The effects of different kinds of user fee on prescribing costs in rural Nepal

K.A. Holloway, B.R. Gautam, B.C. Reeves

The study estimated the cost of irrational prescribing, and compared the effect of three different kinds of user fee on prescribing costs, in rural eastern Nepal between 1992 - 1995. A controlled before-after study was conducted in 33 government primary health care facilities. A fee per prescription (covering all drugs in whatever amounts) was regarded as the control against which two types of fee per drug item were compared. The average total cost to the patient for two drug items was the same in all fee systems. Total cost, expected cost (according to standard treatment guidelines) and wastage costs (total minus expected cost) per prescription were calculated from an average of 400 prescribing episodes per facility per year. The proportion of prescriptions conforming to standard treatment guidelines was calculated from 30 prescriptions per facility per year.

Researchers found that 20 - 52% of total drug costs were due to inappropriate drug prescribing. A fee per drug item, as compared with a fee per prescription, was associated with significantly: fewer drug items prescribed per patient; lower drug costs per prescription; lower wastage due to inappropriate drug prescription; and a significantly greater proportion of prescriptions conforming to standard treatment guidelines. The study concludes that the economic consequences of irrational prescribing are severe, particularly in association with charging a fee per prescription. Item fees in the public sector reduce irrational prescribing and associated costs.

Reference: Health Policy and Planning 2001;16(4):421 - 427.

Ten recommendations to improve use of medicines in developing countries

R. Laing, H.V. Hogerzeil, D. Ross-Degnan

Inappropriate prescribing reduces the quality of medical care and leads to a waste of resources. A variety of educational and administrative approaches have been tried to improve prescribing. This article reviews the experiences of the last decade in order to identify which interventions have been effective in developing countries, and it suggests a range of policy options for health planners and managers.

Considering the magnitude of resources that are wasted on inappropriately used drugs, many promising interventions are relatively inexpensive. Simple methods are available to monitor drug use in a standardised way and to identify inefficiencies. Intervention approaches that have proved effective in some settings are: standard treatment guidelines; essential drugs lists; pharmacy and therapeutics committees; problembased basic professional training; and targeted in-service training of health workers. Some other interventions, such as training of drug sellers and public education, need further testing, but should be supported. Several simplistic approaches have proven ineffective, such as disseminating prescribing information or clinical guidelines in written form only. Two issues that will require a long-term strategic approach are improving prescribing in the private sector and monitoring the impacts of health sector reform.

Sufficient evidence is now available to persuade policy-makers that it is possible to promote rational drug use. If such effective strategies are followed, the quality of health care can be improved and drug expenditures reduced.

Reference: Health Policy and Planning 2001; 16:13 - 20.

Potentially inappropriate medication use in the community-dwelling elderly

C. Zhan, J. Sangl, A.S. Bierman, M.R. Miller, B. Friedman, S.W. Wickizer, G.S. Meyer.

Inappropriate medication use is a major patient safety concern, especially for the elderly. Previous US studies found that 23.5% and 17.5% of the US community-dwelling elderly population used at least 1 of 20 potentially inappropriate medications in 1987 and 1992 respectively. This study was undertaken to determine the prevalence of potentially inappropriate medication use in community-dwelling elderly persons in 1996. Trends over 10 years could be assessed, inappropriate medication use categorised according to explicit criteria, and risk factors for inappropriate medication use examined.

Respondents were aged 65 years or older (n = 2455) from a nationally representative survey of the US non-institutionalised population. A seven-member expert panel was convened to categorise inappropriate medications. The main outcome measure was the prevalence of use of 33 potentially inappropriate medications.

The study showed that in 1996, 21.3% of community-dwelling elderly patients in the USA received at least 1 of 33 potentially inappropriate medications. Using the expert panel's classifications, about 2.6% of elderly patients used at least one of the 11 medications that should always be avoided by elderly patients; 9.1% used at least one of the eight that would rarely be appropriate; and 13.3% used at least one of the 14 medicines that have some indications but are often misused. Use of some inappropriate medicines declined between 1987 and 1996. People with poor health and more prescriptions had a significantly higher risk of inappropriate medication use.

Researchers concluded that overall inappropriate medication use in elderly patients remains a serious problem. Specific criteria can be applied to population- based surveys to identify ways to improve quality of care and patient safety. Enhancement of existing data sources to include dosage, duration and indication may augment national efforts to improve monitoring and increase rational use of medicines among the elderly.

Reference: JAMA 2001;286:2823 - 2829.

Drug supply systems of missionary organizations. Identifying factors affecting expansion and efficiency: case studies from Uganda and Kenya

E. Kawasaki, J. Patten

There are few detailed studies on the management of drug supply by mission organizations, despite their often large contribution to developing countries' health systems. Some mission supply systems have become self-sustainable and have expanded their drug supply capacity to the public and private sectors. In order to identify the key factors for success and obstacles facing mission- run drug store systems, a detailed qualitative and quantitative study was done on the drug management of the Mission for Essential Drugs and Supplies in Kenya and the Joint Medical Store in Uganda. The study methods, using in-depth interviews and analysis of data given by the organizations, have produced a comprehensive overview of both, and have provided lessons regarding sustainability and expansion.

Both MEDS and JMS have grown progressively over the past five years, and are now self-sustaining. Their efficient management is reflected in low operational expenditures - only around 10% of total expenditure is on operational costs, with some 60% of this for staffing. The two organizations charge prices which are very competitive internationally, and their stock availability rates run at about 90%.

The study shows that JMS and MEDS use different approaches because of their different economic environments. Both provide reliable drug supply systems for their customers, and are beginning to supply significant amounts of medicines to organizations in neighbouring countries. The authors conclude that governments should consider exploring areas for linkages and using mission organization drug supply infrastructures. They argue that direct support from international donors in training and computerized operating systems could contribute to self-sustainability of other mission organizations.

Reference: Kawasaki E, Patten J. Drug supply systems of missionary organizations. Identifying factors affecting expansion and efficiency: case studies from Uganda and Kenya. Boston: Boston University School of Public Health; 2002.

An assessment of the health system impact of direct-toconsumer advertising of prescription medicines. Volume II: literature review

B. Mintzes

This review concludes that many gaps remain in the research evidence on outcomes of prescription drug advertising to the public. No reliable evidence exists to support hypotheses of potential health benefits or to exclude potential harm. In 1991, when the US General Accounting Office reviewed the literature on direct-to-consumer advertising, there was little experience with this form of publicity. In the intervening 10 years, the amount of public exposure to direct-to-consumer advertising has grown enormously. However, knowledge of the effects of this type of advertising on health and on the quality of health care services remains elusive.

Reference: Mintzes B. An assessment of the health system impact of direct-to-consumer advertising of prescription medicines. Volume II: literature review. Direct-to-consumer advertising of prescription drugs: what do we know thus far about its effects on health and health care services? Vancouver: Health Policy Research Unit, University of British Columbia; 2001. Ref. no.: HPRU 02:2D. Available on the web at: http://www.chspr.ubc.ca/hpru/pdf/dtca-v2-litreview.pdf