Adherence to Long-Term Therapies - Evidence for Action
(2003; 211 pages) View the PDF document
Table of Contents
View the documentPreface
View the documentAcknowledgements
View the documentScientific writers
View the documentIntroduction
View the documentTake-home messages
Open this folder and view contentsSection I - Setting the scene
Close this folderSection II - Improving adherence rates: guidance for countries
Close this folderChapter IV - Lessons learned
View the document1. Patients need to be supported, not blamed
View the document2. The consequences of poor adherence to long-term therapies are poor health outcomes and increased health care costs
View the document3. Improving adherence also enhances patient safety
View the document4. Adherence is an important modifier of health system effectiveness
View the document5. Improving adherence might be the best investment for tackling chronic conditions effectively
View the document6. Health systems must evolve to meet new challenges
View the document7. A multidisciplinary approach towards adherence is needed
View the document8. References
Open this folder and view contentsChapter V - Towards the solution
Open this folder and view contentsChapter VI - How can improved adherence be translated into health and economic benefits?
Open this folder and view contentsSection III - Disease-Specific Reviews
Open this folder and view contentsAnnexes
Open this folder and view contentsWhere to find a copy of this book
 

6. Health systems must evolve to meet new challenges

In developed countries, the epidemiological shift in disease burden from acute to chronic diseases over the past 50 years has rendered acute care models of health service delivery inadequate to address the health needs of the population. In developing countries this shift is occurring at a much faster rate.

The health care delivery system has the potential to affect patients' adherence behaviour. Health care systems control access to care. For example, health systems control providers' schedules, length of appointments, allocation of resources, fee structures, communication and information systems, and organizational priorities. The following are examples of the ways in which systems influence patients' behaviour:

• Systems direct appointment length, and providers report that their schedules do not allow time to adequately address adherence behaviour (66).

• Systems determine fee structures, and in many systems (e.g. fee-for-service) the lack of financial reimbursement for patient counselling and education seriously threatens adherence-focused interventions.

• Systems allocate resources in a way that may result in high stress and increased demands upon providers which, in turn, have been associated with decreased adherence in their patients (67).

• Systems determine continuity of care. Patients demonstrate better adherence behaviour when they receive care from the same provider over time (68).

• Systems direct information sharing. The ability of clinics and pharmacies to share information on patients' behaviour regarding prescription refills has the potential to improve adherence.

• Systems determine the level of communication with patients. Ongoing communication efforts (e.g. telephone contacts) that keep the patient engaged in health care may be the simplest and most cost-effective strategy for improving adherence (69).


Few studies have evaluated programmes that have used such interventions, and this is a serious gap in the applied knowledge base. For an intervention to be truly multi-level, systemic barriers must be included. Unless variables such as these are addressed, it would be expected that the impact of the efforts of providers and patients would be limited by the external constraints.

The changing nature of disease prevalence also influences activities at the system level. Continued reliance on acute models has delayed the reforms necessary to address longer-term interventions for chronic conditions. In developing countries this shift is occurring at a much faster rate at a time when the battle against communicable diseases is still being fought.

In some countries, the attention of the policy-makers may remain focused on communicable diseases, for example HIV/AIDS and tuberculosis. However, these diseases are not effectively addressed by the acute care model. Even if it were to provide full and unrestricted access to appropriate drugs, the acute care model would lack impact because it does not address the broad determinants of adherence.

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