E-DRUG: Sachs' unfashionable Rx for third world aid (6)
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I have to differ from Paul Lobb's view that re-introducing user fees
would be a good idea, at least in the area of treatment for HIV and
related illnesses. Qualitative research that we did in Zambia - and
subsequent experience in the country when the government made the
decision to provide free ARV treatment and associated lab tests -
indicate very strongly that uptake both of HIV testing and of ARV
treatment escalated rapidly in response. There seem to be some effects
on prevention as well - people who learn to adhere well to their
treatment seem to be more careful generally about their own and other
people's health. There are nearly 60,000 people on ARV treatment in
Zambia now, and most of them would not have been if treatment had not
become free. The frequent funerals and hospital admissions would have
continued...
Most people in low-resource countries are too poor to afford even
low-level user fees. So, in these circumstances, user fees cost lives
and prolong serious morbidity. Even now, the costs of getting to clinic,
buying food, and time lost on income generation, are still serious
barriers for some. There may of course be different arguments for
situations where disease burdens and incomes are different - but the
poorest would still get a raw deal if everyone has to pay.
And yes, there are serious challenges to the sustainability of high
levels of free treatment - but I really don't think user fees would make
much difference to that, since they are expensive to collect and don't
often generate much income.
What will make ARV provision sustainable is the continued (and
increased) commitment of rich countries to supporting health systems and
funding the Global Fund, UNITAID etc to provide the money and health
goods that poor countries with high disease burdens will never be able
to afford on their own. All countries have to commit to ensuring
sustainable supply systems and health services, and to removing
corruption and improving prevention, but without external help for some
time, the tide won't turn easily.
Carolyn Green
Senior Technical Advisor, Care & Support
Care & Impact Mitigation Team
International HIV/AIDS Alliance
104-106 Queens Road
Brighton BN1 3XF
United Kingdom
direct phone: +44 1273 718747
main phone: +44 1273 718900
cellphone: +44 773311 2368
cgreen@aidsalliance.org
E-DRUG: Sachs' unfashionable Rx for third world aid (7)
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I concur with Caroline that re introducing user fees is not the best option at this point in time owing to poverty levels. The administrative nightmare for exemptions and waivers that was apparrently inbuilt to safe guard those whoa re vulnerable was always prone to corruption and only those who have "connections" benefitted. The poor did not benefit. The original objective of user fees was to generate revenue to support health systems. Instead, it created disparity in access to health services (The initial increase in number of people accessing health services was shortlived as governments were unable to sustain medicine supply,among other commodities, from user fee funds).
User fees are definately not suitable for those on chronic long term care as they cannot sustain such long term out of pocket payments
What about Social health insurance or community health insurance systems?
Dr Atieno Ojoo, BPharm, MPH
Chief Pharmacist, Kenyatta National Hospital
Nairobi, Kenya
atisojoo@yahoo.co.uk
E-DRUG: Sachs' unfashionable Rx for third world aid (8)
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I think Sach's point is that donors are spend tens of billions on
HIV, loans and drug revolving funds when for a few billion dollars a
year we can begin to wipe a few tropical diseases off the globe.
This has the potential to improve peoples lives to a greater extent
than treating the popular diseases.
Does it really make sense to spend dollars treating somebody for HIV
when he is going to die of a tropical worm that costs cents to treat?
We want to be seen to be doing the big things but if nobody does the
small things the big things don't really make any impact.
I agree with Carolyn Green that user fees for HIV treatment are
counter productive. HIV is a public heath issue and every person on
treatment is reduces the spread of the disease and increases the
productivity of society. On the other hand we need to ensure that
there is commitment to providing these drugs for life. Any break in
supply or barriers to supply such as the later introduction of a user
fee could cause non-compliance resulting in potential wide scale drug
resistance.
We need to be realistic money does not grow on trees, there will never
be enough. Take look at the long term picture. If your treatment
program is stretched beyond capacity by fund limitations or population
growth/migration, how do you decide who gets life saving drugs and who
to tell to look for alternatives. It is much fairer to the people on
the ground to start off with some sort of fee for those who can pay
and exceptions for those who cannot afford to pay on the understanding
that if their circumstances improve they can contribute to their
future treatment. The introduction of user fees to a free service at a
later stage is very painful.
I really don't know the answers but I know that living in a fantasy
land does not help anybody.
--
Paul Lobb B Pharm (Hons)
email paul.lobb@gmail.com
unaffiliated pharmacist
E-DRUG: Sachs' unfashionable Rx for third world aid (9)
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[The moderator has today attended a conference on systematic reviews of health systems research. There are currently reviews going on on user fees and other forms of patient payment contribution. Very few or no published studies fulfil criteria for inclusion in these reviews. This is the published one: Aaserud M, Dahlgren AT, Kosters JP, Oxman AD, Ramsay C, Sturm H. Pharmaceutical policies: effects of reference pricing, other pricing, and purchasing policies. Cochrane Database Syst Rev. 2006 Apr 19;(2):CD005979. Review.
I fully agree with Carolyn, you have articulated this so well. Please note that even where there are verification committees to determine those that deserve free treatment, user fee systems end up favouring those that have influence in the community other than the real poor!
Deo
Deogratius Kimera
Director Drug Donation Programs
Axios International
Tel:+256-41-340806/7 (office)
Mobile:+256-77-744664 (personnal)
e-mail:Deo.Kimera@axiosint.com
E-DRUG: Sachs' unfashionable Rx for third world aid (10)
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I published a couple of systematic reviews dealing with some of these
topics:
Lexchin J., Grootendorst P. ³The effects of prescription drug user fees on
drug and health services use and health status: a review of the evidence.²
International Journal of Health Services 2004;34:101-122.
Lexchin J. ³Effects of restrictive formularies in the ambulatory care
setting.² American Journal of Managed Care 2002;8:69-76.
Joel Lexchin
--
Joel Lexchin MD
121 Walmer Rd.
Toronto ON
Canada M5R 2X8
Tel: 416-964-7186
Fax: 416-736-5227
E mail: joel.lexchin@utoronto.ca