Transcript Poster presentation

Impact of a NGO-supported supervisory
programme on the quality of care in
private shops in rural E.Nepal
Kathleen Holloway
Bharat Raj Gautam
Britain Nepal Medical Trust (BNMT)
ICIUM 2004
Background
• In Nepal, < 20% of the population use public primary
health care facilities and in many rural communities the
population has no access to essential drugs
• Private drug shops are a primary source of health care for
many people in Nepal and other poor countries, yet the
quality if care is often poor, unsupported and unsupervised
• BNMT, an international NGO, operated a “Hill Drug
Scheme” (HDS) to improve access to essential drugs and
the quality of care offered by private drug shops:
– contract between BNMT and drug shops chosen by the
communities where there were no existing drug shops
– BNMT supplied essential drugs, training and supervision
Objectives
• Compare the quality of care provided by private drug shops
within the Hill Drug Scheme (HDS) and those not (non-HDS)
• Intervention:(HDS)
– contract between BNMT and private shops in communities, where
there were no other existing drug shops
– communities identified a community member with an existing shop
(not already selling drugs) and school leaving certificate to serve the
community and enter into a contract with BNMT
– BNMT supplied (1) essential (EDL) drugs to shops at cost price, (2)
training and supervision, and (3) sponsorship for govt. retailer training
– Shop retailers bought drugs only from BNMT and sold them for a
12.5% mark-up, i.e. drugs were available at cost price plus 22.5%
– Retailers undertook to abide by the 12.5% mark-up rule and good
dispensing practices to stay within the HDS
Methods
• Cross-sectional survey in 1996 in E.Nepal
• all 16 HDS drug shops from 7 districts
• 21 non-HDS drug shops from the same areas as
far as possible as the HDS shops
• Data collection
– 15-30 exiting patient interviews per drug shop (211
patients in HDS shops, 383 patients in non-HDS shops)
– retailer interviews
– observation of the consultation and dispensing
processes
Drug costs and fees paid
Fees paid /
patient (NRs)
15
Drug cost /
patient (NRs)
15
11
27
% mark-up in
drug price
% patients
issued receipt
80
36
2.4
30.5
HDS
non-HDS
Socio-economic status of patients
Patient characteristics
HDS
shops
Non-HDS
shops
% < 5 years
21
11
General
population
statistics
15
% female
42
43
50
Average family size
6.9
6.9
5.4
% Literacy
58
62
45
% with no school leaving
certificate
% landowners
80
76
98
97
96
82
Av. plot size (ropani)
33
34
22
% < 30 mins to water
87
87
-
% using a latrine
64
60
-
Quality of Prescribing
Prescribing indicators
HDS shops
Non-HDS shops
Av. no. drugs / patient
1.3
1.4
% patients sold inj.
4.7%
4.7%
% patients sold AB*
28%
23%
% AB sold in full dose
24%
14%
% sold drugs on EDL
87%
59%
% drugs sold that were
vits/tonics/cough syr.
2.2%
8.5%
*antibiotics
Patient quality of care
Indicator
(no. patients)
HDS shops
(n=211)
Non-HDS shops
(n=383)
3.4 mins
3.8 mins
% customers given
written instructions
11%
7%
% customers knowing
their dosing schedules
75%
77%
Retailer/customer
interaction time
Prescriptions (Px) and quality of care
HDS
shops
Non-HDS
shops
% customers with:
- any kind of Px
- an official Px
27%
22%
20%
12%
% Px-only drugs sold
33%
39%
% dispensing errors
15%
21%
% Px-only drugs sold without Px
63%
66%
% prescribed drugs dispensed
60%
71%
Indicator
Quality of drug retailer service
% key drug stock-out
reported in last 3 months
21
47
% shops with MOH drug
retailer handbook
17
42
% retailers with some kind of
health qualification
% retailers with MOH retailer
qualification
42
53
12
31
HDS
non-HDS
Retailer views on the HDS
• When an HDS shop starts, there is no competition:
– easy to sell only EDL drugs and not sell Px-only drugs without Px
• Often within one year of an HDS shop starting, another
shop starts up nearby in competition:
– lose money if they do not sell non-EDL drugs and Px-only drugs
– cater to patients’ desire to buy more expensive non-EDL drugs,
branded products and drugs in incomplete courses
• Local health workers and wealthier community
members often cease to support the HDS shop:
– may start their own shops in competition with the HDS shops
– often a financial partnership between the retailer and health worker
– deliberately prescribe and sell drugs not available in HDS shops
Conclusions
• Quality of care provided by HDS versus non-HDS was:
– significantly better with regard to cost to the patient and provision
of purchase receipt, use of essential drugs and retailer qualification
– marginally better with regard to fewer dispensing errors, fewer
antibiotics sold in under-dose
– no different in terms of socio-economic status of their customers
– worse with regard to reported drug availability
• Though HDS shops were only started in areas with no drug
shops, competing drug shops soon followed, causing:
– profit loss for HDS shops if they followed the principals of good
retailing in terms of selling only EDL and generic drugs, Px-only
drugs only with a Px, and antibiotics only in full course.
Key lessons, policy implications and
future research
Key lessons
• An NGO-supported supervisory programme was able to improve the
quality of care with regard to use of essential drugs and reduced drug
prices in private shops, but not in areas that reduced competitiveness
with other shops e.g. OTC prescribing of Px-only drugs
Policy implications
• Schemes to improve quality of care in the private sector must take into
account the need of private systems to be competitive and profitable
Future research
• Further schemes to improve quality of care in private shops using
financial incentives should be implemented and evaluated