E-DRUG: Re: Per capita allocation for medicines
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Dear E-druggers,
Mr Dubbeldam is touching upon an important issue: costs of
prescriptions and who will pay for them.
In Bolivia, a national health insurance system (Seguro Basico de
Salud) is being designed and implemented at the moment. Work
has concentrated on developing a broad package of care for the
general population and securing funding from government,
municipalities, and international agencies. Services will include
out-patients consultations, hospitalization, surgery, laboratory
services, transport of patients, and even some services in
communities without health facilities. Drugs are also provided
free of charge under the scheme. The insurance scheme aims
at making basic health care more accessible to the population
of low income.
However, surveys in Bolivia have documented large varieties in
prescribing practices in health facilities. Within a few kilometers of
distance, numbers of drugs per prescription varied from 1.2 to 1.9
and antibiotic prescribing rates from 20% to 83%. Survey results
from elsewhere in Bolivia confirm these data. The only plausible
explanation is differences in practices of individual facilities/
prescribers, possibly linked to variations in diagnostic practices.
Such variations are becoming less and less acceptable to health
insurers in industrialized countries, since they indicate serious
inefficiencies in the health care delivery system in question.
In Bolivia, as in any country, somebody has to pay for prescribed
drugs: either the patient (as is often the case now), or the
insurance scheme (as is planned for the future). If prescribing
(and diagnosing!) remains as inappropriate as it is at the moment,
the insurance scheme may eventually become unsustainable and
collapse. If the patient still has to pay for part of the drugs (the ones
not accepted by the insurance), the scheme may not achieve what it
set out to do: making health care more accessible to the low
income population.
This makes painfully clear that aside from the need to design health
insurance schemes in developing countries, there is a (more?)
urgent need to improve prescribing practices in (at least) public
health care systems. More broadly seen, there is an urgent need to
improve quality and efficiency of health care systems, instead of
only ensuring that low efficiency care systems become more
accessible to populations in developing countries.
Adding to Mr Dubbeldam's final comment, the potential savings of
improved drug prescribing (not to mention avoidance of ill effects of
unnecessary drug therapy) might easily finance a generation of
PhD students in a variety of public health fields.
Hilbrand Haak
Consultants for Health and Development
e-mail: HaakH@compuserve.com
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