Improving rational medicine prescribing at a public district hospital in southwestern Uganda, January-November 2021: a quality improvement initiative
A six-month quality improvement initiative at a public district hospital in southwestern Uganda significantly increased guideline-concordant prescribing and generic medicine use while reducing antibiotic overuse and the average number of medicines per encounter, though high antibiotic rates indicate a need for continued stewardship efforts.
Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). This is an AI-generated explanation of a preprint that has not been peer-reviewed. It is not medical advice. Do not make health decisions based on this content. Read full disclaimer
In hospitals around the world, the act of writing a prescription is a moment of profound trust. A doctor assesses a patient, decides what is wrong, and selects medicines to make them better. For this system to work, the medicines chosen must be the right ones, given in the right amounts, and at a cost the community can afford. When doctors prescribe too many drugs, use expensive brand names when cheaper versions exist, or give antibiotics when they are not needed, the system begins to strain. Patients may suffer side effects, hospitals may run out of essential supplies, and bacteria can learn to resist the very drugs meant to kill them. This is the challenge of rational prescribing: ensuring that every pill and injection serves a clear, necessary purpose. In places where resources are tight, getting this right is not just a matter of good medicine; it is a matter of survival.
At Itojo Hospital, a public district hospital in southwestern Uganda, the pressure on this system was becoming visible. Between 2018 and 2019, the hospital faced recurrent shortages of medicines. An internal look at their records revealed a troubling pattern: doctors were often writing prescriptions that did not follow the country's official treatment guidelines. On average, a patient leaving the outpatient clinic was sent home with three different medicines, and nearly two out of every three prescriptions included an antibiotic. This was happening even though the hospital had clear guidelines on how to treat common illnesses. The staff knew something needed to change, but they needed a plan that fit their specific reality.
In early 2021, a team of doctors, nurses, pharmacists, and administrators at Itojo Hospital launched a focused effort to fix these prescribing habits. They did not bring in outside experts to dictate a new way of working. Instead, they looked closely at their own daily routines to find the cracks in the system. They discovered that doctors often could not easily access the official guidelines, that some staff members who were not authorized to prescribe were writing orders, and that there was no routine check to see if the prescriptions written matched the guidelines. To address this, the team created a simple, practical package of changes. They held training sessions for the prescribers, provided them with digital copies of the guidelines on their phones, and made sure that only recognized clinicians could write prescriptions, with their signatures verified by the pharmacy staff. They also set up a system where prescriptions were regularly checked and the doctors received feedback on their work.
The team measured their progress by comparing prescription records from before these changes began to records from six months later. They looked at thousands of details, from the number of medicines on a single slip of paper to whether the drugs were listed by their generic names rather than brand names. The results showed a clear shift in behavior. The proportion of prescriptions that followed the official guidelines jumped significantly. Before the intervention, less than half of the prescriptions matched the guidelines; after six months, more than three-quarters did. The average number of medicines given to a patient at one time dropped from over three to fewer than three. The use of generic names, which are usually cheaper and more available, became much more common.
Perhaps most importantly, the team saw a reduction in the use of antibiotics, which are powerful drugs that should be used carefully. While antibiotics were still prescribed in nearly two out of every three visits, the rate had fallen noticeably from the start of the project. However, the team noted that this number was still high, suggesting that while the doctors were learning, the habit of prescribing antibiotics for many conditions had not yet been fully broken. The study also found that the use of injections did not change much, likely because it was already very low.
The success of this project at Itojo Hospital offers a hopeful example of how local teams can solve complex problems without waiting for massive external aid. By combining education with simple checks and balances, the hospital staff improved the quality of care they provided. The doctors wrote fewer unnecessary medicines, followed the rules more closely, and used generic drugs more often. Yet, the work is not finished. The fact that antibiotic use remained high indicates that the challenge of changing deep-seated habits is ongoing. The team learned that one round of changes is rarely enough; to keep patients safe and medicines available, the cycle of checking, learning, and adjusting must continue. This story from a single hospital in Uganda shows that when healthcare workers are given the right tools and the space to improve their own systems, they can make a real difference in the health of their community.
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