganda Shillings and the median, minimum and maximum unit prices were estimated. To facilitate cross-country comparisons, medicine prices obtained during the survey were expressed as ratios relative to a standard set of international reference prices [18] by dividing the median local unit price by the international reference unit price. Medicine price ratios were calculated only for medicines with price data from at least four medicine outlets. The exchange rate used to calculate MPRs was 1$ = 3667.9 Uganda Shillings; this was the mid-rate (average of purchase and sale rate) taken from Bank Uganda website on the first day of data collection [19]. Affordability was calculated using the number of days it requires to pay for standard treatment or dose of treatment based on the daily income of the lowest-paid unskilled government employee [12]. The daily wage of the lowest paid government worker (attendants) is approximately UGX 6255 (USD 1.78) as per Uganda Ministry of Public Service salary structure [20]. Treatments that required more than 1 day’s wages to purchase were considered unaffordable [12].
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