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Access To And Use Of
Medicines By Households In
Uganda
Report of a survey conducted 2008
December 2008
Ministry of Health
Access To And Use Of Medicines By Households In Uganda
ACCESS TO AND USE OF MEDICINES
BY HOUSEHOLDS IN UGANDA
Report of a survey conducted 2008
December 2008
Ministry of Health
This document has been produced with the financial assistance from the european community.
The views expressed herein are those of the authors and can therefore in no way be taken to reflect the official
opinion of the european community.
European Community
Access To And Use Of Medicines By Households In Uganda
Acknowledgements
The Ministry of Health is grateful to the people and organisations that contributed to the success of this study. The
World Health Organisation (WHO) provided the funding and technical support; District Health Officers (DHOs)
of the six study districts endorsed and promoted it; and HEPS-Uganda provided oversight and supervision.
We are also grateful to our advisory committee: Mr Joseph Mwoga, Essential Medicines National Professional
Officer, WHO; Mr Martin Oteba, Assistant Commissioner, Pharmacy Division, Ministry of Health (MOH); Mr
Morries Seru, MOH Principal Pharmacist,; Mr Fred Sebisubi, MOH Principal Pharmacist ; and Rosette Mutambi
Executive Director HEPS-Uganda.
We thank the survey team: Joseph Mwoga (WHO), the study co-ordinator; Denis Kibira (HEPS-Uganda), the
survey manager and report writer; Stella Kirya (WHO), logistics manager; Nassan Natseri (WHO), data analyst;
and Richard Hasunira (HEPS-Uganda), report editor.
Conflict of Interest Statement
None of the authors of this report or anyone who had influence on the conduct, analysis or interpretation of the
study results has any competing financial or other interests.
Access To And Use Of Medicines By Households In Uganda
Project Team
Survey Manager
Denis Kibira
Area Supervisors
Thomas Obua Ochwa
Martin Oteba
Joseph Mangusho
Morries Seru
Denis Kibira
Mbonigaba Jane
Data Collection
John Kizito
Emmanuel Umirambe
Monica Adiek
Jimmy Ondoma
Mohamed Lubega
Winnie Wednesday
Collin Semakula
Aaron Muhinda
Sam Omala
John Aturinde
Dufford Okure
Isabella Amony
Fred Kitutu
Prima Kazoora
Christopher Yiga
Catherine Kahinda
Margaret Abigaba
Richard Mugisha
Joseph Mukasa
Joyce Mugarura
Paul Akankwasa
Beatrice Kasisi
Alice Tumwesigye
Topher Ruyooka
Data Entry
Bestason Aliyo
Gertrude Nakanwagi
Connie Nangobi
Christian Nile
Data Analysis
Nassan Natseri
Report Editor
Richard Hasunira
Access To And Use Of Medicines By Households In Uganda
TABLE OF CONTENTS
Acknowledgements............................................................................................................................... ii
Conflict of Interest Statement.............................................................................................................. ii
Project Team.......................................................................................................................................... iii
Table of Contents.................................................................................................................................. iv
List of Tables.......................................................................................................................................... vi
List of Figures........................................................................................................................................ vi
Abbreviations........................................................................................................................................ viii
FOREWORD......................................................................................................................................................... IX
EXECUTIVE SUMMARY....................................................................................................................................... X
List of Key Indicators.............................................................................................................................................................. xii
1. BACKGROUND....................................................................................................................................... 1
1.1. Introduction.............................................................................................................................................................. 1
1.2. Country background.............................................................................................................................................. 1
1.2.1. Health sector............................................................................................................................................. 1
1.2.2. Pharmaceutical sector............................................................................................................................ 2
2. METHODOLOGY.................................................................................................................................... 4
2.1. Overview................................................................................................................................................................... 4
2.2. Selection of geographic areas and reference public health care facilities........................................ 4
2.3. Selection of households....................................................................................................................................... 5
2.4. Selection of respondents..................................................................................................................................... 6
2.5. Data Collection........................................................................................................................................................ 6
2.6. Data Entry.................................................................................................................................................................. 7
2.7. Data Analysis............................................................................................................................................................ 7
3. RESULTS................................................................................................................................................. 8
3.1. Characteristics of surveyed households........................................................................................................ 8
3.1.1. Geographic location................................................................................................................................ 8
3.1.2. Size and composition.............................................................................................................................. 9
3.1.3. Socio-economic status (SES)................................................................................................................ 9
3.1.4. Assets............................................................................................................................................................ 11
3.1.5. Expenditures.............................................................................................................................................. 12
3.1.6. Respondents.............................................................................................................................................. 12
3.1.7. Morbidity..................................................................................................................................................... 14
3.1.8. Medicines found in households.......................................................................................................... 16
3.2. Geographic access and availability of medicines...................................................................................... 17
3.2.1. Proximity to health care facilities........................................................................................................ 17
3.2.2. Proximity to public health care facilities........................................................................................ 18
3.2.3. Sources of medicines found in households.................................................................................. 18
3.2.4. Sources of medicines in case of acute illness............................................................................... 19
3.2.5. Opinions about geographic access and availability of medicines........................................ 20
3.3. Affordability of medicines................................................................................................................................... 21
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Access To And Use Of Medicines By Households In Uganda
3.3.1. Insurance coverage................................................................................................................................ 21
3.3.2. Cost of medicines for acute illnesses............................................................................................... 22
3.3.3. Cost of medicines for chronic diseases........................................................................................... 22
3.3.4. Catastrophic expenditures related to medicines........................................................................ 23
3.3.5. Opinions about affordability of medicines.................................................................................... 23
3.4. Medicine use and medicines at home............................................................................................................ 25
3.4.1. Number of households where medicines could be found...................................................... 25
3.4.2. Labelling and packaging of medicines found in households................................................. 26
3.4.3. Antibacterials found in households................................................................................................. 27
3.4.4. Antimalarials found in households.................................................................................................. 28
3.5. Medicine use during acute illnesses............................................................................................................... 28
3.5.1. Actions taken when an acute illness occurs................................................................................. 28
3.5.2. Medicines taken for a recent acute illness..................................................................................... 29
3.5.3. Prescribers of medicines in case of acute illness......................................................................... 31
3.5.4. Routes of administration of medicines prescribed for acute illness.................................... 31
3.5.5. Reasons for not taking medicines prescribed for acute illness.............................................. 32
3.6. Medicine use for chronic diseases.................................................................................................................... 32
3.6.1. Actions taken when a chronic disease has been diagnosed.................................................. 32
3.6.2. Medicines prescribed for chronic diseases.................................................................................... 33
3.6.3. Reasons for not taking medicines prescribed for a chronic disease.................................... 34
3.7. Opinions about quality of care.......................................................................................................................... 35
3.8. Opinions about pricing and quality of medicines..................................................................................... 36
3.9. Opinions about generic medicines................................................................................................................. 37
ANNEXES............................................................................................................................................................................. 38
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Access To And Use Of Medicines By Households In Uganda
LIST OF TABLES
Table 2.1: Sampling of reference health care facilities, by region........................................................... 5
Table 3.1: Characteristics of surveyed households....................................................................................... 9
Table 3.2: Assets and self-selected level of SES.............................................................................................. 11
Table 3.3: Monthly household expenditures.................................................................................................. 12
Table 3.4: Education and gender of respondents......................................................................................... 13
Table 3.5: Prevalence of acute and chronic conditions in surveyed households............................... 14
Table 3.6: Chronic diseases and gender........................................................................................................... 16
Table 3.7: Most frequent categories of medicines found in households............................................. 17
Table 3.8: Travel time to health care facilities................................................................................................. 17
Table 3.9: Opinions about geographic access and availability of medicines...................................... 20
Table 3.10: Opinions of respondents on geographic access and availability of
medicines according to SES.............................................................................................................. 21
Table 3.11: Medicines insurance coverage......................................................................................................... 21
Table 3.12: Cost of prescriptions for a recent acute illness.......................................................................... 22
Table 3.13: Monthly cost of medicines for chronic diseases....................................................................... 22
Table 3.14: Opinions about affordability of medicines................................................................................. 24
Table 3.15: Opinions of respondents about affordability of medicines.................................................. 24
Table 3.16: Actions taken for a recent acute illness......................................................................................... 29
Table 3.17: Opinions about quality of care......................................................................................................... 35
Table 3.18: Opinions of respondents about quality of care and medicines according to SES........ 35
Table 3.19: Opinions about pricing and quality of medicines.................................................................... 36
Table 3.20: Opinions about generics.................................................................................................................... 37
LIST OF FIGURES
Figure 2.1: Geographic location of the six survey areas sampled in the survey...................................... 4
Figure 2.2: Household Sampling.............................................................................................................................. 5
Figure 2.3: Household Clusters................................................................................................................................. 6
Figure 3.1: Number of surveyed households in each region......................................................................... 8
Figure 3.2: Representation of regions in each household cluster................................................................ 9
Figure 3.3: Household clusters and SES................................................................................................................. 10
Figure 3.4: Figure: Household location by region and SES............................................................................ 10
Figure 3.5: Household clusters and assets............................................................................................................ 11
Figure 3.6: Gender and age of respondents/health care decision makers............................................... 13
Figure 3.7: Reported symptoms and perceived severity of acute illness.................................................. 15
Figure 3.8: Chronic diseases and gender.............................................................................................................. 15
Figure 3.9: Household clusters and travel time to closest public health care facility........................... 18
Figure 3.10: Source of medicines found in households................................................................................... 18
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Access To And Use Of Medicines By Households In Uganda
Figure 3.11: Sources of medicines at home................................................................................................... 19
Figure 3.12: Sources of medicines taken for an acute illness.................................................................. 19
Figure 3.13: Sources of medicines during acute illness and SES............................................................ 20
Figure 3.14: Catastrophic expenditures related to medicines in month preceding survey.......... 23
Figure 3.15: Households with medicines at home....................................................................................... 25
Figure 3.16: Households with medicines at home and SES...................................................................... 25
Figure 3.17: Percentage of medicines found in households with both adequate
label and primary package, by source..................................................................................... 26
Figure 3.18: Most frequent antibacterials found in households............................................................ 27
Figure 3.19: Reasons for keeping antibacterials at home.......................................................................... 27
Figure 3.20: Antimalarials found in households............................................................................................ 28
Figure 3.21: Most frequent EML categories of medicines taken for a recent acute illness........... 29
Figure 3.22: Antibacterials taken for a recent acute illness....................................................................... 30
Figure 3.23: Antimalarials taken for a recent acute illness........................................................................ 30
Figure 3.24: Prescribers of medicines in case of acute illness.................................................................. 31
Figure 3.25: Route of administration of medicines prescribed for acute illness............................... 31
Figure 3.26: Reasons for not taking prescribed medicines for acute illness ...................................... 32
Figure 3.27: Actions taken for chronic diseases........................................................................................... 33
Figure 3.28: Most frequent categories of medicines for chronic diseases.......................................... 33
Figure 3.29: Diuretics and antihypertensive medicines............................................................................ 34
Figure 3.30: Reasons for not taking medicines for a chronic disease as prescribed....................... 34
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Access To And Use Of Medicines By Households In Uganda
ABBREVIATIONS
AF Affordability
AV Availability
DHO District Health Officer
EML Essential Medicines List
GA Geographic access
GDP Gross domestic product
HAI Health Action International
HEPS Coalition for Health Promotion and Social Development
HH Household
HMIS Health Management Information System
Ind. Indicator
Inj Injection
km Kilometre
M Mixed
MOH Ministry of Health
MSH Management Sciences for Health
NGO Non-governmental organisation
NMP National Medicines Policy
NMS National Medical Stores
OB Originator brand
PNFP Private-not-for-profit health facility
Q Quintile
QL Quality
RTI Respiratory tract infection
RU Rational use
SD Standard deviation
SES Socio-economic status
STG Standard Treatment Guidelines
USD/$ United States dollars
UShs/UGX Uganda Shillings
WHO World Health Organization
%ile Percentile
v
Access To And Use Of Medicines By Households In Uganda
FOREWORD
The development of the National Health Policy was informed by the national development framework,
the Poverty Eradication Action Plan. The strategic plan to implement the policy commits the government
to deliver a package of essential interventions commonly referred to as the National Minimum Health Care
Package (NMHCP). Most of these interventions depend on essential medicines.
The National Medicines Policy (NMP) aims to contribute to the attainment of a good standard of health by the
population of Uganda, through ensuring the availability, accessibility and affordability at all times of essential
medicines of appropriate quality, safety and efficacy, and by promoting their rational use. Realisation of the
NMP aspiration continues to be challenging because multiple factors. It is important therefore to have a
systematic method for assessing the pharmaceutical situation in the country in order to have evidence that
will help us improve our interventions and planning.
This pharmaceutical sector assessment using the WHO House Hold survey tools compliments the health
facility survey. It is a reliable measure of access to medicines. It is timely as MOH is in the process of reviewing
and updating the National Policy and Strategic Plan. The results will inform the process as it aims to among
other things to answer the following important questions: how and where people access essential medicines
and how much they pay. It explores barriers to affordability and accessibility and examines appropriateness
of use of medicines.
I congratulate the pharmaceutical division of the Ministry of Health for accomplishing this important work
and urge them together with all partners to make use of this report.
Lastly, I acknowledge with gratitude the financial & technical support from World Health Organisation that
enabled us to make this work a reality.
Dr S. Zaramba
DIRECTOR GENERAL OF HEALTH SERVICES
x
Access To And Use Of Medicines By Households In Uganda
EXECUTIVE SUMMARY
BACKGROUND
A field study to measure access to and use of medicines was undertaken in Uganda in July and August 2008 using
a standardized methodology developed by the World Health Organization (WHO).
METHODS
The survey was conducted in six regions/districts: Kampala, Mbale, Hoima, Kabale, Arua and Lira. In each region, six
reference public heath care facilities were selected among those participating in the Level II Facility Survey that was
run in parallel. Within defined distances from each reference public health care facility, households were selected
by purposive cluster sampling. A total of 1,051 household respondents were interviewed by means of a structured
paper questionnaire that gathered information on the socio-economic level of households, and collected data on
access to and use of medicines for acute and chronic conditions as well as perceptions about medicines. Data entry
and analysis were performed with freeware EpiData.
KEY RESULTS
Geographic access to medicines
Overall, indicators of geographic access to medicines suggest that the majority (72%) of households is close to
a public heath care facility however majority of respondents (72%) were more than one hour’s travel to a public
hospital.
Availability of medicines in public health care facilities
Indicators of availability of medicines suggest that stock out of medicines in public health care facilities affects
access to medicines. Only (33%) of household respondents believe that medicines are available in public heath
care facilities.
Affordability of medicines
Overall, the indicators of affordability of medicines suggest that the price households pay for medicines is an
obstacle to households accessing medicines. Expressed as a ratio of medicines over non-food expenditures
households with sick members had frequent (65%) catastrophic medicines expenditures. The financial burden of
medicines is similar in households with sick members across all Social economic Status. The coverage of medicines
insurance in Uganda is very low (1%) and is limited to households with higher SES. In addition, the majority of
household respondents believe that medicines are not affordable (64%).
Rational use of medicines
(a) Prescribers and sources of medicines
Overall, indicators of rational use of medicines suggest an inappropriate use of medicines among the sampled
population. The most common prescribers are nurses, and the most frequent source of medicines is private
sector. The use of injections during acute illness is low (7%), suggesting an appropriate use of injections. Very
few medicines found at home have an appropriate label and a primary package (33%) in good condition
suggesting that sources of medicines deliver medicines with inadequate labels in unsafe primary packages.
The number of people with chronic diseases for whom medicines were never prescribed is low, however,
percentage of households with chronic disease that had medicines at home was (49%), suggesting that many
patients with chronic illness may not be getting treatment.
(b) Adherence to treatment
For patients who recently had an acute illness, the most frequent reason for non-adherence to treatment was
symptoms had improved (75 out of 110)., While for chronically ill patients, the most common reason for non-
x
Access To And Use Of Medicines By Households In Uganda
adherence was simply not following their prescriptions (105 of 110). It was inferred that low availability and
poor affordability significantly contributed to non-adherence to treatment.
Mixed indicators
(a) Medicines at home
A moderate percentage of households do not have medicines at home. The average number of medicines
found at home is two. The number of medicines tended to increase with higher levels of SES.
(b) Perceptions about quality of medicines and care
Overall, respondents believe that the quality of medicines and services in their public health care facility is
insufficient (56%).
CONCLUSION
Results of the survey show that access to, and use of medicines by households in Uganda should be improved in
order to ensure equity in access to basic medical treatments, especially for the poor.
RECOMMENDATIONS
Based on the results of the survey, the following recommendations have been made to improve the availability,
price and affordability of medicines in Uganda:
< Because of the high out of pocket expenditure on medicines, the study recommends working towards
alternative financing mechanisms such as proportion to the population that subscribes to health insurance,
in order to improve access to medicines.
< Increased sensitization of the public about potential dangers of inappropriate use of medicines and the
benefits of appropriate use is important to improve access to medicine
x
Access To And Use Of Medicines By Households In Uganda
LIST OF KEY INDICATORS
All
Percentage of households at more than one hour travelling distance from closest public
72%
hospital
Percentage of respondents who agree that their household cannot usually afford all the
64%
medicines they need
Percentage of households reporting a chronic disease and where no medicines are
51%
found
Percentage of household medicines with appropriate label and primary package 33%
Percentage of medicines prescribed for a chronic disease and covered by health
1%
insurance
Percentage of prescriptions for an acute illness that were covered by health insurance 1%
x
Access To And Use Of Medicines By Households In Uganda
1. BACKGROUND
1.1 Introduction
In July to August 2008, the Ministry of Health conducted a nationwide study to document access to and use of
medicines by the population and across socio-economic levels. This study was conducted using the standardized
methodology developed by the World Health Organization (WHO).
The study sought to answer the following questions:
< How do people perceive geographic access, affordability and quality of medicines?
< Are medicines geographically accessible? Are there differences between urban, and rural or remote areas?
< Are medicines available in public health care facilities?
< Are medicines affordable for the treatment of common acute and chronic conditions, and especially for
people with low income?
< How widespread is medicines insurance coverage?
< Who does prescribe medicines and where do households buy medicines?
< Is the use of medicines rational?
< How does Uganda compare with other countries with regards to access to and use of medicines?
1.2 Country background
Uganda is a small sized country, covering an area of 241,551km2, with land covering 199,807.4 km2 (82.7%) and the
rest (41,743.2km2) being open water and wetlands. It is divided into 81 districts. The total population was projected
at 29.6 million by mid-2008, with the majority of population, about 85%, living in rural areas.1
Uganda is a low income country with a GDP of US$ 445 per capita2. About 31.1% of the population, consisting
of 8.4 million people, lives on less than US$1 a day. Of the total labour force, approximately 3.2% were estimated
to be unemployed in 2000.3 In 2005/06, the national unemployment rate was about 2%, while the total urban
unemployment rate was about 7%.4
Life expectancy at birth is 50.4 years, with 49% of the population below 15 years. About 3.9% of the population are
estimated to be aged 60 years and above.5 According to the most recent national census in 2002, the average number
of people per household is 5.2. According to the Health Management Information System (HMIS), malaria was the
highest ranked cause of morbidity during 2006/7. Of all persons who fell sick, about six in every 10 persons (61%)
had experienced malaria/fever symptoms. Malaria is followed by respiratory tract infections (RTI, 14%), diarrhoea
(10%), skin infections (3.2%), and injury (2.7%).
1.2.1 Health sector
In 2006/7, the per capita total expenditure on health was US$7.86. In 2003, approximately 7.3% of the GDP was
spent on health, according to the World Health Report 2006. Of the total expenditure on health, 30.4 is government
expenditures, which represents 10.7% of all government expenditures. The remaining 69.6% of total expenditures
Uganda Bureau of Statistics (UBOS, 2008), Statistical Abstract 2008
2
Per capita GDP is computed from the official (UBOS) figure for 2007/08 of UGX 824,742, at an exchange rate of US$ 1=UGX
1,850.
World Bank World Development Indicators: http://devdata.worldbank.org/wdi2006/contents/Section2.htm
UBOS 2008, Statistical Abstract 2008
WHO World Health Report 2006
Average exchange rate US$1=UGX 1,850
Access To And Use Of Medicines By Households In Uganda
on health is private –largely out-of-pocket.
The public health sector is composed of seven levels – health centre I, health centre II, health centre III, health centre
IV, general hospital, regional referral hospital, and national referral hospital. Health centre I is at the community
level but this does not exist in practice. Health centre II is served by an enrolled comprehensive nurse, health centre
III by a clinical officer, and health centre IV by a medical officer. The referral facilities range from health centre IV to
national referral hospital.
1.2.2 Pharmaceutical sector
There are 440 licensed private retail pharmacies and 4742 drug shops in the country as by 2007/8. Sectors which
dispense a substantial proportion of medicines to patients include the public sector, the NGO/mission (PNFP) and
the private for profit sector. The three are not mutually exclusive. In some public health facilities there are private
wings which sell medicines to patients.
National Medicines (Drugs) Policy
In Uganda, a National Medicines Policy (NMP) document exists in official form. It was last updated in 2002. An
implementation plan that sets out activities, responsibilities, budget and timeline is in place (National Pharmaceutical
Sector Strategic Plan); it was last updated for the period 2002 to 2007.
Regulatory system
In Uganda, the National Drug Authority (NDA) is a formal medicines regulatory authority which is funded through
the regular budget from the government/ fees from registration, importation and exportation of medicines. Legal
provisions are in place requiring transparency and accountability and promoting a code of conduct in regulatory
work. The NDA provides information on: legislation, regulatory procedures, prescribing information (such as
indications, contraindications, side effects, etc.), authorized companies, and approved medicines.
Registration fees do not differ between originator brands and generic equivalents, but differ between imported
and locally produced medicines. In Uganda, there are legal provisions for marketing authorization. A total of
468 medicinal products were registered and approved for marketing in 2007/8. A list of all registered products is
publicly accessible on payment of a fee. Legal provisions are in place for the licensing of manufacturers, wholesalers,
distributors, importers, exporters of medicines.
A quality management system with an officially defined protocol for ensuring the quality of medicines is in place
in Uganda. Medicine samples are tested for medicines registration/post-marketing surveillance. In 2007/8, 1593
samples were quality tested, with 51 failing to meet quality standards. Regulatory procedures are in place for
ensuring the quality of imported medicines. Legal provisions are in place for the licensing and practice of both
prescribers and pharmacists. There is an obligation to prescribe by generic name in the public or private sector.
Generic substitution is permitted in pubic or private pharmacies. There are incentives to dispense generic medicines
at pubic or private pharmacies. There are provisions in the medicines regulations covering promotion and/or
advertising of medicines.
Medicines supply system
Public sector procurement is pooled at the national level (i.e. there is centralized procurement for the public health
care facility). Public sector medicines procurement is the responsibility of the Ministry of Health through the National
Medical Stores (NMS), which is also tasked with the responsibility of distribution.
The following tender processes are used for public sector procurement:
< National competitive tender – 90% of total cost
< International competitive tender – 10% of total cost
< Negotiation / direct purchasing – 0% of total cost
Public sector procurement is limited to medicines on the Essential Medicines List (EML). There are regulations for
local preference in public sector procurement.
2
Access To And Use Of Medicines By Households In Uganda
Medicines financing
In 2007/8, the total public expenditure for medicines represented US$4.1 per capita. Approximately 94% of
medicines by value are imported. There is a national policy to provide all medicines free of charge (i.e. patients
do not pay out-of-pocket for medicines) at public primary care facilities. Salaries of public health personnel are
paid by the government.
Prescribers in the public sector never dispense medicines, while prescribers in the private sector frequently/
occasionally dispense medicines.
In Uganda, none of the population has public health insurance. Some of the population has private health
insurance, which covers a limited range of medicines.
Uganda does not have a policy covering medicine prices. Uganda does not have a national medicine price
monitoring system for retail/patient prices. There are no regulations mandating retail/patient medicine price
information to be made publicly accessible. Setting prices is not part of market authorization. The government
does not set the price of either originator brand products or generic products. However, the market is mainly
generic.
There are official written guidelines on medicine donations that provide rules and regulations for donors and
provide guidance to the public, private and/or NGO sectors on accepting and handling donated medicines.
Rational use of medicines
Uganda’s EML, last updated in 2007, contains 538 unique medicine formulations. The national EML is being used
for public sector procurement. There is no committee responsible for the selection of products on the national
EML.
The health ministry produces national standard treatment guidelines (STG) for major conditions. These were last
updated in 2003. Antibiotics are sold over the counter without a prescription, while injections are occasionally
sold over the counter without a prescription.
Access To And Use Of Medicines By Households In Uganda
2. METHODOLOGY
2.1 Overview
The household survey measuring access to and use of medicines in Uganda was conducted using a standardized
WHO methodology. Six different geographic areas were chosen to implement the WHO Level II Facility Survey aimed
at collecting data on 36 public health care facilities. The public health care facilities surveyed in the Level II Facility
Survey were selected to become reference facilities for the purposes of the Household Survey: Six facilities acting as
reference in each area.
The household survey measuring access to and use of medicines collected data from households located in the
vicinity of each reference public health care facility. Households were purposively chosen according to their distance
from the reference facility: a third of sampled households were to be within 5km, a third between 5-10km and a third
further than 10km but not more than 15km from the reference facility.
2.2 Selection of geographic areas and reference public health care facilities
Sampling was conducted in a manner consistent with the WHO Level II Facility methodology. Six regions/districts
were selected as “survey areas” for data collection of the Level II Facility Survey. The major urban centre of Kampala
was selected as one survey area, and an additional five areas were chosen at random from those which could be
reached within a one day’s drive from Kampala. This resulted in the following six survey areas:
1. Kampala (major urban centre)
2. Mbale 3. Hoima 4. Kabale 5. Arua 6. Lira
FIGURE 2:1 GEOGRAPHIC LOCATION OF THE SIX SURVEY AREAS SAMPLED IN THE SURVEY
Access To And Use Of Medicines By Households In Uganda
In each survey area, the sample of reference facilities was identified by first selecting the main public hospital, and
a primary/rural health centre or lowest level public health facility. An additional four public medicine outlets (e.g.
hospital medicine outlets dispensaries) per survey area were then selected at random from all middle level public
health care facilities.
TABLE 2:1 Sampling of reference health care facilities, by region
2.3 Selection of households
A total of 1,051 households participated in the survey. Of these, 178 households were adjacent to the largest public
hospitals in the given regions, and the other 873 households were adjacent to health sub-district (HC IV) facilities.
The quota sample of households per reference facility was divided into six clusters: 10 households (2 clusters) were
selected within a 5km radius from the facility, 10 households (2 clusters) between 5-10km from the facility, and
10 households (2 clusters) more than 10km from the facility. Beginning with the reference health care facility as a
central reference point, the clusters were divided such that they are in different directions, as illustrated in Figure
2.2.
FIGURE 2.2: HOUSEHOLD SAMPLING
Within each cluster, a random starting household was selected at the required distance from the reference health
care facility. After completing an interview with the respondent of this household (or scheduling one for a later
Access To And Use Of Medicines By Households In Uganda
time), a few households were skipped before selecting another household in the cluster. Not every household was
able to participate in the survey; in such cases, the next household was chosen as a replacement. Figure 2.3 presents
the number of households in each cluster.
FIGURE 2.3: HOUSEHOLD CLUSTERS
Households were equally distributed between the two clusters less than 10km from
reference facility but there were households above 10km from reference facility.
2.4 Selection of respondents
Interviewers were trained to use judgment in selecting respondents. Respondents were selected if they met at least
three of the following criteria:
< Main health care decision maker
< Most knowledgeable about health of household members
< Most knowledgeable about health expenditures of the household
< Most knowledgeable about health utilization by household members
< Designated care giver for sick household members
2.5 Data Collection
The survey team consisted of a survey manager, six area supervisors, 24 data collectors and four data entry
personnel. Each area had four data collectors in teams of two composed of a pharmacist and a social scientist. All
survey personnel received training in the standard survey methodology and data collection/data entry procedures
at a workshop held on 14th-18th July 2008. As part of the workshop, a data collection pilot test was conducted in
households which did not form part of the survey sample.
Data collection took place between 21st July and 10th August 2008. Data collectors visited households in pairs and
collected information using a standard paper household questionnaire made of 43 questions (Annex 1). In addition,
an Excel spreadsheet displaying quintiles of monthly household expenditures by number of household members
in Uganda was distributed to data collectors during the training workshop (Annex 2). This spreadsheet was used to
describe categories A, B, C, D, and E of Question 37 during interviews with household respondents.
Area supervisors checked all completed questionnaires at the end of each day of data collection. Upon completion
of the survey, the survey manager conducted a quality control check of all completed questionnaires prior to data
entry.
Access To And Use Of Medicines By Households In Uganda
2.6 Data Entry
Survey data were entered by a team of four data entry persons with experience in data entry procedures. The data
entrants also underwent training between 14th and 18th July 2008. EpiData software was used for data entry. WHO
provided the Epidata entry form created from the questionnaire. Data entry persons used this form after downloading
the free software from www.epidata.dk. Data entry was checked by entering twice 5% of the questionnaires using
the double data entry functions of Epidata; erroneous entries and potential outliers were verified and corrected as
necessary.
2.7 Data Analysis
Household Epidata records were merged into one Uganda file for analysis. Epidata analysis programs that calculated
indicators were provided by WHO. These programs allowed calculating indicators of access to and use of medicines
as defined in the Household Survey Manual (Annex 3)
Access To And Use Of Medicines By Households In Uganda
3. RESULTS
3.1 Characteristics of surveyed households
Understanding the characteristics of surveyed households is critical to assessing their representativeness at the
Uganda level. Interpretation of survey results depends on the location, size, composition and socio-economic status
of households, as well as characteristics of respondents and morbidity of the population included in the survey.
3.1.1 Geographic location
Disparities observed among households may be related to different environments, for example urban versus rural
areas or distance from the closest health care facility. In the medicines survey, regions are determined according
to the WHO methodology for Level II Facility Surveys, which calls for surveying the largest urban area, and five
randomly chosen administrative areas.
Figures 3.1 and 3.2 present the percentage of households per cluster in each of the six selected regions.
FIGURE 3.1: NUMBER OF SURVEYED HOUSEHOLDS IN EACH REGION
• The largest urban area Kampala contributed for 177 households.
• A similar number of households came from each of the other five regions.
8
Access To And Use Of Medicines By Households In Uganda
FIGURE 3.2 REPRESENTATION OF REGIONS IN EACH HOUSEHOLD CLUSTER
• The profile of each cluster of households was similar with regards to region
representation.
• Kampala (the major urban area) accounted for about two in 10 households in
each cluster.
3.1.2 Size and composition
Table 3.1 presents the composition and size of surveyed households.
TABLE 3.1 Characteristics of surveyed households
• The size and composition of sampled households were similar to those of the Uganda
Demographic and Health Survey of 2006.
• There were no variations in household size and expenditures as distance from reference
facility increased.
3.1.3 Socio-economic status (SES)
Socio-economic status is a key attribute of households, influencing their options and decisions about health
care. Socio-economic status can be estimated by collecting information on expenditures/income and assets of
households.
Access To And Use Of Medicines By Households In Uganda
The medicines survey identifies poor households by asking respondents to match their household expenditures with
one of five pre-defined ranges (See Annex 2). In the Uganda survey, the lowest range of expenditures was range A
defined as spending less than 15,000 UGX per person and per month. Range B corresponded to spending between
15,000 and 22,000 UGX per person and per month, range C to spending between 22,001 and 32,000 UGX per person
and per month, range D to spending between 32,001 and 70,000 UGX per person and per month. Range E was the
highest possible range of expenditures, defined as spending more than 70,000 UGX per person and per month.
Respondents chose one of these five ranges of expenditures that corresponded to the monthly total expenditures
of their household.
Figure 3.3 and 3.4 present households by band of expenditures, i.e. by the socio-economic level selected by
respondents.
FIGURE 3.3 HOUSEHOLD CLUSTERS AND SES
• A majority of respondents classified their household in lower socio-economic groups.
• Households of higher self-selected SES level tended live further from reference facilities.
FIGURE:3.4: HOUSEHOLD LOCATION BY REGION AND SES
• A majority of respondents classified their household in lower socio-economic groups.
• Households of higher self-selected SES level tended live further from reference facilities.
0
Access To And Use Of Medicines By Households In Uganda
3.1.4 Assets
Assets are another expression of SES, complementary to household expenditures. The medicines survey collects
information about 15 different items by asking a Yes/No question: ‘Does anyone in your household have such item?’.
Items are Uganda-specific, i.e. each survey team creates a list of assets that best discriminates among socio-economic
strata in their Uganda. Assets chosen by the Uganda survey team were, by alphabetical order: electricity, television,
refrigerator, and tap/running water inside house. Figure 3.5 and Table 3.2 present the percentage of households
with selected assets.
FIGURE 3.5: HOUSEHOLD CLUSTERS AND ASSETS
• The percentage of households with electricity, tap/running water and the percentage of
households owning a television or a refrigerator in the cluster closer to a reference facility
was similar to that in other clusters.
• Overall, the percentage of households with access to tap/running water inside the house
was nine percent. It was low across the clusters.
TABLE 3.2: Assets and self-selected level of SES
Self-selected level of socio-economic status
A- E-
All B C D
Lowest Highest
Car 4.9% 2.4% 2.5% 3.9% 10.0% 40.6%
Bicycle 40.8% 47.6% 41.2% 35.1% 35.4% 21.9%
Television 18.4% 6.4% 15.7% 19.9% 39.8% 71.9%
Radio 57.1% 43.4% 58.7% 65.6% 67.2% 90.6%
Fridge 10.1 2.3% 5.9% 10.4% 25.8% 62.5%
Electricity 21.2% 7.2% 16.2% 30.7% 41.5% 78.1%
Running water in House 8.6% 2.7% 4.2% 10.4% 20.8% 53.1%
The overall percentage of households with access to tap/running water inside the house was only 8.6%
Access To And Use Of Medicines By Households In Uganda
3.1.5. Expenditures
The medicines survey collects direct information on food and health expenditures. Providing an actual value of 4-wk
total expenditures is optional. Recall period of total and health expenditures include the four previous weeks. Recall
period of food expenditures is limited to the previous week: food expenditures results have been adjusted to take
into account the difference in recall period. Discretionary expenditures are calculated as the difference between
total 4-wk expenditures and 4-wk food expenditures.
Table 3.3 presents the mean, 25th percentile, median, and 75th percentile of household expenditures collected in
the Uganda survey. The mean is the average value, sensitive to outliers, whereas the median is the 50th percentile,
i.e. the value below which 50% of the values are positioned. The 25th and 75th percentiles are the boundaries of half
of the values around the median, i.e. 50 % of the values are within the 25th (lower quartile) and 75th (upper quartile)
percentiles. The large difference between means and medians of expenditures displayed on Table 3.3 is due to the
presence of extreme outliers at the higher ranges of expenditures.
TABLE 3.3: Monthly household expenditures
• More than three quarters of the respondents chose to provide an actual amount of
total household expenditures. In this group of 973 respondents, the median value
of total 4-wk household expenditures UGX 30,000.
• During the month preceding the survey, medicines accounted for the majority of
health care expenditures.
3.1.6. Respondents
Respondents are selected by data collectors because they are the household health care decision makers. Therefore,
the gender, age and education of respondents provide information about the characteristics of the main health care
decision makers in households. The profile of respondents important to consider in the interpretation of the opinion
questions of the survey. Figure 3.6 presents the gender and age of respondents.
2
Access To And Use Of Medicines By Households In Uganda
FIGURE 3.6 GENDER AND AGE OF RESPONDENTS/HEALTH CARE DECISION MAKERS
• Respondents were selected because they were the main health care household decision makers.
• Women respondents were slightly more than the male: i.e. 53% percent.
• Bigger proportion of respondents were between 25 and 50 years old: 31 percent were male, and
36 percent were female
• Two in ten of the respondents were over 50 years old: 13% percent were male and 8% percent
were female.
Table 3.4 presents the highest level of education reached by respondents.
TABLE 3.4. Education and gender of respondents
• About 80% of respondents went to school.
• About 27 percent of respondents completed secondary school and 14 percent
continued education beyond secondary school.
• The level of education was comparable between male and female respondents
but more men had received some formal education than women at 86 percent
compared to 75% respectively.
Access To And Use Of Medicines By Households In Uganda
3.1.7 Morbidity
The medicines survey collects information about household morbidity by asking respondents to provide the number
of household members with acute illness within two weeks preceding the survey and the number of members with
chronic diseases.
Table 3.5 presents the prevalence of acute and chronic conditions in surveyed households.
TABLE 3.5 Prevalence of acute and chronic conditions in surveyed households
• About half sampled households was free of current health problem (49 percent).
• On the other hand, 14 percent of sampled households reported both acute and
chronic conditions.
• About half (51 percent) households disclosed one or more recent acute illnesses,
and 28% households reported one or more chronic diseases
• Acute illnesses were reported more often than chronic diseases.
The data collector asks questions on the condition of each sick member. With regards to acute illnesses, symptoms
and perceived severity are documented as they are recalled by the respondent. Figure 3.7 presents symptoms of
recent acute illnesses, by perceived severity.
Access To And Use Of Medicines By Households In Uganda
FIGURE 3.7: REPORTED SYMPTOMS AND PERCEIVED SEVERITY OF ACUTE ILLNESS
• The most frequent symptoms of acute illness were related to malaria:63% percent.
• About 67 percent of the households with recent acute illness reported at least one very
serious symptom.
With regards to chronic conditions, chronic diseases are documented as they are recalled by respondents. Figure 3.8
and table 3.6 present reported chronic diseases, by gender.
FIGURE 3.8: CHRONIC DISEASES AND GENDER
• The most frequent reported chronic diseases were stomach ulcers and
hypertension.
• The proportion of diabetes and tuberculosis were higher in men, whereas
hypertension and HIV/AIDS were more frequent in women.
Access To And Use Of Medicines By Households In Uganda
Table 3.6: Chronic diseases and gender
All Males Females
Number of chronic
310 100% 131 42.3% 179 57.7%
diseases
Hypertension, high blood
84 27.1% 32 38.1% 52 61.9%
pressure
Heart disease, chest
14 4.5% 3 21.4% 11 78.6%
pain, heart attack
Diabetes, high blood
23 7.4% 16 69.6% 7 30.4%
sugar
Asthma, wheezing,
chronic difficulty 44 14.2 19 43.2% 25 56.8%
breathing
HIV /AIDS 42 13.5% 15 35.7% 27 64.3%
Arthritis, chronic body
32 10.3% 15 46.9% 17 53.1%
pain
Epilepsy, seizures, fits 12 3.9% 6 50% 6 50%
Ulcer, chronic stomach
94 30.3% 32 34% 62 66%
pain
Stroke consequences 4 1.3% 2 50% 2 50%
High cholesterol 2 0.6% 1 50% 1 50%
Cancer 3 1% 2 66.7% 1 33.3%
Tuberculosis 11 3.5% 8 72.7% 3 27.3%
Liver Disease 2 0.6% 1 50% 1 50%
Depression 1 0.3% 0 0 1 100%
Other 20 6.5% 8 40% 12 60%
• The most frequent chronic disease of men was diabetes (70 percent)
• HIV/AIDS, hypertension were more prevalent in women
3.1.8 Medicines found in households
In each household, the data collector asks to see all medicines kept at home, and records their name, source, reason
for keeping them, and the condition of their label and primary package. Table 3.7 presents the most frequent
categories of medicines found in households by EML category.
Access To And Use Of Medicines By Households In Uganda
TABLE 3.7: Most frequent categories of medicines found in households
• 35% of the medicines found in the households were analgesics
3.2 Geographic access and availability of medicines
Geographic access to public health facilities is an important indicator of equity in access to medicines.
3.2.1 Proximity to health care facilities
The medicines survey records the proximity of each household to different types of health care facilities, using the
time to travel as unit of distance. Facilities are classified into the following categories: public hospital, private or NGO
hospital, public health care center or dispensary, private clinic or physician, traditional healer, private pharmacy, or
drug seller. For each facility, options to choose from are less than 15 minutes, between 15 minutes and 1 hour, and
over one hour of travel time.
Table 3.8 displays the proximity of households to any health care facility and to public health care facilities.
TABLE 3.8 Travel time to health care facilities
• 63 percent of the surveyed households were within 15 minutes to a health care facility compared to
33% to a public health care facility.
• 25 percent of the surveyed households had to travel more than 1 hour to reach the closest public health
care facility compared to 8% to any healthcare facility.
Access To And Use Of Medicines By Households In Uganda
3.2.2. Proximity to public health care facilities
Figure 3.9 focuses on the proximity of surveyed households to public health care facilities. It presents the percentage
of households that live at more than one hour from different types of public health care facilities, by household
cluster.
FIGURE 3.9: HOUSEHOLD CLUSTERS AND TRAVEL TIME TO CLOSEST PUBLIC HEALTH CARE FACILITY
• Overall, the proportion of households at more than one hour travel time from a
public hospital was 72% and the proportion of households at more than one hour
travel time from a public health care centre or dispensary was 29%.
• The further away households were from reference facilities, the further away
they were from any type of public health care facility.
3.2.3 Sources of medicines found in households
Figure 3.10 and 3.11 present the percentage of medicines found in households that were obtained in different types
of health care facilities, by household cluster.
FIGURE 3.10 SOURCE OF MEDICINES FOUND IN HOUSEHOLDS
• 36 percent of medicines found in households came from a public health care facility.
• This proportion was slightly higher in household closer to the reference facility.
8
Access To And Use Of Medicines By Households In Uganda
FIGURE 3.11: SOURCES OF MEDICINES AT HOME
40%
36%
Percentage obtained from Public
35% 32%
30%
health care facility
25%
20.30%
20%
15% 11.60%
10%
5%
0%
0%
A - Low es t B C D E - H ighes t
Self-selected level of SES
P erc entage of H om e m edic ines obtained from P ublic health c are fac ility
•
The majority of households in higher SES do not obtain medicines from public health care facilities.
3.2.4. Sources of medicines in case of acute illness
Figure 3.12 and 3.13 present the sources of medicines in case of acute illness, by household cluster.
FIGURE 3.12:SOURCES OF MEDICINES TAKEN FORAN ACUTE ILLNES
In case of acute illness, a majority of households obtained their medicines from a
public health care facility.
Access To And Use Of Medicines By Households In Uganda
FIGURE 3.13 SOURCES OF MEDICINES DURING ACUTE ILLNESS AND SES
• Public health care facilities were the most likely source of medicines for acute illnesses.
• Wealthiest households turned to private facilities for medicines
3.2.5 Opinions about geographic access and availability of medicines
Table 3.9 and 3.10 present the percentage of respondents who agreed with statements related to geographic access
and availability of medicines.
TABLE 3.9 Opinions about geographic access and availability of medicines
• 72% of respondents were satisfied with the location of their public health care
facility. This percentage was highest in the household cluster closest to a reference
facility.
• In all three household clusters, respondents perceived that availability of
medicines is better in private than in public health care facilities.
20
Access To And Use Of Medicines By Households In Uganda
TABLE 3.10 Opinions of respondents on geographic access and availability of medicines according to SES
Self-selected level of SES
A- E-
All B C D
Lowest Highest
No. of Respondents
1051 36% 27% 22% 12% 3%
The public health care facility in my
Agree 72% 64% 74% 76% 78% 72%
area is conveniently located
The public health care facility in
my area usually has medicines my Agree 33% 40% 29% 26% 35% 31%
household needs
The private pharmacy in my area
usually has the medicines my Agree 65% 58% 66% 67% 79% 91%
household needs
• About half of the respondents were satisfied with the location of their public health care facility.
• More respondents believed that medicines are available at private pharmacies than in public health care facilities
3.3 Affordability of medicines
Affordability of medicines is another critical indicator of equity in access to medicines. The level of medicine insurance
coverage and the actual cost of medicines for different conditions are important to consider when assessing
medicines affordability. The percentage of households experiencing catastrophic expenditures during the month
preceding the survey provides a useful account of the affordability of medicines in the surveyed population.
3.3.1 Insurance coverage
Table 3.11 presents the percentage of households who receive prescriptions free-of charge in case of acute illness
and the percentage of households who receive insurance coverage in care of acute and chronic conditions, by
household cluster.
TABLE 3.11 Medicines insurance coverage
• 41 percent of prescriptions for acute illness were obtained free of charge.
• Medicines insurance coverage for acute and chronic conditions was practically inexistent.
2
Access To And Use Of Medicines By Households In Uganda
3.3.2 Cost of medicines for acute illnesses
In addition to collecting monthly household expenditures for medicines, the medicines survey collects information
about the cost of prescriptions for recent acute illnesses. Table 3.12 presents the cost of prescriptions for acute
illnesses, by household cluster.
TABLE 3.12: Cost of prescriptions for a recent acute illness
• The average cost of one prescription for acute illness was UGX 5,279.
• The average number of medicines per prescription was 2.
3.3.3 Cost of medicines for chronic diseases
The medicines survey also collects information about the price of medicines taken for chronic diseases. In this case,
the monthly cost of each prescribed medicine is recorded.
Table 3.13 presents the monthly cost of medicines for chronic diseases, by household cluster.
TABLE 3.13 Monthly cost of medicines for chronic diseases
• The average monthly cost of a prescription for chronic disease was UGX 7,181.
• The average number of medicines taken for a chronic disease was 2.
22
Access To And Use Of Medicines By Households In Uganda
3.3.4 Catastrophic expenditures related to medicines
Catastrophic expenditures are payments that push people into poverty. They can be expressed in different ways.
In the survey, catastrophic expenditures are calculated as expenditures higher than 40 percent of discretionary
expenditures.7 Catastrophic expenditures were calculated in the group of 973 respondents who disclosed the actual
amount of total expenditures by their household during the month preceding the survey.
Figure 3.14 presents the percentage of households with catastrophic expenditures related to medicines during
the month preceding the survey, by household cluster.
FIGURE 3.14 CATASTROPHIC EXPENDITURES RELATED TO MEDICINES IN MONTH PRECEDING SURVEY
• During the month preceding the survey, over a 63 percent of households
experienced catastrophic payments related to medicines.
• The percentage of households faced with catastrophic payments related to
medicines was similar in all the clusters of households from the reference facility.
3.3.5 Opinions about affordability of medicines
Table 3.14 and 3.15 present the percentage of respondents who agreed with statements related to affordability of
medicines.
Xu K., The Lancet 2003; 362: 111-117
2
Access To And Use Of Medicines By Households In Uganda
TABLE 3.14 Opinions about affordability of medicines
• 36 percent respondents agreed that they can usually afford to buy all the medicines they need.
• Almost every respondent agreed that medicines are more expensive in private pharmacies than
in public health care facilities.
• The majority of respondents believed that it is possible to obtain free medicines from public
health care facilities.
TABLE 3.15 Opinions of respondents about affordability of medicines
Self-selected level of SES
A- E-
All B C D
Lowest Highest
No. of Respondents
1051 35.6% 27% 22% 12.4% 3%
My household can get free medicines at
Agree 83% 89% 85% 78% 74% 50%
the public health care facility
Medicines are more expensive at private
pharmacies than at public health care Agree 81% 83% 76% 81% 85% 78%
facilities
My household can usually get credit from
Agree 30% 24% 35% 34% 34% 19%
the private pharmacy if we need to
My household can usually afford to buy
Agree 36% 32% 32% 38% 49% 50%
all the medicines we need
My household would obtain prescribed
medicines if insurance reimbursed part of Agree 15% 11% 14% 18% 20% 13%
their cost
In the past, my household had to borrow
Agree 57% 64% 58% 52% 53% 25%
money or sell things to pay for medicines
• Over half respondents agreed that they cannot usually afford to buy all the medicines they need.
• Almost every respondent agreed that medicines are more expensive in private pharmacies.
• Majority of respondents had not heard about health insurance.
2
Access To And Use Of Medicines By Households In Uganda
3.4 Medicine use and medicines at home
The objective of the medicines survey is to understand which medicines people access and use, who prescribes
them, where they can be obtained, how much they cost and why people take or do not take them. Collecting
information on medicines kept at home contributes to answering these questions.
3.4.1 Number of households where medicines could be found
For each medicine found at home, the data collector records name, source, reason for being there, as well as label
and packaging conditions. Medicines are entered in the data base with both their actual and generic names, and a
code derived from the 15th WHO Model List of Essential Medicines.
Figure 3.15 and 3.16 present the percentage of households where medicines were found.
FIGURE 3.15: HOUSEHOLDS WITH MEDICINES AT HOME
• About 40 percent of households kept medicines at home.
• Households closer to reference facilities were more likely to keep medicines at home.
FIGURE 3.16 HOUSEHOLDS WITH MEDICINES AT HOME AND SES
8 0 .0 0 %
7 1 .9 0 %
7 0 .0 0 %
% of Households within SES
6 0 .0 0 %
4 9 .2 0 %
5 0 .0 0 %
42% 4 0 .7 0 %
4 0 .0 0 %
3 3 .4 0 %
3 0 .0 0 %
2 0 .0 0 %
1 0 .0 0 %
0 .0 0 %
A - Lowes t B C D E - H ig h e s t
Self-selected level of SES
• Households of higher SES were more likely to keep medicines at home
2
Access To And Use Of Medicines By Households In Uganda
3.4.2 Labelling and packaging of medicines found in households
Labels of medicines found in households are considered acceptable by data collectors if they include medicine
name, dose, and expiration date. Similarly, the primary package of a medicine is considered acceptable if it is an
envelope or a closable container which contains only one medicine.
Figure 3.17 presents the percentage of medicines that had an acceptable label and primary package, by source of
medicine.
FIGURE 3.17 Percentage of medicines found in households with both adequate label and primary package,
by source
50%
% of medicines with adequate labeling and primary package
36%
33% 32%
30%
0%
A ll me d ic in e s f o u n d O b ta in e d f r o m a O b ta in e d f r o m a O b ta in e d f r o m o th e r
a t h o me p u b lic f a c ility p r iv a te p h a r ma c y o r s ourc e
d r u g s e lle r
• Overall, only 33 percent of medicines found in households had a label in good
condition and were in an appropriate container.
• Medicines from public health care facilities were as likely to be kept in an
adequate container with an appropriate label as medicines from other sources.
2
Access To And Use Of Medicines By Households In Uganda
3.4.3 Antibacterials found in households
Figure 3.18 presents the most frequent antibacterials found in households, by generic name and frequency.
FIGURE 3.18 MOST FREQUENT ANTIBACTERIALS FOUND IN HOUSEHOLDS
100
Number of medicines
93
44
34
18
14
10 9 6 5 3 3
0 2 2 2 2
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• The survey identified antibacterials found in surveyed households represented 14 different
generic entities.
• Sulfamethoxazole/trimethoprim was the antibacterial most frequently found in households.
Figure 3.19 presents the reasons for keeping antibacterials at home.
FIGURE 3.19: REASONS FOR KEEPING ANTIBACTERIALS AT HOME
300
250
150
86 90
74
0
Number of Current treatment Lef t f rom pas t A ntic ipate f uture
antibiotic s f ound in treatment need
hous ehold
100% 34% 36% 30%
30 percent of identified antibacterials found in surveyed households were kept for
future use.
2
Access To And Use Of Medicines By Households In Uganda
3.4.4 Antimalarials found in households
Figure 3.20 presents antimalarials found in households, by generic name and by frequency.
FIGURE 3.20 ANTIMALARIALS FOUND IN HOUSEHOLDS
60
Number of antimalarials
51
42
26
10
9
2
1 1
0
a r te me th e r + c h lo r o q u in e q u in in e a n tima la r ia l s u lf a d o x in e + d ih y d r o a r te mis in a mo d ia q u in e c h lo r o q u in e +
lu me f a n tr in e p y r ime th a min e + p ip e r a q u in e s u lf a d o x in e +
p h o s p h a te p y r ime th a min e
• A total of 142 antimalarials were found in surveyed households.
• A total of seven different antimalarial entities were identified.
• Artemether/lumefantrine accounted for 4 in ten of antimalarials kept at home.
3.5 Medicine use during acute illnesses
For each recent acute illness reported, data collectors record name, route of administration, prescriber, and source
of each medicine taken for this illness. Medicines are entered in the data base with both their actual and generic
names, and a code derived from the 15th WHO Model List of Essential Medicines.
3.5.1 Actions taken when an acute illness occurs
Table 3.16 presents the actions taken in case of recent acute illness.
28
Access To And Use Of Medicines By Households In Uganda
TABLE 3.16: Actions taken for a recent acute illness
All
Number of sick persons with an acute illness
126
perceived as very serious
W ent for c are and took all pres c ribed m edic ines 101 80%
W ent for c are and took s om e of the pres c ribed m edic ines 21 17%
W ent for c are but did not take any m edic ines 0 0%
D id not go for c are 4 3%
Number of sick persons with an acute illness
407
perceived as moderately serious
W ent for c are and took all pres c ribed m edic ines 321 79%
W ent for c are and took s om e of the pres c ribed m edic ines 49 12%
W ent for c are but did not take any m edic ines 12 3%
D id not go for c are 25 6%
Number of sick persons with an acute illness
196
perceived as not serious
W ent for c are and took all pres c ribed m edic ines 137 70%
W ent for c are and took s om e of the pres c ribed m edic ines 23 12%
W ent for c are but did not take any m edic ines 6 3%
D id not go for c are 30 15%
.
80 percent of persons with a very serious acute illness sought care and took all
prescribed medicines.
3.5.2 Medicines taken for a recent acute illness
Figure 3.21 presents the most frequent categories of medicines taken for a recent acute illness.
FIGURE 3.21: MOST FREQUENT EML CATEGORIES OF MEDICINES TAKEN FOR A RECENT ACUTE ILLNESS
500
431 423
228
111
35 35 28 27 26 23 20
0 16 16
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The two most frequent categories of medicines prescribed for acute illness were
antimalarials and analgesics.
2
Access To And Use Of Medicines By Households In Uganda
Figure 3.22 presents antibacterials prescribed for acute illnesses, by generic name and by frequency.
FIGURE 3.22 ANTIBACTERIALS TAKEN FOR A RECENT ACUTE ILLNESS
140
Number of medicines
129
54
32
27 24 20 17 14
9 6 6
0
llin
tic
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A ntibac terials B eta lac tam drugs A ntibac terials other than beta lac tam
• A total of 338 identified antibacterials representing 10 different generic
names were reported to have been taken for a recent acute illness.
• Sulfamethoxazole/trimethoprim was the most frequently used antibacterial
in case of acute illness.
Of all categories of medicines prescribed for acute illness, 31 percent were antimalarials. Figure 3.23 displays which
antimalarials were prescribed, by generic name and by frequency.
FIGURE 3.23 Antimalarials taken for a recent Acute Illness
160
number of antimalarials
136
85 85
74
33
13
0 2 2 1
e
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ne
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in
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ia
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• Artemether/lumefantrine accounted for 32 percent of medicines
antimalarials prescribed in case of acute illness.
• There are many records of ACTs being used for a recent acute illness.
0
Access To And Use Of Medicines By Households In Uganda
3.5.3 Prescribers of medicines in case of acute illness
Figure 3.24 presents prescribers of medicines in case of acute illness, by household cluster.
FIGURE 3.24 PRESCRIBERS OF MEDICINES IN CASE OF ACUTE ILLNESS
A ll 79% 21%
Distance from reference facility
> 10 km 73% 27%
5 to 10 km 79% 21%
< 5 km 82% 18%
0% Percentage of m edicines 100%
Medic ines pres c ribed by a doc tor/nurs e Medic ines pres c ribed by others
• In case of acute illness, the majority of medicines were prescribed by
nurses/doctors.
• Households were as likely to consult a doctor/nurse for an acute
illness irrespective of distance away from reference facilities
3.5.4 Routes of administration of medicines prescribed for acute illness
Figure 3.25 presents the route of administration of medicines prescribed for acute illness.
FIGURE 3.25: ROUTE OF ADMINISTRATION OF MEDICINES PRESCRIBED FOR ACUTE ILLNESS
A ll 91% 7%
Distance from reference facility
> 10 km 92% 6%
5 to 10 km 90% 9%
< 5 km 92% 7%
0% Percentage of m edicines 100%
oral injec tion other
• In case of acute illness, a large percentage of prescribed medicines were pills.
• The percentage of prescribed injections was the similar irrespective of household
distance away from reference facilities.
Access To And Use Of Medicines By Households In Uganda
3.5.5 Reasons for not taking medicines prescribed for acute illness
The medicine survey includes a list of possible reasons that could explain why a person did not take prescribed
medicines. If non-compliance is identified, this list is read to the respondent who chooses yes if he/she feels this
reason explains why the medicine was not taken. Yes may be selected for several possible reasons.
Figure 3.26 presents the number of persons with acute illness who did not take the medicines as recommended,
and the most frequent reasons chosen to explain non-compliance.
FIGURE 3.26 Reasons for not taking prescribed medicines for acute illness
110 105
Number of persons with acute illness
who did not take medicines as
75
prescribed
50
33 32
24 23
18
14
7
4 3
0
A ll < 5 km 5 to 10 km > 10 km
Distance from reference facility
Did not f ollow their pres c ription Sy mptoms had improv ed Could not af f ord medic ines
• Most individuals with a recent acute illness took medicines as prescribed.
• Over 13.3 percent of those who did not take medicines as prescribed could not
afford them
3.6 Medicine use for chronic diseases
295 households reported at least one chronic disease. In households with a person diagnosed with a chronic disease,
the data collector records the name of each medicine prescribed to the person with a chronic disease, the condition
for which it was recommended, the number of days of supply usually obtained, the usual cost for one month, and
insurance coverage for every person with a chronic disease. Medicines are entered in the data base with both their
actual and generic names, and a code derived from the 15th WHO Model List of Essential Medicines.
3.6.1 Actions taken when a chronic disease has been diagnosed
Figure 3.27 presents actions taken in case of chronic disease, by household cluster.
2
Access To And Use Of Medicines By Households In Uganda
FIGURE 3.27 Actions taken for chronic diseases
100%
78% 77%
75%
66%
59%
49%
44% 45%
20%
14% 14% 14%
10% 11% 11%
7%
0%
A ll < 5 km 5 to 10 k m > 10 k m
M edic ines were found in hous ehold
W as told to tak e m edic ines and tak es them as direc ted
W as told to tak e m edic ines and does not tak e them as direc ted
W as not told to tak e m edic ines
• Most of the persons with a chronic disease were told to take medicines and took
them as directed.
• However, only 49 percent of the households with someone diagnosed with a
chronic disease had medicines at home
• Few individuals were diagnosed with a chronic disease and not told to take
medicines
3.6.2. Medicines prescribed for chronic diseases
Figure 3.28 presents the most frequent categories of medicines taken for a chronic disease.
FIGURE 3.28: Most frequent categories of medicines for chronic diseases
Total
B eta lac tam drugs
4%
A ntianginal drugs
4%
Unc las s ified agents A ntac ids /other antiulc er drugs
4% 23%
A ntiepileptic s
4%
Res piratory trac t drugs
5%
A ntias thm atic drugs
5%
Ins ulins /antidiabetic agents
6% A ntihy pertens ive drugs
19%
Non-opioid analges ic s and
NS A IM s
9%
A ntibac terials other than beta
lac tam
17%
A total of 81 medicines were recorded being used for chronic diseases.
Access To And Use Of Medicines By Households In Uganda
Figure 3.29 presents the names of diuretics and anti-hypertensive medicines collected. A total of 14 medicines
were recorded for the 90 cases of hypertension reported.
FIGURE 3.29 Diuretics and antihypertensive medicines
45
number of medicines
42
7 7 6
3 2 2
0 1 1
antihy pertens ive bendrofluaz ide propanolol c aptopril enalapril am lopidine enalapril + furos em ide los artan
hy droc hlorothiaz ide
A ntihy pertens ive drugs Diuretic s
• Diuretics were almost exclusively represented by Bendrofluazide.
• Propranolol was the most frequently used anti-hypertensive, followed by
captopril.
3.6.3. Reasons for not taking medicines prescribed for a chronic disease
Figure 3.30 presents the number of persons with chronic disease who did not take prescribed medicines as
recommended.
FIGURE 3.30: Reasons for not taking medicines for a chronic disease as prescribed
50
46
Number of individuals with chronic disease
17 16 16 15 15
8 7
5 6 5
2
0
A ll < 5 km 5 to 10 k m > 10 k m
Distance from reference facility
Did not follow their pres c ription S y m ptom s had im proved Could not afford m edic ines
• Of the 295 individuals with a chronic disease, 15.6 percent did not take medicines
to treat their disease.
• 16 of the 46 (34.8 percent) persons who did not take medicines to treat their
chronic disease could not afford medicines.
Access To And Use Of Medicines By Households In Uganda
3.7 Opinions about quality of care
The medicines survey collects opinions of respondents about quality of care. Statements describing opinions are
read to respondents who are asked if they agree or disagree. Data collectors are instructed to tick the option ‘do not
know’ only if respondents are not sure or do not want to answer a particular question.
Table 3.17 and 3.18 present opinions of respondents about quality of care in their area.
TABLE 3.17: Opinions about quality of care
Dis tanc e from referenc e fac ility
A ll < 5 km 5 to 10 k m > 10 k m
Number of respondents 1051 387 386 278
The quality of services delivered at public health
Agree 56% 56% 61% 51%
care facilities in my neighborhood is good.
The quality of services delivered by private health
Agree 74% 74% 74% 74%
care providers in my neighborhood is good.
Imported medicines are of better quality than
Agree 26% 26% 24% 28%
locally manufactured medicines.
• Opinions of respondents about the quality of services in public health care
facilities were negative.
• More respondents agreed that the quality of services is worse in public health
care facilities than in private facilities: 56 percent versus 74 percent.
TABLE 3.18 Opinions of respondents about quality of care and medicines according to SES
Self-selected level of SES
A- E-
All B C D
Lowest Highest
Respondents
0 28 2 0 2
The quality of service delivered at public
Agree % 2% % % 8% %
health care facilities in my area is good
The quality of service delivered by private
Agree % % % % 82% %
health care providers in my area is good
Brand name medicines are of better quality
Agree 2% 0 20% 0% 0% %
than generic medicines
Brand name medcnes are cheaper than
Agree % % 0 0% % %
generic medicines
Imported medicines are of better quality than
Agree 2% % % 8% % 0%
locally manufactured medicines
• Respondents had a poor opinion about the quality of services in public health care facilities as opposed to private
facilities across all SES.
• A major proportion of respondents could not tell whether there was a difference in quality between brand and
generic medicines, imported and locally manufactured medicines.
Access To And Use Of Medicines By Households In Uganda
3.8 Opinions about pricing and quality of medicines
The medicines survey collects opinions of respondents about the pricing and quality of medicines. Statements
related to these attributes are read to respondents who are asked if they agree or disagree. Data collectors are
instructed to tick the option ‘do not know’ only if respondents are not sure or do not want to answer a particular
question.
Table 3.19 presents opinions of respondents about pricing and quality of medicines.
TABLE 3.19 Opinions about pricing and quality of medicines
Opinions of respondents about the pricing and quality of medicines suggest
respondents attach quality to pricing
Access To And Use Of Medicines By Households In Uganda
3.9 Opinions about generic medicines
A majority of respondents answered ‘do not know’ to the question related to generic medicines. Table 3.20 presents
the percentage of respondents who knew about generics and agreed with statements related to generics.
TABLE 3.20 Opinions about generics
Of the respondents who heard the word ‘generic’ before, 30 percent believed that
generic medicines are of lesser quality and 47 percent believed that they are less
expensive than brand medicines.
Access To And Use Of Medicines By Households In Uganda
ANNEXES
ANNEX 1: HOUSEHOLD SURVEY QUESTIONNAIRE
Survey Record Number |__||__||__||__| Facility ___________________ Household Number |__| |__|
The "Household Informant" should be the person in the household who is the main health care decision maker. This is
usually the person who is the most knowledgeable about the health, health care expenditures, and health care utilization of
members of the household. The survey should not be completed if this person, or appropriate substitute, is absent.
The person who makes decisions about health care in this household, or appropriate substitute, is available to answer:
1 Yes if Yes, Continue 2 No if No, Stop here.
1. Please give the name, sex and age, relationship to head of household, education, occupation, and marital status of
each of the household members who live here. Let me assure you that any information you provide will be kept
confidential. Write one person per row and use codes provided in each column to complete each row.
A B C D E F G
Relationship Marital
Name Sex Age Education Occupation
to head status
1=Head 1=No formal 1=Farmer/fisherman 1=Married
R 2=Spouse schooling 2=Teacher 2=Consensual
O 3=Child 2=Some primary 3=Artisan union
S 4=Grandchild 3=Completed 4=Office worker 3=Divorced
T 5 =Parent primary 5=Civil Servant 4=Separated
1=Male Write number of 6 =Sibling 4=Completed 6=Agric/fish labor 5=Widowed
E 7=Nephew/niece secondary 7=Non-agric labor 6=Never
Write a name that identifies years in the Years
R column. 8=Other family 5=Completed high 8=Health worker married
each member (initials, first
name, nick name, or complete member school or 9=Self- 7=Non
N name…) Use the Month 9=House helper equivalent employed/own Applicable
U 2=Female column only if less 10= Friend 6=Completed business
M than 1 year old. 99=Other college/pre- 10=Student/pupil
B (specify) university 11=Unemployed
E /university 12=Not in labor
7=Completed force/retired
R post-graduate 99=Other (specify)
Years Months
01 |__||__||__| |__||__|
02 |__||__||__| |__||__|
03 |__||__||__| |__||__|
04 |__||__||__| |__||__|
05 |__||__||__| |__||__|
06 |__||__||__| |__||__|
07 |__||__||__| |__||__|
08 |__||__||__| |__||__|
09 |__||__||__| |__||__|
10 |__||__||__| |__||__|
11 |__||__||__| |__||__|
12 |__||__||__| |__||__|
13 |__||__||__| |__||__|
14 |__||__||__| |__||__|
15 |__||__||__| |__||__|
16 |__||__||__| |__||__|
17 |__||__||__| |__||__|
18 |__||__||__| |__||__|
19 |__||__||__| |__||__|
20 |__||__||__| |__||__|
21 |__||__||__| |__||__|
22 |__||__||__| |__||__|
23 |__||__||__| |__||__|
24 |__||__||__| |__||__|
25 |__||__||__| |__||__|
26 |__||__||__| |__||__|
27 |__||__||__| |__||__|
28 |__||__||__| |__||__|
29 |__||__||__| |__||__|
30 |__||__||__| |__||__|
WHO Household Survey on Access to and Use of Medicines
8
Access To And Use Of Medicines By Households In Uganda
Survey Record Number |__||__||__||__| Facility ___________________ Household Number |__| |__|
Country __________ Region ____________ Investigator________________ Date _ _/_ _/_ _ _ _ (dd/mm/yyyy)
Roster Number of Respondent |__| |__|
Distance of Household from Reference Public Health Facility (tick one )
2. How much time does it take to reach the following health care facilities or providers that are closest to your
household? Read responses and tick one box for each one of the categories.
< 15 15 min to < 15 15 min
> 1 hr > 1 hr
min 1 hr min to 1 hr
a. Public hospital 2 e. Traditional healer 2
b. NGO or Mission hospital 1 2 f. Private pharmacy 1 2
c. Public health center or dispensary 2 g. Drug seller 2
d. Private hospital, clinic or physician 1 2
3. Has anyone in this household been ill in the past two weeks with an acute illness? An acute illness is a conditon
that appears suddenly: the person did not have it immediately before becoming ill.
Yes 0 No If No, Skip to Question 5
4. I will now ask you a series of questions about each person who had an acute illness in the past two weeks. First,
can you give the name of each person who had an acute illness over the past two weeks? Transcribe name and
roster number from the household roster.
Name (as in roster) Roster number Acute illness module completed
Yes No
- |__| |__| 0
- |__| |__| 0
- |__| |__| 0
- |__| |__| 0
- |__| |__| 0
- |__| |__| 0
- |__| |__| 0
- |__| |__| 0
- |__| |__| 0
- |__| |__| 0
Complete one acute module for each person with an acute illness, one sick person per page. After collecting complete
information about one person, check ‘Yes’ under “Acute illness module completed” in the corresponding row. When acute
illness modules are completed and checked for all members listed above, continue on to Question 5 below. The number of
completed acute illness module pages must equal the number of members with acute illness over the past two weeks.
5. Has anyone in this household ever been told by a doctor or other health care provider that they have a chronic
disease? A chronic disease is an illness that will not go away or takes a long time to go away, even when treated.
Yes 0 No If No, Skip to Question 22
6. For each person with a chronic disease, I will now ask you a series of questions about this disease. First, can you
give the name of each person with a chronic disease? Transcribe name and roster number from the household
roster.
Name (as in roster) Roster number Chronic disease module completed
Yes No
- |__| |__| 0
- |__| |__| 0
- |__| |__| 0
- |__| |__| 0
- |__| |__| 0
Complete one chronic module for each person with a chronic disease, one sick person per page. After collecting complete
information about one person, check ‘Yes’ under “Chronic disease module completed” in the corresponding row above.
When chronic disease modules are completed and checked for all members listed above, continue on to Question 22. The
number of completed ‘Chronic disease module’ pages must equal the number of members with chronic diseases.
WHO Household Survey on Access to and Use of Medicines
Access To And Use Of Medicines By Households In Uganda
Survey Record Number |__||__||__||__| Facility ___________________ Household Number |__| |__|
|__| |__|
7. What type of health problems/symptoms did (first name) have during this illness? Do not read. Tick one box for
each group of symptoms mentioned: Yes No Yes No
a. Cough, runny nose, sore throat, ear ache 0 g. Thirst, sweating 0
b. Difficulty breathing, fast breathing 1 0 h. Pain, aches 1 0
c. Fever, headache, hot body 0 i. Bleeding, burn, accident 0
d. Convulsions, fits 1 0 j. Do not know 1 0
e. Could not sleep 0 k. Other (please specify): ______ 0
f. Diarrhea, vomiting, nausea, could not eat 1 0
8. How serious do you think this illness was? Read the choices. Tick one box.
Very Serious 2 Somewhat Serious 3 Not Serious
9. At any point, did (first name) (or anybody else on his/her behalf) seek care for this illness outside the home?
Yes 0 No if No, Skip to Question 11
10. From which of the following sources of care did (first name) receive care at any time during the illness?
Read responses and tick one box for each of the categories:
Yes No Yes No
a. Public hospital 0 e. Traditional healer 0
b. Mission or NGO hospital 1 0 f. Private pharmacy 1 0
c. Public health center or dispensary 0 g. Drug seller 0
d. Private hospital, clinic or physician 1 0 h. Friend or neighbor 1 0
11. Did he/she take any medicine during the acute illness, including medicines taken during hospitalisation?
Yes 0 No if No, Skip to Question 16
12. Which medicines were taken during this illness?
Write one medicine per row, and use codes provided in each column to collect information about each medicine.
A B C D
Medicine Route Recommended / prescribed by Obtained from
Write name of medicine. 1 = oral 1 = self 5 = traditional 1 = available at home 6 = private health care
2 = injection 2 = household healer 2 = friend or neighbour provider
If name is not known, write the most detailed 99 = other member 6 = pharmacist outside household 7 = traditional healer
category given by respondent (“antibiotic’, (specify) 3 = friend/ 7 = drug seller 3 = public hospital 8 = private pharmacy
“antimalaria”, “for fever”) neighbour 99 = other 4 = NGO/mission hospital 9 = drug seller
4 = doctor/nurse (specify) 5 = public health center 99 = other (specify)
Med 1
Med 2
Med 3
Med 4
Med 5
Med 6
Med7
13. How much did your household pay for medicines used to treat this illness? |__| |__||__| |__| |__| |__| local currency
14. Was this cost covered by health insurance? 1 Yes, entirely 2 Part of it was covered 0 No
15. Dd (first name) take all medicines that were recommended or prescribed?
Yes if Yes, this one-page acute module is now complete, go back to Question 4 0 No
16. If answer to Questions 11 or 15 is No, ask the following question: I am going to give you some possible reasons
why (first name) did not take medicines. Can you tell me whether these were reasons why?
Read statements, and tick one box for each statement Yes No
a. Symptoms have gotten better 0
b. Someone in the household decided medicines were not needed 0
c. Someone advised not to take medicines 0
d. Sick person had bad reactions to medicines in the past 0
e. Someone in the household chose a different treatment 0
f. The place where medicines can be obtained was too far away 1 0
g. Medicines were not available at the public health care facility 0
h. Medicines were not available at private pharmacy or drug seller 1 0
i. No one in the household could take time to obtain medcnes 0
j. Our household could not afford the medicines 0
k. Other (please specify): _________________ 0
This one-page acute module is now complete. Go back to Question 4.
WHO Household Survey on Access to and Use of Medicines
0
Access To And Use Of Medicines By Households In Uganda
Survey Record Number |__||__||__||__| Facility ___________________ Household Number |__| |__|
|__| |__|
17. Whch chronc dseases does (first name) have? Read responses. Tick one box for each disease mentioned.
Do not Do not
Yes No Know Yes No Know
a. Hypertension, high blood pressure 0 i. Stroke consequence 0
b. Heart disease, heart attack consequence 1 0 j. High cholesterol 1 0
c. Diabetes, high blood sugar 0 k. Cancer 0
d. Asthma, wheezing, chronic difficulty breathing 1 0 l. Tuberculosis 1 0
e. HIV infection, AIDS 0 m. Liver disease 0
f. Arthritis, chronic body pain 1 0 n. Depresson 0
g. Epilepsy, seizures, fits 0 o. Other (please specify): 0
h. Ulcer, chronic stomach pain 1 0 _________________
18. Has (first name) been told by a doctor or other health care provider that he/she should be taking medicines to
treat this disease?
Yes 0 No if No, this one-page chronic module is now complete, go back to Question 6.
19. Whch medcnes has (first name) been told to take for this chronic disease and for any other condition?
Write one medicine per row, and use codes provided in each column to collect information about each medicine.
A B C D E
Condition for which Number of days of
Any amount of last month
Medicine medicine was supply usually Cost for last month
cost covered by insurance?
recommended obtained
Write name of medicine. Write code provided in In days In local currency Tick Yes if insurance covers
If name is not known, write the most detailed category given Question 17 (i.e. letter Write “0” if Write “0” if not obtained part or all cost.
by respondent (“antibiotic”, “antidepressive”, “for a. for hypertension…) medicine is not regularly or obtained free. Tick No if not obtained or cost
diabetes”) Write “X” if unknown obtained regularly. not covered by insurance.
Med 1 |__| |__| |__| |__| |__| |__| Yes 0 No
Med 2 |__| |__| |__| |__| |__| |__| Yes 0 No
Med 3 |__| |__| |__| |__| |__| |__| Yes 0 No
Med 4 |__| |__| |__| |__| |__| |__| Yes 0 No
Med 5 |__| |__| |__| |__| |__| |__| Yes 0 No
Med 6 |__| |__| |__| |__| |__| |__| Yes 0 No
Med 7 |__| |__| |__| |__| |__| |__| Yes 0 No
Med 8 |__| |__| |__| |__| |__| |__| Yes 0 No
Med 9 |__| |__| |__| |__| |__| |__| Yes 0 No
All Medicines Ask for the total cost of medicines only if the cost of each medicine is not known |__| |__| |__| |__| |__| |__|
20. Sometimes people cannot take all medicines as directed. Does (first name) usually take all medicines as
recommended?
Yes if Yes, this one-page chronic module is now complete, go back to Question 6 0 No
21. If answer to Question 20 is No, ask the following question: I am going to give you some possible reasons why
(first name) may not always take medicines as recommended. Can you tell me whether these are the reasons why
he/she does not take medicines?
Read statements, and tick one box for each statement. Yes No
a. Symptoms have gotten better 0
b. Someone in the household decided medicines were not needed 0
c. Someone advised not to take medicines 0
d. Sick person had bad reactions to medicines in the past 0
e. Someone in the household chose a different treatment 0
f. The place where medicines can be obtained is too far away 1 0
g. Medicines are not available at the public health care facility 0
h. Medicines are not available at private pharmacy or drug seller 1 0
i. No one in the household can take time to obtain medcnes 0
j. Our household cannot afford the medicines 0
k. Other (please specify): _________________ 0
This one-page chronic module is now complete. Go back to Question 6.
WHO Household Survey on Access to and Use of Medicines
Access To And Use Of Medicines By Households In Uganda
Survey Record Number |__||__||__||__| Facility ___________________ Household Number |__| |__|
22. Do you have any medicines available at home today?
Yes 0 No if No, Skip to Question 24
23. Can I please see all of them? Write one medicine per row, and use codes provided in each column to collect
information about each medicine.
A B C D E
In home
Medicine Obtained from Label OK Primary Package OK
because
Write name of medicine. 1= family, friend 5= private health 1=current Tick Yes if label Tick Yes if primary
If name is not known, write the most detailed 2= public hospital care provider treatment includes medicine package is an envelope
category given by respondent (“antibiotic”, 3= NGO/mission 6= traditional name, dose, and or a closable container,
2=left from
“antimalaria”, “for fever”) hospital healer past expiration date. and if it contains only
4= public health 7= private treatment one medicine.
center or pharmacy
dispensary 8= drug seller 3=anticipate
99=other (specify) future need Otherwise tick No Otherwise tick No
Med 1 Yes 0 No Yes 0 No
Med 2 Yes 0 No Yes 0 No
Med 3 Yes 0 No Yes 0 No
Med 4 Yes 0 No Yes 0 No
Med 5 Yes 0 No Yes 0 No
Med 6 Yes 0 No Yes 0 No
Med 7 Yes 0 No Yes 0 No
Med 8 Yes 0 No Yes 0 No
Med 9 Yes 0 No Yes 0 No
Med 10 Yes 0 No Yes 0 No
Med 11 Yes 0 No Yes 0 No
Med 12 Yes 0 No Yes 0 No
24. I am going to read you a series of opinions about price and quality of medicines. For each opinion, please tell me
whether you agree or disagree. Do not read the option “Do not know”. Tick it if the respondent does not want to
answer or is unable to choose between “agree” and “disagree”. Read statements & tick one box for each
statement.
Agree Disagree Do not know
a. In public facilities, health providers take into account our ability to pay when they decide
2
which medicines to prescribe.
b. In private facilities, health providers take into account our ability to pay when they decide
2
which medicines to prescribe.
c. When I receive a prescription, I am comfortable asking how much the medicines will cost. 2
d. It is easy for me to find out how much medicines cost. 2
e. Two identical medicines may be sold at different prices. 2
f. I know where to find medicines at the lowest price in my neighborhood. 2
g. When I buy a medicine, I ask for the least expensive product. 2
h. When a pharmacist recommends a medicine, I can be sure that it is the best value for money. 2
i. When a pharmacist recommends a medicine, I can be sure that it is of good quality. 2
j. Medicines of better quality are more expensive. 2
k. There are places in my neighborhood where I would never buy medicines because they sell
2
medicines of poor quality.
l. Our government makes sure that the medicines we buy are of good quality. 2
m. Different names may be used for the same medicine. 2
n. I have heard the word “generic” before to describe a medicine. 2
If respondent has not heard about generics or does not know, Skip to Question 25
o. A generic medicine is usually lower in quality than a brand medicine. 2
p. A generic medicine is usually lower in price than a brand medicine. 2
WHO Household Survey on Access to and Use of Medicines
2
Access To And Use Of Medicines By Households In Uganda
Survey Record Number |__||__||__||__| Facility ___________________ Household Number |__| |__|
I am going to read you a series of opinions about three topics related to care and medicines: access, affordability, and
quality. There are no correct answers. For each opinion, please tell me whether you agree or disagree. Do not read the
option “Do not know”. Tick it if the respondent does not want to answer or is unable to choose between “agree” and
“disagree”. Read statements, and tick one box for each statement.
25. The first set of opinions is about access to care and medcnes. Agree Disagree Do not know
a. The public health care facility closest to my household is easy to reach. 2
b. My household would use public health care facilities more if opening hours were convenient. 1 2
c. The public health care facility closest to my household usually has the medicines we need. 2
d. The private pharmacy closest to my household usually has the medicines my household needs. 1 2
26. The second set of opinions is about affordability of medicines. Agree Disagree Do not know
a. My household can get free medicines at the public health care facility. 2
b. Medcnes are more expensve at prvate pharmaces than at public health care facilities. 1 2
c. My household can usually get credit from the private pharmacy if we need to. 2
d. My household can usually afford to buy the medicines we need. 1 2
e. My household would obtain prescribed medicines if insurance reimbursed part of their cost. 2
f. In the past, my household had to borrow money or sell things to pay for medicines. 1 2
27. The last set of opinions is about quality of care and medcnes. Agree Disagree Do not know
a. The quality of services delivered at public health care facilities in my neighborhood is good. 2
b. The quality of services delivered by private health care providers in my neighborhood is good. 1 2
c. Imported medicines are of better quality than locally manufactured medicines. 2
Finally I would like to ask a few questions about the possessions that are in your home and how much your household
spends. Remember that any information you provide will be kept confidential.
28. Can you please tell me how many rooms (bedrooms, dining room, kitchen …) are in your home? |__| |__| Rooms
29. Does anyone in your household have: (Items are country-specific. These items should be identified and listed
before the survey by referring to Section 4.3. of the manual)
Yes No Yes No Yes No
a. Item 0 c. Item 0 e. Item 0
b. Item 2 0 d. Item 0 f. Item 0
30. Does your household have:
a. Tap/running water inside house: Yes 0 No c. Electric power network: Yes 0 No
b. Toilet: Yes, its own 2 Yes, shared 0 No If no electric power network, Skip to Question 32
31. Does anyone in your household have: (Electricity-dependent items are country-specific. These items should be
identified and listed before the survey by referring to Section 4.3 of the manual)
Yes No Yes No Yes No
a. Item 0 c. Item 0 e. Item 0
b. Item 8 0 d. Item 0 0
32. In the last week, how much did your household spend on food? Include the value of any food produced and
consumed by the household; exclude alcohol, tobacco, and restaurant meals: |__| |__| |__| |__| |__| |__| in local currency
33. I will now give you five different levels of spending. Please choose the level that is closest to what your
household spent in total over the past 4 weeks. (Read ranges of expenditures corresponding to the size of this
household: A, B, C, D, E are expressed in local currency, and can be found in Annex 3 of the manual)
A 2 B C D E
34. Can you provide the actual total amount? 1 Yes, |__| |__| |__| |__| |__| |__| in local currency 0 No
35. In the last 4 weeks, how much did your household spend on:
a. Care that required staying overnight in a hospital or health care facility |__| |__| |__| |__| |__| |__| in local currency
b. Medicines |__| |__| |__| |__| |__| |__| in local currency
c. Any other health care products or services that were not included above:
(outpatient visits, lab tests, x-rays, dentist, ear & eye care…) |__| |__| |__| |__| |__| |__| in local currency
d. Voluntary health insurance premiums or other prepaid health plans |__| |__| |__| |__| |__| |__| in local currency
36. Does anyone in your household earn money? Yes 0 No If No, Stop.
37. If yes, who is the main earner in the household? Write his/her roster number here: |__| |__|
Thank the interviewed person and reassure about the confidentiality of his/her answers.
WHO Household Survey on Access to and Use of Medicines
Access To And Use Of Medicines By Households In Uganda
ANNEX2: QUINTILES OF MONTHLY EXPENDITURES PER HOUSEHOLD MEMBER
