E-drug: Bamako Initiative (cont'd)
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Dear Michel and other e-druggers,
I and many others will be very interested to hear the output from the
Bamako Initiative conference next week. Will it be possible to arrange
for a summary to be distributed on e-drug? I worked for a number of
years in Nepal on revolving drug funds with the Britain Nepal Medical
Trust (BNMT) and am now completing a PhD investigating the effects
of different charging mechanisms (types of user fee) on the quality
and cost of prescribing in rural Nepal.
In a WHO workshop (Financing essential drugs: report of a WHO
workshop, WHO/DAP/88.10 ), it was expressed that certain kinds of
user fee may encourage irrational drug use and that potentially 50% of
drug costs could be saved by rational prescribing. Despite this, few
studies have examined the relationship between user fee type and
prescribing quality or estimated the cost of irrational prescribing. In
Nepal we found that changing the user fee from a fee per prescription
to a fee per drug item (covering a full course) was associated with an
improvement in prescribing quality of 10-20% and a reduction in the
average drug cost per prescription of over 30%. Such changes in
prescribing quality and cost are of enormous importance both with
regard to patient treatment and sustainability of any revolving drug
funds.
I would be very interested to hear of the experience of any of the
conference participants with regard to user fees and their effect on
the quality and cost of prescribing. I completely agree with the
questions posed by Michel and Jerome and would like to share some
of the experience in Nepal, maybe raising more questions and
stimulating discussion.
1. Equity
In the revolving drug funds run by BNMT, the user fees were set at a
level such that the average patient paid the equivalent to 25-30% of
the average household cash income for a prescription containing two
drugs. This level is much lower than that reported in many countries,
yet the most disadvantaged section of the population was not using
the health facilities. The cost of attending the health facility (in terms
of travel, lost working time, etc) and the poor quality of care (all
aspects, not just drug availability) have been cited by villagers in
Nepal and many other countries as reasons for non-use. How are
Bamako Initiative projects addressing this?
2. Quality of Care
Prescribing health staff were absent from the health posts 20-40% of
the time and all aspects of quality of care (diagnosis, dispensing,
syringe/needle sterilization) were low in the Nepali districts where
BNMT operated its drug schemes. We also found that 30-50% of drug
costs were 'wasted' through irrational prescribing and that 30% of
patients did not know their dosing schedules immediately on exiting
the health facilities. Using the WHO/INRUD core indicators, the quality
of care (prescribing and non-prescribing) found in Nepal was similar to
that seen in many developing countries. In this context, without
addressing these other aspects of care, what does the provision and
financing of drugs achieve?
3. Supervision and sustainability
BNMT provided human resources and finance to supervise the running
of the revolving drug funds. Thus it was ensured that the majority of
patients paid the fees they were supposed to pay, and about 90% of
expected moneys were collected, all these moneys being used to
purchase more essential drugs. However, it has been shown in Nepal
and elsewhere that without such supervision patients often do not pay
the fees they are supposed to (inappropriate exemptions and
non-exemptions, and extra unofficial fees) and often money and drugs
'disappear'. Also, the money may not be collected or not used to
purchase more drugs. All these things affect cost-recovery. In Nepal
the local communities and government are a long way from being able
to deal with these issues. How are these things managed in Bamako
Initiative projects? Are they even monitored? In many projects they are
not.
I would be very interested to hear of sustainable success stories with
regard to the Bamako Initiative. However, unless the above questions
are addressed, I do not think that a judgement can be made
concerning any individual Bamako Initiative project. The mere
presence of regular drug re-supply and reasonable cost recovery does
not necessarily equate with success in terms of improved access to
care of adequate quality.
Kathy Holloway,
Former Drug Scheme Coordinator, BNMT.
Temporary Address: 19 Camden Mews, London NW1 9DB, UK.
Tel: 00 44 171 482 1919
e-mail: k.a.holloway@sbu.ac.uk
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