E-drug: Re: Per capita allocation for medicines
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Dears E-druggers friends,
As Dr. Haak mentioned it is true that in Bolivia, a national health
insurance system (Seguro Basico de Salud) is being designed and possibly
implemented with a more or less broad package of care intended to cover the
general population through the municipalities, whichs since 2 years ago
have the responsability to run health and educational services
(exceptionally based on adequate or technical advice). The system will
count possibly with some funding from government and international agencies
(services will include, as Hildebrand mentioned, out-patients
consultations, hospitalization, surgery, laboratory services, transport of
patients). Looks great!!
The insurance scheme aims at making basic health care more accessible to
the population of low income, and seems quite good. We share completely the
purpose of seeking health equity. Drugs under this scheme, are intended to
be supplied "free of charge". I have to stress that I am very diffident to
accept that something in this life is "free of charge". Bolivians, as
everybody pay taxes, which, unfortunately, not always are invested for
public services and human rights like access to pure water, sanitation,
adequate nutrition, health care.
As consequence, mass media accusations points out that corruption in
Bolivia takes annually an average of 1.132 USD million/year (1,997)
meanwhile there is no money for health services investments. Result is that
just 14 % of Bolivians enjoys Social Security protection and less favoured
people in rural communities remains without any health access, neither
health facilities. The Public Health Budget in Bolivia, is around $us.
96.000.000 USD/year . But just $us. 36.300.000 USD are of direct
availability (the difference is transfered to support other institutions
and areas)(it means that health budget takes 2.9 % of the national general
budget, meanwhile defense and army takes 14 % of the budget) (1994).
85 % of the available financial resources of the national Public Health
budget is addressed to pay salaries and just about 15 % ($us. 5.445.000
USD) remains for operative health investment.
With these figures in mind, do we think, really that it is feasible to
introduce a rational health insurance system (Seguro Basico de Salud),
which ensures honesty and continuity ? or will be another dissapointment
for the Bolivian population ?. However something has to be done. Why not to
invest also efforts and money to stop the descrived levels of corruption ?.
It is not a way to promote equity in access to health care ? It is not a
way to promote access to Essential Drugs ? or it is just a political issue
out of our competences ?
It is true that surveys in Bolivia have documented large varieties in
prescribing practices in health facilities, i.e. numbers of drugs per
prescription varied from 1.2 to 1.9 and antibiotic prescribing rates from
20 % to 83 %. I share the hypothesis of Dr. Haak that differences in
practices of individuals and health facilities/prescribers, obey possibly
to variations in diagnostic and treatment practices. To my view, it is true
that quality of health interventions is the core problem. Due to the poor
acceptable quality of health interventions and inefficiencies in the health
care delivery system, health insurers, are not willing to cover this area.
Anyhow, somebody has to pay for prescribed drugs when they are prescribed:
in Bolivia, usually is the patient, and prices are higher that in many
countries of Europe or USA. I share the point that if health interventions
(and prescribing) remains inappropriate as it is at the moment,the
insurance scheme will become unsustainable and probably will collapse.
An alternative is that the patient has to pay a "forfeit" or "ticket
moderateur" (part of the drugs prices) and the inssurance may recognizes
just ESSENTIAL DRUGS prescribed (according the Bolivian E.D. list). In
such case, perhaps the scheme may achieve what it set out to do: making
health care more accessible to the low income population and to avoid
irrational prescription. However this strategy requires investement on
continuous health EDUCATION programmes for health workers, health
professionals and community members. In other words, a shift of patterns of
prescription and attitudes of health workers and professionals and also to
inform widely that these E.D. are not less effective and of lower quality
as some companies and even health professionals claims.
It is evident that there is an urgent need in Bolivia to improve health
practices and interventions (including prescribing practices). But also, it
is true that we have to pay attention to the overall context, to re-orient
the health policies. I have seen many "wonderful" proposals and programmes,
which after the external support and loans, disappear, unless we develop
SOCIAL CONTROL.
I share completely Dr. Haak point of view, that there is an urgent need to
improve quality and efficiency of health care system, instead of only
ensuring that low efficiency care systems become more accessible to
populations in developing countries.
Oscar Lanza V. MD,MPH.
AIS BOLIVIA COORDINATOR
aisbolol@mail.entelnet.bo
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