November is ‘Intern Spotlight Month’ here at Health Action International, when we shine a light on the interns who make tremendous contributions to our team and the work we do with their fresh perspectives, new ideas, intellect and vivacious spirit. Each week throughout the month of November, we’re introducing you to one of our interns from the past year who’ll explain the research they conducted during their internship, as well as what they gained from it. This week, allow us to introduce you to Gaby Ooms, from the Netherlands.
Why are you interested in your chosen topic?
I have studied global public health over the past four years, and have come to learn that there are so many people around the world who do not have access to some of the most essential medicines, causing widespread needless suffering. I focused on controlled medicines, which are regulated by international law, and are used in several areas of medicine, including pain treatment, treatment of opioid dependence, emergency obstetrics, psychiatry and neurology. The most essential of these, are known as essential controlled drugs (ECDs). In my home country, the Netherlands, accessing ECDs is quite easy, while in many developing countries, patients cannot be certain that the medicine they need will even be available at all. This really struck me as unfair, and as something I wanted to counteract in my work.
What did you discover in your research?
Access to essential controlled drugs (ECDs) in Uganda was obstructed by multiple factors, of which health system factors were the most influential and impactful. Besides a lack of local and international political priority of ECDs, health-system related barriers included an uneven balance between mechanisms for access and control, which at times lead to overregulation of ECDs. There were deficiencies in the design and implementation of the systems which were intended to estimate the health centres’ needs and distribution of ECDs. Additionally, there were inadequate human resources and inadequate training of healthcare professionals, as well as low drug affordability. Besides, regulation was not always properly implemented, which allowed for abuse of some ECDs, such as diazepam.
Outside of the health system, there was also stigma related to the use of the drugs, and a lack of knowledge in the community, in patients, and in healthcare professionals. This was yet another barrier to accessing ECDs. All my findings suggest that strengthening the health system on multiple fronts is needed to improve access to ECDs in Uganda.
Which was your most interesting finding?
In the stakeholder interviews, respondents said that some of the ECDs, such as diazepam, phenobarbital, and ergometrine, were readily available. However, the health facility questionnaires I conducted showed something different: in many health centres the availability of ECDs was actually quite low. Only diazepam was available at almost all health centres, and all the other ECDs were only available at less than half of the health centres, if they were even available at all. This difference between perceived and real availability really proves that together with great expertise and knowledge, field work can always be useful and provide new insights.
Why did you want to do your internship at HAI, and what did you gain from it?
I wanted to do my internship at HAI because I found the topics they work on, and their advocacy, fit very well with my interests and future career plans. I really appreciate the amount of freedom I was given in designing and setting up my research. In just a few months, I have learnt and experienced so much. For instance, the process of applying for ethics approval, was not only interesting, but will also be useful to me in my future research.
One of the most valuable experiences of my internship was visiting Uganda to interview stakeholders and conduct health facility questionnaires. Conducting local field-work, and being able to visit the health centres and stakeholders in person, gave me a greater understanding of both ECDs and Uganda, and the problems with limited access to ECDs became more real and personal to me. The opportunity to connect with such helpful, friendly, and knowledgeable professionals is also something I am very grateful for.
The WHO has created a Model List of Essential Medicines containing medicines that are essential for the health of people worldwide. This list also includes nine controlled drugs; drugs that are considered controlled substances by law through international drug control conventions. These essential controlled drugs (ECDs) are buprenorphine, codeine, diazepam, ephedrine, ergometrine, methadone, morphine, phenobarbital, and potassium permanganate. They are used as anesthetics, for the treatment of opioid dependency, convulsions or epilepsy, anxiety disorders, or post-partum hemorrhaging, as well as for pain management and palliative care. Because of the controlled status, access to ECDs is problematic partly due to the strict regulation surrounding these drugs, which affects the importation, manufacturing, and distribution.
In Uganda access to ECDs is also a problem, even though action has been undertaken by the government to improve access, specifically access to opioids. Other controlled drugs, such as diazepam, ephedrine, ergometrine, and phenobarbital, receive little attention; few research has been done so far specifically on the access to and availability of these drugs in Uganda, highlighting the need for detailed data on all ECDs and their day-to-day availability and accesibility. Consequently, the objective of this research is to identify the availability of ECDs in specialized health centers, and to create an overview of the health system factors that affect the access of ECDs in Uganda. The main research question that this research addresses is what the current situation is in Uganda concerning the availability and accessibility of ECDs. Namely, what are the perceptions of stakeholders towards the prevailing legal, regulatory, and policy provisions with regards to the access and availability of ECDs in Uganda? What is the availability and accessibility of ECDs at specialized health centers in Uganda?
This study used multiple research methods pertaining a country analysis. It consisted of a review of existing literature and regulations, a questionnaire, and semi-structured interviews. The questionnaire collected data from health centers that delivered controlled drugs services to patients, using the designed assessment tool Controlled drugs: Assessing the Availability and Accessibility. The semi-structured interviews were held with key experts and professionals from relevant institutions in Uganda with knowledge on ECDs. The interviews were semi-structured and were guided by a set of questions, and participants were chosen from a breadth of disciplines using stakeholder mapping.
In Uganda, access to ECDs was hindered by multiple aspects, among which health system barriers were one of the most important and influential. The specific barriers that adversely affected access to ECDs were non-prioritization of the drugs, difficulties in balancing control and access, deficiencies in the workings of the estimate- and distribution system, practical and logistical issues, lack of knowledge and stigma among healthcare professionals, patients and the community, inadequate training and human resources, expenses related to use and access, physical and geographical availability. Another finding of this research was that for some ECDs the regulations were quite stringent, while for other ECDs regulation was not always implemented, which resulted in some abuse of specific ECDs. These findings suggest that health system strengthening is needed in order to improve access to ECDs. For this to happen, specific improvements are necessary. The recommendations that resulted from this research are as follows:
- Review and potentially revise existing laws, and ensure the compliance to these laws and regulations
- Improve the knowledge of healthcare professionals regarding ECDs
- Increase the number of healthcare professionals
- Improve service delivery through the improvement of clinical supervision and communication, increasing the prescribing possibilities of healthcare professionals, and integrating ECD services into existing programs
- Strengthening the estimates- and distribution system
- Ensure availability of ECDs in the public sector
- Set up stigma-reduction programs and information campaigns regarding ECDs
Active engagement and concerted effort of the government, regulators, suppliers, educational institutions, patient organizations, advocacy groups, NGOs, and healthcare professionals is needed to improve access to ECDs using the abovementioned recommendations. The findings of this research should be used for a targeted approach to combat the barriers that hinder the access to ECDs in Uganda.